Neck lump clinics: is on-site assessment of fine needle aspirate diagnostic adequacy cost-effective?

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.

Ultrasound-Guided Fine-Needle Aspiration With Optional Core Needle Biopsy of Head and Neck Lymph Nodes and Masses: Comparison of Diagnostic Performance in Treated Squamous Cell Cancer Versus All Other Lesions

OBJECTIVES

To evaluate the diagnostic performance of ultrasound (US)-guided fine-needle aspiration with optional core needle biopsy of head and neck lymph nodes and masses, with attention to differences between biopsy of treated squamous cell carcinoma (SCC) and biopsy of other lesions.

METHODS

Institutional Review Board approval was obtained, and the need for consent was waived for this retrospective study. All 861 US-guided biopsies of head and neck lymph nodes and masses performed between March 1, 2012, and May 16, 2016, were reviewed.

RESULTS

Of the 861 biopsies, 53 targeted SCC with residual masses after treatment. The biopsy procedures yielded benign or malignant pathologic results in 71.7% (38 of 53) of treated SCC and 90.7% (733 of 808) of all other lesions (P < .001). A reference standard based on subsequent pathologic results or clinical and imaging follow-up was established in 68.4% of procedures. In cases with benign or malignant biopsy results and a subsequent reference standard, the sensitivity values for malignancy were 87.5% (95% confidence interval, 64.0%-96.5%) in treated SCC and 98.3% (95% confidence interval, 96.0%-99.3%) in all other cases (P = .047), and the specificity values were 63.6% (95% confidence interval, 35.4%-84.8%) in treated SCC and 99.5% (95% confidence interval, 97.3%-99.9%) in all other cases (P < .001). There were no major complications related to the biopsy procedures.

CONCLUSIONS

Excluding treated SCC, US-guided fine-needle aspiration with optional core needle biopsy of head and neck lymph nodes and masses has excellent diagnostic performance. Needle biopsy of head and neck SCC with a residual mass after therapy has a high rate of nondiagnostic samples, suboptimal sensitivity, and poor specificity.

When Is Rapid On-Site Evaluation Cost-Effective for Fine-Needle Aspiration Biopsy?

Background

Rapid on-site evaluation (ROSE) can improve adequacy rates of fine-needle aspiration biopsy (FNAB) but increases operational costs. The performance of ROSE relative to fixed sampling depends on many factors. It is not clear when ROSE is less costly than sampling with a fixed number of needle passes. The objective of this study was to determine the conditions under which ROSE is less costly than fixed sampling.

Methods

Cost comparison of sampling with and without ROSE using mathematical modeling. Models were based on a societal perspective and used a mechanistic, micro-costing approach. Sampling policies (ROSE, fixed) were compared using the difference in total expected costs per case. Scenarios were based on procedure complexity (palpation-guided or image-guided), adequacy rates (low, high) and sampling protocols (stopping criteria for ROSE and fixed sampling). One-way, probabilistic, and scenario-based sensitivity analysis was performed to determine which variables had the greatest influence on the cost difference.

Results

ROSE is favored relative to fixed sampling under the following conditions: (1) the cytologist is accurate, (2) the total variable cost ($/hr) is low, (3) fixed costs ($/procedure) are high, (4) the setup time is long, (5) the time between needle passes for ROSE is low, (6) when the per-pass adequacy rate is low, and (7) ROSE stops after observing one adequate sample. The model is most sensitive to variation in the fixed cost, the per-pass adequacy rate, and the time per needle pass with ROSE.

Conclusions

Mathematical modeling can be used to predict the difference in cost between sampling with and without ROSE.

Routine non-thyroid head and neck cytology in a large UK centre: clinical utility and pitfalls

Objective:

This study aimed to examine the performance of head and neck cytology at Nottingham University Hospitals between 2009 and 2010.

Methods:

Cases were extracted from the Winpath pathology reporting system and correlations were investigated between results and the histological and clinical outcomes. Specimen adequacy and the sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy of the cytology tests were calculated.

Results:

In all, 19.7 per cent of aspirates were judged to be inadequate. The absolute and relative sensitivities of head and neck cytology were 87.0 per cent and 89.0 per cent, respectively, and the absolute and relative specificities were 99.0 per cent and 97.0 per cent, respectively. The positive predictive values were 99.0 per cent and 96.0 per cent and the negative predictive values were 92.0 per cent and 92.0 per cent for a diagnostic accuracy of 94.5 per cent and 93.0 per cent. The performance was consistent with previous reports and superior to that of a recent UK series. The high rate of inadequate samples is, however, a concern.

Conclusion:

Head and neck cytology is a robust technique at our institution, although there are certain problem areas. There is room for improvement in the technical quality of fine needle aspiration.