Cytopathologists can reliably perform ultrasound-guided thyroid fine needle aspiration: a 1-year audit on 3715 consecutive cases

Resident training in interventional pathology: Ultrasound-guided fine-needle aspiration and rapid on site evaluation-5 years of teaching experience in a single university hospital

INTRODUCTION

Despite the established role of the interventional pathologist, their diagnostic performance is difficult to establish. At least in Spain training of pathology residents in ultrasound-guided interventional procedures for specimen collection is limited or absent in most institutions. We present our teaching experience in the instruction of ultrasound-guided fine-needle aspiration (FNA) to pathology residents in a tertiary-level hospital.

MATERIALS AND METHODS

The training of pathology residents who rotated through the interventional unit of the pathology department and the application of ultrasound-guided FNA and rapid on-site evaluation (U-ROSE) was documented over 5 years. The training period was broken down into learning phases and included the number of ultrasound-guided FNA performed, anatomical location, and their diagnostic performance, among other aspects.

RESULTS

Nineteen (19) pathology residents were trained in U-ROSE, and performed a total of 4003 procedures, with a mean of 211 per resident. In 53% of cases only one pass was required for an adequated sample. The specimen was diagnostic in more than 97% of cases. The most frequently sampled anatomical sites were the thyroid gland (n = 2347), followed by lymph node (n = 667), soft tissues (n = 663) and salivary glands (n = 322).

CONCLUSION

The results support the training programme followed by pathology residents in learning U-ROSE, which is essential to lay the foundations for the future interventional pathologist.

How do cytopathologists learn fine needle aspiration techniques? An international survey

INTRODUCTION

Fine needle aspiration cytology (FNAC) is a widely accepted diagnostic technique, but performance varies according to expertise. Little is known about variation in FNAC training practices worldwide. We surveyed pathologists using social media networks to determine FNAC training practices internationally.

DESIGN

Pathologists were surveyed on questions related to FNAC simulation training using direct messaging on the Twitter and WhatsApp platforms. Survey responses over a period of 2 weeks were collected.

RESULTS

In total, 149 pathologists participated (96.1% response rate). The respondents came from 24 countries and 87 institutions. The majority of the pathologists (63.8%) performed FNAC directly on patients for the first time. Only 36.2% of them had simulation instruction during their training. It was performed on food items such as fruit (64.8%), surgical specimens (37.0%), autopsies (13.0%) and others (9.3%), including commercially available phantom simulators for ultrasound-guided FNAC (US-FNAC) (two pathologists).

DISCUSSION

Most pathologists did not receive formal training in a simulated environment, and of the pathologists who had simulation instruction, food items were commonly used for education. A few participants used a commercial US-FNAC simulator, but since most pathologists perform FNAC by palpation, this method of simulation training is not applicable to many practices. Social media is an effective and efficient way to perform survey research, yielding a very high response rate.

Evaluating local thyroid cytopathology practices by molecular quality metrics: A multi-institutional study on 4651 FNAs with a focus on the role of the interventional cytopathologist

BACKGROUND

The diagnostic accuracy of thyroid fine-needle aspiration (FNA) can be highly influenced by the technical skills of the operator performing the procedure and by interobserver variability in microscopic interpretation. This is particularly true for the indeterminate categories. Recently, molecular testing has been proposed as an ancillary tool for monitoring the performance of different thyroid cytopathology practices. The objective of this multicenter study was to evaluate the quality of different local cytopathology practices by assessing the impact of interventional cytopathologists on FNA adequacy for molecular testing and the variations in mutation rates across different health care centers operating in the Campania region.

METHODS

The study included 4651 thyroid FNA samples diagnosed in different Southern Italian clinical laboratories belonging to the TIRNET (the Tiroide Network). FNA samples were collected by different proceduralists and were classified by local cytopathologists according to The Bethesda System for Reporting Thyroid Cytopathology. FNAs classified as atypia of undetermined significance, follicular neoplasm, suspicious for malignancy, and malignant were centralized for a real-time polymerase chain reaction-based, seven-gene test at the authors' institution.

RESULTS

Centers that employed interventional cytopathologists obtained fewer unsatisfactory FNA samples for molecular testing (11.3%) than centers that employed noncytopathologists (16.7%; p < .05). Furthermore, a significant variation in the mutation rate was observed in FNAs diagnosed by different local cytopathologists; indeterminate categories had the highest percentage of mutation rate variability among centers.

CONCLUSIONS

Interventional cytopathologists obtained higher yields of diagnostic material for molecular testing. Finally, the current results suggest that the variability in mutation rates among different centers may highlight the low reproducibility of microscopic criteria among cytopathologists, particularly for indeterminate cases.

One nodule-one punction-one slide: Optimizing thyroid fine-needle aspiration for a digital workflow

OBJECTIVE

Interventional pathologists have expanded their expertise by acquiring proficiency in ultrasound-guided thyroid fine-needle aspiration biopsy (FNAB) and are now required to optimize punction procedures due to low resources and digital workflows. The aim of this study is to compare FNAB sample adequacy in two series with one versus two slides available for cytopathological analysis and its influence on diagnosis categorization, time taken to reach a final diagnosis, scanning time and size of the digital files produced.

METHODS

Patients were retrospectively selected based on the sampling of thyroid nodules using either two glass slides (two-slide group) or one slide only (one-slide group) and cytological diagnosis was performed using the second edition of the Bethesda system. For each group, the initial 15 cases were sorted to be scanned.

RESULTS

From a total of 713 procedures, 328 were sampled into two slides and 385 on one slide only. No significant differences were found regarding nodule size, location or EU-TIRADS classification between the two groups. The one-slide group did not exhibit a higher prevalence of non-diagnostic or atypia of undetermined significance (AUS) categories. As expected, the mean time taken to finalize diagnoses in cases where only one slide was prepared was 1.2 days faster. Scanning time and total file size were also significantly smaller in the one-slide group.

CONCLUSIONS

Adopting the 'one nodule-one puncture-one slide' strategy for thyroid FNAB optimization enhances procedural efficiency in digital workflows, leading to cost savings without compromising diagnostic accuracy.

Real-World Diagnostic Accuracy of the On-Site Cytopathology Advance Report (OSCAR) Procedure Performed in a Multidisciplinary One-Stop Breast Clinic

Fine-needle aspiration (FNA) cytology has been widely used for the diagnosis of breast cancer lesions with the objective of differentiating benign from malignant masses. However, the occurrence of unsatisfactory samples and false-negative rates remains a matter of concern. Major improvements have been made thanks to the implementation of rapid on-site evaluation (ROSE) in multidisciplinary and integrated medical settings such as one-stop clinics (OSCs). In these settings, clinical and radiological examinations are combined with a morphological study performed by interventional pathologists. The aim of our study was to assess the diagnostic accuracy of the on-site cytopathology advance report (OSCAR) procedure on breast FNA cytologic samples in our breast OSC during the first three years (April 2004 till March 2007) of its implementation. To this goal, we retrospectively analyzed a series of 1820 breast masses (1740 patients) radiologically classified according to the American College of Radiology (ACR) BI-RADS lexicon (67.6% being either BI-RADS 4 or 5), sampled by FNA and immediately diagnosed by cytomorphology. The clinicoradiological, cytomorphological, and histological characteristics of all consecutive patients were retrieved from the hospital computerized medical records prospectively registered in the central information system. Histopathological analysis and ultrasound (US) follow-up (FU) were the reference diagnostic tests of the study design. In brief, we carried out either a histopathological verification or an 18-month US evaluation when a benign cytology was concordant with the components of the triple test. Overall, histology was available for 1138 masses, whereas 491 masses were analyzed at the 18-month US-FU. FNA specimens were morphologically nondiagnostic in 3.1%, false negatives were observed in 1.5%, and there was only one false positive (0.06%). The breast cancer prevalence was 62%. Diagnostic accuracy measures of the OSCAR procedure with their 95% confidence intervals (95% CI) were the following: sensitivity (Se) = 97.4% (96.19-98.31); specificity (Sp) = 94.98% (92.94-96.56); positive predictive value (PPV) = 96.80% (95.48-97.81); negative predictive value (NPV) = 95.91% (94.02-97.33); positive likelihood ratio (LR+) = 19.39 (13.75-27.32); negative predictive ratio (LR-) = 0.03 (0.02-0.04), and; accuracy = 96.45% (95.42-97.31). The respective positive likelihood ratio (LR+) for each of the four categories of cytopathological diagnoses (with their 95% CI) which are malignant, suspicious, benign, and nondiagnostic were 540 (76-3827); 2.69 (1.8-3.96); 0.03 (0.02-0.04); and 0.37 (0.2-0.66), respectively. In conclusion, our study demonstrates that the OSCAR procedure is a highly reliable diagnostic approach and a perfect test to select patients requiring core-needle biopsy (CNB) when performed by interventional cytopathologists in a multidisciplinary and integrated OSC setting. Besides drastically limiting the rate of nondiagnostic specimens and diagnostic turn-around time, OSCAR is an efficient and powerful first-line diagnostic approach for patient-centered care.

Pathologist-performed ultrasound-guided fine needle aspiration biopsies of extrathyroidal sites: An observational study

BACKGROUND

Pathologist-performed ultrasound-guided fine needle aspiration (USFNA) biopsies have become an increasingly important component of the interventional cytopathologist's toolbox. However, its application varies between institutions, and there is limited literature describing its performance characteristics when utilized in extrathyroidal sites. Here we review our institutional experience within our pathologist-run FNA clinic.

METHODS

A retrospective review was conducted of pathologist-performed USFNAs of extrathyroidal sites over a 9-year period. Data collected included lesion site, size, patient age, patient gender, diagnostic category, and corresponding results from surgical resection when available. The diagnosis on surgical resection was considered the gold standard for determining discordance rates.

RESULTS

A total of 143 pathologist-performed USFNAs of extrathyroidal lesions were performed from October 2011 to October 2020. These encompassed a wide range of sites, with most biopsies from the head and neck. The mean recorded size was 2.2 cm, with a range of 0.6-6 cm. Larger lesions (over 2 cm) were more likely to be noted in challenging locations, demonstrate difficult features, or be cystic. Most (n = 133) biopsies were sufficient for diagnosis, with a non-diagnostic rate of 7% (n = 10). Accuracy when compared to subsequent surgical resection was high, with sensitivity of 89%, specificity of 93%, positive predictive value of 94%, and negative predictive value of 87%.

CONCLUSION

Our experience supports that pathologist-performed USFNA of extrathyroidal lesions-even those with challenging features-can result in excellent diagnostic yield and accuracy. The addition of USFNA to the interventional cytopathologists' repertoire can be a valuable tool to enhance patient care.

Operation rate and cancer prevalence among thyroid nodules with FNAC report of suspicious for malignancy (TIR4) or malignant (TIR5) according to Italian classification system: a systematic review and meta-analysis

BACKGROUND

In the Italian system for reporting thyroid cytology (ICCRTC), nodules suspicious for (TIR4) and consistent with (TIR5) malignancy are thought being 5% and 4-8% of all biopsies and having risk of malignancy of 60-80% and >95%, respectively. However, no evidence-based data exist about these figures. The present systematic review aimed at achieving solid estimates about TIR4 and TIR5 also considering potential influencing factors.

METHODS

The review was conducted according to MOOSE. Databases of Google Scholar and Cochrane were searched. No language restriction was used. The last search was performed on February 26th 2022. Quality assessment was performed. Proportion meta-analyses were performed using random-effect model. Statistical analyses were performed using OpenMeta [Analyst].

RESULTS

The online search retrieved 271 articles and 16 were finally included for quantitative analysis. The risk of bias was generally low. The pooled cancer prevalence in TIR4 was 92.5% (95%CI 89.4-95.6%) with unexplained moderate heterogeneity. The pooled cancer rate among TIR5 was 99.7% (95%CI 99.3-100%) without heterogeneity. The resection rate in TIR4 and TIR5 showed heterogeneity, being the latter explained when using their prevalence among biopsies: the higher the prevalence, the higher the operation rate. The pooled risk difference between TIR5 and TIR4 was significant (OR 11.153).

CONCLUSIONS

These figures can form the basis for the next updated version of ICCRTC. Any institution using ICCRTC should revise its series of TIR4/TIR5 to calculate the cancer rate, and, importantly, consider the modifiers of the risk of malignancy. A cross check among institutions is advised.

The Impact of Rapid On-Site Evaluation on the Quality and Diagnostic Value of Thyroid Nodule Fine-Needle Aspirations

Background: Ultrasound-guided fine-needle aspiration (FNA) is the preferred method to evaluate the dignity of thyroid nodules. Nevertheless, the often-reported high nondiagnostic rate burdens affected patients and the health care system. Rapid on-site evaluation (ROSE) constitutes an addition to the thyroid FNA procedure, with various studies showing its beneficial effect on the Bethesda I nondiagnostic rate. We aimed to assess whether ROSE may reduce the rate of Bethesda categories III and V. Additionally, we examined the influence of ROSE on specimen quality. Methods: We performed a retrospective cohort study, comparing Bethesda categorization and specimen quality in specimens subject to ROSE compared with those not subject to ROSE. We also evaluated aspects of specimen quality that differed according to the use of ROSE. We subcategorized Bethesda I into insufficient cellularity or artifacts, and Bethesda categories III and V into cellular without artifacts, sparsely cellular, or artifacts. Results: We evaluated 5030 thyroid FNAs. ROSE was performed in 1304 (25.9%) cases, and ROSE was not utilized for 3726 (74.1%) specimens. The rate of Bethesda I nondiagnostic and Bethesda III categories was reduced in specimens subject to ROSE (4.3%, 56/1304) compared with non-ROSE (39.9%, 1487/3726, p < 0.001). The rate of both benign Bethesda II and malignant Bethesda VI diagnoses was 91.6% (1194/1270) in ROSE specimens compared with 56.6% (1999/3530) in non-ROSE (p < 0.001). This was reflected by a significant improvement in diagnostic accuracy with ROSE (areas under the curve [AUC]_non-ROSE = 0.811, AUC_ROSE = 0.895, p = 0.004). The overall rate of specimens flawed by sparse cellularity in Bethesda categories III and V was 0.1% (1/1304) in ROSE specimens compared with 1.2% (45/3726) in non-ROSE (p < 0.001). The overall artifact rate was 0.3% (4/1304) for ROSE specimens and 2.5% (92/3726) for non-ROSE (p < 0.001). Conclusions: ROSE significantly increased diagnostic accuracy by improving FNA specimens quantitatively and qualitatively. We suggest considering ROSE as standard of care for thyroid FNAs.

Pathologist-performed ultrasound-guided fine-needle aspirations of the thyroid: A single institution observational study

BACKGROUND

Ultrasound-guided fine-needle aspiration biopsies (USFNAs) are increasingly performed by pathologists. This study was designed to assess the diagnostic yield and characterization of thyroid nodules biopsied at a teaching hospital setting in which both attending physicians and trainees are involved in the performance of USFNAs.

METHODS

A retrospective study of pathologist-performed USFNAs of thyroid cases was performed over a period of 9 years at a tertiary medical center. Data collected included patient characteristics and The Bethesda System diagnostic categories.

RESULTS

Over the study period, 1531 USFNAs of thyroid nodules were performed in the pathology-based clinic, with 1209 lesions in females and 322 in males. Ninety-three percent of samples were sufficient for diagnosis (n = 1420). The majority of nodules biopsied were benign (65.4%, n = 1002). Overall, 3.1% of nodules biopsied were diagnostic of malignancy (n = 47). The number of USFNAs over the years showed a rapid increase initially, with a coronavirus disease 2019-related decrease in 2020.

CONCLUSIONS

The authors report their experience with thyroid USFNA over nearly a decade. The most common diagnosis was benign and the second most common was Bethesda category III. Lesions that were diagnostic of malignancy were relatively uncommon. Over the study period, the results showed that at a large tertiary care center in which USFNAs were performed by trainees as well as attending physicians, the diagnostic yield was good with a majority of thyroid nodules biopsied associated with a definitive diagnosis.

Poorly Differentiated Thyroid Carcinoma: Single Centre Experience and Review of the Literature

There is controversy in the literature regarding a distinct subset of thyroid carcinoma whose histologically classification falls between well-differentiated and anaplastic carcinomas, previously identified as ‘poorly differentiated thyroid carcinoma’ (PDTC), or ‘insular carcinoma’, in view of the peculiar morphological characteristics of the cell groupings. The correct diagnosis and treatment of this entity have important prognostic and therapeutic significance. In this review, we describe the epidemiology, diagnosis, and management of PDTC and report our single centre experience to add to the limited evidence existing in the literature.

Ultrasound-Guided Fine-Needle Aspiration of Superficial Lymphadenopathy Performed by Interventional Pathologists: The Applicability of the Sydney System from 2 Years of Experience and 363 Cases

INTRODUCTION

The Sydney system proposal for the study and reporting of lymphadenopathy by fine-needle aspiration (FNA) constitutes one of the first attempts to standardize this procedure. Here, we review its applicability.

MATERIALS AND METHODS

A retrospective study in which all ultrasound-guided FNAs (USFNAs) of superficial lymphadenopathy (palpable or not) performed by interventional pathologists in 2 specialized hospital centers were quantified over 2 years. The procedure was systematized, and the diagnoses were reclassified according to the Sydney system categories.

RESULTS

We analyzed 363 USFNAs of lymphadenopathies. The distribution of cases by categories was as follows: insufficient (n = 13; 3.58%), benign (n = 208; 57.30%), atypia of uncertain significance (n = 7; 1.93%), suspicious (n = 21; 5.79), and malignant (n = 114; 31.40%). The risks of malignancy calculated for categories I, II, III, IV, and V were 27%, 3%, 50%, 100%, and 100%, respectively.

CONCLUSION

The implementation of the Sydney system allows the systematization and standardization of the lymph node FNA methodology, with increased efficacy and efficiency. Assimilating the recommendations enables the qualification of the diagnostic procedure.

Molecular Testing of Thyroid Fine-Needle Aspiration: Local Issues and Solutions. An Interventional Cytopathologist Perspective

Molecular testing has acquired a relevant role for diagnostic and prognostic stratification of indeterminate thyroid nodules. Besides the available commercial solutions marketed in the United States, various local testing strategies have been developed in the last decade. In this setting, the modern interventional cytopathologist, the physician who performs the both aspirate and the morphologic interpretation plays a key role in the correct handling of fine-needle aspiration (FNA) samples not only for microscopy but also for molecular techniques. This review summarizes experiences with local approaches to the molecular testing of thyroid FNA, highlighting the role of the modern interventional cytopathologist.

[Minimally invasive percutaneous musculoskeletal biopsy performed by Interventional Pathologist for myopathy study. Twenty years of experience]

INTRODUCTION

Muscle biopsy plays a major role in the final diagnosis of myopathies. Open muscle biopsy is the benchmark procedure, although minimally invasive percutaneous muscle biopsy (MIPMB) has demonstrated comparable diagnostic performance at a lower cost and can be carried out by interventional pathologists.

MATERIALS AND METHODS

Muscle biopsies performed from 1997 to 2017 were reviewed and classified according to the type of procedure, whether carried out by an interventional pathologist or another specialist, the diagnosis and the effectiveness of the procedure.

RESULTS

738 muscle biopsies were performed; 32% were open biopsies and 68% MIPMB carried out by pathologist. The muscle most often biopsied was the femoral quadriceps and the most frequent diagnosis was inflammatory myopathies. In only 39 cases (20 open biopsies and 19 MIPMB) was there insufficient tissue for diagnosis.

CONCLUSIONS

Muscle biopsy proved highly effective as a diagnostic tool as 90% yielded adequate tissue samples. The results obtained with MIPMB performed by interventionist pathologists were comparable to those of open muscle biopsy.

The patient experience in a cytopathologist-performed ultrasound-guided fine needle aspiration clinic: potential complications and feedback

INTRODUCTION

The number of fine needle aspirations (FNAs) being performed by cytopathologists has been increasing in recent years. As the advantages of cytopathologist-performed FNAs such as more frequent sample adequacy, appropriate specimen triage for ancillary testing, and optimal turnaround time are recognized, little has been reported from the patient's perspective. This study aimed to characterize the patient experience in a cytopathologist-run FNA clinic.

MATERIALS AND METHODS

Patient responses were collected as part of routine post-procedure telephone follow-up. Patient demographics, clinical history, reported complications, general feedback, and procedural data were documented.

RESULTS

Of 303 patients, 126 (41.6%) were available for follow-up. One or more minor complications including pain or soreness, swelling, and bruising at the biopsy site was reported by 46 patients (36.5%). No patients required additional medical treatment. For the patients who were unavailable for telephone follow-up, review of medical records showed 158 (89.3%) had at least one subsequent clinical visit and 1 reported bruising at the FNA site. Overall, none of the 284 patients with available follow-up information reported any major complications related to the FNA procedure. All patients had a generally positive experience, specifically citing the cytopathology team's thorough explanation of the procedure, cytopathologist ability to address questions and concerns, and professionalism.

CONCLUSIONS

Overall, the patient experience at our cytopathologist-run FNA clinic was positive. Minor procedure-related complications were reported in a subset of patients. No major complications were recorded, underscoring the safety of this procedure.

Thyroid fine-needle aspiration trends before, during, and after the lockdown: what we have learned so far from the COVID-19 pandemic

PURPOSE

Nowadays, the clinical management of thyroid nodules needs to be multi-disciplinary. In particular, the crosstalk between endocrinologists and cytopathologists is key. When FNAs are properly requested by endocrinologists for nodules characterised by relevant clinical and ultrasound features, cytopathologists play a pivotal role in the diagnostic work-up. Conversely, improper FNA requests can lead to questionable diagnostic efficiency. Recently, recommendations to delay all non-urgent diagnostic procedures, such as thyroid FNAs, to contain the spread of COVID-19 infection, have made the interplay between endocrinologists and cytopathologists even more essential. The objective of this study was to assess the impact of COVID-19 pandemic on our practice by evaluating the total number of FNAs performed and the distribution of the Bethesda Categories before, during, and after the lockdown.

METHODS

We analysed the FNA trends before (1st January 2019 to March 13th 2020), during (March 14th to May 15th), and after (May 16th to July 7th) the lockdown.

RESULTS

Although the total number of weekly FNAs dropped from 62.1 to 23.1, our referring endocrinologists managed to prioritise patients with high-risk nodules. In fact, in the post-lockdown, the weekly proportion of benign diagnoses dropped on average by 12% and that of high-risk diagnoses increased by 6%.

CONCLUSIONS

The lesson we have learned so far from this pandemic is that by applying safety protocols to avoid contagion and by increasing the threshold for FNA requests for thyroid nodules, we can continue to guarantee our services to high-risk patients even in times of a health crisis.

Juggling the COVID-19 pandemic: A cytopathology point of view

Since its first identification in China at the end of 2019, severe acute respiratory syndrome coronavirus 2 has rapidly spread all over the world, becoming an international healthcare emergency. In the era of coronavirus disease-2019 (COVID-19), several aspects of normal life, including those related to the medical activities, have been radically changed. Extraordinary measures have been adopted by different nations to cope with the rapid diffusion of COVID-19 all over the world. In hospitals, careful attention has been paid to manage infected patients with a possible detrimental effect for patients affected by other diseases. As with other medical fields, cytopathology laboratories have also drastically modified their activities to cope with the COVID-19 healthcare emergency. Here, the main effects of COVID-19 pandemic on the routine practice of cytopathology are summarised, focusing on the prioritisation policy adopted by cytopathologists worldwide.

Amyloid goiter diagnosis by ultrasound-guided fine needle aspiration performed by interventional pathologist

Amyloid goiter (AG) (primary or secondary) is extremely rare. An abdominal fat pad core needle biopsy (CNB) is the diagnostic gold standard for secondary amyloidosis. Although CNB is useful to detect amyloid infiltration of a specific organ, fine-needle aspiration (FNA) is proven to be the best diagnostic method for thyroid disorders. Guidelines recommend an ultrasound-guided FNA (US-FNA) whenever possible. This procedure is usually performed by various interventional specialists, including pathologists, who perform the procedure in addition to validating the adequacy of the sample. We report a rare case of AG diagnosed using US-FNA performed by a pathologist in a 39-year-old patient with systemic amyloidosis. US-FNA performed by pathologists is a proven, less-invasive, and cost-effective tool that ensures acquisition of adequate specimens and reduces nondiagnostic rates of this procedure to ensure timely cytological diagnosis.

Cytology meets next generation sequencing and liquid biopsy: A case of lung adenocarcinoma presenting as metastasis to the phalanx

Carcinomas do rarely metastasize to the finger. Non-small-cell lung cancer is most frequently involved. To date, only a few cases have been reported, on histology. Here we describe the cytological features of a metastatic lung adenocarcinoma case to the phalanx of the right forefinger as initial manifestation of the neoplastic disease in a 69-years-old woman. The cytological microscopic findings, complemented by a wide array of ancillary techniques, were confirmed by histology. Neoplastic cells were positive for cytokeratin 7 (CK7) and thyroid transcription factor 1 (TTF-1), harboring, in tissue and in bloodstream samples, an uncommon epidermal growth factor receptor (EGFR) exon 20 p.S768_D760DUP, detected by next generation sequencing (NGS) and liquid biopsy. Cytology corroborated by immunocytochemistry, NGS, and liquid biopsy is a modern approach to provide diagnostic and therapeutic information even in rare and challenging cases.

Rates of Thy 1-non-diagnostic thyroid fine needle aspiration using the UK Royal College of Pathologists Thy Terminology. A systematic review of the literature comparing patients who undergo rapid on-site evaluation and those who do not

INTRODUCTION

The UK Royal College of Pathologists (RCPath) Thy terminology is an internationally recognised system for reporting thyroid fine needle aspiration. The terminology has been used throughout the UK and Ireland, in some parts of Italy and Switzerland, and elsewhere in the world. There is no systematic review of the literature specifically addressing the use of the non-diagnostic for cytological diagnosis-Thy1/Thy 1c category in the UK RCPath terminology.

METHODS

A comprehensive literature search of online databases was conducted in October 2019 specifically examining overall reported rates of Thy1 and Thy1c in aspirates classified according to the UK Thy terminology.

RESULTS

Twenty-five articles were identified showing a Thy1 rate of 13.4% (2540/18 920). The studies were then stratified according to whether or not the patients underwent rapid on-site evaluation (ROSE): 6.0% (353/5841; range 3.0%-10.9%) of ROSE aspirates were Thy1 whereas 18.5% (2072/11 204; range 7.9%-43.3%) of non-ROSE patients were Thy1; (P < .05). Three studies from 2016 reported Thy1c rates of 5.4%, 6.5% and 10.6%, respectively, implying Thy1 rates excluding Thy1c aspirates of 20.9%, 8.7% and 12.7%, respectively.

CONCLUSION

This systematic review of the literature shows relatively high rates of aspirates non-diagnostic for cytological diagnosis-Thy1 in the peer-reviewed published literature using the UK terminology. Utilisation of ROSE appears to produce lower rates of Thy1 aspirates and ROSE should be considered if rates of non-diagnostic for cytological diagnosis-Thy1/Thy 1c are high.

Thyroid FNA: Is cytopathologist review of ultrasound features useful?

Cytopathologist review of thyroid ultrasound (US) has been proposed to be useful in diagnosis and patient triage. This review explores the implications for practicing cytopathologists of integrating US review into the thyroid fine-needle aspiration diagnosis. At present, there is no agreed-upon system for combining cytologic and US features and communicating those results as a single report. If cytologists are performing tasks that require expertise in US interpretation, then they should know and be fully conversant with US interpretation. Whether cytologists performing aspirations require expertise in US interpretation is not clear. Regardless, cytologists should avoid using US results to alter their cytologic interpretations unless they clearly communicate that this is what they are doing. An evidence-based integrated reporting system that would allow cytologists to clearly explain to other physicians exactly how they reached their interpretation might provide value beyond current standard practice.

Rapid On-site Molecular Evaluation in thyroid cytopathology: A same-day cytological and molecular diagnosis

BACKGROUND

Thyroid fine-needle aspirates (FNAs) with undetermined morphology can be outsourced to centralized laboratories for comprehensive molecular profiling. When a local, rapid screening rules out easily detectable BRAF and NRAS mutations outsourcing is minimized, leading to cost savings. The fully automated Idylla technology, that does not require trained staff, is an emerging option. However, Idylla platform has only been validated to process formalin fixed paraffin embedded (FFPE) sections. Here we investigate whether also the FNA needle rinse could be genotyped by the same cytopathologist who performs the FNA, a procedure that can be termed rapid on site molecular evaluation (ROME).

METHODS

To validate this approach, the Idylla BRAF and NRAS Test was performed on the rinses from 25 simulated (bench-top) FNAs, in a first part of the study. Genotyping data were compared with those obtained on matched histological FFPE blocks. The second part of the study was carried out on 25 prospectively collected routine FNAs to assess the performance of the Idylla BRAF and NRAS assay against a gold standard real time polymerase chain reaction method.

RESULTS

Idylla NRAS-BRAF Mutation Test was performed on needle rinse as well as histological FFPE blocks. A sensitivity of 88.9%, a specificity of 100.0% were obtained comparing the Idylla NRAS-BRAF Mutation Test on needle rinse to the reference method.

CONCLUSIONS

The FNA needle rinse can be directly genotyped. This obviates the need of cell block preparation, making possible a rapid combined morphological and molecular evaluation. Since DNA extraction is no longer necessary, the cytopathologist can perform ROME him/herself.

Coexistence of primary thyroid diffuse large B cell lymphoma and papillary thyroid carcinoma: a case report and literature review

Primary thyroid lymphoma (PTL) is a very rare type of thyroid malignant tumor. PTL coexisting with papillary thyroid carcinoma (PTC) is even scarcer and can be easily overlooked. We present our experience of the diagnosis and treatment of a 37-year-old woman with primary thyroid diffuse large B cell lymphoma complicated with PTC. We also considered this case in the context of previous reports. The results indicated that the incidence of concurrent Hashimoto’s disease varied among patients with different lymphoma subtypes, with the highest incidence in patients with mucosa-associated lymphoid tissue lymphoma. Furthermore, thyroid cancer and thus the combination of PTL and PTC were more common in women.

Follicular proliferation TIR3B: the role of total thyroidectomy vs lobectomy

BACKGROUND

TIR3B thyroid nodules are considered to be at risk of malignancy (15-30%) but guidelines recommend conservative surgery with lobectomy with primary diagnostic porpoise. Risk stratification mainly based on ultrasound, elastography and genetic mutations usually may influences the surgical approach.

METHODS

We retrospectively analyzed 52 cases of TIR3B underwent between 2015 and 2017 total thyroidectomy (TT) and lobectomy (L), focusing mainly on the observed rate of malignancy. Chi-squared test and Fisher's exact probability test were used for analysis, considering a P values less than 0.05 as significant.

RESULTS

Out of 52 patients 49 underwent TT and 3 L. In TT group a multinodular goiter was associated in 67.3% of patients. Malignancy rate was 81.6 and 33.3% respectively after TT and L (P 0.003). Multicentric and contralateral tumors were detected respectively in 36.7% and in 32.6% of patients underwent TT. No main post-operative complications were registered.

CONCLUSIONS

Ultrasound and elastography are useful to define within the TIR3B group those lesions at higher risk and therefore requiring a more radical approach. TT seems an appropriate approach to TIR3B lesions, especially in multinodular goiter, considering the incidence of malignancy with probably higher rate than previously reported.

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.

Lobular breast carcinoma metastasis to skeletal muscle, two case reports diagnosed by ultrasound guided FNA with evaluation of the roles of interventional cytopathology

Skeletal muscle metastasis from breast carcinoma is a relatively rare clinical entity. We report two cases of breast cancer metastatic to the skeletal muscle, diagnosed by ultrasound guided fine needle aspiration (US-FNA) biopsy done by interventional cytopathologists at an outpatient cytopathology center. Our two patients presented with lower anterior neck firmness and chest wall mass, respectively. Ultrasound evaluation of our first case demonstrated hypo-echoic thickened anterior strap muscles while in the second case there was significant distortion of the anatomy from previous surgeries. It was necessary to proceed with FNA biopsy even when their ultrasound findings were equivocal, to establish a definite rapid diagnosis. The immediate onsite evaluation findings were suggestive of malignancy in both cases with subsequent core biopsy confirming the diagnosis of metastatic breast carcinoma. In cytopathology, point-of-care (POC) ultrasound is used as an adjunct tool that offers visual guidance during FNA of nonpalpable masses and enables sampling of lesional "hot" spots to ensure specimen adequacy. Studies have demonstrated a reduction in FNA nondiagnostic rates with the use of ultrasound-guidance consequently reducing health care costs associated with nondiagnostic FNAs. US-FNA also provides adequate samples for cell block preparations. Metastatic lobular carcinoma of the breast has a wide range of clinical presentations and a high level of suspicion is advised. Cytopathologists-performed US-FNA is a proven, less-invasive, cost-effective tool that provides timely cytologic diagnosis.

Value of rapid on-site evaluation for ultrasound-guided thyroid fine needle aspiration

Objective

Application of rapid on-site evaluation (ROSE) for thyroid fine needle aspiration (FNA) is controversial. Therefore, ROSE has not been universally applied. This study aimed to evaluate the value of ROSE for ultrasound-guided thyroid FNA.

Methods

A total of 997 patients with 1103 suspicious thyroid nodules had ultrasound-guided FNA performed from January 2016 to February 2018. There were 513 nodules with ROSE and 590 nodules without ROSE. The cytological nondiagnostic rate, needle passes, and procedural times of thyroid FNA with or without ROSE were compared. The nondiagnostic rates of subsets of suspicious thyroid nodules were further compared.

Results

There was no significant effect of ROSE on the nondiagnostic rate of FNA. However, FNA with ROSE significantly reduced the numbers of sub-centimeter, mixed solid-cystic, macrocalcified, and hypervascular nodules. There was a significantly smaller number of needle passes and less procedural times with ROSE than without ROSE. There was no significant difference in the complication rate of FNA with and without ROSE.

Conclusion

ROSE for thyroid FNA reduces the number of needle passes and procedural times. ROSE has a higher clinical application value in subsets of thyroid nodules, which tend to be difficult to diagnose with FNA.

Comparison of Cytopathologist-Performed Ultrasound-Guided Fine-Needle Aspiration With Cytopathologist-Performed Palpation-Guided Fine-Needle Aspiration: A Single Institutional Experience

Context.—

Although fine-needle aspiration (FNA) practice by pathologists is now well established, it has been primarily performed by manual palpation. In recent years, pathologists have begun to venture into ultrasound-guided FNAs (UGFNAs). Reports on experiences with this relatively new technique for pathologists have shown promising results. However to date, there have been few studies in the literature comparing pathologist-performed UGFNA with the more traditional pathologist-performed palpation-guided FNA (PGFNA).

Objective.—

To compare UGFNA to PGFNA by cytopathologists at an academic medical center.

Design.—

A retrospective study of FNAs performed by cytopathologists within the University of California, Los Angeles (UCLA) pathology departmental FNA clinic was performed. Data collected included performance technique (UGFNA versus PGFNA), lesion site and size, adequacy status (nondiagnostic rate), and number of passes per procedure. Corresponding surgical pathology/flow cytometric/cytogenetic result follow-up was compared to FNA results. Findings between UGFNA and PGFNA cases were compared.

Results.—

Of 1029 FNA cases during the study period, there were 449 UGFNA cases (43.6%) and 580 PGFNA cases (56.4%). Nondiagnostic rates with UGFNA and PGFNA were 6.7% (30 of 449 cases) and 20.7% (120 of 580 cases), respectively. Nondiagnostic rate was also significantly lower with UGFNA than with PGFNA for lesions within the thyroid (6.0% versus 33.3%), head and neck (6.6% versus 21.2%), and salivary gland (6.2% versus 17.1%), and across all nodule sizes. A total of 495 of 1029 FNA cases (48.1%) had follow-up. Discordance rate was significantly lower with UGFNA than with PGFNA (5.4% versus 12.8%).

Conclusions.—

This study shows improved performance characteristics of cytopathologist-performed UGFNA versus PGFNA.

Cytopathologist-performed and ultrasound-guided fine needle aspiration cytology enhances diagnostic accuracy and avoids pitfalls: An overview of 20 years of personal experience with a selection of didactic cases

Over the last few decades, fine needle aspiration cytology (FNA) has emerged as a SAFE (Simple, Accurate, Fast, Economical) diagnostic tool based on the morphologic evaluation of cells. The first and most important step in obtaining accurate results from FNA is to procure sufficient and representative material from the lesion and to appropriately transfer this material to the laboratory. Unfortunately, the most important aspect of this task occurs beyond the control of the cytopathologist, a key reason for obtaining unsatisfactory results with FNA. There is growing interest in the field of cytology in "cytopathologist-performed ultrasound (US)-guided FNA," which has been reported to yield accurate results. The first author has been applying FNA in his own private cytopathology practice with a radiologist and under the guidance of US for more than 20 years. This study retrospectively reviews the utility of this practice. We present a selection of didactic examples under different headings that highlight the application of FNA by a cytopathologist, accompanied by US, under the guidance of a radiologist, in the form of an "outpatient FNA clinic." The use of this technique enhances diagnostic accuracy and prevents pitfalls. The highlights of each case are also outlined as "take-home messages."

Different qualifiers of AUS/FLUS thyroid FNA have distinct BRAF, RAS, RET/PTC, and PAX8/PPARg alterations

BACKGROUND

The Bethesda System for Reporting Thyroid Cytopathology category of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) includes fine-needle aspiration (FNA) specimens that cannot straightforwardly be classified as benign or malignant. To determine whether morphological subcategorization based on atypia qualifiers and molecular testing could improve malignancy risk stratification of AUS/FLUS patients, this study assessed the correlation between these qualifiers and the molecular alterations commonly harbored by thyroid neoplasms.

METHODS

A total of 162 AUS/FLUS cases were subcategorized by atypia qualifiers (Hürthle cell changes, architectural atypia, and cytologic atypia [CyA]) and were tested for BRAF, N-H-KRAS, RET/PTC, and paired box 8 (PAX8)/peroxisome proliferator activated receptor γ (PPARg) mutations.

RESULTS

CyA was observed more frequently in mutation-positive AUS/FLUS (14 of 37 [37.84%]) than mutation-negative AUS/FLUS (20 of 125 [16.00%]; P < .0084), and it specifically harbored the BRAFV600E point mutation. Malignancy was confirmed in the available follow-up. Conversely, although RAS was the most frequent mutation identified in AUS/FLUS FNA specimens (26 of 37 cases [70.27%]; P < .0001), it was distributed across various AUS/FLUS subcategories and was not significantly associated with a specific atypia qualifier or malignant outcome according to the available follow-up. Rearrangements of both RET/PTC (n = 1) and PAX8/PPARg (n = 3) were rarely retrieved in the FNA samples.

CONCLUSIONS

BRAF and RAS mutations are associated with different AUS/FLUS qualifiers and hence have different risks of malignancy. Consequently, a hybrid molecular and morphological subcategorization system could improve the malignancy risk stratification of thyroid FNA samples diagnosed as AUS/FLUS. Cancer Cytopathol 2018;126:317-25. © 2018 American Cancer Society.

Intra-institutional second opinion diagnosis can reduce unnecessary surgery for indeterminate thyroid FNA: A preliminary report on 34 cases

INTRODUCTION

Indeterminate diagnoses are rendered on 15%-30% of thyroid fine-needle aspirates (FNA). Thus, a second diagnostic opinion given by an outside expert pathologist is a common practice that facilitates a more appropriate clinical management. Conversely, the role of an intra-institutional second opinion diagnosis (iSOD), which is usually informally performed in-house, has not been well established.

METHODS

To assess the contribution of iSOD, a retrospective series of 34 thyroid FNA diagnosed as follicular neoplasm/suspicious follicular neoplasm (FN/SFN) with matched histological follow-up and a malignancy rate of 17.6% was selected and independently reviewed by two cytopathologists (CYT1 and 2). Cases with discrepant diagnoses were referred to a third in-house senior cytopathologist for the iSOD. The malignancy rates (MR) obtained after single independent reviews and iSOD were compared.

RESULTS

MR obtained after CYT1 and CYT2 re-screening was similar (14.28% and 19.04%, respectively) and did not improve the original MR (17.64%). Conversely, after the iSOD of discrepant diagnoses, the overall malignancy rate increased up to the 27.27%, potentially sparing unnecessary surgical procedures.

CONCLUSIONS

Intra-institutional second opinion practice for "indeterminate" thyroid FNA avoids unnecessary surgeries and maximises the detection of malignant cases diagnosed as FN/SFN.

Surgical treatment of thyroid follicular neoplasms: results of a retrospective analysis of a large clinical series

The most appropriate surgical management of "follicular neoplasm/suspicious for follicular neoplasm" lesions (FN), considering their low definitive malignancy rate and the limited predictive power of preoperative clinic-diagnostic factors, is still controversial. On behalf of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB), we collected and analyzed the experience of 26 endocrine centers by computerized questionnaire. 1379 patients, surgically treated after a FN diagnosis from January 2012 and December 2103, were evaluated. Histological features, surgical complications, and medium-term outcomes were reported. Total thyroidectomy (TT) was performed in 1055/1379 patients (76.5 %), while hemithyroidectomy (HT) was carried out in 324/1379 cases (23.5 %). Malignancy rate was higher in TT than in HT groups (36.4 vs. 26.2 %), whereas the rates of transient and definitive hypoparathyroidism following TT were higher than after HT. Consensual thyroiditis (16.8 vs. 9.9 %) and patient age (50.9 vs. 47.9 %) also differed between groups. A cytological FN diagnosis was associated to a not negligible malignancy rate (469/1379 patients; 34 %), that was higher in TT than in HT groups. However, a lower morbidity rate was observed in HT, which should be considered the standard of care in solitary lesions in absence of specific risk factors. Malignancy could not be preoperatively assessed and clinical decision-making is still controversial. Further efforts should be spent to more accurately preoperatively classify FN thyroid nodules.

Role of prophylactic central compartment lymph node dissection in clinically N0 differentiated thyroid cancer patients: analysis of risk factors and review of modern trends

In the last years, especially thanks to a large diffusion of ultrasound-guided FNBs, a surprising increased incidence of differentiated thyroid cancer (DTC), "small" tumors and microcarcinomas have been reported in the international series. This led endocrinologists and surgeons to search for "tailored" and "less aggressive" therapeutic protocols avoiding risky morbidity and useless "overtreatment". Considering the most recent guidelines of referral endocrine societies, we analyzed the role of routine or so-called prophylactic central compartment lymph node dissection (RCLD), also considering its benefits and risks. Literature data showed that the debate is still open and the surgeons are divided between proponents and opponents of its use. Even if lymph node metastases are commonly observed, and in up to 90% of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is subject to intensive research and the best indications of lymph node dissection are still controversial. Identification of prognostic factors for central compartment metastases could assist surgeons in determining whether to perform RLCD. Considering available evidence, a general agreement to definitely reserve RCLD to "high-risk" cases was observed. More clinical researches, in order to identify risk factors of meaningful predictive power and prospective long-term randomized trials, should be useful to validate this selective approach.