Blog

Thyroid Awareness Month

How Common Is Thyroid Cancer? (Putting Risk in Perspective)

Hearing the word cancer is frightening—but it’s important to understand the actual risk.

📊 How common is thyroid cancer?

Thyroid cancer accounts for ~1–2% of all cancers Although diagnoses have increased (largely due to better imaging), most thyroid cancers are low-risk Survival rates are excellent, especially when detected early

🧠 What does this mean for patients?

Only 5–10% of thyroid nodules are cancer The most common type, papillary thyroid cancer, has a >95% long-term survival Many patients can be treated with limited surgery or even active surveillance

🔍 Why are we diagnosing more thyroid cancer?

Widespread use of high-resolution ultrasound Detection of small, clinically indolent tumors ➡️ This is why risk stratification and thoughtful management are critical—to avoid overtreatment.

🦋 The big picture

Thyroid cancer is:

✔️ Commonly curable

✔️ Often slow-growing

✔️ Best managed with individualized, evidence-based care

👨‍⚕️ Dr. Rodrigo Arrangoiz, MD

Surgical Oncologist – Thyroid, Head & Neck, Breast

Mount Sinai Medical Center

📌 Take-home message:

Most thyroid nodules are benign, and even when cancer is present, outcomes are overwhelmingly favorable when managed correctly.

📚 References

SEER Cancer Statistics Review Haugen BR et al. ATA Guidelines. Thyroid Brito JP et al. Overdiagnosis of Thyroid Cancer. BMJ

Thyroid Awareness Month

What Is a Thyroid Fine-Needle Aspiration (FNA) Biopsy?

A thyroid FNA biopsy is the standard, evidence-based test used to determine whether a thyroid nodule is benign or malignant—and it is far simpler than most patients expect.

🧪 How is the biopsy performed? (Step-by-step)

Ultrasound guidance precisely targets the nodule A very thin needle is used to collect cells Multiple passes may be taken to ensure accuracy The procedure takes 5–10 minutes You go home the same day and resume normal activities

✔️ No general anesthesia

✔️ Minimal discomfort

✔️ Very low risk of complications

🔬 What happens to the sample?

The cells are analyzed by an experienced cytopathologist and reported using the Bethesda System, which helps guide:

Observation Repeat biopsy Molecular testing (when appropriate) Surgery (only when necessary)

📊 Key facts for patients

Most biopsies come back benign FNA prevents unnecessary thyroid surgery Results allow for personalized, evidence-based care

🦋 Why this matters

A properly performed, ultrasound-guided FNA is:

Accurate Safe Essential for making the right treatment decision

👨‍⚕️ Dr. Rodrigo Arrangoiz, MD

Surgical Oncologist – Thyroid, Head & Neck, Breast

Mount Sinai Medical Center

📌 Take-home message:

A thyroid biopsy is not something to fear —

it is a tool that helps ensure you get the right care and avoid unnecessary treatment.

📚 References

Cibas ES, Ali SZ. The Bethesda System for Reporting Thyroid Cytopathology. Thyroid Haugen BR et al. ATA Guidelines for Thyroid Nodules. Thyroid Gharib H et al. Fine-Needle Aspiration of Thyroid Nodules. Endocrine Practice

• Excisional biopsy:
  • Is recommended for most ADH lesions diagnosed on core needle breast biopsy (CNB)
• The chance of upgrade at excision to:
  • Ductal carcinoma in situ (DCIS) or invasive carcinoma is generally in the:
    • 12% to 22% range in the literature
• The need for routine excision of pure flat epithelial atypia (FEA) has been less clear:
  • Some authors have reported an upgrade rate of 9.6% following excision of lesions that show pure FEA without ADH when the vast majority of biopsies were done with a 14-gauge spring-loaded core biopsy device:
    • It is not clear that biopsy with a vacuum-assisted device would yield the same results:
      • In fact, in one study reporting biopsy of low-risk calcifications with a vacuum-assisted device, pure FEA never resulted in an upgrade to malignancy
    • An article from the Mayo Clinic:
      • Showed that FEA does not seem to convey an independent risk of breast cancer beyond that of associated proliferative disease without atypia or associated ADH
• The risk of upgrade at surgical excision for ADH:
  • Has been reported to correlate with the number of ducts or terminal duct lobular units involved on vacuum-assisted core biopsy:
    • With two or fewer foci of involvement:
      • There was no upgrade on excision
    • With four or more foci of involvement:
      • There was a strong probability of upgrade to ductal carcinoma in situ or invasive carcinoma at excision
• Work continues to try to define a low-risk group who could potentially avoid excisional biopsy:
  • Particularly those with small areas of calcifications completely removed with core needle biopsy and only focal ADH on pathology
• Apocrine metaplasia, florid epithelial hyperplasia of the usual variety, and columnar cell change without atypia:
  • Do not confer a significant risk of upgrade and do not require excision
• References
  • Eby PR, Ochsner JE, DeMartini WB, Allison KH, Peacock S, Lehman CD. Is surgical excision necessary for focal atypical ductal hyperplasia found at stereotactic vacuum-assisted breast biopsy? Ann Surg Oncol. 2008;15(11):3232-3238.
  • Ely KA, Carter BA, Jensen RA, Simpson JF, Page DL. Core biopsy of the breast with atypical ductal hyperplasia: a probabilistic approach to reporting. Am J Surg Pathol. 2001;25(8):1017-1021.
  • Khoumais NA, Scaranelo AM, Moshonov H, Kulkarni SR, Miller N, McCready DR, et al. Incidence of breast cancer in patients with pure flat epithelial atypia diagnosed at core-needle biopsy of the breast. Ann Surg Oncol. 2013;20(1):133-138.
  • Said SM, Visscher DW, Nassar A, Frank RD, Vierkant RA, Frost MH, et al. Flat epithelial atypia and risk of breast cancer: a Mayo cohort study. Cancer. 2015;121(10):1548-1555.
  • McGhan LJ, Pockaj BA, Wasif N, Giurescu ME, McCullough AE, Gray RJ. Atypical ductal hyperplasia on core biopsy: an automatic trigger for excisional biopsy? Ann Surg Oncol. 2012;19(10):3264-3269.

• The eighth edition of the American Joint Committee on Cancer (AJCC) staging system:
  • Defines microinvasion as:
    • Invasion of breast cancer cells:
      • Through the basement membrane at one or more foci:
        • None of which exceeds a dimension of 1 mm
  • DCIS:
    • Is a Tis lesion:
      • Is classified as stage 0 cancer
  • DCIS with microinvasion is considered:
    • T1mi:
      • Upstages DCIS from stage 0 to stage I disease:
        • The earliest stage of invasive cancer:
          • In the AJCC staging system
• By definition:
  • DCIS does not have the ability to metastasize to axillary lymph nodes or distant sites:
    • Whereas DCIS with microinvasion does
• Axillary metastasis:
  • Has been reported in 0% to 20% (0% to 28% in some series) of patients:
    • With DCIS with microinvasion
• The incidence of microinvasion in DCIS:
  • Varies according to:
    • The size and extent of the index lesion
  • Lagios et al. (1989):
    • Reported a 2% incidence of microinvasion in patients with DCIS:
      • Measuring ≤ 25 mm in diameter
    • Compared with a 29% incidence of microinvasion:
      • In those with lesions ≥ than 26 mm
  • The incidence of microinvasion is also higher in patients with:
    • High-grade or comedo-type DCIS with necrosis
    • In patients with DCIS who present with:
      • A palpable mass
      • Nipple discharge
• Historically, patients with DCIS with microinvasion:
  • Have been observed to have a worse prognosis:
    • Compared with those who have DCIS alone
  • Mirza et al. (2000):
    • Reported the long-term results of breast-conserving therapy in patients with:
      • DCIS
      • DCIS with microinvasion
      • T1 invasive breast cancers
    • The 20-year disease-specific survival rates in patients with:
      • DCIS were better:
        • Than those among patients with DCIS with microinvasion or with T1 invasive tumors
      • Patients with microinvasion and those with T1 tumors:
        • Had similar survival rates
  • In a retrospective study of 1,248 serially sectioned DCIS tumors, de Mascarel et al. (2002):
    • Reported a 10.1% incidence of axillary metastases:
      • In cases of DCIS with microinvasion
    • Patients with DCIS had a better 10-year distant metastasis-free survival rate:
      • Than patients with DCIS with microinvasion:
        • 98% and 91%, respectively
    • The overall survival rate was also better in patients with DCIS compared to DCIS with microinvasion:
      • 96.5% vs. 88.4%
    • However, the metastasis-free and overall survival rates:
      • Were worse in patients with invasive ductal carcinoma compared with those with DCIS with microinvasion
    • These results suggest that DCIS with microinvasion:
      • Should be characterized as a small invasive tumor with a good outcome:
        • The therapeutic approach for these patients should be similar to that for patients with invasive cancer
• However, more recent studies have pointed toward DCIS with microinvasion having a more similar natural history to pure DCIS than to early-stage invasive disease:
  • In a review of 393 patients treated at Yale between 1973 and 2004:
    • There was no statistically significant difference between patients with DCIS and those with DCIS with microinvasion with regard to the presence of axillary metastases (in those who had axillary staging) or the likelihood of recurrence (locoregional and distant) or overall survival (Parikh et al., 2012)

#Arrangoiz #CancerSurgeon #BreastSurgeon #SurgicalOncologist #BreastCancer #LCIS #DCIS #DuctalCarcinomaInsitu #LobularNeoplasia #LobularCarcinomaInsitu #Surgeon #Teacher #Miami #Mexico #MSMC #MountSinaiMedicalCenter

• Significant increase in incidence after mammography screening:
  • 17-fold increase from 1970’s to 2004:
    • 1 in 1300 mammograms
  • Represents 20% of all screen-detected breast neoplasias diagnosed annually
• DCIS by it self:
  • Is not a risk to life
• DCIS may progress to invasion and compromise survival:
  • If left untreated:
    • 1 in 6 DCIS patients:
      • Progress to invasive breast cancer (IBC):
        • 70% estimated to remain indolent
• At this time we do not have any robust biomarkers:
  • That can quantify the risk of progression to IBC or
  • Help us separate indolent disease:
    • From the potentially dangerous lesions
• Risk of overtreament:
  • The increase incidence of DCIS in mammographically detected cases:
    • Has not lead to a decrease in the incidence of IBC or reduction of IBC morality
• Risk factors for progression / recurrence of DCIS:
  • The risk factors for IBC recurrence may be different from the risks factors for DCIS recurrence?
    • Risk of IBC recurrence:
      • African American race
      • Premenopausal status
      • Detection by palpation
      • Involved margins
      • High histologic grade
      • High p16 expression
    • Risk of IBC or DCIS recurrence:
      • DCIS size
      • Histology type
      • Comedo necrosis
      • Grade
      • Young age
      • Close margins or positive margins
  • Patients with DICIS that recur with an IBC:
    • Some patients with DCIS may develop:
      • Progression of there disease
      • Some will have a de novo invasive breast cancer
      • Some might have a missed invasive cancer?
  • Patient that have a DCIS recurrence:
    • Might be a true in situ recurrence
    • De novo DCIS
    • Residual disease?
  • Studies are describing observations of events:
    • Synchronous IBC
    • Subsequent ipsilateral or contralateral DCIS or IBC (often a mixture)
    • We have limited data on DCIS progression with paired molecular profiles
• The most consistent biological feature of DCIS:
  • Heterogeneity:
    • In clinical presentation
    • Morphology
    • Protein expression:
      • Including receptor status
    • Gene expression
    • Genetic alterations
    • Epigenetic alterations
  • The heterogeneity is:
    • Between patients – within the lesion – and within cells in a single duct
• Morphological features that help us predict progression is:
  • Histologic grading:
    • Combing the nuclear grade 1 to 3 and necrosis into a three tier system (the good, the bad, and the ugly):
      • Low / intermediate / high grade
      • Grade 1 to 3
      • Van Nuys Group 1 to 3
      • DIN 1 to 3
    • We all know that there is regression towards the mean and substantial interobserver variation

• Unclear prognostic value of the 3-tier system:
  • We suspect that:
    • Low to intermediate grade = low risk of progression
    • High grade system = high risk of progression or shorter time to progression
  • Maxwell, A.J. Eur.J.Surg.Oncol.,2018, Ryser, MD. J.Natl Cancer Inst., 2019:
    • Risk of ipsilateral recurrence (DCIS / IBC) at 10 years:
      • High grade 17.6% (95% CI=12.1-25.2%)
      • Non high grade 12.2 (95% CI=8.6-17.1%):
        • Including grade 2
    • There is overlap in the confidence intervals
  • Low grade DCIS are the lesions that might have:
    • Discontinuous growth and skip lesions that might lead to a:
      • Greater likelihood of residual disease and recurrence?
  • Heterogeneity of grade within a lesion
• Histology subtype as a prognostic factor:
  • Subtype:
    • Cribriform is more often a grade 1 lesion
    • Comedo type is more often a grade 3 lesion
  • Usually histology subtype correlates with grade but:
    • There is often a mixture of growth patterns:
      • Compromising the use for prognostication

• Tumor micro environment:
  • Could potentially be the most important morphologic feature suggestive of progression especially:
    • Circumferential periductal fibrosis and associated tumor infiltrating lymphocytes (TIL):
      • Indicating host reaction to the tumor cells
  • Tumor micro environment includes:
    • Myoepithelial cell layer
    • Tumor infiltrating lymphocytes (TIL)
    • Adipocytes
    • Fibroblasts
    • Matrix

• The myoepithelial layer acts as a gatekeeper:
  • Has tumor suppressive functions
  • The largest gene expression change from normal tissue to DCIS:
    • Occurs in the myoepithelial layer
  • DCIS associated myoepithelial loss:
    • That leads the decrease tumor suppressor functions
  • The myoepithelial layer is lost in IBC

• Disruption of the myoepithelial defense:

• Conflicting data on prognostic value of TIL:
  • Some studies have reported no prognostic value of stromal TIL for subsequent recurrences:
    • Does the spatial location of the immune cells matter?
      • The TIL in direct contact with the DCIS might be more important that the TIL that are further away
  • Other studies have shown a correlation between higher levels of TIL and increased risk of subsequent IBC and a shorter (ipsilateral) recurrence-free survival

When Do Thyroid Nodules Need a Biopsy?

Not every thyroid nodule needs a biopsy.

The decision is based on ultrasound findings and size—not symptoms alone.

🔍 What determines the need for biopsy?

Using high-resolution ultrasound and validated systems (ATA / ACR TI-RADS), we assess:

Ultrasound risk features (solid, hypoechoic, irregular margins, microcalcifications, taller-than-wide) Nodule size Patient-specific risk factors (e.g., prior radiation exposure)

➡️ Only nodules meeting specific risk and size criteria should undergo biopsy.

🧪 What type of biopsy is used?

The standard test is an ultrasound-guided fine-needle aspiration biopsy (FNAB):

✔️ Minimally invasive

✔️ Performed in the office

✔️ No general anesthesia

✔️ Very low complication rate

✔️ High diagnostic accuracy

📊 Key facts for patients

Most nodules do NOT require biopsy FNAB helps avoid unnecessary surgery Results guide observation vs surgery vs further testing

🦋 Why this matters

Performing biopsies only when indicated:

Reduces patient anxiety Prevents overtreatment Focuses care on clinically significant disease

👨‍⚕️ Dr. Rodrigo Arrangoiz, MD

Surgical Oncologist – Thyroid, Head & Neck, Breast

Mount Sinai Medical Center

📌 Take-home message:

The goal is not to biopsy every nodule —

it’s to biopsy the right nodule at the right time.

📚 References

Haugen BR et al. ATA Guidelines for Thyroid Nodules. Thyroid Tessler FN et al. ACR TI-RADS. Radiology Gharib H et al. Fine-Needle Aspiration of Thyroid Nodules. Endocrine Practice

Not all thyroid nodules are the same. Ultrasound risk stratification helps determine which nodules need biopsy and which can be safely observed.

🔍 What are TI-RADS and ATA?

ACR TI-RADS and ATA ultrasound patterns are validated systems that estimate cancer risk based on ultrasound features—not symptoms. They standardize care and reduce unnecessary biopsies and surgeries.

📊 How do these systems work?

Ultrasound evaluates:

Composition (solid vs cystic) Echogenicity Margins Calcifications Shape (taller-than-wide)

Each feature contributes to a risk category, which guides:

✔️ Whether to biopsy

✔️ When to follow up

✔️ How closely to monitor

🧪 Key patient takeaway

Low-risk nodules → observation with periodic ultrasound Intermediate/high-risk nodules → biopsy at size thresholds ➡️ This approach is safe, evidence-based, and personalized.

🦋 Why this matters

Risk stratification:

Avoids overdiagnosis Focuses treatment on clinically meaningful disease Improves patient reassurance and outcomes

👨‍⚕️ Rodrigo Arrangoiz, MD

Surgical Oncologist – Thyroid, Head & Neck, Breast

Mount Sinai Medical Center

📌 Take-home message:

The goal is the right test for the right nodule at the right time.

📚 References

Tessler FN et al. ACR TI-RADS. Radiology Haugen BR et al. ATA Guidelines for Thyroid Nodules. Thyroid Russ G et al. EU-TI-RADS. Eur J Endocrinol

• Adjuvant endocrine therapy is evolving: 
  Oral SERD in early HR+ / HER2− disease:
  • lidERA (giredestrant vs standard endocrine therapy):
    • What it tested:
      • Adjuvant giredestrant (oral SERD) vs standard endocrine therapy after surgery in ER+ /HER2− early breast cancer
  • Headline result:
    • Significant iDFS improvement:
      • They reported ~30% relative risk reduction (HR ~0.70) vs standard ET
    • Why it matters:
      • First credible signal in a long time that “better endocrine backbone” (beyond AI / tamoxifen) could become standard for selected early HR+ patients:
        • Especially if subgroup and safety data remain favorable
    • Surgical implication:
      • Expect more conversations about systemic escalation / de-escalation:
        • For example who truly needs CDK4/6 inhibitors vs a more potent endocrine option
• Post-neoadjuvant HER2+ residual disease: 
  T-DXd moves earlier:
  • DESTINY-Breast05 (T-DXd vs T-DM1):
    • Population:
      • HER2+ early breast cancer with residual invasive disease after neoadjuvant therapy:
        • High-risk post-NAC setting
    • Key outcome:
      • T-DXd superior to T-DM1 for invasive disease-free outcomes
    • Reported data (NEJM / PubMed):
      • Events 6.4% vs 12.6%, HR 0.47:
        • With 3-year DFS 92.3% vs 83.5%
    • Why it matters:
      • This is a direct “KATHERINE-successor” story:
        • If adopted into guidelines / pathways, it could reset the post-neoadjuvant standard for residual HER2+ disease 
    • Surgical implication:
      • Reinforces the importance of accurate residual disease documentation (pathology, RCB, nodal status) because this is what triggers the post-NAC systemic pathway
• Axillary de-escalation: 
  Omitting SLNB in selected cN0 patients:
  • Dutch randomized trial (BOOG 2013-08):
    • Design:
      • Clinically node-negative (cT1 to cT2), treated with BCS + whole-breast RT, randomized to SLNB vs omission
    • Message:
      • Regional control / oncologic outcomes were not worse with omission in carefully selected patients, supporting a further step in axillary de-escalation
    • SABCS:
      • Also highlighted interpretation alongside RT fields (since RT contributes to axillary control)
  • Practical “surgeon filter”:
    • This is not “no axillary surgery for everyone,” but it strengthens the discussion for:
      • Older / low-risk, cN0, BCS+RT patients in centers that can replicate selection / imaging rigor
• Pre-op staging MRI:
  • Routine use questioned in specific early BC subsets:
    • Alliance A011104 / ACRIN 6694:
      • Population:
        • Stage I / II HR-negative early breast cancer
      • Result:
        • Routine pre-op MRI did not improve key oncologic outcomes
        • MD Anderson reported 5-yr locoregional recurrence 6.8% with MRI vs 4.3% without (not favoring MRI)
      • Message:
        • More evidence that routine MRI may not improve outcomes and can drive additional procedures
      • Surgical implication:
        • Helps justify a more selective MRI strategy, dense breasts, lobular carcinoma, occult primary, discordant imaging, suspected multicentric disease, rather than reflex MRI for all
• Immune priming concept: 
  • Preoperative RT + pembrolizumab
     in HR+ / HER2− (early signal):
    • TBCRC-053 (P-RAD):
      • Concept:
        • Short-course preoperative RT (e.g., 24 Gy / 3 fractions) added to pembrolizumab + chemotherapy
    • Signal:
      • Increased tumor T-cell infiltration and “immune activation” endpoints:
        • Hypothesis-generating but compelling
    • Clinical implication:
      • Not practice-changing yet, but it’s a blueprint for future trials aiming to convert HR+ tumors into more immunogenic disease
• DCIS de-escalation reality check: 
  Tamoxifen-only (no surgery) did not meet safety bar:
  • LORETTA (JCOG1505):
    • Design:
      • Single-arm tamoxifen without surgery for selected low-risk ER+ / HER2− DCIS
    • Outcome:
      • Reported 5-year ipsilateral invasive events exceeded prespecified safety threshold (widely summarized from SABCS)
    • Takeaway:
      • Supports continued caution:
        • Endocrine-only, surgery-free DCIS management should remain investigational / exceptional rather than broadly adopted
• What to say at tumor board (tight synthesis) HR+/HER2−:
  • LidERA:
    • Suggests a credible pathway toward next-generation endocrine therapy (oral SERD) in early disease
  • HER2+ residual disease post-NAC:
    • T-DXd > T-DM1 in DESTINY-Breast05 – likely a major sequencing shift as pathways update 
  • Surgery de-escalation:
    • Growing evidence that less axillary surgery and less routine MRI can be safe in well-defined populations
  • Translational front:
    • Preoperative RT + IO is an emerging strategy to watch, not a standard yet
  • DCIS:
    • Surgery-free endocrine-only strategies still struggle with invasive recurrence risk thresholds

• Is a randomized phase III trial:
  • That established trastuzumab deruxtecan (T-DXd) as the preferred therapy for patients with HER2-positive metastatic breast cancer:
    • Previously treated with trastuzumab emtansine (T-DM1)
• Population:
  • HER2-positive unresectable or metastatic breast cancer
  • Prior therapy:
    • Trastuzumab + taxane and T-DM1
  • Randomization: T
    • DXd vs Investigator’s choice (trastuzumab + capecitabine or lapatinib + capecitabine)
  • Primary endpoint:
    • Progression-free survival (PFS, BICR)
  • Key secondary endpoints:
    • Overall survival (OS), ORR, duration of response, safety
• Mechanism of Action (Why T-DXd Is Different):
  • Trastuzumab deruxtecan is a next-generation antibody–drug conjugate (ADC) with:
    • High drug-to-antibody ratio (≈8:1)
    • Cleavable linker membrane-permeable topoisomerase I payload bystander effect:
      • Enabling killing of adjacent tumor cells with heterogeneous HER2 expression:
        • This design explains its activity after T-DM1 failure, where resistance commonly develops.
• Efficacy Results:
  • Progression-Free Survival (Primary Endpoint):
    • Median PFS:
      • T-DXd:
        • ~17.8 months
      • Control:
        • ~6.9 months
      • Hazard ratio:
        • ~0.36
      • Risk reduction:
        • ~64% reduction in progression or death
    • Clinically transformative improvement in disease control
  • Overall Survival:
    • Median OS:
      • T-DXd:
        • ~39.2 months
      • Control:
        • ~26.5 months
      • Hazard ratio:
        • ~0.66
    • Statistically significant and clinically meaningful OS benefit, uncommon in heavily pretreated HER2-positive MBC trials
  • Objective Response Rate:
    • T-DXd:
      • ~69%
    • Control:
      • ~29%
    • Complete responses:
      • Observed with T-DXd
• Safety Profile:
  • Common Adverse Events (T-DXd):
    • Nausea
    • Fatigue
    • Alopecia
    • Vomiting
    • Neutropenia
    • Anemia
    • Interstitial Lung Disease (ILD) / Pneumonitis:
      • Any-grade ILD:
        • ~10%
      • Grade ≥3 ILD:
        • ~1–2%
      • Fatal events:
        • Rare but reported
• Key clinical takeaway:
  • Early recognition, prompt drug interruption, and steroid initiation are essential
  • Patient education and routine symptom monitoring are mandatory
• How DESTINY-Breast 02 Changed Practice:
  • Before DESTINY-Breast 02:
    • Post-T-DM1 options relied on capecitabine-based combinations:
      • Limited durability and modest survival benefit
  • After DESTINY-Breast 02:
    • T-DXd is the standard of care after T-DM1:
      • Supported by PFS + OS superiority:
        • Endorsed by NCCN, ASCO, ESMO
  • Represents a paradigm shift in the HER2-positive metastatic sequence
• Treatment Sequencing (Current Standard):
  • First line:
    • Trastuzumab + pertuzumab + taxane
  • Second line:
    • T-DXd
  • Later lines:
    • Tucatinib-based regimens
    • Clinical trials
    • Other HER2-targeted agents
• Surgical and Multidisciplinary Relevance:
  • Durable systemic control increases:
    • Consideration of local therapies for oligoprogression
    • Delayed need for palliative surgery
  • Highlights importance of:
    • Early referral to medical oncology
    • Coordinated surveillance for pulmonary toxicity
• Key Take-Home Messages:
  • DESTINY-Breast 02 firmly establishes T-DXd as best-in-class post-T-DM1 therapy:
    • Demonstrates both PFS and OS benefit in a refractory population
  • ILD monitoring is critical to safe delivery
  • Confirms the power of ADC engineering in overcoming resistance

When a thyroid nodule is suspected or discovered, high-resolution thyroid ultrasound is the single most important diagnostic study.

🔍 What does a thyroid ultrasound tell us?

Ultrasound allows us to evaluate:

Size and exact location of the nodule Composition (solid, cystic, or mixed) Margins (smooth vs irregular) Echogenicity and calcifications Vascularity (with Doppler imaging) Cervical lymph nodes

➡️ These features are far more predictive of cancer risk than symptoms or blood tests.

📊 Risk stratification matters

Using ultrasound findings, nodules are categorized with validated systems such as:

ATA risk patterns ACR TI-RADS

These systems help determine:

✔️ Which nodules need biopsy

✔️ Which nodules can be safely observed

✔️ Appropriate follow-up intervals

🧪 Important clarification

Blood tests do not diagnose thyroid cancer CT scans and MRIs are NOT first-line tests for thyroid nodules Ultrasound provides real-time, radiation-free, highly accurate evaluation

🦋 Why this matters for patients

Proper ultrasound evaluation:

Prevents unnecessary biopsies and surgeries Ensures early diagnosis of clinically significant thyroid cancer Guides personalized management

👨‍⚕️ Rodrigo Arrangoiz, MD

Surgical Oncologist – Thyroid, Head & Neck, Breast

Mount Sinai Medical Center

📌 Take-home message:

Not all ultrasounds are equal.

Expert, high-resolution thyroid ultrasound makes all the difference.

📚 References

Haugen BR et al. ATA Guidelines for Thyroid Nodules. Thyroid Tessler FN et al. ACR TI-RADS. Radiology Russ G et al. EU-TI-RADS. European Journal of Endocrinology