The use of core needle biopsy as first-line in diagnosis of thyroid nodules reduces false negative and inconclusive data reported by fine-needle aspiration

Current role of interventional radiology in thyroid nodules

Thyroid nodules are a prevalent health issue in society. Interventional radiological methods are successfully applied for both the diagnosis and treatment of nodules. Diagnostically, a fine-needle aspiration biopsy and a core needle biopsy can be performed to ascertain the benign or malignant nature of a lesion. In recent years, imaging-guided percutaneous treatment methods have become popular in the treatment of thyroid nodules. Aspiration, ablation, and embolization are techniques employed in the treatment process. In this study, we aimed to discuss the current role of interventional radiology in the diagnosis and treatment of thyroid nodules, which occupy an important place in clinical practice.

Parenchymal microcalcifications in the thyroid gland: Clinical significance and management strategy

This study is firstly, to investigate the presence of microcalcification among the patients who underwent thyroid ultrasound and biopsy and to evaluate the incidence of intrathyroid lymphatic spread and cervical lymph node metastasis of thyroid cancer with thyroid microcalcifications. Also, we compared the diagnostic performance between fine needle aspiration (FNA) and core needle biopsy (CNB) for assessing parenchymal microcalcifications in the thyroid gland. We retrospectively assessed total 66 patients with thyroid microcalcifications on ultrasound. The histopathologic characteristics of the surgical specimens considered as the gold standard for diagnosing malignancy. Patients with surgically proven malignancy were evaluated for multifocality, intrathyroid lymphatic spread in the opposite lobe, or cervical lymph node metastasis. Among the 66 confirmed patients, 53 patients had malignant lesions (80.3%) and 13 patients had benign lesions (19.7%). The pathologic results of the 44 patients who underwent total thyroidectomy. Among them, 33 patients (75%) showed multifocality, 30 patients (68.2%) showed intrathyroid lymphatic tumor spread. CNB was performed on 41 patients, and FNA was performed on 54 patients. Both CNB and FNA were performed on 29 patients. There were no statistical differences in terms of diagnostic performance between CNB and FNA. Thyroid microcalcifications demonstrate a high prevalence of malignancy. Both CNB and FNA demonstrate similar diagnostic accuracies.

Reevaluating diagnostic categories and associated malignancy risks in thyroid core needle biopsy

As the application of core needle biopsy (CNB) in evaluating thyroid nodules rises in clinical practice, the 2023 Korean Thyroid Association Management Guidelines for Patients with Thyroid Nodules have officially recognized its value for the first time. CNB procures tissue samples preserving both histologic structure and cytologic detail, thereby supplying substantial material for an accurate diagnosis and reducing the necessity for repeated biopsies or subsequent surgical interventions. The current review introduces the risk of malignancy within distinct diagnostic categories, emphasizing the implications of noninvasive follicular thyroid neoplasm with papillary-like nuclear features on these malignancy risks. Prior research has indicated diagnostic challenges associated with follicular-patterned lesions, resulting in notable variation within indeterminate diagnostic categories. The utilization of mutation-specific immunostaining in CNB enhances the accuracy of lesion classification. This review underlines the essential role of a multidisciplinary approach in diagnosing follicular-patterned lesions and the potential of mutation-specific immunostaining to strengthen diagnostic consensus and inform patient management decisions.

Preoperative Risk Stratification of Follicular-patterned Thyroid Lesions on Core Needle Biopsy by Histologic Subtyping and RAS Variant-specific Immunohistochemistry

Follicular-patterned lesions often have indeterminate results (diagnostic category III or IV) by core needle biopsy (CNB) and fine needle aspiration (FNA). However, CNB diagnoses follicular neoplasm (category IV) more frequently than FNA. Therefore, we aimed to develop a risk stratification system for CNB samples with category III/IV using immunohistochemistry (IHC). The specificity of the RAS Q61R antibody was validated on 58 thyroid nodules with six different types of RAS genetic variants and 40 cases of RAS wild-type. We then applied IHC analysis of RAS Q61R to 207 CNB samples with category III/IV in which all patients underwent surgical resection. RAS Q61R IHC had 98% sensitivity and 98% specificity for detecting the RAS p.Q16R variant. In an independent dataset, the positive rate of RAS Q61R was significantly higher in NIFTP (48%) and malignancies (45%) than in benign tumors (19%). The risk of NIFTP/malignancy was highest in the group with nuclear atypia and RAS Q61R expression (86%) and lowest in the group without both parameters (32%). The high-risk group with either nuclear atypia or RAS Q61R had 67.3% sensitivity, 73.4% specificity, 75.2% positive predictive value, and 65.1% negative predictive value for identifying NIFTP/malignancy. We conclude that RAS Q61R IHC can be a rule-in diagnostic test for NIFTP/malignancy in CNB category III/IV results. Combining of the histologic parameter (nuclear atypia) with RAS Q61R IHC results can further stratify CNB category III/IV into a high-risk group, which is sufficient for a surgical referral, and a low-risk group sufficient for observation.

Combined fine-needle aspiration with core needle biopsy for assessing thyroid nodules: a more valuable diagnostic method?

PURPOSE

This study aimed to evaluate the diagnostic value of combined fine-needle aspiration (FNA) with core needle biopsy (CNB) in thyroid nodules.

METHODS

FNA and CNB were performed simultaneously on 703 nodules. We compared the proportions of inconclusive results and the diagnostic performance for malignancy among FNA, CNB, and combined FNA/CNB for different nodule sizes.

RESULTS

Combined FNA/CNB showed lower proportions of inconclusive results than CNB for all nodules (2.8% vs. 5.7%, P<0.001), nodules ≤1.0 cm (4.9% vs. 7.3%, P=0.063), nodules >1.0 cm (2.0% vs. 5.0 %, P<0.001), nodules ≤1.5 cm (3.8% vs. 7.9 %, P<0.001), and nodules >1.5 cm (2.1% vs. 3.9 %, P=0.016). The sensitivity of combined FNA/CNB in predicting malignancy was significantly higher than that of CNB (89.0% vs. 80.0%, P<0.001) and FNA (89.0% vs. 58.1%, P<0.001) for all nodules. Within American College of Radiology Thyroid and Imaging Reporting and Data System grades 4-5, in the subgroup of nodules ≤1.5 cm, combined FNA/ CNB showed the best sensitivity in predicting malignancy (91.4%), significantly higher than that of CNB (81.0%, P<0.001) and FNA (57.8%, P<0.001). However, in the subgroup of nodules >1.5 cm, the difference between combined FNA/CNB and CNB was not significant (84.2% vs. 78.9%, P=0.500).

CONCLUSION

Regardless of nodule size, combined FNA/CNB tended to yield lower proportions of inconclusive results than CNB or FNA alone and exhibited higher performance in diagnosing malignancy. The combined FNA/CNB technique may be a more valuable diagnostic method for nodules ≤1.5 cm and nodules with a risk of malignancy than CNB and FNA alone.

A Matched-Pair Analysis of Nuclear Morphologic Features Between Core Needle Biopsy and Surgical Specimen in Thyroid Tumors Using a Deep Learning Model

Core needle biopsy (CNB) is a method that can be used as an alternative to fine-needle aspiration for the sampling of thyroid nodules to provide a preoperative diagnosis. Nuclear atypia is of paramount importance in diagnosing thyroid tumors. We aimed to identify the differences in nuclear morphologic features between CNB and surgical specimens. Quantitative image analysis was performed on whole slide images (WSI) of paired CNB and surgical specimens from 50 follicular cell-derived tumors including adenoma, non-invasive follicular thyroid neoplasm with papillary-like nuclear features, and carcinoma. The nuclear features of tumor cells were extracted from WSI using a pre-trained deep-learning model. In matched-pair analysis, the ratios (surgical specimens-to-CNB) of the mean nuclear diameters and the areas of the tumor cells were 1:0.75-0.85 and 1:0.54-0.73 according to the tumor types, respectively. The ratio of the nuclear optical density of tumor cells was 1.68-2.44 times higher in CNB specimens than it was in their corresponding surgical specimens. The significant nuclear size reduction and optical density increase in CNB were most prominent in papillary carcinoma cells. Normal follicular cells showed nuclear size reduction in CNB but no change in nuclear optical density between CNB and surgical specimens. Nuclear vacuolar artifacts mimicking nuclear pseudoinclusions were frequently seen in CNB regardless of the tumor types. In conclusion, tumor cells in CNB showed marked nuclear shrinkage, darker nuclear staining, and nuclear vacuolar changes. Awareness of the morphological differences according to the sampling types can facilitate correct diagnosis in thyroid histopathology.

Malignancy risk stratification of thyroid nodules smaller than 10 mm with ACR-TIRADS, K-TIRADS, and ATA-2015 guidelines: a prospective study

Background

Small thyroid nodules (≤ 10 mm) are common findings in thyroid ultrasonography. The first purpose of this study was to compare the performance of three guidelines in the diagnosis of malignancy for small thyroid nodules. The second aim was to find the ultrasonographic characteristics potentially associated with the risk of malignancy. This prospective cross-sectional study was performed on the patients with a diagnosis of small thyroid nodules (≤ 10 mm), who were rereferred to the radiologists for sonography and FNA. Sonographic features were recorded and scored according to the American College of Radiology-Thyroid Imaging Reporting and Data System (ACR-TIRADS), American Thyroid Association (ATA-2015), and Korean-TIRADS (K-TIRADS). Finally, FNA was conducted and cytological findings were reported.

Results

In total, 287 thyroid nodules from 256 subjects (64 men and 192 women) were finally included in the study. The accuracy of ACR-TIRADS categories TR5 and TR4/5 was 88.9% and 72.1%, respectively. This rate for ATA-2015 classes high suspicion and intermediate suspicion/high suspicion was 88.9% and 82.6%, respectively. For K-TIRADS classes 5 and 4/5, the diagnostic accuracy was 89.6% and 82.9%, respectively. Significant direct associations were found between malignancy and punctate echogenic foci (odds ratio [OR] = 6.46), hypoechogenicity (OR = 6.39), ill-defined margin (OR = 4.38), and irregular margin (OR = 7.33).

Conclusion

The differences in the strength of the three guidelines in the prediction of the malignancy should be considered by clinicians and radiologists in the management of thyroid nodules smaller than 10 mm.

Diagnostic Performance of Thyroid Core Needle Biopsy Using the Revised Reporting System: Comparison with Fine Needle Aspiration Cytology

BACKGROUND

We aim to validate the diagnostic performance of thyroid core needle biopsy (CNB) for diagnosing malignancy in clinical settings to align with the changes made in recently updated thyroid CNB guidelines.

METHODS

We retrospectively analyzed 1,381 thyroid CNB and 2,223 fine needle aspiration (FNA) samples. The FNA and CNB slides were interpreted according to the Bethesda System for Reporting Thyroid Cytopathology and updated practice guidelines for thyroid CNB, respectively.

RESULTS

Compared to FNA, CNB showed lower rates of inconclusive results categories I (2.8% vs. 11.2%) and III (1.2% vs. 6.2%), and higher rates of categories II (60.9% vs. 50.4%) and IV (17.5% vs. 2.0%). The upper and lower bounds of the risk of malignancy (ROM) for category IV of CNB were 43.2% and 26.6%, respectively. The CNB subcategory IVb with nuclear atypia had a higher ROM than the subcategory without nuclear atypia (40%-62% vs. 23%-36%). In histologically confirmed cases, there was no significant difference in the diagnostic performance between CNB and FNA for malignancy. However, neoplastic diseases were more frequently detected by CNB than by FNA (88.8% vs. 77.6%, P=0.046). In category IV, there was no difference in unnecessary surgery rate between CNB and FNA (4.7% vs. 6.9%, P=0.6361).

CONCLUSION

Thyroid CNB decreased the rate of inconclusive results and showed a higher category IV diagnostic rate than FNA. The revised guidelines for thyroid CNB proved to be an excellent reporting system for assessing thyroid nodules.

Application of biomarkers in the diagnosis of uncertain samples of core needle biopsy of thyroid nodules

Core needle biopsy (CNB) is now more frequently used for the preoperative diagnosis of thyroid nodules. Based on morphology alone, 5–20% of CNB samples cannot be determined as malignant or benign. Compared to fine-needle biopsy (FNB), samples collected by CNB are more accessible for various tests. Therefore, studying biomarkers’ application in distinguishing uncertain CNB samples of thyroid nodules is a practical need. Patients of thyroid nodules with both CNB and matched resected specimens were reviewed. Cases classified as indeterminate lesions, follicular neoplasms, and suspicious for malignancy were retrieved. All CNB samples were stained by immunohistochemistry (IHC) using antibodies against CK19, galectin-3, HBME-1, and CD56 and detected by next-generation sequencing (NGS) using an OncoAim® thyroid cancer multigene assay kit (Singlera Genomics) that detected 26 genes. Taking the resected specimens’ classification as the gold standard, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy of a single biomarker, and various combinations for discriminating malignancy from benignity were calculated. The sensitivity, specificity, PPV, NPV, and accuracy for preoperative malignancy evaluation were as follows. In the cohort of non-follicular-neoplasm-lesions (non-FN-lesion), they were 95.16%, 53.85%, 90.77%, 70.00%, and 88.00% for CK19; 95.16%, 38.46%, 88.06%, 62.50%, and 85.33% for galectin-3; 77.42%, 76.92%, 94.12%, 41.67%, and 58.00% for HBME-1; 66.13%, 100.00%, 100.00%, 38.24%, and 72.00% for CD56; 90.32%, 92.31%, 98.25%, 66.67%, and 90.67% for NGS; and 88.71%, 92.30%, 98.21%, 63.16%, and 89.33% for integrated IHC. In the cohort of follicular neoplasms (FN), they were 30.43%, 77.77%, 77.77%, 30.43%, and 43.75% for CK19; 73.91%, 66.67%, 85.00%, 50.00%, and 71.88% for galectin-3; 26.09%, 88.89%, 85.71%, 32.00%, and 43.75% for HBME-1; 26.09%, 100.00%, 100.00%, 34.62%, and 46.88% for CD56; 52.17%, 88.89%, 92.31%, 42.11%, and 62.50% for NGS; 82.61%, 66.67%, 86.36%, 60.00%, and 78.13% for integrated IHC; and 100%, 66.67%, 88.46%, 100%, and 90.63% for integrated IHC-NGS. The application of biomarkers in distinguishing uncertain CNB samples of thyroid nodules is available and capable. CD56 negative or NGS positive suggests malignancy strongly for both FN and non-FN-lesion, which may be used as a “rule in” tool. The negative predictive value of the integrated IHC and the integrated IHC-NGS implies a high possibility to be benign for non-FN-lesion and FN separately, which can work as a “rule out” tool. Considering the balance of specificity and sensitivity, NGS is the best for non-FN-lesion and the integrated IHC-NGS is the best for FN.

Diagnostic performance of core needle biopsy as a first-line diagnostic tool for thyroid nodules according to ultrasound patterns: Comparison with fine needle aspiration using propensity score matching analysis

OBJECTIVE

This study aimed to compare the diagnostic performance of core-needle biopsy (CNB) to fine-needle aspiration (FNA) as a first-line diagnostic tool in initially detected thyroid nodules, according to ultrasound (US) patterns.

MATERIALS AND METHODS

This study included 778 consecutive nodules from 705 patients who underwent CNB from one institution and 627 nodules from 583 patients who underwent FNA from two institutions. Adjustments for significant differences in patients' characteristics were facilitated via propensity score matching. We compared the diagnostic performance of CNB and FNA for thyroid malignancy according to three diagnostic criteria for all nodules and the US patterns.

RESULTS

A 1:1 matching of 469 patients yielded no significant differences between CNB and FNA for any covariates. CNB showed a significantly higher sensitivity for malignancy than FNA with any criterion (criterion 1: category VI, criterion 2: category V and VI, criterion 3: category IV, V and VI) in overall and high suspicion nodules (90.1-99.5% vs 69.7%-88.3%, all P-values < 0.001) and low/intermediate suspicion nodules, except criterion 1 (61.9%-100% vs 36.4%-45.5%, all P ≤ .016). In ROC curve analysis, the areas under the ROC curve of CNB were significantly higher than those for FNA with any criterion in overall and high suspicion nodules (P < .001) and in low/intermediate suspicion nodules, except criterion 1 (P ≤ .008). CNB had a slightly higher minor complication rate than FNA (0.7% vs 0%, P ≥ .069).

CONCLUSION

Our study suggests that CNB has a complementary role as an alternative first-line diagnostic tool to FNA for the initial diagnosis of thyroid nodules when performed by an experienced operator.

Evaluating biochemical differences in thyroglobulin from normal and goiter tissues by infrared spectral imaging

Thyroglobulin is a glycoiodoprotein that is produced by thyroid follicular cells; it is stored in follicles in structures known as colloids. The main function of this protein is to stock the hormones triiodothyronine (T3) and thyroxine (T4) until the body requires them. This study aims to demonstrate that infrared spectral imaging with appropriate multivariate analysis can reveal biochemical changes in this glycoprotein. The results achieved herein point out biochemical differences in the colloid samples obtained from normal and goiter patients including glycosylation and changes in the secondary conformational structure. We have presented the first spectral histopathology-based method to detect biochemical differences in thyroid colloids, such as TG iodination, glycosylation, and changes in the secondary structure in normal and goiter patients. The observed changes in the colloids were mainly due to the alterations in amide I and amide II (secondary conformation of proteins) and there is a correlation with different glycosylation between normal and goiter tissues.

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.

Diagnostic Efficacy and Safety of Core Needle Biopsy as a First-Line Diagnostic Method for Thyroid Nodules: A Prospective Cohort Study

Background: The diagnostic role of ultrasonography (US)-guided core needle biopsy (CNB) as a first-line diagnostic method for thyroid nodules remains controversial. This study was performed to determine the diagnostic efficacy and safety of CNB as a first-line diagnostic method for thyroid nodules. Methods: From February 2016 to January 2018, CNB was prospectively performed by an experienced radiologist in all consecutive patients with thyroid nodules indicated for fine-needle aspiration (FNA). Three patients refused this protocol. Finally, 212 consecutive patients with 248 thyroid nodules were enrolled in this prospective study. Combined CNB/FNA was selectively performed in 43 patients. The diagnostic efficacy of CNB was evaluated by the rate of inconclusive results (nondiagnostic or indeterminate results), and its feasibility was estimated by calculating the successful biopsy rate and by measuring the procedure time from the time of the initial skin puncture to the last withdrawal of the biopsy needle from the skin. The safety of the procedure was evaluated by the major and minor complication rates. A US evaluation was performed before and after manual self-compression to assess for hemorrhage at the biopsy site, and delayed complications were assessed 5-7 days after the biopsy. Any hemorrhage that did not require hospitalization was classified as a minor complication. Results: CNB was performed once (n = 125, 50.4%), twice (n = 122, 49.2%), or three times (n = 1, 0.4%) per nodule. The diagnostic results of CNB were as follows: nondiagnostic (0.8%), benign (63.3%), indeterminate (10.1%), follicular neoplasm (3.2%), suspected malignancy (2.4%), and malignancy (20.1%); the rate of inconclusive results was 10.9%. The successful biopsy rate of CNB was 100%, and the median procedure time was 102 seconds (interquartile range 51-181 seconds). There were no major or delayed complications. There were 6 cases (2.8%) of minor complications, which included 2 cases (0.9%) with symptomatic hematomas and 4 cases (1.9%) with asymptomatic small hematomas. Conclusion: The findings confirm that CNB is effective in reducing the rate of inconclusive results and it is safe. CNB may be used as an alternative first-line diagnostic method for thyroid nodules by an experienced operator.

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.

The relationship of thyroid nodule size on malignancy risk according to histological type of thyroid cancer

Background

Although several studies have examined the value of thyroid nodule size as a malignancy predictor, the results are conflicting.

Purpose

To investigate the relationship between nodule size and malignancy risk and to evaluate the impact of nodule size on the false-negative rate of fine needle aspiration or core needle biopsy according to the histological type of thyroid cancer.

Material and Methods

From January 2013 to December 2013, 3970 thyroid nodules that underwent ultrasound-guided fine needle aspiration or core needle biopsy were retrospectively reviewed. We assessed the relationship between nodule size and malignancy risk according to histological type of thyroid cancer. In addition, we compared the false-negative rate by thyroid nodule size category.

Results

Of 3970 thyroid nodules, 1170 nodules were malignant. For papillary thyroid carcinoma, nodule size was inversely related to malignancy risk, whereas in nodules of follicular carcinoma and follicular variant papillary thyroid carcinoma, nodule size was positively related to malignancy risk ( P < 0.001). The false-negative rate tended to increase as nodule size increased ( P = 0.002) for all nodules and the overall false-negative rate was 2.3%.

Conclusion

Overall, nodule size does not correlate with risk of malignancy, but the relationship between nodule size and malignancy risk depends on the histological type of thyroid cancer.

Comparison Between Fine Needle Aspiration and Core Needle Biopsy for the Diagnosis of Thyroid Nodules: Effective Indications According to US Findings

Thyroid nodules are initially handled by fine needle aspiration (FNA). However, the stance of thyroid core needle biopsy (CNB) still is a challenge. This study aimed to compare the diagnostic performances and conclusive rates of FNA and CNB for the diagnosis of thyroid nodules and to define effective indications of CNB. This retrospective study enrolled 1,060 consecutive thyroid nodules in 1,037 patients who underwent FNA from January 2008 to May 2008, and 462 consecutive nodules in 453 patients who underwent CNB from January 2014 to December 2015 at our institution. Ultrasound (US) features were classified according to the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) and Korean TIRADS (K-TIRADS). We compared diagnostic performances and conclusive rates between FNA and CNB groups. Propensity score matching was conducted to match FNA patients with CNB patients. After matching, the diagnostic performances for selecting surgical candidates and predicting malignancy were comparable between the two biopsy groups. Based on US findings, conclusive results were obtained significantly more in CNB than in FNA when thyroid nodules were classified as ACR TI-RADS or K-TIRADS category 4 and measured larger than 2 cm. Diagnostic performances between FNA and CNB were comparable. Superiority of CNB to FNA was found for thyroid nodules larger than 2 cm and classified as ACR TI-RADS or K-TIRADS category 4.

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.

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

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

Preoperative Diagnostic Categories of Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features in Thyroid Core Needle Biopsy and Its Impact on Risk of Malignancy

This study was designed to evaluate the preoperative diagnostic categories of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) using thyroid core needle biopsy (CNB) and to analyze its impact on the risk of malignancy (ROM). A total of 2687 consecutive thyroid CNBs were reviewed retrospectively and classified into six diagnostic categories using a standardized reporting system similar to the Bethesda System for Reporting Thyroid Cytopathology. Diagnostic categories of CNBs were compared with the final surgical diagnoses, and the ROM in each category was calculated both before and after excluding NIFTP from malignancy. Of 946 surgically resected cases, 683 were diagnosed as papillary thyroid carcinoma (PTC), and 32 (4.7% of PTC) were reclassified as NIFTP. The CNB diagnostic categories of NIFTP were as follows: follicular neoplasm in 20 (62.5%; 14, with nuclear atypia), indeterminate lesion in 11 (34.4%), and suspicious for malignancy in one (3.1%). When combined, NIFTP and encapsulated follicular variant of PTC (EFVPTC) were more often categorized as follicular neoplasm compared with other PTC variants including infiltrative FVPTC. Exclusion of NIFTP from malignant diagnosis led to a significant decrease in the ROM in follicular neoplasm with nuclear atypia category. Thus, thyroid CNB enables to differentiate NIFTP/EFVPTC from other PTCs, providing a useful guide for optimal treatment in patients with these tumors.

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.

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.

Pathological diagnosis of thyroid nodules based on core needle biopsies: comparative study between core needle biopsies and resected specimens in 578 cases

BACKGROUND

Pathological diagnosis based on core needle biopsy (CNB) should be different from a resected specimen because it is difficult to apply the histological criteria established for resected specimens to CNB due to sampling limitations. A pathological classification for thyroid nodule on CNB was first proposed by the Korean Group in 2015. The objective of this study was to test the reliability and clinical value of this proposal.

METHODS

According to the Korean proposal, the CNB diagnoses were categorized into unsatisfactory, benign, indeterminate, follicular neoplasm, suspicious for malignancy and malignant. A comparative study between the diagnoses of CNB and resected specimens was performed.

RESULTS

The consistency was moderate (κ = 0.448). Combined indeterminate, suspicious for malignancy and malignant into a single group collectively referred to as "malignant" with the remaining merged into "others", CNB demonstrated a 95.93% sensitivity, 97.30% specificity, 62.07% accuracy, 99.81% positive predictive value (PPV) and 62.07% negative predictive value (NPV) for preoperative malignancy evaluation.

CONCLUSIONS

The Korean proposal for pathological classification of thyroid nodules on CNB is objective, operable and highly valuable.

Role of Immunohistochemistry in Fine Needle Aspiration and Core Needle Biopsy of Thyroid Nodules

Objectives

Immunohistochemistry (IHC) has been used for the diagnosis of indeterminate results in fine needle aspiration (FNA) of thyroid nodules. However, the role of IHC in core needle biopsy (CNB) is not clear and the efficacy of testing for molecular markers following CNB has not been evaluated. The aim of this study is to compare the role of IHC staining in CNB with that in FNA when examining thyroid nodules and to compare the sensitivity and usefulness of different molecular markers.

Methods

Consecutive cases of thyroid FNA and CNB accompanied by IHC from 2004 to 2014 were included in this study with retrospective review of medical record. The rate of remaining nondiagnostic result (unsatisfactory, atypia of undetermined significance or follicular lesion of undetermined significance [AUS/FLUS]) and rate of strong expression of each molecular marker according to the diagnosis were evaluated.

Results

IHC was more frequently performed in CNB with multiple molecular markers compared to FNA (38.1% vs. 2.8%, 3 or 4 markers [Gal-3, HBME-1, CK19, and CD56] vs. 1 marker [Gal-3]). In the CNB group, 11.3% remained as AUS/FLUS after IHC, and the rate remaining nondiagnostic was significantly less than in the FNA group (42.9%). Gal-3 and CK19 showed higher specificity and expressed mainly in conventional type of papillary carcinoma and HBME-1 showed higher sensitivity for the diagnosis of carcinoma with expression in both conventional type and follicular variant papillary thyroid carcinoma.

Conclusion

With these data, we could conclude that IHC was more effective following CNB than following FNA.

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.

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

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

Evaluation of Modified Core-Needle Biopsy in the Diagnosis of Thyroid Nodules

Objective

Core needle biopsy (CNB) of the thyroid is an additional diagnostic method for non-diagnostic or indeterminate cytology samples. We sought to evaluate a new modified core biopsy technique and compare the concordance of its diagnosis with the final diagnosis of the surgically resected specimen.

Materials and Methods

A retrospective analysis was conducted on 842 patients who had a thyroid CNB with or without a previous fine-needle aspiration from August 2002 to March 2015; 38% of patients ultimately underwent thyroidectomy. We divided the patients into two groups for comparison: conventional group (n = 329) and new modified technique group (n = 513) that enabled sampling of not only the lesion but also the margin and surrounding parenchyma. The diagnostic conclusiveness of CNB and concordant rate with thyroidectomy was compared between the two groups.

Results

The overall diagnostic conclusiveness did not exhibit a significant increase (77% in the conventional technique group and 75% in the modified technique group, p = 0.408). In terms of the diagnostic concordance rate between CNB and thyroidectomy, no overall significant increase was observed (83% in the conventional technique group and 88% in the modified technique group, p = 0.194). However, only in follicular-patterned lesions (nodular hyperplasia, follicular neoplasm, and follicular variant of papillary thyroid carcinoma), a significant increase in the diagnostic concordance rate was observed (83% in the conventional group and 94% in the modified technique group, p = 0.033).

Conclusion

Modified CNB technique can be beneficial for the accurate diagnosis of follicular-patterned thyroid lesions.

The role of core needle biopsy in the diagnosis of initially detected thyroid nodules: a systematic review and meta-analysis

OBJECTIVES

To systematically review the published literature and evaluate the efficacy and safety of core needle biopsy (CNB) for initially detected thyroid nodules.

METHODS

The Ovid-MEDLINE and Embase databases were searched for studies evaluating CNB for the diagnosis of initially detected thyroid nodules. A meta-analysis was performed to evaluate non-diagnostic results, inconclusive results and diagnostic accuracy for a diagnosis of malignancy with CNB. To overcome heterogeneity, multiple subgroup analyses were performed. The complication rate was also evaluated.

RESULTS

Thirteen eligible studies, which included a total sample size of 9,166 patients with 13,585 nodules, were included. The pooled proportions were 3.5% (95% CI 2.4-5.1) for non-diagnostic results and 13.8% (95% CI 9.1-20.3) for inconclusive results. Considerable heterogeneity was observed among the studies in terms of the pooled proportions for CNB (I²=92.9%, 97%). With regard to the diagnostic performance for malignancy, the sensitivity was 80% (95% CI 75-85) and the specificity was 100% (95% CI 93-100). Only two major complications of CNB were observed.

CONCLUSIONS

CNB demonstrates a low non-diagnostic result rate and high diagnostic accuracy for initially detected thyroid nodules and a low major complication rate. These findings indicate that CNB may be a feasible diagnostic tool for patients with initially detected thyroid nodules.

KEY POINTS

CNB demonstrates high diagnostic accuracy for initially detected thyroid nodules. CNB demonstrates a low major complication rate. CNB may be a feasible diagnostic tool for patients with initially detected thyroid nodules.

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.

Nuclear features of papillary thyroid carcinoma: Comparison of Core needle biopsy and thyroidectomy specimens

BACKGROUND

Core needle biopsy (CNB) has been used as an alternative or a complementary method for diagnosis of thyroid nodules. However, morphological analysis of the nuclear features of papillary thyroid carcinoma (PTC) cells obtained via CNB remains unclear. Hence, we examined the differences between the PTC nuclear features in CNB and thyroidectomy specimens.

METHODS

Ten PTC patients, who underwent both CNB and thyroidectomy, were selected. Microscopic photographs of three representative areas of the PTC and adjacent parenchyma were taken. Ten cells per photograph were chosen, and 1200 cells were evaluated (300 PTC and 300 follicular cells in the CNB and thyroidectomy specimens, respectively). The area, circumference, major axis, and minor axis were measured using an image analyzer. Detailed nuclear features (size and shape, membrane irregularity, chromatin characteristics) were scored using a 3-point scale.

RESULTS

The mean nuclear area, circumference, major axis, and minor axis of PTC cells in the CNB specimen were 1.76, 1.34, 1.34, and 1.29 times larger than those of the follicular cells (p<0.001); similar results were seen in the thyroidectomy specimens (2.04, 1.41, 1.37, and 1.37: p<0.001). Comparative analysis revealed that these parameters were significantly smaller in the CNB specimens than those in the thyroidectomy specimens (p<0.001). Nuclear grades were also lower in the former owing to poor chromatin characteristics (clearing and margination) (p<0.01).

CONCLUSION

Considering that the PTC nuclei in CNB specimens are smaller with fewer irregularities and less clear than those in thyroidectomy specimens, we need to emphasize caution when using CNB specimens for diagnosis.

Integration of biomimicry and nanotechnology for significantly improved detection of circulating tumor cells (CTCs)

Circulating tumor cells (CTCs) have received a great deal of scientific and clinical attention as a biomarker for diagnosis and prognosis of many types of cancer. Given their potential significance in clinics, a variety of detection methods, utilizing the recent advances in nanotechnology and microfluidics, have been introduced in an effort of achieving clinically significant detection of CTCs. However, effective detection and isolation of CTCs still remain a tremendous challenge due to their extreme rarity and phenotypic heterogeneity. Among many approaches that are currently under development, this review paper focuses on a unique, promising approach that takes advantages of naturally occurring processes achievable through application of nanotechnology to realize significant improvement in sensitivity and specificity of CTC capture. We provide an overview of successful outcome of this biomimetic CTC capture system in detection of tumor cells from in vitro, in vivo, and clinical pilot studies. We also emphasize the clinical impact of CTCs as biomarkers in cancer diagnosis and predictive prognosis, which provides a cost-effective, minimally invasive method that potentially replaces or supplements existing methods such as imaging technologies and solid tissue biopsy. In addition, their potential prognostic values as treatment guidelines and that ultimately help to realize personalized therapy are discussed.

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.

Utility of a formatted pathologic reporting system in thyroid core needle biopsy: A validation study of 1998 consecutive cases

OBJECTIVE

Thyroid core needle biopsy (CNB) is increasingly being used as a tool for evaluating thyroid nodules; thus, standardization of its diagnostic terminology is called for. We aimed to analyse the pathologic reporting system of thyroid CNB based on the recently proposed protocol by the Korean Endocrine Pathology Thyroid Core Needle Biopsy Study Group and evaluate its usefulness.

DESIGN/METHODS

A total of 1998 consecutive cases of thyroid CNBs were reviewed and divided into six categories according to the protocol. Malignancy rate in each category and the diagnostic performance of thyroid CNB were calculated using 705 resected cases.

RESULTS

Thyroid CNB yielded 132 nondiagnostic (6.6%), 791 benign (39.6%), 328 indeterminate (16.4%), 227 follicular neoplasm (11.4%), 69 suspicious for malignancy (3.5%) and 451 malignant lesions (22.6%). In resected specimens, all of the cases designated as suspicious for malignancy and malignant categories in CNB were proven to be true malignant lesions. Lesions diagnosed with follicular neoplasm in CNB were identified as malignant lesions in 57.0%. Malignancy rate was significantly higher in indeterminate lesions with nuclear atypia compared to those with architectural atypia (80.0% vs 28.2%). When CNB diagnoses of indeterminate lesions or higher categories were considered positive, the sensitivity and positive predictive value for final malignant diagnoses were 99.2% and 81.3%, respectively.

CONCLUSIONS

CNB is an accurate method of evaluating thyroid nodules and can serve as an alternative to fine needle aspiration when it is used and reported according to standardized diagnostic categories.

Recent Advances in Core Needle Biopsy for Thyroid Nodules

Core needle biopsy (CNB) was introduced as an alternative diagnostic tool to fine-needle aspiration (FNA), and is increasingly being used in the preoperative assessment of thyroid nodules. CNB provides a definitive diagnosis in most cases, but it sometimes may be inconclusive. CNB has the advantage of enabling a histologic examination in relation to the surrounding thyroid tissue, immunohistochemistry, and molecular testing that can provide a more accurate assessment than FNA in selected cases. Nevertheless, CNB should be performed only by experienced experts in thyroid interventions to prevent complications because CNB needles are larger in caliber than FNA needles. As recent evidence has accumulated, and with improvements in the technique and devices for thyroid CNB, the Korean Society of Thyroid Radiology released its 2016 thyroid CNB guidelines and the Korean Endocrine Pathology Thyroid Core Needle Biopsy Study Group published a consensus statement on the pathology reporting system for thyroid CNB in 2015. This review presents the current consensus and recommendations regarding thyroid CNB, focusing on indications, complications, and pathologic classification and reporting.

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

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

The effect of routine radiological reporting of thyroid incidentalomas on rates of thyroid needle biopsy, thyroid surgery and detection of thyroid malignancy

OBJECTIVE

This study looked at the effect of a changing radiology reporting policy to routinely review the thyroid gland where visible and report on any thyroid lesion, recommending further investigation as appropriate.

CONTEXT

Incidentaloma is a term used to describe a lesion found on imaging unrelated to the clinical issue under investigation. There is variability in the radiological reporting of thyroid incidentalomas and conflicting recommendations as to how these lesions should be managed.

DESIGN

Data were collected retrospectively during a two-year period, including 12 months before and 12 months after the change in reporting policy and categorized according to whether the lesion under investigation was a thyroid incidentaloma or a symptomatic thyroid lesion.

PATIENTS

All patients undergoing ultrasound-guided fine-needle aspiration cytology or core biopsy were included.

MEASUREMENTS

The effects of the change in policy were analysed including rates of needle biopsy, rates of malignancy and subsequent surgical intervention.

RESULTS

There was a 122% increase in thyroid incidentalomas undergoing needle biopsy, the majority of these were detected on computed tomography. The number of malignancies increased from 1 to 4 from year 1 to year 2. All patients were >35 years old. One patient had a positron emission tomography (PET)-detected cancer, two of four of the non-PET-detected malignancies were <1.5 cm.

CONCLUSION

This study posits that routine radiological reporting of thyroid incidentalomas, with further investigation when clinically appropriate, is warranted. The results suggest that lesion size and CT characteristics are not reliable criteria to triage patients for investigation/biopsy.

Role of core needle biopsy as a first-line diagnostic tool for thyroid nodules: a retrospective cohort study

PURPOSE

The purpose of this study was to evaluate the diagnostic efficacy of fine-needle aspiration (FNA), core needle biopsy (CNB), and combined FNA/CNB for the first-line diagnosis of thyroid nodules.

METHODS

A total of 782 consecutive nodules that underwent simultaneous FNA and CNB were analyzed in this study. We compared the rate of inconclusive results and the diagnostic values for malignancy among FNA, CNB, and combined FNA/CNB.

RESULTS

CNB showed a lower rate (10.2%) of inconclusive results than FNA (23.7%) (P&lt;0.001). Combined FNA/CNB showed a lower rate (6.5%) of inconclusive results than FNA (all nodules, P&lt;0.001; macronodules, P&lt;0.001; and micronodules, P&lt;0.001, respectively) or CNB (all nodules, P&lt;0.001; macronodules, P&lt;0.001; and micronodules, P=0.003, respectively). Combined FNA/ CNB and CNB showed significantly higher sensitivity, accuracy, and diagnostic performance for malignancy as defined by criterion 1 (Bethesda category VI) or criterion 2 (Bethesda categories IV/V/VI) than FNA (P&lt;0.001). However, there was no significant difference in the sensitivity, accuracy, or diagnostic performance between combined FNA/CNB and CNB (with criterion 1, P=0.063, P=0.063, and P=0.412, respectively; with criterion 2, P=0.500, P=0.500, and P=0.348, respectively).

CONCLUSION

CNB was found to be more effective than FNA for the diagnosis of thyroid nodules, and its sensitivity and diagnostic performance for malignancy were similar to those of combined FNA/CNB. CNB has the potential to be an effective alternative first-line diagnostic tool for thyroid nodules when performed by an experienced operator.

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 differential diagnosis of thyroid nodules: A systematic review and meta-analysis

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

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.

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 the efficacy and safety of ultrasound-guided core needle biopsy versus fine-needle aspiration for evaluating thyroid nodules

OBJECTIVE

Ultrasound-guided core needle biopsy (UG-CNB) is a procedure that is often performed either after repeated inadequate or nondiagnostic ultrasound-guided fine-needle aspiration (UG-FNA) or in combination with UG-FNA in the evaluation of thyroid nodules. The purpose of this study was to compare the efficacy and safety of UG-CNB and UG-FNA for evaluating thyroid nodules.

METHODS

This was a retrospective study of 350 consecutive patients who had thyroid nodules biopsied by UG-CNB or UG-FNA from January 2007 until November 2011 at our institution. Biopsy results were compared to the surgical specimen pathology reports for the 105 patients who subsequently underwent hemi- or total thyroidectomy in order to determine whether UG-CNB has advantages over UG-FNA for diagnosing thyroid malignancy and neoplasia.

RESULTS

Out of 461 thyroid nodules biopsied from 350 patients, 365 (79%) involved UG-CNB and 96 (21%) involved UG-FNA. The UG-FNA biopsy group had a significantly higher rate of inadequate sampling than the UG-CNB group (P<.0001; Fisher's exact test). Out of 365 UG-CNB samples, 6 (2%) were deemed inadequate for histologic diagnosis, whereas 26 (27%) of the 96 UG-FNA samples were considered inadequate for cellularity. Comparison of biopsy results with the surgical specimen pathology reports revealed that the diagnostic accuracy of UG-CNB and UG-FNA for detecting malignancy was similar, at 89 and 94%, respectively (not significant by Fisher's exact test). However, the UG-CNB group had a higher detection rate for benign follicular lesions compared to the UG-FNA group (65% versus 48% for UG-FNA; P = .002). Although UG-FNA detected neoplasia with high sensitivity (100%), the specificity was poor (30%). Neither biopsy group had any significant immediate or delayed procedure-related complications.

CONCLUSION

Our study demonstrated that UG-CNB is safe and is less likely to result in a nondiagnostic biopsy. The accuracy of the UG-CNB technique is similar to that of UG-FNA for detecting thyroid malignancy.