“Noninvasive follicular thyroid neoplasm with papillary-like nuclear features” or NIFTP

[univlad]

http://www.nytimes.com/2016/04/15/health/thyroid-tumor-cancer-reclassification.html

http://oncology.jamanetwork.com/article.aspx?articleid=2513250

Apparently a group is suggesting that we rename or has renamed small encapsulated papillary thyroid carcinomas as NIFT-P. Is this an official change that we all should be using? Will CAP update their tumor protocols accordingly? What about thyroid FNA's? Should we change to calling them positive for a papillary 'neoplasm' since we can't tell if there is a capsule?

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[yaah]

Yes. Institutions are already starting to do this. The publication of the paper gave us "permission" essentially to start using the entity. This is more than just "a group" who is suggesting this change. It's a huge, international endeavor which has been going on for years. It's as close as anything to the gospel truth.

Have not seen official guidance on FNAs or on the clinical management of abnormal FNAs as a result. Would expect that would be forthcoming.

 

[Amerek]

Treatment of cytology is currently under discussion. It's possible we could start calling all FVPTC "suspicious for follicular neoplasm."

This would allow cytologists to triage people for diagnostic lobectomy and do completions on the FVPTC that turn out to be invasive.

 

[WEBB PINKERTON]

I hope the thyroid bethesda system doesn't need to be changed again. Cytology serves no purpose other than triage. Positive for papillary neoplasm...oh boy.

They probably should just have two diagnoses for all cytology specimens anyways-thumbs up, thumbs down.

 

[univlad]

Treatment of cytology is currently under discussion. It's possible we could start calling all FVPTC "suspicious for follicular neoplasm."

This would allow cytologists to triage people for diagnostic lobectomy and do completions on the FVPTC that turn out to be invasive.

Wouldn't the FVPTC and regular PTC carcinoma look the same under FNA? You'd just see grooves and inclusions likely unless you were lucky enough to get psamoma bodies or see some fragments of papillary architecture.

 

[Euchromatin]

Complete agree with Yaah. This was a huge undertaking involving essentially every endocrine pathology "expert." This is about the most official nomenclature change I have ever seen and, yes, we should all be using it. I know some academic pathologists had already started using the new terminology even before the publication and I, like many others, have just waiting for the publication to start doing so. The NIFTP article notes "Staging would be unnecessary," so I would interpret this to indicate that staging and a CAP synoptic report are no longer recommended for NIFTP lesions. I'm not sure how soon CAP will update the thyroid protocol to reflect the fact that completely encapsulated/well-demarcated FVPTC without invasion no longer "counts" as carcinoma or needs a synoptic, as that one was just updated in January of this year.

I'm not sure if there will be a change in the Bethesda system or other cytology diagnoses. There have been a few articles published addressing the fact that the rates of malignancy for the existing Bethesda categories significantly drops when lesions previously called noninvasive FVPTC are considered NIFTP (listed below), but that's all I've seen so far. I'm not sure how applicable this would be to FNA diagnosis (I don't routinely do cytopath), but, in my experience, FVPTC generally has more subtle papillary nuclear features and rarely has more severe changes like pseudoinclusions. In almost every case in which the nuclear features are immediately obvious, you can typically find at least one or two good papillae, which makes the entire lesion conventional/classic PTC.
http://www.ncbi.nlm.nih.gov/pubmed/26572991
http://www.ncbi.nlm.nih.gov/pubmed/26114752
http://www.ncbi.nlm.nih.gov/pubmed/26457584

 

[yaah]

Yes. Staging is unnecessary, it is a benign lesion. We signed out a case this week with this dx.

I eagerly await the 5 years down the road publications of "NIFT with equivocal papillary features" showing that these also are benign.