Radiologist versus Non-Radiologist Detection of Lymph Node Metastasis in Papillary Thyroid Carcinoma by Ultrasound: A Meta-Analysis

Papillary thyroid carcinoma (PTC) is the most common thyroid cancer worldwide and is known to spread to adjacent neck lymphatics. Lymph node metastasis (LNM) is a known predictor of disease recurrence and is an indicator for aggressive resection. Our study aims to determine if ultrasound sonographers’ degree of training influences overall LNM detection. PubMed, Embase, and Scopus articles were searched and screened for relevant articles. Two investigators independently screened and extracted the data. Diagnostic test parameters were determined for all studies, studies reported by radiologists, and studies reported by non-radiologists. The total sample size amounted to 5768 patients and 10,030 lymph nodes. Radiologists performed ultrasounds in 18 studies, while non-radiologists performed ultrasounds in seven studies, corresponding to 4442 and 1326 patients, respectively. The overall sensitivity of LNM detection by US was 59% (95%CI = 58–60%), and the overall specificity was 85% (95%CI = 84–86%). The sensitivity and specificity of US performed by radiologists were 58% and 86%, respectively. The sensitivity and specificity of US performed by non-radiologists were 62% and 78%, respectively. Summary receiver operating curve (sROC) found radiologists and non-radiologists to detect LNM on US with similar accuracy (p = 0.517). Our work suggests that both radiologists and non-radiologists alike detect overall LNM with high accuracy on US.

Standardization of thyroid fine needle aspiration procedure and outcomes within an endocrine surgery department

Background

Fine needle aspiration (FNA) biopsy is an essential procedure for thyroid nodules. Although, the efficacy of surgeon-performed thyroid FNA biopsies has been demonstrated in the literature, there are insufficient data regarding how to establish an efficient program with a low insufficiency rate within a group practice.

Methods

An endocrine surgery thyroid FNA biopsy program was established in 2000 by one surgeon, with training of additional partners during fellowship and upon recruitment. The results within 18 years were analyzed. The FNA biopsies were performed by endocrine surgeons under ultrasound guidance without on-site pathologist review.

Results

A total of 5,469 FNA biopsies were performed by 7 surgeons. The total number of FNA biopsies performed by each surgeon varied between 291-1,378. FNA biopsies were performed in 2 passes using 22-gauge needles under constant suction. The overall insufficiency rate was 4.3%, with individual surgeon rates ranging between 2.7% and 7.2%. The insufficiency rate for the whole team ranged between 3.3% and 5% when examined in 5-year blocks.

Conclusions

This study shows that an establishment of a highly efficient thyroid FNA biopsy program within a group practice is possible with a structured endocrine surgical training and adoption of a standard technique.

Diagnostic utility of high-risk human papillomavirus mRNA in situ hybridisation in squamous cell carcinoma of unknown primary in the head and neck and implementing American Society of Clinical Oncology guideline recommendations

INTRODUCTION

The American Society of Clinical Oncology (ASCO)-endorsed College of American Pathologists guideline recommends high-risk human papillomavirus (HPV) testing for metastatic squamous cell carcinoma (SCC) of lymph nodes level II/III of unknown primary. Herein, the performance of HPV-RNA in situ hybridisation (ISH) in detection of HPV-related SCC is evaluated implementing the ASCO guideline recommendations.

METHODS

Eighty head and neck (HN) SCC fine needle aspirations, which utilized HPV-RNA ISH/P16, were evaluated at Johns Hopkins Hospital (2015-2018) to investigate their performance and concordance with histology. The results were compared to a prior study of 59 HNSCCs, which HPV-DNA ISH.

RESULTS

Of the 80 reviewed fine needle aspirations, 65 (50 male, 15 female) were included. The mean age was 63.2 ± 14.0 years. The most common site was neck lymph nodes (47, 72.3%). Fifty-five cases (84.6%) were accompanied by concurrent core biopsy, and 48 cases (59.4%) had surgical follow-ups. HPV-RNA ISH was positive in 44 (67.7%), and P16 was strongly positive in 46 (70.8%). The HPV-RNA ISH/ P16 concordance rate was 92.3% on cytology material. The cytology/surgical concordance rate for HPV-RNA ISH was 88.9% (16/18). There was a discordance between the results in five cases (7.7%; HPV-RNA ISH-/P16+).

CONCLUSION

HPV-RNA ISH is a robust and reliable method for detecting HPV-related HNSCC on cytology material showing concordance rate of 92.3% between HPV-RNA ISH and P16, which is a sensitive but non-specific marker. Compared to HPV-DNA ISH, HPV-RNA ISH reproducibly identifies HPV-related HNSCC with fewer discrepancies between cytology and histology. The findings of this study are in agreement with the ASCO recommendations.

Determining whether surgeons perform thyroid fine-needle aspiration as well as radiologists: an analysis of the adequacy and efficiency of ultrasound-guided fine-needle aspiration performed by newly trained head and neck surgeons and radiologists

Background

Ultrasound-guided fine-needle aspiration (FNA) cytology is a crucial diagnostic technique used to assess thyroid nodules. In the past, ultrasound-guided FNA was performed mainly by radiologists. However, many surgeons are increasingly being trained for this procedure now. In this study, we aimed to compare the adequacy and efficiency of ultrasound-guided FNA performed by newly trained head and neck surgeons with experienced radiologists in a single institution. We also assessed the malignancy rates in nondiagnostic nodules and the differences between benign and malignant nodules.

Methods

This is a retrospective study. The data from patients who underwent ultrasound-guided FNA performed by surgeons or radiologists in two consecutive years were collected. Medical records, cytology results, and surgical pathology results were analyzed.

Results

During the study period, a total of 2,405 ultrasound-guided FNAs were performed on 2,163 patients. The head and neck surgeons and radiologists performed 1,132 and 1,273 ultrasound-guided FNA procedures, respectively. The nondiagnostic rate was 14.49% for surgeons and 15.40% for radiologists (P=0.533). There were no differences in patient age, gender, nodule size, and other sonographic characteristics between the groups of patients who were treated by radiologists versus surgeons. The median waiting time from biopsy appointment to performing ultrasound-guided FNA was 0 days for head and neck surgeons, and 6 days for radiologists (P<0.001). Of the 40 patients who had a repeat FNA or surgery, 19 (47.50%) had a malignancy. Preoperative information about age, gender, operator, and characteristics of nodules did not predict the outcome of nodules with Bethesda category I.

Conclusions

The adequacy of ultrasound-guided FNAs performed by head and neck surgeons is similar to that of skilled radiologists, while surgeons are more efficient than radiologists. Nondiagnostic FNA reports should not be considered benign, and repeat FNA or selective surgical treatment is recommended.

Needle Biopsy Adequacy in the Era of Precision Medicine and Value-Based Health Care

CONTEXT.—

Needle biopsy of diseased tissue is an essential diagnostic tool that is becoming even more important as precision medicine develops. However, the capability of this modality to efficiently provide samples adequate for diagnostic and prognostic analysis remains quite limited relative to current diagnostic needs. For physicians and patients, inadequate biopsy frequently leads to diagnostic delay, procedure duplication, or insufficient information about tumor biology leading to delay in treatment; for health systems, this results in substantial incremental costs and inefficient use of scarce specialized diagnostic resources.

OBJECTIVE.—

To review current needle biopsy technology, devices, and practice with a perspective to identify current limitations and opportunities for improvement in the context of advancing precision medicine.

DATA SOURCES.—

PubMed searches of fine-needle aspiration and core needle biopsy devices and similar technologies were made generally, by tissue site, and by adequacy as well as by health economics of these technologies.

CONCLUSIONS.—

Needle biopsy adequacy can be improved by recognizing the importance of this diagnostic tool by promoting common criteria for needle biopsy adequacy; by optimizing needle biopsy procedural technique, technologies, clinical practice, professional education, and quality assurance; and by bundling biopsy procedure costs with downstream diagnostic modalities to provide better accountability and incentives to improve the diagnostic process.

In-Office Ultrasonographic Evaluation of Neck Masses/Thyroid Nodules

Office-based ultrasonography is increasingly becoming an integral part of an otolaryngology-head and neck surgery practice. A thorough knowledge of the ultrasonic appearance of normal and abnormal pathology are key for performing/interpreting office-based head and neck ultrasonography. A focused but systematic approach allows for efficient and effective office-based head and neck ultrasonography. Office-based ultrasonography also allows for imaging procedures expanding the otolaryngologist's armamentarium. Ultrasound-guided fine needle aspiration (USgFNA) is an integral part of clinician-performed ultrasonography because it allows cytologic diagnosis of suspicious lesions. Understanding the successful techniques and pitfalls in this procedure are critical for the otolaryngologist performing USgFNA.