Surgical treatment of thyroid follicular neoplasms: results of a retrospective analysis of a large clinical series

Abstract

The most appropriate surgical management of "follicular neoplasm/suspicious for follicular neoplasm" lesions (FN), considering their low definitive malignancy rate and the limited predictive power of preoperative clinic-diagnostic factors, is still controversial. On behalf of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB), we collected and analyzed the experience of 26 endocrine centers by computerized questionnaire. 1379 patients, surgically treated after a FN diagnosis from January 2012 and December 2103, were evaluated. Histological features, surgical complications, and medium-term outcomes were reported. Total thyroidectomy (TT) was performed in 1055/1379 patients (76.5 %), while hemithyroidectomy (HT) was carried out in 324/1379 cases (23.5 %). Malignancy rate was higher in TT than in HT groups (36.4 vs. 26.2 %), whereas the rates of transient and definitive hypoparathyroidism following TT were higher than after HT. Consensual thyroiditis (16.8 vs. 9.9 %) and patient age (50.9 vs. 47.9 %) also differed between groups. A cytological FN diagnosis was associated to a not negligible malignancy rate (469/1379 patients; 34 %), that was higher in TT than in HT groups. However, a lower morbidity rate was observed in HT, which should be considered the standard of care in solitary lesions in absence of specific risk factors. Malignancy could not be preoperatively assessed and clinical decision-making is still controversial. Further efforts should be spent to more accurately preoperatively classify FN thyroid nodules.

Thyroid FNA cytology in Asian practice—Active surveillance for indeterminate thyroid nodules reduces overtreatment of thyroid carcinomas

“…We believe surveillance is sufficient to prevent missing lethal cancers because long term follow‐up of patients not only prevents overtreatment but also confirms the benign diagnosis. Diagnostic lobectomy for FN/SFN nodules increases the risk of treatment‐related complications, which should be avoided, and Conzo et al reported that 15.1% of 1379 patients treated with thyroidectomy for FN/SFN nodules in 26 Italian hospitals had surgery‐related complications. Do not harm patients is the first and most important element in Asian clinical practice, similarly emphasised in western practice …”

“…As the majority of cases with indeterminate cytology are benign or borderline tumours, and the majority of thyroid carcinomas in indeterminate categories were low‐risk, clinical follow‐up of these nodules is one method recommended by the JTA clinical guidelines as long as they have benign clinical features …”

“…FT-UMP (10) As the majority of cases with indeterminate cytology are benign or borderline tumours, and the majority of thyroid carcinomas in indeterminate categories were low-risk, [49][50][51][52] clinical follow-up of these nodules is one method recommended by the JTA clinical guidelines as long as they have benign clinical features. 16,17,45 Proper better risk stratification of thyroid cancer, which is a common practice in Asia. 16,17,22,24,42,43,46 Of the proposed modifications and updates for the second edition of the Bethesda system, application of molecular tests, clinicoradiological risk stratification, and a multidisciplinary team approach for both AUS/FLUS and FN/SFN nodules were emphasised.…”

The futility of intraoperative frozen section in the evaluation of follicular thyroid lesions

“…However, aggressive variants of PTC, for example, tall cell variant, medullary thyroid carcinoma (MTC), and distant metastatic carcinomas to the thyroid, although rare, may be diagnosed as FLUS or FN/SFN on FNA and should be included in the differential diagnosis . In a multi‐institutional review of 1,379 patients with FN undergoing surgical treatment, Conzo et al reported a final malignancy rate of 34% (469 cases), which included eight cases of MTC (0.6%) . Similarly, Hurthle cell lesions represent a distinct challenge to pathologists on FNA and iFS .…”

“…22 In a multi-institutional review of 1,379 patients with FN undergoing surgical treatment, Conzo et al reported a final malignancy rate of 34% (469 cases), which included eight cases of MTC (0.6%). 23 Similarly, Hurthle cell lesions represent a distinct challenge to pathologists on FNA and iFS. 24 Oncocytic changes may arise in benign conditions such as chronic lymphocytic thyroiditis, humoral-mediated hyperthyroidism, and multinodular goiters.…”