Advertisement

World Journal of Surgery

, Volume 38, Issue 3, pp 614–621 | Cite as

Thyroid Nodules (≥4 cm): Can Ultrasound and Cytology Reliably Exclude Cancer?

  • Laura I. Wharry
  • Kelly L. McCoy
  • Michael T. Stang
  • Michaele J. Armstrong
  • Shane O. LeBeau
  • Mitch E. Tublin
  • Biatta Sholosh
  • Ari Silbermann
  • N. Paul Ohori
  • Yuri E. Nikiforov
  • Steven P. Hodak
  • Sally E. Carty
  • Linwah YipEmail author
Article

Abstract

Background

Whether a threshold nodule size should prompt diagnostic thyroidectomy remains controversial. We examined a consecutive series of patients who all had thyroidectomy for a ≥4 cm nodule to determine (1) the incidence of thyroid cancer (TC) and (2) if malignant nodules could accurately be diagnosed preoperatively by ultrasound (US), fine needle aspiration biopsy (FNAB) cytology and molecular testing.

Methods

As a prospective management strategy, 361 patients with 382 nodules ≥4 cm by preoperative US had thyroidectomy from 1/07 to 3/12.

Results

The incidence of a clinically significant TC within the ≥4 cm nodule was 22 % (83/382 nodules). The presence of suspicious US features did not discriminate malignant from benign nodules. Moreover, in 86 nodules ≥4 cm with no suspicious US features, the risk of TC within the nodule was 20 %. US-guided FNAB was performed for 290 nodules, and the risk of malignancy increased stepwise from 10.4 % for cytologically benign nodules, 29.6 % for cytologically indeterminate nodules and 100 % for malignant FNAB results. Molecular testing was positive in 9.3 % (10/107) of tested FNAB specimens, and all ten were histologic TC.

Conclusions

In a large consecutive series in which all ≥4 cm nodules had histology and were systematically evaluated by preoperative US and US-guided FNAB, the incidence of TC within the nodule was 22 %. The false negative rate of benign cytology was 10.4 %, and the absence of suspicious US features did not reliably exclude malignancy. At minimum, thyroid lobectomy should be strongly considered for all nodules ≥4 cm.

Keywords

Thyroid Cancer Thyroid Nodule Total Thyroidectomy Fine Needle Aspiration Biopsy Thyroid Lobectomy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Conflict of interest

None.

References

  1. 1.
    Meko JB, Norton JA (1995) Large cystic/solid thyroid nodules: a potential false-negative fine-needle aspiration. Surgery 118: 996–1003; discussion 1003–1004Google Scholar
  2. 2.
    Rosario PW, Salles DS, Bessa B, Purisch S (2009) Low false-negative rate of cytology in thyroid nodules > or =4 cm. Arq Bras Endocrinol Metabol 53:1143–1145PubMedGoogle Scholar
  3. 3.
    Albuja-Cruz MB, Goldfarb M, Gondek SS et al (2013) Reliability of fine-needle aspiration for thyroid nodules greater than or equal to 4 cm. J Surg Res 181:6–10PubMedCrossRefGoogle Scholar
  4. 4.
    Banks ND, Kowalski J, Tsai HL et al (2008) A diagnostic predictor model for indeterminate or suspicious thyroid FNA samples. Thyroid 18:933–941PubMedCrossRefGoogle Scholar
  5. 5.
    Kamran SC, Marqusee E, Kim MI et al (2013) Thyroid nodule size and prediction of cancer. J Clin Endocrinol Metab 98:564–570PubMedCrossRefGoogle Scholar
  6. 6.
    Kuru B, Gulcelik NE, Gulcelik MA, Dincer H (2010) The false-negative rate of fine-needle aspiration cytology for diagnosing thyroid carcinoma in thyroid nodules. Langenbecks Arch Surg 395:127–132PubMedCrossRefGoogle Scholar
  7. 7.
    Pinchot SN, Al-Wagih H, Schaefer S et al (2009) Accuracy of fine-needle aspiration biopsy for predicting neoplasm or carcinoma in thyroid nodules 4 cm or larger. Arch Surg 144:649–655PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Carrillo JF, Frias-Mendivil M, Ochoa-Carrillo FJ, Ibarra M (2000) Accuracy of fine-needle aspiration biopsy of the thyroid combined with an evaluation of clinical and radiologic factors. Otolaryngol Head Neck Surg 122:917–921PubMedCrossRefGoogle Scholar
  9. 9.
    McCoy KL, Jabbour N, Ogilvie JB et al (2007) The incidence of cancer and rate of false-negative cytology in thyroid nodules greater than or equal to 4 cm in size. Surgery 142:837–844; discussion 844, e831–833Google Scholar
  10. 10.
    Mehanna R, Murphy M, McCarthy J et al (2013) False negatives in thyroid cytology: impact of large nodule size and follicular variant of papillary carcinoma. Laryngoscope 123:1305–1309PubMedCrossRefGoogle Scholar
  11. 11.
    McHenry CR, Huh ES, Machekano RN (2008) Is nodule size an independent predictor of thyroid malignancy? Surgery 144:1062–1068; discussion 1068–1069Google Scholar
  12. 12.
    Porterfield JR Jr, Grant CS, Dean DS et al (2008) Reliability of benign fine needle aspiration cytology of large thyroid nodules. Surgery 144:963–968; discussion 968–969Google Scholar
  13. 13.
    Shrestha M, Crothers BA, Burch HB (2012) The impact of thyroid nodule size on the risk of malignancy and accuracy of fine-needle aspiration: a 10-year study from a single institution. Thyroid 22:1251–1256PubMedCrossRefGoogle Scholar
  14. 14.
    Tee YY, Lowe AJ, Brand CA, Judson RT (2007) Fine-needle aspiration may miss a third of all malignancy in palpable thyroid nodules: a comprehensive literature review. Ann Surg 246:714–720PubMedCrossRefGoogle Scholar
  15. 15.
    Moon WJ, Jung SL, Lee JH et al (2008) Benign and malignant thyroid nodules: US differentiation—multicenter retrospective study. Radiology 247:762–770PubMedCrossRefGoogle Scholar
  16. 16.
    Bongiovanni M, Spitale A, Faquin WC et al (2012) The Bethesda system for reporting thyroid cytopathology: a meta-analysis. Acta Cytol 56:333–339PubMedCrossRefGoogle Scholar
  17. 17.
    Cibas ES, Ali SZ (2009) The Bethesda system for reporting thyroid cytopathology. Thyroid 19:1159–1165PubMedCrossRefGoogle Scholar
  18. 18.
    Nikiforov YE, Ohori NP, Hodak SP et al (2011) Impact of mutational testing on the diagnosis and management of patients with cytologically indeterminate thyroid nodules: a prospective analysis of 1056 FNA samples. J Clin Endocrinol Metab 96:3390–3397PubMedCrossRefGoogle Scholar
  19. 19.
    Cantara S, Capezzone M, Marchisotta S et al (2010) Impact of proto-oncogene mutation detection in cytological specimens from thyroid nodules improves the diagnostic accuracy of cytology. J Clin Endocrinol Metab 95:1365–1369PubMedCrossRefGoogle Scholar
  20. 20.
    American Thyroid Association Guidelines Taskforce on Thyroid Nodules, Differentiated Thyroid Cancer, Cooper DS et al (2009) Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 19:1167–1214PubMedCrossRefGoogle Scholar
  21. 21.
    Raj MD, Grodski S, Woodruff S et al (2012) Diagnostic lobectomy is not routinely required to exclude malignancy in thyroid nodules greater than four centimetres. ANZ J Surg 82:73–77PubMedCrossRefGoogle Scholar
  22. 22.
    Elsheikh TM, Asa SL, Chan JK et al (2008) Interobserver and intraobserver variation among experts in the diagnosis of thyroid follicular lesions with borderline nuclear features of papillary carcinoma. Am J Clin Pathol 130:736–744PubMedCrossRefGoogle Scholar
  23. 23.
    Widder S, Guggisberg K, Khalil M, Pasieka JL (2008) A pathologic re-review of follicular thyroid neoplasms: the impact of changing the threshold for the diagnosis of the follicular variant of papillary thyroid carcinoma. Surgery 144:80–85PubMedCrossRefGoogle Scholar
  24. 24.
    Jean-Gilles J, Fischer AH, Luu MH, Owens CL (2012) Clinical and pathologic features and clinical impact of false negative thyroid fine-needle aspirations. Cancer Cytopathol 120:326–333PubMedCrossRefGoogle Scholar
  25. 25.
    Siddiqui MA, Griffith KA, Michael CW, Pu RT (2008) Nodule heterogeneity as shown by size differences between the targeted nodule and the tumor in thyroidectomy specimen: a cause for a false-negative diagnosis of papillary thyroid carcinoma on fine-needle aspiration. Cancer 114:27–33PubMedCrossRefGoogle Scholar
  26. 26.
    Cappelli C, Castellano M, Pirola I et al (2007) The predictive value of ultrasound findings in the management of thyroid nodules. QJM 100:29–35PubMedCrossRefGoogle Scholar
  27. 27.
    Papini E, Guglielmi R, Bianchini A et al (2002) Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab 87:1941–1946PubMedCrossRefGoogle Scholar
  28. 28.
    Yoon JH, Kwak JY, Moon HJ et al (2011) The diagnostic accuracy of ultrasound-guided fine-needle aspiration biopsy and the sonographic differences between benign and malignant thyroid nodules 3 cm or larger. Thyroid 21:993–1000PubMedCrossRefGoogle Scholar
  29. 29.
    Chen H, Nicol TL, Zeiger MA et al (1998) Hürthle cell neoplasms of the thyroid: are there factors predictive of malignancy? Ann Surg 227:542–546PubMedCrossRefGoogle Scholar
  30. 30.
    Sippel RS, Elaraj DM, Khanafshar E et al (2008) Tumor size predicts malignant potential in Hürthle cell neoplasms of the thyroid. World J Surg 32:702–707. doi: 10.1007/s00268-007-9416-5 PubMedCrossRefGoogle Scholar
  31. 31.
    Zhang YW, Greenblatt DY, Repplinger D et al (2008) Older age and larger tumor size predict malignancy in Hürthle cell neoplasms of the thyroid. Ann Surg Oncol 15:2842–2846PubMedCrossRefGoogle Scholar
  32. 32.
    Yip L, Farris C, Kabaker AS et al (2012) Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies. J Clin Endocrinol Metab 97:1905–1912PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2013

Authors and Affiliations

  • Laura I. Wharry
    • 1
  • Kelly L. McCoy
    • 1
  • Michael T. Stang
    • 1
  • Michaele J. Armstrong
    • 1
  • Shane O. LeBeau
    • 2
  • Mitch E. Tublin
    • 3
  • Biatta Sholosh
    • 3
  • Ari Silbermann
    • 1
  • N. Paul Ohori
    • 4
  • Yuri E. Nikiforov
    • 4
  • Steven P. Hodak
    • 2
  • Sally E. Carty
    • 1
  • Linwah Yip
    • 1
    Email author
  1. 1.Department of SurgeryUniversity of Pittsburgh School of MedicinePittsburghUSA
  2. 2.Department of EndocrinologyUniversity of PittsburghPittsburghUSA
  3. 3.Department of RadiologyUniversity of PittsburghPittsburghUSA
  4. 4.Department of PathologyUniversity of PittsburghPittsburghUSA

Personalised recommendations