Clinical Endocrinology (2016) 84, 315–320
doi: 10.1111/cen.12806
REVIEW ARTICLE
BRAF-mutated carcinomas among thyroid nodules with prior indeterminate FNA report: a systematic review and meta-analysis Pierpaolo Trimboli*,†, Giorgio Treglia†, Emma Condorelli*, Francesco Romanelli‡, Anna Crescenzi§, Massimo Bongiovanni¶ and Luca Giovanella† *Section of Endocrinology and Diabetology, Ospedale Israelitico, Rome, Italy, †Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland, ‡Department of Experimental Medicine, Sapienza University, Rome, Italy, §Section of Pathology, University Hospital Campus Bio Medico, Rome, Italy and ¶Institute of Pathology, University Hospital, Lausanne, Switzerland
Summary
Introduction
Background Several molecular analyses have been investigated for risk stratification of thyroid nodules, with a particular focus on the V600E mutation of the BRAF gene [BRAF(V600E)]. To date, there is no high-level evidence supporting or refuting a role for BRAF analysis in thyroid nodules with prior indeterminate cytology. To obtain more robust evidence, we reviewed and meta-analysed data from published articles. Research Design and Methods A comprehensive literature search of the PubMed/MEDLINE, Embase and Scopus databases was conducted using the terms ‘BRAF’, ‘thyroid’ and ‘indeterminate’. The search was updated until March 2015, and references of the retrieved articles were also screened. Only original articles reporting BRAF mutation testing within nodules with indeterminate FNA were eligible for inclusion. Results The literature search revealed 82 articles, of which 8 were eligible for the study. Five studies were prospective and three retrospective. The majority of authors analysed BRAF mutations in FNA samples which were classified by the British or Bethesda system. Of the initial series of studies, a pooled number of 1361 cases were achieved of which 43 were BRAF mutated. Overall, the BRAF mutation rate was 46% (95% CI: 1–108%), ranging from 0 to 229%. When we included only histological series, 978 thyroid nodules were found. Of these, 245 were cancers. Conclusions A very low rate of lesions with indeterminate cytology are BRAF mutated. Thus, the role of this biomarker to detect or exclude cancers in patients with such FNA reports is marginal and should be reconsidered in guidelines.
Cytology from fine-needle aspiration (FNA) is recognized as a major tool in evaluating thyroid nodules due to its high accuracy, reproducibility and cost-effectiveness.1,2 Nevertheless, a not insignificant number (up to 20–25%) of FNA cytologies are reported as indeterminate neoplasms, representing a ‘grey’ zone of uncertain behaviour. In this context, surgery is traditionally warranted to achieve a diagnosis; however, because about four in five of these nodules are benign at final postoperative histology, a presurgical identification of parameters which are predictive of cancer is needed.1,2 Several papers have reported that various markers could assess the risk of malignancy in thyroid nodules. In particular, a novel gene-expression classifier analysing 167 genes achieved negative predictive value (NPV) of 95% in this context.3 Immunohistochemistry for Galectin-3 and HBME-1, as well as ultrasonographic and scintigraphic parameters, have also been used to detect or exclude malignancy in nodules with prior indeterminate FNA.4–10 In addition, other biopsy strategies were reported as accurate in this context, and core needle biopsy (CNB) has been recently described as a second-line approach for indeterminate thyroid lesions.11–16 In the last decade, several molecular markers, such as BRAF, RAS, RET/PTC and PAX8/PPAR, have been explored to identify those cancers displaying greater clinical aggressiveness; their use has been proposed to stratify the risk of thyroid nodules.17–19 A particular focus has related to the V600E mutation of the BRAF gene, involving substitution of glutamate (E) for valine (V) at codon 600, hereafter referred to as BRAF(V600E). This mutation is found in up to 70% of papillary thyroid carcinomas (PTC) and may be an independent predictor of poor prognosis,20 even if its association with increased cancer-related mortality is still a matter of debate.21 To date, there is no strong evidence either for or against routine BRAF evaluation in the initial work up of thyroid nodules. Also, this approach appears difficult in FNA samples.22,23 Potentially, analysis of BRAF mutational status could be useful in the risk stratification of thyroid lesions, which
(Received 20 March 2015; returned for revision 2 April 2015; finally revised 8 April 2015; accepted 21 April 2015)
Correspondence: Pierpaolo Trimboli, Section of Endocrinology and Diabetology, Ospedale Israelitico di Roma, Via Fulda, 14 – 00148 – Rome, Italy. Tel.: +39 06 655891; Fax: +39 06 65589329; E-mail: [email protected] © 2015 John Wiley & Sons Ltd
315
316 P. Trimboli et al. are read as indeterminate at FNA. In this context, American Thyroid Association (ATA) guidelines recommend its use in indeterminate lesions with rating C.2 Here, we aimed to systematically review the literature on BRAF mutation analysis among thyroid nodules with an indeterminate FNA report. Furthermore, to obtain more robust evidence from these data, a meta-analysis of the published articles was also conducted.
(significant heterogeneity was defined as an I-square value >50%). The possible causes of significant heterogeneity were explored if the I-square value was >50% and a secondary analysis was performed after exclusion of articles causing significant heterogeneity. Egger’s test was carried out to evaluate the possible presence of a significant publication bias. Statistical analyses were performed using the STATSDIRECT statistical software version 2.8 (StatsDirect Ltd., Altrincham, UK).
Material and methods
Results
Search strategy
Eligible articles
A comprehensive computer literature search of the PubMed/ MEDLINE, Embase and Scopus databases was conducted to find published studies searching BRAF mutations in thyroid nodules with previous indeterminate FNA (i.e. Thy 3 or Category IIIIV). The search algorithm was based on the following terms: ‘BRAF’ AND ‘thyroid’ AND ‘indeterminate’. No start date limit was adopted, the search was updated until 4 March 2015, and no language restriction was used. To expand our search, the references of the retrieved articles were also screened to identify additional studies.
The literature search revealed 82 articles. Review of titles and abstracts excluded 73 articles according to the above criteria, and nine articles25–33 were initially selected and their full-text version retrieved. For the meta-analysis, one study29 was excluded for overlapping data, and eight papers were finally included. Of these, five were prospective, while the other three had a retrospective design. The authors of the included studies were from the USA (n = 5), Italy (n = 2) and the UK (n = 1). Data on the final histological follow-up were not clearly detailed in some of these studies. As a consequence, the true percentage of malignancy within the pooled series of indeterminate nodules could not be calculated.
Study selection Only original articles that investigated BRAF mutations within series of nodules with indeterminate FNA were eligible for inclusion. The main exclusion criteria were articles that did not provide clear study characteristics and studies with overlapping patient data. Case reports were excluded. Three researchers (PT, EC and GT) independently reviewed the titles and abstracts of the retrieved articles, applying the inclusion and exclusion criteria previously described. The same researchers then independently reviewed the full-text version of the remaining articles to determine their eligibility for inclusion. Data extraction For each included study, information was extracted concerning study data (authors, year of publication and country of origin), number of patients evaluated, number of BRAF-mutated lesions and number of thyroid cancers detected. Statistical analysis The prevalence of BRAF-mutated lesions among indeterminate thyroid nodules was obtained from individual studies using the formula: number of BRAF-mutated lesions/number of indeterminate thyroid nodules 9 100. For statistical pooling of the data, the DerSimonian and Laird method (random-effects model)24 was used. In this model, pooled data represent weighted averages related to the sample size of the individual studies. Pooled data were presented with 95% confidence intervals (95%CI) and displayed using forest plots. To quantify the heterogeneity among the studies, the I-square index was used
Qualitative analysis (systematic review) The large majority of the included studies analysed BRAF only in FNA samples, and BRAF mutation analysis was performed in histological specimens in only one study.25 One paper33 adopted British Thyroid Association (BTA) guidelines and nodules were divided into Thy-3a or Thy-3f34; other researchers27,28,30–32 used the Bethesda Classification system and lesions were assessed as Category III or IV,35 while the remaining studies25,26 did not specify a classification system and reported the lesions as ‘indeterminate’ at FNA. The indeterminate classes of the above two systems34,35 (Thy-3a and Thy-3f, and Categories III-IV, respectively) could be considered as quite similar.36 The main characteristics of the included studies are shown in Table 1. Of the eight included papers, six studies reported the frequency of BRAF-mutated lesions in their initial series. A pooled number of 1361 indeterminate nodules were achieved and 43 BRAF-mutated cancers were found (Table 2). Nikiforov et al.28 evaluated several possible mutations in a consecutive series of 1056 indeterminate lesions; of these, sufficient material was collected in 967 cases and only 19 (18%) BRAF-mutated lesions were found. Adeniran and colleagues27,29 conducted two studies on a quite similar FNA series; they found 19 BRAF-mutated nodules of 83 (229%)27 and 12 BRAF-mutated nodules within an initial series of 89 cases (135%).29 This rate of BRAF-positive results was significantly lower than that recorded in another group of malignant nodules at FNA (79%). Also, BRAF mutations were recorded only in Category IV of the Bethesda system, while no mutated cases were found in Category III.27 Moreover, © 2015 John Wiley & Sons Ltd Clinical Endocrinology (2016), 84, 315–320
BRAF mutation in follicular neoplasms 317 Table 1. Main characteristics of the included studies
First author
Year
Journal
Country
Study design
Rowe25 Sapio26 Adeniran27 Nikiforov28 Kleiman30 Ohori31 Agretti32 Johnson33 Total
2006 2007 2011 2011 2013 2013 2014 2014
CytoJournal Clin Endocrinol Acta Cytol J Clin Endocrinol Metab Cancer Ca Cytopathol J Endocrinol Invest Cytopathol
USA Italy USA USA USA USA Italy UK
Retrospective Prospective Retrospective Retrospective Prospective Prospective Prospective Prospective
Indeterminate lesions with histological follow-up
Cancers at histology
19 21 48 461 274 15 54 86 978
19 2 27 93 63 15 15 11 245
Most benign nodules were excluded in the studies; hence, the malignancy rate of the pooled series of indeterminate nodules could not be calculated.
Table 2. Prevalence of BRAF-mutated lesions among the initial series of indeterminate nodules
First author Rowe25 Sapio26 Adeniran27 Nikiforov28 Kleiman30 Ohori31 Agretti32 Johnson33 Total
Indeterminate nodules (n) N/A 21 83 1056 61 N/A 54 86 1361
BRAF mutation (n) N/A 0 19 19 2 N/A 1 2 43
Table 3. Distribution of BRAF-mutated cancers in different subtypes of PTC
First author
BRAF-mutated cancers
PTC classic
PTC follicular variant
PTC tall cell variant
Other
Rowe25 Sapio26 Adeniran27 Nikiforov28 Kleiman30 Ohori31 Agretti32 Johnson33
9 0 16 7 2 7 1 2
7 – 6 5 N/A N/A 1 1
2 – 6 2 N/A N/A – –
– – 2 – N/A N/A – 1
– – 2 – N/A N/A – –
% – 0 229 18 33 – 19 23
N/A, data not available.
N/A, data not available.
a 3%, 19% and 23% of mutated BRAF lesions was reported by Kleiman et al.,30 Agretti et al.32 and Johson et al.,33 respectively. Of the mutations recorded in the eight studies, only BRAF (V600E) was detected in almost all cases; in the series by Ohori,31 eight cases of BRAF(K601E) were also reported (5 in AUS/ FLUS and 3 in FN/SFN group). When we considered only those cases reported with postsurgical follow-up, 978 indeterminate nodules were identified, of which 245 were proven thyroid cancers, and 44/245 were BRAF mutated. The majority of these were classic PTC, some cases were follicular variant PTC, and other cases were rarely reported (Table 3).
CI = 2 to 4; P = 03). A secondary analysis performed after exclusion of the article by Adeniran et al.27 showed a rate of BRAF mutations of 2% (95%CI: 13–29%). The I-square value in this secondary analysis was 0% demonstrating lack of heterogeneity.
Quantitative analysis (meta-analysis) The rate of BRAF-mutated lesions among the pooled series of indeterminate thyroid nodules was 46% (95%CI: 1–108%), ranging from 0 to 229% (Fig. 1). The included studies were statistically heterogeneous (I-square >75%) for prevalence of BRAF-mutated lesions among indeterminate nodules. A significant publication bias was not evident (Egger’s test = 12; 95% © 2015 John Wiley & Sons Ltd Clinical Endocrinology (2016), 84, 315–320
Discussion Generally, differentiated thyroid cancers have an indolent behaviour and only a few PTCs have poor prognosis. BRAF gene mutation has been reported to be associated with these aggressive PTC types (i.e. tall cell variant)20,21 and international guidelines recommend this analysis in nodules with a malignant or suspicious for cancer FNA report.1,2,34 In addition, testing of BRAF status has been investigated in nodules with indeterminate FNA, such as Thy-3 or Category III-IV. Only one in four of these nodules is a cancer, and a good prognosis of patients with preoperative indeterminate FNA has been found,37,38 mainly due to the low rate of more aggressive cancer types in this cytologic class.37 Therefore, detection of benign nodules and avoidance of unnecessary thyroidectomy is an important priority.39
318 P. Trimboli et al.
Fig. 1 Pooled prevalence of BRAF-mutated lesions among thyroid nodules with indeterminate FNA cytology.
Here, we aimed to systematically review and meta-analyse all published articles reporting BRAF mutation analysis in thyroid nodules with preoperative indeterminate FNA. The main finding of the present study was that a very low prevalence of BRAF-mutated lesions was found among these nodules (43 in 1361 cases). The majority of the published studies reported a BRAF mutation rate between 0 and 3% in their initial series of indeterminate thyroid nodules, while only one study described a rate of 23%. All in all, the meta-analysis revealed that about 5% of indeterminate lesions were BRAF mutated, and almost all mutations reported were V600E. Of relevance, the study with the largest sample size28 found a BRAF mutation rate of 18%, this finding being quite similar to that recorded in other smaller series.30,32,33 In addition, this percentage was significantly lower than that reported in the group of nodules with malignant FNA cytology.27,29 The study which reported a higher rate of BRAF mutations27 merits particular attention. The authors noted a comparatively high prevalence of malignancy among indeterminate nodules but they used a nonconventional classification system and BRAF-mutated cancers were found only in a subcategory of lesions with nuclear atypia. This raises concern for a PTC and might be quoted as suspicious for malignancy (i.e. Thy-4) by other authors. As we describe above, this study produced heterogeneity among the meta-analysed studies. Two-hundred and forty-five cancers were histologically proven after surgery in the pooled series. Unfortunately, the true prevalence of malignancy, and the frequency of positive BRAF cases, in the overall series of indeterminate nodules could not be accurately established because some of the studies did not report data on the initial series and/or final histological follow-up. Our findings have implications for clinical practice. Recommendation 8 of the revised ATA guidelines states that the use of molecular markers, such as BRAF, may be considered for patients with indeterminate cytology to help their management (recommendation rating C, based on expert opinion).2 The onlyreference on the use of BRAF testing supporting that recom-
mendation was the study by Sapio et al.26 which was the only prospective paper published at that time. However, as detailed above, this series did not record BRAF-mutated cancers within a small set of 21 indeterminate lesions. In this context, no specific recommendation has been stated by the BTA34 nor the AACE/ AME/ETA.1 Based on the present review and meta-analysis, the use of BRAF mutation analysis might not be encouraged in nodules with Thy-3/Category III-IV assessment at cytology. In an ideal cohort of one-hundred indeterminate thyroid cases, one could expect about twenty-five cancers1,2,34 and only 5/100 should be BRAF positive. The remaining twenty malignancies might not be detected by this genetic analysis. This has to be considered as a very low sensitivity and negative predictive value. Furthermore, the elevated costs of the BRAF test (about 400 Euros per patient, with variation according to the different methods of analysis) have to be taken into account. Additionally, clinical, ultrasonographic, scintigraphic and immunocytochemical parameters have been shown to be useful in stratifying the risk of malignancy among indeterminate nodules,4–10 and thyroid lobectomy can provide definitive diagnosis with a low rate of complications.34 Indeterminate thyroid nodules carry a 20–30% risk of malignancy, and if atypia are present that risk increases up to 42%.40,41 Atypia are usually features suspicious for PTC; hence, the rate of BRAF-mutated cases may depend on the ability of the cytopathologist to discriminate among worrisome nuclear characteristics which can be reported as benign (i.e. Thy-2/Category II) or suspicious for cancer (Thy-4/Category V). In these cases, a second opinion should be quicker and cheaper. In the AUS class, BRAF analysis may support the surgical strategy as a rule-in test. This approach should be evaluated for each patient because, regardless of FNA, several other factors can influence the clinical decision. In a recent study by the Johns Hopkins Hospital, it has been demonstrated that molecular testing may be overused in patients for whom the results would not change surgical management.42 When only follicular proliferations are considered, BRAF testing alone achieves low sensitivity. In fact, © 2015 John Wiley & Sons Ltd Clinical Endocrinology (2016), 84, 315–320
BRAF mutation in follicular neoplasms 319 many lesions included in these ‘indeterminate follicular neoplasms’, such as follicular adenoma, follicular carcinoma and follicular variant of PTC, cannot be distinguished by BRAF mutation analysis.17 In this context, a recent study using laser capture microdissection showed the potential usefulness of additional molecular tests in follicular neoplasms.43 Publication bias is a major concern in a meta-analysis. In fact, those studies reporting positive findings are more likely to be published than those describing negative results. Also, small sample-size studies are likely to report positive relationships, which are not confirmed in subsequent larger series. Here, Egger’s test demonstrated a lack of important publication bias. The present study has some limitations such as heterogeneity and selection bias of included articles. In particular, heterogeneity arises from diversity in patient characteristics, methodological aspects and global study quality. By I-square index, significant heterogeneity in the prevalence of BRAF-mutated nodules was found, and this heterogeneity was accounted for using a random-effects model.24 In conclusion, a very low rate (i.e. 5%) of BRAF mutations is found in nodules with indeterminate cytology, such as Thy-3 or Category III-IV. Considering this negligible pretest probability, BRAF genetic analysis is not cost-effective in nodules with indeterminate FNA reports, and may not be useful to detect or exclude cancers in these patients.
7
8
9
10
11 12
13
14
Conflict of interests The authors have no conflict of interests to declare.
15
References 1 Gharib, H., Papini, E., Paschke, R. et al. (2010) American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocrine Practice : Official Journal only of the American Association of Clinical Endocrinologists, 1, 1–43. 2 American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper, D.S., Doherty, G.M. et al. (2009) Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid, 19, 1167– 1214. 3 Alexander, E.K., Kennedy, G.C., Baloch, Z.W. et al. (2012) Preoperative diagnosis of benign thyroid nodules with indeterminate cytology. New England Journal of Medicine, 367, 705–715. 4 Trimboli, P., Treglia, G., Guidobaldi, L. et al. (2014) Clinical characteristics as predictors of malignancy in patients with indeterminate thyroid cytology: a meta-analysis. Endocrine, 46, 52–59. 5 Trimboli, P., Condorelli, E., Catania, A. et al. (2009) Clinical and ultrasound parameters in the approach to thyroid nodules cytologically classified as indeterminate neoplasm. Diagnostic Cytopathology, 37, 783–785. 6 Heinzel, A., M€ uller, D., Behrendt, F.F. et al. (2014) Thyroid nodules with indeterminate cytology: molecular imaging with ⁹⁹mTc-methoxyisobutylisonitrile (MIBI) is more cost-effective © 2015 John Wiley & Sons Ltd Clinical Endocrinology (2016), 84, 315–320
16
17
18 19
20
21
than the Afirma gene expression classifier. European Journal of Nuclear Medicine and Molecular Imaging, 41, 1497–1500. Giovanella, L., Ceriani, L. & Treglia, G. (2014) Role of isotope scan, including positron emission tomography/computed tomography, in nodular goitre. Best Practice & Research. Clinical Endocrinology & Metabolism, 28, 507–518. Bartolazzi, A., Orlandi, F., Saggiorato, E. et al. (2008) Galectin3-expression analysis in the surgical selection of follicular thyroid nodules with indeterminate fine-needle aspiration cytology: a prospective multicentre study. The Lancet. Oncology, 9, 543–549. Trimboli, P., Treglia, G. & Giovanella, L. (2015) Preoperative measurement of serum thyroglobulin to predict malignancy in thyroid nodules: a systematic review. Hormone and Metabolic Research, 47, 247–252. Trimboli, P., Treglia, G., Sadeghi, R. et al. (2014) Reliability of real-time elastography to diagnose thyroid nodules previously read at FNAC as indeterminate: a meta-analysis. Endocrine, doi: 10.1007/s12020-014-0510-9. Trimboli, P. & Crescenzi, A. (2015) Thyroid core needle biopsy: taking stoke of the situation. Endocrine, 48, 779–785. Park, K.T., Ahn, S.H., Mo, J.H. et al. (2011) Role of core needle biopsy and ultrasonographic finding in management of indeterminate thyroid nodules. Head and Neck, 33, 160–165. Nasrollah, N., Trimboli, P., Guidobaldi, L. et al. (2013) Thin core biopsy should help to discriminate thyroid nodules cytologically classified as indeterminate. A new sampling technique. Endocrine, 43, 659–665. Nasrollah, N., Trimboli, P., Rossi, F. et al. (2014) Patient’s comfort with and tolerability of thyroid core needle biopsy. Endocrine, 45, 79–83. Na, D.G., Kim, J.H., Sung, J.Y. et al. (2012) Core-needle biopsy is more useful than repeat fine-needle aspiration in thyroid nodules read as nondiagnostic or atypia of undetermined significance by the Bethesda system for reporting thyroid cytopathology. Thyroid, 22, 468–475. Choi, Y.J., Baek, J.H., Ha, E.J. et al. (2014) Different risk of malignancy and management recommendations in subcategories of thyroid nodules with atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS): the role of US-guided core-needle biopsy (CNB). Thyroid, 24, 494–501. Eszlinger, M. & Paschke, R. (2010) Molecular fine-needle aspiration biopsy diagnosis of thyroid nodules by tumor specific mutations and gene expression patterns. Molecular and Cellular Endocrinology, 322, 29–37. Nikiforova, M.N. & Nikiforov, Y.E. (2009) Molecular diagnostics and predictors in thyroid cancer. Thyroid, 19, 1351–1361. Couto, J.P., Prazeres, H., Castro, P. et al. (2009) How molecular pathology is changing and will change the therapeutics of patients with follicular cell-derived thyroid cancer. Journal of Clinical Pathology, 62, 414–421. Elisei, R., Viola, D., Torregrossa, L. et al. (2012) The BRAF (V600E) mutation is an independent, poor prognostic factor for the outcome of patients with low-risk intrathyroid papillary thyroid carcinoma: single-institution results from a large cohort study. Journal of Clinical Endocrinology and Metabolism, 97, 4390–4398. Xing, M., Alzahrani, A.S., Carson, K.A. et al. (2013) Association between BRAF V600E mutation and mortality in patients with papillary thyroid cancer. JAMA, 309, 1493–1501.
320 P. Trimboli et al. 22 Boufraqech, M., Patel, D., Xiong, Y. et al. (2013) Diagnosis of thyroid cancer: state of art. Expert Opinion on Medical Diagnostics, 7, 331–342. 23 Crescenzi, A., Guidobaldi, L., Nasrollah, N. et al. (2014) Immunohistochemistry for BRAF(V600E) antibody VE1 performed in core needle biopsy samples identifies mutated papillary thyroid cancers. Hormone and Metabolic Research, 46, 370–374. 24 DerSimonian, R. & Laird, N. (1986) Meta-analysis in clinical trials. Controlled Clinical Trials, 7, 177–188. 25 Rowe, L.R., Bentz, B.G. & Bentz, J.S. (2006) Utility of BRAF V600E mutation detection in cytologically indeterminate thyroid nodules. CytoJournal, 3, 10. 26 Sapio, M.R., Posca, D., Raggioli, A. et al. (2007) Detection of RET/PTC, TRK and BRAF mutations in preoperative diagnosis of thyroid nodules with indeterminate cytological findings. Clinical Endocrinology (Oxford), 66, 678–683. 27 Adeniran, A.J., Hui, P., Chhieng, D.C. et al. (2011) BRAF mutation testing of thyroid fine-needle aspiration specimens enhances the predictability of malignancy in thyroid follicular lesions of undetermined significance. Acta Cytologica, 55, 570–575. 28 Nikiforov, Y.E., Ohori, N.P., Hodak, S.P. 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. Journal of Clinical Endocrinology and Metabolism, 96, 3390–3397. 29 Adeniran, A.J., Theoharis, C., Hui, P. et al. (2011) Reflex BRAF testing in thyroid fine-needle aspiration biopsy with equivocal and positive interpretation: a prospective study. Thyroid, 21, 717–723. 30 Kleiman, D.A., Sporn, M.J., Beninato, T. et al. (2013) Preoperative BRAF(V600E) mutation screening is unlikely to alter initial surgical treatment of patients with indeterminate thyroid nodules: a prospective case series of 960 patients. Cancer, 119, 1495– 1502. 31 Ohori, N.P., Singhal, R., Nikiforova, M.N. et al. (2013) BRAF mutation detection in indeterminate thyroid cytology specimens: underlying cytologic, molecular, and pathologic characteristics of papillary thyroid carcinoma. Cancer Cytopathology, 121, 197–205. 32 Agretti, P., Niccolai, F., Rago, T. et al. (2014) BRAF mutation analysis in thyroid nodules with indeterminate cytology: our
33
34
35 36
37
38
39 40
41
42
43
experience on surgical management of patients with thyroid nodules from an area of borderline iodine deficiency. Journal of Endocrinological Investigation, 37, 1009–1014. Johnson, S.J., Hardy, S.A., Roberts, C. et al. (2014) Pilot of BRAF mutation analysis in indeterminate, suspicious and malignant thyroid FNA cytology. Cytopathology, 25, 146–154. Perros, P., Boelaert, K., Colley, S. et al. (2014) Guidelines for the management of thyroid cancer. Clinical Endocrinology (Oxford), 81(Suppl 1), 1–122. Cibas, E.S. & Ali, S.Z. (2009) The Bethesda system for reporting thyroid cytopathology. Thyroid, 19, 1159–1165. Bongiovanni, M., Spitale, A., Faquin, W.C. et al. (2012) The Bethesda system for reporting thyroid cytopathology: a metaanalysis. Acta Cytologica, 56, 333–339. Trimboli, P., Bongiovanni, M., Rossi, F. et al. (2015) Differentiated thyroid cancer patients with a previous indeterminate (Thy 3) cytology have a better prognosis than those with suspicious or malignant FNAC reports. Endocrine, 49, 191–195. Rago, T., Scutari, M., Latrofa, F. et al. (2014) The large majority of 1520 patients with indeterminate thyroid nodule at cytology have a favorable outcome, and a clinical risk score has a high negative predictive value for a more cumbersome cancer disease. Journal of Clinical Endocrinology and Metabolism, 99, 3700–3707. Sebo, T.J. (2012) What are the keys to successful thyroid FNA interpretation? Clinical Endocrinology, 77, 13–17. Goldstein, R.E., Netterville, J.L., Burkey, B. et al. (2002) Implications of follicular neoplasms, atypia, and lesions suspicious for malignancy diagnosed by fine-needle aspiration of thyroid nodules. Annals of Surgery, 235, 656–662. Kato, M.A., Buitrago, D., Moo, T.A. et al. (2011) Predictive value of cytologic atypia in indeterminate thyroid fine-needle aspirate biopsies. Annals of Surgical Oncology, 18, 2893–2898. Aragon Han, P., Olson, M.T., Fazeli, R. et al. (2014) The impact of molecular testing on the surgical management of patients with thyroid nodules. Annals of Surgical Oncology, 21, 1862–1869. Bongiovanni, M., Molinari, F., Eszlinger, M. et al. (2014) Laser capture microdissection is a valuable tool in the preoperative molecular screening of follicular lesions of the thyroid: an institutional experience. Cytopathology, doi: 10.1111/cyt.12226.
© 2015 John Wiley & Sons Ltd Clinical Endocrinology (2016), 84, 315–320
doi: 10.1111/cen.12806
REVIEW ARTICLE
BRAF-mutated carcinomas among thyroid nodules with prior indeterminate FNA report: a systematic review and meta-analysis Pierpaolo Trimboli*,†, Giorgio Treglia†, Emma Condorelli*, Francesco Romanelli‡, Anna Crescenzi§, Massimo Bongiovanni¶ and Luca Giovanella† *Section of Endocrinology and Diabetology, Ospedale Israelitico, Rome, Italy, †Department of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland, ‡Department of Experimental Medicine, Sapienza University, Rome, Italy, §Section of Pathology, University Hospital Campus Bio Medico, Rome, Italy and ¶Institute of Pathology, University Hospital, Lausanne, Switzerland
Summary
Introduction
Background Several molecular analyses have been investigated for risk stratification of thyroid nodules, with a particular focus on the V600E mutation of the BRAF gene [BRAF(V600E)]. To date, there is no high-level evidence supporting or refuting a role for BRAF analysis in thyroid nodules with prior indeterminate cytology. To obtain more robust evidence, we reviewed and meta-analysed data from published articles. Research Design and Methods A comprehensive literature search of the PubMed/MEDLINE, Embase and Scopus databases was conducted using the terms ‘BRAF’, ‘thyroid’ and ‘indeterminate’. The search was updated until March 2015, and references of the retrieved articles were also screened. Only original articles reporting BRAF mutation testing within nodules with indeterminate FNA were eligible for inclusion. Results The literature search revealed 82 articles, of which 8 were eligible for the study. Five studies were prospective and three retrospective. The majority of authors analysed BRAF mutations in FNA samples which were classified by the British or Bethesda system. Of the initial series of studies, a pooled number of 1361 cases were achieved of which 43 were BRAF mutated. Overall, the BRAF mutation rate was 46% (95% CI: 1–108%), ranging from 0 to 229%. When we included only histological series, 978 thyroid nodules were found. Of these, 245 were cancers. Conclusions A very low rate of lesions with indeterminate cytology are BRAF mutated. Thus, the role of this biomarker to detect or exclude cancers in patients with such FNA reports is marginal and should be reconsidered in guidelines.
Cytology from fine-needle aspiration (FNA) is recognized as a major tool in evaluating thyroid nodules due to its high accuracy, reproducibility and cost-effectiveness.1,2 Nevertheless, a not insignificant number (up to 20–25%) of FNA cytologies are reported as indeterminate neoplasms, representing a ‘grey’ zone of uncertain behaviour. In this context, surgery is traditionally warranted to achieve a diagnosis; however, because about four in five of these nodules are benign at final postoperative histology, a presurgical identification of parameters which are predictive of cancer is needed.1,2 Several papers have reported that various markers could assess the risk of malignancy in thyroid nodules. In particular, a novel gene-expression classifier analysing 167 genes achieved negative predictive value (NPV) of 95% in this context.3 Immunohistochemistry for Galectin-3 and HBME-1, as well as ultrasonographic and scintigraphic parameters, have also been used to detect or exclude malignancy in nodules with prior indeterminate FNA.4–10 In addition, other biopsy strategies were reported as accurate in this context, and core needle biopsy (CNB) has been recently described as a second-line approach for indeterminate thyroid lesions.11–16 In the last decade, several molecular markers, such as BRAF, RAS, RET/PTC and PAX8/PPAR, have been explored to identify those cancers displaying greater clinical aggressiveness; their use has been proposed to stratify the risk of thyroid nodules.17–19 A particular focus has related to the V600E mutation of the BRAF gene, involving substitution of glutamate (E) for valine (V) at codon 600, hereafter referred to as BRAF(V600E). This mutation is found in up to 70% of papillary thyroid carcinomas (PTC) and may be an independent predictor of poor prognosis,20 even if its association with increased cancer-related mortality is still a matter of debate.21 To date, there is no strong evidence either for or against routine BRAF evaluation in the initial work up of thyroid nodules. Also, this approach appears difficult in FNA samples.22,23 Potentially, analysis of BRAF mutational status could be useful in the risk stratification of thyroid lesions, which
(Received 20 March 2015; returned for revision 2 April 2015; finally revised 8 April 2015; accepted 21 April 2015)
Correspondence: Pierpaolo Trimboli, Section of Endocrinology and Diabetology, Ospedale Israelitico di Roma, Via Fulda, 14 – 00148 – Rome, Italy. Tel.: +39 06 655891; Fax: +39 06 65589329; E-mail: [email protected] © 2015 John Wiley & Sons Ltd
315
316 P. Trimboli et al. are read as indeterminate at FNA. In this context, American Thyroid Association (ATA) guidelines recommend its use in indeterminate lesions with rating C.2 Here, we aimed to systematically review the literature on BRAF mutation analysis among thyroid nodules with an indeterminate FNA report. Furthermore, to obtain more robust evidence from these data, a meta-analysis of the published articles was also conducted.
(significant heterogeneity was defined as an I-square value >50%). The possible causes of significant heterogeneity were explored if the I-square value was >50% and a secondary analysis was performed after exclusion of articles causing significant heterogeneity. Egger’s test was carried out to evaluate the possible presence of a significant publication bias. Statistical analyses were performed using the STATSDIRECT statistical software version 2.8 (StatsDirect Ltd., Altrincham, UK).
Material and methods
Results
Search strategy
Eligible articles
A comprehensive computer literature search of the PubMed/ MEDLINE, Embase and Scopus databases was conducted to find published studies searching BRAF mutations in thyroid nodules with previous indeterminate FNA (i.e. Thy 3 or Category IIIIV). The search algorithm was based on the following terms: ‘BRAF’ AND ‘thyroid’ AND ‘indeterminate’. No start date limit was adopted, the search was updated until 4 March 2015, and no language restriction was used. To expand our search, the references of the retrieved articles were also screened to identify additional studies.
The literature search revealed 82 articles. Review of titles and abstracts excluded 73 articles according to the above criteria, and nine articles25–33 were initially selected and their full-text version retrieved. For the meta-analysis, one study29 was excluded for overlapping data, and eight papers were finally included. Of these, five were prospective, while the other three had a retrospective design. The authors of the included studies were from the USA (n = 5), Italy (n = 2) and the UK (n = 1). Data on the final histological follow-up were not clearly detailed in some of these studies. As a consequence, the true percentage of malignancy within the pooled series of indeterminate nodules could not be calculated.
Study selection Only original articles that investigated BRAF mutations within series of nodules with indeterminate FNA were eligible for inclusion. The main exclusion criteria were articles that did not provide clear study characteristics and studies with overlapping patient data. Case reports were excluded. Three researchers (PT, EC and GT) independently reviewed the titles and abstracts of the retrieved articles, applying the inclusion and exclusion criteria previously described. The same researchers then independently reviewed the full-text version of the remaining articles to determine their eligibility for inclusion. Data extraction For each included study, information was extracted concerning study data (authors, year of publication and country of origin), number of patients evaluated, number of BRAF-mutated lesions and number of thyroid cancers detected. Statistical analysis The prevalence of BRAF-mutated lesions among indeterminate thyroid nodules was obtained from individual studies using the formula: number of BRAF-mutated lesions/number of indeterminate thyroid nodules 9 100. For statistical pooling of the data, the DerSimonian and Laird method (random-effects model)24 was used. In this model, pooled data represent weighted averages related to the sample size of the individual studies. Pooled data were presented with 95% confidence intervals (95%CI) and displayed using forest plots. To quantify the heterogeneity among the studies, the I-square index was used
Qualitative analysis (systematic review) The large majority of the included studies analysed BRAF only in FNA samples, and BRAF mutation analysis was performed in histological specimens in only one study.25 One paper33 adopted British Thyroid Association (BTA) guidelines and nodules were divided into Thy-3a or Thy-3f34; other researchers27,28,30–32 used the Bethesda Classification system and lesions were assessed as Category III or IV,35 while the remaining studies25,26 did not specify a classification system and reported the lesions as ‘indeterminate’ at FNA. The indeterminate classes of the above two systems34,35 (Thy-3a and Thy-3f, and Categories III-IV, respectively) could be considered as quite similar.36 The main characteristics of the included studies are shown in Table 1. Of the eight included papers, six studies reported the frequency of BRAF-mutated lesions in their initial series. A pooled number of 1361 indeterminate nodules were achieved and 43 BRAF-mutated cancers were found (Table 2). Nikiforov et al.28 evaluated several possible mutations in a consecutive series of 1056 indeterminate lesions; of these, sufficient material was collected in 967 cases and only 19 (18%) BRAF-mutated lesions were found. Adeniran and colleagues27,29 conducted two studies on a quite similar FNA series; they found 19 BRAF-mutated nodules of 83 (229%)27 and 12 BRAF-mutated nodules within an initial series of 89 cases (135%).29 This rate of BRAF-positive results was significantly lower than that recorded in another group of malignant nodules at FNA (79%). Also, BRAF mutations were recorded only in Category IV of the Bethesda system, while no mutated cases were found in Category III.27 Moreover, © 2015 John Wiley & Sons Ltd Clinical Endocrinology (2016), 84, 315–320
BRAF mutation in follicular neoplasms 317 Table 1. Main characteristics of the included studies
First author
Year
Journal
Country
Study design
Rowe25 Sapio26 Adeniran27 Nikiforov28 Kleiman30 Ohori31 Agretti32 Johnson33 Total
2006 2007 2011 2011 2013 2013 2014 2014
CytoJournal Clin Endocrinol Acta Cytol J Clin Endocrinol Metab Cancer Ca Cytopathol J Endocrinol Invest Cytopathol
USA Italy USA USA USA USA Italy UK
Retrospective Prospective Retrospective Retrospective Prospective Prospective Prospective Prospective
Indeterminate lesions with histological follow-up
Cancers at histology
19 21 48 461 274 15 54 86 978
19 2 27 93 63 15 15 11 245
Most benign nodules were excluded in the studies; hence, the malignancy rate of the pooled series of indeterminate nodules could not be calculated.
Table 2. Prevalence of BRAF-mutated lesions among the initial series of indeterminate nodules
First author Rowe25 Sapio26 Adeniran27 Nikiforov28 Kleiman30 Ohori31 Agretti32 Johnson33 Total
Indeterminate nodules (n) N/A 21 83 1056 61 N/A 54 86 1361
BRAF mutation (n) N/A 0 19 19 2 N/A 1 2 43
Table 3. Distribution of BRAF-mutated cancers in different subtypes of PTC
First author
BRAF-mutated cancers
PTC classic
PTC follicular variant
PTC tall cell variant
Other
Rowe25 Sapio26 Adeniran27 Nikiforov28 Kleiman30 Ohori31 Agretti32 Johnson33
9 0 16 7 2 7 1 2
7 – 6 5 N/A N/A 1 1
2 – 6 2 N/A N/A – –
– – 2 – N/A N/A – 1
– – 2 – N/A N/A – –
% – 0 229 18 33 – 19 23
N/A, data not available.
N/A, data not available.
a 3%, 19% and 23% of mutated BRAF lesions was reported by Kleiman et al.,30 Agretti et al.32 and Johson et al.,33 respectively. Of the mutations recorded in the eight studies, only BRAF (V600E) was detected in almost all cases; in the series by Ohori,31 eight cases of BRAF(K601E) were also reported (5 in AUS/ FLUS and 3 in FN/SFN group). When we considered only those cases reported with postsurgical follow-up, 978 indeterminate nodules were identified, of which 245 were proven thyroid cancers, and 44/245 were BRAF mutated. The majority of these were classic PTC, some cases were follicular variant PTC, and other cases were rarely reported (Table 3).
CI = 2 to 4; P = 03). A secondary analysis performed after exclusion of the article by Adeniran et al.27 showed a rate of BRAF mutations of 2% (95%CI: 13–29%). The I-square value in this secondary analysis was 0% demonstrating lack of heterogeneity.
Quantitative analysis (meta-analysis) The rate of BRAF-mutated lesions among the pooled series of indeterminate thyroid nodules was 46% (95%CI: 1–108%), ranging from 0 to 229% (Fig. 1). The included studies were statistically heterogeneous (I-square >75%) for prevalence of BRAF-mutated lesions among indeterminate nodules. A significant publication bias was not evident (Egger’s test = 12; 95% © 2015 John Wiley & Sons Ltd Clinical Endocrinology (2016), 84, 315–320
Discussion Generally, differentiated thyroid cancers have an indolent behaviour and only a few PTCs have poor prognosis. BRAF gene mutation has been reported to be associated with these aggressive PTC types (i.e. tall cell variant)20,21 and international guidelines recommend this analysis in nodules with a malignant or suspicious for cancer FNA report.1,2,34 In addition, testing of BRAF status has been investigated in nodules with indeterminate FNA, such as Thy-3 or Category III-IV. Only one in four of these nodules is a cancer, and a good prognosis of patients with preoperative indeterminate FNA has been found,37,38 mainly due to the low rate of more aggressive cancer types in this cytologic class.37 Therefore, detection of benign nodules and avoidance of unnecessary thyroidectomy is an important priority.39
318 P. Trimboli et al.
Fig. 1 Pooled prevalence of BRAF-mutated lesions among thyroid nodules with indeterminate FNA cytology.
Here, we aimed to systematically review and meta-analyse all published articles reporting BRAF mutation analysis in thyroid nodules with preoperative indeterminate FNA. The main finding of the present study was that a very low prevalence of BRAF-mutated lesions was found among these nodules (43 in 1361 cases). The majority of the published studies reported a BRAF mutation rate between 0 and 3% in their initial series of indeterminate thyroid nodules, while only one study described a rate of 23%. All in all, the meta-analysis revealed that about 5% of indeterminate lesions were BRAF mutated, and almost all mutations reported were V600E. Of relevance, the study with the largest sample size28 found a BRAF mutation rate of 18%, this finding being quite similar to that recorded in other smaller series.30,32,33 In addition, this percentage was significantly lower than that reported in the group of nodules with malignant FNA cytology.27,29 The study which reported a higher rate of BRAF mutations27 merits particular attention. The authors noted a comparatively high prevalence of malignancy among indeterminate nodules but they used a nonconventional classification system and BRAF-mutated cancers were found only in a subcategory of lesions with nuclear atypia. This raises concern for a PTC and might be quoted as suspicious for malignancy (i.e. Thy-4) by other authors. As we describe above, this study produced heterogeneity among the meta-analysed studies. Two-hundred and forty-five cancers were histologically proven after surgery in the pooled series. Unfortunately, the true prevalence of malignancy, and the frequency of positive BRAF cases, in the overall series of indeterminate nodules could not be accurately established because some of the studies did not report data on the initial series and/or final histological follow-up. Our findings have implications for clinical practice. Recommendation 8 of the revised ATA guidelines states that the use of molecular markers, such as BRAF, may be considered for patients with indeterminate cytology to help their management (recommendation rating C, based on expert opinion).2 The onlyreference on the use of BRAF testing supporting that recom-
mendation was the study by Sapio et al.26 which was the only prospective paper published at that time. However, as detailed above, this series did not record BRAF-mutated cancers within a small set of 21 indeterminate lesions. In this context, no specific recommendation has been stated by the BTA34 nor the AACE/ AME/ETA.1 Based on the present review and meta-analysis, the use of BRAF mutation analysis might not be encouraged in nodules with Thy-3/Category III-IV assessment at cytology. In an ideal cohort of one-hundred indeterminate thyroid cases, one could expect about twenty-five cancers1,2,34 and only 5/100 should be BRAF positive. The remaining twenty malignancies might not be detected by this genetic analysis. This has to be considered as a very low sensitivity and negative predictive value. Furthermore, the elevated costs of the BRAF test (about 400 Euros per patient, with variation according to the different methods of analysis) have to be taken into account. Additionally, clinical, ultrasonographic, scintigraphic and immunocytochemical parameters have been shown to be useful in stratifying the risk of malignancy among indeterminate nodules,4–10 and thyroid lobectomy can provide definitive diagnosis with a low rate of complications.34 Indeterminate thyroid nodules carry a 20–30% risk of malignancy, and if atypia are present that risk increases up to 42%.40,41 Atypia are usually features suspicious for PTC; hence, the rate of BRAF-mutated cases may depend on the ability of the cytopathologist to discriminate among worrisome nuclear characteristics which can be reported as benign (i.e. Thy-2/Category II) or suspicious for cancer (Thy-4/Category V). In these cases, a second opinion should be quicker and cheaper. In the AUS class, BRAF analysis may support the surgical strategy as a rule-in test. This approach should be evaluated for each patient because, regardless of FNA, several other factors can influence the clinical decision. In a recent study by the Johns Hopkins Hospital, it has been demonstrated that molecular testing may be overused in patients for whom the results would not change surgical management.42 When only follicular proliferations are considered, BRAF testing alone achieves low sensitivity. In fact, © 2015 John Wiley & Sons Ltd Clinical Endocrinology (2016), 84, 315–320
BRAF mutation in follicular neoplasms 319 many lesions included in these ‘indeterminate follicular neoplasms’, such as follicular adenoma, follicular carcinoma and follicular variant of PTC, cannot be distinguished by BRAF mutation analysis.17 In this context, a recent study using laser capture microdissection showed the potential usefulness of additional molecular tests in follicular neoplasms.43 Publication bias is a major concern in a meta-analysis. In fact, those studies reporting positive findings are more likely to be published than those describing negative results. Also, small sample-size studies are likely to report positive relationships, which are not confirmed in subsequent larger series. Here, Egger’s test demonstrated a lack of important publication bias. The present study has some limitations such as heterogeneity and selection bias of included articles. In particular, heterogeneity arises from diversity in patient characteristics, methodological aspects and global study quality. By I-square index, significant heterogeneity in the prevalence of BRAF-mutated nodules was found, and this heterogeneity was accounted for using a random-effects model.24 In conclusion, a very low rate (i.e. 5%) of BRAF mutations is found in nodules with indeterminate cytology, such as Thy-3 or Category III-IV. Considering this negligible pretest probability, BRAF genetic analysis is not cost-effective in nodules with indeterminate FNA reports, and may not be useful to detect or exclude cancers in these patients.
7
8
9
10
11 12
13
14
Conflict of interests The authors have no conflict of interests to declare.
15
References 1 Gharib, H., Papini, E., Paschke, R. et al. (2010) American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocrine Practice : Official Journal only of the American Association of Clinical Endocrinologists, 1, 1–43. 2 American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper, D.S., Doherty, G.M. et al. (2009) Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid, 19, 1167– 1214. 3 Alexander, E.K., Kennedy, G.C., Baloch, Z.W. et al. (2012) Preoperative diagnosis of benign thyroid nodules with indeterminate cytology. New England Journal of Medicine, 367, 705–715. 4 Trimboli, P., Treglia, G., Guidobaldi, L. et al. (2014) Clinical characteristics as predictors of malignancy in patients with indeterminate thyroid cytology: a meta-analysis. Endocrine, 46, 52–59. 5 Trimboli, P., Condorelli, E., Catania, A. et al. (2009) Clinical and ultrasound parameters in the approach to thyroid nodules cytologically classified as indeterminate neoplasm. Diagnostic Cytopathology, 37, 783–785. 6 Heinzel, A., M€ uller, D., Behrendt, F.F. et al. (2014) Thyroid nodules with indeterminate cytology: molecular imaging with ⁹⁹mTc-methoxyisobutylisonitrile (MIBI) is more cost-effective © 2015 John Wiley & Sons Ltd Clinical Endocrinology (2016), 84, 315–320
16
17
18 19
20
21
than the Afirma gene expression classifier. European Journal of Nuclear Medicine and Molecular Imaging, 41, 1497–1500. Giovanella, L., Ceriani, L. & Treglia, G. (2014) Role of isotope scan, including positron emission tomography/computed tomography, in nodular goitre. Best Practice & Research. Clinical Endocrinology & Metabolism, 28, 507–518. Bartolazzi, A., Orlandi, F., Saggiorato, E. et al. (2008) Galectin3-expression analysis in the surgical selection of follicular thyroid nodules with indeterminate fine-needle aspiration cytology: a prospective multicentre study. The Lancet. Oncology, 9, 543–549. Trimboli, P., Treglia, G. & Giovanella, L. (2015) Preoperative measurement of serum thyroglobulin to predict malignancy in thyroid nodules: a systematic review. Hormone and Metabolic Research, 47, 247–252. Trimboli, P., Treglia, G., Sadeghi, R. et al. (2014) Reliability of real-time elastography to diagnose thyroid nodules previously read at FNAC as indeterminate: a meta-analysis. Endocrine, doi: 10.1007/s12020-014-0510-9. Trimboli, P. & Crescenzi, A. (2015) Thyroid core needle biopsy: taking stoke of the situation. Endocrine, 48, 779–785. Park, K.T., Ahn, S.H., Mo, J.H. et al. (2011) Role of core needle biopsy and ultrasonographic finding in management of indeterminate thyroid nodules. Head and Neck, 33, 160–165. Nasrollah, N., Trimboli, P., Guidobaldi, L. et al. (2013) Thin core biopsy should help to discriminate thyroid nodules cytologically classified as indeterminate. A new sampling technique. Endocrine, 43, 659–665. Nasrollah, N., Trimboli, P., Rossi, F. et al. (2014) Patient’s comfort with and tolerability of thyroid core needle biopsy. Endocrine, 45, 79–83. Na, D.G., Kim, J.H., Sung, J.Y. et al. (2012) Core-needle biopsy is more useful than repeat fine-needle aspiration in thyroid nodules read as nondiagnostic or atypia of undetermined significance by the Bethesda system for reporting thyroid cytopathology. Thyroid, 22, 468–475. Choi, Y.J., Baek, J.H., Ha, E.J. et al. (2014) Different risk of malignancy and management recommendations in subcategories of thyroid nodules with atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS): the role of US-guided core-needle biopsy (CNB). Thyroid, 24, 494–501. Eszlinger, M. & Paschke, R. (2010) Molecular fine-needle aspiration biopsy diagnosis of thyroid nodules by tumor specific mutations and gene expression patterns. Molecular and Cellular Endocrinology, 322, 29–37. Nikiforova, M.N. & Nikiforov, Y.E. (2009) Molecular diagnostics and predictors in thyroid cancer. Thyroid, 19, 1351–1361. Couto, J.P., Prazeres, H., Castro, P. et al. (2009) How molecular pathology is changing and will change the therapeutics of patients with follicular cell-derived thyroid cancer. Journal of Clinical Pathology, 62, 414–421. Elisei, R., Viola, D., Torregrossa, L. et al. (2012) The BRAF (V600E) mutation is an independent, poor prognostic factor for the outcome of patients with low-risk intrathyroid papillary thyroid carcinoma: single-institution results from a large cohort study. Journal of Clinical Endocrinology and Metabolism, 97, 4390–4398. Xing, M., Alzahrani, A.S., Carson, K.A. et al. (2013) Association between BRAF V600E mutation and mortality in patients with papillary thyroid cancer. JAMA, 309, 1493–1501.
320 P. Trimboli et al. 22 Boufraqech, M., Patel, D., Xiong, Y. et al. (2013) Diagnosis of thyroid cancer: state of art. Expert Opinion on Medical Diagnostics, 7, 331–342. 23 Crescenzi, A., Guidobaldi, L., Nasrollah, N. et al. (2014) Immunohistochemistry for BRAF(V600E) antibody VE1 performed in core needle biopsy samples identifies mutated papillary thyroid cancers. Hormone and Metabolic Research, 46, 370–374. 24 DerSimonian, R. & Laird, N. (1986) Meta-analysis in clinical trials. Controlled Clinical Trials, 7, 177–188. 25 Rowe, L.R., Bentz, B.G. & Bentz, J.S. (2006) Utility of BRAF V600E mutation detection in cytologically indeterminate thyroid nodules. CytoJournal, 3, 10. 26 Sapio, M.R., Posca, D., Raggioli, A. et al. (2007) Detection of RET/PTC, TRK and BRAF mutations in preoperative diagnosis of thyroid nodules with indeterminate cytological findings. Clinical Endocrinology (Oxford), 66, 678–683. 27 Adeniran, A.J., Hui, P., Chhieng, D.C. et al. (2011) BRAF mutation testing of thyroid fine-needle aspiration specimens enhances the predictability of malignancy in thyroid follicular lesions of undetermined significance. Acta Cytologica, 55, 570–575. 28 Nikiforov, Y.E., Ohori, N.P., Hodak, S.P. 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. Journal of Clinical Endocrinology and Metabolism, 96, 3390–3397. 29 Adeniran, A.J., Theoharis, C., Hui, P. et al. (2011) Reflex BRAF testing in thyroid fine-needle aspiration biopsy with equivocal and positive interpretation: a prospective study. Thyroid, 21, 717–723. 30 Kleiman, D.A., Sporn, M.J., Beninato, T. et al. (2013) Preoperative BRAF(V600E) mutation screening is unlikely to alter initial surgical treatment of patients with indeterminate thyroid nodules: a prospective case series of 960 patients. Cancer, 119, 1495– 1502. 31 Ohori, N.P., Singhal, R., Nikiforova, M.N. et al. (2013) BRAF mutation detection in indeterminate thyroid cytology specimens: underlying cytologic, molecular, and pathologic characteristics of papillary thyroid carcinoma. Cancer Cytopathology, 121, 197–205. 32 Agretti, P., Niccolai, F., Rago, T. et al. (2014) BRAF mutation analysis in thyroid nodules with indeterminate cytology: our
33
34
35 36
37
38
39 40
41
42
43
experience on surgical management of patients with thyroid nodules from an area of borderline iodine deficiency. Journal of Endocrinological Investigation, 37, 1009–1014. Johnson, S.J., Hardy, S.A., Roberts, C. et al. (2014) Pilot of BRAF mutation analysis in indeterminate, suspicious and malignant thyroid FNA cytology. Cytopathology, 25, 146–154. Perros, P., Boelaert, K., Colley, S. et al. (2014) Guidelines for the management of thyroid cancer. Clinical Endocrinology (Oxford), 81(Suppl 1), 1–122. Cibas, E.S. & Ali, S.Z. (2009) The Bethesda system for reporting thyroid cytopathology. Thyroid, 19, 1159–1165. Bongiovanni, M., Spitale, A., Faquin, W.C. et al. (2012) The Bethesda system for reporting thyroid cytopathology: a metaanalysis. Acta Cytologica, 56, 333–339. Trimboli, P., Bongiovanni, M., Rossi, F. et al. (2015) Differentiated thyroid cancer patients with a previous indeterminate (Thy 3) cytology have a better prognosis than those with suspicious or malignant FNAC reports. Endocrine, 49, 191–195. Rago, T., Scutari, M., Latrofa, F. et al. (2014) The large majority of 1520 patients with indeterminate thyroid nodule at cytology have a favorable outcome, and a clinical risk score has a high negative predictive value for a more cumbersome cancer disease. Journal of Clinical Endocrinology and Metabolism, 99, 3700–3707. Sebo, T.J. (2012) What are the keys to successful thyroid FNA interpretation? Clinical Endocrinology, 77, 13–17. Goldstein, R.E., Netterville, J.L., Burkey, B. et al. (2002) Implications of follicular neoplasms, atypia, and lesions suspicious for malignancy diagnosed by fine-needle aspiration of thyroid nodules. Annals of Surgery, 235, 656–662. Kato, M.A., Buitrago, D., Moo, T.A. et al. (2011) Predictive value of cytologic atypia in indeterminate thyroid fine-needle aspirate biopsies. Annals of Surgical Oncology, 18, 2893–2898. Aragon Han, P., Olson, M.T., Fazeli, R. et al. (2014) The impact of molecular testing on the surgical management of patients with thyroid nodules. Annals of Surgical Oncology, 21, 1862–1869. Bongiovanni, M., Molinari, F., Eszlinger, M. et al. (2014) Laser capture microdissection is a valuable tool in the preoperative molecular screening of follicular lesions of the thyroid: an institutional experience. Cytopathology, doi: 10.1111/cyt.12226.
© 2015 John Wiley & Sons Ltd Clinical Endocrinology (2016), 84, 315–320
