Do sonographic and cytological features predict malignancy in cytologically indeterminate thyroid nodules?

INTRODUCTION

The current algorithm for managing patients with indeterminate (Thy3) thyroid cytology is a thyroid lobectomy followed by a completion thyroidectomy depending on histology. We investigated whether sonographic and or cytological features in addition to clinical characteristics would predict the potential for malignancy in a cohort of patients with thyroid nodules of indeterminate cytology.

METHODS

Perusing a clinical database of all patients undergoing ultrasonography guided fine needle aspiration (FNA) of thyroid nodules, we identified all Thy3 lesions. The demographic, ultrasonography and cytological details of benign and malignant groups were compared by t-test, chi-square test and, when appropriate, Fisher''s exact test. Association between studied characteristics and malignancy was tested by binary logistic regression using single input. A p-value of <0.05 was considered significant.

RESULTS

During the retrospective study period of January 2003 to July 2010, a total of 1,019 patients underwent FNA, of which 69 (6.8%) were classed as Thy3. Of these, 59 underwent surgical treatment and the histological outcomes were grouped as benign (n=42, 71.2%) and malignant (n=17, 28.8%). These groups were analysed for the predictive variables. Age, sex and sonological characters were similar in the two groups (p>0.05). The two microcalcifications observed were both in the malignant group. Among all the variables assessed, only the absence of normal follicular cells was associated with malignant nodules (univariate analysis, p=0.034).

CONCLUSIONS

Malignancy was more common in Thy3 patients with an absence of normal follicular cells and such patients may therefore warrant a total thyroidectomy.     

Is bone quality associated with collagen age?

The World Health Organization defines osteoporosis as a systemic disease characterized by decreased bone tissue mass and microarchitectural deterioration, resulting in increased fracture risk. Since this statement, a significant amount of data has been generated showing that these two factors do not cover all risks for fracture. Other independent clinical factors, such as age, as well as aspects related to qualitative changes in bone tissue, are believed to play an important role. The term “bone quality” encompasses a variety of parameters, including the extent of mineralization, the number and distribution of microfractures, the extent of osteocyte apoptosis, and changes in collagen properties. The major mechanism controlling these qualitative factors is bone remodeling, which is tightly regulated by the osteoclast/osteoblast activity. We focus on the relationship between bone remodeling and changes in collagen properties, especially the extent of one posttranslational modification. In vivo, measurements of the ratio between native and isomerized C-telopeptides of type I collagen provides an index of bone matrix age. Current preclinical and clinical studies suggests that this urinary ratio provides information about bone strength and fracture risk independent of bone mineral density and that it responds differently according to the type of therapy regulating bone turnover.     

Is the Yedikule-solitary pulmonary nodule malignancy risk score sufficient to predict malignancy? An internal validation study

Open in a separate window OBJECTIVESWe aimed to develop a malignancy risk score model for solitary pulmonary nodules (SPNs) using the demographic, radiological and clinical characteristics of patients in our centre. The model was then internally validated for malignancy risk estimation. METHODSA total of 270 consecutive patients who underwent surgery for SPN between June 2017 and May 2019 were retrospectively analysed. Using the receiver operating characteristic curve analysis, cut-off values were determined for radiological tumour diameter, maximum standardized uptake value and the Brock University probability of malignancy (BU-PM) model. The Yedikule-SPN malignancy risk model was developed using these cut-off values and demographic, radiological and clinical criteria in the first 180 patients (study cohort) and internally validated with the next 90 patients (validation cohort). The Yedikule-SPN model was then compared with the BU-PM model in terms of malignancy prediction.RESULTSMalignancy was reported in 171 patients (63.3%). Maximum standardized uptake value and BU-PM scores were sufficient to predict malignancy (P < 0.001 for both), while the effectiveness of nodule size determined on thoracic computed tomography did not reach statistical significance (P = 0.09). When the Yedikule-SPN model developed with the study cohort was applied to the validation cohort, it significantly predicted malignancy (area under the receiver operating characteristic curve: 0.883, 95% confidence interval: 0.827–0.957, P < 0.001). Comparison of patients in the validation group with Yedikule-SPN scores above (n = 53) and below (n = 37) the cut-off value of 65.75 showed that the malignancy rate was significantly higher among patients with Yedikule-SPN score over 65.75 (86.8% vs 21.6%, P < 0.001, odds ratio = 23.821, 95% confidence interval: 7.805–72.701). When compared with the BU-PM model in all patients, the Yedikule-SPN model tended to be a better predictor of malignancy (P = 0.06).CONCLUSIONSThe internally validated Yedikule-SPN model is also a good predictor of the malignancy of SPN(s). Prospective and multicentre external validation studies with large patients’ cohorts are needed.     

Is age a risk factor for esophagectomy?

In recent years, the number of elderly patients with esophageal cancer as well as the number submitted for esophageal resection has been increasing. With respect to nutritional and pulmonary evaluations, surgical staging, and mortality, 37 patients over the age of 65 who underwent esophagectomy and simultaneous reconstruction were analyzed. This group was compared statistically with a group of 162 patients younger than 65 to determine whether age was a factor influencing treatment and outcome. There was no statistical difference between the groups relating to the described variables. Age should not be a limiting factor when it comes to offering an aggressive surgical approach for the esophageal cancer patient aged 65 or more. This approach can be performed as safely in older patients as it is in younger patients, with similar incidence of mortality.     

Nondiagnostic fine-needle aspirations of the thyroid: is the risk of malignancy higher?

Background

Nondiagnostic fine-needle aspirations (FNAs) pose a dilemma in the management of patients with thyroid nodules. In most cases, these patients undergo either repeat FNA or surgical resection. However, a significant number of patients will only be observed, assuming that the risk of malignancy is low. Therefore, the purpose of this study was to determine whether the risk of malignancy is higher in patients with thyroid nodules and nondiagnostic FNAs.

Methods

We reviewed reports from 4286 consecutive FNA biopsies performed on patients with thyroid nodules at our institution between 2002 and 2010. We divided FNAs into two categories: diagnostic and nondiagnostic. We collected demographic, follow-up, and pathology data from both groups and then analyzed them with analysis of variance and chi-square tests.

Results

Of the 4286 FNAs, 259 were classified as nondiagnostic (6%). We saw no significant differences in age or gender between patients with diagnostic versus nondiagnostic FNAs. Of the patients with nondiagnostic FNAs, 62 underwent diagnostic thyroidectomy (24%), 74 had a repeat FNA (29%), and 123 had observation only (47%); thus, 136 patients had a cytologic or pathologic diagnosis. Patients with nondiagnostic FNAs had a significantly higher rate of all types of thyroid cancer, compared with those with diagnostic FNAs (12% versus 5%, respectively; P < 0.001). Impressively, the chance of papillary thyroid cancer was twofold higher in patients with nondiagnostic FNAs.

Conclusions

The percentage of nondiagnostic FNA at our institution during this period (6%) was relatively low. However, the incidence of malignancy in these patients was significantly higher. Therefore, we recommend that patients with thyroid nodules and nondiagnostic FNAs undergo either repeat biopsy or diagnostic thyroidectomy.     

Increased costs of perioperative risk assessment for thyroid surgery in elderly people (over 80 years) presenting with benign disease

Background/objectives

Evaluate how surgical treatment of benign thyroid disease in elderly people is prone to induce an increase of costs in the next future due to the aging process of the population.

Methods

A retrospective analysis has been performed on a total of 116 patients operated between January 2007 and September 2011, divided in a group of 58 patients aged over 80 years (Group A) and 58 patients younger than 80 years (Group B). The analyzed data included age, preoperative diagnosis, severe co-morbidities, procedures other than standard needed to evaluate anaesthesiological risk, postoperative hospital stay, complications, duration of postoperative intensive care monitoring, pathologic characteristics, and costs of anaesthesiological risk assessment.

Results

Statistical analysis of collected data showed that the costs related to perioperative risk assessment (p value < 0.001) and the duration of hospital stay (p value < 0.001) were higher in Group A than in Group B. Instead, surgery-related complications were not statistically different.

Conclusions

Despite feasibility and safety of modern surgical techniques, indications for surgery in elderly patients affected by benign thyroid disease should be reserved mainly for those patients with severe medical necessity.     

Is there a learning curve associated with the use of remifentanil?

This study prospectively determined whether there was a learning curve with the use of remifentanil, as indicated by decreased hemodynamic variability, improved recovery profile, and decreased incidence of opioid-related adverse events with increasing experience. Patients undergoing diverse surgical procedures (outpatient [n = 1340] and inpatient [n = 560]) were enrolled by investigators (n = 190) who had no previous experience with remifentanil use. Each investigator enrolled 10 patients. A standardized protocol for administration of remifentanil was used. Data were analyzed to determine differences between the first three patients and the last three patients enrolled for each anesthesiologist in the study. There were no differences in hemodynamic variables between the first triad and the last triad in either outpatients or inpatients. Requirements for hypnotic drugs and the doses of remifentanil used were also similar between groups. Analgesic medications administered at the end of surgery and in the postanesthesia care unit (PACU) were similar between groups, except that the last triad in the outpatient group received smaller doses of fentanyl compared with the first triad. Times to response to verbal command, tracheal extubation, and operating room discharge did not differ between groups. However, patients in the last triad undergoing outpatient surgery had shorter times to eligibility for PACU discharge, but times to eligibility for discharge home did not differ. The overall incidence of all adverse events (i.e., hypotension, hypertension, muscle rigidity, respiratory depression, apnea, nausea, and vomiting) was less in the last triad as compared with the first triad. When analyzed separately, only the incidence of vomiting (in the outpatient group) was decreased in the last triad as compared with the first triad. This study suggests that there is a learning curve that aids reduction of minor adverse effects associated with the use of analgesic medications administered at the end of surgery in outpatients, which might have reduced the incidence of postoperative vomiting and the duration of PACU stay. Implications: This study demonstrated that anesthesiologists rapidly acquire the ability to use remifentanil with limited experience. However, there is a learning curve that aids reduction of minor adverse effects associated with the use of analgesic medications administered at the end of surgery in outpatients, which might have reduced the incidence of postoperative vomiting and the duration of postanesthesia care unit stay.