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The Utility of Frozen Section Evaluation for Follicular Thyroid Lesions

Nuclear Medicine Service, Santa Casa de Belo Horizonte, Minas Gerais, Brazil.

To the Editor:

Fine-needle aspiration is the main method used to investigate the cause of thyroid nodules; however, this examination cannot differentiate benign and malignant follicular lesions, an important distinction in the definition of the surgical extent (lobectomy versus bilateral thyroidectomy). To define the nature of the lesion during surgery, many surgeons use intraoperative frozen sections (FS), with total thyroidectomy being performed in those patients in whom FS reveal malignancy, thus avoiding reoperation.

In the January 2004 issue of Annals of Surgical Oncology, Callcut et al.¹ reported the results of 152 patients who had surgical resection for follicular neoplasms. Of those, 41 (32%) FS were classified as benign, 5 (4%) as malignant, and 3 (2%) as indeterminate, and in 80 (62%) cases the diagnosis was "follicular lesion." FS for the diagnosis of follicular thyroid cancer had a sensitivity, specificity, positive predictive value, and accuracy of 67%, 100%, 100%, and 96%, respectively. In most cases (64%), FS provided no additional information at the time of surgery. The authors concluded that, because of its low sensitivity, the routine use of FS is not cost-effective in patients with follicular thyroid lesions.

To contribute to the data of Callcut et al.¹ demonstrating that the routine use of FS has a limited role in patients with a preoperative diagnosis of follicular neoplasia, we report our experience which supports this conclusion, despite differences related to the high prevalence of carcinoma observed in our series. FS revealed malignancy in 23 cases (32.8%), benign lesions in 20 (28.5%), and follicular lesions in 27 (38.5%). The sensitivity of FS for the diagnosis of carcinoma was 70% and specificity was 95%, with a 91.3% positive predictive value and 90.7% accuracy. Lesions with a diameter >3 cm, age >50, and male gender were found significantly more frequently among patients with carcinoma than among those with benign lesions. In addition to confirming the limited sensitivity of FS for carcinoma, we also consider the possibility of false-positive results as already demonstrated in other studies,^2–4 which would result in unnecessary total thyroidectomy. Thus, supporting the conclusion of Callcut et al.¹, we believe that FS should not be used routinely in patients with a diagnosis of follicular lesions.

REFERENCES

1. Callcut RA, Selvaggi SM, Mack E, Ozgul O, Warner T, Chen H. The utility of frozen section evaluation for follicular thyroid lesions. Ann Surg Oncol 2004; 11: 94–8.[Abstract/Free Full Text]
2. Duek SD, Goldenberg D, Linn S, Krausz MM, Hershko DD. The role of fine-needle aspiration and intraoperative frozen section in the surgical management of solitary thyroid nodules. Surg Today 2002; 32: 857–61.[Medline]
3. Taneri F, Poyraz A, Salman B, et al. Using imprint and frozen sections in determining the surgical strategies for thyroid pathologies. Endocr Regul 2001; 35: 71–4.[Medline]
4. Lukacs GL, Miko TL, Fabian E, Zs-Nagy I, Csaky G, Balazs G. The validity of some morphologic methods in the diagnosis of thyroid malignancy. Acta Chir Scand 1983; 149: 759–66.[Medline]

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