Clinical Utility Of Molecular Testing In The Management Of Thyroid Follicular Neoplasms (Bethesda IV Nodules)
Sally E Carty, *N Paul Ohori, *Kelly L McCoy, *Dane A Hilko, *Esra K French, *Pooja Manroa, *Elena Morariu, *Shaum Sridharan, *Raja S Seethala, Linwah Yip
University of Pittsburgh, Pittsburgh, PA
OBJECTIVE(S): Follicular neoplasms (FN) present a management quandary; they are often benign but may also be aggressive thyroid cancers (TC) requiring resection for diagnosis. Although molecular tests (MT) have robust benefit in hypothetical cost analyses, a study validating clinical utility is eagerly awaited. We investigate if MT use for FN directs appropriate thyroidectomy (Tx) for TC while triaging to surveillance nodules that are truly benign.
METHODS: Data were analyzed for 288 consecutive patients managed from 11/14-9/19 for 299 <4 cm FN excluding oncocytic neoplasms. TC was defined as same-nodule histologic malignancy. When obtained, MT was performed using ThyroSeq; MT positive results (MT+) had a >10% TC risk.
RESULTS: With a mean size of 2.2±0.8 cm, MT was used in 275 FN (92%) and was positive in 40%. Tx (either lobectomy or total) was performed for 63% of FN managed without MT versus 44% with MT (p=0.09). Tx for histologic TC was more likely with MT+ results (58% v 20%, p=0.006). Low-risk TC were most often diagnosed (80%); all Intermediate- (12%), High-risk (5%), and medullary TC (3%) were MT+. Ultrasound surveillance was recommended for 139 MT-negative FN, and with mean follow-up of 22±13 months, 6(8%) required Tx yielding 2 Low-risk TC and 83% remained stable in size.
CONCLUSIONS: MT for FN leads to a 3-fold higher rate (60%) of appropriate Tx for TC, identifies all potentially aggressive malignancies, and allows apparently safe nonoperative surveillance for >50% of patients. MT use optimizes patient outcomes sufficiently to justify its incorporation into routine practice.
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