majornod32

157received07.
01.
2015accepted12.
03.
2015BibliographyDOIhttp://dx.
doi.
org/10.
1055/s-0035-1548873Publishedonline:May7,2015HormMetabRes2016;48:157–162GeorgThiemeVerlagKGStuttgart·NewYorkISSN0018-5043CorrespondenceA.
Crescenzi,MDPathologyUnitCampusBio-MedicoUniversityHospitalViaAlvarodelPortillo20000128RomeItalyTel.
:+39/06/225411106Fax:+39/06/225411928a.
crescenzi@unicampus.
itKeywordsthyroidcancerTERTcoreneedlebiopsy(CNB)PreoperativeAssessmentofTERTPromoterMutationonThyroidCoreNeedleBiopsiesSupportsDiagnosisofMalignancyandAddressesSurgicalStrategyworseoutcome,withahigherrateofdiseaserecur-renceandahigherdisease-specificmortality[7].
TERTpromotermutationshavebeeninvestigatedinpapillary(PTC),follicular(FTC),poorlydifferen-tiated(PDTC),andanaplastic(ATC)thyroidcarcino-maswithaprevalenceof7.
5,17.
1,29,and33%,respectively[8].
Noteworthy,todatenoTERTmutationhasbeenreportedinnon-neoplasticthy-roidtissue[1].
WhileTERTmutationshavenotbeengenerallyreportedinthyroidadenomas,asinglestudydescribedthepresenceoftheC228Tmutationinfollicularadenomas,mainlytheatypi-calsubtype.
DuetothepotentialdevelopmentintoFTCofthistypeoflesions,TERTpromotermuta-tionscouldrepresentanearlygeneticeventinthy-roidfolliculartumorsthatdonotyetrevealmalignantfeaturesonroutinehistopathologicalworkup[9].
Onthebasisoftheserecentdata,theassessmentofthepresenceofTERTmutationscouldholdamainroleintheclinicaldiagnosisandmanagementofthyroidcancerpatients.
IntroductionThetelomerasereversetranscriptase(TERT)pro-motermutationsC228TandC250Thavebeenfoundinseveralmalignanciesincludingmela-noma,glioma,bladder,andthyroidcancer[1–4].
Thesemutationsoccurin2hotspotpositions,located124and146bpupstreamfromtheATGstartsite(124G>Aand146G>A,C>Tontheoppositestrand)andconferenhancedTERTpromoteractivityputativelybygeneratingacon-sensusbindingsite(GGAA)forETStranscriptionfactorswithintheTERTpromoterregion[2,3].
Inthyroidcancers,TERTmutationshavebeencor-relatedwithaggressivetumorfeatures.
Moreover,theymaybeassociatedwithBRAForcombinedBRAF/RASmutations[5,6].
Onthebasisoftheavailableevidence,TERTmutationsappeartoinflu-encethebiologicalandclinicalbehaviorofthyroidtumors,aswellaspatientssurvivalandprognosis.
Hence,TERT-mutatedthyroidcancersmayhaveaAuthorsA.
Crescenzi1,P.
Trimboli2,D.
CicciarellaModica3,C.
Taffon1,L.
Guidobaldi3,S.
Taccogna4,A.
Rainer5,M.
Trombetta5,E.
Papini6,G.
Zelano7AffiliationsAffiliationaddressesarelistedattheendofthearticleAbstractInthelastdecade,severalmolecularmarkershavebeenproposedtoimprovethediagnosisofthyroidnodules.
Amongthese,mutationsinthetelomerasereversetranscriptase(TERT)pro-moterhavebeencorrelatedtomalignanttumors,characterizedbyhighestrecurrenceanddecreasedpatients'survival.
ThissuggestsanimportantroleofTERTmutationalanalysisintheclinicaldiagnosisandmanagementofthyroidcancerpatients.
Theaimofthestudywastodemonstratetheadequacyofcoreneedlebiopsy(CNB)forthepreoperativeassessmentofTERTmutationalstatus,toreachamoreaccuratedefi-nitionofmalignancyandamoreappropriatesur-gicalplanning.
Indeed,CNBisgainingmomentumforimprovingdiagnosisofthyroidnodulesdeemedinconclusivebyfineneedleaspirate(FNA).
Thestudyincluded50patientssubmittedtoCNBduetoinconclusiveFNAreport.
TERTmutationalstatuswascorrelatedwithBRAFmutation,definitivehistology,andpost-opera-tiveTNMstagingoftheneoplasia.
C228Tmuta-tionoftheTERTpromoterwasreportedin10%ofthepapillarycarcinomas(PTC)series.
Whencomparedwithfinalhistology,allcasesharbor-ingTERTmutationresultedaslocallyinvasivePTCs.
TheprevalenceofTERTmutatedcaseswas17.
6%amonglocallyadvancedPTCs.
TERTanaly-sisonCNBallowstheassessmentofthepatho-logicalpopulationonparaffinsectionsbeforeDNAisolation,minimizingtheriskoffalsenega-tivesduetopoorsamplingthataffectsFNA,andgatheringaggregateinformationaboutmorphol-ogyandTERTmutationalstatus.
Dataindicatingaworseoutcomeofthetumormightbeusedtoindividualizetreatmentdecision,surgicaloption,andfollow-updesign.
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158Themicro-histologicalevaluationofsamplesobtainedbycoreneedlebiopsy(CNB)hasbeenproposedforaconclusivedefini-tionofthyroidnoduleswithinadequateorindeterminatecytol-ogy.
CNBprovidesinalargepartofthesenodulesaconclusivediagnosis,withminimalsideeffectsandgoodtolerabilityforthepatient[10–16].
Recently,themicro-histologicalspecimensobtainedbyCNBweredemonstratedtobeanexcellentmaterialformolecularandimmunohistochemicalstudies[10,17].
TheaimofthepresentstudyistoinvestigatethepotentialuseofCNBforthepreoperativeassessmentofTERTmutationalstatus,inordertoreachamoreaccuratedefinitionofmalignancyandamoreappropriateplanningofsurgicalextension.
TheresultsobtainedonCNBwerecomparedwithfinalhistologyonsurgicalspecimenswithregardtohistologicaldiagnosisandpathologicalstaging.
PatientsandMethodsPatientsTheseriesincluded50thyroidnodules,retrospectivelyselectedamong187patientswhounderwentCNBduringthelast2yearsat2institutions:OspedaleIsraelitico,Rome,andOspedaleReginaApostolorum,AlbanoLaziale,Italy.
Thirty-onecasesofthyroidcancer(30PTC,1FTC),9offollicularadenomaand10ofnodularhyperplasiathatunderwentsurgerywithfinalhistol-ogywereincludedinthepresentstudy.
AlltheselesionshadbeensubmittedtoCNBduetoaninconclusiveFNAreportofindeterminate(Thy3/TIR3),orinadequate(Thy1/TIR1)thyroidcytology[18–20].
AtCNB26PTC,5follicularneoplasms,11fol-licularproliferation/indeterminate,and8benignhyperplasiaswererecorded.
Informedconsentwasobtainedfromallpatients.
The50enrolledspecimenswerepreviouslyevaluatedandsub-mittedtomanualdissectioninordertoobtainanamountofover50%oflesionalcellsandinordertoruleoutthepresenceofinflammatorycomponentforthecorrectinterpretationofthestudyresults.
CNBandmicro-histologicalexaminationThyroidCNBprocedurewasperformedunderultrasoundguid-anceinanoutpatientsurgeryunitaspreviouslydescribed[15,17,21].
Coresampleswerefixedin10%bufferedformalinimmediatelyfollowingthebiopsy.
Formalin-fixedtissuecoreswereautomaticallyprocessedandembeddedinparaffin.
Then,4μmsectionswerecollectedonpositivelychargedslidesandstainedwithhematoxylin-eosinformorphologicalevaluation.
MicroscopicdiagnosiswasreportedasPTCwhenthetypicalfeatureswerepresent,asfollicularhyperplasiawhenthemicro-follicularpatternwascombinedwithnormo-andmacro-follicularaspectsandwasseennexttonon-neoplasticparen-chyma,andasfollicularneoplasmwhenmicro-follicularpatternwasmonomorphicwithcrowednucleiandseparatedfromnon-neoplasticparenchymabythickfibroussepta(probablyfibrouscapsule).
Follicularproliferation/indeterminatewasreportedwhenafollicularpatternwasdetectedbutthesampledidnotcontainthelimitwithextra-nodularparenchyma.
FinalhistologyAftersurgery,thyroidexplantswereformalin-fixedandparaf-fin-embeddedforroutinehistology.
ThyroidtumorsandlesionswereclassifiedaccordingtothemostrecentcriteriaoftheWorldHealthOrganization[22].
TNMstagingwasperformedinagree-mentwithAJCC7th,edition[23].
TERTmutationalanalysisTERTmutationalanalysiswasperformedbySangersequencing.
GenomicDNAwasisolatedfromformalin-fixed,paraffin-embeddedtissuesamples.
Fiveμmparaffinsectionsweredewaxed,hydratedandsubmittedforDNAextractionusingtheQIAampDNAMiniKit(Qiagen,Germany)aftermanualdissec-tionofthepathologicalareas.
About40–50ngofgenomicDNAwereusedinthePCR.
SequencingofTERTpromotertodetectthemutationsC228TandC250Tlocatedatpositions124and146bpupstreamoftheATG(startcodon)wascarriedoutasrecentlyreported[7].
Thetargetregionwasamplifiedbypolymerasechainreaction(PCR)usingprimers5′-AGTG-GATTCGCGGGCACAGA-3′(forward)and5′-CAGCGCTGCCT-GAAACTC-3′(reverse),resultinginaPCRproductof235bp,whichcontainedthesitesofC228TandC250Tmutations(chr5:1,295,228;chr5:1,295,250,respectively;hg19)[7].
Theamplificationprotocolconsistedofaninitialdenaturationat95°Cfor3min,40cyclesofdenaturationat95°Cfor40s,anneal-ingat55°Cfor40s,extensionat68°Cfor1min,followedbyafinalextensionat68°Cfor10min.
Eachreactionmixturecon-tained10mmol/lTris(pH8.
3),200μmol/lofeachdeoxynucleo-tidetriphosphate(dNTP),1.
5mmol/lmagnesiumchloride,50mmol/lpotassiumchloride,10pmolofeachprimer,50ngofgenomicDNA,and0.
2UofTaqpolymerase,inafinalvolumeof10μl.
AsinglemajorPCRproductwasconfirmedbyelectropho-resingeachPCRproductona2.
5%(w/v)agarosegel.
PCRprod-uctsweresubsequentlysequencedusingtheabovedescribedforwardprimerandBigDyeterminatorV3.
1cyclesequencingreagents(LifeTechnologies)byPCRamplification(25cyclesofdenaturationat96°Cfor10s,annealingat50°Cfor5s,andextensionat60°Cfor4min).
EachDNAsequencewasreadonanABI-Prism3100automaticsequencer(LifeTechnologies).
ThegeneratedsequenceswereanalyzedusingGeneiousver.
7.
1.
7software(www.
geneious.
com).
WhenamutationwasidentifiedbyBigDyesequencingusingthesenseprimer,anindependentPCRamplification/sequenc-ing,bothinforwardandreversedirections,wasperformedtoconfirmthemutation.
BRAFmutationalanalysisTheanalysisofBRAFmutationalstatuswasperformedasprevi-ouslydescribed[17].
Briefly,5mlofgenomicDNAwasamplifiedandsequencedusinganAnti-EGFRMoabResponse(BRAFsta-tus)kit,(DiatechPharmacogeneticsSrl,Jesi,Italy)accordingtothemanufacturer'sinstructions.
Real-timePCRwasrunonaRotor-Gene6000(Corbett,Syd-ney,Australia).
Afteramplification,thepresenceofPCRproductswasdetectedbymeltinganalysis.
Forpyrosequencinganalysis,single-strandedDNAtemplateswereimmobilizedonstreptavi-din-coatedSepharosehigh-performancebeads(GEHealthcare,Uppsala,Sweden)andthenannealedtothesequencingprimerusingthePyroMarkQ96VacuumPrepWorkstation(BiotageAB,Qiagen).
Theprimedsingle-strandedDNAtemplateswerethentransferredtothemicrotiterplate-basedPSQHS96(Bio-tage,Sweden),wherereal-timesequencingofthesequencesur-roundingcodon600ofBRAFwasperformedbyusingPyroMarkGoldreagents(Qiagen)onaPyroMarkQ96IDinstrument(Biotage,Sweden).
Anegativecontrolandawild-typecontrolwererunwitheachseriesofsamples.
Real-timecurvesandpyrogramswereinterpretedaccordingtothekitinstructionsandPyroMarkIDsoftware(Qiagen)alloweddeterminationofmutantallelicfrequencyaccordingtorelativepeakheight.
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159DataanalysisTERTpointmutationobservedbySangerwascorrelatedwithpyrosequencinganalysisofBRAF,definitivehistologicaldiagno-sis,andpost-operativeTNMstagingoftheneoplasia.
ForthepositiveTERTmutationcases,themutationalanalysiswascon-firmedonfinalpost-surgicalhistologicalsamplestoverifythereliabilityofTERTmutationalstatusinCNBspecimens.
TERTmutationalanalysiswasalsoperformedon5definitivespeci-mensrandomlyselectedamongPTCcaseswithCNBwildtypeforC228T.
ResultsAtfinalhistologyaftersurgery,all26PTCand8hyperplasiasdiagnosedatmicrohistologywereconfirmed;5follicularneo-plasmsresultedin1follicularcarcinomaand4adenomas;regardingthose11lesionsassessedatCNBasuncertain/indeter-minate,4PTC,5follicularadenomas,2nodularhyperplasias,werefound.
TwocasesoutoftheindeterminateCNBdidnotallowadequateDNAextractionforthemolecularanalysis.
Asabove,thecollectedDNAwasadequateformolecularanalysisinallbut2ofthe50CNBsamples(96%).
The2cases(1adenomaand1nodularhyperplasia,4%)hadinsufficientqualityofDNAduetoextensivefragmentationandwerethereforeexcludedfromthestudy.
Table1describestheresultsandthecorrelationbetweenthepresenceofTERTmutationandthemultifocality,TNMstage,andBRAFmutationalstatusoftheseriesofthyroidlesionsunderevaluation.
C228TmutationoftheTERTpromoterwasreportedin3of30PTCs(10%),whiletheonlycaseofFC,theadenomas,andthehyperplasticnodulesdidnotshowTERTmutationandwereclassifiedaswild-type.
Fig.
1showsrepresentativeDNAsequenceelectropherogramsofthyroidtissuesampleswithandwithoutC228TmutationintheTERTpromoter.
AllC228TmutatedPTCsshowedadvancedTNMstaging,withanincidenceof17.
6%amongthelocallyadvanced(T3,T4)PTCseries.
TheBRAFmutationalstatuswasassessedinall48caseswithsufficientDNA.
Ofthese,11(22.
9%)wereV600Emutatedandtheremaining37(77.
1%)werewild-type.
Inagreementwiththeliterature[24],V600EmutationwasrestrictedtoPTCs(36.
6%).
AmongBRAFmutatedcasesthemutationrateatpyrosequenc-ingrangedfrom14.
2to39.
1%.
Ofrelevance,allTERTmutatedPTCsshowedconcomitantBRAFmutation(Table1).
Fig.
2showsthehistologyofoneofthedoublemutatedcases.
AllcaseswithaC228TTERTmutationonCNBshowedthesamemutationonsurgicalspecimens.
The5casesofPTCwithnega-tiveTERTanalysisonCNBresultedinwild-typeforC228Tonthedefinitivehistology.
DiscussionDuetoitshighsensitivity,specificityandaccuracy,thyroidFNAhasbeenestablishedasthemaintooltoidentifymalignantthy-roidnodules[25].
Itsmainlimitationsarenon-diagnosticandindeterminate(follicular)specimens,thelatteraccountingforabout15–20%ofallresults[26,27].
Inthesecases,thediagnosisofcancercannotbereliablyexcludedonamorphologicalbasis,Table1Histologicaltypes,TNMstaging,andBRAF/TERTmutationalstatusrecordedin48thyroidlesions.
TERTstatusHistologictypeTNM*BRAFmutatedcasesTERTmutated(n=3)PTC(n=3)T4N1b(n=1)1T3mN1b(n=1)1T3N1a(n=1)1All3(100%)TERTwildtype(n=45)PTC(n=27)T3mN1a(n=1)1T3N1b(n=3)1T3N1a(n=3)1T3N0(n=6)2T3Nx(n=1)1T1aN1a(n=3)–T2N0(n=1)–T2Nx(n=3)1T1amN0(n=1)1T1aN0(n=1)–T1aNx(n=4)–All8(29.
6%)FTC(n=1)T2Nx(n=1)–FA(n=8)––Nodularhyperplasia(n=9)––*CasesarelistedinorderofdecreasingTNMstagingPTC:Papillarythyroidcancer;FTC:Follicularthyroidcancer;FA:FollicularadenomaFig.
1TERTpromotermutation.
RepresentativeDNAsequenceelectropherogramsfromthyroidCNBspecimens.
Sensesequenceofawild-typeTERTpromotersample(top)andnucleotidechangesofapositiveC228Tsample(bottom).
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160andthepatientsrequiresurgeryforaconclusivediagnosis.
Atfinalhistology,themalignancyrateinthesecytologicalcatego-riesresultsinabout25%[28].
Intheareaofindeterminateandinconclusivecytologicaldiagnoses,severalstudiesanalyzingclinical,cytological,imaging,ormolecularparametersaspoten-tialriskpredictorshavebeenreported,withcontroversialfind-ings[29].
Todate,however,areliablediagnosticmolecularmarkerthatmaybeofuseforbothfollicularandpapillarythy-roidcarcinomasisstilllacking.
Thisrepresentsamajordraw-backwhentheoptionbetweenaconservativeorsurgicalmanagementofthesepatientsisconsidered.
Toovercomethislimitation,duringthelastdecadeaflourishingnumberofresearchreportshaveidentifiednovelmolecularmarkerstobetterassessthyroidcanceraggressiveness,andtheirusehasbeenproposedforclinicalpractice[30–32].
Inparticu-lar,greatrelevancehasbeenascribedtothemutationsofBRAF,RAS,RET/PTC,andPAX8/PPARγ,whichhavebeeninsomecasesdescribedaspotentialmalignancypredictors[30–32].
Thedem-onstrationofsomaticmutationsinabouttwo-thirdsofPTCs(BRAFmutationsandRET/PTCrearrangements)andofFTCs(RASmutationsandPAX8/PPARγrearrangements)hasopenednewperspectivesfortheclassificationanddiagnosisofthyroidtumors.
BRAFV600Erepresentsthemostextensivelystudiedmutationinthisdiagnosticcontext.
Unfortunately,thediagnos-ticeffectivenessofthedetectionofBRAFmutationinreassess-inginconclusivecytologicalcasesisdefinitelylow[30].
Morerecently,somestudieshavefoundevidencethatpatientswithTERT-mutatedtumorshadadecreasedsurvivalifcom-paredtoTERTwild-typetumors.
TERTmutationswerereportedashighlyprevalentinadvancedthyroidcancers,particularlyinthoseharboringBRAForRASmutation[33],sincetheacquisi-tionofaTERTpromotermutationmayprolongthesurvivalofBRAForRASdrivenclonesandmakepossibletheaccumulationofadditionalgeneticdefects,leadingtodiseaseprogression.
Additionally,asignificantassociationofTERTpromotermuta-tionswithdistantmetastasisandshorterdisease-specificsur-vivalwasfoundinFTCsandPTCsasawhole[34].
TheidentificationofTERTmutationsasaprognosticmarkerindifferentiatedthy-roidcarcinomas(DTC)mayturnrelevantfor2reasons:i)onlyasmallpercentageofthesecarcinomasbehaveaggressivelyandmayultimatelyturnlethal,andii)reliableprognosticindicatorsinthispathologicsettingareuptonowlacking[8].
ThemainlimitationinthepreoperativeuseofthyroidmolecularmarkersreliesonthelowreliabilityofFNAspecimensfortheseancillarystudies,sothatcurrentinternationalguidelinesdonotrecommendtheirroutineuse.
Inthissetting,theATAguidelinestates:"Manyofthesemarkersareavailableforcommercialuseinreferencelaboratoriesbuthavenotyetbeenwidelyappliedinclinicalpractice.
ItislikelythatsomecombinationofmolecularmarkerswillbeusedinthefuturetooptimizemanagementofpatientswithindeterminatecytologyonFNAspecimens.
TheuseofmolecularmarkersmaybeconsideredforpatientswithindeterminatecytologyonFNAtohelpguidemanagement"[35].
WeproposeCNBasasample,whichallowscombinationofmorphology,immunohistochemistry,andmolecularanalysis.
Veryrecently,apaperbyLiuetal.
[36]evaluatedTERTstatusin308cytologicalFNAsamples.
Theyrecordeda7%rateofTERTmutatedcancersandnoTERTmutationsinbenignlesions.
How-ever,ageneticconfirmationinsurgicalsampleswasnotper-formed.
Then,theactualreliabilityofFNAsamplestodetectTERTmutatedthyroidcancersisstillnotknown.
Coreneedlebiopsyhasbeendescribedasadiagnostictoolininconclusivecytologicaldiagnosis[10,15,37],andthemicro-histologicalevaluationofCNBsampleshasbeenproposedasacomplementarydiagnostictoolforthyroidnoduleswithincon-clusiveFNAreports.
ByCNB,alargepercentageofnodulesthatarereadasindeterminateorinadequateatFNAexaminationmaybereassessedasdiagnostic.
ThesemiautomatedCNBnee-dlesusedareofsmallcaliber(20to22gauge),allowingfullaccesstobothlargeandsmallthyroidnoduleswithfewcompli-cationsandhighpatienttolerability[16].
Thedevice'scostisslightlyhigherthanthoseofFNAbutitisthesameforallbiopsypractices,alsoofothersorgans.
Moreover,duetotheavailabilityofmultipleparaffinsections,thecorespecimenisperfectlysuit-ableforancillarystudiesincludingmolecularandimmuno-chemicalmarkers,andthereforeimprovesdiagnosticandprognosticevaluation.
Toourknowledge,therearenoreportsontheclinicaluseofTERTanalysisforthepreoperativeevaluationofpatientswiththyroidnodulardiseaseonCNBspecimens.
Noteworthy,theinadequacyrateformolecularanalysisinourstudyonCNBsam-pleswasonly4%,muchlowerthanthereportedadequacyonFNAspecimens,about8%inspecializedcenters[37].
Ofimpor-tance,weperformedthemicroscopicdissectionofcoresectionstoobtainDNAisolationfromsampleswithatleast50%ofpatho-logicalcells.
TheseenrichedsamplesavoidproblemsduetotherelativelylowsensitivityoftheSangermethod.
ThispossibilityisoneoftheadditionalvaluesoftheCNBvs.
FNAmethodology.
TosupportouraffirmationweperformedTERTmutationalanal-ysison5definitivespecimensrandomlyselectedamongPTCcaseswithCNBwildtypeforC228T,andallofthemconfirmedthewildtypestatus.
ForthepositiveTERTmutationcasesonCNB,moreover,themutationalstatuswasconfirmedonfinalpost-surgicalhistologicalsamples.
Whencomparedwithfinalhistologicaldiagnosisandstaging,allourcasesharboringTERTmutation(10%ofthePTCseries)resultedaslocallyinvasivePTCwithmultiplelymph-nodesmetastasisand,inonepatient,withlungmetastasis.
TheseresultsareinagreementwiththehighprevalenceofTERTmuta-tionreportedintheadvancedformofthedisease[33].
Inourseries,theprevalenceofTERTmutatedcasesis17.
6%amongFig.
2Histologicaldiagnosis.
PapillarythyroidcarcinomaharboringTERTandBRAFmutations.
Fibrousstromalreactionisevidentaroundneoplasticfoci.
H&Ehighpowerfield.
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161locallyadvancedPTCs.
Ontheotherhand,noTERTmutationwasfoundinfollicularadenomasorhyperplasia,confirmingthepre-viousdata[7,8]reportingamutationthatisrestrictedtomalig-nantlesions.
Inagreementwitharecentpublication[35],apositiveTERTpromotermutationtestnotonlydefinitivelydiag-nosesathyroidnoduleascancer,butalsopreoperativelyidenti-fiesacancerwithaggressivepotential.
Moreover,ourresultsconfirmtheassociationofTERTmutationwithBRAFV600Emutation,highlightingthecoexistenceofactivationofBRAFandofTERTgenespreviouslyreportedinmelanoma[2]andthyroidcarcinoma[1,5,6].
InconsiderationofthepoorresponsetoradioiodinetreatmentdemonstratedbyDTCswithTERTmutation,thisinformationcouldbeparticularlyrelevantduringstagingofthepatients,accordingtothecurrenttrendtoappropriatelylimitthenumberofpatientssubmittedtoradioiodineablation.
Arecentpublicationgivesevidenceofadiagnosticandprognos-ticroleofTERTpromotermutationsinthyroidfineneedlebiopsy(FNA)demonstratingthevalueofthisnovelmoleculartestinginthediagnosisandriskstratificationofthyroidnodule[36].
ThepresentstudydemonstratesthefeasibilityofTERTpro-motermutationalanalysisonthyroidcoreneedlebiopsies:thismethodsallowstheassessmentofpathologicalpopulationonparaffinsectionsbeforeDNAisolationavoidingtheriskofTERTfalsenegativeduetoinadequateorpoorsamplingbyFNA.
ThepossibilitytoreliablyidentifyTERTmutationsonthincorebiopsysamplesenablestheextensionoftheproposedmethod-ologytosolidtumorsindifferentanatomicalsitesusuallysam-pledbyCNBandinwhichTERThasbeenidentifiedasnegativeprognosticmarker.
Themostimportantaddedvalueofthepre-sentstudyisthedemonstrationofviabilityofTERTmutationalanalysisonthyroidcorebiopsyduringtheinitialevaluationofpatientswiththyroidnodule,providingaggregateinformationaboutmorphologyandTERTmutationalstatus.
Targetingmolecularmarkersforriskstratificationandsurgicalindication,theinclusionofTERTwithinthetraditionalmutationalpanel[38],characterizedbyanearly63%sensitivity,couldfurtherincreasethediagnosticaccuracyofpreoperativemolecularanal-ysisinthyroidnodulardiseases.
Thisapproachmoreovermayintegrateothertestsaimedtobestpredictmalignancyinthyroidnodules[39–41].
Theinformationindicatingaworseoutcomeofthetumor,maybeusedtoindividualizetreatmentdecision,surgicaloption,andfollow-updesign.
ThemajoradvantageofTERTmutationalanal-ysisonthyroidCNBwhencomparedwithFNAcytologyisthemoreconstantavailabilityandadequacyofcellularmaterialforacompletemolecularanalysis.
ConflictofInterestTheauthorsdeclarenoconflictofinterest.
Affiliations1PathologyUnit,CampusBio-MedicoUniversityHospital,Rome,Italy2SectionofEndocrinologyandDiabetology,OspedaleIsraelitico,Rome,Italy3SectionofPathology,OspedaleIsraelitico,Rome,Italy4SectionofPathology,OspedaleReginaApostolorum,AlbanoLaziale,Rome,Italy5TissueEngineeringUnit,CampusBio-MedicoUniversity,Rome,Italy6SectionofEndocrinology,OspedaleReginaApostolorum,AlbanoLaziale,Rome,Italy7InstituteofHumanAnatomyandCellBiology,SacroCuoreCatholicUniversityHospital,Rome,ItalyReferences1VinagreJ,AlmeidaA,PópuloH,BatistaR,LyraJ,PintoV,CoelhoR,CelestinoR,PrazeresH,LimaL,MeloM,daRochaAG,PretoA,CastroP,CastroL,PardalF,LopesJM,SantosLL,ReisRM,Cameselle-TeijeiroJ,Sobrinho-SimesM,LimaJ,MáximoV,SoaresP.
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