title: A clinical algorithm for fine-needle aspiration molecular testing effectively guides the appropriate extent of initial thyroidectomy.
abstract: OBJECTIVE
  To test whether a clinical algorithm using routine cytological molecular testing (MT) promotes initial total thyroidectomy (TT) for clinically significant thyroid cancer (sTC) and/or correctly limits surgery to lobectomy when appropriate.
  
  
  BACKGROUND
  Either TT or lobectomy is often needed to diagnose differentiated thyroid cancer. Determining the correct extent of initial thyroidectomy is challenging.
  
  
  METHODS
  After implementing an algorithm for prospective MT of in-house fine-needle aspiration biopsy specimens, we conducted a single-institution cohort study of all patients (N = 671) with nonmalignant cytology who had thyroidectomy between October 2010 and March 2012, cytological diagnosis using 2008 Bethesda criteria, and 1 or more indications for thyroidectomy by 2009 American Thyroid Association guidelines. sTC was defined by histological differentiated thyroid cancer of 1 cm or more and/or lymph node metastasis. Cohort 2 patients did not have MT or had unevaluable results. In cohort 1, MT for a multigene mutation panel was performed for nonbenign cytology, and positive MT results indicated initial TT.
  
  
  RESULTS
  MT guidance was associated with a higher incidence of sTC after TT (P = 0.006) and a lower rate of sTC after lobectomy (P = 0.03). Without MT results, patients with indeterminate (follicular lesion of undetermined significance/follicular or oncocytic neoplasm) cytology who received initial lobectomy were 2.5 times more likely to require 2-stage surgery for histological sTC (P < 0.001). In the 501 patients with non-sTC for whom lobectomy was the appropriate extent of surgery, lobectomy was correctly performed more often with routine preoperative MT (P = 0.001).
  
  
  CONCLUSIONS
  Fine-needle aspiration biopsy MT for BRAF, RAS, PAX8-PPARγ, and RET-PTC expedites optimal initial surgery for differentiated thyroid cancer, facilitating succinct definitive management for patients with thyroid nodules.
authors.affiliation: Departments of *Surgery †Pathology ‡Endocrinology §Hematology/Oncology ¶Otolaryngology ‖Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA.
authors.forename: Linwah
authors.initials: L
authors.lastname: Yip
authors.forename: Laura I
authors.initials: LI
authors.lastname: Wharry
authors.forename: Michaele J
authors.initials: MJ
authors.lastname: Armstrong
authors.forename: Ari
authors.initials: A
authors.lastname: Silbermann
authors.forename: Kelly L
authors.initials: KL
authors.lastname: McCoy
authors.forename: Michael T
authors.initials: MT
authors.lastname: Stang
authors.forename: Nobuyuki P
authors.initials: NP
authors.lastname: Ohori
authors.forename: Shane O
authors.initials: SO
authors.lastname: LeBeau
authors.forename: Christopher
authors.initials: C
authors.lastname: Coyne
authors.forename: Marina N
authors.initials: MN
authors.lastname: Nikiforova
authors.forename: Julie E
authors.initials: JE
authors.lastname: Bauman
authors.forename: Jonas T
authors.initials: JT
authors.lastname: Johnson
authors.forename: Mitch E
authors.initials: ME
authors.lastname: Tublin
authors.forename: Steven P
authors.initials: SP
authors.lastname: Hodak
authors.forename: Yuri E
authors.initials: YE
authors.lastname: Nikiforov
authors.forename: Sally E
authors.initials: SE
authors.lastname: Carty
mesh_terms: D000465:Algorithms; D044963:Biopsy, Fine-Needle / Q000379:methods*; D003937:Diagnosis, Differential; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D015203:Reproducibility of Results; D012189:Retrospective Studies; D013961:Thyroid Gland / Q000473:pathology* / Q000601:surgery; D013964:Thyroid Neoplasms / Q000473:pathology* / Q000601:surgery; D016606:Thyroid Nodule / Q000473:pathology* / Q000601:surgery; D013965:Thyroidectomy / Q000379:methods*