Departments of *Surgery †Pathology ‡Endocrinology §Hematology/Oncology ¶Otolaryngology ‖Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA.
Ann Surg. 2014 Jul;260(1):163-8. doi: 10.1097/SLA.0000000000000215.
To test whether a clinical algorithm using routine cytological molecular testing (MT) promotes initial total thyroidectomy (TT) for clinically significant thyroid cancer (sTC) and/or correctly limits surgery to lobectomy when appropriate.
Either TT or lobectomy is often needed to diagnose differentiated thyroid cancer. Determining the correct extent of initial thyroidectomy is challenging.
After implementing an algorithm for prospective MT of in-house fine-needle aspiration biopsy specimens, we conducted a single-institution cohort study of all patients (N = 671) with nonmalignant cytology who had thyroidectomy between October 2010 and March 2012, cytological diagnosis using 2008 Bethesda criteria, and 1 or more indications for thyroidectomy by 2009 American Thyroid Association guidelines. sTC was defined by histological differentiated thyroid cancer of 1 cm or more and/or lymph node metastasis. Cohort 2 patients did not have MT or had unevaluable results. In cohort 1, MT for a multigene mutation panel was performed for nonbenign cytology, and positive MT results indicated initial TT.
MT guidance was associated with a higher incidence of sTC after TT (P = 0.006) and a lower rate of sTC after lobectomy (P = 0.03). Without MT results, patients with indeterminate (follicular lesion of undetermined significance/follicular or oncocytic neoplasm) cytology who received initial lobectomy were 2.5 times more likely to require 2-stage surgery for histological sTC (P < 0.001). In the 501 patients with non-sTC for whom lobectomy was the appropriate extent of surgery, lobectomy was correctly performed more often with routine preoperative MT (P = 0.001).
Fine-needle aspiration biopsy MT for BRAF, RAS, PAX8-PPARγ, and RET-PTC expedites optimal initial surgery for differentiated thyroid cancer, facilitating succinct definitive management for patients with thyroid nodules.
检验临床算法中应用常规细胞学分子检测（MT）是否有助于对有临床意义的甲状腺癌（sTC）患者进行初始全甲状腺切除术（TT），以及（或）是否有助于正确地将手术限制在适当的甲状腺叶切除术。
诊断分化型甲状腺癌通常需要进行 TT 或甲状腺叶切除术。确定初始甲状腺切除术的正确范围具有挑战性。
在实施针对内部细针抽吸活检标本的前瞻性 MT 算法后，我们对 2010 年 10 月至 2012 年 3 月间因非恶性细胞学诊断、采用 2008 年 Bethesda 标准进行细胞学诊断、且符合 2009 年美国甲状腺协会指南 1 项或多项甲状腺切除术适应证而接受甲状腺切除术的所有患者（N=671）进行了单机构队列研究。sTC 定义为 1cm 或更大的组织学分化型甲状腺癌和（或）淋巴结转移。队列 2 患者未进行 MT 或 MT 结果不可评估。在队列 1 中，对非良性细胞学标本进行多基因突变 panel MT，如果 MT 结果阳性，则进行初始 TT。
MT 指导与 TT 后 sTC 的发生率升高（P=0.006）和 TT 后 sTC 的发生率降低（P=0.03）相关。没有 MT 结果时，接受初始甲状腺叶切除术的不确定（滤泡性病变意义未确定/滤泡性或嗜酸细胞肿瘤）细胞学患者发生组织学 sTC 时需要进行 2 阶段手术的可能性增加 2.5 倍（P<0.001）。在 501 例非 sTC 患者中，甲状腺叶切除术是适当的手术范围，术前常规 MT 更有助于正确进行甲状腺叶切除术（P=0.001）。
BRAF、RAS、PAX8-PPARγ 和 RET-PTC 的细针抽吸活检 MT 可加速分化型甲状腺癌的初始最佳手术，促进甲状腺结节患者简明明确的管理。
