Complications after fine-needle aspiration cytology: a retrospective study of 7449 consecutive thyroid nodules

Needle size for thyroid fine needle aspiration cytology. A single institution experience

Background

Fine needle aspiration cytology (FNAC) is an invasive diagnostic technique which is widely used for the cytological diagnosis of thyroid nodules. This procedure is generally widely tolerated by patients, albeit often accompanied by local pain and discomfort. Despite various proposals of execution methods, no approach is universally accepted,especially regarding the size of the needle to be used for sampling. Needle gauge preferences vary across regions, with 25-gauge needles more common in Western countries and 22-gauge needles favored in Asian countries. Complications associated with larger needles have been studied but remain inconclusive.

Materials and methods

Over one year, we conducted 300 FNAC procedures under ultrasound guidance, employing both 22-gauge and 25-gauge needles. In no patient was local anesthesia performed before starting the procedure, which in all was performed by the same operator. Similarly the cytological examination of the material taken was performed by a single operator. Patients, 105 males and 195 females, were divided into two groups of 150 each based on the needle size used.

Results

Patients treated with 22-gauge needles reported higher levels of pain during the procedure and increased discomfort afterward. Similarly, a greater incidence of hematomas and vasovagal reactions was noted in this group. However, the cell sample obtained and diagnostic response rates were consistent across both groups.

Conclusion

On the basis of our observations we concluded that the size of the needle used is irrelevant for the purposes of the diagnostic result, as long as the procedure is performed by expert personnel. However, the 25-gauge needle is preferable because it's more tolerated and accepted by patients. Our results do not represent a single and conclusive verdict, but they could represent the starting point for further research.

Neck lump evaluation and pseudoaneurysm

Pseudoaneurysm is the formation of a sac due to damage in the continuity of the arterial wall. Iatrogenic carotid artery aneurysm is a rare, life-threatening complication following fine needle aspiration (FNA). We are presenting here a case of pseudoaneurysm following FNA with a literature review.

Role of advanced MRI sequences for thyroid lesions assessment. A narrative review

Despite not being the first imaging modality for thyroid gland assessment, Magnetic Resonance Imaging (MRI), thanks to its optimal tissue contrast and spatial resolution, has provided some advancements in detecting and characterizing thyroid abnormalities. Recent research has been focused on improving MRI sequences and employing advanced techniques for a more comprehensive understanding of thyroid pathology. Although not yet standard practice, advanced MRI sequences have shown high accuracy in preliminary studies, correlating well with histopathological results. They particularly show promise in determining malignancy risk in thyroid lesions, which may reduce the need for invasive procedures like biopsies. In this line, functional MRI sequences like Diffusion Weighted Imaging (DWI), Dynamic Contrast-Enhanced MRI (DCE-MRI), and Arterial Spin Labeling (ASL) have demonstrated their potential usefulness in evaluating both diffuse thyroid conditions and focal lesions. Multicompartmental DWI models, such as Intravoxel Incoherent Motion (IVIM) and Diffusion Kurtosis Imaging (DKI), and novel methods like Amide Proton Transfer (APT) imaging or artificial intelligence (AI)-based analyses are being explored for their potential valuable insights into thyroid diseases. This manuscript reviews the critical physical principles and technical requirements for optimal functional MRI sequences of the thyroid and assesses the clinical utility of each technique. It also considers future prospects in the context of advanced MR thyroid imaging and analyzes the current role of advanced MRI sequences in routine practice.

US of thyroid nodules: can AI-assisted diagnostic system compete with fine needle aspiration?

OBJECTIVES

Artificial intelligence (AI) systems can diagnose thyroid nodules with similar or better performance than radiologists. Little is known about how this performance compares with that achieved through fine needle aspiration (FNA). This study aims to compare the diagnostic yields of FNA cytopathology alone and combined with BRAFV600E mutation analysis and an AI diagnostic system.

METHODS

The ultrasound images of 637 thyroid nodules were collected in three hospitals. The diagnostic efficacies of an AI diagnostic system, FNA-based cytopathology, and BRAFV600E mutation analysis were evaluated in terms of sensitivity, specificity, accuracy, and the κ coefficient with respect to the gold standard, defined by postsurgical pathology and consistent benign outcomes from two combined FNA and mutation analysis examinations performed with a half-year interval.

RESULTS

The malignancy threshold for the AI system was selected according to the Youden index from a retrospective cohort of 346 nodules and then applied to a prospective cohort of 291 nodules. The combination of FNA cytopathology according to the Bethesda criteria and BRAFV600E mutation analysis showed no significant difference from the AI system in terms of accuracy for either cohort in our multicenter study. In addition, for 45 included indeterminate Bethesda category III and IV nodules, the accuracy, sensitivity, and specificity of the AI system were 84.44%, 95.45%, and 73.91%, respectively.

CONCLUSIONS

The AI diagnostic system showed similar diagnostic performance to FNA cytopathology combined with BRAFV600E mutation analysis. Given its advantages in terms of operability, time efficiency, non-invasiveness, and the wide availability of ultrasonography, it provides a new alternative for thyroid nodule diagnosis.

CLINICAL RELEVANCE STATEMENT

Thyroid ultrasonic artificial intelligence shows statistically equivalent performance for thyroid nodule diagnosis to FNA cytopathology combined with BRAFV600E mutation analysis. It can be widely applied in hospitals and clinics to assist radiologists in thyroid nodule screening and is expected to reduce the need for relatively invasive FNA biopsies.

KEY POINTS

• In a retrospective cohort of 346 nodules, the evaluated artificial intelligence (AI) system did not significantly differ from fine needle aspiration (FNA) cytopathology alone and combined with gene mutation analysis in accuracy. • In a prospective multicenter cohort of 291 nodules, the accuracy of the AI diagnostic system was not significantly different from that of FNA cytopathology either alone or combined with gene mutation analysis. • For 45 indeterminate Bethesda category III and IV nodules, the AI system did not perform significantly differently from BRAFV600E mutation analysis.

A meta-analysis of the value of serum TSH concentration in the diagnosis of differentiated thyroid cancer in patients with thyroid nodules

Background

In recent years, most studies believe that high TSH level is positively correlated with the incidence of thyroid cancer, but it is still controversial. For this reason, the purpose of this study is to analyze the correlation between preoperative TSH level and thyroid malignant nodules using pathological diagnosis as the gold standard. To evaluate the role of serum TSH in predicting malignancy of thyroid nodules with uncertain cytology.As an important member of the hypothalamus-pituitary-thyroid axis in the endocrine system, TSH plays a crucial role in regulating the growth, differentiation, and function of thyroid cells (Zhang et al., 2023) [1]. Therefore, it has always been considered closely related to TC. Currently, most studies have compared the TSH levels of TC patients and individuals with benign thyroid disease or healthy controls. These findings from various studies indicated that TC patients often demonstrate elevated TSH levels, even when their TSH falls within the normal range. However, it is important to highlight that the current evidence primarily relies on cross-sectional studies, which mainly describe a phenomenon without establishing causal relationships. The involvement of TSH in the early onset or late progression of TC remains unknown, the interaction between TSH and other factors and how it affects TC is not well understood (Gubbi et al., 2020) [2].Symptoms of thyroid cancer are usually insidious, and early thyroid cancer often has no obvious clinical symptoms. Therefore, early detection and early treatment are particularly important, and how to improve the preoperative diagnosis rate of thyroid nodules is also a problem that clinicians pay close attention to.

Objective

To evaluate the value of serum TSH concentration in the diagnosis of differentiated thyroid carcinoma in patients with thyroid nodules.

Methods

Our study searched databases in both Chinese and English.China Academic Journals FULL-text Database (CNKI), China Online Journals, Chinese Scientific Journals database and Chinese Biomedical Literature Database (CBM) were searched by computer. The English literature was established by PubMed, Embase, Cochrane Library, Web of Science and other databases until June 2022 to search for relevant literatures on the diagnostic test of serum TSH concentration in patients with thyroid nodule. The literatures that met the criteria were screened, the data were extracted, and the literature quality was evaluated. The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio of the method for the diagnosis of differentiated thyroid carcinoma were calculated and summarized. The receiver operating characteristic (SROC) curve was drawn and the area under the curve was obtained.

Results

A total of 23 diagnostic tests were included (5348 lesions). Meta-analysis showed that the combined sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio of serum TSH concentration in the diagnosis of differentiated thyroid carcinoma were 0.64, 0.72, 2.511, 0.386 and 7.14, respectively. The area under SROC curve (AUC) was 0.79, and the Q index was 0.7283, indicating no statistically significant difference.

Conclusion

Based on current evidence, detection of serum TSH concentration in thyroid nodule patients has high sensitivity and specificity for the diagnosis of differentiated thyroid cancer, which has good clinical application value. However, other auxiliary examinations are still needed to improve the diagnosis rate.

Comparative analysis of machine learning-based ultrasound radiomics in predicting malignancy of partially cystic thyroid nodules

OBJECTIVE

To investigate the application of machine learning (ML) model-based thyroid ultrasound radiomics in the evaluation of malignancy in partially cystic thyroid nodules (PCTNs).

METHODS

One hundred and ninety-two patients with 197 nodules PCTNs from January 2020 to December 2020 were retrospectively analyzed. Radiomics features were extracted based on hand-crafted features from the ultrasound images, and machine learning methods were used to build a classification model by radiomics features. The least absolute shrinkage and selection operator regression was applied to select the features of nonzero coefficients from radiomics features. The prediction performance of the established model was mainly evaluated by the area under the curve (AUC) and accuracy, sensitivity, and specificity.

RESULTS

Nineteen radiomics features were extracted from the original images for each nodule. Eight ML classifiers were able to differentiate malignancy in PCTNs. The AUC, accuracy, sensitivity, and specificity of k-Nearest Neighbor (KNN) model were 0.909, 82.95%, 83.33%, and 89.90%, respectively, on the test cohort. The comparative result showed statistically equivalent performance for thyroid nodule diagnosis based on image fusion and single image. In addition, the ML-Based ultrasound radiomics system showed a better AUC as compared with ACR TI-RADS model and the ultrasound features model.

CONCLUSION

The novel ultrasonic-based ML model has an important clinical value for predicting malignancy in PCTNs. It can provide clinicians with a preoperative non-invasive primary screening method for PCTN diagnosis to avoid unnecessary medical investment and improve treatment outcomes.

Diagnostic Value of Preparing Additional Liquid-Based Cytology Slides and Cell Blocks from Residue Material in Thyroid fine Needle Aspiration

Background and Aims

After liquid-based cytology (LBC) technique developed for cervical cytology, it has been used for nongynecological samples and has been very successful. It offers having extra slides of the samples for further examination and ancillary tests. Moreover, cell blocks can be formed from the residue material. The study aimed to evaluate the importance of preparing a second LBC slide or a cell block from the residue material of thyroid fine needle aspiration (FNA) samples to reach a definitive diagnosis in cases diagnosed as nondiagnostic (ND) after the first slide.

Material and Methods

Seventy five cases diagnosed as ND after the first slide were included in study. For 50 cases, the second LBC slides were prepared (LBC group); for 25 cases, cell block was performed from residue material (CB group). Two groups were compared in terms of reaching a definitive diagnosis.

Results

At the end of secondary procedures, a definitive diagnosis was reached in a total of 24 cases (32%). Twenty of 50 cases (40%) in LBC group reached a definitive diagnosis while four cases (16%) in the CB group reached a definitive diagnosis. Achieving a definitive diagnosis was found statistically higher in the LBC group in which the second slide was formed compared to the CB group (P =0.036).

Conclusion

Preparing a second slide with LBC method is more purposive than preparing a cell block from the residue material of thyroid FNA samples. Reducing the percentage of ND cases will protect patients from complications and morbidity that may arise from repeated FNA.

When and why patients drop out from benign thyroid nodules follow-up: a single centre experience

PURPOSE

Drop-out in clinical long-term follow-up is a general problem that is potentially harmful to patients. No data about patients that drop out from thyroid ultrasound follow-up is available literature. The aim of the present retrospective study was to evaluate the characteristics of patients that dropped out from ultrasound thyroid nodule follow-up.

PATIENTS AND METHODS

We reviewed medical records of all consecutive patients who underwent a fine needle aspiration from January 2007 to March 2009 in our department. All the patients with benign nodule(s) were recommended annual ultrasounds; patients who had dropped out from follow-up were included and a telephone interview was obtained to evaluate the reasons for dropping out.

RESULTS

289/966 (30%) of patients with benign nodules dropped out during follow-up; 94% of them within the first 5 years. Phone interviews were obtained from 201/289 (70%) of the patients. In the 57% of cases, the main declared reason for dropping out was nodular dimension stability during the first 2-3 years; 8.7% of them had forgotten about the appointment; 6.4% of subjects claimed to check only serum TSH, and 3.2% stated that they would undergo an ultrasound only if the nodule(s) were symptomatic. Finally, 10.7% patients continued follow-up in other centres.

CONCLUSION

we showed that a third of patients miss their thyroid ultrasound follow-ups, and that the major cause is the low perceived threat coming from the disease. As a certain amount of drop-out is inevitable, attempting to reinforce our patients' awareness regarding their own health state is mandatory.

TRIAL REGISTRATION

Trial registration: no. 4084.

Ultrasound-Guided Conventional Versus Trans-isthmic Fine Needle Aspiration: Comparison of Post-biopsy Hematoma Rates and Patients' Pain

Objective Fine needle aspiration (FNA) is an invasive procedure; however, it is the simplest and safest method of identifying thyroid nodules that is well tolerated by patients. The most common complication is minor bleeding and pain. The objective of this study was to evaluate pain and complications among patients with thyroid nodules undergoing ultrasound (US)-guided FNA procedures. Materials and methods A total of 757 patients who underwent US-guided biopsy of the thyroid nodule in our institution between January 2017 and July 2022 were reviewed retrospectively. Demographic characteristics, US features, nodule depth and size, developing hematoma dimensions, and visual analog scale (VAS) scores during the procedure and at the 30th minute after the procedure were recorded in all cases. Results Overall, 272 (206 female and 66 male) patients who underwent US-guided conventional FNA (US-CFNA) procedure and 485 (361 female and 124 males) patients who underwent US-guided trans-isthmic FNA (US-TIFNA) were included. There was no significant difference between the two groups in terms of gender or age (p=0.691 and p=0.539, respectively). Although the mean nodule size of the US-TIFNA group was larger than that of the US-CFNA group, there was no statistically significant difference between the groups (p=0.137). There was a statistically significant difference between the two groups regarding the mean pain score during the procedures and 30 minutes after the procedure (p=0.032 and p=0.001, respectively). A total of 18 patients had procedural bleeding complications. While hematoma was detected in 11 (4.04%) patients who underwent the US-CFNA procedure, it was detected in seven (1.44%) patients who underwent the TIFNA procedure (p=0.024). Conclusion We compared the incidence of hematoma and the comfort of patients during and after the procedure between the US-TIFNA procedure and the US-CFNA procedure. The frequency of hematoma was higher in US-CFNA patients during and after the biopsy, and it was statistically significant. Moreover, the evaluation of patients' pain levels has shown that the US-TIFNA procedure resulted in significant patient satisfaction.

Prevalence of Thyroid Nodules and Thyroid Cancer in Individuals with a First-Degree Family History of Non-Medullary Thyroid Cancer: A Cross-Sectional Study Based on Sonographic Screening

Background: The actual rates of suspicious thyroid nodules (TNs) and confirmed thyroid cancer (TC) in putatively "at-risk" selected populations (e.g., individuals with family history of TC) are still uncertain. Methods: Our aim was to explore the prevalence of TC and TN in a cross-sectional study of a consenting population of unaffected individuals (10 years of age or older) with a first-degree relative known to have non-medullary TC (NMTC). Enrolled subjects underwent ultrasonographic studies of the neck between 2009 and 2018. Nodules considered suspicious according to current guidelines were subjected to fine-needle aspiration biopsy (FNAB) for cytology. Results: The screenee population comprised 1176 individuals (median age 42 [26-56] years, 650 females, 55.3%) from 473 kindreds (346 with 1 established NMTC diagnosis at entry, 103 with 2 established NMTC diagnoses, and 24 with 3 or more established NMTC diagnoses at entry). Screening revealed TNs in 500 screenees (42.5%; confidence interval [CI] 39.7-45.4%). Ninety-seven of these (19.4%; CI 16.2-23.1%) underwent FNAB. Only 11 cases of TC were diagnosed in the whole population (0.9%; CI 0.5-1.7%). The prevalence of TC in screenees from kindreds with ≥3 cases (3/24, 12.5%) was higher than that for kindreds with one affected member (6/346, 1.7%; p = 0.01, odds ratio [OR] 7.99; CI 1.21-40.75) and for those with two affected members (2/103, 1.9%; p = 0.05, OR 7.05; CI 0.76-89.44). The prevalence of TNs was 61.8% (CI 56.6-66.8%), 75.7% (CI 66.6-83%), and 66.7% (CI 46.7-82%) in the kindreds with 1, 2, and ≥3 cases, respectively (p = 0.03). Conclusions: On the whole, ultrasound-based screening of unaffected relatives of individuals with established diagnoses of NMTC is likely to reveal a high prevalence of TN and a low prevalence of TC. However, a significantly higher prevalence of TC may be found among screenees from kindreds with at least three established NMTC diagnoses before screening, suggesting that closer surveillance may be warranted in kindreds with this level of familiality.

Comparison of GATA3, GCDFP15, Mammaglobin and SOX10 Immunocytochemistry in Aspirates of Metastatic Breast Cancer

Introduction: Metastatic cancers are frequently detected on fine-needle aspiration (FNA) cytology, and confirmation of metastatic breast cancer often requires immunocytochemistry. Tissue provisioning for FNA specimens is important. In this study, GATA3, gross cystic disease fluid protein-15 (GCDFP15), mammaglobin (MMG), and SOX10 were performed on cell block preparations from aspirates of histologically confirmed metastatic breast cancers. The diagnostic performance of single markers and combinations of these markers were investigated with the aim to construct a tissue-efficient immunopanel. Methodology: Aspirates of metastatic breast cancer with corresponding histology and biomarker (estrogen receptor (ER), progesterone receptor (PR), HER2 and ki67) profile were retrieved. ER, GATA3, GCDFP15, MMG and SOX10 immunostains were performed on cell block sections and their expressions were assessed and compared. Results: Immunostaining was performed on a total of 115 aspirates. GATA3 showed the highest expression, followed by MMG, GCDFP15 and SOX10. Twenty-three, five and five cases expressed GATA3, MMG and SOX10 only. The five cases expressing SOX10 only were ER negative, and SOX10 expression was negatively associated with ER (p = 0.001), MMG (p = 0.001), GCDFP15 (p = 0.010) and GATA3 (p = 0.002), whereas GATA3 expression showed positive correlation with ER positivity (p < 0.001). MMG and GCDFP15 showed association with high Ki67 (p < 0.05), and no correlations were found with HER2 expression. Conclusion: In this cohort, GATA3 was the most sensitive single marker. The addition of MMG and SOX10 increases the sensitivity for detection of ER positive and ER negative breast cancers, respectively. These findings support the use of a combination of GATA3/MMG/SOX10 for confirmation of metastatic breast cancer.

SuperSonic shear imaging for the differentiation between benign and malignant thyroid nodules: a meta-analysis

PURPOSE

To assess the diagnostic value of SuperSonic shear imaging (SSI) for the differentiation between benign and malignant thyroid nodules through meta-analysis.

METHODS

Online database searches were performed on PubMed, EMBASE, the Cochrane Library, and the Web of Science until 31 July 2021. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to assess the quality of the included studies. Three measures of diagnostic test performance were used to examine the value of SSI, including the summary area under the receiver operating characteristic curve (AUROC), the summary diagnostic odds ratio (DOR), and the summary sensitivity and specificity. Heterogeneity was explored using meta-regression and subgroup analyses.

RESULTS

Finally, 21 studies with 3376 patients were included in this study. There were a total of 4296 thyroid nodules, in which 1806 malignant nodules and 2490 benign ones were involved. Thyroid nodules exhibited a malignancy rate of 42.0% (range 5.6-79.8%), 95.1% of which were of papillary variant. SSI showed a summary sensitivity of 74% [95% confidence interval (CI) 67-79%], specificity of 82% (95% CI 77-87%) and AUROC of 0.85 (95% CI 0.82-0.88) for the differentiation between benign and malignant thyroid nodules. The summary positive likelihood ratio (LR), negative LR, and DOR were 4.2 (95% CI 3.3-5.3), 0.32 (95% CI 0.26-0.40), and 13 (95% CI 9-18), respectively.

CONCLUSIONS

SSI showed high accuracy in the diagnostic differentiation between benign and malignant thyroid nodules and can be served as a noninvasive and important adjunct for thyroid nodule evaluation.

Acute transient thyroid swelling after fine-needle aspiration biopsy: A case report of a rare complication and a literature review

Fine-needle aspiration biopsy (FNAB) is a safe and effective thyroid examination method with rare complications. Herein, we report a rare case of acute transient thyroid swelling that occurred after ultrasound-guided FNAB. The patient experienced acute pain with rapid thyroid swelling. Ultrasound imaging revealed a nodule with a linear, hypoechoic, and "patch-like" appearance, indicating edema without hemorrhage. After receiving anti-anaphylaxis and detumescence therapy for 1 day, the swelling regressed. Acute transient thyroid swelling is an extremely rare event that occurs shortly after FNAB and may frighten patients; therefore, clinicians should be aware of this complication in this context.

Exploring the Value of Radiomics Features Based on B-Mode and Contrast-Enhanced Ultrasound in Discriminating the Nature of Thyroid Nodules

Background

With the improvement of ultrasound imaging resolution and the application of various new technologies, the detection rate of thyroid nodules has increased greatly in recent years. However, there are still challenges in accurately diagnosing the nature of thyroid nodules. This study aimed to evaluate the clinical application value of the radiomics features extracted from B-mode ultrasound (B-US) images combined with contrast-enhanced ultrasound (CEUS) images in the differentiation of benign and malignant thyroid nodules by comparing the diagnostic performance of four logistic models.

Methods

We retrospectively collected and ultimately included B-US images and CEUS images of 123 nodules from 123 patients, and then extracted the corresponding radiomics features from these images respectively. Meanwhile, a senior radiologist combined the thyroid imaging reporting and data system (TI-RADS) and the enhancement pattern of the ultrasonography to make a graded diagnosis of the malignancy of these nodules. Next, based on these radiomics features and grades, logistic regression was used to help build the models (B-US radiomics model, CEUS radiomics model, B-US+CEUS radiomics model, and TI-RADS+CEUS model). Finally, the study assessed the diagnostic performance of these radiomics features with a comparison of the area under the curve (AUC) of the receiver operating characteristic curve of four logistic models for predicting the benignity or malignancy of thyroid nodules.

Results

The AUC in the differential diagnosis of the nature of thyroid nodules was 0.791 for the B-US radiomics model, 0.766 for the CEUS radiomics model, 0.861 for the B-US+CEUS radiomics model, and 0.785 for the TI-RADS+CEUS model. Compared to the TI-RADS+CEUS model, there was no statistical significance observed in AUC between the B-US radiomics model, CEUS radiomics model, B-US+CEUS radiomics model, and TI-RADS+CEUS model (P>0.05). However, a significant difference was observed between the single B-US radiomics model or CEUS radiomics model and B-US+CEUS radiomics model (P<0.05).

Conclusion

In our study, the B-US radiomics model, CEUS radiomics model, and B-US+CEUS radiomics model demonstrated similar performance with the TI-RADS+CEUS model of senior radiologists in diagnosing the benignity or malignancy of thyroid nodules, while the B-US+CEUS radiomics model showed better diagnostic performance than single B-US radiomics model or CEUS radiomics model. It was proved that B-US radiomics features and CEUS radiomics features are of high clinical value as the combination of the two had better diagnostic performance.

The Importance of miRNA in the Diagnosis and Prognosis of Papillary Thyroid Cancer

In recent years, the global incidence of thyroid cancer has been increasing. Despite the significant progress in the diagnostic tools applied for papillary thyroid cancer (PTC) diagnosis, commonly used methods require undergoing invasive diagnostic procedures, such as liquid biopsy, which still, in some cases, remains imprecise. In this case, novel screening and diagnostic biomarkers are still being evaluated using highly specialized techniques, which could increase PTC detection. Currently, a number of genes and proteins associated with PTC development are currently under investigation to assess their clinical utility. Accordingly, a literature search was undertaken to collect novel information about the diagnosis of and prognosis for PTC with a particular emphasis on the role of microRNA (miRNA) evaluation. The early identification of novel biomarkers is essential for facilitating appropriate therapeutic decisions. Moreover, the evaluation of plasma- and serum-derived miRNA measurements could be considered as equivalent thyroid cancer screening tools in the future. On the other hand, the PTC pathogenesis could be evaluated further with the use of miRNA evaluation, which may bring novel insights for potential medical target determination.

Acute diffuse thyroid swelling after fine-needle aspiration: A case report and review of the literature

Fine-needle aspiration (FNA) is the first-line and a cost-effective examination method of nonfunctional thyroid nodules. Acute transient thyroid swelling after an FNA is a rare complication, and to date, only 14 cases have been reported in the English literature. Herein, we report a case of a 26-year-old woman with acute transient thyroid swelling, which occurred after an ultrasound-guided FNA of a thyroid nodule. Although the patient had undergone an FNA without complication 2 years previously, the second FNA caused acute thyroid swelling. The present case emphasizes the potential risk of acute thyroid swelling associated with every FNA procedure.

Update on the Evaluation of Thyroid Nodules

Thyroid nodules (TN) are prevalent in the general population and represent a common complaint in clinical practice. Most are asymptomatic and are associated with a 7%-15% risk of malignancy (1). Methods: PubMed and Medline were searched for articles with a focus on the epidemiology, diagnosis, and management of TN over the past 5 y. Results: The increase in frequency of imaging has led to a rise in the incidence of incidentally diagnosed TN. The initial evaluation of a TN includes assessing thyroid function, clinical risk factors, and neck imaging. Ultrasound remains the gold standard for assessing TN morphology, and biopsy is the standard method for determining whether a TN is benign. Recently published risk stratification systems using morphologic characteristics on ultrasonography have been effective in reducing the number of unnecessary biopsies. Advances in molecular testing have reduced the number of surgical procedures performed for diagnostic purposes on asymptomatic TN with indeterminate cytology. Scintigraphy is the first-line study for assessing a hyperfunctioning nodule. Many TN can be followed clinically or with serial ultrasound after the initial diagnosis. Surgical intervention is warranted when local symptoms are present, in patients with clinical risk factors, as well as in most situations with malignant cytology. Active surveillance is an option in cases of micropapillary thyroid cancer. Emerging nonsurgical approaches for treating TN include ethanol ablation for TN; sclerotherapy for thyroid cysts; and thermal techniques, such as radiofrequency ablation, laser ablation, microwaves, and high-intensity focused ultrasound. Conclusion: Most TN are benign and can be safely monitored. The indications for biopsy and frequency of imaging should be tailored on the basis of risk stratification. Treatment options should be individualized for each patient's particular situation. Active surveillance should be considered in certain cases of papillary microcarcinoma.

Ultrasound Image Classification of Thyroid Nodules Using Machine Learning Techniques

Background and Objectives: Thyroid nodules are lumps of solid or liquid-filled tumors that form inside the thyroid gland, which can be malignant or benign. Our aim was to test whether the described features of the Thyroid Imaging Reporting and Data System (TI-RADS) could improve radiologists' decision making when integrated into a computer system. In this study, we developed a computer-aided diagnosis system integrated into multiple-instance learning (MIL) that would focus on benign-malignant classification. Data were available from the Universidad Nacional de Colombia. Materials and Methods: There were 99 cases (33 Benign and 66 malignant). In this study, the median filter and image binarization were used for image pre-processing and segmentation. The grey level co-occurrence matrix (GLCM) was used to extract seven ultrasound image features. These data were divided into 87% training and 13% validation sets. We compared the support vector machine (SVM) and artificial neural network (ANN) classification algorithms based on their accuracy score, sensitivity, and specificity. The outcome measure was whether the thyroid nodule was benign or malignant. We also developed a graphic user interface (GUI) to display the image features that would help radiologists with decision making. Results: ANN and SVM achieved an accuracy of 75% and 96% respectively. SVM outperformed all the other models on all performance metrics, achieving higher accuracy, sensitivity, and specificity score. Conclusions: Our study suggests promising results from MIL in thyroid cancer detection. Further testing with external data is required before our classification model can be employed in practice.

Ultrasound of benign thyroid nodules: A 120 months follow-up study

OBJECTIVE

Some evidence suggests that most benign nodules exhibit no significant size increase during 5 years of follow-up, although conflicting results have emerged. The aim of the present study is to evaluate the frequency and the magnitude of growth in benign nodules during 120 months of follow-up.

DESIGN

We reviewed the medical and imaging records of patients who were submitted to ultrasound-guided FNA of thyroid nodules at our hospital from January 2007 to March 2009. We selected only patients with benign nodules who underwent annual ultrasound evaluation in our Department.

RESULTS

Among 966 selected patients, 289 were lost during follow-up, meaning that the total number of patients analysed was 677 (474 women and 203 men), with a mean age of 45.6 (16-71) years. In 559/677 patients (82.7%), the size of the nodule remained stable during follow-up; 42 (6.2%) patients experienced spontaneous nodule shrinkage, and 75 (11.1%) patients showed nodule growth. Patients with or without nodule growth during follow-up were superimposable at baseline for age, gender, TSH values, number of patients on levothyroxine treatment and nodule characteristics. All baseline variables in predicting nodular growth were entered to an adjusted multivariate logistic regression model. None of the parameters taken into account was associated with nodular growth.

CONCLUSIONS

In conclusion, the majority of benign nodules remained stable over the period of monitoring. On the basis of our experience, we recommend ultrasound examination at a distance of 2 and 5 years following cytological evaluation, then every 4-5 years from then on.

Acute thyroid swelling after fine needle aspiration-a case report of a rare complication and a systematic review

BACKGROUND

Thyroid fine needle aspiration (FNA) is the procedure of choice in the management of thyroid nodules. Acute thyroid swelling after FNA is a rare complication and is reported in a finite number of literatures. To the best of our knowledge, only seven reported cases exist in literatures. This study describes an addition case with an acute thyroid swelling after FNA, as well as puts forward a new hypothesis of this phenomenon.

CASE PRESENTATION

The case is presented of a 30-year-old female with an acute thyroid swelling after FNA, with funicular hypoechoic lesions in thyroid gland. The size of thyroid was 1.5-fold enlarged in the unilateral thyroid gland. No complains of pain or other discomforts with her and no signs of hemorrhage were found along the passage of the fine needle. The episode was recovered spontaneously.

CONCLUSIONS

An acute thyroid swelling is a rare complication of FNA. A hypothesis of anaphylactic reaction was suggested in our study. Physicians should pay more attention of this phenomenon and more information is needed to support our hypothesis.

Thyroid scintigraphy in the era of fine-needle aspiration cytology

PURPOSE

To evaluate whether thyroid scintigraphy would alter the clinical management of patients referred for fine-needle aspiration cytology (FNA).

METHODS

We reviewed the medical and imaging records of patients referred to our Department between 2016 and 2019. All the patients had to take a serum thyrotropin test administered in our hospital at least two months before the FNA; where the TSH level was ≤1.5 mIU/L, the patients were subjected to a scan and subsequently to FNA, where indicated. We selected only healthy patients with no previous history of thyroid disease, who were not taking any drugs and who had a TSH level of ≤1.5 mIU/L. We excluded patients with multinodular goitre.

RESULTS

A total of 176 patients were analysed. A total of 67/176 patients (38%) showed a serum of TSH ≤ 0.27 mIU/L. Scintigraphy identified a hot nodule in 142 lesions (80.7%), a warm nodule in 8 lesions (4.5%) and a cold nodule in 26 lesions (14.8%). The ROC curve analysis indicated that a TSH value of ≤0.42 mIU/L identified patients with hyperfunctioning nodules with a sensitivity of 65% and a specificity of 77%. All patients with cold and warm nodules were submitted to FNA: 22/26 (85%) and 5/8 (63%) lesions showed suspected malignancy or were compatible with malignancy, respectively.

CONCLUSION

Speculating on our data, if we had subjected our patients to FNA as indicated by the 2015 ATA guidelines, we would have subjected 117 patients to cytology, from whom 83 had undetected hot nodules. Conversely, by adopting scintigraphy for all patients with TSH ≤ 1.5 mIU/L, 109 patients have avoided FNA. However, our study was performed in a region with a history of mild iodine deficiency. Therefore, we cannot claim that our observation is valid for patients born and living in areas with sufficient iodine uptake. We recommend thyroid scintigraphy for treating single thyroid nodules in euthyroid patients born and living in regions with an iodine deficiency, when TSH levels are below 1.5 mIU/L before FNA.

Fine Needle Aspiration Cytology (FNAC) for Chinese Patients With Acral and Cutaneous Melanoma: Accuracy and Safety Analysis From a Single Institution

This study aimed to investigate the accuracy and safety of fine-needle aspiration cytology (FNAC) in Chinese patients with acral and cutaneous melanoma, and also to evaluate the influencing factors and their impact on prognosis. Data of 128 patients with stage 0-III acral and cutaneous melanoma treated in Fudan University Shanghai Cancer Center from 2009 to 2016 were collected from a prospective database. Further, 128 patients who did not undergo FNAC but had similar parameters were recruited as the matched group. Clinical features, FNAC status, and recurrence or metastasis status of patients were analyzed for overall survival (OS), melanoma-specific survival (MSS), recurrence-free survival (RFS), and metastasis-free survival (MFS). Of the 128 patients with FNAC, 5.5% (7/128) had a negative cytological diagnosis, 12.2% (5/41) had primary lesions, and 2.3% (2/87) had lesions in lymph nodes. Tumor thickness, status of ulceration, and subtype were not associated with accuracy for both primary and lymph node FNAC. With a median follow-up of 40 months in all patients, 55 had melanoma-specific death; the median OS and MSS were 95 months and 104 months, respectively. Patients with FNAC had significantly worse OS. Tumor progression occurred in 130 patients. The survival analysis revealed differences in OS and disease-free survival between the two groups. FNAC impacted patients' RFS and MFS; the difference in survival curves of RFS and MFS was also statistically significant. FNAC on primary or superficial lymphatic lesions was a good diagnostic tool for Chinese patients with acral and cutaneous melanoma, but it adversely impacted prognosis.

Contemporary Thyroid Nodule Evaluation and Management

CONTEXT

Approximately 60% of adults harbor 1 or more thyroid nodules. The possibility of cancer is the overriding concern, but only about 5% prove to be malignant. The widespread use of diagnostic imaging and improved access to health care favor the discovery of small, subclinical nodules and small papillary cancers. Overdiagnosis and overtreatment is associated with potentially excessive costs and nonnegligible morbidity for patients.

EVIDENCE ACQUISITION

We conducted a PubMed search for the recent English-language articles dealing with thyroid nodule management.

EVIDENCE SYNTHESIS

The initial assessment includes an evaluation of clinical risk factors and sonographic examination of the neck. Sonographic risk-stratification systems (e.g., Thyroid Imaging Reporting and Data Systems) can be used to estimate the risk of malignancy and the need for biopsy based on nodule features and size. When cytology findings are indeterminate, molecular analysis of the aspirate may obviate the need for diagnostic surgery. Many nodules will not require biopsy. These nodules and those that are cytologically benign can be managed with long-term follow-up alone. If malignancy is suspected, options include surgery (increasingly less extensive), active surveillance or, in selected cases, minimally invasive techniques.

CONCLUSION

Thyroid nodule evaluation is no longer a 1-size-fits-all proposition. For most nodules, the likelihood of malignancy can be confidently estimated without resorting to cytology or molecular testing, and low-frequency surveillance is sufficient for most patients. When there are multiple options for diagnosis and/or treatment, they should be discussed with patients as frankly as possible to identify an approach that best meets their needs.

Diagnostic Efficacy and Safety of Core Needle Biopsy as a First-Line Diagnostic Method for Thyroid Nodules: A Prospective Cohort Study

Background: The diagnostic role of ultrasonography (US)-guided core needle biopsy (CNB) as a first-line diagnostic method for thyroid nodules remains controversial. This study was performed to determine the diagnostic efficacy and safety of CNB as a first-line diagnostic method for thyroid nodules. Methods: From February 2016 to January 2018, CNB was prospectively performed by an experienced radiologist in all consecutive patients with thyroid nodules indicated for fine-needle aspiration (FNA). Three patients refused this protocol. Finally, 212 consecutive patients with 248 thyroid nodules were enrolled in this prospective study. Combined CNB/FNA was selectively performed in 43 patients. The diagnostic efficacy of CNB was evaluated by the rate of inconclusive results (nondiagnostic or indeterminate results), and its feasibility was estimated by calculating the successful biopsy rate and by measuring the procedure time from the time of the initial skin puncture to the last withdrawal of the biopsy needle from the skin. The safety of the procedure was evaluated by the major and minor complication rates. A US evaluation was performed before and after manual self-compression to assess for hemorrhage at the biopsy site, and delayed complications were assessed 5-7 days after the biopsy. Any hemorrhage that did not require hospitalization was classified as a minor complication. Results: CNB was performed once (n = 125, 50.4%), twice (n = 122, 49.2%), or three times (n = 1, 0.4%) per nodule. The diagnostic results of CNB were as follows: nondiagnostic (0.8%), benign (63.3%), indeterminate (10.1%), follicular neoplasm (3.2%), suspected malignancy (2.4%), and malignancy (20.1%); the rate of inconclusive results was 10.9%. The successful biopsy rate of CNB was 100%, and the median procedure time was 102 seconds (interquartile range 51-181 seconds). There were no major or delayed complications. There were 6 cases (2.8%) of minor complications, which included 2 cases (0.9%) with symptomatic hematomas and 4 cases (1.9%) with asymptomatic small hematomas. Conclusion: The findings confirm that CNB is effective in reducing the rate of inconclusive results and it is safe. CNB may be used as an alternative first-line diagnostic method for thyroid nodules by an experienced operator.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Could Serum TSH Levels Predict Malignancy in Euthyroid Patients Affected by Thyroid Nodules with Indeterminate Cytology?

BACKGROUND

Serum TSH levels in the upper-normal range were reported to be associated with increased risk of thyroid malignancy. However, measurement of TSH levels is currently not recommended for assessing the risk of malignancy in patients with newly diagnosed thyroid nodules.

OBJECTIVE

To evaluate a possible relationship between the serum levels of TSH and the histological outcome of patients undergoing thyroidectomy for thyroid nodules with indeterminate cytology.

MATERIALS AND METHODS

We collected the clinical data of all patients who had performed ultrasound-guided FNA of thyroid nodules with cytological diagnosis of indeterminate lesions (TIR3A and TIR3B) and serum TSH levels within the normal range. All patients had been submitted to thyroid surgery (hemi or thyroidectomy, as appropriate), and histological diagnosis had been performed.

RESULTS

A histological diagnosis of thyroid malignancy was rendered in 74/378 (19.6%) nodules. Patients with histologically proven thyroid malignancy were characterized by higher serum levels of TSH as compared to patients with histologically proven benign nodules (3.03 ± 1.16 vs. 2.37 ± 1.19 mIU/L, p < 0.001). To further analyze the role of serum TSH in predicting thyroid cancer, patients were stratified in 4 groups according to quartiles of TSH concentrations. The prevalence of malignancy was 12.2% for the first quartile and 50.0% for the last quartile. ROC curve analysis identified that a serum TSH level of ≥2.7 mIU/L predicted thyroid malignancy with a sensitivity of 61% and a specificity of 65%.

CONCLUSIONS

TSH levels in the upper-normal range are associated with an increased risk of thyroid malignancy in patients affected by thyroid nodules with indeterminate cytology at FNA. The measurement of serum TSH levels represents an easily performed additional tool for decision-making in patients with indeterminate cytological findings.

Thyroid Fine-Needle Aspiration Cytology: Focusing on Adherence to Guidelines and Hospital Organization

Patient: Female, 39-year-old

Final Diagnosis: Goiter with periprocedural complication

Symptoms: None

Medication:—

Clinical Procedure: Fine-needle aspiration cytology

Specialty: Radiology

Quantitative Evaluation of Bleeding during Blood Vessel Puncture Caused by Fine Needle in Lower Abdomen

Inserting a fine needle presents a trade-off problem between safety and accuracy. As one of the serious complications due to tissue damages during needle insertion, severe bleeding often occurs owing to blood vessel puncture. However, there are few researches to evaluate the safety quantitatively regarding bleeding during the fine needle insertion. Therefore, the purpose of this study was the quantitative evaluation of the amount of bleeding due the artery and vein puncture depending on the needle size. We developed a blood circulation system for measuring the amount of bleeding due to blood vessel puncture. Using the system, the amount of bleeding due to different needle sizes was evaluated. The results suggested that the amount of bleeding per unit time increased depending on the needle radius. According to ordinal safety standards, the 22-gauge needle is appropriate for insertion into the lower abdomen.

Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment

Thyroid nodules are extremely common and can be detected by sensitive imaging in more than 60% of the general population. They are often identified in patients without symptoms who are undergoing evaluation for other medical complaints. Indiscriminate evaluation of thyroid nodules with thyroid biopsy could cause a harmful epidemic of diagnoses of thyroid cancer, but inadequate selection of thyroid nodules for biopsy can lead to missed diagnoses of clinically relevant thyroid cancer. Recent clinical guidelines advocate a more conservative approach in the evaluation of thyroid nodules based on risk assessment for thyroid cancer, as determined by clinical and ultrasound features to guide the need for biopsy. Moreover, newer evidence suggests that for patients with indeterminate thyroid biopsy results, a combined assessment including the initial ultrasound risk stratification or other ancillary testing (molecular markers, second opinion on thyroid cytology) can further clarify the risk of thyroid cancer and the management strategies. This review summarizes the clinical importance of adequate evaluation of thyroid nodules, focuses on the clinical evidence for diagnostic tests that can clarify the risk of thyroid cancer, and highlights the importance of considering the patient's values and preferences when deciding on management strategies in the setting of uncertainty about the risk of thyroid cancer.

Screening for differentiated thyroid cancer in selected populations

The main purpose of cancer screening programmes should not be to detect all cancers, but to discover potentially fatal or clinically relevant cancers. The US Preventive Services Task Force recommends against screening for thyroid cancer in the general, asymptomatic adult population, as such screening would result in harms that outweigh any potential benefits. This recommendation does not apply to patients with symptoms or to individuals at increased risk of thyroid cancer because of a history of exposure to ionising radiation (in childhood, as radioactive fallout, or in medical treatment as low-dose radiotherapy for benign conditions or high-dose radiation for malignancy), inherited genetic syndromes associated with thyroid cancer (eg, familial adenomatous polyposis), or one or more first-degree relatives with a history of thyroid cancer. We discuss the evidence for and against screening individuals who are at high risk, and consider the different screening tools available.

ACR TI-RADS: An advance in the management of thyroid nodules or Pandora's box of surveillance?

Numerous sets of guidelines have been proposed regarding ultrasound of thyroid nodules. None has been universally accepted. American College of Radiology-Thyroid Imaging, Reporting and Data System (ACR-TIRADS) has been promoted as an improvement to existing guidelines such as the 2015 revised American Thyroid Association (ATA) guidelines. This commentary compares and contrasts these two guidelines. Adoption of TI-RADS is likely to result in large-scale, costly surveillance without clear benefit. Replacement of 2015 revised ATA guidelines by TI-RADS is not justified. The shortcomings that exist in the ATA guidelines can be addressed as described in this commentary.

Thyroid Radiology Practice: Diagnosis and Interventional Treatment of Patients with Thyroid Nodules

갑상선 영상의학 진료란 갑상선 질환 환자를 영상의학적 방법을 활용하여 질병 진단과 중재적 치료를 하는 의료 행위로 정의될 수 있으며 주요 진료 대상은 갑상선 결절 질환 환자들이다. 갑상선 결절의 진단은 일차적으로 초음파 영상진단과 생검에 의해서 이루어지고 결절의 치료는 비수술적 중재적 치료와 갑상선절제술이다. 갑상선 낭종 혹은 낭성우세 양성 결절에서는 에탄올절제술이 일차적 치료법이고 고주파절제술은 고형 혹은 고형우세 양성 결절과 갑상선 재발암 치료에 적용되고 있다. 갑상선 영상의학 진료는 갑상선 결절 질환 환자의 진단 및 비수술적 치료의 대부분을 담당하는 중요한 임상적 역할을 가지고 있으며, 적절한 환자 진료를 위해서는 표준적 진료 지침에 근거하여 진료가 수행되어야 한다. 환자에게 최적의 갑상선 영상의학 진료를 제공하기 위해서는 영상의학과 외래에서 환자를 진료하는 것이 바람직하며 외래 중심의 갑상선 영상의학 진료를 확대하도록 함께 노력해야 할 시점이다.

Orbital metastasis diagnosed by ultrasound-guided fine-needle aspiration biopsy: Case report of unknown primary site

Twenty five percent of orbital metastasis is usually of unknown primary origin and it requires histopathological and immunohistochemical confirmation. The fine-needle aspiration biopsy of the orbit is an alternative procedure to conventional orbitotomy. The case is presented of a 60 year-old woman with a right orbit tumour mass and neoplastic lesions in her brain and cranium. As an incidental finding, she had a thrombus in her left atrium, and so an orbitotomy procedure was ruled out. An ultrasound-guided fine-needle aspiration biopsy was performed instead with rapid on-site evaluation of biopsy samples. These showed malignant cells of a lung adenocarcinoma, which was confirmed with immunohistochemistry and chest diagnostic images. In conclusion, biopsy samples obtained by fine-needle aspiration biopsy, together with cytopathological and immunohistological analysis, enabled orbital metastasis to be identified in the case described, and showed that fine-needle aspiration biopsy is a safe, effective, and minimally invasive alternative.

Comparison of cytological adequacy and pain scale score in ultrasound-guided fine-needle aspiration of solid thyroid nodules for liquid-based cytology with with 23- and 25-gauge needles: a single-center prospective study

In ultrasound (US)-guided fine-needle aspiration (FNA) of solid thyroid nodules (STN) using liquid-based cytology (LBC), the most appropriate needle size for LBC remains unclear. This study compared the cytological adequacy and complications associated with using 23- and 25-gauge needles in US-guided FNA of STNs using LBC. US-guided FNA was performed in consecutive patients by one radiologist to diagnose STNs ≥ 5 mm in the largest diameter. The one-sampling technique through a single needle puncture and multiple to-and-fro needle motions was used in each patient. The 23- and 25-guage needles were used consecutively each day. After FNA, the pain and complications experienced by each patient were investigated by a nurse, who was blinded to the information of needle gauge used. A cytopathologist retrospectively analyzed the cytological adequacy and cellularity of the cases. Of the 99 STNs, eight (8.1%) exhibited inadequate cytology (4 each with 23- and 25-gauge needles). The rate of cytological adequacy was not statistically different between the groups (p = 0.631). The mean pain scale values with 23- and 25-gauge needles were 2.1 ± 1.3 and 1.6 ± 1.3, respectively (p = 0.135). There were no significant complications in either group. In conclusion, both 23- and 25-gauge needles are useful in LBC because cytological adequacy and complications were not statistically different with both sizes of the needles.

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.

Virtual evaluation of selected cervical lymph nodes with three-dimensional ultrasound in thyroid cancer patients after thyroidectomy

BACKGROUND

We evaluated the usefulness of three-dimensional (3D) ultrasound of cervical lymph nodes (LN), when two-dimensional (2D) ultrasound evaluation is not sufficient to clearly evaluate lymph node characteristics, in thyroid cancer patients being followed after thyroidectomy.

METHODS

Two readers retrospectively analyzed 2D and 3D images of 147 LNs; LNs were categorized as normal, reactive, suspicious, or indeterminate, and confidence level was rated. Results were compared to cytological/clinical data. Inter-reader agreement was calculated.

RESULTS

Addition of 3D ultrasound significantly increased specificity (0.787 with 2D ultrasound vs 0.905 with 2D + 3D ultrasound for reader 1, P = .009; 0.701 with 2D ultrasound vs 0.898 with 2D + 3D ultrasound for reader 2, P = .01). Addition of 3D ultrasound significantly increased confidence level of readers (P < .001). Inter-reader agreement in LN categorization was almost perfect with 2D + 3D ultrasound.

CONCLUSION

3D ultrasound of cervical LNs enables better demonstration of imaging features that are important in differentiating benign and malignant LNs. These improvements can potentially obviate the need for FNA in post thyroidectomy cancer patients.

Needle Biopsy of Routine Thyroid Nodules Should Be Performed Using a Capillary Action Technique with 24- to 27-Gauge Needles: A Systematic Review and Meta-Analysis

BACKGROUND

Fine-needle biopsy is the international standard for diagnostic evaluation of thyroid nodules. There is a lack of consensus regarding the optimal needle biopsy technique. The implementation of capillary action versus aspiration and the optimal needle gauge remain topics of debate.

METHODS

A systematic review of the Medline, Embase, and Cochrane databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles evaluating the effects of capillary action versus aspiration and needle gauge on success rates of fine-needle biopsy of the thyroid were assessed for inclusion. The primary outcome of interest was the rate of non-diagnostic cytopathology.

RESULTS

Twenty-four articles with a collective 4428 nodules were ultimately included in the review. Twenty articles evaluated capillary action versus aspiration, and six evaluated needle gauge. All but two studies were prospective, most of which were blinded trials with or without randomization. Using a random-effects model, capillary action was associated with a statistically significant reduction in the relative risk of non-diagnostic cytopathology (relative risk = 0.57 [confidence interval 0.34-0.92]; p = 0.02). There was a nonsignificant trend in favor of smaller needle gauges.

CONCLUSION

Given the statistically significant deceased rate of non-diagnostic cytopathology with capillary action and the potential for increased pain and complications with larger needles without a proven benefit, needle biopsy of routine thyroid nodules should be performed without aspiration and with smaller needle gauges (24-27G).

Comparison Study of the Adequacy and Pain Scale of Ultrasound-Guided Fine-Needle Aspiration of Solid Thyroid Nodules with a 21- or 23-Gauge Needle for Liquid-Based Cytology: a Single-Center Study

No published study has compared the cytological adequacy between different caliber needles in liquid-based cytology (LBC) after fine-needle aspiration (FNA) of thyroid nodules. This study aimed to compare cytological adequacy, pain scale, and associated complications depending on the use of a 21- and 23-gauge needle in LBC. From January 2017 to April 2017, 88 solid thyroid nodules (STNs) in 88 patients underwent consecutive ultrasonography (US)-guided FNA (US-FNA) by a single radiologist. The selection of the needle size was randomized and changed biweekly. After FNA, the pain scale and other complications related to FNA were immediately evaluated for each patient. In all cases, adequacy and cellularity in cytology were retrospectively investigated by a single cytopathologist. Of the 88 STNs, 10 (11.4%) showed inadequate cytology: 6 for 21-gauge and 4 for 23-gauge needles. The rate of cytological adequacy was higher in the 23-gauge needle group than in the 21-gauge group, but this was not statistically significant (p = 0.318). The mean values of the pain scale in the 21- and 23-gauge needle groups were 1.8 ± 1.3 and 1.4 ± 1.1, respectively, but this difference was not statistically significant (p = 0.567). There were no significant complications associated with US-FNA, except for one case of mild intrathyroidal hemorrhage. In US-FNA of STNs using LBC, the use of a 23-gauge needle may be recommended rather than a 21-gauge needle.