The combination of four molecular markers improves thyroid cancer cytologic diagnosis and patient management.

BACKGROUND: Papillary thyroid cancer is the most common endocrine malignancy. The most sensitive and specific diagnostic tool for thyroid nodule diagnosis is fine-needle aspiration (FNA) biopsy with cytological evaluation. Nevertheless, FNA biopsy is not always decisive leading to "indeterminate" or "suspicious" diagnoses in 10%-30% of cases. BRAF V600E detection is currently used as molecular test to improve the diagnosis of thyroid nodules, yet it lacks sensitivity. The aim of the present study was to identify novel molecular markers/computational models to improve the discrimination between benign and malignant thyroid lesions. METHODS: We collected 118 pre-operative thyroid FNA samples. All 118 FNA samples were characterized for the presence of the BRAF V600E mutation (exon15) by pyrosequencing and further assessed for mRNA expression of four genes (KIT, TC1, miR-222, miR-146b) by quantitative polymerase chain reaction. Computational models (Bayesian Neural Network Classifier, discriminant analysis) were built, and their ability to discriminate benign and malignant tumors were tested. Receiver operating characteristic (ROC) analysis was performed and principal component analysis was used for visualization purposes. RESULTS: In total, 36/70 malignant samples carried the V600E mutation, while all 48 benign samples were wild type for BRAF exon15. The Bayesian neural network (BNN) and discriminant analysis, including the mRNA expression of the four genes (KIT, TC1, miR-222, miR-146b) showed a very strong predictive value (94.12% and 92.16%, respectively) in discriminating malignant from benign patients. The discriminant analysis showed a correct classification of 100% of the samples in the malignant group, and 95% by BNN. KIT and miR-146b showed the highest diagnostic accuracy of the ROC curve, with area under the curve values of 0.973 for KIT and 0.931 for miR-146b. CONCLUSIONS: The four genes model proposed in this study proved to be highly discriminative of the malignant status compared with BRAF assessment alone. Its implementation in clinical practice can help in identifying malignant/benign nodules that would otherwise remain suspicious.

Break-apart interphase fluorescence in situ hybridization assay in papillary thyroid carcinoma: on the road to optimizing the cut-off level for RET/PTC rearrangements.

OBJECTIVE: Chromosomal rearrangements of the RET proto-oncogene is one of the most common molecular events in papillary thyroid carcinoma (PTC). However, their pathogenic role and clinical significance are still debated. This study aimed to investigate the prevalence of RET/PTC rearrangement in a cohort of BRAF WT PTCs by fluorescence in situ hybridization (FISH) and to search a reliable cut-off level in order to distinguish clonal or non-clonal RET changes. DESIGN: Forty BRAF WT PTCs were analyzed by FISH for RET rearrangements. As controls, six BRAFV600E mutated PTCs, 13 follicular adenomas (FA), and ten normal thyroid parenchyma were also analyzed. METHODS: We performed FISH analysis on formalin-fixed, paraffin-embedded tissue using a commercially available RET break-apart probe. A cut-off level equivalent to 10.2% of aberrant cells was accepted as significant. To validate FISH results, we analyzed the study cohort by qRT-PCR. RESULTS: Split RET signals above the cut-off level were observed in 25% (10/40) of PTCs, harboring a percentage of positive cells ranging from 12 to 50%, and in one spontaneous FA (1/13, 7.7%). Overall, the data obtained by FISH matched well with qRT-PCR results. Challenging findings were observed in five cases showing a frequency of rearrangement very close to the cut-off. CONCLUSIONS: FISH approach represents a powerful tool to estimate the ratio between broken and non-broken RET tumor cells. Establishing a precise FISH cut-off may be useful in the interpretation of the presence of RET rearrangement, primarily when this strategy is used for cytological evaluation or for targeted therapy.

Molecular characterization of 54 cases of false-negative fine-needle aspiration among 1347 papillary thyroid carcinomas.

BACKGROUND: Fine-needle aspiration (FNA) has been widely accepted as the most crucial step in the preoperative assessment of thyroid nodules, but the false-negative rates are generally reported to be between 3.6% and 10.2%. To lower the overall incidence of this false-negative testing, new reporting systems encourage the molecular testing of thyroid nodules. However, to the authors' knowledge, the role of molecular testing in false-negative FNA has not yet been evaluated. METHODS: In total, 1347 consecutive papillary thyroid carcinomas (PTCs) with both cytological and histological diagnoses were collected from the same center. A blinded revision of the false-negative cases was performed. An analysis of the BRAF and Ras genes in the false-negative cases was then performed. RESULTS: The false-negative rate at the time of primary FNA diagnosis was 4.8% (65 of 1347 cases). False-negative cases were 15 follicular variant PTCs, 2 classical variant, and 1 solid variant that lacked peculiar PTC cytomorphological features. Adequate cellular material for molecular analysis was available only in 54 of the 65 false-negative cases. Mutations were found in 6 cases (11%), and Ras alterations were present in 16 cases (29.6%). The addition of molecular analysis decreased the false-negative rate to 0.4% (5 of 1347 cases). CONCLUSIONS: The results of the current study confirm the feasibility of BRAF and Ras analysis in routine FNA. However, when the false-negative FNA rate is low, the cost-benefit analysis of the detection of BRAF and Ras mutations should be carefully evaluated. Consequently, the authors suggest that preoperative molecular assessment could be helpful for benign nodules, but only in the presence of clinical suspicion of malignancy.

Presence in the pre-surgical fine-needle aspiration of potential thyroid biomarkers previously identified in the post-surgical one.

Fine-needle aspiration biopsy (FNA) is usually applied to distinguish benign from malignant thyroid nodules. However, cytological analysis cannot always allow a proper diagnosis. We believe that the improvement of the diagnostic capability of pre-surgical FNA could avoid unnecessary thyroidectomy. In a previous study, we performed a proteome analysis to examine FNA collected after thyroidectomy. With the present study, we examined the applicability of these results on pre-surgical FNA. We collected pre-surgical FNA from 411 consecutive patients, and to obtain a correct comparison with our previous results, we processed only benign (n=114), papillary classical variant (cPTC) (n=34) and papillary tall cell variant (TcPTC) (n=14) FNA. We evaluated levels of five proteins previously found up-regulated in thyroid cancer with respect to benign nodules. ELISA and western blot (WB) analysis were used to assay levels of L-lactate dehydrogenase B chain (LDHB), Ferritin heavy chain, Ferritin light chain, Annexin A1 (ANXA1), and Moesin in FNA. ELISA assays and WB analysis confirmed the increase of LDHB, Moesin, and ANXA1 in pre-surgical FNA of thyroid papillary cancer. Sensitivity and specificity of ANXA1 were respectively 87 and 94% for cPTC, 85 and 100% for TcPTC. In conclusion, a proteomic analysis of FNA from patients with thyroid nodules may help to distinguish benign versus malignant thyroid nodules. Moreover, ANXA1 appears to be an ideal candidate given the high sensitivity and specificity obtained from ROC curve analysis.

Are risk factors common to thyroid cancer and nodule? A forty years observational time-trend study.

A progressive increase in the incidence of thyroid cancer (TC) has been reported over the last few decades. This either reflects the increased number of newly discovered and accurately selected thyroid nodules with more sensitive technologies and a relative more potent carcinogenic effect of pathogenetic factors in malignant, but not benign nodules. This observational time-trend study addresses this issue by analysing the proportion of TC within 8411 consecutive thyroid nodule (TN) patients evaluated in Pisa by the same pathology Department and individual clinician over a four-decade period. From 1972 to 1979 surgery was used to detect TC among the TN patients: 1140 TN patients were operated on and 35 cancers were detected (3.1% of all the TN patients). Subsequently, needle aspiration techniques were used to select TN for surgery. From 1980 to 1992, 5403 TN patients were examined, 483 were selected for surgery, and 150 cancers were found (2.8% of all the TN patients). From 1993 to 2010, 1568 TN patients were examined, 143 were selected for surgery, and 46 cancers were found (2.9% of all the TN patients). Therefore, in the University Hospital of Pisa, and independent of preoperative TN selection protocols, these proportions of TN eventually found to harbor TC remained statistically unchanged over 40 years (p = 0.810). This finding suggests that pathogenic risk factors and more sensitive diagnostic technologies did not differentially affect the incidence of TN and TC.

A molecular computational model improves the preoperative diagnosis of thyroid nodules.

BACKGROUND: Thyroid nodules with indeterminate cytological features on fine needle aspiration (FNA) cytology have a 20% risk of thyroid cancer. The aim of the current study was to determine the diagnostic utility of an 8-gene assay to distinguish benign from malignant thyroid neoplasm. METHODS: The mRNA expression level of 9 genes (KIT, SYNGR2, C21orf4, Hs.296031, DDI2, CDH1, LSM7, TC1, NATH) was analysed by quantitative PCR (q-PCR) in 93 FNA cytological samples. To evaluate the diagnostic utility of all the genes analysed, we assessed the area under the curve (AUC) for each gene individually and in combination. BRAF exon 15 status was determined by pyrosequencing. An 8-gene computational model (Neural Network Bayesian Classifier) was built and a multiple-variable analysis was then performed to assess the correlation between the markers. RESULTS: The AUC for each significant marker ranged between 0.625 and 0.900, thus all the significant markers, alone and in combination, can be used to distinguish between malignant and benign FNA samples. The classifier made up of KIT, CDH1, LSM7, C21orf4, DDI2, TC1, Hs.296031 and BRAF had a predictive power of 88.8%. It proved to be useful for risk stratification of the most critical cytological group of the indeterminate lesions for which there is the greatest need of accurate diagnostic markers. CONCLUSION: The genetic classification obtained with this model is highly accurate at differentiating malignant from benign thyroid lesions and might be a useful adjunct in the preoperative management of patients with thyroid nodules.

MicroRNA expression profile helps to distinguish benign nodules from papillary thyroid carcinomas starting from cells of fine-needle aspiration.

OBJECTIVE: MicroRNAs (miRNAs) are small endogenous noncoding RNAs that pair with target messengers regulating gene expression. Changes in miRNA levels occur in thyroid cancer. Fine-needle aspiration (FNA) with cytological evaluation is the most reliable tool for malignancy prediction in thyroid nodules, but cytological diagnosis remains undetermined for 20% of nodules. DESIGN: In this study, we evaluated the expression of seven miRNAs in benign nodules, papillary thyroid carcinomas (PTCs), and undetermined nodules at FNA. METHODS: The prospective study included 141 samples obtained by FNA of thyroid nodules from 138 patients. miRNA expression was evaluated by quantitative RT-PCR and statistical analysis of data was performed. Genetic analysis of codon 600 of BRAF gene was also performed. RESULTS: Using data mining techniques, we obtained a criterion to classify a nodule as benign or malignant on the basis of miRNA expression. The decision model based on the expression of miR-146b, miR-155, and miR-221 was valid for 86/88 nodules with determined cytology (97.73%), and adopting cross-validation techniques we obtained a reliability of 78.41%. The prediction was valid for 31/53 undetermined nodules with 16 false-positive and six false-negative predictions. The mutated form V600E of BRAF gene was demonstrated in 19/43 PTCs and in 1/53 undetermined nodules. CONCLUSIONS: The expression profiles of three miRNAs allowed us to distinguish benign from PTC starting from FNA. When the assay was applied to discriminate thyroid nodules with undetermined cytology, a low sensitivity and specificity despite the low number of false-negative predictions was obtained, limiting the practical interest of the method.

c-KIT receptor expression is strictly associated with the biological behaviour of thyroid nodules.

BACKGROUND: A large amount of information has been collected on the molecular tumorigenesis of thyroid cancer. A low expression of c-KIT gene has been reported during the transformation of normal thyroid epithelium to papillary carcinoma suggesting a possible role of the gene in the differentiation of thyroid tissue rather than in the proliferation. The initial presentation of thyroid carcinoma is through a nodule and the best way nowadays to evaluate it is by fine-needle aspiration (FNA). However many thyroid FNAs are not definitively benign or malignant, yielding an indeterminate or suspicious diagnosis which ranges from 10 to 25% of FNAs. BRAF mutational analysis is commonly used to assess the malignancy of thyroid nodules but unfortunately it still leaves indeterminate diagnoses. The development of molecular initial diagnostic tests for evaluating a thyroid nodule is needed in order to define optimal surgical approach for patients with uncertain diagnosis pre- and intra-operatively. METHODS: In this study we extracted RNA from 82 FNA smears, 46 malignant and 36 benign at the histology, in order to evaluate by quantitative Real Time PCR the expression levels of c-KIT gene. RESULTS: We have found a highly preferential decrease rather than increase in transcript of c-KIT in malignant thyroid lesions compared to the benign ones. To explore the diagnostic utility of c-KIT expression in thyroid nodules, its expression values were divided in four arbitrarily defined classes, with class I characterized by the complete silencing of the gene. Class I and IV represented the two most informative groups, with 100% of the samples found malignant or benign respectively. The molecular analysis was proven by ROC (receiver operating characteristic) analysis to be highly specific and sensitive improving the cytological diagnostic accuracy of 15%. CONCLUSION: We propose the use of BRAF test (after uncertain cytological diagnosis) to assess the malignancy of thyroid nodules at first, then the use of the c-KIT expression to ultimately assess the diagnosis of the nodules that otherwise would remain suspicious. The c-KIT expression-based classification is highly accurate and may provide a tool to overcome the difficulties in today's preoperative diagnosis of thyroid suspicious malignancies.

Detection of the BRAF(V600E) mutation in fine needle aspiration cytology of thyroid papillary microcarcinoma cells selected by manual macrodissection: an easy tool to improve the preoperative diagnosis.

BACKGROUND: Papillary carcinomas with diameters that are less than or equal to 1 cm (thyroid papillary microcarcinoma [mPTC]) are quite common but can carry more risk than previously thought. The proper treatment and management of these lesions is still being debated. Even though fine needle aspiration cytology (FNAC) is considered the best method for the diagnosis of thyroid nodules, its efficacy is still questioned for mPTC. We investigated the role of BRAF gene status in preoperative cytological samples, using manual macrodissection as an additional tool to improve the diagnostic accuracy of mPTC. METHODS: DNA was extracted directly from stained FNAC smears of 95 patients including 85 with histological diagnoses of papillary thyroid carcinoma (PTC) ≤1 cm and 10 with goiters. The cytological diagnoses of the 95 cases included the following: 42 samples were suspicious for papillary carcinoma, 38 were PTCs, and 15 were indeterminate lesions. DNA was then extracted from the FNAC slides after performing a "manual macrodissection" procedure. The BRAF(V600E) mutational status was determined by sequence analysis in all the patients. RESULTS: In this study, we showed that the BRAF(V600E) mutation was present with a high frequency in patients with mPTC (74%). The presence of the mutation was independent of the size of the tumor. In our study, the combination of the cytological diagnosis and the molecular analysis was able to identify 82% of all cases of mPTC, with an increase of 37% compared with a morphological diagnosis alone. The morpho-molecular analysis was able to reduce the number of suspicious cases by >70%. All of the goiters had a wild-type BRAF status. CONCLUSIONS: The analysis of BRAF mutational status in FNAC obtained from papillary microcarcinomas demonstrates that molecular pathology, combined with morphology and molecular biology is a powerful tool for cytological diagnosis of mPTC. Our results also confirm the data supporting the biological relevance of PTCs with diameters that are ≤1 cm and the importance of "manual macrodissection" in the molecular analysis of cytological material.

Large needle aspiration biopsy histology for preoperative selection of Hürthle cell thyroid nodules.

AIMS: To assess whether the large needle aspiration biopsy (LNAB) histological distinction between pure microfollicular nodules and mixed micro-macrofollicular nodules can assist preoperative selection of a Hürthle cell nodule (HCN) discovered by fine needle aspiration cytology (FNAC). METHODS AND RESULTS: In 24 HCN identified by preoperative FNAC, preoperative LNAB histology was compared with postoperative pathology. FNAC demonstrated seven benign HCN (negative), eight HCN with atypia (positive); seven suspected cancers with HC (positive); and two cancers with Hürthle cells (positive). LNAB showed mixed micro-macrofollicular hyperplastic features in 12 nodules (negative) and a microfollicular structure in 12 nodules (positive), two of which included findings of papillary cancer. Postoperative findings were benign (negative) in 16 patients and malignant (positive) in eight patients. The sensitivity and specificity for FNAC were 87.5% [seven of eight, 95% confidence interval (CI): 47.3-99.7%) and 37.5% (six of 16, 95% CI: 15.2-64.6%], respectively, and for LNAB were 87.5% (seven of eight, 95% CI: 47.3-99.7%) and 68.8% (11 of 16, 95% CI: 41.3-89.0%), respectively. FNAC results were significantly different from postoperative results (McNemar's test, exact two-sided P=0.012), while LNAB results were not (McNemar's test, exact two-sided P=0.219). CONCLUSIONS: These data suggest that LNAB histology is more accurate than FNAC cytology for the preoperative selection of HCN.

BRAF status of follicular variant of papillary thyroid carcinoma and its relationship to its clinical and cytological features.

BACKGROUND: The cytological discrimination between benign and malignant follicular-patterned lesions of the thyroid can represent a diagnostic challenge, even for experienced pathologists. To attempt to clarify this diagnostic problem, we analyzed the BRAF status of thyroid tumors in a group of patients with follicular variant of papillary thyroid carcinoma (FVPTC) and its correlation with cytomorphological features. METHODS: The BRAF status was evaluated in a total of 187 patients in whom FVPTC was consecutively diagnosed by histology between January 2006 and January 2009. Each case had a previous fine-needle aspiration diagnosis classified according to the British Thyroid Association Guidelines categorized as inadequate (Thy1) (n = 19), benign (Thy2) (n = 19), follicular lesion and follicular lesion with atypia (Thy3) (n = 109), suspicious of PTC (Thy4) (n = 29), or malignant (Thy5) (n = 11). The first 68 cases were selected for a morphological study by a quantitative analysis of four cytological features (grooves, intranuclear cytoplasmatic inclusions, number of cells per high power field (400 ×), and mean nuclear diameter) of the carcinomas. RESULTS: The BRAF status of each tumor was correlated with the cytological classes. 54.5% and 27.6% of Thy5 and Thy4, respectively, were BRAF-mutated, against 12.1% of follicular lesions and 9.3% of follicular lesion with atypia (Thy3). This comparison was statistically significative (p = 0.0017). Among the 68 cases selected for the cyto-morphological study, the BRAF status frequency was similar to that of the total case series. No significant differences were found correlating the cytological classes with the number of cells, the number of grooves, and the mean cell diameters. Only the number of intranuclear cytoplasmatic inclusions were associated (p < 0.05) with the Thy5 cytological class. CONCLUSIONS: BRAF is mutated in a low percentage of FVPTC, and most of these mutated cases are suspicious or positive on fine-needle aspiration. BRAF analysis is of limited value in the preoperative diagnosis of FVPTC.

Are the clinical and pathological features of differentiated thyroid carcinoma really changed over the last 35 years? Study on 4187 patients from a single Italian institution to answer this question.

BACKGROUND: In the last decades, a marked increased prevalence of differentiated thyroid cancer (DTC) has been observed worldwide. The aim of this study was to evaluate the changing features of DTC referred to our institution between 1969 and 2004. METHODS: Clinical and pathological features and prognostic factors were analyzed in 4187 DTC patients, subdivided into two groups: group 1 (n = 1215) and group 2 (n = 2972) diagnosed before and after 1990, respectively. RESULTS: Group 2 showed an increased proportion of micropapillary carcinoma and a concomitant decrease of follicular histotype. Male percentage was greater in group 2, whereas median age at diagnosis was unchanged. DTC of group 2 were more frequently associated with multinodular goiter or autoimmune thyroiditis, but many were unexpected findings. Features of aggressiveness were significantly less frequent in group 2, and the survival rate was greater (98.7 vs. 91.4%, P < 0.0001). Gender, age, histotype, tumor size, extrathyroidal macroinvasion, and lymph node and/or distant metastases were found to be poor prognostic factors in both groups using univariate analysis, but with multivariate analysis, only advanced age (odds ratio = 22.52 for older patients) and advanced stage (odds ratio = 53.54 for more advanced cases) were independently correlated with a lower survival. CONCLUSIONS: DTC patients diagnosed after 1990 have smaller tumors with less advanced stage and a better prognosis. The question of whether this is related to the finding of tumors with a low clinical penetrance or to the anticipation of diagnosis remains to be clarified. Despite these significant differences, both advanced stage and older age still represent the most important poor prognostic factors for survival.

Fine-needle and large-needle percutaneous aspiration biopsy of testicles in men with nonobstructive azoospermia: safety and diagnostic performance.

OBJECTIVE: To assess by ultrasonography the safety of the association fine-needle aspiration (FNA) plus a new percutaneous large-needle aspiration biopsy technique (LNAB), and to compare the results obtained with the two techniques in the same testicle and with FNA in the two testicles of the same patient. DESIGN: Retrospective analysis of clinical, ultrasonographic, and pathologic data. SETTING: Clinical and academic research environment. PATIENT(S): Three hundred and eighty-seven testicles of 233 patients (ages 19 to 57 years) with nonobstructive azoospermia were consecutively examined with FNA (154) or FNA + LNAB (233); 54 patients (89 testicles) examined with FNA + LNAB underwent a second ultrasonography up to 63 days after. INTERVENTION(S): Ultrasonography, FNA, LNAB. MAIN OUTCOME MEASURE(S): Hypoechoic area at ultrasonography; cytologic picture at FNA or LNAB of only Sertoli cells (category 1), spermatogenetic cells different from elongated spermatids or spermatozoa (category 2), and elongated spermatids and/or spermatozoa (category 3). RESULT(S): Among the 54 patients monitored by ultrasonography 48 (88.9%) showed no difference and 6 (11.1%) showed an hypoechoic area < or =1 cm in the second image. Category 1 occurred at FNA or LNAB in a very similar number of testicles (36% vs. 36.9%). Categories 2 and 3 were more frequent at LNAB (29.9% vs. 9.8%) and at FNA (54.2% vs. 33.2%), respectively. One hundred and sixty-six patients had both testicles examined by FNA; 147 pair of testicles were concordant for the presence or the absence of spermatozoa or elongated spermatids. In the remaining 19 patients (11.4%), these spermatogenetic cells were shown only in the specimen from one of the two testicles. These 19 patients accounted for 20.0% of 93 patients with spermatogenetic cells in at least one of the two testicles. CONCLUSION(S): The combination of FNA and LNAB did not produce clinically or subclinically relevant complications. No important differences in the identification of category 1 with FNA or LNAB were found. Fine-needle aspiration was more adequate in identifying category 3, which was particularly relevant in 20% of the men who had these cells in at least one of the two testicles.

Large needle aspiration biopsy results of palpable thyroid nodules diagnosed by fine-needle aspiration as a microfollicular nodule with atypical cells or suspected cancer.

Among 1875 patients with palpable thyroid nodules examined with FNA cytology and LNAB histology, 132 with a preoperative FNA diagnosis of microfollicular nodule with atypical cells (n = 50) or suspected cancer (n = 82) were operated on. The 50 nodules showed the following preoperative LNAB finding: inadequate (8), benign (15), microfollicular (20), microfollicular with atypical cells (5), suspected cancer (2). The postoperative cancer incidence in the nodules with the benign LNAB diagnosis was 0% while it was 10%, 60% (P = 0.008), 100% (P = 0.007) in the other three LNAB diagnostic categories. The 82 nodules showed the following preoperative LNAB finding: inadequate (21), benign (21), microfollicular (15), microfollicular with atypical cells (15), suspected cancer (10). The postoperative incidence of cancer in the 21 (14%) and 10 (80%) nodules diagnosed by LNAB as benign nodule or suspected cancer, respectively, was significantly different (P = 0.0007). These data suggest that LNAB can be used for the preoperative selection of the palpable thyroid nodules diagnosed by FNA as a microfollicular nodule with atypical cells or suspected cancer.

Impact of routine measurement of serum calcitonin on the diagnosis and outcome of medullary thyroid cancer: experience in 10,864 patients with nodular thyroid disorders.

The survival rate of patients with medullary thyroid carcinoma (MTC) is significantly better in patients diagnosed and treated when the tumor is limited to the thyroid. In a pioneer study carried out in 1991, we demonstrated that routine measurement of serum calcitonin (CT) in nodular thyroid disease allowed the preoperative diagnosis of unsuspected sporadic MTC with better accuracy than routine fine needle aspiration cytology (FNAC). This finding has been confirmed in subsequent studies. In the present study we report the results of CT screening in 10,864 patients with thyroid nodular disease seen in the years 1991-1998 (group 1). We analyzed the prevalence of MTC and compared their outcomes with those of a historical group of patients (group 2) diagnosed before the introduction of CT screening (1970-1990). The prevalence of MTC found by CT screening in group 1 was 0.40% (44 patients). A positive CT test had a higher diagnostic sensitivity and specificity compared with FNAC. CT screening allowed the diagnosis of MTC at an earlier stage compared with group 2 (P = 0.004). Normalization of serum CT levels (undetectable) after surgery was more frequently observed in group 1. At the end of follow-up, complete remission was observed in 59% of group 1 and in 2.7% of group 2 (P = 0.0001). Our study confirms that MTC is not an infrequent finding among patients with thyroid nodules (nearly 1 in 250 patients). In addition, screening thyroid nodules with serum CT measurement allows the diagnosis and treatment of MTC at an earlier stage, resulting in a better outcome compared with MTC not detected by serum CT measurement. One of the reasons for this finding is that increasing the preoperative diagnostic accuracy of MTC prompts the surgeon to perform a more radical and possibly curative treatment. On this basis, routine measurement of basal serum CT levels should be considered an integral part of the diagnostic evaluation of thyroid nodules.

Spermatogenesis in azoospermic, formerly cryptorchid men. Use of needle aspiration techniques.

OBJECTIVE: To assess the use of testicular needle aspiration techniques to evaluate fertility potential in azoospermic, formerly cryptorchid men. STUDY DESIGN: Fifteen consecutive adult azoospermic, formerly cryptorchid patients (eight unilateral and seven bilateral) were examined by needle aspiration techniques, fine (FNA) and large needle (LNAB) testicular aspiration biopsy, for cytologic and histologic analysis. Five of the 15 subsequently underwent surgical biopsy for attempted assisted fertilization. RESULTS: Spermatozoa or spermatids were detected by FNA cytology or LNAB histology in one or both testicles in 87.5% of the unilateral and 28.6% of the bilaterally affected, formerly cryptorchid patients (P = .041, Fisher's exact test). The addition of LNAB to FNA identified spermatids in one patient with unilateral cryptorchidism and only Sertoli cells on FNA cytology. Furthermore, LNAB differentiated testicles with the cytologic finding of only Sertoli cells into those with or without diffuse fibrosis. In the five patients in whom assisted fertilization was attempted, the needle aspiration techniques predicted the presence or absence of spermatozoa in the subsequent surgical biopsy. CONCLUSION: The two needle aspiration techniques can be used to assess the fertility potential of azoospermic, formerly cryptorchid men and to select patients for assisted fertilization.

Large-needle aspiration biopsy for the preoperative selection of follicular adenoma diagnosed by fine-needle aspiration as a microfollicular nodule or suspected cancer.

The preoperative fine-needle aspiration (FNA) cytologic diagnoses of microfollicular nodule and suspected cancer include nodules that yield histologic results of typically benign lesions, nodular hyperplasia and follicular adenomas, and differentiated thyroid cancer postoperatively. We reviewed the clinical and pathologic data for patients with palpable thyroid nodules with these two cytologic diagnoses; nodules were also examined by large-needle aspiration biopsy (LNAB) to assess whether the distinction achieved by LNAB in pure microfollicular or mixed microfollicular-macrofollicular nodules could be used preoperatively to better predict the diagnosis of follicular adenoma. One hundred fourteen nodules of this type were excised. Postoperative results were grouped in nodular hyperplasia (90 nodules), follicular adenoma (8), and differentiated carcinoma (16). The prevalence of the follicular adenoma and thyroid carcinoma postoperative findings was 33% among the microfollicular nodules and 5.9% among the microfollicular-macrofollicular nodules at preoperative LNAB, (p = 0.0004). Within the postoperatively benign nodules, the prevalence of follicular adenoma was 14.3% among the microfollicular nodules and 2% among the microfollicular-macrofollicular nodules at LNAB (p = 0.028). These data indicate that histologic examination of the LNAB specimen can be used to identify those thyroid nodules diagnosed by FNA as microfollicular nodules or suspected cancer, which are most likely to be follicular adenomas postoperatively.