1. Thyroid cancer : a morphological and molecular entity cytologically detectable Sessione Anatomia Patologica e Ricerca Molecolare Molecular Cytology Chairman Gianni Simone and Leonardo Resta beatrix.cochand-priollet@cch.aphp.fr

2. History of the thyroid FNAs Lipton RF, Abel MS: aspiration biopsy of the thyroid in the evaluation of thyroid dysfunction Am J Med Sci 1944 Löwhagen T (Sweden)1970th 1980-1990th: Kini SR, Koss LG; Frable WJ (USA) Akerman M (Sweden) Orell S (Australia) France: Institut Curie (Zajicek J)

3. Clinicians asked for: More specific diagnoses Assessment for risk cancer Helpful diagnosis linked with the patients’management Series SensitivitySpecificity Loewhagen, 1979 91 69 Gharib, 1985 9070 Akerman, 1985 5798 Baloch, 1998 9284 Ramzy, 2001 9376 Cheung, 2006 54100 Sangalli, 2006 9374

4. Terminologies Follicular lesion without nuclear atypia: 6.8 % K Follicular lesion with nuclear atypia : 44.4 % K Nuclear atypia: 20 % K (PTC exclusively) R. Goldstein Ann Surg 2002; 235 : 656-62 Benign Malignant « Indeterminate » B. Miller, Am J Surg 2004; 188 : 459-62

5. Terminologies: The professionnal Societies Recommandations PSC 1997ATA 2006AACE 2006 Working group 2006 Inadequate Benign Malignant or suspicious US Lesion Presence of atypical cells Indeterminate/ suspicious for neoplasia Follicular neoplasia Suspicious for malignancy Indeterminate/ Suspicious for carcinoma Non Diagnostic or Suspicious US Suspicious Malignant BenignUnsatisfactory PSC : Papanicolaou Society of Cytology; Working group : Thyroid 2006;16

6. The current terminologies BTA 2009 SIAPEC 2014 Thy1Insufficient for dg Thy 1c-Cyst fluid with macs only Tir 1 Non diagnostic Thy 2 Non neoplastic Thy 2c- cyst fluid with colloid Tir 2 Negative for malignant cells Thy 3a-atypia Neoplasm possible Thy3f- follicular neoplasm Tir3 atypical Thy4 Suspicious of malignancy Tir 3 follicular proliferation Thy 5 MalignantTir 4 suspicious for malignancy Tir 5 diagnostic for malignancy Terminology 2009 Malignancy Risk (%) Usual Management Non Diagnostic or Unsatisfactory ** Repeat FNA with US Benign 0-3 Clinical Follow- up 6-18 months AUS or FLUS 5-15 Repeat FNA Foll Neoplasm or Suspicious for a foll neoplasm (specify if Hürthle cell (oncocytic) type) 15-30 Surgical lobectomy Suspicious for malignancy 60-75 Near-total Thyroidectomy or Surgical lobectomy Malignant 97-99 Near-total thyroidectomy

7. Blue book essential : Criteria well described Key for diagnostic reproducibility National/ International correlation

8. Selection of the patients TIRADS 0 TIRADS 1NormalNothing else to do TIRADS 2BenignUS control TIRADS 3Likely benignFNA depending on the context TIRADS 4SuspiciousFNA recommended TIRADS 5Likely malignantFNA recommended TIRADS 6Malignant on histology Russ, J Radiol, 2011 Russ, Eur J Endocrinol, 2013 sens = 95.7%, spec = 61%, NPV= 99.7%

9. Selection of the patients Olson MT Acta Cytol 2014 Meta-analysis SM 50 192 cas/12 articles post BSRTC 51 863 cas/13 articles pre BSRTC -Percentage of cancers is now higher in the thyroid with surgical control (14% →50%) -Specificity 50% higher for cat V; 100% cat VI Kocjan G Acta Cytol 2011 -Cat V BSRTC combined with score TI-RADS 4B and 5 : Malignancy risk> 75% Maia FF Clin Endocrinol 2014

10. The indeterminate cases still represent 20-25% of all FNAs How can we still improve these results ? To analyze our own cytological results To optimize the FNA quality To apply ancillary techniques

11. Number of casesNon diagn BenignFLUS Or AUS FN/ FNHC SMMalignant 2277 2009/10 2210 2011/12 14.1% 14.3% 64.9% 65.5% 9.2% 11% 5.6% 4.9% 4.2% 2.3% 2% Analysis of our own results CancerNA 25.9%15.1%58.7%100% Bethesda <15% ? 60% 0-3% <7% 5-15% 6-11% 15-30% 2-8% 60 -75% 3-7% 97 -99 %

12. FLUS and risk of malignancy CYTOLOGICAL CRITERIA and Risk of malignancy AA Renshaw Cancer Cytopathol 2011 MH Luu Acta Cytol 2011 MT Olson Acta Cytol 2011 S Onder Cytopathol 2013 Microfollicular architecture but sparse cellularity 21-34% 27%6.9% Predominant oncocytic cells and low cellularity 0% Predominant oncocytic cells and goiter or Hashimoto Cytological atypias suggesting papillary carcinoma 39%32.3%48% 28% Atypical « cyst lining cells » Cytological atypias50% 22% Cytological atypias due to technical artifact Abnormal lymphocytic population % FLUS/AUS/% malignant (BCP) % FLUS/AUS/% malignant 9-11%/25.9% 8%/25% 3.2%/26% 3.3%/32%6.7%/18.9%

13. 2011-2012 9970 thyroid ultrasound-guided FNAs Russ G and Royer B BRSTC CategoryNumber% Non diagnostic4084 Benign738974 Atypia of undetermined significance 105410.5 Follicular neoplasm (FN)598 (170 Oncocytic type)6 Suspicious for malignancy2883 Malignant2332.5

14. Litterature Results AuthorsCases Number Non diagn BenignFLUS or AUS FN/ FNHC SMMalignant Cochand-Priollet B et al 2012 221014.3%65.5%11% (23.6%) 4.9% (15.2%) 2.3% (58.7%) 2% (100%) Lacoste-Collin L et al 2012 131731.6%48%7.8% (18.5%) 7% (22.2%) 3% (55.6%) 2.6% (100%) Bongiovanni et al 2012 76862%54.7%6.3% (14.4%) 25.3% 32.1% 6.3% (74.9%) 4% 99.4% Önder S et al 2013 655 (6310) 25.6%61.1%6.7% (18.9%) 1.7% (45.7%) 2% (71%) 2.9% (98.3%) Bethesda <15% ? 60% 0 - 3% <7% 5 -15% 6-11% 15 - 30% 2-8% 60 -75% 3-7% 97 - 99 % Litterature Results

15. AuthorsCases Number Non diagn BenignFLUS or AUS FN/ FNHC SMMalignant Mastorakis et al Cytopathology 2012 500 NA 49% 72.2% 9.4% (23.4%) 5% (8%) 1.2% 2.2% 10.6% (96%) 3.2% (87.5%) 26.8% (100%) 12.2% (100%) Elsheikh et al 2012138220.1%39% (3%) 27.2% (6%) 8.4% (22%) 2.6% (56%) 2.7% (100%) Firat P et al 201276411.7%64.1%9.8% (36%) 3.7% (45%) 3.5% (100%) 7.2% (100%) Mondal SK et al 2013 10201.2% (0%) 87.5% (4.5%) 1% (20% ) 4.2% (30.6%) 1.4% (75%) 10% (97.8%) Park JH et al 2014173013.3% (35.3%) 40.6% (5.6%) 9.1% (69%) 0.4% (50%) 19.3% (98.7%) 17.3% (98.9%) Bethesda <15% ? 60% 0 - 3% <7% 5 -15% 6-11% 15 - 30% 2-8% 60 -75% 3-7% 97 - 99 %

16. Techniques to improve the FNAs quality Conventional slides Liquid-based cytology Ancillary techniques Quantity of cytological material

17. Conventional slides

18. Liquid-based cytology

19. Ancillary techniques

20. ICC Thyroid. 2011 Oct;21(10):1067-7

21. Terminology Bethesda 2009 Risk of cancer Alternatives for the Management Non Diagnostic or Unsatisfactory ? Repeat FNA with US Benign 0-3% Clinical Follow-up 6-18 months AUS or FLUS 5-15% Repeat FNA Or Clinical and US follow-up Foll Neoplasm or Suspicious for a foll neoplasm (specify if Hürthle cell (oncocytic) type) 15-30 % Surgical Lobectomy Or Clinical and US follow-up Suspicious for malignancy 60-75% Near-total Thyroidectomy or Surgical lobectomy Malignant 97-99% Near-total thyroidectomy

22. Rossi ED et al Cancer Cytopathology 2005: RET/HBME1/Galectine 3 Fadda G et al Eur J Endocrinol 2011: HBME1/Galectine 3 Lacoste Collin L et al Cytopathology 2014: CK19/HBME1/Ki67 Pustaszeri MF et al Cancer Cytopathology CD117 Thyroglobulin, TCT, PTH etc……… Simone G, Cytopathology 2014 TROP-2

24. Molecular markers/BRAF V600E mutation-MAPKinase Highly specific for PTC 80% PTC Tall cells 60% PTC classic variant 10% PTCFV

25. Molecular markers/BRAF Poller D et al Cytopathology 2014 Johnson SJ et al Cytopathology 2014 Rossi ED et al Cancer Cytopathology 2014 Zimmerman AK et al Cancer Cytopathol 2014

26. Molecular markers/ RAS 40-50% FC 10-20% PTCFV 20-40% PDC/Anapl K 20-40% FA Cancer cytopathology 2014

28. New algorithms

29. Rossi ED et al Cancer Cytopathology 2014

30. Tests Afirma test (RNA based test) miRInform test (DNA and RNA based test) ThyroSeq test (DNA based test/12 genes) The Afirma GEC demonstrates a lower than expected rate of benign reports in FN/HCN, and a lower than anticipated malignancy rate within GEC-suspicious nodules. These data suggest that the PPV of the GEC is lower than previously reported, and call into question the performance of the test when applied in the context of specialized Academic cytopathology.

31. Mc Iver et al JCEM 2014

32. Aragon P Ann Surg Oncol 2014

34. MicroRNA Dettmer et al, Thyroid 2013

35. TAKE HOME MESSAGES Cytology is still relevant ICC is helpful but resolves only about 50% of the « indeterminate » Sensitivity and specificity of the Molecular testings are not sufficient to recommend these techniques in a routine practice But all these techniques are promising and feasible on cytology A rigourous technique is required Targeted therapies will change our approach