J Pathol Transl Med.  2023 Jul;57(4):208-216. 10.4132/jptm.2023.06.20.

Reevaluating diagnostic categories and associated malignancy risks in thyroid core needle biopsy

• Jung CK

• KMID: 2544328
• DOI: http://doi.org/10.4132/jptm.2023.06.20

Abstract

As the application of core needle biopsy (CNB) in evaluating thyroid nodules rises in clinical practice, the 2023 Korean Thyroid Association Management Guidelines for Patients with Thyroid Nodules have officially recognized its value for the first time. CNB procures tissue samples preserving both histologic structure and cytologic detail, thereby supplying substantial material for an accurate diagnosis and reducing the necessity for repeated biopsies or subsequent surgical interventions. The current review introduces the risk of malignancy within distinct diagnostic categories, emphasizing the implications of noninvasive follicular thyroid neoplasm with papillary-like nuclear features on these malignancy risks. Prior research has indicated diagnostic challenges associated with follicular-patterned lesions, resulting in notable variation within indeterminate diagnostic categories. The utilization of mutation-specific immunostaining in CNB enhances the accuracy of lesion classification. This review underlines the essential role of a multidisciplinary approach in diagnosing follicular-patterned lesions and the potential of mutation-specific immunostaining to strengthen diagnostic consensus and inform patient management decisions.

Keyword

Thyroid nodule; Thyroid neoplasms; Biopsy, Core needle; Mutation; Practice guideline

Figure

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  Fig. 1. Core needle biopsy of a microfollicular proliferative lesion exhibiting morphological differences from adjacent thyroid tissue. (A) Although the lesion is distinctly segregated from surrounding tissue, the absence of a discernible tumor capsule typically leads to its categorization under category III based on histomorphology. (B) Immunohistochemistry for RAS Q61R clearly delineates immunostaining-positive tumor cells from the immunostaining-negative normal thyroid tissue. Ultimately, with the incorporation of immunostaining results, the specimen should be appropriately diagnosed as follicular neoplasm, conventional type (category IVa).

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  Fig. 2. The core needle biopsy displays a microfollicular proliferative lesion that exhibits morphological differences from the adjacent thyroid tissue, but lacks a fibrous capsule (A). (B) The tumor component tests positive for RAS Q61R immunostaining. (C) A high-power view reveals microfollicles lined by tumor cells exhibiting nuclear atypia and thin fibrous bands within the stroma. (D) Tumor cells show cytoplasmic and membranous positivity for RAS Q61R. This specimen should be appropriately classified as a follicular neoplasm with nuclear atypia (category IVb). After conducting a diagnostic lobectomy, the definitive pathological diagnosis was confirmed as an invasive encapsulated follicular variant of papillary thyroid carcinoma.

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  Fig. 3. The core needle biopsy specimen exhibits both follicular and abortive papillary architecture. (A) In light of the nuclear atypia and predominantly follicular growth, the diagnostic considerations span from category III to IV. (B) The positive result for BRAF VE1 immunostaining confirmed the diagnosis, categorizing the specimen as category VI - papillary thyroid carcinoma. The inset image provides a magnified view of the indicated region as a square, facilitating the observation of nuclear atypia. Arrows indicate abortive papillae.

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  Fig. 4. The core needle biopsy specimen reveals a microfollicular proliferative lesion surrounded by a thick fibrous capsule (A) and exhibiting positivity for RAS Q61R immunostaining (B). Considering these characteristics, the specimen can be confidently classified as follicular neoplasm, conventional type (category IVa). After a diagnostic lobectomy, the tumor was conclusively identified as follicular thyroid carcinoma.

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  Fig. 5. The core needle biopsy specimen reveals a follicular proliferative lesion characterized by follicles of varying sizes and a discernible fibrous capsule (A), and demonstrates positivity for RAS Q61R immunostaining (B). (C) A high-power view reveals follicles lined by tumor cells exhibiting nuclear atypia, intermixed with follicles comprised of cells with no nuclear atypia. (D) Tumor cells show cytoplasmic and membranous positivity for RAS Q61R. The specimen was diagnosed as a follicular neoplasm with nuclear atypia (category IVb). Following a diagnostic lobectomy, the definitive pathological diagnosis was established as noninvasive follicular thyroid neoplasm with papillary-like nuclear features.

Reference

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