Int J Thyroidol.  2015 Nov;8(2):153-160. 10.11106/ijt.2015.8.2.153.

Molecular Diagnosis for Cytologically Indeterminate Thyroid Nodules

Affiliations
  • 1Department of Pathology, Konkuk University School of Medicine, Seoul, Korea. tshwang@kuh.ac.kr

Abstract

An accurate diagnosis of cancer or benign disease is important for the effective clinical management of the patients. Thyroid fine needle aspiration cytology (FNAC) is a safe and cost effective technic for evaluating thyroid nodules. However, 20-30% of thyroid FNAC specimens are indeterminate and fall into one of the following categories; AUS/FLUS (atypical ceils of undetermined significance/follicular cells of undetermined significance), FN/SFN (follicular neoplasm/suspicious for follicular neoplasm), and SMC (suspicious for malignant cells). The AUS/FLUS, FN/SFN, and SMC diagnostic category is associated with a 5-15%, 15-30%, and 60-75% risk of malignancy, respectively. Of the indeterminate thyroid nodules that are surgically resected, 10-40% were confirmed to be malignant. A significant progress has been made in the development of molecular tests for cancer diagnosis in thyroid nodules. Most common molecular alteration in thyroid cancer is the activation of mitogen-activated protein kinase (MAPK) pathway. Activation of this pathway in thyroid cells results from point mutation of BRAF and RAS genes and rearrangement of RET/PTC and NTRK genes and these genetic alterations are mutually exclusive. Preoperative molecular diagnostic techniques could be applied in FNAC specimen when optimum dissection techniques are provided to collect sufficient numbers of target cells without contamination of blood cells, inflammatory cells including histiocytes, and stromal cells. The optimum number of cells for PCR is about 100 although as few 50 cells has been successful. To obtain a good DNA yield from a very limited number of target cells, avoid DNA loss as much as possible.

Keyword

Molecular diagnosis; FNAC; Indeterminate nodule; Thyroid cancer

MeSH Terms

Biopsy, Fine-Needle
Blood Cells
Diagnosis*
DNA
Genes, ras
Histiocytes
Humans
Molecular Diagnostic Techniques
Point Mutation
Polymerase Chain Reaction
Protein Kinases
Stromal Cells
Thyroid Gland*
Thyroid Neoplasms
Thyroid Nodule*
DNA
Protein Kinases

Reference

References

1. http://www.cancer.go.kr. [cited September 23, 2015].
2. Cibas ES, Ali SZ. Conference NCITFSotS. The Bethesda System for Reporting Thyroid Cytopathology. Am J Clin Pathol. 2009; 132(5):658–65.
Article
3. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, et al. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2006; 16(2):109–42.
Article
4. Greaves TS, Olvera M, Florentine BD, Raza AS, Cobb CJ, Tsao-Wei DD, et al. Follicular lesions of thyroid: a 5-year fine-needle aspiration experience. Cancer. 2000; 90(6):335–41.
5. Cibas ES, Ali SZ. The Bethesda System for Reporting Thyroid Cytopathology. Thyroid. 2009; 19(11):1159–65.
Article
6. Baloch ZW, LiVolsi VA, Asa SL, Rosai J, Merino MJ, Randolph G, et al. Diagnostic terminology and morphologic criteria for cytologic diagnosis of thyroid lesions: a synopsis of the National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference. Diagn Cytopathol. 2008; 36(6):425–37.
Article
7. Mazzaferri EL. Management of a solitary thyroid nodule. N Engl J Med. 1993; 328(8):553–9.
Article
8. Bhaijee F, Nikiforov YE. Molecular analysis of thyroid tumors. Endocr Pathol. 2011; 22(3):126–33.
Article
9. Kimura ET, Nikiforova MN, Zhu Z, Knauf JA, Nikiforov YE, Fagin JA. High prevalence of BRAF mutations in thyroid cancer: genetic evidence for constitutive activation of the RET/PTC-RAS-BRAF signaling pathway in papillary thyroid carcinoma. Cancer Res. 2003; 63(7):1454–7.
10. Xing M. BRAF mutation in thyroid cancer. Endocr Relat Cancer. 2005; 12(2):245–62.
Article
11. Nikiforova MN, Kimura ET, Gandhi M, Biddinger PW, Knauf JA, Basolo F, et al. BRAF mutations in thyroid tumors are restricted to papillary carcinomas and anaplastic or poorly differentiated carcinomas arising from papillary carcinomas. J Clin Endocrinol Metab. 2003; 88(11):5399–404.
Article
12. Jung CK, Little MP, Lubin JH, Brenner AV, Wells SA Jr, Sigurdson AJ, et al. The increase in thyroid cancer incidence during the last four decades is accompanied by a high frequency of BRAF mutations and a sharp increase in RAS mutations. J Clin Endocrinol Metab. 2014; 99(2):E276–85.
13. Mathur A, Moses W, Rahbari R, Khanafshar E, Duh QY, Clark O, et al. Higher rate of BRAF mutation in papillary thyroid cancer over time: a single-institution study. Cancer. 2011; 117(19):4390–5.
14. Kim TY, Kim WB, Rhee YS, Song JY, Kim JM, Gong G, et al. The BRAF mutation is useful for prediction of clinical recurrence in low-risk patients with conventional papillary thyroid carcinoma. Clin Endocrinol (Oxf). 2006; 65(3):364–8.
Article
15. Chung KW, Yang SK, Lee GK, Kim EY, Kwon S, Lee SH, et al. Detection of BRAFV600E mutation on fine needle aspiration specimens of thyroid nodule refines cytopathology diagnosis, especially in BRAF600E mutation-prevalent area. Clin Endocrinol (Oxf). 2006; 65(5):660–6.
16. Kim SK, Hwang TS, Yoo YB, Han HS, Kim DL, Song KH, et al. Surgical results of thyroid nodules according to a management guideline based on the BRAF(V600E) mutation status. J Clin Endocrinol Metab. 2011; 96(3):658–64.
Article
17. Hong AR, Lim JA, Kim TH, Choi HS, Yoo WS, Min HS, et al. The frequency and clinical implications of the BRAF(V600E) mutation in papillary thyroid cancer patients in Korea over the past two decades. Endocrinol Metab (Seoul). 2014; 29(4):505–13.
18. Ahn D, Park JS, Sohn JH, Kim JH, Park SK, Seo AN, et al. BRAFV600E mutation does not serve as a prognostic factor in Korean patients with papillary thyroid carcinoma. Auris Nasus Larynx. 2012; 39(2):198–203.
Article
19. Nikiforov YE, Ohori NP. Papillary carcinoma. Nikiforov YE, Biddinger PW, Thompson LDR, editors. editors.Diagnostic pathology and molecular genetics of the thyroid. 2nd ed.Philadelphia: Lippincott Williams and Wilkins;2012. p. 183–246.
20. Cho U, Oh WJ, Bae JS, Lee S, Lee YS, Park GS, et al. Clinicopathological features of rare BRAF mutations in Korean thyroid cancer patients. J Korean Med Sci. 2014; 29(8):1054–60.
Article
22. Trovisco V, Vieira de Castro I, Soares P, Maximo V, Silva P, Magalhaes J, et al. BRAF mutations are associated with some histological types of papillary thyroid carcinoma. J Pathol. 2004; 202(2):247–51.
Article
23. Lupi C, Giannini R, Ugolini C, Proietti A, Berti P, Minuto M, et al. Association of BRAF V600E mutation with poor clinicopathological outcomes in 500 consecutive cases of papillary thyroid carcinoma. J Clin Endocrinol Metab. 2007; 92(11):4085–90.
Article
24. Lemoine NR, Mayall ES, Wyllie FS, Williams ED, Goyns M, Stringer B, et al. High frequency of ras oncogene activation in all stages of human thyroid tumorigenesis. Oncogene. 1989; 4(2):159–64.
25. Namba H, Rubin SA, Fagin JA. Point mutations of ras oncogenes are an early event in thyroid tumorigenesis. Mol Endocrinol. 1990; 4(10):1474–9.
Article
26. Burns JS, Blaydes JP, Wright PA, Lemoine L, Bond JA, Williams ED, et al. Stepwise transformation of primary thyroid epithelial cells by a mutant Ha-ras oncogene: an in vitro model of tumor progression. Mol Carcinog. 1992; 6(2):129–39.
Article
27. Zhu Z, Gandhi M, Nikiforova MN, Fischer AH, Nikiforov YE. Molecular profile and clinical-pathologic features of the follicular variant of papillary thyroid carcinoma. An unusually high prevalence of ras mutations. Am J Clin Pathol. 2003; 120(1):71–7.
28. Nikiforov YE, Ohori NP. Follicular carcinoma. Nikiforov YE, Biddinger PW, Thompson LDR, editors. editors.Diagnostic pathology and molecular genetics of the thyroid. 2nd ed.Philadelphia: Lippincott Williams and Wilkins;2012. p. 152–82.
29. Vasko V, Ferrand M, Di Cristofaro J, Carayon P, Henry JF, de Micco C. Specific pattern of RAS oncogene mutations in follicular thyroid tumors. J Clin Endocrinol Metab. 2003; 88(6):2745–52.
Article
30. Eszlinger M, Paschke R. Molecular fine-needle aspiration biopsy diagnosis of thyroid nodules by tumor specific mutations and gene expression patterns. Mol Cell Endocrinol. 2010; 322(1–2):29–37.
Article
31. Di Cristofaro J, Marcy M, Vasko V, Sebag F, Fakhry N, Wynford-Thomas D, et al. Molecular genetic study comparing follicular variant versus classic papillary thyroid carcinomas: association of N-ras mutation in codon 61 with follicular variant. Hum Pathol. 2006; 37(7):824–30.
Article
32. Park JY, Kim WY, Hwang TS, Lee SS, Kim H, Han HS, et al. BRAF and RAS mutations in follicular variants of papillary thyroid carcinoma. Endocr Pathol. 2013; 24(2):69–76.
Article
33. Nikiforova MN, Nikiforov YE. Molecular genetics of thyroid cancer: implications for diagnosis, treatment and prognosis. Expert Rev Mol Diagn. 2008; 8(1):83–95.
Article
34. Agrawal N, Jiao Y, Sausen M, Leary R, Bettegowda C, Roberts NJ, et al. Exomic sequencing of medullary thyroid cancer reveals dominant and mutually exclusive oncogenic mutations in RET and RAS. J Clin Endocrinol Metab. 2013; 98(2):E364–9.
35. Bongarzone I, Vigneri P, Mariani L, Collini P, Pilotti S, Pierotti MA. RET/NTRK1 rearrangements in thyroid gland tumors of the papillary carcinoma family: correlation with clinicopathological features. Clin Cancer Res. 1998; 4(1):223–8.
36. Tallini G, Santoro M, Helie M, Carlomagno F, Salvatore G, Chiappetta G, et al. RET/PTC oncogene activation defines a subset of papillary thyroid carcinomas lacking evidence of progression to poorly differentiated or undifferentiated tumor phenotypes. Clin Cancer Res. 1998; 4(2):287–94.
37. Nikiforov YE. RET/PTC Rearrangement–a link between Hashimoto's thyroiditis and thyroid cancer…or not. J Clin Endocrinol Metab. 2006; 91(6):2040–2.
Article
39. Nikiforov YE, Rowland JM, Bove KE, Monforte-Munoz H, Fagin JA. Distinct pattern of ret oncogene rearrangements in morphological variants of radiation-induced and sporadic thyroid papillary carcinomas in children. Cancer Res. 1997; 57(9):1690–4.
40. Fenton CL, Lukes Y, Nicholson D, Dinauer CA, Francis GL, Tuttle RM. The ret/PTC mutations are common in sporadic papillary thyroid carcinoma of children and young adults. J Clin Endocrinol Metab. 2000; 85(3):1170–5.
41. Adeniran AJ, Zhu Z, Gandhi M, Steward DL, Fidler JP, Giordano TJ, et al. Correlation between genetic alterations and microscopic features, clinical manifestations, and prognostic characteristics of thyroid papillary carcinomas. Am J Surg Pathol. 2006; 30(2):216–22.
Article
42. Nikiforov YE. Genetic alterations involved in the transition from well-differentiated to poorly differentiated and anaplastic thyroid carcinomas. Endocr Pathol. 2004; 15(4):319–27.
Article
43. Nikiforova MN, Lynch RA, Biddinger PW, Alexander EK, Dorn GW 2nd, Tallini G, et al. RAS point mutations and PAX8-PPAR gamma rearrangement in thyroid tumors: evidence for distinct molecular pathways in thyroid follicular carcinoma. J Clin Endocrinol Metab. 2003; 88(5):2318–26.
44. Dwight T, Thoppe SR, Foukakis T, Lui WO, Wallin G, Hoog A, et al. Involvement of the PAX8/peroxisome proli-ferator-activated receptor gamma rearrangement in follicular thyroid tumors. J Clin Endocrinol Metab. 2003; 88(9):4440–5.
45. Armstrong MJ, Yang H, Yip L, Ohori NP, McCoy KL, Stang MT, et al. PAX8/PPARgamma rearrangement in thyroid nodules predicts follicular-pattern carcinomas, in particular the encapsulated follicular variant of papillary carcinoma. Thyroid. 2014; 24(9):1369–74.
46. Lu J, Getz G, Miska EA, Alvarez-Saavedra E, Lamb J, Peck D, et al. MicroRNA expression profiles classify human cancers. Nature. 2005; 435(7043):834–8.
Article
47. Pallante P, Visone R, Ferracin M, Ferraro A, Berlingieri MT, Troncone G, et al. MicroRNA deregulation in human thyroid papillary carcinomas. Endocr Relat Cancer. 2006; 13(2):497–508.
Article
48. Weber F, Teresi RE, Broelsch CE, Frilling A, Eng C. A limited set of human MicroRNA is deregulated in follicular thyroid carcinoma. J Clin Endocrinol Metab. 2006; 91(9):): 3584–91.
Article
49. He H, Jazdzewski K, Li W, Liyanarachchi S, Nagy R, Volinia S, et al. The role of microRNA genes in papillary thyroid carcinoma. Proc Natl Acad Sci U S A. 2005; 102(52):19075–80.
Article
50. Nikiforov YE, Carty SE, Chiosea SI, Coyne C, Duvvuri U, Ferris RL, et al. Highly accurate diagnosis of cancer in thyroid nodules with follicular neoplasm/suspicious for a follicular neoplasm cytology by ThyroSeq v2 next-generation sequencing assay. Cancer. 2014; 120(23):3627–34.
Article
51. Alexander EK, Kennedy GC, Baloch ZW, Cibas ES, Chudova D, Diggans J, et al. Preoperative diagnosis of benign thyroid nodules with indeterminate cytology. N Engl J Med. 2012; 367(8):705–15.
Article
52. Jung CK, Im SY, Kang YJ, Lee H, Jung ES, Kang CS, et al. Mutational patterns and novel mutations of the BRAF gene in a large cohort of Korean patients with papillary thyroid carcinoma. Thyroid. 2012; 22(8):791–7.
Article
53. Hwang TS, Kim WY, Han HS, Lim SD, Kim WS, Yoo YB, et al. Preoperative RAS mutational analysis is of great value in predicting follicular variant of papillary thyroid carcinoma. Biomed Res Int. 2015; 2015:697068.
Article
54. Nikiforov YE, Ohori NP, Hodak SP, Carty SE, LeBeau SO, Ferris RL, et al. Impact of mutational testing on the diagnosis and management of patients with cytologically indeterminate thyroid nodules: a prospective analysis of 1056 FNA samples. J Clin Endocrinol Metab. 2011; 96(11):3390–7.
Article
55. Lee SR, Jung CK, Kim TE, Bae JS, Jung SL, Choi YJ, et al. Molecular genotyping of follicular variant of papillary thyroid carcinoma correlates with diagnostic category of fine-needle aspiration cytology: values of RAS mutation testing. Thyroid. 2013; 23(11):1416–22.
Article
56. Oh SY, Kim WY, Hwang TS, Han HS, Lim SD, Kim WS. Development of an ammonium sulfate DNA extraction method for obtaining amplifiable DNA in a small number of cells and its application to clinical specimens. Biomed Res Int. 2013; 2013:546727.
Article
Full Text Links
  • IJT
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr