Incidental thyroid carcinoma: Correlation between FNAB cytology and pathological examination in 1093 cases

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In most cases, thyroid nodules are benign, but they are surgically treated when symptomatic or if malignancy is suspected.<a class="elsevierStyleCrossRef" href="#bib0003">3</a> Fine-Needle Aspiration Biopsy (FNAB) guided by Ultrasonography (USG) is the most important investigation method and is essential for surgical treatment indication.<a class="elsevierStyleCrossRef" href="#bib0004">4</a>,<a class="elsevierStyleCrossRef" href="#bib0005">5</a> The main purpose of investigating thyroid nodules is to diagnose malignancy.<a class="elsevierStyleCrossRef" href="#bib0002">2</a> Thyroid carcinomas are called “incidental” when diagnosed by a pathological study of the surgical specimen, with no previous suspicion by other diagnostic methods before surgery. Incidental thyroid cancer rates have been evaluated by Smith et al.<a class="elsevierStyleCrossRef" href="#bib0006">6</a> in a multicenter study that demonstrated high rates in men and young people. There are reports of patients with incidental thyroid carcinoma who did have an FNAB performed preoperatively, but those sampled only benign nodules, demonstrating the need for a more careful selection of the biopsy sites.<a class="elsevierStyleCrossRef" href="#bib0007">7</a> When compared to non-incidental thyroid carcinomas, incidentalomas are more frequent in older patients. In earlier stages, they have more favorable histopathological characteristics and a better prognosis.<a class="elsevierStyleCrossRef" href="#bib0008">8</a> Despite the more optimistic profile recorded in the literature, Maturo et al.<a class="elsevierStyleCrossRef" href="#bib0009">9</a> identified evidence of lymph node metastases in 57.7% of patients with incidental thyroid carcinomas. Moreover, 4% of the 282 incidentalomas in a study conducted by Christakis et al.<a class="elsevierStyleCrossRef" href="#bib0010">10</a> were classified as intermediate risk according to the ATA (American Thyroid Association) guidelines.The present study aims to analyze the incidence of incidental malignant lesions in patients who underwent total thyroidectomy by comparing the results of Fine Needle Aspiration Biopsy (FNAB) cytology and postoperative pathological findings.Patients and methodsThe present study is derived from a survey carried out in 2009‒2013 at Hospital das Clínicas of Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), and the first results were published in 2018 by Mosca et al.<a class="elsevierStyleCrossRef" href="#bib0011">11</a>Medical records of 1,479 patients who underwent total thyroidectomy and pathological examination of the resected thyroid were reviewed. FNAB results of preoperatively biopsied lesions were compared with the pathological studies conducted after thyroidectomy. Each surgical specimen investigated received two independent histopathological diagnoses: LD (Local Diagnosis) ‒ for the same area or nodule in which the FNAB was performed; and FD (Final Diagnosis), which includes the investigation of the entire surgical specimen. Of the 1479 individuals that underwent thyroidectomy, 248 were excluded due to insufficient general data, and another 138 were excluded due to the impossibility of correlating the area submitted to FNAB and the final pathological diagnosis.<a class="elsevierStyleCrossRef" href="#bib0011">11</a> The Bethesda system was used in the interpretation of the results of FNAB cytology. For analysis purposes, Bethesda's categories were grouped into “benign” (Bethesda II), “atypical or suspicious” (Bethesda III, IV and V), “malignant” (Bethesda VI) and “nondiagnostic or unsatisfactory” (Bethesda I). Surgical indications for patients with a nondiagnostic result of FNAB or benign diagnosis were compressive symptoms due to goiter, hyperthyroidism refractory to non-surgical treatments, substernal goiter, and high clinical or radiological suspicion of malignancy.The present study was approved by HCFMUSP Institutional Review Board (Comissão de Ética para Análise de Projetos de Pesquisa ‒ CAPPesq).ResultsOne thousand and ninety-three patients were investigated. Of these, 969 (88.7%) were female. The 'patients' mean age was 52.7, ranging from 13 to 87 years. FNAB results were as follows: malignant in 187 patients (17.1%), benign in 204 cases (18.7%), suspicious or indeterminate in 668 cases (61.1%), and inconclusive in 34 cases (3.1%). The pathological result of the site where FNAB was performed was benign in 201 of the 204 cases classified as Bethesda II. Therefore, 1.5% of the cases (3 patients) were false-negative in the preoperative cytological analysis. Two (1.1%) out of 187 patients classified as Bethesda VI were found to be false positive, as they had benign LD (<a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>). Of the 1,093 patients that underwent total thyroidectomy, 294 were diagnosed with malignancy at the biopsy site (LD). In the remaining 799 patients, LD was benign. Of these, 121 cases had a diagnosis of malignancy considering the histopathological evaluation of the entire surgical specimen (FD), characterizing, therefore, a 15.1% prevalence of incidental thyroid carcinoma.<elsevierMultimedia ident="tbl0001"></elsevierMultimedia>Considering the 201 patients classified as Bethesda II in FNAB and with benign LD, it was found that 183 had benign FD and 18 had malignant FD, characterizing a 9.0% prevalence of incidental diagnosis of malignancy in the group of patients categorized as Bethesda II (<a class="elsevierStyleCrossRef" href="#fig0001">Fig. 1</a>). The incidence of incidentalomas was higher in Bethesda III and IV groups (<a class="elsevierStyleCrossRefs" href="#fig0002">Figs. 2 and 3</a>). There was no incidental thyroid carcinoma in cases preoperatively diagnosed as Bethesda V (<a class="elsevierStyleCrossRef" href="#fig0004">Fig. 4</a>). Regarding the 'incidentalomas' size, 82 (67.8%) were smaller than or equal to 0.5 cm, 16 (13.2%) were between 0.5 and 1.0 cm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 5</a>), and 23 (19%) were larger than 1cm on the major axis (<a class="elsevierStyleCrossRef" href="#tbl0002">Table 2</a>). 'Incidentalomas' predominant histological type was papillary thyroid carcinoma (118 cases, 97.5%), but occurrences of follicular carcinoma, medullary carcinoma, and a carcinoma without other specifications were also found (<a class="elsevierStyleCrossRef" href="#tbl0003">Table 3</a>).<elsevierMultimedia ident="fig0001"></elsevierMultimedia><elsevierMultimedia ident="fig0002"></elsevierMultimedia><elsevierMultimedia ident="fig0003"></elsevierMultimedia><elsevierMultimedia ident="fig0004"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0002"></elsevierMultimedia><elsevierMultimedia ident="tbl0003"></elsevierMultimedia>DiscussionThe present study compared the result of preoperative cytological analysis of thyroid lesions with the respective pathological examination of the thyroidectomy surgical specimen. Pre and postoperative results were compared for determining malignancy or benignity. Preoperatively, the Bethesda system was used to determine the risk of malignancy of a biopsied nodule. Lesions classified as Bethesda II were considered benign, Bethesda VI as malignant and Bethesda III, IV and V as atypical or suspicious. Postoperatively, two different pathological evaluations were performed, which adds value to the interpretation of the results presented. Firstly, it was verified whether the nodule or the lesion biopsied by FNAB had a pathological diagnosis compatible with its preoperative cytological classification, that is if the diagnosis was confirmed. Only 3 (1.5%) of the lesions considered benign by FNAB were malignant in the local pathological exam (false-negative). The second review of the pathological exam verified whether there was malignancy in any region of the excised surgical specimen, and not only in the place where the biopsy was performed preoperatively. This second evaluation revealed the occurrence of incidental cancer in 15.1% of the patients with benign anatomical pathology at the site of the FNAB. Considering only the cases that were benign in FNAB (Bethesda II), the incidentaloma prevalence dropped to 9.0%. A multicenter study,<a class="elsevierStyleCrossRef" href="#bib0006">6</a> published in 2013 by Smith et al., showed that incidental thyroid carcinoma rate reached 15.6% of the 1,523 patients operated for benign preoperative pathologies (excluding pathologies of undetermined significance and suspected for malignancy). Despite presenting similar incidentaloma rates, it is important to note that, while the first study compared the FNAB results with the final pathological examination, the present study compares the pathological examination result of the site in which FNAB was performed with the final pathological examination of the entire surgical specimen.Corroborating the present study, Bradley et al.<a class="elsevierStyleCrossRef" href="#bib0012">12</a> concluded that 12% of patients were operated on for benign conditions, such as Hashimoto's thyroiditis, follicular adenoma, multinodular goiter, and Graves' disease, had an Incidental Papillary Carcinoma (IPC) as their final histopathological diagnosis. The author even suggests that total thyroidectomy should be considered in patients with Hashimoto thyroiditis and follicular adenoma due to the high incidence of IPC in the contralateral lobe. A preference for total thyroidectomy as the first surgical treatment for benign diseases is also stated in other studies<a class="elsevierStyleCrossRef" href="#bib0006">6</a>,<a class="elsevierStyleCrossRef" href="#bib0009">9</a>,<a class="elsevierStyleCrossRefs" href="#bib0012">12–16</a> due to the high prevalence of incidental neoplasms. However, the authors recommend cautiousness and attention to the classic indications for total thyroidectomy in order to avoid rare but potentially serious complications, such as definitive hypoparathyroidism and inferior laryngeal nerve injury in patients without malignancy suspicion. When non-surgical intervention is indicated for patients with benign FNAB, the possibility of coexisting microcarcinoma with its variable prognosis should be taken into account and explained to the patient.<a class="elsevierStyleCrossRef" href="#bib0017">17</a>Machala et al., in a study that also compared FNAB and thyroid anatomopathological results, concluded that the cytological method is essential for diagnostic investigation of thyroid lesions because it is safe, simple, fast, and cost-effective since it receives adequate pathological interpretation.<a class="elsevierStyleCrossRef" href="#bib0018">18</a> New investigation methods of thyroid nodules, such as elastography, PET/CT, biomarkers, and tumor markers are being investigated, but there is a consensus that USG-guided FNA is essential for the management of patients with thyroid nodules.<a class="elsevierStyleCrossRefs" href="#bib0003">3–5</a>,<a class="elsevierStyleCrossRef" href="#bib0008">8</a> Nevertheless, the high occurrence of incidentalomas draws attention to the need for a more careful selection of thyroid sites to be biopsied. When only the LD results are compared with the preoperative diagnosis, it can be seen that the false-negative percentage in the Bethesda II category is 1.5% in this study, compatible with the error rate predicted for the method in the literature 0% to 3%.<a class="elsevierStyleCrossRef" href="#bib0019">19</a> Thus, it can be affirmed that the high rates of incidental thyroid carcinoma are due to a thyroid biopsy site selection problem rather than failure of the FNAB cytological interpretation itself. Miccoli et al. reported that in some cases of incidental thyroid carcinoma, FNAB was performed preoperatively in another nodule, which was benign. The authors concluded that there is a need not only to select the biopsy sites more carefully but also to collect several samples from the same nodule when it exceeds 2 cm in diameter.<a class="elsevierStyleCrossRef" href="#bib0007">7</a>Pezzolla et al.<a class="elsevierStyleCrossRef" href="#bib0020">20</a> compared the occurrence of incidentalomas in patients undergoing thyroidectomy for presumably benign diseases and patients with Bethesda III nodules undergoing thyroidectomy. This study obtained 16.8% of incidentalomas in the first group and 16.2% of malignant lesions in the second, but not in the same biopsied site preoperatively diagnosed as Bethesda III. Attention should be given to the indications for FNAB in thyroid nodules: preferably nodules larger than 10 mm, solid, hypoechoic, taller-than-wide, with irregular margins, taller than wide, with extrathyroid extension, intranodular vascular spots, or microcalcifications.<a class="elsevierStyleCrossRef" href="#bib0018">18</a>,<a class="elsevierStyleCrossRef" href="#bib0021">21</a>,<a class="elsevierStyleCrossRef" href="#bib0022">22</a> However, it may be necessary to optimize such indications in order to reduce not only the occurrence of postoperative diagnosis of malignant lesions but also the overdiagnosis of clinically insignificant thyroid neoplasms. In the present study, 19% of patients with an incidental malignant lesion had tumors larger than 1.0 cm, which, therefore, would be probably identifiable by preoperative USG. Active Surveillance (AS) is a clinical practice proposed for the management of selected Papillary Thyroid Microcarcinomas (mPTC) instead of the primary surgical approach. AS could be an alternative to immediate surgery to avoid overtreatment in unifocal intrathyroidal mPTC, without metastatic lymph nodes or aggressive cytological features. However, multifocality is a potential contraindication for this practice, as well as the subcapsular location of the mPTC, previous external radiotherapy, or family history of differentiated thyroid carcinoma.<a class="elsevierStyleCrossRef" href="#bib0023">23</a> Although the authors of the present study believe that AS plays a key role in mPTC, the authors stress that the high incidence of incidental thyroid carcinoma should be considered when multifocality is suspected, which is a potential contraindication for AS, as mentioned above. Thyroid carcinoma prevalence identified at autopsies is high, reaching 35.6% of consecutive autopsied patients in a Finnish study,<a class="elsevierStyleCrossRef" href="#bib0024">24</a> which concluded that papillary tumors smaller than 0.5 cm could be a frequent finding in the thyroid gland. In contrast, Christakis et al.<a class="elsevierStyleCrossRef" href="#bib0010">10</a> published the occurrence of intermediate-risk incidentalomas (according to ATA 2015) in 4% of the incidental thyroid carcinomas in their series (282 incidentalomas/1,369 patients), highlighting the oncological relevance of such findings.The present study also emphasizes the importance of performing anatomopathological analysis on the entire extension of the resected thyroid gland, and not only in the site of the lesion in focus, given the risk of incidental neoplasms.ConclusionThe ITC incidence is high. Although the occurrence of false-negative results in Bethesda II nodules is only 1.5%, 9% of these patients presented ITC in the thyroid parenchyma outside the nodule evaluated by preoperative FNAB. The incidence of ITC in the same scenario was even higher in Bethesda III (17.5%) and Bethesda IV cases (19%). Despite the high incidence of incidentalomas, the authors recommend cautiousness and attention to the classic indications for total thyroidectomy in order to avoid potentially serious complications. Most incidentalomas are less than 0.5 cm in the largest diameter. Papillary thyroid carcinoma is the predominant histological type. Anatomopathological examination of the surgical specimen should be performed in the entire specimen, and not only in macroscopic lesions. Ultrasonography-guided FNAB is an excellent method for thyroid nodules clinical evaluation. Nevertheless, the areas to be biopsied must be carefully selected.Authors' contributionsAll authors contributed to this study. Data collection and case review were performed by Mosca L and Araujo-Neto VJ. Data analysis was supervised by Silva LF and Kowalski LP. Araujo-Filho VJ and Carneiro PC were responsible for the study design and data analysis The manuscript draft and its final version were written by Rodrigues MG. The final version of the manuscript was reviewed by  Silva LF, Kowalski LP, Araujo-Filho VJ and Carneiro PC. All approved the final manuscript. The corresponding author is Carneiro PC who attests that all participants in this study meet the criteria for authorship." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1954098" "titulo" => "Highlights" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abss0001" ] ] ] 1 => array:3 [ "identificador" => "xres1954099" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abss0003" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abss0004" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abss0005" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abss0006" "titulo" => "Conclusion" ] ] ] 2 => array:2 [ "identificador" => "xpalclavsec1682154" "titulo" => "Keywords" ] 3 => array:2 [ "identificador" => "sec0001" "titulo" => "Introduction" ] 4 => array:2 [ "identificador" => "sec0002" "titulo" => "Patients and methods" ] 5 => array:2 [ "identificador" => "sec0003" "titulo" => "Results" ] 6 => array:2 [ "identificador" => "sec0004" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0005" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0006" "titulo" => "Authors' contributions" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-09-27" "fechaAceptado" => "2021-12-08" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1682154" "palabras" => array:4 [ 0 => "Thyroid neoplasms" 1 => "Incidental findings" 2 => "Pathology" 3 => "Diagnosis" ] ] ] ] "tieneResumen" => true "highlights" => array:2 [ "titulo" => "Highlights" "resumen" => "<ul class="elsevierStyleList" id="celist0001"><li class="elsevierStyleListItem" id="celistitem0001">•Incidental thyroid carcinomas are diagnosed by pathological study of the surgical specimen, with no previous suspicion by other diagnostic methods before surgery.</li><li class="elsevierStyleListItem" id="celistitem0002">•Incidental thyroid cancer has been found at high rates in men and young people, usually, but not always, with more favorable histopathological characteristics and better prognosis.</li><li class="elsevierStyleListItem" id="celistitem0002a">•The better understanding of incidental thyroid cancer can improve decisions towards active surveillance strategies for the management of papillary thyroid carcinoma.</li></ul>" ] "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo investigate Incidental Thyroid Carcinoma (ITC) by comparing the results of Fine Needle Aspiration Biopsy (FNAB) cytology and the postoperative pathological findings. MethodsData of 1479 patients who underwent total thyroidectomy were retrieved. Three hundred eighty-six patients were excluded due to insufficient data. Each surgical specimen studied received two histopathological diagnoses: the local diagnosis ‒ for the same area in which the FNAB was performed; and the final diagnosis, which includes a study of the entire surgical specimen. ResultsA thousand and ninety-three patients were investigated. FNAB result was malignant in 187 patients, benign in 204, suspicious or indeterminate in 668 cases, and inconclusive in 34 cases. The prevalence of ITC was 15.1%. Most of the ITC in this series was less than 0.5 cm. The incidence of ITC was higher in Bethesda III (17.5% ITC) and IV (19% ITC) than in Bethesda II cases (1.5% false negatives and 9% ITC). ConclusionAlthough the incidence of false-negative results in Bethesda II nodules is only 1.5%, 9% of these patients had ITC in the thyroid parenchyma outside the nodule that underwent preoperative FNAB. The incidence of ITC in the same scenario was even higher in Bethesda III (17.5%) and Bethesda IV cases (19%). Ultrasonography-guided FNAB is an excellent method for the assessment of thyroid nodules. However, biopsy sites should be carefully selected. Despite the high incidence of incidentalomas, total thyroidectomy should not always be the treatment of choice due to its rare but potentially serious complications. The findings of the present study can assist future clinical decisions towards active surveillance strategies for the management of papillary thyroid carcinoma." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abss0003" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abss0004" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abss0005" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abss0006" "titulo" => "Conclusion" ] ] ] ] "multimedia" => array:8 [ 0 => array:8 [ "identificador" => "fig0001" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1334 "Ancho" => 3153 "Tamanyo" => 252579 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0001" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Anatomopathological exams of patients categorized as Bethesda II." ] ] 1 => array:8 [ "identificador" => "fig0002" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1333 "Ancho" => 3167 "Tamanyo" => 215761 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0002" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Anatomopathological exams of patients categorized as Bethesda III." ] ] 2 => array:8 [ "identificador" => "fig0003" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1333 "Ancho" => 3167 "Tamanyo" => 217728 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0003" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Anatomopathological exams of patients categorized as Bethesda IV." ] ] 3 => array:8 [ "identificador" => "fig0004" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 931 "Ancho" => 3001 "Tamanyo" => 148342 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0004" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Anatomopathological exams of patients categorized as Bethesda V." ] ] 4 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 958 "Ancho" => 1500 "Tamanyo" => 138713 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0005" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Gross appearance of an incidental papillary carcinoma with a major axis of 0.5 cm (blue arrow)." ] ] 5 => array:8 [ "identificador" => "tbl0001" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0006" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0001"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="top" scope="col">Postoperative local diagnosis \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0002"></a><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Preoperative Bethesda findings</th></tr><tr title="table-row"><a name="en0001a"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0004"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">I \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0005"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">II \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0006"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">III \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0007"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">IV \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0008"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">V \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0009"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">VI \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0010"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0011"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Adenoma \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0012"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0013"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0014"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0015"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0016"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0017"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0018"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0019"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Goiter/Thyroiditis/Graves \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0020"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0021"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">196 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0022"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">314 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0023"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">189 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0024"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0025"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0026"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">740 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0027"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Anaplastic carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0028"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0029"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0030"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0031"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0032"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0033"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0034"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0035"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Follicular carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0036"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0037"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0038"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0039"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0040"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0041"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0042"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0043"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Medullary carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0044"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0045"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0046"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0047"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0048"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0049"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0050"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0051"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Papillary carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0052"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0053"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0054"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0055"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0056"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0057"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">171 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0058"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">259 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0059"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Poorly differentiated carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0060"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0061"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0062"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0063"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0064"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0065"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0066"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0067"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Other types of carcinomas \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0068"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0069"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0070"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0071"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0072"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0073"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0074"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0075"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Linfoma \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0076"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0077"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0078"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0079"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0080"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0081"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0082"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0083"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0084"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0085"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">204 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0086"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">411 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0087"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">242 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0088"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0089"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">187 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0090"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1,093 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3252764.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Association of preoperative FNAB Bethesda classification and local diagnosis at the final pathological report." ] ] 6 => array:8 [ "identificador" => "tbl0002" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0007" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0091"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Tumor size \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0092"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Number of incidentalomas (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0093"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">≤ 0.5 cm \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0094"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">82 (67.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0095"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">> 0.5 cm to ≤ 1.0 cm \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0096"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">16 (13.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0097"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">> 1.0 cm \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0098"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">23 (19.0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3252766.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Size of incidentalomas." ] ] 7 => array:8 [ "identificador" => "tbl0003" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0008" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0099"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Histological types \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0100"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Number of cases (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0101"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Papillary carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0102"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">118 (97.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0103"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Follicular carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0104"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0105"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Medullary carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0106"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0107"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Other types of carcinomas \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0108"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3252765.png" ] ] ] ] 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Mariana Gonçalves Rodriguesa, Luiz Fernando Ferraz da Silvab, Vergilius José Furtado de Araujo-Filhoa, Letícia de Moraes Moscaa, Vergilius José Furtado de Araujo-Netoa, Luiz Paulo Kowalskia, Paulo Campos Carneirob,

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p.carneiro@fm.usp.br

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a Departamento de Cirurgia, Cirurgia de Cabeça e Pescoço, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, Brazil

b Departamento de Patologia, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, Brazil

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          "en" => "<p id="spara005" class="elsevierStyleSimplePara elsevierViewall">Gross appearance of an incidental papillary carcinoma with a major axis of 0&#46;5 cm &#40;blue arrow&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0008">Introduction</span><p id="para0007" class="elsevierStylePara elsevierViewall">Thyroid cancer incidence has increased in the last years&#44; and one of the main reasons for this fact is the rise in incidental detection of small nodules by imaging exams&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a> Thyroid nodules are frequent in the population&#44; especially in women and the elderly&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> They are identified by physical examination or incidentally detected in imaging tests requested for other reasons&#46; In most cases&#44; thyroid nodules are benign&#44; but they are surgically treated when symptomatic or if malignancy is suspected&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> Fine-Needle Aspiration Biopsy &#40;FNAB&#41; guided by Ultrasonography &#40;USG&#41; is the most important investigation method and is essential for surgical treatment indication&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> The main purpose of investigating thyroid nodules is to diagnose malignancy&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> Thyroid carcinomas are called &#8220;incidental&#8221; when diagnosed by a pathological study of the surgical specimen&#44; with no previous suspicion by other diagnostic methods before surgery&#46; Incidental thyroid cancer rates have been evaluated by Smith et&#160;al&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> in a multicenter study that demonstrated high rates in men and young people&#46; There are reports of patients with incidental thyroid carcinoma who did have an FNAB performed preoperatively&#44; but those sampled only benign nodules&#44; demonstrating the need for a more careful selection of the biopsy sites&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> When compared to non-incidental thyroid carcinomas&#44; incidentalomas are more frequent in older patients&#46; In earlier stages&#44; they have more favorable histopathological characteristics and a better prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> Despite the more optimistic profile recorded in the literature&#44; Maturo et&#160;al&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> identified evidence of lymph node metastases in 57&#46;7&#37; of patients with incidental thyroid carcinomas&#46; Moreover&#44; 4&#37; of the 282 incidentalomas in a study conducted by Christakis et&#160;al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> were classified as intermediate risk according to the ATA &#40;American Thyroid Association&#41; guidelines&#46;</p><p id="para0008" class="elsevierStylePara elsevierViewall">The present study aims to analyze the incidence of incidental malignant lesions in patients who underwent total thyroidectomy by comparing the results of Fine Needle Aspiration Biopsy &#40;FNAB&#41; cytology and postoperative pathological findings&#46;</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0009">Patients and methods</span><p id="para0009" class="elsevierStylePara elsevierViewall">The present study is derived from a survey carried out in 2009&#8210;2013 at Hospital das Cl&#237;nicas of Faculdade de Medicina da Universidade de S&#227;o Paulo &#40;HCFMUSP&#41;&#44; and the first results were published in 2018 by Mosca et&#160;al&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a></p><p id="para0010" class="elsevierStylePara elsevierViewall">Medical records of 1&#44;479 patients who underwent total thyroidectomy and pathological examination of the resected thyroid were reviewed&#46; FNAB results of preoperatively biopsied lesions were compared with the pathological studies conducted after thyroidectomy&#46; Each surgical specimen investigated received two independent histopathological diagnoses&#58; LD &#40;Local Diagnosis&#41; &#8210; for the same area or nodule in which the FNAB was performed&#59; and FD &#40;Final Diagnosis&#41;&#44; which includes the investigation of the entire surgical specimen&#46; Of the 1479 individuals that underwent thyroidectomy&#44; 248 were excluded due to insufficient general data&#44; and another 138 were excluded due to the impossibility of correlating the area submitted to FNAB and the final pathological diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> The Bethesda system was used in the interpretation of the results of FNAB cytology&#46; For analysis purposes&#44; Bethesda&#39;s categories were grouped into &#8220;benign&#8221; &#40;Bethesda II&#41;&#44; &#8220;atypical or suspicious&#8221; &#40;Bethesda III&#44; IV and V&#41;&#44; &#8220;malignant&#8221; &#40;Bethesda VI&#41; and &#8220;nondiagnostic or unsatisfactory&#8221; &#40;Bethesda I&#41;&#46; Surgical indications for patients with a nondiagnostic result of FNAB or benign diagnosis were compressive symptoms due to goiter&#44; hyperthyroidism refractory to non-surgical treatments&#44; substernal goiter&#44; and high clinical or radiological suspicion of malignancy&#46;</p><p id="para0011" class="elsevierStylePara elsevierViewall">The present study was approved by HCFMUSP Institutional Review Board &#40;Comiss&#227;o de &#201;tica para An&#225;lise de Projetos de Pesquisa &#8210; CAPPesq&#41;&#46;</p></span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0010">Results</span><p id="para0012" class="elsevierStylePara elsevierViewall">One thousand and ninety-three patients were investigated&#46; Of these&#44; 969 &#40;88&#46;7&#37;&#41; were female&#46; The &#39;patients&#39; mean age was 52&#46;7&#44; ranging from 13 to 87 years&#46; FNAB results were as follows&#58; malignant in 187 patients &#40;17&#46;1&#37;&#41;&#44; benign in 204 cases &#40;18&#46;7&#37;&#41;&#44; suspicious or indeterminate in 668 cases &#40;61&#46;1&#37;&#41;&#44; and inconclusive in 34 cases &#40;3&#46;1&#37;&#41;&#46; The pathological result of the site where FNAB was performed was benign in 201 of the 204 cases classified as Bethesda II&#46; Therefore&#44; 1&#46;5&#37; of the cases &#40;3 patients&#41; were false-negative in the preoperative cytological analysis&#46; Two &#40;1&#46;1&#37;&#41; out of 187 patients classified as Bethesda VI were found to be false positive&#44; as they had benign LD &#40;<a class="elsevierStyleCrossRef" href="#tbl0001">Table&#160;1</a>&#41;&#46; Of the 1&#44;093 patients that underwent total thyroidectomy&#44; 294 were diagnosed with malignancy at the biopsy site &#40;LD&#41;&#46; In the remaining 799 patients&#44; LD was benign&#46; Of these&#44; 121 cases had a diagnosis of malignancy considering the histopathological evaluation of the entire surgical specimen &#40;FD&#41;&#44; characterizing&#44; therefore&#44; a 15&#46;1&#37; prevalence of incidental thyroid carcinoma&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><p id="para0013" class="elsevierStylePara elsevierViewall">Considering the 201 patients classified as Bethesda II in FNAB and with benign LD&#44; it was found that 183 had benign FD and 18 had malignant FD&#44; characterizing a 9&#46;0&#37; prevalence of incidental diagnosis of malignancy in the group of patients categorized as Bethesda II &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46;&#160;1</a>&#41;&#46; The incidence of incidentalomas was higher in Bethesda III and IV groups &#40;<a class="elsevierStyleCrossRefs" href="#fig0002">Figs&#46; 2 and 3</a>&#41;&#46; There was no incidental thyroid carcinoma in cases preoperatively diagnosed as Bethesda V &#40;<a class="elsevierStyleCrossRef" href="#fig0004">Fig&#46;&#160;4</a>&#41;&#46; Regarding the &#39;incidentalomas&#39; size&#44; 82 &#40;67&#46;8&#37;&#41; were smaller than or equal to 0&#46;5 cm&#44; 16 &#40;13&#46;2&#37;&#41; were between 0&#46;5 and 1&#46;0 cm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46;&#160;5</a>&#41;&#44; and 23 &#40;19&#37;&#41; were larger than 1cm on the major axis &#40;<a class="elsevierStyleCrossRef" href="#tbl0002">Table&#160;2</a>&#41;&#46; &#39;Incidentalomas&#39; predominant histological type was papillary thyroid carcinoma &#40;118 cases&#44; 97&#46;5&#37;&#41;&#44; but occurrences of follicular carcinoma&#44; medullary carcinoma&#44; and a carcinoma without other specifications were also found &#40;<a class="elsevierStyleCrossRef" href="#tbl0003">Table&#160;3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><elsevierMultimedia ident="fig0002"></elsevierMultimedia><elsevierMultimedia ident="fig0003"></elsevierMultimedia><elsevierMultimedia ident="fig0004"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0002"></elsevierMultimedia><elsevierMultimedia ident="tbl0003"></elsevierMultimedia></span><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0011">Discussion</span><p id="para0014" class="elsevierStylePara elsevierViewall">The present study compared the result of preoperative cytological analysis of thyroid lesions with the respective pathological examination of the thyroidectomy surgical specimen&#46; Pre and postoperative results were compared for determining malignancy or benignity&#46; Preoperatively&#44; the Bethesda system was used to determine the risk of malignancy of a biopsied nodule&#46; Lesions classified as Bethesda II were considered benign&#44; Bethesda VI as malignant and Bethesda III&#44; IV and V as atypical or suspicious&#46; Postoperatively&#44; two different pathological evaluations were performed&#44; which adds value to the interpretation of the results presented&#46; Firstly&#44; it was verified whether the nodule or the lesion biopsied by FNAB had a pathological diagnosis compatible with its preoperative cytological classification&#44; that is if the diagnosis was confirmed&#46; Only 3 &#40;1&#46;5&#37;&#41; of the lesions considered benign by FNAB were malignant in the local pathological exam &#40;false-negative&#41;&#46; The second review of the pathological exam verified whether there was malignancy in any region of the excised surgical specimen&#44; and not only in the place where the biopsy was performed preoperatively&#46; This second evaluation revealed the occurrence of incidental cancer in 15&#46;1&#37; of the patients with benign anatomical pathology at the site of the FNAB&#46; Considering only the cases that were benign in FNAB &#40;Bethesda II&#41;&#44; the incidentaloma prevalence dropped to 9&#46;0&#37;&#46; A multicenter study&#44;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> published in 2013 by Smith et&#160;al&#46;&#44; showed that incidental thyroid carcinoma rate reached 15&#46;6&#37; of the 1&#44;523 patients operated for benign preoperative pathologies &#40;excluding pathologies of undetermined significance and suspected for malignancy&#41;&#46; Despite presenting similar incidentaloma rates&#44; it is important to note that&#44; while the first study compared the FNAB results with the final pathological examination&#44; the present study compares the pathological examination result of the site in which FNAB was performed with the final pathological examination of the entire surgical specimen&#46;</p><p id="para0015" class="elsevierStylePara elsevierViewall">Corroborating the present study&#44; Bradley et&#160;al&#46;<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a> concluded that 12&#37; of patients were operated on for benign conditions&#44; such as Hashimoto&#39;s thyroiditis&#44; follicular adenoma&#44; multinodular goiter&#44; and Graves&#39; disease&#44; had an Incidental Papillary Carcinoma &#40;IPC&#41; as their final histopathological diagnosis&#46; The author even suggests that total thyroidectomy should be considered in patients with Hashimoto thyroiditis and follicular adenoma due to the high incidence of IPC in the contralateral lobe&#46; A preference for total thyroidectomy as the first surgical treatment for benign diseases is also stated in other studies<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0012"><span class="elsevierStyleSup">12&#8211;16</span></a> due to the high prevalence of incidental neoplasms&#46; However&#44; the authors recommend cautiousness and attention to the classic indications for total thyroidectomy in order to avoid rare but potentially serious complications&#44; such as definitive hypoparathyroidism and inferior laryngeal nerve injury in patients without malignancy suspicion&#46; When non-surgical intervention is indicated for patients with benign FNAB&#44; the possibility of coexisting microcarcinoma with its variable prognosis should be taken into account and explained to the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a></p><p id="para0016" class="elsevierStylePara elsevierViewall">Machala et&#160;al&#46;&#44; in a study that also compared FNAB and thyroid anatomopathological results&#44; concluded that the cytological method is essential for diagnostic investigation of thyroid lesions because it is safe&#44; simple&#44; fast&#44; and cost-effective since it receives adequate pathological interpretation&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> New investigation methods of thyroid nodules&#44; such as elastography&#44; PET&#47;CT&#44; biomarkers&#44; and tumor markers are being investigated&#44; but there is a consensus that USG-guided FNA is essential for the management of patients with thyroid nodules&#46;<a class="elsevierStyleCrossRefs" href="#bib0003"><span class="elsevierStyleSup">3&#8211;5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> Nevertheless&#44; the high occurrence of incidentalomas draws attention to the need for a more careful selection of thyroid sites to be biopsied&#46; When only the LD results are compared with the preoperative diagnosis&#44; it can be seen that the false-negative percentage in the Bethesda II category is 1&#46;5&#37; in this study&#44; compatible with the error rate predicted for the method in the literature 0&#37; to 3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a> Thus&#44; it can be affirmed that the high rates of incidental thyroid carcinoma are due to a thyroid biopsy site selection problem rather than failure of the FNAB cytological interpretation itself&#46; Miccoli et&#160;al&#46; reported that in some cases of incidental thyroid carcinoma&#44; FNAB was performed preoperatively in another nodule&#44; which was benign&#46; The authors concluded that there is a need not only to select the biopsy sites more carefully but also to collect several samples from the same nodule when it exceeds 2 cm in diameter&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a></p><p id="para0017" class="elsevierStylePara elsevierViewall">Pezzolla et&#160;al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a> compared the occurrence of incidentalomas in patients undergoing thyroidectomy for presumably benign diseases and patients with Bethesda III nodules undergoing thyroidectomy&#46; This study obtained 16&#46;8&#37; of incidentalomas in the first group and 16&#46;2&#37; of malignant lesions in the second&#44; but not in the same biopsied site preoperatively diagnosed as Bethesda III&#46; Attention should be given to the indications for FNAB in thyroid nodules&#58; preferably nodules larger than 10 mm&#44; solid&#44; hypoechoic&#44; taller-than-wide&#44; with irregular margins&#44; taller than wide&#44; with extrathyroid extension&#44; intranodular vascular spots&#44; or microcalcifications&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0022"><span class="elsevierStyleSup">22</span></a> However&#44; it may be necessary to optimize such indications in order to reduce not only the occurrence of postoperative diagnosis of malignant lesions but also the overdiagnosis of clinically insignificant thyroid neoplasms&#46; In the present study&#44; 19&#37; of patients with an incidental malignant lesion had tumors larger than 1&#46;0 cm&#44; which&#44; therefore&#44; would be probably identifiable by preoperative USG&#46; Active Surveillance &#40;AS&#41; is a clinical practice proposed for the management of selected Papillary Thyroid Microcarcinomas &#40;mPTC&#41; instead of the primary surgical approach&#46; AS could be an alternative to immediate surgery to avoid overtreatment in unifocal intrathyroidal mPTC&#44; without metastatic lymph nodes or aggressive cytological features&#46; However&#44; multifocality is a potential contraindication for this practice&#44; as well as the subcapsular location of the mPTC&#44; previous external radiotherapy&#44; or family history of differentiated thyroid carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0023"><span class="elsevierStyleSup">23</span></a> Although the authors of the present study believe that AS plays a key role in mPTC&#44; the authors stress that the high incidence of incidental thyroid carcinoma should be considered when multifocality is suspected&#44; which is a potential contraindication for AS&#44; as mentioned above&#46; Thyroid carcinoma prevalence identified at autopsies is high&#44; reaching 35&#46;6&#37; of consecutive autopsied patients in a Finnish study&#44;<a class="elsevierStyleCrossRef" href="#bib0024"><span class="elsevierStyleSup">24</span></a> which concluded that papillary tumors smaller than 0&#46;5 cm could be a frequent finding in the thyroid gland&#46; In contrast&#44; Christakis et&#160;al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> published the occurrence of intermediate-risk incidentalomas &#40;according to ATA 2015&#41; in 4&#37; of the incidental thyroid carcinomas in their series &#40;282 incidentalomas&#47;1&#44;369 patients&#41;&#44; highlighting the oncological relevance of such findings&#46;</p><p id="para0018" class="elsevierStylePara elsevierViewall">The present study also emphasizes the importance of performing anatomopathological analysis on the entire extension of the resected thyroid gland&#44; and not only in the site of the lesion in focus&#44; given the risk of incidental neoplasms&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0012">Conclusion</span><p id="para0019" class="elsevierStylePara elsevierViewall">The ITC incidence is high&#46; Although the occurrence of false-negative results in Bethesda II nodules is only 1&#46;5&#37;&#44; 9&#37; of these patients presented ITC in the thyroid parenchyma outside the nodule evaluated by preoperative FNAB&#46; The incidence of ITC in the same scenario was even higher in Bethesda III &#40;17&#46;5&#37;&#41; and Bethesda IV cases &#40;19&#37;&#41;&#46; Despite the high incidence of incidentalomas&#44; the authors recommend cautiousness and attention to the classic indications for total thyroidectomy in order to avoid potentially serious complications&#46; Most incidentalomas are less than 0&#46;5 cm in the largest diameter&#46; Papillary thyroid carcinoma is the predominant histological type&#46; Anatomopathological examination of the surgical specimen should be performed in the entire specimen&#44; and not only in macroscopic lesions&#46; Ultrasonography-guided FNAB is an excellent method for thyroid nodules clinical evaluation&#46; Nevertheless&#44; the areas to be biopsied must be carefully selected&#46;</p></span><span id="sec0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0013">Authors&#39; contributions</span><p id="para0020" class="elsevierStylePara elsevierViewall">All authors contributed to this study&#46; Data collection and case review were performed by Mosca L and Araujo-Neto VJ&#46; Data analysis was supervised by Silva LF and Kowalski LP&#46; Araujo-Filho VJ and Carneiro PC were responsible for the study design and data analysis The manuscript draft and its final version were written by Rodrigues MG&#46; The final version of the manuscript was reviewed by&#160; Silva LF&#44; Kowalski LP&#44; Araujo-Filho VJ and Carneiro PC&#46; All approved the final manuscript&#46; The corresponding author is Carneiro PC who attests that all participants in this study meet the criteria for authorship&#46;</p></span></span>"
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    "fechaRecibido" => "2021-09-27"
    "fechaAceptado" => "2021-12-08"
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    "highlights" => array:2 [
      "titulo" => "Highlights"
      "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><p id="spara009" class="elsevierStyleSimplePara elsevierViewall"><ul class="elsevierStyleList" id="celist0001"><li class="elsevierStyleListItem" id="celistitem0001"><span class="elsevierStyleLabel">&#8226;</span><p id="para0001" class="elsevierStylePara elsevierViewall">Incidental thyroid carcinomas are diagnosed by pathological study of the surgical specimen&#44; with no previous suspicion by other diagnostic methods before surgery&#46;</p></li><li class="elsevierStyleListItem" id="celistitem0002"><span class="elsevierStyleLabel">&#8226;</span><p id="para0002" class="elsevierStylePara elsevierViewall">Incidental thyroid cancer has been found at high rates in men and young people&#44; usually&#44; but not always&#44; with more favorable histopathological characteristics and better prognosis&#46;</p></li><li class="elsevierStyleListItem" id="celistitem0002a"><span class="elsevierStyleLabel">&#8226;</span><p id="para0002a" class="elsevierStylePara elsevierViewall">The better understanding of incidental thyroid cancer can improve decisions towards active surveillance strategies for the management of papillary thyroid carcinoma&#46;</p></li></ul></p></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abss0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Objective</span><p id="spara010" class="elsevierStyleSimplePara elsevierViewall">To investigate Incidental Thyroid Carcinoma &#40;ITC&#41; by comparing the results of Fine Needle Aspiration Biopsy &#40;FNAB&#41; cytology and the postoperative pathological findings&#46;</p></span> <span id="abss0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Methods</span><p id="spara011" class="elsevierStyleSimplePara elsevierViewall">Data of 1479 patients who underwent total thyroidectomy were retrieved&#46; Three hundred eighty-six patients were excluded due to insufficient data&#46; Each surgical specimen studied received two histopathological diagnoses&#58; the local diagnosis &#8210; for the same area in which the FNAB was performed&#59; and the final diagnosis&#44; which includes a study of the entire surgical specimen&#46;</p></span> <span id="abss0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0005">Results</span><p id="spara012" class="elsevierStyleSimplePara elsevierViewall">A thousand and ninety-three patients were investigated&#46; FNAB result was malignant in 187 patients&#44; benign in 204&#44; suspicious or indeterminate in 668 cases&#44; and inconclusive in 34 cases&#46; The prevalence of ITC was 15&#46;1&#37;&#46; Most of the ITC in this series was less than 0&#46;5 cm&#46; The incidence of ITC was higher in Bethesda III &#40;17&#46;5&#37; ITC&#41; and IV &#40;19&#37; ITC&#41; than in Bethesda II cases &#40;1&#46;5&#37; false negatives and 9&#37; ITC&#41;&#46;</p></span> <span id="abss0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0006">Conclusion</span><p id="spara013" class="elsevierStyleSimplePara elsevierViewall">Although the incidence of false-negative results in Bethesda II nodules is only 1&#46;5&#37;&#44; 9&#37; of these patients had ITC in the thyroid parenchyma outside the nodule that underwent preoperative FNAB&#46; The incidence of ITC in the same scenario was even higher in Bethesda III &#40;17&#46;5&#37;&#41; and Bethesda IV cases &#40;19&#37;&#41;&#46; Ultrasonography-guided FNAB is an excellent method for the assessment of thyroid nodules&#46; However&#44; biopsy sites should be carefully selected&#46; Despite the high incidence of incidentalomas&#44; total thyroidectomy should not always be the treatment of choice due to its rare but potentially serious complications&#46; The findings of the present study can assist future clinical decisions towards active surveillance strategies for the management of papillary thyroid carcinoma&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0001"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="top" scope="col"><span class="elsevierStyleBold">Postoperative local diagnosis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0002"></a><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">Preoperative Bethesda findings</span></th></tr><tr title="table-row"><a name="en0001a"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0004"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">I</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0005"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">II</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0006"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">III</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0007"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0008"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">V</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0009"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">VI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0010"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">Total</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0011"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Adenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0012"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0013"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0014"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0015"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0016"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0017"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0018"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0019"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Goiter&#47;Thyroiditis&#47;Graves&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0020"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0021"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">196&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0022"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">314&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0023"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">189&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0024"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0025"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0026"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">740&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0027"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Anaplastic carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0028"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0029"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0030"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0031"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0032"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0033"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0034"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0035"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Follicular carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0036"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0037"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0038"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0039"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0040"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0041"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0042"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0043"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Medullary carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0044"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0045"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0046"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0047"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0048"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0049"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0050"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0051"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Papillary carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0052"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0053"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0054"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0055"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0056"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0057"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">171&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0058"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">259&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0059"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Poorly differentiated carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0060"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0061"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0062"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0063"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0064"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0065"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0066"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0067"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Other types of carcinomas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0068"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0069"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0070"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0071"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0072"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0073"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0074"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0075"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Linfoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0076"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0077"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0078"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0079"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0080"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0081"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0082"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0083"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><span class="elsevierStyleBold">Total</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0084"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><span class="elsevierStyleBold">34</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0085"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><span class="elsevierStyleBold">204</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0086"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><span class="elsevierStyleBold">411</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0087"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><span class="elsevierStyleBold">242</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0088"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><span class="elsevierStyleBold">42</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0089"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><span class="elsevierStyleBold">187</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0090"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><span class="elsevierStyleBold">1&#44;093</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3252764.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara006" class="elsevierStyleSimplePara elsevierViewall">Association of preoperative FNAB Bethesda classification and local diagnosis at the final pathological report&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0002"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0007"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0091"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">Tumor size</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0092"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">Number of incidentalomas &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0093"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8804; 0&#46;5 cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0094"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">82 &#40;67&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0095"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#62; 0&#46;5 cm to &#8804; 1&#46;0 cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0096"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16 &#40;13&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0097"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#62; 1&#46;0 cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0098"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">23 &#40;19&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab3252766.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara007" class="elsevierStyleSimplePara elsevierViewall">Size of incidentalomas&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0003"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0008"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0099"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Histological types&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0100"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">Number of cases &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0101"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Papillary carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0102"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">118 &#40;97&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0103"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Follicular carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0104"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0105"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Medullary carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0106"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0107"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Other types of carcinomas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0108"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3252765.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara008" class="elsevierStyleSimplePara elsevierViewall">Incidentalomas histological types&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "cebibsec1"
          "bibliografiaReferencia" => array:24 [
            0 => array:3 [
              "identificador" => "bib0001"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Increased incidence of differentiated thyroid carcinoma and detection of subclinical disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "W&#46;D&#46; Kent"
                            1 => "S&#46;F&#46; Hall"
                            2 => "P&#46;A&#46; Isotalo"
                            3 => "R&#46;L&#46; Houlden"
                            4 => "R&#46;L&#46; George"
                            5 => "P&#46;A&#46; Groome"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1503/cmaj.061730"
                      "Revista" => array:7 [
                        "tituloSerie" => "CMAJ"
                        "fecha" => "2007"
                        "volumen" => "177"
                        "numero" => "11"
                        "paginaInicial" => "1357"
                        "paginaFinal" => "1361"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18025426"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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Article information

ISSN: 18075932
Original language: English

DOI:10.1016/j.clinsp.2022.100022

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Year/Month	Html	Pdf	Total

2024 November	4	1	5
2024 October	54	29	83
2024 September	52	20	72
2024 August	48	26	74
2024 July	38	21	59
2024 June	38	30	68
2024 May	44	18	62
2024 April	32	16	48
2024 March	68	19	87
2024 February	69	22	91
2024 January	72	13	85
2023 December	38	29	67
2023 November	55	47	102
2023 October	49	49	98
2023 September	62	37	99
2023 August	55	11	66
2023 July	24	28	52
2023 June	27	18	45
2023 May	15	4	19
2023 April	13	4	17
2023 March	12	2	14
2023 February	15	10	25
2023 January	7	5	12
2022 December	29	2	31
2022 November	0	0	0

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