title: Clinical and cytological features predictive of malignancy in thyroid follicular neoplasms.
abstract: BACKGROUND
  The preoperative diagnosis of malignancy in nodules suspicious for a follicular neoplasm remains challenging. A number of clinical and cytological parameters have been previously studied; however, none have significantly impacted clinical practice. The aim of this study was to determine predictive characteristics of follicular neoplasms useful for clinical application.
  
  
  METHODS
  Four clinical (age, sex, nodule size, solitary nodule) and 17 cytological variables were retrospectively reviewed for 144 patients with a nodule suspicious for follicular neoplasm, diagnosed preoperatively by fine-needle aspiration (FNA), from a single institution over a 2-year period (January 2006 to December 2007). The FNAs were examined by a single, blinded pathologist and compared with final surgical pathology. Significance of clinical and cytological variables was determined by univariate analysis and backward stepwise logistic regression. Odds ratios (ORs) for malignancy, a receiver operating characteristic curve, and predicted probabilities of combined features were determined.
  
  
  RESULTS
  There was an 11% incidence of malignancy (16/144). On univariate analysis, nodule size >OR=4.0 cm nears significance (p = 0.054) and 9 of 17 cytological features examined were significantly associated with malignancy. Three variables stay in the final model after performing backward stepwise selection in logistic regression: nodule size (OR = 0.25, p = 0.05), presence of a transgressing vessel (OR = 23, p < 0.0001), and nuclear grooves (OR = 4.3, p = 0.03). The predicted probability of malignancy was 88.4% with the presence of all three variables on preoperative FNA. When the two papillary carcinomas were excluded from the analysis, the presence of nuclear grooves was no longer significant, and anisokaryosis (OR = 12.74, p = 0.005) and presence of nucleolus (OR = 0.11, p = 0.04) were significantly associated with malignancy. Excluding the two papillary thyroid carcinomas, a nodule size >or=4 cm, with a transgressing vessel and anisokaryosis and lacking a nucleolus, has a predicted probability of malignancy of 96.5%.
  
  
  CONCLUSIONS
  A combination of larger nodule size, transgressing vessels, and specific nuclear features are predictive of malignancy in patients with follicular neoplasms. These findings enhance our current limited predictive armamentarium and can be used to guide surgical decision making. Further study may result in the inclusion of these variables to the systematic evaluation of follicular neoplasms.
authors.affiliation: Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts 02114, USA. clubitz@partners.org
authors.forename: Carrie C
authors.initials: CC
authors.lastname: Lubitz
authors.forename: William C
authors.initials: WC
authors.lastname: Faquin
authors.forename: Jingyun
authors.initials: J
authors.lastname: Yang
authors.forename: Michal
authors.initials: M
authors.lastname: Mekel
authors.forename: Randall D
authors.initials: RD
authors.lastname: Gaz
authors.forename: Sareh
authors.initials: S
authors.lastname: Parangi
authors.forename: Gregory W
authors.initials: GW
authors.lastname: Randolph
authors.forename: Richard A
authors.initials: RA
authors.lastname: Hodin
authors.forename: Antonia E
authors.initials: AE
authors.lastname: Stephen
mesh_terms: D000236:Adenoma / Q000098:blood supply / Q000175:diagnosis* / Q000473:pathology; D000328:Adult; D000368:Aged; D044963:Biopsy, Fine-Needle; D002452:Cell Count; D002466:Cell Nucleolus / Q000473:pathology; D053144:Cell Nucleus Shape; D053145:Cell Nucleus Size; D048430:Cell Shape; D048429:Cell Size; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009389:Neovascularization, Pathologic / Q000473:pathology; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D013223:Statistics as Topic; D013964:Thyroid Neoplasms / Q000098:blood supply / Q000175:diagnosis* / Q000473:pathology; D016606:Thyroid Nodule / Q000098:blood supply / Q000175:diagnosis* / Q000473:pathology; D047368:Tumor Burden