US-guided core-needle biopsy of the thyroid gland

Assessing Adequacy: A Meta-Analysis of Rapid Onsite Evaluation of Thyroid Nodules

INTRODUCTION

Fine-needle aspiration (FNA) is the standard form of preoperative evaluation of thyroid nodule cytological status. A significant number FNAs are classified as inadequate for interpretation, requiring a repeat FNA which is potentially avoidable, costly, and delays treatment. To address these concerns and maximize first-time FNA adequacy, rapid onsite evaluation (ROSE) of FNA specimens was introduced. Our study aims to determine the impact of ROSE on FNA adequacy.

METHODS

PubMed, Embase, and Web of Science were searched for primary articles assessing the adequacy of ROSE in thyroid nodules.

RESULTS

A total of 17 studies were included for a total of 24,649 thyroid nodes. Thirteen thousand two hundred fifteen (53.6%) thyroid nodules were assessed utilizing ROSE and 11,434 (46.4%) were not. Pooled adequacy increased significantly from 76% without ROSE to 92% with rose (P = 0.001). Use of ROSE increased the odds of adequate FNA by 22% (risk ratio (RR) = 1.22, 95% confidence interval (CI) = 1.12-1.32). At institutions with less than 85% effective diagnostic adequacy without ROSE, the risk for diagnostic adequacy increased by 28% with ROSE implementation (RR = 1.28, 95% CI = 1.20-1.37). In contrast, in studies reported from institutions with an effective diagnostic rate greater than 85% without the use of ROSE, the diagnostic adequacy only increased by 5% with ROSE implementation (RR = 1.05, 95% CI = 1.03-1.06).

CONCLUSIONS

The use of ROSE during first-time FNA of thyroid nodules can significantly improve adequacy, especially at institutions with baseline high inadequacy rates. Implementation of ROSE can reduce repeat FNAs and its associated consequences.

The Diagnostic Role of Repeated Biopsy of Thyroid Nodules with Atypia of Undetermined Significance with Architectural Atypia on Core-Needle Biopsy

BACKGRUOUND

We aimed to evaluate the utility of repeat biopsy of thyroid nodules classified as atypia of undetermined significance with architectural atypia (IIIB) on core-needle biopsy (CNB).

METHODS

This retrospective study evaluated patients with thyroid nodules categorized as IIIB on CNB between 2013 and 2015. Demographic characteristics, subsequent biopsy results, and ultrasound (US) images were evaluated. The malignancy rates of nodules according to number of CNBs and the number of IIIB diagnoses was compared. Demographic and US features were evaluated to determine factors predictive of malignancy.

RESULTS

Of 1,003 IIIB nodules on CNB, the final diagnosis was determined for 328 (32.7%) nodules, with 121 of them confirmed as malignant, resulting in a malignancy rate of 36.9% (95% confidence interval, 31.7% to 42.1%). Repeat CNB was performed in 248 nodules (24.7%), with 75 (30.2%), 131 (52.8%), 13 (5.2%), 26 (10.5%), one (0.4%), and two (0.8%) reclassified into categories II, IIIB, IIIA, IV, V, and VI, respectively. Malignancy rates were not significantly affected by the number of CNBs (P=0.291) or the number of IIIB diagnoses (P=0.473). None of the nodules confirmed as category II on repeat CNB was malignant. US features significantly associated with malignancy (P<0.003) included solid composition, irregular margins, microcalcifications, and high suspicion on the US risk stratification system.

CONCLUSION

Repeat biopsy of nodules diagnosed with IIIB on CNB did not increase the detection of malignancy but can potentially reduce unnecessary surgery. Repeat biopsy should be performed selectively, with US features guiding the choice between repeat biopsy and diagnostic surgery.

Usefulness of ultrasound-guided core biopsy in thyroid nodules with inconclusive fine-needle aspiration biopsy findings

OBJECTIVES

To determine the diagnostic performance of ultrasound-guided core-needle biopsy in thyroid nodules after two inconclusive fine-needle aspiration biopsies. To assess the complications of core-needle biopsy. To analyze the reliability of diagnoses obtained with core-needle biopsy. To measure the economic impact of avoiding lobectomies in patients with benign core-needle biopsy findings.

MATERIAL AND METHODS

This retrospective study reviewed 195 core-needle biopsies in 178 patients. To determine the reliability of the core-needle biopsy findings, we compared the diagnosis from the core-needle specimen versus the histologic findings in the surgical specimens when core-needle biopsy findings indicated malignancy or follicular proliferation and versus the stability of the nodule on ultrasound follow-up for one year when core-biopsy findings indicated benignity.

RESULTS

Core-needle biopsy yielded a diagnosis for 179 (91.7%) nodules, of which 122 (62.5%) were classified as benign, 50 (25.6%) as follicular proliferation, and 7 (3.6%) as malignant. The findings were inconclusive for 16 (8.3%) nodules. Minor complications were observed in 4 (2%) patients; no major complications were observed. The sensitivity of core-needle biopsy for the diagnosis of thyroid cancer was low (42.8%) because the technique was unable to detect capsular or vascular invasion, although the specificity and positive predictive value (PPV) were 100%. However, when we considered histologic findings of malignancy and follicular proliferation positive because both require surgical resection, the sensitivity increased to 97.5% and the PPV decreased to 83.3%. There were 79 nodules with ultrasound follow-up for at least one year; 76 (96.2%) had negative core-needle biopsy findings, and 74 (97.3%) of these remained stable. The negative predictive value (NPV) for malignancy of the benign nodules was 98.6%, although no malignant transformation was observed. Nevertheless, the results of the statistical analysis do not allow us to recommend forgoing ultrasound follow-up in patients with benign core-biopsy findings. The cost savings of avoiding lobectomy in patients with benign nodules and stability of the nodule on ultrasound follow-up for at least one year was about 90%.

CONCLUSIONS

Core-needle biopsy of thyroid nodules is effective because it diagnoses more than 90% of nodules with inconclusive findings after fine-needle aspiration biopsy. It is safe if done by experienced professionals. It is reliable because it yields 100% specificity and 100% PPV for malignant nodule, 97.5% sensitivity for the detection of nodules that require surgery, and 98.6% NPV for benign nodules. It is efficient because it reduces the costs of diagnosis compared to lobectomy in benign nodules.

Diagnostic efficacy, performance and safety of side-cut core needle biopsy for thyroid nodules: comparison of automated and semi-automated biopsy needles

PURPOSE

This study was performed to compare the utility of the semi-automated and automated side-cut core biopsy needles for thyroid nodules.

METHODS

Between January 2014 and March 2020, biopsy was performed for 278 thyroid nodules using the semi-automated core needle and for 225 nodules using the automated core needle. Nondiagnostic rate, inconclusive rate, diagnostic performance and complication rates were evaluated and compared between two core needle types.

RESULTS

There were 1.2% (6/503) nondiagnostic results and 15.9% (80/503) inconclusive results. Nondiagnostic rate between two needle types was not significantly different. The semi-automated type (33/278, 11.9%) showed lower inconclusive rate than the automated type (47/225, 20.9%) (p = 0.006). The sensitivity, specificity, PPV, NPV and diagnostic accuracy for diagnosis of malignancy of the semi-automated type were 70.18, 100, 100, 84.96 and 88.89%, respectively; the corresponding rates of automated type were 70.45, 100, 100, 86.6, and 89.84%. There were 12 minor complications: four hematomas (4/278, 1.4%) for the semi-automated type and eight hematomas (8/225, 3.6%) for the automated type, which difference was not statistically significant.

CONCLUSION

Core needle biopsy for thyroid nodules using either the semi-automated or automated needle is a safe diagnostic tool. Semi-automated needle has lower inconclusive rate than automated needle.

Core Needle Biopsy Can Early and Precisely Identify Large Thyroid Masses

Background

Large thyroid masses, particularly if rapidly growing, are often characterized by compression and infiltration of the vital structures of the neck. Therefore, an early and precise diagnosis, not only of malignancy but also of histotype, is mandatory to set up the right therapy. The aim of this study was to evaluate the diagnostic performance of fine needle aspiration cytology (FNAC) and core needle biopsy (CNB) in this setting.

Patients and Methods

We prospectively evaluated 95 patients with large and rapidly growing thyroid masses admitted to the University Hospital of Pisa between April 2014 and January 2020. All patients were submitted to FNAC and CNB in the same session. The ability of both procedures to diagnose the malignancy of the lesions, particularly the histotype, and to obtain sufficient material to perform molecular analysis was evaluated.

Results

FNAC obtained adequate tumor sample to reach a diagnosis in 76 of 95 (80%) patients, while a higher percentage was obtained with CNB (92/95, 96.8%). FNAC was able to identify the malignancy of the lesion in 74 of 95 (77.9%) cases, but only in 16 of 74 (21.6%) cases was it able to define the histotype. CNB was able to define the malignancy of the lesion in all but three cases (92/95, 96.8%), and in all specimens, the histotype was identified. Moreover, in all cases, the material extracted from CNB was optimal to perform molecular analysis. No surgery-related complications were experienced with both procedures.

Conclusions

CNB is a rapid and safe procedure with higher performance compared to FNAC in identifying the histotype of large and rapidly growing thyroid masses. Moreover, adequate material can be obtained to characterize the molecular profile for the treatment of potentially lethal cancers. In the era of precision medicine, CNB should be introduced in routine clinical practice as a key procedure for an early diagnosis and therapy of these diseases.

Thyroid diagnostic modalities (fine needle aspiration and core needle biopsy) with histology correlation: a tertiary centre experience

AIMS

To determine the proportion of thyroid fine needle aspiration (FNA) and core needle biopsy (CNB) cases reported at a single institute into each UK Royal College of Pathologists (RCPath) Thy1-5 and local T category, respectively. Where subsequent histology was available, malignancy rates, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy were compared for both procedures.

METHODS

1591 FNAs (2010-2018) and 514 CNBs (2013-2018) cases were identified, together with paired histology excision specimens.

RESULTS

The FNA samples were classified as: Thy1: 45.3%, Thy2/Thy2c: 22.1%, Thy3a/Thy3f: 28%, Thy4: 1.6% and Thy5: 3%; while the CNB were classified as: T1: 7.2%, T2: 22.4%, T3 59.3%, T4: 1% and T5: 10.1%. Comparison of FNA and CNB classified as Thy5/T5 showed a 100% risk of malignancy (ROM), sensitivity (98% vs 100%), specificity (14.1% vs 12.1%), PPV (29.4% vs 29.4%), NPV (94.9% vs 100%) and accuracy (36.5% vs 35.6%), respectively, for a diagnosis of malignancy. ROMs for other categories were: Thy1/T1 (9% vs 6.7%), Thy2/T2 (5.1% vs 0%), Thy3/T3 (17.5% vs 18.4%) and Thy4/T4 (73.3% vs 100%).

CONCLUSIONS

The proportion of cases in each RCPath Thy category has remained relatively stable during the 9-year study period, with the exception of the Thy3a category, which has increased over time. This finding is in line with other more recent reports in the literature and the proportion of T3 cases in the CNB group. The proportion of Thy2/Thy2c cases has also reduced over time, reflecting a local change in the triaging protocol for probable benign lesions. Both FNA and CNB showed comparable performance in our study.

The importance of using fine-needle aspiration cytology in the diagnosis of thyroid nodules

Background

Thyroid nodules are common diseases, frequent in middle-aged women; only 5%–30% are malignant. Fine needle aspiration cytology is a simple, rapid and non invasive diagnostic test, performed to predict malignancy and avoid unnecessary surgery.

The aim of this study is to evaluate the accuracy of fine needle aspiration in the management of thyroid lesions.

Materials and methods

Our study was retrospective, including all cases of thyroid fine needle aspiration between January 2010 and December 2017, which were verified by microscopic examination, Data was obtained from the files of Pathology and ENT Department of Farhat Hached Hospital of Sousse and from nuclear medicine department of Sahloul Hospital of Sousse, Tunisia.

Results

A total of 58 cases were studied, the main age was 40 ± 15,57 years and the sex ratio was 0.03 with female predominance. Concordance between fine needle aspiration and histology was seen in 45 cases. The sensitivity was 60% and the specificity was 100%. The negative and positive predictive values were 100 and 92%, respectively. The concordance index Kappa was of 0.67.

Conclusion

Thyroid fine needle aspiration in experienced hands is an easily performed diagnostic procedure with very little associated risk. It should be performed in suspect nodules for treatment stratification.

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The thyroid nodules are a frequent disease.

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We present a serie case of 58 thyroid nodules to enhance the importance of using of fine needle cytology to predict malignancy and avoid unnecessary surgery.

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We describe clinical, gross and microscopic examinations for diagnosis and treatment.

Comparison of core-needle biopsy and repeat fine-needle aspiration for thyroid nodules with inconclusive initial cytology

PURPOSE

We aimed to compare the efficacy of ultrasound-guided core-needle biopsy (CNB) with repeat fine-needle aspiration (rFNA) cytology in thyroid nodules with inconclusive results in initial fine-needle aspiration cytology.

METHODS

We studied 402 patients who required a repeat biopsy of thyroid nodules using ultrasound-guided CNB (n = 192) or rFNA (n = 210) because of inconclusive results in initial FNA, corresponding to categories I, III, and IV of the Bethesda System for Reporting Thyroid Cytopathology. If repeat biopsy results were benign (category II), suspicious malignancy (category V), or malignancy (category VI), they were defined as "diagnostic results". The diagnostic yield and performances of repeat biopsy were analyzed and compared between the rFNA and CNB groups.

RESULTS

The diagnostic results were obtained significantly higher in the CNB group than in the rFNA group (72.4% vs. 52.4%; P < 0.001). In the subgroup analysis, the diagnostic results were significantly higher in the CNB group than in the rFNA group for patients of categories I and III (P < 0.001 in both) in initial FNA. However, in patients with category IV nodules, there were no significant differences in diagnostic results between the two groups (P = 0.46).

CONCLUSION

Compared to rFNA, ultrasound-guided CNB is useful and effective as a repeat biopsy option for thyroid nodules with non-diagnostic results (category I) and atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) (category III) in initial FNA.

Usefulness of ultrasound-guided core biopsy in thyroid nodules with inconclusive fine-needle aspiration biopsy findings

OBJECTIVES

To determine the diagnostic performance of ultrasound-guided core-needle biopsy in thyroid nodules after two inconclusive fine-needle aspiration biopsies. To assess the complications of core-needle biopsy. To analyze the reliability of diagnoses obtained with core-needle biopsy. To measure the economic impact of avoiding lobectomies in patients with benign core-needle biopsy findings.

MATERIAL AND METHODS

This retrospective study reviewed 195 core-needle biopsies in 178 patients. To determine the reliability of the core-needle biopsy findings, we compared the diagnosis from the core-needle specimen versus the histologic findings in the surgical specimens when core-needle biopsy findings indicated malignancy or follicular proliferation and versus the stability of the nodule on ultrasound follow-up for one year when core-biopsy findings indicated benignity.

RESULTS

Core-needle biopsy yielded a diagnosis for 179 (91.7%) nodules, of which 122 (62.5%) were classified as benign, 50 (25.6%) as follicular proliferation, and 7 (3.6%) as malignant. The findings were inconclusive for 16 (8.3%) nodules. Minor complications were observed in 4 (2%) patients; no major complications were observed. The sensitivity of core-needle biopsy for the diagnosis of thyroid cancer was low (42.8%) because the technique was unable to detect capsular or vascular invasion, although the specificity and positive predictive value (PPV) were 100%. However, when we considered histologic findings of malignancy and follicular proliferation positive because both require surgical resection, the sensitivity increased to 97.5% and the PPV decreased to 83.3%. There were 79 nodules with ultrasound follow-up for at least one year; 76 (96.2%) had negative core-needle biopsy findings, and 74 (97.3%) of these remained stable. The negative predictive value (NPV) for malignancy of the benign nodules was 98.6%, although no malignant transformation was observed. Nevertheless, the results of the statistical analysis do not allow us to recommend forgoing ultrasound follow-up in patients with benign core-biopsy findings. The cost savings of avoiding lobectomy in patients with benign nodules and stability of the nodule on ultrasound follow-up for at least one year was about 90%.

CONCLUSIONS

Core-needle biopsy of thyroid nodules is effective because it diagnoses more than 90% of nodules with inconclusive findings after fine-needle aspiration biopsy. It is safe if done by experienced professionals. It is reliable because it yields 100% specificity and 100% PPV for malignant nodule, 97.5% sensitivity for the detection of nodules that require surgery, and 98.6% NPV for benign nodules. It is efficient because it reduces the costs of diagnosis compared to lobectomy in benign nodules.

Degenerating Thyroid Nodules: Ultrasound Diagnosis, Clinical Significance, and Management

Degenerating nodules (DNs), which primarily manifest as benign thyroid nodules, are one of the main causes of discordance in ultrasonography (US) and cytological assessments. Intranodular hemorrhage is one of the mechanisms contributing to discordant nodules, and an impaired blood supply may explain further DN shrinkage and infarction. The surgical specimens can be divided into acute and chronic stages based on the histological changes, which usually mimic the US features of malignant tumors. Serial US follow-up should be recommended instead of other unnecessary procedures. However, repeated fine-needle aspiration, diagnostic surgery, or core-needle biopsy may still be necessary for indeterminable or highly suspicious DNs.

Nerve Injury During Ultrasound-Guided Thyroid Biopsy-A First Reported Complication of Permanent Vocal Fold Paralysis

Needle biopsy is a well-established component in the evaluation of thyroid nodules. The biopsy is usually performed with an ultrasound guidance and consists of either fine-needle aspiration or core needle biopsy. Although these terms are often used interchangeably, their difference is important. To our knowledge, we discuss the first reported case of biopsy-proven laryngeal nerve injury and permanent vocal fold paralysis following ultrasound-guided core biopsy of the thyroid. We advocate this complication be discussed as part of the consent process.

2019 Practice guidelines for thyroid core needle biopsy: a report of the Clinical Practice Guidelines Development Committee of the Korean Thyroid Association

Ultrasound-guided core needle biopsy (CNB) has been increasingly used for the pre-operative diagnosis of thyroid nodules. Since the Korean Society of the Thyroid Radiology published the ‘Consensus Statement and Recommendations for Thyroid CNB’ in 2017 and the Korean Endocrine Pathology Thyroid CNB Study Group published ‘Pathology Reporting of Thyroid Core Needle Biopsy’ in 2015, advances have occurred rapidly not only in the management guidelines for thyroid nodules but also in the diagnostic terminology and classification schemes. The Clinical Practice Guidelines Development Committee of the Korean Thyroid Association (KTA) reviewed publications on thyroid CNB from 1995 to September 2019 and updated the recommendations and statements for the diagnosis and management of thyroid nodules using CNB. Recommendations for the resolution of clinical controversies regarding the use of CNB were based on expert opinion. These practical guidelines include recommendations and statements regarding indications for CNB, patient preparation, CNB technique, biopsy-related complications, biopsy specimen preparation and processing, and pathology interpretation and reporting of thyroid CNB.

Thyroid core needle biopsy: patients' pain and satisfaction compared to fine needle aspiration

PURPOSE

The purpose of this study was to compare patients' pain and satisfaction of fine needle aspiration (FNA) and core needle biopsy (CNB) for a thyroid nodule.

METHODS

We consecutively enrolled patients with thyroid nodules who underwent ultrasound-guided FNA or CNB in our institution. The patients answered a questionnaire about pain scores during the procedure, immediately after the procedure and 20 min after the procedure, and any complication after the biopsy. Through a phone interview which was conducted 2 weeks after the procedure, a researcher asked the patients about residual pain and overall subjective satisfaction score about the procedures. Patients were also asked to report any complication or complaint after the procedures on the phone interview.

RESULTS

The 167 patients who had undergone thyroid FNA (n = 87) or CNB (n = 80) were included. The pain scores were not significantly different between the two groups during the procedure and after the procedure. Overall satisfaction scores after 2 weeks were not different, either. There was no acute or delayed major complication in both groups.

CONCLUSIONS

Differences regarding patients' pain and satisfaction scores between CNB and FNA were not demonstrated.

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.

Ultrasound-guided needle biopsy of large thyroid nodules: Core needle biopsy yields more reliable results than fine needle aspiration

PURPOSE

The objective of this study was to compare the false negative rate, sensitivity and false positive rate of ultrasound (US)-guided fine needle aspiration (FNA) with those of US-guided core needle biopsy (CNB) for large thyroid nodules ≥2.0 cm, which reportedly have an increased risk of thyroid malignancy.

METHODS

We retrospectively studied surgically confirmed thyroid nodules that had preoperative US-guided FNA or CNB between March 2005 and December 2013. We reviewed nodule size, sonographic features, cytohistologic results, and final surgical pathology. We assessed false negative rates, sensitivity, and false positive rates by biopsy method and nodule size for diagnosis of thyroid malignancy. We assessed complications for procedures.

RESULTS

US-guided CNB showed better diagnostic performance, in terms of lower false negative rates and greater sensitivity, than US-guided FNA in large thyroid nodules. There was no significant difference in false positive rate according to biopsy methods in large thyroid nodules. The false negative rates of large thyroid nodules (≥2.0 cm) were higher than those of small nodules (<2.0 cm). There were no major complications, and no significant differences in complication according to biopsy methods.

CONCLUSION

US-guided CNB improved the false negative rate and sensitivity for large nodules. Therefore, US-guided CNB can be considered a useful diagnostic method for large thyroid nodules that might reduce the risk of unnecessary diagnostic surgery.

The Role of Core Needle Biopsy for the Evaluation of Thyroid Nodules with Suspicious Ultrasound Features

Objective

Recent studies demonstrated that core needle biopsy (CNB) can effectively reduce the possibility of inconclusive results and prevent unnecessary diagnostic surgery. However, the effectiveness of CNB in patients with suspicious thyroid nodules has not been fully evaluated. This prospective study aimed to determine the potential of CNB to assess thyroid nodules with suspicious ultrasound (US) features.

Materials and Methods

Patients undergoing CNB for thyroid nodules with suspicious features on US were enrolled between May and August 2016. Diagnostic performance and the incidence of non-diagnostic results, inconclusive results, conclusive results, malignancy, unnecessary surgery, and complications were analyzed. Subgroup analysis according to nodule size was performed. The risk factors associated with inconclusive results were evaluated using multivariate logistic regression analysis.

Results

A total of 93 patients (102 thyroid nodules) were evaluated. All samples obtained from CNB were adequate for diagnosis. Inconclusive results were seen in 12.7% of cases. The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for diagnosis of malignancy were 93.8%, 100%, 100%, 78.9%, and 95%, respectively. None of the patients underwent unnecessary surgery. The diagnostic performance was not significantly different according to nodule size. On multivariate logistic regression analysis, larger nodule size and shorter needle length were independent risk factors associated with inconclusive results.

Conclusion

Samples obtained by CNB were sufficient for diagnosis in all cases and resulted in high diagnostic values and conclusive results in the evaluation of suspicious thyroid nodules. These findings indicated that CNB is a promising diagnostic tool for suspicious thyroid nodules.

Comparison of the Diagnostic Efficacy of Ultrasound-Guided Core Needle Biopsy With 18- Versus 20-Gauge Needles for Thyroid Nodules

OBJECTIVES

To compare the diagnostic efficacy, complication rate, and core needle biopsy (CNB) specimen yield in 18- versus 20-gauge ultrasound (US)-guided CNB for diagnosis of thyroid nodules.

METHODS

We included 81 consecutive thyroid nodules with US-guided biopsy by a 20-gauge core needle and 86 consecutive thyroid nodules with US-guided biopsy by an 18-gauge core needle during 2 years. The rate of inconclusive results, including nondiagnostic or atypia/follicular lesion of undetermined significance, was compared. The diagnostic performance for malignancy was assessed in nodules with a final diagnosis. The complication rate and CNB specimen yield were also compared.

RESULTS

Eighteen-gauge CNB showed a lower rate of nondiagnostic results (1.2% versus 8.6%; P = .024) than 20-gauge CNB; however, the rates of atypia/follicular lesion of undetermined significance and inconclusive results were not significantly different between the groups (P > .05). In addition, 18-gauge CNB showed higher sensitivity (75.0% versus 66.7%), a higher negative predictive value (83.9% versus 75.9%), and higher accuracy (78.3% versus 74.4%) for detecting malignancy than 20-gauge CNB, although the results did not achieve statistical significance. No major complications occurred in either of the CNB groups. The 18-gauge needle group had significantly fewer CNBs and larger specimen diameters (P < .001).

CONCLUSIONS

Core needle biopsy with an 18-gauge needle could be more effective for the diagnosis of thyroid nodules than CNB with a 20-gauge needle.

A Comparison of Ultrasound-Guided Fine Needle Aspiration versus Core Needle Biopsy for Thyroid Nodules: Pain, Tolerability, and Complications

BACKGROUND

To compare pain, tolerability, and complications associated with fine needle aspiration (FNA) versus core needle biopsy (CNB).

METHODS

FNAs were performed using 23-gauge needles and CNBs were performed using 18-gauge double-action spring-activated needles in 100 patients for each procedure. Patients were asked to record a pain score using a 10-cm visual analog scale and procedure tolerability. Complications and number of biopsies were recorded.

RESULTS

The median pain scores were similar for the FNA and CNB approaches during and 20 minutes after the biopsy procedures (3.7 vs. 3.6, P=0.454; 0.9 vs. 1.1, P=0.296, respectively). The procedure was tolerable in all 100 FNA patients and in 97 CNB patients (P=0.246). The mean number of biopsies was fewer in the CNB group (1.4 vs. 1.2, P=0.002). By subgroup analysis (staff vs. non-staff), no significant difference was detected in any parameter. There were no major complications in either group, but three patients who underwent CNB had minor complications (P=0.246).

CONCLUSION

FNA and CNB show no significant differences for diagnosing thyroid nodules in terms of pain, tolerability, or complications.

Statement and Recommendations on Interventional Ultrasound as a Thyroid Diagnostic and Treatment Procedure

The recently published guidelines of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) on interventional ultrasound (INVUS)-guided procedures summarize the intended interdisciplinary and multiprofessional approach. Herewith, we report on recommendations for interventional procedures for diagnosis and treatment of the thyroid gland.

US-Guided Percutaneous Radiofrequency versus Microwave Ablation for Benign Thyroid Nodules: A Prospective Multicenter Study

Compared with microwave ablation (MWA), percutaneous radiofrequency ablation (RFA) and laser ablation (LA) have been recommended as minimally invasive treatments for patients with symptomatic benign thyroid nodules (BTNs) because of the large number of clinical applications. This prospective multicenter study sought to evaluate the clinical outcomes of RFA and MWA for BTNs. In eight participating institutions, the total number of 1252 patients treated by RFA and MWA were 649 ones with 687 BTNs and 603 ones with 664 BTNs, respectively. The clinical outcomes including the nodular maximal diameter reduction ratio (MDRR), the nodular volume reduction ratio (VRR), and the incidence of complications were compared to evaluate the efficacy and safety of the two techniques. The results for the nodular MDRR and VRR in the RFA group were significantly better than those in the MWA group at 6 months and later follow-up, and the major complication rates of 4.78% and 6.63% in RFA and MWA groups showed no statistically significant differences. In conclusion, both RFA and MWA are safe and effective techniques for selected patients with symptomatic BTNs. The achieved MDRR and VRR in the RFA group were greater than those in the MWA group at 6 months and later follow-up.

Efficacy and safety of core-needle biopsy in initially detected thyroid nodules via propensity score analysis

We compared the efficacy and complications of core-needle biopsy (CNB) with those of fine-needle aspiration (FNA) in a large population of patients with initially detected thyroid nodules via a propensity score analysis. Outpatients with initially detected thyroid nodules, who had undergone CNB or FNA between January 2013 and December 2013, were selected. This study included 4,822 thyroid nodules from 4,553 consecutive patients. Adjustments for significant differences in patients’ baseline characteristics were facilitated via propensity score analysis. Subgroup analyses were performed according to nodule sizes ≥ 1 cm. The non-diagnostic result rate, malignancy rate, complication rate, and diagnostic accuracy were compared. A 1:1 matching of 1,615 patients yielded no significant differences between two groups for any covariate. The non-diagnostic result rate was significantly lower in the core-needle biopsy group than in the fine-needle aspiration group (5.2% vs. 12.1%), while the malignancy rate (23.7% vs. 11.8%) and sensitivity (75.9% vs. 55.6%) were significantly higher. However, the specificities were similar (100% and 99.9%, respectively). Propensity score and subgroup analyses showed similar results. The complication rate was similar between groups in matched cohorts. CNB is a promising and safe diagnostic tool for patients with initially detected thyroid nodules.

Ultrasound-Guided Core Needle Biopsy for Head and Neck Mass Lesions in Patients Undergoing Antiplatelet or Anticoagulation Therapy: A Preliminary Report

OBJECTIVES

We compared the complications and diagnostic adequacy of ultrasound (US)-guided core needle biopsy (CNB) for head and neck mass lesions between patients who did and did not receive antiplatelet/anticoagulation therapy.

METHODS

This study was designed as a prospective case study including 146 consecutive patients who underwent US-guided CNB for head and neck mass lesions. Of these, 32 patients were undergoing antiplatelet/anticoagulation therapy involving aspirin, clopidogrel, cilostazol, and warfarin.

RESULTS

None of the patients had clinical bleeding/hematoma in either group. Subclinical bleeding/hematoma recognized only by a US examination was not significantly different between the groups (P = .229). No other complications were noticed. The rate of unsatisfactory sampling was also not different between the groups (P > .999). Furthermore, when patients receiving aspirin (n = 18) were reclassified into the no-antiplatelet/anticoagulation therapy group, there was still no significant difference in the incidences of complications compared with the patients receiving clopidogrel, cilostazol, or warfarin (n = 14).

CONCLUSIONS

Our study suggests that US-guided CNB is safe and provides good diagnostic results without necessitating the discontinuation of antiplatelet/anticoagulation therapy in patients with head and neck mass lesions. However, as this was a preliminary study, the cohort was relatively small. Larger studies are needed to confirm our findings.

Ultrasound-Pathology Discordant Nodules on Core-Needle Biopsy: Malignancy Risk and Management Strategy

BACKGROUND

The reported malignancy rates of thyroid nodules that appear suspicious on ultrasound (US) but yield benign fine-needle aspiration (FNA) cytology results range from 13.6% to 56.6%. However, the malignancy risk of nodules that are discordant on US and core-needle biopsy (CNB) pathological findings has not been evaluated. This study evaluated the malignancy risk associated with thyroid nodules that are suspicious on US but yield benign CNB results.

METHODS

Between July 2008 and November 2011, 1309 patients with 1313 thyroid nodules underwent US-guided CNB. Among these, 166 thyroid nodules that were suspicious on US but yielded benign CNB results were retrospectively reviewed. Benign nodules were diagnosed by surgery, FNA, and/or CNB that was repeated at least twice or CNB and lesion size stability on follow-up. The malignancy risk of US-pathology discordant nodules was calculated according to recommendations by Moon et al., and a further evaluation was conducted using four different US risk systems. Factors that differentiated benign from malignant nodules were assessed using the chi-square test or Fisher's exact test. Moreover, the histological findings of US-pathology discordant nodules were analyzed.

RESULTS

Patients with benign and malignant nodules did not differ significantly regarding clinical and demographic characteristics. Of the 166 US-pathology discordant nodules, seven (4.2%) were confirmed malignant. The malignancy risks associated with the five US risk systems ranged from 3.6% to 5.5%. Regarding suspicious US features, only the number of suspicious features was associated with malignancy (p = 0.002). Histological analysis of benign CNB specimens with suspicious US features revealed fibrosis (77.6%), thyroiditis (28.7%), calcifications (10.6%), and hemosiderin deposition (6.4%).

CONCLUSIONS

The malignancy risk among thyroid nodules with discordant US and CNB results ranged from 3.6% to 5.5%, depending on US risk systems. However, repeated biopsy may be necessary for selected thyroid nodules with more than two suspicious US features.

What Is the Ideal Core Number for Ultrasonography-Guided Thyroid Biopsy of Cytologically Inconclusive Nodules?

BACKGROUND AND PURPOSE

Core needle biopsy of the thyroid under ultrasonographic guidance provides a larger tissue sample and may facilitate a more precise histologic diagnosis, reducing the need for repetitive fine-needle aspiration or a diagnostic operation. However, there is no consensus regarding the ideal number of specimens to be obtained for ultrasonography-guided core needle biopsy. The aim of this study was to decide the ideal core number for ultrasonography-guided core needle biopsy of cytologically inconclusive nodules.

MATERIALS AND METHODS

Sixty consecutive biopsies were performed in 60 thyroid nodules with Bethesda Category I or III cytology. Three biopsy cores were obtained for each thyroid nodule. The first biopsy specimens were taken from the nodule, while the second and third specimens obtained included the nodular tissue, nodular capsule, and surrounding parenchyma. Diagnostic ability was evaluated according to the following: protocol A, first specimen; protocol B, first and second specimens; and protocol C, all specimens. The McNemar test was used for statistical analysis.

RESULTS

Of the 60 nodules, diagnostic ability was achieved in 41 nodules (68%) with protocol A, in 56 nodules (93%) with protocol B, and in 58 nodules (97%) with protocol C. The diagnostic ability of protocols B and C was significantly higher than that of protocol A (all P values < .001). However, the diagnostic ability of protocol B was not significantly different from that of protocol C.

CONCLUSIONS

Ultrasonography-guided core needle biopsy for cytologically inconclusive thyroid nodules should obtain at least 2 core specimens with intranodular and capsule targets.

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.

Follicular variant of papillary thyroid carcinoma: comparison of ultrasound-guided core needle biopsy and ultrasound-guided fine needle aspiration in a multicentre study

OBJECTIVE

Pre-operative diagnosis of the follicular variant of papillary thyroid carcinoma (FVPTC) by ultrasound-guided fine needle aspiration (US-FNA) remains a challenge. The goal of this study was to investigate whether ultrasound-guided core needle biopsy (US-CNB) is superior to US-FNA in refining the surgical indications for the treatment of FVPTC.

DESIGN

This retrospective study enrolled 212 patients with 218 FVPTCs who were surgically confirmed at three university hospitals from January 2008 through December 2014. All patients underwent both or either US-FNA or US-CNB. FNA and CNB results were divided into identified surgical candidates or not based on the Bethesda system. Relevant clinical information and the rate of surgical candidates were compared between US-FNA and US-CNB groups.

RESULTS

Among 218 thyroid nodules, US-FNA was performed for 200 nodules and US-CNB for 51 nodules. Thirty-three nodules underwent both US-FNA and US-CNB. The rates of surgical candidates identified by US-FNA and US-CNB were 61·5% and 86·3%, respectively (P = 0·001). The rates of surgical candidates identified by repeat US-FNA and initial US-FNA with subsequent US-CNB were 53·9% and 78·8%, respectively (P = 0·042). A precise diagnosis of FVPTC was made in 1% of the patients in the US-FNA group and in 29·4% of the patients in the US-CNB group. The predominant US findings of FVPTCs included solid tumours (89·4%), wider-than-tall shape (82·6%), no calcifications (51·3%), hypoechogenicity (46·3%) and indeterminate diagnosis on US (50·5%).

CONCLUSIONS

In patients with FVPTC, US-CNB is a superior indicator for surgery compared to US-FNA. If a FVPTC is suspected but is initially indeterminate at FNA cytology, subsequent US-CNB should be considered instead of repeat US-FNA.

First-Line Use of Core Needle Biopsy for High-Yield Preliminary Diagnosis of Thyroid Nodules

BACKGROUND AND PURPOSE

Although core needle biopsy was introduced as a diagnostic alternative to fine-needle aspiration, the utility and safety of core needle biopsy for thyroid nodules in a large population has yet to be studied comprehensively. We evaluate core needle biopsy yields on a large-scale basis to investigate its potential in the preliminary diagnosis of thyroid nodules.

MATERIALS AND METHODS

Between March 2005 and December 2013, 2448 initially detected thyroid nodules from 2120 consecutive patients who underwent core needle biopsy were retrospectively evaluated. Of these, 72 thyroid nodules from 63 patients were excluded due to prior fine-needle aspiration attempts. The inconclusive and conclusive result rates, diagnostic accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and unnecessary surgery rate of core needle biopsy were evaluated.

RESULTS

With core needle biopsy as the first-line method, the inconclusive result rate was 11.9% (283/2376) and the conclusive result rate was 88.1% (2093/2376). The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of core needle biopsy for the diagnosis of malignancy were 96.7% (1160/1200), 89.7% (347/387), 100% (813/813), 100% (347/347), and 95.3% (813/853), respectively. There were no major complications and 12 minor complications.

CONCLUSIONS

We have demonstrated that first-line use of core needle biopsy may well improve diagnostic accuracy in thyroid nodules, reducing inconclusive or false-negative results and unnecessary operations. Such benefits underscore the promising role of core needle biopsy in managing thyroid nodules and optimizing related surgical decision-making.

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.

Comparison of core-needle biopsy and fine-needle aspiration in screening for thyroid malignancy: a systematic review and meta-analysis

OBJECTIVE

Core-needle biopsy (C.N.B.) is a procedure that is usually performed after repeated non-diagnostic fine-needle aspiration (F.N.A.) or in combination with F.N.A. in the detection of thyroid malignancy. The purpose of this study was to: (1) compare the accuracy of C.N.B. and F.N.A. in the detection of thyroid malignancy; (2) evaluate the accuracy of C.N.B. in nodules with prior non-diagnostic F.N.A.

METHODS

Meta-analysis was performed with Comprehensive Meta-Analysis statistical software, version 2.0. A bivariate approach of hierarchical summary R.O.C. was performed using R software. Study quality was assessed with the Cochrane Risk of Bias Tool. Publication bias analysis was performed by funnel plot and Egger's test analysis.

RESULTS

The main results of our study are as follows. 1) Overall C.N.B. had fewer non-diagnostic results than F.N.A. (pooled O.R. = 4.93, 95% C.I.: 2.17-11.19). Pooled sensitivities and specificities of C.N.B. and F.N.A. did not differ significantly. (2) There was no significant difference in the rates of non-diagnostic results of first-line F.N.A. and C.N.B. (O.R. = 2.42, 95% C.I. 0.95-6.18). Pooled sensitivities and specificities did not differ significantly. C.N.B. yielded fewer non-diagnostic results compared to repeated F.N.A. (O.R. = 19.13, 95% C.I. 7.08-51.65) for thyroid cancers with prior non-diagnostic F.N.A.

RESULTS

The A.U.C.s of the hierarchical summary R.O.C. (H.S.R.O.C.) were 0.669 for repeated F.N.A. and 0.984 for C.N.B. with separated confidence regions for sensitivity and false positive rate.

CONCLUSION

C.N.B. has higher diagnostic accuracy than repeat F.N.A. for thyroid nodules with prior non-diagnostic F.N.A.

RESULTS

There is no significant difference in the diagnostic performance of C.N.B. and F.N.A. as first-line diagnostic tools.

Burkitt lymphoma presenting as a mass in the thyroid gland: a clinicopathologic study of 7 cases and review of the literature

Burkitt lymphoma presenting in the thyroid gland is rare, and only a few cases have been reported. We retrospectively reviewed 7 patients diagnosed with Burkitt lymphoma of the thyroid gland between 2000 and 2015. There were 4 men and 3 women with a median age of 41 years (range, 19-49 years). All patients presented with a rapidly growing neck mass associated with upper airway compression in 5 (71%) patients. Two patients presented with localized (stage I/II) and 5 patients with disseminated (stage III/IV) disease. All cases showed morphologic and immunophenotypic features of Burkitt lymphoma with MYC rearrangement in all 5 cases tested. One case showed evidence of concurrent Hashimoto thyroiditis. Six of 7 patients were treated primarily with rituximab, hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone. One patient was treated primarily with dose-adjusted rituximab, etoposide, prednisolone, vincristine, and cyclophosphamide. At the end of the study period, 5 patients were alive: 4 in complete remission and 1 with persistent disease. Two patients died with persistent disease (median follow-up, 25 months; range, 12-361 months). We conclude that Burkitt lymphoma of the thyroid gland shows clinicopathologic features similar to sporadic Burkitt lymphoma at other anatomic sites, but patients present at an older median age. The clinical course is aggressive with a high frequency of disseminated disease at diagnosis; however, a subset of patients responds well to aggressive chemotherapy.

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.

Initial clinical experience with BRAF(V600E) mutation analysis of core-needle biopsy specimens from thyroid nodules

OBJECTIVE

The accurate diagnosis of thyroid nodules is important for making management decisions. The purpose of this study was to evaluate the feasibility of core-needle biopsy with BRAF(V600E) mutation analysis (CNB + BRAF(V600E) ) and to compare the clinical usefulness of CNB + BRAF(V600E) and fine-needle aspiration with BRAF(V600E) mutation analysis (FNA + BRAF(V600E) ) in the diagnosis of thyroid malignancy.

DESIGN, PATIENTS AND MEASUREMENTS

The results of BRAF(V600E) mutation analyses of 820 nodules from 820 patients (153 men, 667 women; mean age, 51·1 years), who underwent CNB + BRAF(V600E) (n = 256) or FNA + BRAF(V600E) (n = 564) between January 2011 and March 2012 were retrospectively evaluated. The feasibility of CNB + BRAF(V600E) was assessed by comparing its rate of detection of BRAF(V600E) mutations and positive predictive value with those of FNA + BRAF(V600E) . The clinical usefulness of CNB + BRAF(V600E) was determined by comparing rates of inconclusive results, the additional value of BRAF(V600E) mutation analysis, diagnostic surgery and diagnostic performance with those of FNA + BRAF(V600E) .

RESULTS

CNB + BRAF(V600E) and FNA + BRAF(V600E) had similar rates of BRAF(V600E) mutation detection (66·3% vs 64·4%, P = 0·883) and positive predictive value (100·0% vs 96·6%, P = 0·135). CNB + BRAF(V600E) had a significantly higher diagnostic accuracy rate (95·7% vs 85·9%, P < 0·001), and significantly lower rates of inconclusive results (8·2% vs 51·8%, P < 0·001), and diagnostic surgery (8·9% vs 22·3%, P = 0·006), than FNA + BRAF(V600E) .

CONCLUSIONS

The greater diagnostic performance of CNB + BRAF(V600E) and its lower rate of inconclusive results than FNA + BRAF(V600E) suggest that CNB + BRAF(V600E) can reduce rates of preventable diagnostic surgery.

Malignant-looking thyroid nodules with size reduction: core needle biopsy results

Purpose

The aim of this study was to evaluate whether malignant-looking thyroid nodules with size reduction were malignant or not.

Methods

From November 2010 to July 2011, we retrospectively enrolled 16 patients with 16 nodules (11 females and five males; mean age, 55 years) who underwent core needle biopsy (CNB), and whose thyroid nodules had malignant ultrasonographic (US) features, although they showed size reduction (>20% decrease in maximum diameter) during the follow-up period (mean, 37±27 months). The histologic findings of the CNB specimen were reviewed and correlated with the US findings. US studies were analyzed for their internal content, shape, margin, echogenicity, the presence of microcalcification and macrocalcification, inner isoechoic rim, and low-echoic halo.

Results

All nodules were confirmed as benign by CNB. Pathologic analysis was available for 12 CNB specimens. US imaging showed central hypoechogenicity or marked hypoechogenicity in all cases and a peripheral isoechoic rim in 15 nodules. US-pathologic correlation showed that the central hypoechoic area was primarily composed of fibrosis (12/12) and hemorrhage (8/12) and that the isoechoic rim was composed of follicular cells.

Conclusion

In our study, the CNB results of all of the malignant-looking thyroid nodules with size reduction were benign and were primarily composed of internal fibrosis and hemorrhage. Understanding these US and pathologic features could prevent repeated fine-needle aspiration or unnecessary diagnostic surgery.

The Role of Core-Needle Biopsy as a First-Line Diagnostic Tool for Initially Detected Thyroid Nodules

BACKGROUND

The aim of this study was to evaluate the role of core-needle biopsy (CNB) as a first-line diagnostic tool for initially detected thyroid nodules.

METHODS

This observational study evaluated 632 initially detected thyroid nodules in 632 consecutive patients who underwent CNB between October 2008 and December 2011. CNB results were categorized into the six categories of the Bethesda System. A final diagnosis of malignancy was based on surgery or CNB, whereas a final diagnosis of benign nodules was based on surgery, two benign biopsy results, or benign cytology of stable size after one year. The rates of Bethesda category 1 and inconclusive results, diagnostic performance, unnecessary surgery, and complications were evaluated. Subgroup analysis based on nodule size was performed. Risk factors for inconclusive results were evaluated by multivariate logistic regression analysis.

RESULTS

The rates of Bethesda category 1 and inconclusive results by CNB were 1.3% and 5.9%, respectively. The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for the diagnosis of malignancy were 97.6%, 90.0%, 100%, 100%, and 92.3%, respectively. The rate of unnecessary surgery was 0.5%, and the complications rate was 0.2%. Based on subgroup analysis, the diagnostic performance was not significantly associated with nodule size. There were no independent risk factors associated with inconclusive results.

CONCLUSION

CNB showed low rates of Bethesda category 1 and inconclusive results and a high diagnostic accuracy. CNB also minimized unnecessary surgery. CNB seems to be a promising diagnostic tool for patients with initially detected thyroid nodules.

Diagnosis of Metastasis to the Thyroid Gland: Comparison of Core-Needle Biopsy and Fine-Needle Aspiration

OBJECTIVES

Early detection and diagnosis of metastasis to the thyroid gland is important. This study aims to evaluate the clinical value of core-needle biopsy (CNB) by comparing the results of CNB and fine-needle aspiration (FNA) in patients with clinically suspected metastasis to the thyroid gland.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary referral practice.

SUBJECTS

Fifty-two thyroid nodules from 52 patients with clinically suspected metastasis to the thyroid gland (mean age, 62.8 years).

METHODS

Of these 52 patients, FNA was initially used in 41 patients and CNB in 20 patients (11 patients as the initial approach and 9 patients after inconclusive FNA results). Ultrasound features of metastasis to the thyroid gland were evaluated. The diagnostic performance, repeated diagnostic examination rate, and diagnostic surgery rate were evaluated for FNA and CNB.

RESULTS

Among these 52 patients, 46 were diagnosed with thyroid metastases and 6 were diagnosed with primary thyroid cancer. Common ultrasound features were an ovoid to round shape (58.7%), ill-defined margin (56.5%), hypoechogenicity (65.2%), and no calcifications (87.0%). Core-needle biopsy achieved a significantly higher sensitivity than FNA (100.0% vs 58.6%, P = .008) without any false-negative results. Both the repeated diagnostic examination rate and the diagnostic surgery rate were significantly lower in CNB than in FNA (5.0% vs 46.3%, P = .001, and 5.0% vs 34.1%, P = .013, respectively).

CONCLUSIONS

In cases of known rare primary malignancy, nontypical ultrasound features of primary thyroid malignancy, and need for an additional immunohistochemical analysis, CNB may be primarily considered.

Modified Core Biopsy Technique to Increase Diagnostic Yields for Well-Circumscribed Indeterminate Thyroid Nodules: A Retrospective Analysis

BACKGROUND AND PURPOSE

The results of conventional core biopsy for some thyroid nodules with indeterminate cytology have still remained indeterminate. The aim of this study was to evaluate whether the ultrasonography-guided core needle biopsy technique containing the nodule, capsular portion, and surrounding parenchyma was more effective than a conventional method in enhancing diagnostic yield for circumscribed solid thyroid nodules without malignant sonographic features.

MATERIALS AND METHODS

This retrospective comparative study evaluated 26 thyroid nodules in 26 consecutive patients between 2006 and 2010. They were biopsied by using a conventional method, and 61 nodules from 60 patients were biopsied by using a modified ultrasonography-guided core needle biopsy technique in 2013. The patients enrolled in this study presented with circumscribed solid thyroid nodules without malignant sonographic features, classified as nondiagnostic or atypia/follicular lesions of undetermined significance at previous cytology. The ultrasonography-guided core needle biopsy results of the 2 groups were compared.

RESULTS

The rate of inconclusive ultrasonography-guided core needle biopsy results was 34.6% (9/26) in the conventional group and 11.4% (7/61) in the modified technique group (P = .018). There was no significant difference in the mean size of the nodules between the 2 groups (P = .134). The malignancy rate was 33% (3/9) for the conventional group and 52% (27/52) for the modified technique group (P = .473). The most common malignant pathology was a follicular variant of papillary thyroid carcinoma and follicular adenoma was the most common benign lesion.

CONCLUSIONS

For circumscribed solid nodules without malignant sonographic features with indeterminate cytology, the ultrasonography-guided core needle biopsy technique containing the nodule, capsular portion, and surrounding parenchyma is more effective in diagnostic yield compared with a conventional method that biopsies the intranodular portion.

THE ROLE OF CORE-NEEDLE BIOPSY FOR THYROID NODULES WITH INITIALLY NONDIAGNOSTIC FINE-NEEDLE ASPIRATION RESULTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

OBJECTIVE

This study evaluated the prevalence of nondiagnostic results, diagnostic performance, and complications of core-needle biopsy (CNB) compared with repeat fine-needle aspiration (FNA) for thyroid nodules with previous nondiagnostic FNA findings.

METHODS

The Ovid-MEDLINE and EMBASE databases were thoroughly searched for studies evaluating CNB or repeat FNA for thyroid nodules with initially nondiagnostic FNA results. Pooled proportions of nondiagnostic results of CNB and repeat FNA were calculated. A meta-analysis was performed to evaluate the diagnostic accuracy of CNB and repeat FNA for a diagnosis of malignancy using a bivariate random-effects model. Complication rates were also evaluated.

RESULTS

A review of 52 articles identified 4 eligible articles, involving 1,028 patients with 1,028 thyroid nodules, which were included in the meta-analysis. CNB demonstrated significantly lower rates of nondiagnostic results (6.4%) than repeat FNA (36.5%) (P<.0001). In the 3 studies that analyzed the diagnostic accuracy of CNB in diagnosing malignancy, CNB demonstrated significantly higher summary estimates of sensitivity (89.8%) than repeat FNA (60.6%) (P = .022), but summary specificity did not differ between CNB (99.2%) and repeat FNA (99.0%) (P = .576). None of the patients who underwent CNB or repeat FNA experienced any major complications.

CONCLUSION

CNB demonstrates lower rates of nondiagnostic results and higher diagnostic accuracy than repeat FNA. CNB, rather than repeat FNA, can be utilized to diagnose thyroid nodules previously nondiagnostic on FNA.

ABBREVIATIONS

CI = confidence interval CNB = core-needle biopsy FNA = fine-needle aspiration SROC = summary receiver operating characteristic US = ultrasound.

Value of sonographic features in predicting malignancy in thyroid nodules diagnosed as follicular neoplasm on cytology

BACKGROUND

The cytological diagnosis of follicular neoplasm (Thy3F) remains a diagnostic challenge. The main aim of this study was to stratify the risk of malignancy in thyroid nodules diagnosed as Thy3F on cytology (Thy3F) using thyroid imaging reporting and data system (TIRADS).

METHODS

A database of thyroid nodules with Thy3F cytological results from ultrasound-guided FNA (US-FNA) between January 2007 and March 2014 was studied retrospectively. Information on patient demographics, ultrasound characteristics and final histology of the nodules was collated. The number of suspicious US features of each thyroid nodule was counted based on TIRADS. The malignancy rate of each of the TIRADS category was also calculated based on the final histological outcomes of the nodules and compared to that calculated using a recently proposed thyroid malignancy risk prediction model.

RESULTS

The overall malignancy rate of Thy3F cytology was 24·3%. There were significantly higher percentages of malignant nodules with irregular margins (20·0% vs 0%, P = 0·000), hypo-echogenicity (74·3% vs 51·4%, P = 0·013) and taller-than-wide morphology (17·1% vs 0·9%, P = 0·001) when compared to benign nodules. The risk of malignancy increased with advancing TIRADS score: TIRADS 4A (14·3%), TIRADS 4B (23·1%), TIRADS 4C (87·5%) and TIRADS 5 (100%). The malignancy rate calculated using the prediction model similarly increased with advancing TIRADS score: TIRADS 4A (6·2%), TIRADS 4B (32·5%), TIRADS 4C (79·9%) and TIRADS 5 (90%).

CONCLUSION

Thyroid nodules with TIRADS scores 4C and 5 should be considered for single definitive surgery in view of the high malignant rate.

The ultrasonography features of hyalinizing trabecular tumor of the thyroid gland and the role of fine needle aspiration cytology and core needle biopsy in its diagnosis

BACKGROUND

Hyalinizing trabecular tumor (HTT) of the thyroid gland is a rare, benign neoplasm of follicular cell origin. Misdiagnosis of HTT as either papillary or medullary thyroid carcinoma after fine-needle aspiration (FNA) may lead to unnecessary surgery.

PURPOSE

To evaluate the ultrasonography (US) findings of HTT of the thyroid gland and the role of FNA cytology and core needle biopsy (CNB) in its diagnosis.

MATERIAL AND METHODS

Data from 24 patients with a histopathological diagnosis of HTT between January 2000 and May 2013 were retrospectively analyzed. US findings were categorized according to shape, margin, orientation, echogenicity, composition, calcification, and vascularity. Cytologic and histologic results of FNA, CNB, and surgery were reviewed.

RESULTS

US revealed the following tumor features: oval-to-round (24/24), solid (22/24), smooth margin (21/24), hypoechoic or marked hypoechogenicity (18/24), and peri- and/or intranodular vascularity (17/17). Malignant US features such as marked hypoechogenicity (n = 7) and a spiculated margin (n = 3) were also observed. Final confirmation was by surgery in 22 patients and by CNB in two patients. All 19 patients who underwent FNA were initially misdiagnosed, including 12 with malignancies and five with atypia of undetermined significance. All four patients who underwent CNB were correctly diagnosed with HTT. The histology of CNB specimens suggested HTT, which was confirmed by immunostaining of MIB-1.

CONCLUSION

HTT should be suspected when the cytological diagnosis of papillary thyroid carcinoma is made after FNA without malignant US findings. CNB could prevent unnecessary surgery for HTT.

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.

Evaluation of the Clinical Usefulness of BRAFV600E Mutation Analysis of Core-Needle Biopsy Specimens in Thyroid Nodules with Previous Atypia of Undetermined Significance or Follicular Lesions of Undetermined Significance Results

BACKGROUND

The accurate diagnosis of thyroid nodules is important for making management decisions. The purpose of this study is to evaluate the clinical usefulness of BRAF(V600E) mutation analysis with core-needle biopsy (CNB+BRAF(V600E)) in thyroid nodules with previous atypia of undetermined significance (AUS) or follicular lesions of undetermined significance (FLUS) results.

MATERIALS AND METHODS

From January 2011 to December 2012, 590 CNB+BRAF(V600E) mutation analyses were performed. We analyzed 200 nodules from 200 patients with previous AUS/FLUS results (22 men, 178 women; mean age, 48.6 years). The clinical usefulness of CNB+BRAF(V600E) was assessed by comparing the rates of conclusive results, the additional value of BRAF(V600E) mutation analysis, diagnostic performances, and therapeutic/diagnostic surgery results with those of CNB alone. For the subgroup analysis, the study patients were divided into those with nodules with previous AUS results and those with previous FLUS results.

RESULTS

All CNB+BRAF(V600E) procedures were well-tolerated. CNB+BRAF(V600E) did not show significantly better diagnostic performance than CNB alone in thyroid nodules with previous AUS/FLUS results. However, the conclusive result rate of CNB+BRAF(V600E) was improved in thyroid nodules with previous AUS/FLUS results (76.5% vs. 73.0%, p=0.016), especially with previous AUS results (81.1% vs. 76.4%, p=0.031). Of the 56 previous AUS result thyroid nodules with surgical management, BRAF(V600E) mutation analysis led to therapeutic surgery in 5.4% by decreasing unnecessary diagnostic surgery.

CONCLUSIONS

In general, CNB+BRAF(V600E) did not show significantly higher diagnostic accuracy than CNB alone. Although CNB+BRAF(V600E) may add additional value in nodules with previous AUS results, routinely adding BRAF(V600E) mutation analysis to CNB is not recommended.

Comparison of pre-operation diagnosis of thyroid cancer with fine needle aspiration and core-needle biopsy: a meta-analysis

BACKGROUND

The aim of this meta-analysis was to compare sensitivities and specificities of fine needle aspiration (FNA) and core needle biopsy (CNB) in the diagnosis of thyroid cancer.

MATERIALS AND METHODS

Articles were screened in Medline, the Cochrane Library, EMBASE and Google Scholar, and subsequently included and excluded based on the patient/problem-intervention-comparison-outcome (PICO) principle. Primary outcome was defined in terms of diagnostic values (sensitivity and specificity) of FNA and CNB for thyroid cancer. Secondary outcome was defined as the accuracy of diagnosis. Compiled FNA and CNB results from the final studies selected as appropriate for meta-analysis were compared with cases for which final pathology diagnoses were available. Statistical analyses were performed for FNA and CNB for all of the selected studies together, and for individual studies using the leave-one-out approach.

RESULTS

Article selection and screening yielded five studies for meta-analysis, two of which were prospective and the other three retrospective, for a total of 1,264 patients. Pooled diagnostic sensitivities of FNA and CNB methods were 0.68 and 0.83, respectively, with specificities of 0.93 and 0.94. The areas under the summary ROC curves were 0.905 (± 0.030) for FNA and 0.745 (± 0.095) for CNB, with no significant difference between the two. No one study had greater influence than any other on the pooled estimates for diagnostic sensitivity and specificity.

CONCLUSIONS

FNA and CNB do not differ significantly in sensitivity and specificity for diagnosis of thyroid cancer.

Usefulness of core needle biopsy for thyroid nodules with macrocalcifications: comparison with fine-needle aspiration

BACKGROUND

This study was performed to determine the benefits of core needle biopsy (CNB), as compared with fine-needle aspiration (FNA), for the diagnosis of thyroid nodules with macrocalcifications.

MATERIALS AND METHODS

The institutional review board approved this retrospective study, and informed consent was waived. From February 2010 to March 2012, the study included 147 thyroid nodules with macrocalcification of 145 consecutive patients who underwent simultaneous FNA and CNB for each nodule. Diagnostic accuracy and inconclusive diagnoses, including nondiagnostic reading and atypia of undetermined significance or follicular lesion of undetermined significance reading were compared among FNA, CNB, and a combination of FNA and CNB (FNA/CNB) using McNemar's test; the benefits of CNB were calculated.

RESULTS

Compared to FNA, CNB and FNA/CNB showed fewer inconclusive diagnoses (FNA vs. CNB: 62/147 [42.2%] vs. 14/147 [9.5%], p<0.001; FNA vs.

FNA/CNB

62/147 [42.2%] vs. 14/147 [9.5%], p<0.001), resulting in the avoidance of repeat FNA or diagnostic surgery in 48 of 62 patients (77.4%, respectively in CNB and FNA/CNB) who would have undergone these procedures if only FNA was performed. Compared to FNA, FNA/CNB showed higher sensitivity and accuracy (sensitivity: 23/32 [71.9%] vs. 31/32 [96.9%], p=0.008; accuracy: 77/86 [89.5%] vs. 85/86 [98.8%], p=0.008), resulting in avoidance of delayed surgery in eight of nine patients (88.9%) with thyroid cancer in whom the surgery would have been missed if FNA only had been performed.

CONCLUSION

In the workup of thyroid nodules with macrocalcification, compared with FNA alone, FNA/CNB decreases inconclusive diagnoses and increases sensitivity, thereby reducing repeated FNA procedures, diagnostic surgeries, and delayed therapeutic surgeries.