Follicular lesion of undetermined significance (FLUS) and FIIRMA’s Veracyte- pro

Mnagement of a follicular lesion of undetermined significance (FLUS) of thyroid is difficult.  The rate of malignancy for FLUS varies among centers. For example, at the University of Wisconsin is approximately 30%, but ranges among institutions. Management options for FLUS include surgery, repeat FNA and observation. The surgeon’s recommendation to the patient must be made with the knowledge of the institutional rate of malignancy for FNAs read as FLUS. If the institutional rate of malignancy for FLUS is only 5%, it is reasonable to observe with serial ultrasounds. However, if the rate of malignancy is greater than that of a follicular neoplasm, then surgery with a thyroid lobectomy or a total thyroidectomy should be undertaken.

Recent work published in The New England Journal of Medicine evaluated the use of a gene-expression classifier (Veracyte) to identify benign nodules among a group of indeterminate FNAs. The negative predictive value of Veracyte for FLUS was 95%

Thus, as well as it is known, performing Veracyte to rule malignancy can be defended and is within the range of acceptable practice.

    1. Ross D, Cooper SD, Mulder JE.  Diagnostic approach to and treatment of thyroid nodules.  UpToDate, February 2013.

     

    1. Ali SZ, Fish SA, Lanman R, Randolph GW, Sosa JA.  Use of the Afirma Gene Expression Classifier for Preoperative Identification of Benign Thyroid Nodules with Indeterminate Fine Needle Aspiration Cytopathology.  PLoS Curr.  2013 Feb 11:5.

    NCCN Guidelines:  Thyroid Carcinoma, 2012 and 2015.

    Duick DS, Klopper JP, Diggans JC, Friedman L, Kennedy GC, Lanman RB, McIver B.  The impact of benign gene expression classifier test results on the endocrinologist-patient decision to operate on patients with thyroid nodules with indeterminate fine-needle aspiration cytopathology.  Thyroid.  2012 Oct;22(10):996-1001.

    Alexander EK, Kennedy GC, Baloch ZW, Cibas ES, Chudova D, Diggans J.  Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology.  N Engl J Med.  2012 Aug 23;367(8):705-15.

    Ho AS, Sarti EE, Jain KS et al. Malignancy rate in thyroid nodules classified as Bethesda Category III (AUS/FLUS). Thyroid. 2013 Dec 16 [Epub ahead of print].Alexander EK, Kennedy GC, Baloch ZW et al. Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology. N Eng J Med. 2012;367(8):705-715.

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