AHNS Series: Do you know your guidelines? AHNS Endocrine Section Consensus Statement: State‐of‐the‐art thyroid surgical recommendations in the era of noninvasive follicular thyroid neoplasm with papillary‐like nuclear features

Abstract

The newly introduced pathologic diagnosis of noninvasive follicular thyroid neoplasm with papillary‐like nuclear features (NIFTP) will result in less bilateral thyroid surgery as well as deescalation in T4 suppressive and radioactive iodine treatment. Although, NIFTP is a nonmalignant lesion that has nuclear features of some papillary malignancies, the challenge for the surgeon is to identify a lesion as possibly NIFTP before the pathologic diagnosis. NIFTP, due to its reduction of overall rates of malignancy, will result in the initial surgical pendulum swinging toward lobectomy instead of initial total thyroidectomy. This American Head and Neck Society endocrine section consensus statement is intended to inform preoperative evaluation to attempt to identify those patients whose final pathology report may ultimately harbor NIFTP and can be offered a conservative surgical plan to assist in cost‐effective, optimal management of patients with NIFTP.

Risk of malignancy and neoplasia predicted by three molecular testing platforms in indeterminate thyroid nodules on fine‐needle aspiration

“…All follicular‐patterned tumors, including NIFTP, remain surgical disease. A nodule's entire capsule needs to be examined thoroughly to make the diagnosis . Whereas most studies focus on malignancy, the risk of neoplasm is important.…”

“…While the BRAF V600E mutation and RET‐PTC1/3 fusions correlate with a very high risk of malignancy, this is not true for all targets in the molecular assays. RAS mutations and PAX8‐PPARγ fusions have been recognized in a broad spectrum of follicular‐based tumors, ranging from benign to malignant neoplasms …”

“…If the diagnostic criteria are strictly applied, these tumors are not anticipated to have the molecular aberrations such as BRAF V600E that are strongly associated with classic PTC. Rather, they exhibit a high number of mutations related to follicular‐based tumors, with the most common being RAS mutations …”

“…For these patients, extensive surgery can be deemed overtreatment. There has been a noticeable shift toward more conservative management and personalized medicine . Ancillary molecular testing is often endorsed as a supplement to enhance the diagnostic yield of FNAs with indeterminate cytology .…”

The new 4th edition World Health Organization classification for thyroid tumors, Asian perspectives

“…According to the current ATA clinical guidelines, NIFTP is a surgical disease. It requires surgical removal and histological evaluation, because it is a precancer in definition and should be removed under the Western logic . However, in Asian perspectives, accurate distinction between FA and borderline tumors (UMP and NIFTP) is not important clinically, and under‐diagnosis of borderline tumors as FA does not harm to the patients because both can be treated by simple excision and cured.…”