Ultrasound scan-guided core sampling for diagnosis versus freehand FNAC of the thyroid gland

Comparison of diagnostic yield of core-needle and fine-needle aspiration biopsies of thyroid lesions: Systematic review and meta-analysis

Objectives

Thyroid nodular disease is one of the most commonly observed medical conditions. Cytological evaluation of the specimens obtained with fine-needle aspiration biopsy (FNAB) is the most accurate tool for selecting nodules which should be further surgically removed. A major limitation of this method is the high occurrence of non-diagnostic results. This indicates the need for improvement of the thyroid biopsy technique. The aim of this meta-analysis was to compare the diagnostic value of thyroid core-needle biopsies (CNBs) and FNABs.

Materials and methods

PubMed/MEDLINE, Cochrane Library, Scopus, Cinahl, Academic Search Complete, Web of Knowledge, PubMed Central, PubMed Central Canada and Clinical Key databases were searched. Risk ratios (RRs) of non-diagnostic results were meta-analysed using the random-effects model.

Results

Eleven studies were included in the quantitative analysis. CNB yielded significantly more diagnostic results – the pooled risk ratio (RR) of gaining a non-diagnostic result was 0.27 (p<0.0001). For lesions with one previous non-diagnostic FNAB, RR was 0.22 (p<0.0001).

Conclusions

CNB seems to be a valuable diagnostic technique yielding a higher proportion of diagnostic results than conventional FNAB. It is also significantly more effective in case of nodules with a prior non-diagnostic result of FNAB results than repeated FNABs.

Key Points

• Core-needle biopsy yields a higher proportion of diagnostic results than fine-needle biopsy.

• Core-needle biopsies may decrease the amount of unnecessary thyroidectomies.

• Probability of gaining non-diagnostic result using core-needle biopsy is almost four times lower.

Fine-Needle Aspiration Followed by Core-Needle Biopsy in the Same Setting: Modifying Our Approach

Fine-needle aspiration biopsy (FNAB) is a well-established initial diagnostic tool. However, in some instances limitations and shortcomings arise, making it insufficient for determining a specific diagnosis. Consequently, patients have to undergo another diagnostic procedure. The second procedure is either repeat FNAB, core-needle or open biopsy, and can be inconvenient and costly. In some centers, the FNAB is immediately followed by core-needle biopsy (CNB) in the same setting after assuring adequacy on the initial FNAB utilizing rapid on-site specimen evaluation (ROSE). It is argued that implementing such an approach will eventually have additional critical advantages that include the following: (a) it is more convenient to patients to have both procedures in one visit, (b) the tissue procured by both procedures will be more adequate, enabling cytopathologists to reach an accurate diagnosis, and (c) it is ultimately a cost-effective approach if we take into consideration the avoidance of a potential second more invasive diagnostic procedure. Since we are living in an era of patient-centered medicine coupled with cost-cutting strategies, we present here a brief review of the topic with analysis of this alternative approach, review of the pertinent literature and shed light on a few scenarios that justify this approach.

Fine needle aspiration: an atraumatic method to diagnose head and neck masses

BACKGROUND

Patients presenting with a mass require tissue biopsy for histological diagnosis and treatment. Fine needle aspiration (FNA) is offered as an atraumatic, well tolerated, and inexpensive method for obtaining a biopsy from these lesions.

OBJECTIVES

In this study we evaluated the accuracy of FNA as an atraumatic method among patients with nonthyroidal masses for diagnosis of neoplastic masses compared to open surgery.

PATIENTS AND METHODS

In a cross-sectional study, 65 patients with a head and neck masses (nonthyroidal) referred to us from 2004 to 2009. Those who had both FNA and open biopsy (the gold standard) were assessed for specificity, sensitivity, positive and negative predictive values of FNA in diagnoses.

RESULTS

Sixty-five cases with both definite diagnoses of open biopsy and FNA were assessed. The mean (± standard deviation) age of patients was 39.96 ± 19.69 years (range 10 to 82 years). Twenty-five (40.8%) subjects were categorized as malignant neoplasms, 16 (19.4%) as benign neoplasms, and 24 (39.8%) as non-neoplastic lesions. The sensitivity, specificity, positive and also negative predictive values of FNA in the diagnosis of neoplastic masses were 95%, 85%, 92.68%, and 91.66% respectively, and the diagnostic accuracy was 92.3%.

CONCLUSIONS

It seems that FNA is a useful atraumatic diagnostic technique with a high diagnostic accuracy which can provide a highly sensitive diagnosis with low false positive diagnoses in patients with nonthyroidal masses.

Does elastography reduce the need for thyroid FNAs?

OBJECTIVE

Ultrasound elastography (USE) assesses lesion stiffness by evaluating tissue distortion in response to stress; it is emerging as a potentially useful tool to augment the ultrasound characterisation of thyroid nodules. The aim of this study was to assess the accuracy of USE examination of thyroid nodules compared with pathological outcome, especially to determine whether USE could reliably detect benign nodules and reduce the numbers of ultrasound guided fine needle aspiration cytology (USgFNAC).

DESIGN

Over a three-year period, thyroid nodules were initially characterised by B-mode ultrasound (US) findings. Where USgFNAC was indicated by clinical concern and/or the sonographic appearances, the lesion was then subjected to USE by an experienced operator prior to the USgFNAC.

PATIENTS

147 thyroid nodules were examined by USE and USgFNAC in 146 patients.

MEASUREMENTS

The elastographic appearance was subjectively categorized at the time of the examination (soft, intermediate or hard) and subsequently compared with the cytological/histological outcome.

RESULTS

A total of 122 nodules were non-neoplastic, 5 nodules were benign neoplasms, 10 nodules had indeterminate cytology and 10 were malignant neoplasms. The sensitivity of USE for malignancy was 90.0%, specificity was 79.6%, PPV was 24.3%, NPV was 99.1% and accuracy was 80.3%.

CONCLUSION

Thyroid nodules that are soft at USE have a high likelihood of being non-neoplastic and subjective USE assessment of thyroid nodules by an experienced operator can be a useful means of avoiding USgFNAC for benign nodules. In contrast, we suggest that all nodules that are intermediate or hard on USE undergo USgFNAC.

Sonographically suspicious thyroid nodules with initially benign cytologic results: the role of a core needle biopsy

PURPOSE

To evaluate the diagnostic role of core needle biopsy (CNB) in sonographically suspicious thyroid nodules with initially benign cytologic results through a histologic analysis of CNB specimens.

METHODS

Between October 2008 and July 2011, 88 patients underwent ultrasound (US)-guided CNB for initially benign cytologic results with suspicious US features at our institution. In all, 85 patients with 85 focal thyroid nodules were included in the study after surgery or concordant benign readings following fine-needle aspiration biopsy (FNAB) and CNB. We evaluated the risk of malignancy, diagnostic performance of CNB, and histologic findings for these nodules.

RESULTS

Of the 85 nodules, 28 (32.9%) were histologically upgraded on CNB specimens including one case of atypia of undetermined significance (AUS), seven cases of follicular neoplasm, one case of suspicious for malignancy, and 19 cases of malignancy. Of these, 27 (31.8%) were finally confirmed as malignant, and one as follicular adenoma at surgery. The 27 malignant nodules included 21 papillary thyroid carcinomas (PTCs), five follicular thyroid carcinomas, and one Hürthle cell carcinoma. All PTCs were diagnosed from CNB readings of AUS suspicious for malignancy or malignancy. Follicular thyroid carcinomas and Hürthle cell carcinoma were diagnosed from CNB readings of follicular neoplasm. Histologic analysis of benign CNB specimens revealed severe fibrosis (96.4%), hemosiderin (21.4%), calcification (17.9%), granulation tissue (12.5%), and focal lymphocytic thyroiditis (12.5%).

CONCLUSIONS

The histologic information obtained by analysis of CNB specimens may enable more confident diagnosis for benign nodules with suspicious US features and reduce the need for repetitive FNABs or diagnostic surgery.

Endocrine surgeon-performed US guided thyroid FNAC is accurate and efficient

BACKGROUND

Ultrasound guided fine needle aspiration cytology (US-FNAC) is a key diagnostic technique used to assess thyroid nodules. This procedure has been the domain of radiologists, but it is increasingly performed by endocrine surgeons. In the present study we aimed to assess the accuracy and clinical efficiency of US-FNAC performed by endocrine surgeons.

PATIENTS AND METHODS

This study was a retrospective review of consecutive patients in a 3-year period who underwent US-FNAC performed by endocrine surgeons and radiologists. Medical records, cytology results, and surgical pathology results were collected and analyzed.

RESULTS

A total of 576 US-FNAC were performed on 402 patients during the study period. The endocrine surgeons and radiologists performed 299 and 277 US-FNAC, respectively. The FNAC inadequacy rate was 5.3 % for the endocrine surgeons and 9.3 % for the radiologists (p = 0.05). For thyroid cancer, the sensitivity, specificity, and false negatives of the US-FNAC for the endocrine surgeons was 87 %, 98 %, and 3 %, respectively while that for the radiologists was 88 %, 95 %, and 3.5 %, respectively. Patients with thyroid cancer had a shorter time to surgery in the endocrine surgeons' group (mean 15.3 days) compared to the radiologists' group (mean: 53.3 days; p = 0.01).

CONCLUSIONS

US-FNAC performed by an experienced endocrine surgeon is accurate and allows efficient surgical management for patients with thyroid cancer.

Core-needle biopsy is more useful than repeat fine-needle aspiration in thyroid nodules read as nondiagnostic or atypia of undetermined significance by the Bethesda system for reporting thyroid cytopathology

BACKGROUND

Thyroid nodules with fine-needle aspiration (FNA) readings of nondiagnostic or atypia of undetermined significance (AUS), also referred to as follicular lesion of undetermined significance (FLUS) are problematic for their optimal management. The usefulness of performing a core-needle biopsy (CNB) to clarify whether these nodules are benign or malignant has not been established. The purpose of the present study was to determine whether CNB provides better diagnostic information than repeat FNA (rFNA) in thyroid nodules having nondiagnostic or AUS/FLUS readings.

MATERIALS AND METHODS

The Bethesda System for Reporting Thyroid Cytopathology was used for FNA readings and for CNB readings. The study included 225 thyroid nodules from 220 consecutive patients who previously had nondiagnostic (Group N-DIAG, n=64) or AUS/FLUS (Group AF, n=161) FNA readings. All patients simultaneously underwent rFNA and CNB of each nodule. The nondiagnostic and AUS/FLUS readings by rFNA and by CNB were compared. The diagnostic sensitivities of rFNA and CNB for malignancy in thyroid nodules were also assessed. Statistical analysis was performed using a McNemar's test.

RESULTS

In N-DIAG Group, the nondiagnostic readings for the CNBs were lower than that those for rFNAs (1.6% vs. 28.1%, p<0.001). In the AF Group, the AUS/FLUS readings for the CNBs were lower than those for the rFNAs (23.6% vs. 39.8%, p<0.001). The inconclusive diagnoses (nondiagnostic or AUS/FLUS) for the CNBs were lower than those for the rFNAs in Group N-DIAG (12.5% vs. 45.3%, p<0.001) and Group AF (26.7% vs. 49.1%, p<0.001). The sensitivity of CNB for thyroid malignancy was higher than that of rFNA in Group N-DIAG (100% vs. 71.4%, p=0.125) and Group AF (78.5% vs. 55.4%, p<0.001).

CONCLUSION

After patients have had one FNA of a thyroid nodule yielding inconclusive diagnostic results (nondiagnostic or AUS/FLUS), CNB is more useful than rFNA for reducing the frequency of inconclusive diagnostic results. CNB will improve the diagnostic performance for malignancy more than rFNA in thyroid nodules that on the first FNA had nondiagnostic or AUS/FLUS readings.

Ultrasound-guided percutaneous thyroid nodule core biopsy: clinical utility in patients with prior nondiagnostic fine-needle aspirate

BACKGROUND

Five percent to 20% of thyroid nodule fine-needle aspiration (FNA) samples are nondiagnostic. The objective of this study was to determine whether a combination of FNA and core biopsy (CFNACB) would yield a higher proportion of diagnostic readings compared with FNA alone in patients with a history of one or more prior nondiagnostic FNA readings.

METHODS

We conducted a retrospective study of 90 core biopsies (CBs) performed in 82 subjects (55 women and 27 men) between 2006 and 2008 in an outpatient clinic.

RESULTS

CFNACB yielded a diagnostic reading in 87%. The diagnostic reading yield of the CB component of CFNACB was significantly superior to the concurrent FNA component, with CB yielding a diagnosis in 77% of cases and FNA yielding a diagnosis in 47% (p<0.0001). The combination of CB and FNA had a higher diagnostic reading yield than either alone. In 69 nodules that had only one prior nondiagnostic FNA, CB was diagnostic in 74%, FNA was diagnostic in 52%, CFNACB was diagnostic in 87%, and CB performed significantly better than FNA (p=0.0135). In 21 nodules with two or more prior nondiagnostic FNAs, CFNACB and CB were diagnostic in 86%, FNA was diagnostic in 29%, and CB was significantly better than FNA (p=0.0005). Clinical, ultrasound, or histopathologic follow-up was available for 81% (73/90) of the CFNACB procedures. No subject with a benign CFNACB reading was diagnosed with thyroid malignancy in the follow-up period (range 4-37 months, mean 18 months), although one subject had minimal increase in nodule size and was awaiting repeat sonography at study conclusion.

CONCLUSION

Thyroid nodule CFNACB is safe and clinically useful in selected patients when a prior FNA reading is nondiagnostic. CFNACB is superior to either CB or FNA alone. CFNACB should be strongly considered as an alternative to surgery in individuals with two prior nondiagnostic FNAs.

Diagnostic accuracy of fine-needle aspiration versus core-needle biopsy for the diagnosis of thyroid malignancy in a clinical cohort

OBJECTIVES

To retrospectively compare the accuracy of fine-needle aspiration (FNA) and core-needle biopsy (CNB) for the diagnosis of thyroid malignancy

METHODS

We evaluated the results of FNA and CNB in 555 consecutive thyroid nodules with final diagnoses (malignancy 318, benign 237). All patients underwent FNA and CNB simultaneously for each nodule. We assessed the sensitivity, specificity and accuracy of FNA, CNB and FNA/CNB for the diagnosis of thyroid malignancy.

RESULTS

The sensitivity of FNA, CNB and FNA/CNB for thyroid malignancy was 68.6%, 86.8% and 90.6%, specificity 100%, 99.2% and 99.2%, and accuracy 82.0%, 92.1% and 94.2%, respectively. The sensitivity and accuracy of CNB or FNA/CNB for thyroid malignancy were significantly higher than those of FNA (P < 0.001). Compared with CNB alone, FNA/CNB was more accurate for thyroid malignancy only in small nodules less than 1 cm (P < 0.001).

CONCLUSIONS

Our clinical cohort data demonstrated that CNB was more accurate for the diagnosis of thyroid malignancy than FNA, and FNA/CNB was more accurate than CNB alone in small thyroid nodules. CNB will play a complementary role in optimal surgical decision-making and the management of thyroid nodules.

KEY POINTS

• CNB was more accurate for the diagnosis of malignancy than FNA. • Combined FNA/CNB was more accurate than CNB alone in small thyroid nodules. • CNB should play at least a complementary role in managing thyroid nodules.

Thyroid surgery

Diseases of the thyroid are common and surgical treatment is often the preferred option. Thyroid surgery is becoming subspecialised and falls within the repertoire of maxillofacial, and head and neck surgeons. Multidisciplinary management of most patients with diseases of the thyroid is key to providing the best care particularly for those with malignancies and retrosternal extension. To reduce postoperative complications a meticulous search for, and protection of the recurrent laryngeal nerve and parathyroid glands, with an incision along the skin crease in the lower neck, which can be extended for neck dissection, are paramount. Recent advances in thyroid surgery include ultrasound-guided cervical plexus block, use of the Harmonic Scalpel(®) (Ethicon Endo-Surgery, Inc., USA), intraoperative nerve stimulation to monitor the recurrent laryngeal nerve, use of TissuePatch™ 3 (Tissuemed Ltd., Leeds, UK) adhesive sealant, and minimal access surgery.

Thyroid nodules; interpretation and importance of fine-needle aspiration (FNA) for the clinician - practical considerations

Thyroid nodules are very common lesions. Despite that the great majority is benign, in a significant percentage of them there is an underlying malignancy. Malignant thyroid nodules should be managed surgically, while the more common benign thyroid nodules may be managed conservatively. A systemic and careful diagnostic evaluation is needed to recognize nodules (overtly malignant or with malignant potential), and to avoid unnecessary surgery in a large percentage of patients with benign disease. Fine-needle aspiration (FNA) has a central role in the diagnostic investigation of the patient with thyroid nodules. FNA is a safe, useful, and cost-effective procedure. To increase accuracy, FNA can be performed under ultrasonographic guidance (if needed). Its results may be particularly helpful in determining the indication for surgery. In contrast, the role of FNA in selecting the extent of surgery is limited today. This is due to the fact that during the last decade there is a clear trend toward radical surgical management of thyroid nodular disease (both benign and malignant) by total/near-total thyroidectomy.

How to interpret thyroid biopsy results: a three-year retrospective interventional radiology experience

Results of thyroid biopsy determine whether thyroid nodule resection is appropriate and the extent of thyroid surgery. At our institution we use 20/22-gauge core biopsy (CBx) in conjunction with fine-needle aspiration (FNA) to decrease the number of passes and improve adequacy. Occasionally, both ultrasound (US)-guided FNA and CBx yield unsatisfactory specimens. To justify clinical recommendations for these unsatisfactory thyroid biopsies, we compare rates of malignancy at surgical resection for unsatisfactory biopsy results against definitive biopsy results. We retrospectively reviewed a database of 1979 patients who had a total of 2677 FNA and 663 CBx performed by experienced interventional radiologists under US guidance from 2003 to 2006 at a tertiary-care academic center. In 451 patients who had surgery following biopsy, Fisher's exact test was used to compare surgical malignancy rates between unsatisfactory and malignant biopsy cohorts as well as between unsatisfactory and benign biopsy cohorts. We defined statistical significance at P = 0.05. We reported an overall unsatisfactory thyroid biopsy rate of 3.7% (100/2677). A statistically significant higher rate of surgically proven malignancies was found in malignant biopsy patients compared to unsatisfactory biopsy patients (P = 0.0001). The incidence of surgically proven malignancy in unsatisfactory biopsy patients was not significantly different from that in benign biopsy patients (P = 0.8625). In conclusion, an extremely low incidence of malignancy was associated with both benign and unsatisfactory thyroid biopsy results. The difference in incidence between these two groups was not statistically significant. Therefore, patients with unsatisfactory biopsy specimens can be reassured and counseled accordingly.

Cost-effectiveness comparison between palpation- and ultrasound-guided thyroid fine-needle aspiration biopsies

BACKGROUND

The aim of this study is to perform a cost-effectiveness comparison between palpation-guided thyroid fine-needle aspiration biopsies (P-FNA) and ultrasound-guided thyroid FNA biopsies (USG-FNA).

METHODS

Each nodule was considered as a case. Diagnostic steps were history and physical examination, TSH measurement, Tc99m thyroid scintigraphy for nodules with a low TSH level, initial P-FNA versus initial USG-FNA, repeat USG-FNA for nodules with initial inadequate P-FNA or USG-FNA, hemithyroidectomy for inadequate repeat USG-FNA. American Thyroid Association thyroid nodule management guidelines were simulated in estimating the cost of P-FNA strategy. American Association of Clinical Endocrinologists guidelines were simulated for USG-FNA strategy. Total costs were estimated by adding the cost of each diagnostic step to reach a diagnosis for 100 nodules. Strategy cost was found by dividing the total cost to 100. Incremental cost-effectiveness ratio (ICER) was calculated by dividing the difference between strategy cost of USG-FNA and P-FNA to the difference between accuracy of USG-FNA and P-FNA. A positive ICER indicates more and a negative ICER indicates less expense to achieve one more additional accurate diagnosis of thyroid cancer for USG-FNA.

RESULTS

Seventy-eight P-FNAs and 190 USG-FNAs were performed between April 2003 and May 2008. There were no differences in age, gender, thyroid function, frequency of multinodular goiter, nodule location and diameter (median nodule diameter: 18.4 mm in P-FNA and 17.0 mm in USG-FNA) between groups. Cytology results in P-FNA versus USG-FNA groups were as follows: benign 49% versus 62% (p = 0.04), inadequate 42% versus 29% (p = 0.03), malignant 3% (p = 1.00) and indeterminate 6% (p = 0.78) for both. Eleven nodules from P-FNA and 18 from USG-FNA group underwent surgery. The accuracy of P-FNA was 0.64 and USG-FNA 0.72. Unit cost of P-FNA was 148 Euros and USG-FNA 226 Euros. The cost of P-FNA strategy was 534 Euros and USG-FNA strategy 523 Euros. Strategy cost includes the expense of repeat USG-FNA for initial inadequate FNAs and surgery for repeat inadequate USG-FNAs. ICER was -138 Euros.

CONCLUSION

Universal application of USG-FNA for all thyroid nodules is cost-effective and saves 138 Euros per additional accurate diagnosis of benign versus malignant thyroid nodular disease.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00571090.

How to combine ultrasound and cytological information in decision making about thyroid nodules

The purpose of this study was to evaluate the role of sonographic-cytological correlation in determining which nodules should be reaspirated to reduce the false-negative rate of fine-needle aspiration biopsy (FNAB). A retrospective cohort study was performed on a database of 568 patients with 672 focal thyroid nodules. An independent two-sample t-test was used to compare the risk of malignancy according to clinical factors. We evaluated the risk stratification of malignancy according to US groupings and cytological results. Additionally, we calculated the false-negative rate of FNAB and investigated the cytological results of repeat aspiration. The malignancy rate (92.2-98.5%) was high in thyroid nodules designated "malignant" or "suspicious for papillary carcinoma" on FNAB, regardless of US features. In contrast, when focal thyroid nodules had "benign" readings on FNAB, the malignancy rate was lower for the "probably benign" US features (2.9%) than for the suspicious nodules (56.6%). The false-negative rate of FNAB was 5.8%. Repeat aspiration revealed "suspicious for malignancy" or "malignancy" results in 15 (93.8%) of 16 thyroid cancers with "benign" results on initial aspirate. This study demonstrated repeat FNAB should be performed on focal thyroid nodules with suspicious US features even when initial FNAB results are benign.

Thin core needle biopsy crush preparations in conjunction with fine-needle aspiration for the evaluation of thyroid nodules: a complementary approach

BACKGROUND

Fine-needle aspiration (FNA) is widely accepted as the initial test to evaluate thyroid nodules; however, inadequate and suboptimal specimens have been 1 of its limitations. Unsatisfactory rates of 4.1% to 43% have been reported, but suboptimal specimens with adequate epithelial cells and other limiting factors, such as clotting, often are not addressed. The authors' institution has a low unsatisfactory rate, especially for thyroid biopsies performed under ultrasound in the Interventional Radiology (IR) Department. In addition to on-site evaluation for all cases, they concomitantly use thin, 22/20-gauge core needle biopsy (CB) crush preparations (CP) for unsatisfactory/suboptimal FNAs. The CB usually is done after 2 FNA passes and, in most cases, is exhausted by making an air-dried CP, which is evaluated on site for adequacy; any residual tissue is processed for tissue sections. Experience is required to interpret CP on air-dried smears. In this report, the authors describe a complementary approach to thyroid biopsy that has worked well.

METHODS

All thyroid FNA and CB/CP that were performed in the IR Department during the year 2005 were reviewed. Follow-up histology and records of all procedural complications were retrieved.

RESULTS

Seven hundred thirteen thyroid biopsies qualified, 225 biopsies (31%) had FNA with CB/CP (85% had only CP for evaluation), and 488 biopsies (69%) had only FNA. The final unsatisfactory rate in IR for FNA was 8.7%; this was reduced to 3.4% with the use of CB/CP. The addition of CB also helped to obtain a more definitive diagnosis in suboptimal FNA specimens. Cytologic-histologic correlation was comparable for FNA only cases and FNA/CB cases. There were no significant procedural complications in CB cases.

CONCLUSIONS

FNA in conjunction with a thin CB/CP performed during the same procedure is a safe technique that can reduce the rate of unsatisfactory and suboptimal thyroid biopsy.

Fine needle aspiration of head and neck masses in the operating room: accuracy and potential benefits

Fine needle aspiration (FNA) in the operating room is a convenient optional diagnostic approach. Our objective of this study was to evaluate the accuracy and study the potential benefits of fine needle aspiration in the operating room. Retrospective review of all intraoperative FNA that were requested and performed by pathologists over 20-month period was carried out. Immediate smears were interpreted by the cytopathology team after staining with Diff Quik stain. All cases were reviewed and correlation with subsequent tissue diagnosis was done. Accuracy was calculated and potential benefits were discussed. The number of aspirates was 32. Adequate material for immediate and final interpretation was achieved in 31 cases (sensitivity 97%). In 20 cases (63%), malignancy was diagnosed while a benign diagnosis was rendered in 12 (37%). All cases had a follow up tissue diagnosis. No false-positive cases were identified (specificity 100%). The information gained from this approach was considered helpful to the surgeons. We concluded that FNA of head and neck masses in the operating room is an accurate and sensitive diagnostic approach. The service provides helpful information to surgeons and is an additional optional diagnostic approach.

Immunohistochemical staining for thyroid peroxidase (TPO) of needle core biopsies in the diagnosis of scintigraphically cold thyroid nodules

BACKGROUND

Cold thyroid nodules are common, in particular in iodine-deficient areas, but only a minority of them are malignant requiring surgery. Thyroid peroxidase (TPO) immunostaining of fine-needle aspiration cytology (FNAC) material has proven helpful in diagnosing cells from malignant lesions, but the procedure has its limitations in a routine setting.

PURPOSE

To improve diagnosis and reduce surgery rate, the FNAC procedure was replaced by needle core biopsy (NCB), which was routinely stained for TPO by the monoclonal antibody mAb 47.

MATERIALS AND METHODS

During a 5-year period 427 consecutive patients with a cold thyroid nodule were evaluated by ultrasound-guided NCB, which had been routinely stained for TPO in an automated immunostainer. Sensitivity and specificity and predictive values of the TPO immunostaining were estimated, based on the final diagnosis obtained from surgical resection.

RESULTS

The majority of nodules with benign NCB diagnosis were not surgically removed, and thus a subgroup of 140 operated nodules formed the basis for the calculations. Sensitivity and specificity for benign and malignant lesions were 100% if the oxyphilic variant of adenomas and minimally invasive follicular carcinomas were excluded. By inclusion of these, the values fell to 89% and 97%, respectively. The predictive value of a positive test was 96% and the predictive value of a negative test was 97%.

CONCLUSION

TPO immunostaining was found to be a valuable adjunct to morphology in the diagnosis of cold thyroid nodules of the nonoxyphilic type.

Comparison of palpation-versus ultrasound-guided fine-needle aspiration biopsies in the evaluation of thyroid nodules

BACKGROUND

The aim of this study was to compare the results of palpation-versus ultrasound-guided thyroid fine-needle aspiration (FNA) biopsies.

FINDINGS

Clinical data, cytology and histopathology results were retrospectively analyzed on all patients who underwent thyroid FNA biopsy in our outpatient endocrinology clinic between January 1998 and April 2003. The same investigators performed all thyroid FNAs (ASC) and cytological evaluations (KP). Subjects in the ultrasound-guided group were older, otherwise there were no differences in baseline characteristics (gender, thyroid function, the frequency of multinodular goiter, nodule diameter and nodule location) between groups. Cytology results in nodules aspirated by palpation (n = 202) versus ultrasound guidance (n = 184) were as follows: malignant 2.0% versus 2.7% (p = 0.74), benign 69.8% versus 79.9% (p = 0.02), indeterminate 1.0% versus 4.9% (p = 0.02), inadequate 27.2% versus 12.5% (p < 0.01). Malignant results were compared with Fisher's exact test. Other cytology categories were compared with chi-square test. Eighteen patients from the palpation- and 23 from ultrasound-guided group underwent surgery. In the palpation-guided group, the sensitivity of FNA was 100%, specificity 94%, positive predictive value 67% and negative predictive value 100%. In the ultrasound-guided group, the sensitivity of FNA was 100%, specificity 80%, positive predictive value 73% and negative predictive value 100%.

CONCLUSION

We demonstrate that ultrasound guidance for thyroid FNA significantly decreases inadequate for evaluation category. We also confirm the high sensitivity and specificity of thyroid FNA biopsy in the diagnosis of thyroid cancer. Where available, we recommend universal application of ultrasound guidance for thyroid FNA biopsy as a standard component of this diagnostic technique.

Thyroid fine needle aspiration: how to improve clinicians' confidence and performance with the technique

Studies from single institutions report an acceptable accuracy rate for thyroid fine needle aspiration (FNA). However, FNA accuracy is much lower in many other centers in Europe and the USA and large multicenter studies indicate that the clinicians' confidence in the FNA technique remains low. One explanation for this is that there is an excess of inadequate and indeterminate findings for a follicular nodule at FNA cytology. In a University Hospital with large and qualified experience on thyroid nodule diagnosis, a review of 320 slides with an FNA diagnosis of indeterminate follicular nodule from different minor Italian Hospitals led to a different diagnosis in 61%. Since ancillary thyroid imaging may be overutilized and only a few authors report a proportion of excised nodules lower than 10%, we suspect that use of the FNA procedure is suboptimal. Several techniques are reported to improve the performance of thyroid FNA. Among these are tumor markers and large needle aspiration biopsy (LNAB). Immunodetection of the tumor marker galectin-3 has been evaluated by large multinational studies. Analysis of LNAB specimens reduces the number of inadequate FNA findings, improves the diagnostic determination of indeterminate follicular FNA findings and represents a better substrate for the determination of galectin-3. Therefore, we propose that clinical practice guidelines reflect these adjuvant techniques to thyroid FNA in order to improve selection criteria for thyroid nodule surgery.

Percutaneous large-needle aspiration biopsy histology of palpable thyroid nodules: technical and diagnostic performance

AIM

To report original and review existing data on safety and performance of large-needle aspiration biopsy (LNAB) histology in the preoperative selection of palpable thyroid nodule.

METHODS AND RESULTS

The English literature and original data were reviewed or analysed. The literature on LNAB of thyroid nodules did not report any complications. A study on needle dimensions has explained why LNAB obtains more tissue than fine-needle aspiration (FNA) and is safe. LNAB histology has higher specificity than FNA cytology and markedly reduces the number of inadequate and indeterminate FNA findings. A comparison of 150 FNA-derived cell blocks with 200 LNAB-derived histological blocks after galectin-3 determination in a large nationwide (Italian) study has shown that one to two sections in 10% of the FNA cell blocks and at least five sections in 90% of the LNAB blocks were available for further determinations of thyroid tumour markers.

CONCLUSION

LNAB merits further consideration for the preoperative selection of thyroid nodules.

Progress in the preoperative diagnosis of thyroid nodules: managing uncertainties and the ultimate role for molecular investigation

The preoperative evaluation of thyroid nodules currently relies on a clinical assessment of risk factors and an algorithm based on imprecise tests. With serum TSH, thyroid ultrasound and fine-needle aspiration (FNA) with or without ultrasound guide, accounting for the routine initial evaluation, indeterminate aspirates remain the major obstacle for confidently advising patients whether to have surgery or not. Recent clinical guidelines have attempted to settle various controversies but many inherent errors of clinical testing result in delayed diagnosis and unnecessary surgery. A better solution may ultimately involve the use of molecular markers of thyroid carcinogenesis but further research is still needed regarding the basic biology of thyroid cancer.