Surgeon-performed ultrasound guided fine-needle aspirate biopsy with report of learning curve; a consecutive case-series study

A comparison of ultrasound-guided aspiration with open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis

OBJECTIVES

Image-guided aspiration has been proposed as an alternative to the traditional open drainage in acute suppurative cervical lymphadenitis, although little evidence comparing these approaches exists. The aim of this study was to compare ultrasound-guided aspiration and open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis.

METHODS

Patients treated for acute suppurative cervical lymphadenitis at a tertiary referral pediatric hospital over a three-year period were retrospectively analyzed.

RESULTS

Of eighteen patients included, 9 (50 %) underwent aspiration and 9 (50 %) underwent open surgical drainage. None required repeat intervention or readmission over a median follow up of 10.5 weeks. Those undergoing aspiration had a shorter post-operative length of stay (1.67 vs 4.33 days, p = 0.001) compared with open surgical drainage.

CONCLUSION

Ultrasound-guided aspiration of pediatric acute suppurative cervical lymphadenitis is a safe and effective alternative to open drainage.

Intraoperative Sentinel Node Fine-Needle Aspiration Biopsy as a Substitute for Whole Sentinel Node Excisional Biopsy in Breast Cancer Patients. Initial Report

INTRODUCTION

Sentinel Node Biopsy (SNB) is the choice procedure for axillary staging in Breast Cancer. Following the ACOSOG Z11 trial, axillary dissection is advised only in patients with more than 2 positive SNs. We aimed at exploring palpation-guided, intraoperative fine-needle aspiration biopsy of the SN as a replacement for whole SN excision in node-negative BC patients to minimize side-effects.

PATIENTS AND METHODS

We included 80 patients with BC undergoing SNB between December 2020 and May 2022. After identification of the SN, the breast surgeon performed SN-FNAB. Results were compared with definitive pathological assessment. ResultsDiagnostic yield was 80%, including a "learning curve." 58 of 64 patients with suitable samples tested negative. In this group, the Negative Predictive Value was 77.6% (IC 64.7%-87.5 %). If micro metastasis is disregarded, the NPV would increase to 86.2% (IC 74.6%-93.9%). If we accept the Z11 criterion for axillary dissection, the NPV would rise to 100%. Six patients had a positive SN-FNAB. They were all confirmed as having macro metastatic-positive SNs at the final pathological assessment, and 3 of them also displayed extra nodal extension (ENE).

CONCLUSION

We believe that intraoperative SN-FNAB is highly accurate for swiftly depicting both low axillary tumor burden/negative cases, in whom axillary dissection is to be omitted, as well as high axillary tumor burden cases.

THE LEARNING CURVE AND PERFORMANCE OF A NEWLY ESTABLISHED THYROID FINE-NEEDLE ASPIRATION CENTER

Context

Thyroid fine-needle aspiration (FNA) cytology is the best tool for preoperative diagnosis of thyroid carcinoma; however, its learning curve is poorly described. Our aim was to assess the learning curve of a new thyroid FNA center involving unexperienced operator and pathologist.

Methods

We retrieved from our tertiary endocrinology center database all thyroid FNA procedures done by a single operator (endocrinologist with no experience in FNA) between 2018 and 2021. Cytology was assessed by two pathologists with limited or no experience in thyroid cytology. We also got the corresponding sex, age, nodule diameter, EU-TIRADS score, Bethesda category and final pathology report.

Results

There were 1872 FNA in 1618 patients. Proportion of Bethesda 1 nodules decreased significantly (p for trend=0.003) from 17% in the first 100 FNA procedures to 4% in the 401-500 group of procedures, and remained constant between 9% and 4% (p for trend=NS) for the rest of the study. Proportion of Bethesda 2 rose steady from 26% in the first 100 nodules to 80.1% in the last 241 nodules (p for trend<0.001). Indeterminate lesions (Bethesda 3 and 4) decreased significantly (p for trend=0.001) from 16% and 35% in the first 100 nodules to 2.5% and 5.8% in the last 241 lesions. Proportions of Bethesda 5+6 categories varied non-significantly over time. There were no time trends in the malignancy rate of surgically removed nodules.

Conclusions

At least 300 procedures are needed to reach the standard performance. A steadily state for the whole center is obtained after about 500 procedures.

Surgeon-performed ultrasound with fine-needle aspiration biopsy for the diagnosis of parotid gland tumors

BACKGROUND

Ultrasound (US) with or without fine-needle aspiration cytology (FNAC) are readily available and can offer in office and rapid diagnosis of parotid lumps.

METHODS

We analyzed 398 of patients who underwent blind FNAC or US with FNAC performed by an operating head and neck surgeon. Specificity, sensitivity, as well as accuracy were calculated for US alone, FNAC alone, and US-FNAC combined.

RESULTS

Nondiagnostic US-guided FNAC rate was 3.1% and 7.2% for blind FNAC. With those cases removed, final accuracy for US alone in diagnosis of malignancy, pleomorphic adenoma (PA), and Warthin tumor (WT) were 90.8%, 81%, and 77.4% respectively. For US-FNAC accuracy for malignancy, PA, and WT were 92.1%, 94 0.8%, and 95.4% respectively.

CONCLUSION

US with FNAC is cost-effective and rapid diagnostic tool and may help surgeon to deliver more accurate informed consent to a patient.

Standardization of thyroid fine needle aspiration procedure and outcomes within an endocrine surgery department

Background

Fine needle aspiration (FNA) biopsy is an essential procedure for thyroid nodules. Although, the efficacy of surgeon-performed thyroid FNA biopsies has been demonstrated in the literature, there are insufficient data regarding how to establish an efficient program with a low insufficiency rate within a group practice.

Methods

An endocrine surgery thyroid FNA biopsy program was established in 2000 by one surgeon, with training of additional partners during fellowship and upon recruitment. The results within 18 years were analyzed. The FNA biopsies were performed by endocrine surgeons under ultrasound guidance without on-site pathologist review.

Results

A total of 5,469 FNA biopsies were performed by 7 surgeons. The total number of FNA biopsies performed by each surgeon varied between 291-1,378. FNA biopsies were performed in 2 passes using 22-gauge needles under constant suction. The overall insufficiency rate was 4.3%, with individual surgeon rates ranging between 2.7% and 7.2%. The insufficiency rate for the whole team ranged between 3.3% and 5% when examined in 5-year blocks.

Conclusions

This study shows that an establishment of a highly efficient thyroid FNA biopsy program within a group practice is possible with a structured endocrine surgical training and adoption of a standard technique.

Diagnostic Accuracy of Fine-Needle Aspiration Cytology in Head and Neck Lesions from a Tertiary Health Facility in Southwestern Nigeria

Background

Fine-needle aspiration cytology (FNAC) is widely employed as an initial investigative tool in the diagnosis of various lesions in the body, however, it is limited in the provision of precise architectural detail of lesions. This is said to be responsible for the wide variation in the documented usefulness and accuracy relative to histopathology. This study aimed to correlate cytopathological and histopathological examination (HPE) of head and neck lesions, and assess the usefulness and accuracy of FNAC in our center.

Materials and Methods

This was a retrospective study that utilized historical data obtained from case notes and histopathology records of 91 patients that had both FNAC and HPE done for head and neck lesions in our center during the study. The FNAC results were correlated with that of the histopathological diagnosis to obtain the accuracy of the FNAC diagnosis. Diagnostic validity of FNAC in terms of sensitivity, specificity, and predictive value were also evaluated.

Results

A total of 91 FNAC-HPE sample pairs were included. The Sensitivity and specificity for benign lesion was 95.4% and 42.3%, respectively, while for sensitivity and specificity for malignant lesion was 31.8% and 96.9%, respectively. The overall Sensitivity and specificity for cytology was 96.8% and 30.4%, respectively.

Conclusion

FNAC appears to be a useful tool in the initial assessment of head and neck lesions in our center, however, the high rate of missed diagnosis especially as concerned malignancies has dire negative treatment implications. There is need to develop capacity for improved skill in making cytopathologic diagnoses among anatomical pathologists involved in the use of FNAC as diagnostic and screening tool.

Surgeon-performed ultrasound in a head and neck surgical oncology clinic: saving time and improving patient care

INTRODUCTION

Surgeon-performed ultrasound (SUS) for head and neck masses is increasingly being performed by head and neck surgeons. This is the first study assessing its impact in a head and neck surgical oncology clinic, examining the effect on various parameters.

METHODS

Retrospective analysis was conducted on a database, analysing and comparing all new patients reviewed 6 months prior to (pre-SUS group) and 6 months following (post-SUS group) the introduction of SUS to the outpatient head and neck surgical oncology clinic. The numbers of radiology imaging investigations (ordered through a medical imaging department), fine-needle aspirations (FNAs) performed, clinical appointments and time to definitive treatment decision were analysed and compared.

RESULTS

A total of 365 patients were included: 169 in the pre-SUS group and 196 in the post-SUS group. There was a statistically significant difference in the number of total radiological imaging investigations performed (1.60 vs. 0.70, p < 0.00001), radiologist-performed FNAs (0.24 vs. 0.10, p = 0.0234), time for definitive treatment decision being made (16.4 days vs. 11.6 days, p = 0.04338), and number of clinical encounters (3.03 vs. 2.29, p < 0.00001). No statistically significant difference was observed in the number of head and neck surgical oncology clinic appointments (1.70 vs. 1.66, p = 0.6672).

CONCLUSION

Surgeon-performed ultrasound reduces the number of radiological imaging investigations and FNAs performed, reduces time for definitive treatment decision being made, and reduces the number of clinical encounters for patients. This supports its use in head and neck cancer setting and has important implications for both patients and the health-care system.

Ultrasound-Guided Fine-Needle Biopsy of First 1000 Consecutive Thyroid Nodules: Single-Surgeon Experience

Objective

To study the feasibility, safety, and learning curve of ultrasound-guided fine-needle biopsy (USGFNB) performed by a newly trained otolaryngologist in a community office in a setting.

Study Design

Collect USGFNB data of all thyroid nodules in a prospective manner.

Setting

A dedicated ultrasound clinic in a large community-based practice, operated by a single surgeon with the purpose of providing office-based point-of-care diagnostic ultrasonography and USGFNB.

Subjects and Methods

Data on the first 1000 unselected consecutive thyroid nodules that underwent USGFNB over a 3-year period were analyzed. Chi-square analysis was used to assess the statistical significance of characteristics of diagnostic vs nondiagnostic nodules. A multivariate regression analysis was conducted to determine nodule characteristics predictive of adequate sampling. Diagnostic yield and time efficiency data were plotted over a 3-year period to study the learning curve for the USGFNB procedure performed by an operator with no previous experience.

Results

A total of 1000 nodules in 734 patients including 142 males and 592 females (age range, 17-87 years) were studied. Of the patients, 188 of 734 had more than 1 nodule biopsied, with a maximum of 4 nodules biopsied in 1 setting. The procedure was successfully completed in all patients, with no major complications. A steep learning curve was observed, and adequate samples were obtained in 91.9% of the patients on the first attempt. The cystic nature of the nodule was the biggest predictor of a nondiagnostic yield.

Conclusions

Otolaryngologist-performed USGFNB of the thyroid is safe, effective, and desirable.

Needle Biopsy Adequacy in the Era of Precision Medicine and Value-Based Health Care

CONTEXT.—

Needle biopsy of diseased tissue is an essential diagnostic tool that is becoming even more important as precision medicine develops. However, the capability of this modality to efficiently provide samples adequate for diagnostic and prognostic analysis remains quite limited relative to current diagnostic needs. For physicians and patients, inadequate biopsy frequently leads to diagnostic delay, procedure duplication, or insufficient information about tumor biology leading to delay in treatment; for health systems, this results in substantial incremental costs and inefficient use of scarce specialized diagnostic resources.

OBJECTIVE.—

To review current needle biopsy technology, devices, and practice with a perspective to identify current limitations and opportunities for improvement in the context of advancing precision medicine.

DATA SOURCES.—

PubMed searches of fine-needle aspiration and core needle biopsy devices and similar technologies were made generally, by tissue site, and by adequacy as well as by health economics of these technologies.

CONCLUSIONS.—

Needle biopsy adequacy can be improved by recognizing the importance of this diagnostic tool by promoting common criteria for needle biopsy adequacy; by optimizing needle biopsy procedural technique, technologies, clinical practice, professional education, and quality assurance; and by bundling biopsy procedure costs with downstream diagnostic modalities to provide better accountability and incentives to improve the diagnostic process.

Ultrasound-guided fine needle aspiration of thyroid nodules with on-site cytological examination: Diagnostic efficacy, prevalence, and factors predicting for Bethesda category I results

BACKGROUND AND OBJECTIVE

Ultrasound-guided fine needle aspiration of thyroid nodules with on-site cytological examination may decrease the number of Bethesda categoryI cytologies. The study objective was to evaluate our second-year experience with this procedure to analyze diagnostic efficacy, prevalence, and factors predicting for Bethesda categoryI results.

PATIENTS AND METHOD

A retrospective study was conducted of 279 nodules from 233 patients. Ultrasound -guided fine needle aspiration was performed according to the 2015 criteria of the American Thyroid Association. A specimen of each aspiration was air-fixed on site before Diff-Quik staining and microscopic examination to assess its suitability; otherwise, nodule aspiration was repeated up to 5times. Diagnostic efficacy was assessed based on sensitivity and specificity on the cytological categories BethesdaII and BethesdaVI.

RESULTS

Diagnostic sensitivity and specificity were both 100%, 5.4% Bethesda categoryI results were obtained, and variables independently associated were age (4.7% increase per year of life) and nodule volume (2.3% increase per each 1mL of volume).

CONCLUSIONS

Ultrasound-guided fine needle aspiration of thyroid nodules with on-site cytological examination allows for a high diagnostic efficacy and has been shown to be a highly relevant procedure because it has a very low rate of cytological results of Bethesda categoryI, whose risk has been higher in older subjects and with larger nodules.

Aspirin Increases the Risk of Nondiagnostic Yield of Fine-Needle Aspiration and Biopsy of Thyroid Nodules

BACKGROUND

The link between the diagnostic yield of thyroid fine-needle aspiration and biopsy (FNAB) in patients taking antithrombotic or anticoagulant medications (AT/AC) remains poorly characterized.

OBJECTIVES

We studied the risk of obtaining a nondiagnostic sample with ultrasound-guided thyroid FNAB in patients taking AT/AC medications.

METHODS

This is a retrospective cohort study using medical rec-ords of 556 patients who underwent thyroid FNAB. All cytology samples were reported using the Bethesda classification. For patients with a nondiagnostic cytology, logistic regression was used to calculate OR for patients taking AT/AC medications. Multivariate regression was used to adjust for potential confounding variables including age, cystic ultrasound features, presence of eggshell calcifications, number of passes performed, cystic aspirate on FNAB, and position of the nodule.

RESULTS

Out of 556 patients, cytology results were available for 547 patients. Of these, 46 subjects were taking aspirin and 1 was on warfarin. Among the entire cohort, 17.5% of the subjects had a nondiagnostic cytology. Among the patients on AT/AC medications, 34% had a nondiagnostic result compared to 16% for those not taking them (OR = 2.70, p = 0.003). The subgroup of patients taking aspirin had similarly higher odds of a nondiagnostic cytology (OR = 2.78, p = 0.002). These differences remained statistically significant after multivariate adjustment.

CONCLUSIONS

This is the first study to demonstrate a 3-fold independently greater risk of a nondiagnostic FNAB cytology in patients taking aspirin. Our results highlight the importance of evaluating the need for continuation of aspirin in patients undergoing thyroid FNAB as this may impact the diagnostic yield of the procedure.

Effect of a Biopsy Center on Adequacy Rates of Thyroid Nodule Fine-Needle Aspiration

OBJECTIVE

The purpose of this study was to investigate the effect of a biopsy center-a dedicated space with a dedicated ultrasound machine and technologist, staffed daily by a radiologist responsible for performing ultrasound-guided procedures only-on the rate of non-diagnostic or unsatisfactory thyroid fine-needle aspiration (FNA).

MATERIALS AND METHODS

Three radiologists performed FNA on 1200 nodules in 998 patients between September 2010 and November 2015. We compared rates of nondiagnostic or unsatisfactory FNA before and after implementation of a biopsy center in September 2014 as part of a quality improvement initiative. Before the establishment of our biopsy center, ultrasound-guided procedures were scheduled between diagnostic studies in the main ultrasound department and were performed by a radiologist responsible for both. Multivariate logistic regression analysis was performed to assess the effect of the biopsy center on the odds of obtaining an adequate sample.

RESULTS

Rates of nondiagnostic or unsatisfactory FNA decreased significantly from 15.1% to 8.5% (p < 0.001) after implementation of the biopsy center. The odds of obtaining an adequate sample were higher in the biopsy center (odds ratio, 2.07; 95% CI, 1.43-3.01), even after adjusting for patient age, nodule size, the radiologist performing the procedure, and time over the study period.

CONCLUSION

The implementation of a biopsy center was associated with significantly lower rates of nondiagnostic or unsatisfactory thyroid FNA, suggesting target rates of 10% or lower are achievable with quality improvement measures.

Perioperative practices in thyroid surgery: An international survey

BACKGROUND

Perioperative practices in thyroid surgery vary from one specialty, institution, or country to the next. We evaluated the preoperative, intraoperative, and postoperative practices of thyroid surgeons focusing on preoperative ultrasound, vocal cord evaluation, wound drains, and hospitalization duration, among others.

METHODS

A survey was sent to 7 different otolaryngology and endocrine/general surgery associations.

RESULTS

There were 965 respondents from 52 countries. Surgeon-performed ultrasound is practiced by more than one third of respondents. Otolaryngologists perform preoperative and postoperative vocal cord evaluation more often than endocrine/general surgeons (p < .001). Sixty percent of respondents either never place drains or place drains <50% of the time in thyroid lobectomies (43% for total thyroidectomies). Outpatient thyroid surgery is most frequently performed by surgeons in the United States (63%).

CONCLUSION

This epidemiologic study is the first global thyroid survey of its kind and clearly demonstrates the variability and evolving trends in thyroid surgery. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1296-1305, 2017.

Evaluation of the American college of surgeons thyroid and parathyroid ultrasound course: Results of a web-based survey

OBJECTIVES/HYPOTHESIS

The American College of Surgeons Thyroid and Parathyroid Ultrasound Skills-Oriented Course (TPUSC) was designed to teach surgeons how to interpret and perform office-based head and neck ultrasound (HNUS). The objective of this study was to survey attendees of the TPUSC to evaluate the usefulness of the course, to track surgeon performed HNUS practice patterns, and to help identify potential roadblocks to incorporation of HNUS into a surgeon's practice.

STUDY DESIGN

Cross-sectional survey.

METHODS

A Web-based survey was sent to 952 surgeons who completed the TPUSC between 2010 and 2014. Questions included surgeon specialty, practice type, Likert scale rating of the TPUSC, competency with different HNUS procedures, and current HNUS practice patterns.

RESULTS

The response rate was 24%. On a scale from 1 (not useful) to 5 (extremely valuable), the mean course usefulness rating was 4.2. Educational goals were met for 194 (92%) surgeons, and 162 (77%) surgeons reported performing HNUS in their practice. Of 48 surgeons not performing HNUS, 24 (50%) attributed insufficient time in their clinic schedule, and 21 (44%) attributed high equipment costs.

CONCLUSIONS

The TPUSC is a valuable educational experience for surgeons seeking to gain proficiency in HNUS. The majority of TPUSC graduates gain competency with at least one type of HNUS procedure following the course.

LEVEL OF EVIDENCE

NA Laryngoscope, 127:1950-1958, 2017.