Thyroid core needle biopsy: taking stock of the situation

Histology-based and cytology-based needle sampling for targeted next-generation sequencing in the indeterminate thyroid tumors

PURPOSE

To establish the optimal and minimally invasive diagnostic approach for targeted next-generation sequencing (NGS) in the indeterminate thyroid tumors.

METHODS

The patients with indeterminate thyroid tumors were prospectively recruited and analyzed in a single tertiary medical center. We performed FNA and core needle biopsy (CNB) at the surgical specimens to confirm the quality of each sampling procedure. Cytological diagnosis by FNA, histological diagnosis by CNB and confirmed diagnosis by final surgery were compared to demonstrate the agreement among these approaches for the indeterminate thyroid tumors. The quality of the samples from FNA and CNB was evaluated, respectively to determine the optimal approach for targeted NGS. Finally, we performed ultrasound-guided CNB and FNA (US-CNB and US-FNA) on one case to confirm the clinical feasibility of being a pre-operative minimally invasive diagnostic approach.

RESULTS

A total of 6 female patients (average age: 50.83 ± 15.18 years) with indeterminate thyroid tumors (average size: 1.79 ± 0.91 cm) were recruited for further analyses. The pathological diagnoses could be obtained by CNB in the first five cases, and the sample quality of CNB for targeted NGS was better than that of FNA, even after 10X dilution. The gene mutations associated with thyroid malignancy could be detected by NGS. In the case treated with US-CNB, the pathological and targeted NGS results were successfully obtained, which suggested the possibility of thyroid malignancy to facilitate immediate decision of subsequent treatment.

CONCLUSION

CNB could serve as a minimally invasive diagnostic approach in the indeterminate thyroid tumors by providing pathological diagnoses and qualified samples for detection of mutated genes, which facilitates appropriate and immediate management.

Comparison of Diagnostic Accuracy of Thyroid Cancer With Ultrasound-Guided Fine-Needle Aspiration and Core-Needle Biopsy: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to evaluate the accuracy of fine-needle aspiration (FNA) and core-needle biopsy (CNB) in diagnosing thyroid cancer. The PubMed, Embase, and Cochrane Library databases were retrieved up to May 2019, and the overall accuracy of FNA and CNB in diagnosing thyroid cancer was evaluated by meta-analysis. The sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) were calculated. The summary receiver operating characteristic (ROC) curve was estimated, and the area under the ROC curve (AUC) was calculated. Ten eligible studies, involving 10,078 patients with 10,842 thyroid nodules, were included. The overall sensitivity and specificity of FNA and CNB for thyroid cancer were 0.72 [95 % confidence interval (CI): 0.69-0.74], 0.99 (95% CI: 0.98-0.99), and 0.83 (95% CI: 0.81-0.85), 0.99 (95% CI: 0.98-0.99), respectively. Other parameters used to assess efficacy included PLR 41.71 (2.15-808.27) and 51.56 (3.20-841.47), NLR 0.31 (0.22-0.42) and 0.22 (0.15-0.32), for FNA and CNB, respectively. Overall, the pooled summary ROC (AUC) value of FNA and CNB was 0.9025 and 0.7926, respectively. No significant difference was observed between the two AUCs of FNA and CNB (P = 0.164). FNA and CNB are still similar as first-line diagnostic tools. FNA remains a good first-line method for detecting thyroid malignancies.

Combination of contrast-enhanced ultrasound and strain elastography to assess cytologically non-diagnostic thyroid nodules

The aim of the present study was to investigate the benefits of combining contrast-enhanced ultrasound (CEUS) and strain elastography (SE) for the diagnosis of thyroid nodules with non-diagnostic fine-needle aspiration cytology (FNAC) results. Between October 2013 and March 2017, CEUS and SE were performed in 226 patients (236 thyroid nodules) with non-diagnostic FNAC results prior to thyroidectomy. The diagnostic value of CEUS, SE and their combination (CEUS+SE) in distinguishing malignant from benign thyroid nodules was evaluated, using surgical pathology as a reference. Receiver operating characteristic curve analysis was used to assess the diagnostic performance of CEUS, SE and CEUS+SE in determining malignant thyroid nodules. Subsequently, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of CEUS, SE and CEUS + SE were calculated. The malignancy rate in patients with thyroid nodules and non-diagnostic FNAC results was 26.3% in the present study. The sensitivity, specificity, PPV, NPV, accuracy and area under the curve in predicting malignant thyroid nodules were 80.6, 85.6, 66.7, 92.5, 84.3 and 0.831%, respectively, using SE alone; 59.7, 95.9, 84.1, 86.9, 86.4 and 0.778%, respectively, using CEUS alone; and 83.9, 89.1, 73.6, 94.5, 88.1 and 0.865%, respectively, using the combination of CEUS and SE. Overall, the combination of CEUS with SE resulted in higher sensitivity, NPV and accuracy in the diagnosis of cytologically non-diagnostic thyroid nodules compared with CEUS or SE alone.

Core needle biopsy in the management of thyroid nodules with an indeterminate fine-needle aspiration report

Ultrasonography (US)-guided fine-needle aspiration biopsy (FNAB) cytology is widely used but is limited due to its pathologically indeterminate results in diagnosing thyroid nodules. Recently, US-guided core-needle biopsy (CNB) was introduced as an effective and safe technique for diagnosing indeterminate thyroid nodules. Using CNB, information about architectural histologic structure such as nodule capsule or more immunochemical staining can be obtained which lead to a more accurate diagnosis. Up to 98% of indeterminate thyroid lesions can be classified as malignant or benign when CNB is used for follow-up analysis. Other evidences revealed the effectiveness of CNB in reducing inconclusive results and improving the diagnostic performance of thyroid nodules initially diagnosed as AUS/FLUS by FNAB. In this review, we investigate how to deal with indeterminate thyroid nodules diagnosed by FNAB and determine how CNB has a role in diagnosing these indeterminate thyroid nodules.

The Current Histologic Classification of Thyroid Cancer

Thyroid cancers of follicular cell derivation provide excellent phenotype-genotype correlations. Current morphologic classifications are complex and require simplification. Benign adenomas have follicular or papillary architecture and bland cytology. Well-differentiated thyroid carcinomas exhibit follicular architecture, expansile growth, and variable cytologic atypia and invasiveness; low-risk tumors have excellent prognosis after surgical resection whereas widely-invasive and angioinvasive tumors warrant total thyroidectomy and radioablation. Papillary carcinoma is less differentiated; indolent microcarcinomas can be managed by active surveillance, whereas clinical lesions with local or distant spread require therapy. Progression gives rise to poorly differentiated and anaplastic carcinomas that are less common but far more aggressive.

Core needle biopsy of thyroid nodules: outcomes and safety from a large single-center single-operator study

Background There currently remains a debate over the use of core needle biopsy (CNB) or fine needle aspiration (FNA) for diagnosis of thyroid nodules. The major drawbacks of previous CNB studies include heterogeneity of the study population, variable techniques, devices, and operator experience affecting the outcome of the procedure. Purpose To assess the diagnostic performance and safety of CNB of thyroid nodules performed by a single experienced operator in consecutive patients. Material and Methods From January 2012 to December 2012, 538 thyroid nodules that underwent CNB were retrospectively evaluated. All CNB procedures were performed by a single operator with 18 years of experience. The histopathology of the surgical specimens was considered as the standard reference for malignancy. A final diagnosis of benignity was made by surgery, one benign lesion on FNA and/or CNB with no change on follow-up examinations (>1 year) or benign lesion on ≥2 FNA and/or CNB. The diagnostic performance, incidence of technical failure, unnecessary surgery, and complication were evaluated. Results The diagnostic accuracy, sensitivity, and specificity of CNB for malignancy were 92.0%, 85.3%, and 100%, respectively. The non-diagnostic result rate of CNB was 4.8% (26/538) and the inconclusive result rate was 24.3% (131/538). The incidence of technical failure was 0.6% (3/541) and unnecessary surgery was 0.6%. The complication rate was 0.2%, without life-threatening complications. The sensitivity, specificity, and accuracy were 85.3% (156/183), 100.0% (154/154), and 92.0% (310/337), respectively. Conclusion CNB shows a high diagnostic performance for detection of thyroid malignancy and follicular neoplasm, with low rates of technical failure and complications.

Performance of Italian Consensus for the Classification and Reporting of Thyroid Cytology (ICCRTC) in discriminating indeterminate lesions at low and high risk of malignancy. A systematic review and meta-analysis

BACKGROUND

Italian consensus for the classification and reporting of thyroid cytology was published in 2014 and it has been used in almost all Italian institutions. To date, there are not solid data on the reliability of Italian consensus for the classification and reporting of thyroid cytology in classifying low and high risk indeterminate nodules (Tir 3A and Tir 3B, respectively). Here, we reviewed and meta-analyzed the results of published articles to obtain evidence-based information on this topic.

RESEARCH DESIGN AND METHODS

A comprehensive literature exploration of online databases was conducted by searching all published papers citing Italian consensus for the classification and reporting of thyroid cytology. The search was updated until June 2017, and references of the retrieved articles were also screened. Only original articles reporting histologic follow-up of nodules cytologically classified as Tir 3A and Tir 3B were eligible for inclusion.

RESULTS

The literature search revealed 62 articles and six of these were eligible for the study. All papers were retrospective and published very recently. Overall, 423 indeterminate lesions, of which 180 Tir 3A and 243 Tir 3B, were found. Of these, 29 cancers were recorded in Tir 3A and 127 in Tir 3B. The pooled rate of malignancy was 17% (95% CI = 12 to 22%) in Tir 3A and 52% (95% CI = 46 to 58%) in Tir 3B. No significant publication bias was evident.

CONCLUSIONS

Italian consensus for the classification and reporting of thyroid cytology 2014 shows high reliability in discriminating indeterminate lesions at low risk of malignancy from those at high risk.

Histologic Outcome of Indeterminate Thyroid Nodules Classified at Low or High Risk

The revised Italian consensus for the classification and reporting of thyroid cytology (ICCRTC) was published in 2014. Very recently, a high reliability of ICCRTC in classifying low and high risk indeterminate nodules (Tir 3A and Tir 3B, respectively) was demonstrated. This finding prompted us to review our case series of thyroid indeterminate lesions to verify these data. Only lesions undergone FNAC from December 2014 to October 2017 with subsequent histology at our institutions were eligible for the study. All cytologic samples had originally been classified according to ICCRTC in the subcategories of indeterminate lesion, such as Tir 3A and Tir 3B by three cytopathologists and another one with more than 10 years experience, when necessary. Sixty-three indeterminate FNAC were diagnosed during the study period, of which 51 were subsequently surgically treated. Overall, 9 carcinomas (7 follicular and 2 papillary) and 42 benign lesions were found at histology. The cancer rate observed in the Tir 3A category (3/40, 7.5%) was significantly (p = 0.0015) lower than that found in Tir 3B (6/11, 54.5%). No significant differences were found in age and size of the sampled nodules between the two subcategories. We can confirm in our series that the Italian reporting system for thyroid cytology shows high reliability in discriminating low risk indeterminate lesions from those at high risk of malignancy.

Reliability of core needle biopsy as a second-line procedure in thyroid nodules with an indeterminate fine-needle aspiration report: a systematic review and meta-analysis

PURPOSE

This study was undertaken to summarize the published data and to provide more robust estimates regarding the issue of core needle biopsy (CNB) for discriminating thyroid nodules with indeterminate fine-needle aspiration (FNA) results.

METHODS

The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The sources comprised studies published through November 2017. Original articles that investigated CNB in indeterminate thyroid lesions were searched. A random-effects model was used for statistical pooling of the data. The I² index was used to quantify the heterogeneity among the studies. The Egger test was carried out to evaluate the possible presence of significant publication bias. Quality assessment of the studies was performed according to QUADAS-2.

RESULTS

A total of 205 articles were retrieved, seven were initially selected, and the data of five papers were ultimately pooled in a meta-analysis. The overall cancer rate was 34%. The rate of cancers correctly diagnosed by CNB was 83% (95% confidence interval [CI], 76 to 89), with neither heterogeneity (I²=25%) nor publication bias (Egger test, P=0.918). The rate of benign nodules correctly assessed by CNB was 84% (95% CI, 65 to 97), with significant heterogeneity (I²=93.4%) and publication bias (Egger test, P=0.016).

CONCLUSION

Evidence was found that CNB can correctly diagnose the majority of nodules previously read as indeterminate on FNA.

Comparison of Consecutive Results from Fine Needle Aspiration and Core Needle Biopsy in Thyroid Nodules

There are papers suggesting the complementary role of core needle biopsy (CNB) in the diagnosis of thyroid nodules. By comparing the result of CNB and fine needle aspiration (FNA) cytology performed in consecutive cases of thyroid nodules, the role of CNB was evaluated. Retrospective reviews of 2131 FNA and 275 CNB which were performed as first-line biopsy for 2406 thyroid nodules in 2187 patients were performed. The ultrasound (US) feature of thyroid nodule was classified following the risk of malignancy suggested by American Thyroid Association (ATA) guideline. Rate of unsatisfactory and cellular atypia could be decreased significantly by first-line CNB in all US group, and the nodules with highly suspicious feature showed significant decrease in inconclusive result by first-line CNB. However, increased rates of architectural and follicular neoplasm (FN) were identified in CNB group especially in intermediate and low suspicious nodules, and the first-line CNB could not decrease the inconclusive result in these US groups. The diagnostic rate of neoplasm diagnosed by surgery following the result of architectural atypia or FN was not different between FNA and CNB even with significantly higher rate in CNB group. Furthermore, the sensitivity for follicular neoplasm (21.2 vs. 61.9%) was significantly higher in CNB group. The CNB can be considered in nodules with highly suspicious feature with advantage of significantly lower inconclusive diagnostic rate than FNA group. However, significantly increased diagnosis of architectural atypia or FN in other nodules by CNB is recognized and should be evaluated in future to understand the meaning.

Ultrasound-guided fine needle aspiration versus core needle biopsy: comparison of post-biopsy hematoma rates and risk factors

PURPOSE

To compare post-biopsy hematoma rates between ultrasound guided-fine needle aspiration and ultrasound guided-core needle biopsy, and to investigate risk factors for post-biopsy hematoma.

METHODS

A total of 5304 thyroid nodules which underwent ultrasound guided biopsy were included in this retrospective study. We compared clinical and US features between patients with and without post-biopsy hematoma. Associations between these features and post-biopsy hematoma were analyzed.

RESULTS

Post-biopsy hematoma rate was 0.8% (43/5121) for ultrasound guided-fine needle aspiration and 4.9% (9/183) for ultrasound guided-core needle biopsy (P < 0.001). For ultrasound guided-fine needle aspiration, gender, age, size, presence of vascularity, and suspicious US features were not associated with post-biopsy hematoma according to experience level. Post-biopsy hematoma occurred significantly more with ultrasound guided-core needle biopsy (9/179, 5.0%) than with ultrasound guided-fine needle aspiration (9/1138, 0.8%) (P < 0.001) in experienced performers and ultrasound guided-core needle biopsy was the only significant risk factor for post-biopsy hematoma (adjusted Odds Ratio, 6.458, P < 0.001).

CONCLUSION

Post-biopsy hematoma occurred significantly more in ultrasound guided-core needle biopsy than in ultrasound guided-fine needle aspiration and ultrasound guided-core needle biopsy was the only independent factor of post-biopsy hematoma in thyroid nodules.

Ultrasound-guided core needle biopsy for differential diagnosis of thyroid nodules: A systematic review and meta-analysis

Ultrasound-guided core needle biopsy (US-CNB) of thyroid nodules is a relatively new technique used in surgical workup. However, no systematic review of this method has yet been performed. In the present meta-analysis, literature databases consisting of Cochrane Library, Medline, Embase, Scopus and Google Scholar were searched. Following eligibility assessments of the studies, quality appraisals were performed on the included studies using the Quality Assessment Tool for Diagnostic Accuracy Studies-2 method. The data were systematically analyzed by using Review Manager (version 5.3) and Meta-Disc (version 1.4). Eight investigations were included, and the study qualities were good. There were 1,621 nodules included in the final meta-analysis. The summary estimated that US-CNB had a sensitivity of 0.96 [95% confidence interval (CI)=0.94–0.97] and a specificity of 0.96 (95% CI=0.94–0.97). Positive and negative likelihood ratios, and the diagnostic odds ratio of US-CNB were 18.20 (95% CI=2.21–156.41), 0.08 (95% CI=0.02–0.27) and 250.60 (95% CI=19.11–3286.76), respectively. The area under the summary receiver operating characteristic curve was 0.979. Therefore, US-CNB may be considered as a reliable method in the assessment of thyroid nodules, and has an acceptable risk of complications.

Core Needle Biopsy of the Thyroid: 2016 Consensus Statement and Recommendations from Korean Society of Thyroid Radiology

Core needle biopsy (CNB) has been suggested as a complementary diagnostic method to fine-needle aspiration in patients with thyroid nodules. Many recent CNB studies have suggested a more advanced role for CNB, but there are still no guidelines on its use. Therefore, the Task Force Committee of the Korean Society of Thyroid Radiology has developed the present consensus statement and recommendations for the role of CNB in the diagnosis of thyroid nodules. These recommendations are based on evidence from the current literature and expert consensus.

Should Core Needle Biopsy be Used in the Evaluation of Thyroid Nodules?

Fine needle aspiration (FNA) is the first choice in thyroid nodules suspected of harboring malignancy on sonography in routine practice. However, sampling with core needle biopsy (CNB) is also being used, especially in cases with repeated nondiagnostic/indeterminate diagnoses. The aim of this study was the retrospective evaluation of CNB samples. A total of 604 thyroid CNB samples registered in the Department of Pathology at Bezmialem Foundation University Medical Faculty within the 1-year period between June 2014 and June 2015 were re-evaluated by correlation with previous FNA and later resection results. CNB was divided into diagnostic groups of insufficient, malignant, suspicious for malignancy, no evidence of malignancy/benign, atypia of uncertain significance (AUS)/follicular lesions of uncertain significance (FLUS), and follicular neoplasm (FN)/suspicious for follicular neoplasm (SFN). Among the 604 cases, 15 cases (2.48 %) were classified as malignant and 9 cases (1.49 %) as suspicious for malignancy. No evidence of malignancy was seen in 512 cases (84.76 %). There were 26 (4.3 %) cases in the AUS/FLUS-FN/SFN group, and the sample was inadequate in 42 cases (6.95 %). Resection was performed for 17 of the cases classified as malignant or suspicious for malignancy, and all were found to be malignant. There were also 10 resected cases with a diagnosis of no evidence of malignancy, and all were found to be benign. We think that sampling with CNB may be useful especially in repeating inadequate biopsies or cases diagnosed with AUS/FLUS that have hesitations regarding clinical management. Larger series including comparisons with FNA and resection results are required.

The role of core-needle biopsy in the diagnosis of thyroid malignancy in 4580 patients with 4746 thyroid nodules: a systematic review and meta-analysis

To evaluate the effectiveness and complications of core-needle biopsy (CNB) compared to fine-needle aspiration (FNA) for diagnosing thyroid malignancy. The Ovid-MEDLINE and EMBASE databases were searched for studies using CNB for diagnosing thyroid malignancy. A meta-analysis was performed to evaluate the diagnostic accuracy, the incidence of non-diagnostic, inconclusive results, and the complications of CNB and FNA. To overcome the heterogeneity, additional analyses based on three, homogeneous inclusion criteria were performed and subgroup analyses were performed. Twenty eligible studies of 4580 patients (4746 nodules) were included. Both CNB and FNA demonstrated a high sensitivity (91 %, 74 %, respectively; p = .053) and specificity (99 %, 100 %, respectively; p = .914). The area under the curve was larger in CNB (0.99) than in FNA (0.94). CNB demonstrated a significantly lower pooled proportion of non-diagnostic (5.5 %; p < .001) and inconclusive results (8.0 %; p < .001) than FNA (22.6 %, 40.2 %, respectively). The complications rate of FNA (0.0 %) was lower than that of CNB (0.01 %), although not significantly (p = .948). This meta-analysis showed variable heterogeneities, i.e., no heterogeneity to considerable heterogeneity. Additional meta-analyses based on three, homogeneous inclusion criteria demonstrated that heterogeneities were reduced, and the results are in agreement with those of all of the included studies. Subgroup analyses have explained the cause of heterogeneity across studies. Both CNB and FNA may be acceptable diagnostic tools for diagnosing thyroid malignancy. CNB may be a complementary diagnostic tool in nodules with initially non-diagnostic and indeterminate results on previous FNA.

(99m)Tc-Methoxy-Isobutyl-Isonitrile Scintigraphy Is a Useful Tool for Assessing the Risk of Malignancy in Thyroid Nodules with Indeterminate Fine-Needle Cytology

BACKGROUND

Thyroid nodular disease is a very common clinical problem. The diagnostic algorithm includes laboratory tests, thyroid ultrasound (US), thyroid scintigraphy, and, if necessary, US-guided fine-needle aspiration cytology. However, cytology results are reported as indeterminate in a not negligible number of patients. This is a central problem in the workup of patients, since about 55-85% of those undergoing surgery do not have thyroid cancer at final histology diagnosis. The aim of this study was to evaluate prospectively the role of (99m)Tc-methoxy-isobutyl-isonitrile ((99m)Tc-MIBI) thyroid scintigraphy in differentiating malignant from benign thyroid nodules with indeterminate cytology using quantitative analysis.

METHOD

One hundred five patients affected by nodular thyroid goiter and with a euthyroid or hypothyroid functional status were prospectively evaluated. All patients had a suspicious nodule ≥15 mm in maximal diameter on US. All nodules were "cold" on (99m)Tc-pertechnetate scintigraphy and had a cytological diagnosis of class III or IV according to the Bethesda system. Planar images of the thyroid were acquired 10 and 60 minutes after (99m)Tc-MIBI administration. All cold nodules were MIBI-positive. Using quantitative analysis, the MIBI washout index (WOind) was calculated as a percentage reduction value of mean MIBI nodular uptake between early (+10 minutes) and late (+60 minutes) scans.

RESULTS

Subdividing the patients into positive and negative for malignancy (either including or excluding patients with Hürthle cell adenoma) and performing receiver operating characterist curve analysis, the optimal WOind cutoff in differentiating malignant from benign follicular lesions was set at -19%. The overall sensitivity and specificity of (99m)Tc-MIBI quantitative analysis in identifying patients with malignant lesions was 100% and 90.9%, respectively. However, after excluding patients with Hürthle cell adenomas from the negative patient group, the overall sensitivity and specificity both reached 100%.

CONCLUSION

The use of MIBI scintigraphy using quantitative analysis in the workup of cold nodules with indeterminate cytology is suggested in order to stratify patient risk for a malignant lesion better, thus reducing the number of patients referred to surgery. Surgical treatment should be planned in those patients with a WOind up to -19%.

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.

Galectin-3 and HBME-1 improve the accuracy of core biopsy in indeterminate thyroid nodules

Core needle biopsy (CNB) has been recently described as an accurate second-line test in thyroid inconclusive cytology (FNA). Here we retrospectively investigated the potential improvement given by Galectin-3, Cytokeratin-19, and HBME-1 on the accuracy of CNB in thyroid nodules with prior indeterminate FNA report. The study included 74 nodules. At CNB diagnosis, 15 were cancers, 40 were benign, and 19 had uncertain/non-diagnostic CNB report. The above immunohistochemical (IHC) panel was analyzed in all cases. After surgery, 19 malignant and 55 benign lesions were found. All 15 cancers and all 40 benign nodules diagnosed at CNB were confirmed at final histology. Regarding the uncertain CNB group, 4 (21 %) were malignant and 15 (79 %) benign. When we considered all the series, the most accurate IHC combination was Galectin-3 plus HBME-1, while HBME-1 was the most sensitive marker in those nodules with uncertain CNB report. The combination of CNB plus IHC could indentify 19/19 cancers and 53/55 benign lesions. Sensitivity and specificity of CNB increased from 79 to 100 % and from 73 to 96 %, respectively, by adding IHC. CNB can diagnose the majority of thyroid nodules with previous indeterminate FNA cytology, while the accuracy of CNB is increased by adding Galectin-3, Cytokeratin-19, and HBME-1 panel. We suggest to adopt CNB as a second-line approach to indeterminate thyroid FNA, and apply IHC in those lesions with uncertain/non-diagnostic CNB report. This approach should improve the pre-surgical diagnosis of patients. These results should be confirmed in larger prospective series.

BRAF-mutated carcinomas among thyroid nodules with prior indeterminate FNA report: a systematic review and meta-analysis

BACKGROUND

Several molecular analyses have been investigated for risk stratification of thyroid nodules, with a particular focus on the V600E mutation of the BRAF gene [BRAF(V600E)]. To date, there is no high-level evidence supporting or refuting a role for BRAF analysis in thyroid nodules with prior indeterminate cytology. To obtain more robust evidence, we reviewed and meta-analysed data from published articles.

RESEARCH DESIGN AND METHODS

A comprehensive literature search of the PubMed/MEDLINE, Embase and Scopus databases was conducted using the terms 'BRAF', 'thyroid' and 'indeterminate'. The search was updated until March 2015, and references of the retrieved articles were also screened. Only original articles reporting BRAF mutation testing within nodules with indeterminate FNA were eligible for inclusion.

RESULTS

The literature search revealed 82 articles, of which 8 were eligible for the study. Five studies were prospective and three retrospective. The majority of authors analysed BRAF mutations in FNA samples which were classified by the British or Bethesda system. Of the initial series of studies, a pooled number of 1361 cases were achieved of which 43 were BRAF mutated. Overall, the BRAF mutation rate was 4·6% (95% CI: 1-10·8%), ranging from 0 to 22·9%. When we included only histological series, 978 thyroid nodules were found. Of these, 245 were cancers.

CONCLUSIONS

A very low rate of lesions with indeterminate cytology are BRAF mutated. Thus, the role of this biomarker to detect or exclude cancers in patients with such FNA reports is marginal and should be reconsidered in guidelines.

DIAGNOSIS OF ENDOCRINE DISEASE: High-yield thyroid fine-needle aspiration cytology: an update focused on ancillary techniques improving its accuracy

Thyroid fine-needle aspiration (FNA) cytology is a fast growing field. One of the most developing areas is represented by molecular tests applied to cytological material. Patients that could benefit the most from these tests are those that have been diagnosed as 'indeterminate' on FNA. They could be better stratified in terms of malignancy risk and thus oriented with more confidence to the appropriate management. Taking in to consideration the need to improve and keep high the yield of thyroid FNA, professionals from various fields (i.e. molecular biologists, endocrinologists, nuclear medicine physicians and radiologists) are refining and fine-tuning their diagnostic instruments. In particular, all these developments aim at increasing the negative predictive value of FNA to improve the selection of patients for diagnostic surgery. These advances involve terminology, the application of next-generation sequencing to thyroid FNA, the use of immunocyto- and histo-chemistry, the development of new sampling techniques and the increasing use of nuclear medicine as well as molecular imaging in the management of patients with a thyroid nodule. Herein, we review the recent advances in thyroid FNA cytology that could be of interest to the 'thyroid-care' community, with particular focus on the indeterminate diagnostic category.

Molecular imaging with (99m)Tc-MIBI and molecular testing for mutations in differentiating benign from malignant follicular neoplasm: a prospective comparison

PURPOSE

To compare mutation analysis of cytology specimens and (99m)Tc-MIBI thyroid scintigraphy for differentiating benign from malignant thyroid nodules in patients with a cytological reading of follicular neoplasm.

METHODS

Patients ≥18 years of age with a solitary hypofunctioning thyroid nodule (≥10 mm), normal thyrotropin and calcitonin levels, and a cytological diagnosis of follicular neoplasm were prospectively enrolled. Mutation analysis and (99m)Tc-MIBI scintigraphy were performed and patients were subsequently operated on to confirm or exclude a malignant lesion. Mutations for KRAS, HRAS and NRAS and for BRAF and translocations of PAX8/PPARγ, RET/PTC1 and RET/PTC3 were investigated. Static thyroid scintigraphic images were acquired 10 and 60 min after intravenous injection of 200 MBq of (99m)Tc-MIBI and visually assessed. Additionally, the MIBI washout index was calculated using a semiquantitative method.

RESULTS

In our series, 26 % of nodules with a follicular pattern on cytology were malignant with a prevalence of follicular carcinomas. (99m)Tc-MIBI scintigraphy was found to be significantly more accurate (positive likelihood ratio 4.56 for visual assessment and 12.35 for semiquantitative assessment) than mutation analysis (positive likelihood ratio 1.74). A negative (99m)Tc-MIBI scan reliably excluded malignancy.

CONCLUSION

In patients with a thyroid nodule cytologically diagnosed as a follicular proliferation, semiquantitative analysis of (99m)Tc-MIBI scintigraphy should be the preferred method for differentiating benign from malignant nodules. It is superior to molecular testing for the presence of differentiated thyroid cancer-associated mutations in fine-needle aspiration cytology sample material.

A cost analysis of thyroid core needle biopsy vs. diagnostic surgery

BACKGROUND

Twenty percent of thyroid fine needle aspiration (FNA) is indeterminate. Because 3 in 4 of these are actually benign, a method of clarifying the pathology could help patients to avoid diagnostic thyroidectomy. Recently, core needle biopsy (CNB) has been proven to be highly reliable for this purpose. However, there are no reports of any potential cost benefit provided by CNB. Here we analyzed the impact on management costs of CNB compared with traditional diagnostic surgery in indeterminate FNA.

METHODS

Over 24 months, 198 patients with thyroid indeterminate cytology underwent CNB at Ospedale Israelitico of Rome or diagnostic surgery at the Department of Surgery of Sapienza University of Rome. We tabulated costs of the medical instruments, operating theater, surgical team, patient recovery, and pathologic examination for each method.

RESULTS

In CNB group, 42.4% of patients had benign lesions and avoided surgery, 20.8% was cancer, and the remaining 36.8% uncertain. The malignancy rate in CNB group was 26.4%, and mean cost of CNB per nodule was 1,032€. In diagnostic surgery group, 24.7% had cancer and 75.3% had benign lesions, and mean expense for each thyroidectomy was 6,364€. In an ideal cohort of 100 patients with indeterminate FNA, the cost of CNB is 33.8% lower than that of diagnostic surgery.

CONCLUSIONS

CNB can detect a large proportion of the benign thyroid nodules that are classified as indeterminate by FNA. These patients can avoid diagnostic thyroidectomy and hospitals can reduce their surgical costs by one-third.

Pathology Reporting of Thyroid Core Needle Biopsy: A Proposal of the Korean Endocrine Pathology Thyroid Core Needle Biopsy Study Group

In recent years throughout Korea, the use of ultrasound-guided core needle biopsy (CNB) has become common for the preoperative diagnosis of thyroid nodules. However, there is no consensus on the pathology reporting system for thyroid CNB. The Korean Endocrine Pathology Thyroid Core Needle Biopsy Study Group held a conference on thyroid CNB pathology and developed guidelines through contributions from the participants. This article discusses the outcome of the discussions that led to a consensus on the pathology reporting of thyroid CNB.