Thyroid Ultrasound-Guided Fine-Needle Aspiration: The Positive Influence of On-Site Adequacy Assessment and Number of Needle Passes on Diagnostic Cytology Rate

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.

Examining the impact of several factors including COVID-19 on thyroid fine-needle aspiration biopsy

OBJECTIVE

The study explores various factors, including coronavirus disease 2019 (COVID-19) history and vaccination status, that influence the classification value of ultrasonography-guided thyroid fine needle aspiration biopsy (TFNAB) by comparing non-diagnostic (Bethesda-I) and diagnostic (Bethesda II-VI) results.

METHODS

We conducted a retrospective observational study in a high-volume tertiary care center involving patients who underwent TFNAB from November 2022 to April 2023. The study retrospectively analyzed the cytopathology of 482 thyroid nodules. Patients were categorized into non-diagnostic (n = 136) and Diagnostic groups (n = 346) based on TFNAB. A comprehensive set of parameters was examined, including demographic, anthropometric and clinical data, thyroid ultrasonography findings, COVID-19 history and immunization status.

RESULTS

The mean age was 55.1 ± 12.1 years in the non-diagnostic group and 53.5 ± 13 years in the Diagnostic group (p = .223). 75.7% (n = 103) of the non-Diagnostic group and 82.9% (n = 287) of the Diagnostic group were male (p = .070). The mean nodule longitudinal diameter of the Diagnostic group was significantly higher than that of the non-diagnostic group (p = .015). The TIRADS score of the nodules showed a statistical difference between the groups (p = .048). The groups had no significant differences regarding other ultrasonographic parameters and COVID-19-related variables.

CONCLUSION

It can be assumed that when the longitudinal diameter of the thyroid nodule is small and in TIRADS categories other than the TIRADS3 category, TFNAB is less likely to be diagnostic. However, future research may be needed to confirm these findings and uncover any long-term effects of COVID-19 or vaccines on thyroid nodule diagnostics.

Core Needle Biopsy in the Diagnosis of Thyroid Nodules

BACKGROUND

Core needle biopsy (CNB) is a relatively new technique for the diagnosis of thyroid nodules, and there are currently no large clinical series available. CNB results from 3000 cases are presented in this article.

METHODS

A spring-loaded 20-gauge needle was used for CNB under local anesthesia and ultrasonography guidance for 3000 patients with nodular goiter (584 males, 2416 females, mean age: 48.5). One physician performed all biopsy procedures without conducting on-site pathological examinations.

RESULTS

There were non-diagnostic 22 (.7%), benign 2620 (87.4%), atypia of undetermined significance and/or, follicular lesion of undetermined significance 90 (3%), follicular neoplasms and/or suspicious for follicular neoplasm 53 (1.7%), suspicious for malignancy 160 (5.4%), and malignant 55 (1.8%) cases. The CNB procedure was repeated in 19 non-diagnostic cases, and 17 of these patients were benign and two had malignancy. Thyroidectomy was performed on patients who had malign CNB results. All final pathology reports, except for one, were malignant for the patients who had malignant CNB results. The specificity and the sensitivity of CNB were found to be 99.9% and 100%, respectively. There were no serious complications.

CONCLUSION

In thyroid nodules, core needle biopsy is a highly sensitive, specific, and reliable method that could be performed by a single physician. It does not require on-site pathological analysis and has a low incidence of complications and non-diagnostic rates.

Telecytology rapid onsite evaluation, with real-time communication between cytopathologist, cytotechnologist, and proceduralist, offers better adequacy rates for lymph node, but not thyroid, fine-needle aspirations

INTRODUCTION

Rapid onsite evaluation (ROSE) decreases rates of inadequate fine-needle aspirations (FNAs). Telecytology allows pathologists to perform ROSE without being physically "on site", thereby saving cytopathologists' travel time and allowing them to perform ROSE for multiple institutions. Little research exists comparing telecytology to non-telecytology ROSE for FNA inadequacy rates.

MATERIALS AND METHODS

Using previously obtained quality metrics, we compared inadequacy rates for lymph node and thyroid FNAs with and without ROSE and with non-telecytology ROSE compared with telecytology ROSE. Use of ROSE was determined by the proceduralist. Type of ROSE was location-based, as only certain locations at our institution have telecytology capabilities. Chi-squared testing was used to compare proportions of populations and P value was set to 0.05.

RESULTS

A total of 1168 lymph node and 1177 thyroid FNAs were included in our adequacy analysis. We found any ROSE decreased our inadequacy rate for both lymph node (20.4% to 12.7%, P = 0.002) and thyroid (34.7% to 4.8%, P = 7.4 × 10-18) FNAs. We found telecytology further decreased our inadequacy rate for lymph node (13.8% to 5.9%, P = 0.016), but not thyroid (3.3% to 5.0%, P = 0.34), FNAs.

CONCLUSIONS

At our institution, when using telecytology, slides are read in real time with the cytotechnologist and the proceduralist looking at slides together near the patient bedside, while the cytopathologist is on the phone looking at slides on the computer screen via Dameware. When non-telecytology ROSE is performed, the cytotechnologist evaluates a slide, brings it to the cytopathologist's office and then the cytopathologist calls the proceduralist to discuss the slide. We believe telecytology offers an opportunity for more inclusive communication thereby improving adequacy rates for more complex cases, like lymph nodes, without affecting adequacy rates for cases where assessment of adequacy is less complex, like thyroid. This research supports use of telecytology especially for complex cases.

Screening adequacy of unstained thyroid fine needle aspiration samples using a deep learning-based classifier

Fine needle aspiration (FNA) biopsy of thyroid nodules is a safe, cost-effective, and accurate diagnostic method for detecting thyroid cancer. However, about 10% of initial FNA biopsy samples from patients are non-diagnostic and require repeated FNA, which delays the diagnosis and appropriate care. On-site evaluation of the FNA sample can be performed to filter out non-diagnostic FNA samples. Unfortunately, it involves a time-consuming staining process, and a cytopathologist has to be present at the time of FNA. To bypass the staining process and expert interpretation of FNA specimens at the clinics, we developed a deep learning-based ensemble model termed FNA-Net that allows in situ screening of adequacy of unstained thyroid FNA samples smeared on a glass slide which can decrease the non-diagnostic rate in thyroid FNA. FNA-Net combines two deep learning models, a patch-based whole slide image classifier and Faster R-CNN, to detect follicular clusters with high precision. Then, FNA-Net classifies sample slides to be non-diagnostic if the total number of detected follicular clusters is less than a predetermined threshold. With bootstrapped sampling, FNA-Net achieved a 0.81 F1 score and 0.84 AUC in the precision-recall curve for detecting the non-diagnostic slides whose follicular clusters are less than six. We expect that FNA-Net can dramatically reduce the diagnostic cost associated with FNA biopsy and improve the quality of patient care.

Factors Influencing the Sample Adequacy of Ultrasound-Guided Fine-Needle Aspiration from Solid Thyroid Nodules for Liquid-Based Cytology: A Demographic, Sonographic, and Technical Perspective

Background and Objectives: To identify factors that influence the sample adequacy of solid thyroid nodules based on ultrasound-guided fine-needle aspiration (FNA) with subsequent liquid-based cytology. Materials and Methods: We retrospectively reviewed 855 patients who underwent ultrasound-guided FNA at our hospital between July 2019 and July 2020. The final analysis included 801 solid thyroid nodules in 801 patients. After reviewing the demographic data, ultrasonic features, and FNA technique-related factors, we defined 14 potential variables. For cytological results, the Bethesda categories II−VI were defined as adequate sample results. Univariate and multivariate analyses were performed to identify factors that influenced sample adequacy. Results: The adequate sample rate was 87.1%. The univariate analysis showed that four factors were related to adequate sampling in patients with thyroid FNA. These factors included age (p < 0.001), nodule orientation (p = 0.0232), calcification (p = 0.0034), and operator experience (p = 0.0286). After the multivariate analysis, five independent factors were identified to improve the diagnostic results of FNA for solid thyroid nodules: (1) the presence of Hashimoto’s thyroiditis (odds ratio (OR) = 1.810; 95% confidence interval (CI): 1.076−3.045; p = 0.0254), (2) a taller-than-wide orientation (OR = 2.038; 95% CI: 1.260−3.296; p = 0.0037), (3) the presence of calcification (OR = 1.767; 95% CI: 1.115−2.799; p = 0.0153), (4) four needle passes to obtain material (OR = 1.750; 95% CI: 1.094−2.799; p = 0.0196), and (5) an experienced operator (OR = 0.561; 95% CI: 0.319−0.987; p = 0.0451). Conclusions: A taller-than-wide orientation, the presence of calcification, and the presence of Hashimoto’s thyroiditis were found to affect the sample adequacy of ultrasound-guided FNA with liquid-based cytology. The sample adequacy could be improved when FNA is performed with four needle passes by experienced doctors.

Telecytology validation: is there a recipe for everybody?

INTRODUCTION

Telecytology offers a suitable solution to the cost and time efficiency questions on rapid onsite evaluation (ROSE). An increasing number of institutions are adopting new telecytology systems to meet the increasing ROSE requests, although there is no agreement on the details of how a telecytology validation study needs to be conducted. We propose a standardized approach for telecytology validation studies that could be done in a variety of practices.

MATERIALS AND METHODS

Consecutive cases from 6 months prior were chosen to reflect a case mix comparable to real life. A fellow assessed the slides at the ROSE site while 6 cytopathology faculty convened in a conference room with a television screen, and noted the adequacy, diagnostic category, and specific diagnoses. All participants were blinded to the original adequacy assessment and final diagnoses. For each case, evaluation time and the slides counts were noted.

RESULTS

Fine-needle aspiration specimens from 52 patients were included in the study. Of these, 13 cases were used in the first "test" session. The adequacy concordance rates ranged between 92.3% and 100%, with an overall concordance rate of 94.8%. The diagnostic category concordance rates ranged between 90.3% and 95.5%, with an overall concordance rate of 91.9%. The specific diagnosis concordance rates ranged between 84.6% and 92.9%, with an overall concordance rate of 88.1%.

CONCLUSIONS

Validation of telecytology requires a standardized approach just like any other new technology. In this study, we propose an efficient and accurate method for cytopathology departments of various case volumes to conduct telecytology validation studies.

The current practice of telecytology for rapid on-site evaluation (ROSE): Practical considerations and limitations

Advances in digital imaging technology and development of high-speed internet has brought a change in ROSE practice from the traditional in-person to remote evaluation. The rapid expansion of image-guided procedures to obtain tissues for diagnosis and ancillary testing has put a huge demand on cytopathologists' time to perform on-site adequacy assessment. The technology of transmitting digital slide images in real-time via the internet from procedure site that can be viewed remotely and provide preliminary diagnosis, has had a huge impact on the practice of ROSE. Telecytology (TC) has increased the efficiency of cytopathologists, by cutting down on travel time to procedure sites and eliminate the long wait time between procedures/needle passes. It also provides the cytopathologist with the flexibility of covering ROSE procedures occurring at several locations simultaneously. The options and design of TC systems are driven by clinical needs, availability of resources and case volume. A buy-in from stakeholders early in the process, infrastructure planning and information technology (IT) support are critical for the successful implementation of TC. Training of staff, validation study and compliance training should be performed according to established guidelines. There are different TC platforms commercially available in the market today, these include static image sharing, real-time video streaming, robotic microscopy and whole slide imaging (WSI). Additionally, low-cost TC system can be built and designed using equipment that are available off-the-shelf. The intent of this review is to highlight the current practices of TC, the pros and cons of each system are discussed.

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

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

Role of the cytopathologist during the procedure of fine-needle aspiration biopsy of thyroid nodules

Purpose

This study aimed to conduct a diagnostic and cost-effective analysis of the cytopathology assistance in the ultrasound (US)-guided fine-needle aspiration biopsy (FNAB) for characterising thyroid nodules.

Materials and methods

We reviewed the reports relative to 9061 US-guided FNABs for the histologic definition of the nature of thyroid nodules: 45.4% completed with the cytopathologist assistance and 54.6% by the radiologist alone.

We also performed the cost-effectiveness analysis (CEA) of the procedure with and without the cytopathologist assistance.

Results

We found a significant positive correlation between the adoption/non-adoption of cytopathologist assistance and the number of indeterminate (TIR1) (Chi-square; z-score, Z = 10.22; critical value 5%, C = 1.96; p < 0.001). The cytopathologist's absence was correlated with the number of TIR 1 (Pearson correlation, product–moment correlation r = 0.059; critical value 5%, C = 0.008; p < 0.001).

The total cost of the model's cytopathologist-assistance branch is 109.87€, while the total cost of the non-cytopathologist-assistance branch is 95.08€.

Conclusion

The cytopathologist assistance resulted in fewer nondiagnostic results, thus excluding the procedure's repetition but involved a higher expense, mainly due to the professional cost of the pathologist's participation. These data may provide decision-makers in healthcare with a practical evidence based on the opportunity to include the cytopathologist assistance in the thyroid nodule's FNAB depending on the available resources and the population's expectance.

Supplementary information

The online version contains supplementary material available at 10.1186/s13244-021-01053-y.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Application Value of Ultrasound-Guided Fine Needle Aspiration Cytological Examination and Ultrasound Evaluation

In this paper, chronic inflammatory cell infiltration was seen during this period. The reason for the false-positive result may be the atypical proliferation of cells caused by chronic inflammatory stimulation with malignant cytology. 12 cases of false negative results, including 2 cases of type I nodules, 10 cases of type III nodules, postoperative histology and pathology were papillary carcinoma, there are many reasons for false negative results, including the size of the nodules, the puncture operator, the technical level, internal tissue composition and properties of the nodules all affect the accuracy of puncture and cytopathology results. The satisfaction of puncture specimens of each group was calculated and compared. For thyroid nodules with the maximum diameter ≤5 mm, the satisfaction rate of puncture specimens was 87.2%, and the diagnostic sensitivity and accuracy of ultras guided fine needle aspiration biopsy were relatively low. Cytological results were in poor agreement with postoperative histological and pathological results, so it was recommended to take active follow-up for thyroid nodules with the maximum diameter ≤5 mm to reduce unnecessary puncture. The overall puncture success rate is relatively high, ≤10 mm low-echo nodules or even ≤5 mm nodules can be cytological puncture, especially the kind of close to the capsule, trachea and recurrent laryngeal nerve nodules, for the largest diameter of >5 mm, the satisfaction rate of puncture specimens is relatively high is 93.2%. Moreover, the sensitivity and accuracy of ultrasound guided fine needle aspiration biopsy were relatively high, and the cytological results were in good agreement with the postoperative histological and pathological results. Therefore, it was feasible to confirm the diagnosis of suspected malignant nodules by ultrasound. The diagnostic in each group and the consistency between cytological diagnosis and histological diagnosis were analyzed by comparing the histological and pathological results after surgery. Ultrasound-guided fine needle aspiration biopsy can be used more effectively in clinical practice.

A New Device for Fine-Needle Aspiration Cytology Consisting of a Vibrating Linear Resonant Actuator

OBJECTIVE

To evaluate the efficacy of a new device for fine-needle aspiration cytology (FNAC) consisting of a vibrating linear resonant actuator (LRA).

STUDY DESIGN

Prospective clinical study.

METHODS

The LRA frequency was optimized by visualization of the needle motion using a high-speed camera. The FNAC device consists of a vibrating motor fixed to the stopper of a 5-ml syringe and piston. Upon insertion of the syringe needle into a thyroid nodule (with the stopper attached to the syringe piston), sufficient negative pressure with 1-ml suction was maintained. Subsequently, samples were obtained using vibration generated by an LRA or an eccentric rotating mass (ERM). Surgically resected thyroid specimens from 10 patients were evaluated. The number of follicular groups required for adequate diagnosis and the number of larger follicular groups were counted. Next, 254 thyroid nodules from 187 patients were also evaluated by FNAC. The inadequacy rate was determined, and final cytology was classified according to thyroid Bethesda categories.

RESULTS

The optimized LRA frequency was 155 Hz. Both the LRA and ERM devices resulted in sufficient amounts of diagnostic material and achieved low inadequacy rates. The number of large follicular groups obtained was significantly greater with the LRA device compared with the ERM device.

CONCLUSIONS

The vibrating device using an LRA for thyroid FNAC resulted in sufficient amounts of thyroid follicular groups and achieved low inadequacy rates. In addition, the LRA device allowed for collection of larger follicular groups sufficient to diagnose appropriate thyroid Bethesda categories.

LEVEL OF EVIDENCE

2 Laryngoscope, 131:E1393-E1399, 2021.

Conditions associated with the need for additional needle passes in ultrasound-guided thyroid fine-needle aspiration with rapid on-site pathology evaluation

BACKGROUND

Rapid on-site evaluation (ROSE) is a valuable tool for specimen adequacy assessment in thyroid ultrasound (US)-guided fine-needle aspiration (US-guided FNA). To reduce the risk of nondiagnostic samples, additional needle passes may be needed at ROSE to ensure adequate sampling. Recommendations regarding the number of aspirates to ensure specimen adequacy are not well defined. Furthermore, there are limited data regarding nodule characteristics that may require increased sampling. In this study, we investigate conditions associated with requiring more than three needle passes during ROSE.

METHODS

A retrospective quality review of all patients who underwent US-guided thyroid FNA by a single board-certified radiologist over a 1-year period was performed. A total of 122 patients were identified: 70 with three passes performed and 52 with more than three passes to achieve adequacy.

RESULT

Our data demonstrate that large nodules (≥3 cm) were more likely than small nodules (≤1.1 cm) to require more than three passes to achieve adequacy. If a nodule was predominantly cystic or mixed cystic and solid, the sample was often adequate with only three passes. In cases of thyroiditis or nodules suspicious or diagnostic of neoplasia, there is a trend to require only three passes for adequacy.

CONCLUSION

On the basis of the data presented in this study, cytopathologists should be prepared for the potential need to obtain additional needle passes in larger (≥3 cm) nodules and provide reassurance to patients that this is an anticipated finding for these larger nodules.

Review of different platforms to perform rapid onsite evaluation via telecytology

There is increased utilisation of cytopathology to provide a rapid onsite evaluation (ROSE) of fine needle aspiration and touch preparations of small biopsies. A well-executed ROSE procedure can significantly impact the diagnostic quality and appropriate specimen triage of procured biopsy materials. To accommodate the demand for ROSE, telecytology has been increasingly implemented to facilitate ROSE occurring remotely. Telecytology can be categorised based on camera systems including eyepiece system, camera port system and robotic microscope/whole slide image scanner system. Image sharing methods include static images, broadcast only live video streaming, teleconferencing and whole slide image management system. In this review, we will discuss the advantages and disadvantages of each of these systems and deployment considerations.

Determining whether surgeons perform thyroid fine-needle aspiration as well as radiologists: an analysis of the adequacy and efficiency of ultrasound-guided fine-needle aspiration performed by newly trained head and neck surgeons and radiologists

Background

Ultrasound-guided fine-needle aspiration (FNA) cytology is a crucial diagnostic technique used to assess thyroid nodules. In the past, ultrasound-guided FNA was performed mainly by radiologists. However, many surgeons are increasingly being trained for this procedure now. In this study, we aimed to compare the adequacy and efficiency of ultrasound-guided FNA performed by newly trained head and neck surgeons with experienced radiologists in a single institution. We also assessed the malignancy rates in nondiagnostic nodules and the differences between benign and malignant nodules.

Methods

This is a retrospective study. The data from patients who underwent ultrasound-guided FNA performed by surgeons or radiologists in two consecutive years were collected. Medical records, cytology results, and surgical pathology results were analyzed.

Results

During the study period, a total of 2,405 ultrasound-guided FNAs were performed on 2,163 patients. The head and neck surgeons and radiologists performed 1,132 and 1,273 ultrasound-guided FNA procedures, respectively. The nondiagnostic rate was 14.49% for surgeons and 15.40% for radiologists (P=0.533). There were no differences in patient age, gender, nodule size, and other sonographic characteristics between the groups of patients who were treated by radiologists versus surgeons. The median waiting time from biopsy appointment to performing ultrasound-guided FNA was 0 days for head and neck surgeons, and 6 days for radiologists (P<0.001). Of the 40 patients who had a repeat FNA or surgery, 19 (47.50%) had a malignancy. Preoperative information about age, gender, operator, and characteristics of nodules did not predict the outcome of nodules with Bethesda category I.

Conclusions

The adequacy of ultrasound-guided FNAs performed by head and neck surgeons is similar to that of skilled radiologists, while surgeons are more efficient than radiologists. Nondiagnostic FNA reports should not be considered benign, and repeat FNA or selective surgical treatment is recommended.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

The Application of Ultrasound and Fine-Needle Aspiration in Low-Volume Lateral Lymph Nodes of Papillary Thyroid Carcinoma Patients

This research investigates the application of high-frequency ultrasound (US) examination and US-guided fine-needle aspiration (US-FNA) in diagnosing low-volume metastatic lateral lymph nodes (LLNs) from papillary thyroid carcinoma patients. This study reviewed the medical records of 996 LLNs from 858 patients with suspicious thyroid nodules or after thyroidectomy from January 2013 to January 2016. All patients took US-FNA. The US characteristics and the malignancy rate of LLNs classified into group A and group B based on size were analyzed and compared (group A, ≥6 mm; group B, <6 mm). Size was not an independent predictor for malignancy (P > 0.005) in multiple regression analysis, whereas the malignancy rate in the large LLNs (286/425; 67.3%) was slightly higher than that in the small LLNs (338/571; 59.2%) (P = 0.01). However, no significant difference was observed between the groups in terms of calcification, absence of hilum, and peripheral vascularization. The prevalence of malignant LLNs was slightly higher in the small LLNs than that in the large ones when there were less than 3 suspicious US features (P < 0.05), and there was no significant difference between the small and large LLNs when there were 3 or more suspicious US features (P > 0.05). The results indicate that metastases may occur in the lymph nodes even when they were small. Ultrasound and US-FNA showed excellent performance in the diagnosis of low-volume metastatic lateral lymph nodes from papillary thyroid carcinoma patients.

Comparison of Two Different Methods of Fine Needle Aspiration Biopsy and Histopathology for Thyroid Nodules

OBJECTIVE

 Two different methods for fine needle aspiration biopsy (FNAB) of thyroid nodules (multi-pass conventional smear, MPCS; single-pass liquid-based cytology, SPLBC) were evaluated regarding the magnitude of nondiagnostic/unsatisfactory sampling ratio, and basic demographic and ultrasonographic (USG) factors to predict such outcome.

METHODS

 One thousand FNAB patients were retrospectively assessed. Of them, 517 nodules were evaluated with the conventional smear method, and the rest were evaluated with liquid-based cytology method using the Bethesda System for Reporting Thyroid Cytopathology. FNAB technique had certain procedural differences for both pathological methods. For conventional smear, a modified "needle-only" technique with three independent passes was performed, whereas a single pass was used for liquid-based cytology. The reduction of nondiagnostic/unsatisfactory results constituted the basis of this study. Pathological results, therefore, were subgrouped under "nondiagnostic/unsatisfactory" (Category I), "benign" (Category II), and "atypia/neoplasia/malignancy" (Category III-VI).

RESULTS

 Both FNAB groups were not statistically different or only slightly different regarding size (P = 0.196), echogenicity (P = 0.014), and the presence of echogenic foci (P = 0.11), therefore considered to have equal USG properties. In MPCS method, the nondiagnostic/unsatisfactory rate (i.e., Category I) was 24%. Other cytological results were as follows: Category II (67.1%), Category III-VI (8.8%). In SPLBC method, the nondiagnostic/unsatisfactory rate (i.e., Category I) was 14.5%. Other cytological results were as follows: Category II (77.6%), Category III-VI (7.8%). A significant difference was found between two sampling methods regarding pathological results (Independent samples t-test, P < 0.0001). The demographic and USG factors, considered in this study, did not offer a successful prediction of nondiagnostic/unsatisfactory outcomes.

CONCLUSION

 SPLBC has significantly lower (14.5% vs 24%) nondiagnostic rate than MPCS, and higher 77.6% vs 67.1%) Category II rate than MPCS. This may point to the possibility that MPCS method undercategorizes many benign (i.e., Category II) nodules under nondiagnostic/unsatisfactory category. The success of the former is due to the elimination of confounding material during the process. Single pass, also, increases patient comfort and compliance, and has additional advantages for the interventionalist, as it obviates the need to smear aspirates. This dramatically decreases the actual duration of the biopsy procedure and is free of interventionalist expertise for smearing.

Comparison of Number of Passes and Cytopathological Specimen Adequacy for Thyroid Fine-Needle Aspiration Biopsy in the Absence of an On-Site Pathologist

AIM

Ultrasound-guided fine-needle aspiration biopsy (FNAB) is a reliable, minimally invasive diagnostic method with high sensitivity and specificity in the evaluation of thyroid nodules. Our aim in this retrospective study was to determine if there was a difference in the adequacy ratio based on the number of needle passes in the thyroid FNABs in the absence of rapid on-site evaluation (ROSE) by the pathologist and to determine the optimal needle pass number for FNAB.

METHODS

Between November 2018 and February 2019, thyroid FNABs of 121 (99 female, 22 male) patients were evaluated retrospectively. Samples for each biopsy were numbered according to the order of retrieval, and 4 pairs of slides were prepared by the radiologist without on-site microscopic evaluation. Cytological results were determined according to the Bethesda classification.

RESULTS

The rate of adequacy in the first, second, third, and fourth passes were 76.0, 82.6, 77.7, and 71.2%, respectively. No statistically significant difference was found between these four groups in terms of adequacy (p = 0.21). The adequacy rates of the 1st, 1st+2nd, 1st+2nd+3rd, and cumulative evaluation of all four biopsies were 76.0, 87.6, 90.1, and 91.7%, respectively (p = 0.001). A statistically significant difference was found in the comparison of the 1st biopsy and the cumulative 1st+2nd biopsy in terms of adequacy rates (p = 0.019). However, there was no statistically significant difference between the cumulative 1st+2nd biopsy and the cumulative 1st+2nd+3rd biopsy in terms of adequacy rates (p = 0.54).

CONCLUSIONS

In cases where ROSE cannot be performed, we recommend a minimum of 2 and a maximum of 3 needle entries for FNAB adequacy with the right technique and preparation.

Comparison of cytological adequacy and pain scale score in ultrasound-guided fine-needle aspiration of solid thyroid nodules for liquid-based cytology with with 23- and 25-gauge needles: a single-center prospective study

In ultrasound (US)-guided fine-needle aspiration (FNA) of solid thyroid nodules (STN) using liquid-based cytology (LBC), the most appropriate needle size for LBC remains unclear. This study compared the cytological adequacy and complications associated with using 23- and 25-gauge needles in US-guided FNA of STNs using LBC. US-guided FNA was performed in consecutive patients by one radiologist to diagnose STNs ≥ 5 mm in the largest diameter. The one-sampling technique through a single needle puncture and multiple to-and-fro needle motions was used in each patient. The 23- and 25-guage needles were used consecutively each day. After FNA, the pain and complications experienced by each patient were investigated by a nurse, who was blinded to the information of needle gauge used. A cytopathologist retrospectively analyzed the cytological adequacy and cellularity of the cases. Of the 99 STNs, eight (8.1%) exhibited inadequate cytology (4 each with 23- and 25-gauge needles). The rate of cytological adequacy was not statistically different between the groups (p = 0.631). The mean pain scale values with 23- and 25-gauge needles were 2.1 ± 1.3 and 1.6 ± 1.3, respectively (p = 0.135). There were no significant complications in either group. In conclusion, both 23- and 25-gauge needles are useful in LBC because cytological adequacy and complications were not statistically different with both sizes of the needles.

Rapid on-site evaluation using telecytology: A major cancer center experience

BACKGROUND

Rapid on-site evaluation (ROSE) with cytology preparations plays a critical role in minimally invasive procedures. The time spent by a pathologist performing ROSE is unpredictable and could be used for more cost-effective activities. The solution encountered by several institutions to address this issue is the use of telecytology (TC). This study analyzes the experience of using telecytology for ROSE in a major cancer center over a period of over 2 years.

METHODS

A retrospective analysis of all remote TC evaluations for adequacy on fine needle aspiration (FNA) and touch preparations (TP) of core biopsies (CB) performed at a major cancer center was performed. The preliminary adequacy assessment was then compared to the adequacy assessment at final diagnosis.

RESULTS

A total of 12 949 adequacy assessments were analyzed. The most common sites biopsied in our institution were lymph node, lung, and liver. There were 7725 adequacy assessments for CB (59.7%), while adequacy assessment for FNA specimens represented 40.3% (n = 5224) of the total number of specimens evaluated by ROSE. Perfect concordance between initial adequacy assessment and the adequacy assessment at final cytologic diagnosis was 93% (12 049/12 949). The final diagnosis adequacy upgrade rate was 6.7% (n = 863), and the adequacy downgrade (a specimen considered adequate on-site that was determined to be nondiagnostic on final examination) was 0.3% (n = 37).

CONCLUSIONS

TC can be easily implemented with the current technologies available. It is cost-effective and allows for better patient care with a more efficient use of the pathologist's time and laboratory resources.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Size and Ultrasound Features Affecting Results of Ultrasound-Guided Fine-Needle Aspiration of Thyroid Nodules

OBJECTIVES

Our goal was to assess the diagnostic efficacy of ultrasound (US)-guided fine-needle aspiration (FNA) of thyroid nodules according to size and US features.

METHODS

A retrospective correlation was made with 1745 whole thyroidectomy and hemithyroidectomy specimens with preoperative US-guided FNA results. All cases were divided into 5 groups according to nodule size (≤5, 5.1-10, 10.1-15, 15.1-20, and >20 mm). For target nodules, static images and cine clips of conventional US and color Doppler were obtained. Ultrasound images were reviewed and evaluated by two radiologists with at least 5 years US working experience without knowing the results of pathology, and then agreement was achieved.

RESULTS

The Bethesda category I rate was higher in nodules larger than 15 mm (P < .05). The diagnostic accuracy was best in nodules of 5 to 10 mm in diameter. The sensitivity, accuracy, PPV, and LR for negative US-guided FNA results were better in nodules with a size range of 5 to 15 mm. The specificity, negative predictive value (NPV), and LR for positive results and the Youden index rose with increasing nodule size. Seventeen false-positive and 60 false-negative results were found in this study. The false-negative rate rose with increasing nodule size. However, the false-positive rate was highest in the group containing the smallest nodules. Nodules with circumscribed margins and those that were nonsolid and nonhypoechoic and had no microcalcifications correlated with Bethesda I FNA results. Nodules with circumscribed margins and those that were nonsolid, heterogeneous, and nonhypoechoic and had increased vascularity correlated with false-negative FNA results. Borders correlated with Bethesda I false-negative and false-positive FNA results.

CONCLUSIONS

Tiny nodules (≤5 mm) with obscure borders tended to yield false-positive FNA results. Large nodules (>20 mm) with several US features tended to yield false-negative FNA results.

The incidental thyroid nodule

Incidental thyroid nodules that are found on an imaging study performed for reasons other than thyroid pathology represent a common scenario encountered by health care providers. The initial workup for these nodules comprises a thorough history and physical examination, thyroid function tests, a dedicated thyroid ultrasound, and fine-needle aspiration of any suspicious lesions. Management ranges from observation and reassurance to surgical resection and depends on the cytologic diagnosis. In cases of cytologically indeterminate or discordant nodules, surgical excision (lobectomy) offers a definitive diagnosis, although molecular testing or a reasonable period of observation may be useful as less invasive adjuncts. CA Cancer J Clin 2018;68:97-105. © 2018 American Cancer Society.

Factors that Influence Sample Adequacy in Liquid-Based Cytology after Ultrasonography-Guided Fine-Needle Aspiration of Thyroid Nodules: A Single-Center Study

OBJECTIVE

The factors that influence the acquisition of adequate samples during liquid-based cytology (LBC) remain unclear. This study aimed to identify factors that affect cytological adequacy in LBC after ultrasonography (US)-guided fine-needle aspiration (US-FNA) of thyroid nodules.

STUDY DESIGN

From January 2017 to May 2017, a single radiologist performed US-FNA to diagnose 112 thyroid nodules in 112 consecutive patients. Based on US findings after US-FNA, the size, location, position, composition, calcification, and vascularity of each nodule, as well as the US-based diagnosis, were investigated by the same radiologist. Blinded to US information, a single cytopathologist investigated cytological adequacy, cytological cellularity, and Bethesda category.

RESULTS

Of the 112 thyroid nodules, cytological adequacy was achieved in 91.1% (102/112). Thyroid nodules with sizes ≥20 mm or those that were predominantly cystic showed a higher rate of cytological inadequacy (p < 0.05). Thyroid nodule location, position, calcification status, and vascularity did not influence cytological adequacy, nor did US-based diagnosis (p > 0.05). Nodule composition or calcification significantly influenced cytological cellularity (p < 0.05), whereas nodule size, location, position, vascularity, and US-based diagnosis did not (p > 0.05).

CONCLUSIONS

Most investigated factors did not influence cytological adequacy or cellularity.

Experience of the Implementation of Rapid On-Site Evaluation in Ultrasound-Guided Fine-Needle Aspiration Biopsy of Thyroid Nodules

OBJECTIVE

To evaluate the effect of the implementation of the rapid on-site evaluation (ROSE) technique in ultrasound-guided fine-needle aspiration biopsy of thyroid nodules.

MATERIALS AND METHODS

We conducted an observational and retrospective study approved by the Institutional Ethics Committee as an investigation without risk. Between January 2012 and December 2015, 892 ultrasound-guided fine-needle aspiration biopsy procedures were performed under ultrasound guidance. In our study, we included 522 procedures from 473 patients that were taken as part of an investigation of the thyroid nodule (average age: 56 ± 14; 84% were women). We compared the percentage of unsatisfactory samples in the procedures performed with and without the use of the ROSE technique, the cytology adequacy agreement with the cytopathology, and we also assessed the relationship with the number of years of experience of the radiologist.

RESULTS

The ROSE technique led to a decrease of 30.5% of unsatisfactory samples. By 2014, more than half of the procedures were performed with the ROSE technique, and the percentage of unsatisfactory samples decreased progressively each year. The technical implementation of ROSE improved the results of all radiologists; however, those radiologists with the least number of years of experience showed the greatest benefits from the implementation of the ROSE technique. The concordance between the ROSE technique and the cytopathology report was good (Cohen κ = 0.75).

CONCLUSION

In our experience, the implementation of the ROSE technique has helped to reduce the percentage of unsatisfactory samples, which improves the quality and safety of patient care.

Diagnostic utility of fine-needle aspiration cytology of lesions involving bone

BACKGROUND

Fine-needle aspiration (FNA) is utilized in the diagnostic work-up of bone lesions in a number of institutions, either in isolation or in conjunction with core biopsy. We report our experience with FNA of bone-based lesions, including comparison of this approach with concurrent core biopsy specimens.

METHODS

Retrospective review over a 5-year period (2011-2015) revealed 233 cases of bone FNAs.

RESULTS

The most commonly encountered diagnosis was malignant neoplasm (160 cases, 68.7%); within this group of malignancies, 103 cases (64.4%) represented metastatic carcinoma. Benign lesions were encountered infrequently (9 cases, 3.9%). While 37 cases (15.9%) revealed "no evidence of malignancy," 12 cases (5.2%) showed atypical findings, 3 cases (1.3%) demonstrated inflammatory conditions, and 12 aspiration biopsies were deemed nondiagnostic (5.2%). In 202 cases, concurrent core biopsies were performed following FNA and rapid on-site evaluation (ROSE). Comparison of the FNA and core biopsy diagnoses among malignant neoplasms revealed 19 diagnostic discrepancies, including 16 cases with a false-negative FNA (7.9% of all FNAs with concurrent core biopsy) and 3 cases with a false-negative core biopsy (1.5% of all cases with corresponding FNA).

CONCLUSION

Our findings indicate that FNA of bone lesions is a useful diagnostic technique with high sensitivity, particularly when the cytologic findings are interpreted in conjunction with the core biopsy and pertinent clinical and radiologic findings. In addition, ROSE followed by open, dynamic communication with the performing radiologist leads to an extremely low rate of inadequate core biopsy specimens, resulting in optimal patient diagnosis and management. Diagn. Cytopathol. 2017;45:608-613. © 2017 Wiley Periodicals, Inc.

Repeated nondiagnostic result of thyroid fine-needle aspiration biopsy

Aim of the study

Fine-needle aspiration biopsy (FNAB) is the most accurate and cost-effective method to evaluate the risk of malignancy of thyroid nodules, but approximately 1–24% of FNABs generate a nondiagnostic result (ND-FNAB). The aim of this study was to determine the predictive factors of a repeated nondiagnostic result of FNAB.

Material and methods

A total of 4018 FNABs performed in a territorial referral centre were analysed, of which 288 (7.17%) were nondiagnostic. Medical records were available for 245 biopsies performed in 228 patients. The retrospective analysis of factors that may influence a repeat ND-FNAB, including demographic, clinical and ultrasound characteristics, was performed.

Results

A repeat FNAB was performed in 159 nodules giving a diagnostic result in 79.2% of cases. The time between the biopsies ranged from 1 to 611 days (mean 154.4, median 119). The timing of a repeat FNAB did not significantly alter the diagnostic output (p = 0.29). In the univariate analysis, significant predictors of a repeat ND-FNAB were older patient age (p = 0.02), L-thyroxine supplementation (p = 0.05), and a history of ¹³¹I therapy (p < 0.0001). In the multivariate analysis, only a history of ¹³¹I therapy was a statistically significant risk factor for a repeat ND-FNAB (p = 0.002).

Conclusions

Patients with a history of ¹³¹I therapy and ND-FNAB should undergo periodic ultrasonographic assessment rather than a repeat biopsy. The interval between repeated FNABs recommended by guidelines does not affect the diagnostic output.