2 MD, Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences SCHOOL OF MEDICINE AND SURGERY. Università degli Studi della Campania “Luigi Vanvitelli”, Naples
3MD, Department of Surgical Anesthesiology and Emergency Sciences. Università degli Studi della Campania “Luigi Vanvitelli”, Naples
4MD, Department of Surgical Anesthesiology and Emergency Sciences. Università degli Studi della Campania “Luigi Vanvitelli”, Naples
5MD,Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences SCHOOL OF MEDICINE AND SURGERY. Università degli Studi della Campania “Luigi Vanvitelli”, Naples
6PhD,Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences SCHOOL OF MEDICINE AND SURGERY.Università degli Studi della Campania “Luigi Vanvitelli”,Naples
7PhD, Professor of General Surgery, Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences SCHOOL OF MEDICINE AND SURGERY. Università degli Studi della Campania “Luigi Vanvitelli”, Naples
Fulvio Freda, Researcher, Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences SCHOOL OF MEDICINE AND SURGERY. Università degli Studi della Campania “Luigi Vanvitelli”. Piazza Miraglia 2 80138, Naples, Italy. Tel: 00393332670626; E-mail:
Materials and Methods: We conducted a prospective randomized study on 50 patients who attend to our structure from 2013 to 2016 in order to study the predictive effects of the B-RAF mutation on fine needle aspiration cytology (FNAC) in patients with nodular thyroid disease.
Results: From our study we can see that the molecular dosage of B-RAF is superfluous when the cytomorphological examination is based on characteristics of benignity (Tir 2) or malignancy (Tir 5); it is of great help in cases of indefinite (Tir 3) or suspicion nodule (Tir 4), even though its negativity does not allow us to exclude a cancer, its positivity gives us a diagnosis of certainty.
Conclusions: Improvement of FNAC’s diagnostic accuracy through the molecular dosage of mutated B-RAF represents a valuable achievement for the management of patients with nodular thyroid disease with clinical-instrumental features of suspicion both for preoperative and postoperative strategies, permitting us to quickly dispel the uncertainties of the cytomorphological examination and allowing to start the patient towards the most appropriate therapeutic strategy.
A 2005 study found that BRAF mutating itself would not be enough to induce an aggressive biological behavior of the tumor: the mutation would induce some genomic instability and a greater predisposition of mutated cells to acquire further defects (e.g., RAS mutations) together, it can explain the increased aggressiveness found in B-RAF mutated PTCs [16]. Finally, some studies, including a multicenter study of 219 patients, demonstrated that the B-RAFV600E mutation is an independent predictor of tumor recurrence after a variable follow-up period between different studies [1,12,16-18].
The relief of the B-RAFV600E mutation could also be useful in the diagnosis of PTC on DNA samples obtained from cytological withdrawal with FNA, as confirmed by a study by Salvatore, et al. [19] where mutation identification has been found to have enabled PTC diagnosis in 5 out of 15 samples previously considered undetermined or insufficient for cytological diagnosis. Two other studies by Marchetti, et al. [20] and Zatelli, et al. [21] have shown that the combination of traditional cytology with the molecular analysis of the B-RAFV600E mutation on FNA samples has improved PTC’s diagnostic accuracy from 62.3 % to 82.2% and from 77.3% to 86.7% [20,21]. However, the B-RAFV600E mutation is only positive in about 50% of PTC, and in the case of a negative result one cannot rule out a malignanttumor.
It is understood therefore that preoperative research of this mutation, alongside cytomorphology, may be of utmost utility in the diagnostic-therapeutic approach of PTC. The 2015 American Thyroid Association (ATA) guidelines simply provide a recommendation for the use of B-RAF as a molecular indicator in an attempt to improve clinical management in patients with FNAC displaying undetermined cytology [22]. The use of B-RAF may also be helpful in guiding therapy, as it is useful not only in selecting patients with thyroid disease to undergo surgery, but also in modulating PTC treatment, which uses surgery and ablative metabolic radio-iodine therapies [23-24]. Indeed, several studies have shown that the B-RAFV600E mutation is associated with a high risk of recurrence and a reduction in iodine [8,16,23- 26].
Fine needle aspiration cytology (FNAC) |
Nodules number |
Presence of BRAFV600E mutation |
Histological examination |
Tir 2 |
14 nodules |
14 negative |
14 benign |
Tir 3 |
4 nodules |
1 positive 3 negative |
1 BRA-FV600E positive: -1 papillary carcinoma 3 BRA-FV600E negative: - 2 benign -1 papillary carcinoma follicular variant |
Tir 4 |
3 nodules |
1 positive 2 negative |
1 BRA-FV600E positive: -1 papillary carcinoma 2 BRA-FV600E negative: -2 benign |
Tir 5 |
4 nodules |
3 positive 1 negative |
3 BRA-FV600E positive: -3 papillary carcinoma 1 BRA-FV600E negative: -1 papillary carcinoma follicular variant |
Fine needle aspiration cytology (FNAC) |
Nodules number |
Histological examination |
Tir 2 |
15 nodules |
15 benign |
Tir 3 |
3 nodules |
1 papillary carcinoma |
Tir 4 |
4 nodules |
1 papillary carcinoma follicular variant |
Tir 5 |
3 nodules |
3 papillary carcinomas |
In these cases, the therapeutic options may be different, in the case of an indefinite nodule, the surgical indication is relative: you can adopt a very attentive attitude, repeating the needle after six months, or a more aggressive attitude, pointing to the surgical intervention. In this case, however, there are extremely controversial scientific opinions about the extension of surgical exeresis when there are no other reasons indicative for total Thyroidectomy: in cases of single nodule, in fact, there are those who, however, wish to perform a total Thyroidectomy and who, on the basis of a probabilistic benignity criterion, propose in a first instance loboistemectomy, reserving the totalization intervention at a later stage, when cancer is diagnosed with histopathology.
In the case of suspected nodular lesions (Tir4), the surgical indication is absolute, even in this case; however, opinions about the extension of exeresis are controversial, with the same considerations being discussed for indefinite nodules (Tir3). In these two diagnostic categories then the determination of the B-RAFV600E seems to be overwhelming, in fact, while considering the relative size of the experimental samples tested, the sensitivity of the test is 83.3%, since false positives are possible, while its specificity is 100%, since no false positives have been found. Test sensitivity, unfortunately, is not 100%, because in thyroid cancers the B-RAFV600E mutation is not always present. As a characteristic of the genetic base of each cancer, in fact it is necessary a mosaic of mutations of proto-oncogens, onco-suppressor genes, pro-apoptotic genes, and anti-apoptotic genes, which contribute to alter the cell cycle regulation to the point of bringing out the malignant neoplastic phenotype. In this mosaic the B-RAFV600 mutation is not always present, it is absent in follicular carcinomas, and within papilliferous tends to prevail in classical and high-cell variants, generally lacking in the other. In spite of this, its specificity is 100%, therefore, in the face of a positive molecular assay, we have a diagnostic orientation of certainty towards a papillary carcinoma lesion ; this data, in the face of a cytomorphologic diagnosis of indefinite nodule, renders the surgical indication absolute, it also makes it vanish the probabilistic “benignity” criterion on which the current diatribe is based on the extension of surgical exeresis , which also involves cytomorphologic ally suspect nodules (Tir4).
Consideration should now be given to the therapeutic management of micro carcinoma. In these cases there are two currents of thought: one in favor of lobectomy, the other in favor of total Thyroidectomy. Those claiming for total Thyroidectomy are in favor of this treatment basically for two reasons: on the one side that of multicentricity-multifocality of cancer, whether for polyclonal origin, whether for intra-glandular metastasis, and on the other side that the follow-up after total Thyroidectomy is easier (dosage of serum Thyroglobulin and total body scintigraphy) allowing an earlier diagnosis of a possible recurrence of the disease. In this regard, the pre-operative diagnosis of B-RAFV600E molecular assay positivity has a particular meaning, although this mutation is more frequently present in classical papillary carcinoma, which is considered a favorable histotype , it is also frequently present in the high-cell variant, which has a worse prognosis. Regardless of the histological variant, it is still demonstrated that the expression of the B-RAFV600E mutation correlates with greater biological aggressiveness of the neoplasia, resulting in extra capsular extension with or without invasion of the nearby structures and regardless of size, local-regional lymph node metastasis, and relapse of the disease, all with a higher and statistically significant frequency than the negative B-RAFV600E neoplasm’s. Based on this data it is thus understood how the positivity of the molecular dosage of the B-RAFV600E can be of fundamental help not only in the diagnostic definition but also in the choice of the surgical strategy regarding the extension of the exegesis and in the post-operative, both with regard to the possibility of relapse of disease at a distance of time both with regard radioiodine sensitivity therapy that is reduced in PTC expressing the B-RAF V600E mutation.
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