Does large needle aspiration biopsy add pain to the thyroid nodule evaluation?

Effect of local anesthesia on pain scale and specimen adequacy in fine-needle aspiration biopsy of thyroid nodules for liquid-based cytology

Fine-needle aspiration biopsy (FNAB) is a routine diagnostic test for thyroid nodules. The use of local anesthesia (LA) before the procedure is still controversial. This prospective study aimed to evaluate the degree of pain and specimen adequacy in liquid-based cytology (LBC) for FNAB of thyroid nodules with and without LA. A total of 100 consecutive patients with thyroid nodules who underwent FNAB with and without LA between January and December 2020 were included. Patients who received LA had a significantly lower immediate pain scale score (P = 0.01). Multivariate analysis demonstrated that no use of LA (odds ratio [OR] = 3.48, 95% confidence interval [CI] = 1.50-8.10, P = 0.004) and lesion abutting the trachea (OR = 6.14, 95% CI = 1.56-24.12, P = 0.009) were independently and significantly associated with pain degree immediately after FNAB. A higher proportion of patients who previously underwent FNAB thought that LA was helpful and should be performed prior to FNAB. However, the use of LA did not improve the specimen adequacy (P = 0.075). The results showed that administration of LA with a proper technique before ultrasound-guided FNAB might reduce immediate pain after the procedure, and patients may experience more pain when the aspirated nodules abut the trachea.

Patient Discomfort in Relation to Thyroid Nodule Fine-Needle Aspiration (FNA) Performed with or without Parenteral and/or Topical Anesthetic

OBJECTIVE

There is much reported variation in the impact of local anesthesia on thyroid fine-needle aspiration (FNA) related discomfort. We compare patients undergoing thyroid FNA with subcutaneous injection or topical anesthetic to no anesthetic.

METHODS

We conducted a retrospective review of 585 sequential ultrasound guided thyroid FNA procedures in Mayo Clinic. Group 1 (n = 200), no anesthetic; Group 2 (n = 185), subcutaneous injection anesthetic; and Group 3 (n = 200), topical anesthetic. Patient demographics, number of FNA passes, needle gauge, and cytopathology were recorded plus a discomfort score (0 to 10) before and immediately post procedure in all 3 groups and peak discomfort during the FNA in Groups 1 and 2.

RESULTS

There were no differences among the 3 groups in age, sex, FNA sufficiency rate, cytopathology, and FNA passes number. There was no significant difference between Groups 1 and 2 in peak discomfort score during the FNA: 0 (45%, 42.2%), 1 to 2 (19%, 24.9%), 3 to 5 (23.5%, 20.5%), 6 to 8 (9.5%, 10.8%), 9 to 10 (3%, 1.6%), respectively. Discomfort score post procedure: 0 (78.5%, 77.8%, 53.5%), 1 to 2 (13%, 13%, 36.5%), 3 to 5 (7%, 7%, 9%), 6 to 8 (1.5%, 2.2%, 1%), 9 to 10 (0%, 0%, 0%) for groups 1, 2, and 3, respectively. There were no significant differences among the 3 groups for a discomfort score ≥3.

CONCLUSION

FNA associated patient discomfort was comparable during and after the procedure regardless of the use of anesthetic or the type utilized. Approximately 90% of patients experienced mild to moderate discomfort during the procedure. And 90% reported no more than a level 2 discomfort post procedure.

ABBREVIATIONS

End = endocrinology; FNA = fine-needle aspiration; MCF = Mayo Clinic Florida; MCR = Mayo Clinic Rochester.

Optimal needle size for thyroid fine needle aspiration cytology

Concerning the needle size for thyroid fine needle aspiration cytology (FNAC), 25-27-gauge needles are generally used in Western countries. However, in Japan, the use of larger needles (21-22-gauge needles) is common. The aim of our study was to determine the optimal needle size for thyroid FNAC. We performed ultrasound-guided FNAC for 200 thyroid nodules in 200 patients using two different-sized needles (22 and 25 gauge). For each nodule, two passes with the different-sized needles were performed. The order of needle sizes was reversed for the second group of 100 nodules. The second aspiration was more painful than the first, regardless of the needle size. An association with more severe blood contamination was more frequently observed with the use of 22-gauge needles (32.0%) than with the use of 25-gauge needles (17.5%) and in the second aspiration (37.5%) than in the initial aspiration (12.0%). The initial aspiration samples were more cellular than the second aspiration samples. Regarding the unsatisfactory and malignancy detection rates, there was no statistical difference between the needles. In three of seven markedly calcified nodules, it was difficult to insert 25-gauge needles into the nodules. In terms of the diagnostic accuracy and pain, either needle size can be used. We recommend using 22-gauge needles for markedly calcified nodules because 25-gauge needles bend more easily in such cases. We demonstrated that the initial aspiration tended to obtain more cellular samples and to be less contaminated. Thus, the initial aspiration is more important and should be closely attended.

Assessment of pain score and specimen adequacy for ultrasound-guided fine-needle aspiration biopsy of thyroid nodules

Objective

The aim of this study was to evaluate pain scores and specimen adequacy for ultrasound-guided fine-needle aspiration biopsy (US-FNAB) of thyroid nodules without and with local anesthesia (LA).

Materials and methods

The US-FNAB procedure was performed on 183 patients with and without LA. One puncture was made for solid nodules, and if patients could tolerate it, a two-puncture technique was used for nodules with a cystic change. Four-point verbal rating scores were assessed by a nursing assistant after completion of US-FNAB. To be an adequate specimen, at least six groups of follicular cells are required, and each group should contain at least 10 cells.

Results

Immediately after US-FNAB, 92% of patients with LA and 80% without LA reported no or mild pain (p=0.01). Most patients tolerated the procedure well, with no pain (82.5%) reported 5 minutes after the procedure. In univariate logistic regression, irregular boundary (odds ratio [OR]: 2.52, 95% confidence interval [CI]: 1.04–6.06, p=0.04), calcification (OR: 2.86, 95% CI: 1.06–7.76, p=0.04), and LA (OR: 0.35, 95% CI: 0.15–0.86, p=0.02) were significantly associated with immediate moderate or severe pain. Specimen adequacy was significantly associated with age (OR: 0.95, 95% CI: 0.92–0.97, p<0.01), heterogeneous echo-texture (OR: 1.76, 95% CI: 1.23–5.17, p=0.01), predominate solid architecture (OR: 2.78, 95% CI: 1.42–5.41, p<0.01), and the use of LA (OR: 3.34, 95% CI: 1.70–6.56, p<0.01). In multivariate logistic regression, patients receiving LA had lower risk of moderate or severe pain (OR: 0.25, 95% CI: 0.09–0.67, p=0.01) and higher chances of specimen adequacy (OR: 4.84, 95% CI: 2.17–10.7, p<0.01) compared to patients who did not receive LA.

Conclusion

US-FNAB is a safe procedure, and most patients report no pain 5 minutes after the procedure. The use of LA was associated with lower immediate pain scales and higher specimen adequacy.

Ultrasound-guided fine needle aspiration versus core needle biopsy: comparison of post-biopsy hematoma rates and risk factors

PURPOSE

To compare post-biopsy hematoma rates between ultrasound guided-fine needle aspiration and ultrasound guided-core needle biopsy, and to investigate risk factors for post-biopsy hematoma.

METHODS

A total of 5304 thyroid nodules which underwent ultrasound guided biopsy were included in this retrospective study. We compared clinical and US features between patients with and without post-biopsy hematoma. Associations between these features and post-biopsy hematoma were analyzed.

RESULTS

Post-biopsy hematoma rate was 0.8% (43/5121) for ultrasound guided-fine needle aspiration and 4.9% (9/183) for ultrasound guided-core needle biopsy (P < 0.001). For ultrasound guided-fine needle aspiration, gender, age, size, presence of vascularity, and suspicious US features were not associated with post-biopsy hematoma according to experience level. Post-biopsy hematoma occurred significantly more with ultrasound guided-core needle biopsy (9/179, 5.0%) than with ultrasound guided-fine needle aspiration (9/1138, 0.8%) (P < 0.001) in experienced performers and ultrasound guided-core needle biopsy was the only significant risk factor for post-biopsy hematoma (adjusted Odds Ratio, 6.458, P < 0.001).

CONCLUSION

Post-biopsy hematoma occurred significantly more in ultrasound guided-core needle biopsy than in ultrasound guided-fine needle aspiration and ultrasound guided-core needle biopsy was the only independent factor of post-biopsy hematoma in thyroid nodules.

Comparison of diagnostic yield of core-needle and fine-needle aspiration biopsies of thyroid lesions: Systematic review and meta-analysis

Objectives

Thyroid nodular disease is one of the most commonly observed medical conditions. Cytological evaluation of the specimens obtained with fine-needle aspiration biopsy (FNAB) is the most accurate tool for selecting nodules which should be further surgically removed. A major limitation of this method is the high occurrence of non-diagnostic results. This indicates the need for improvement of the thyroid biopsy technique. The aim of this meta-analysis was to compare the diagnostic value of thyroid core-needle biopsies (CNBs) and FNABs.

Materials and methods

PubMed/MEDLINE, Cochrane Library, Scopus, Cinahl, Academic Search Complete, Web of Knowledge, PubMed Central, PubMed Central Canada and Clinical Key databases were searched. Risk ratios (RRs) of non-diagnostic results were meta-analysed using the random-effects model.

Results

Eleven studies were included in the quantitative analysis. CNB yielded significantly more diagnostic results – the pooled risk ratio (RR) of gaining a non-diagnostic result was 0.27 (p<0.0001). For lesions with one previous non-diagnostic FNAB, RR was 0.22 (p<0.0001).

Conclusions

CNB seems to be a valuable diagnostic technique yielding a higher proportion of diagnostic results than conventional FNAB. It is also significantly more effective in case of nodules with a prior non-diagnostic result of FNAB results than repeated FNABs.

Key Points

• Core-needle biopsy yields a higher proportion of diagnostic results than fine-needle biopsy.

• Core-needle biopsies may decrease the amount of unnecessary thyroidectomies.

• Probability of gaining non-diagnostic result using core-needle biopsy is almost four times lower.

Thyroid core needle biopsy: taking stock of the situation

Recently, the microhistologic evaluation by core needle biopsy (CNB) has been reported as high accurate to diagnose thyroid nodules with previous indeterminate or not adequate fine-needle aspiration cytology. In addition, sparse data have been reported regarding the use of CNB in other conditions. Aim of this review was to furnish the state of the art of this topic by summarizing published data about the diagnostic performance of CNB in thyroid lesions, and provide an easy to use reference for clinical practice. Sources encompass studies published through May 2014. Original articles were investigated and following specific aspects were discussed: 1. The "large" needle biopsy in 90's; 2. Complications by and patient's comfort with thyroid CNB; 3. Advantages provided by examination of a microhistologic sample of thyroid nodule; 4. Use of CNB in thyroid nodules with previous not adequate (Thy 1/Class 1/Category I) cytology; 5. Use of CNB in thyroid neoplasms (Thy 3/Class 3/Category III-IV) cytology; 6. Use of CNB in specific ultrasonographic presentations of thyroid nodules or in patients with peculiar clinical contexts; 7. First-line approach by CNB in thyroid nodules; 8. Immunohistochemistry and molecular tests on CNB samples; and 9. Future perspective.

Tissue imaging and serum lipidomic profiling for screening potential biomarkers of thyroid tumors by matrix-assisted laser desorption/ionization-Fourier transform ion cyclotron resonance mass spectrometry

Changes in serum lipidome and in tissue lipidome are associated with cancer. In this study, tissue mass spectrometry imaging (MSI) and serum lipid profiling by matrix-assisted laser desorption/ionization-Fourier transform ion cyclotron resonance mass spectrometry (MALDI-FTICR MS) were performed to investigate significantly changed lipids in both tumor (malignant thyroid cancer (MTC) and benign thyroid tumor (BTT)) tissues and sera. Y-scatterplots of variable importance in the projection (VIP) values vs. fold change values indicate that change trends in the levels of ten lipids (i.e., phosphatidylcholine (PC)(34:1), PC(36:1), PC(38:6), phosphatidic acid (PA) (36:2), PA(36:3), PA(38:3), PA(38:4), PA(38:5), PA(40:5), and sphingomyelin (SM)(34:1)) in both tissues and sera from MTC patients, BTT patients, and normal individuals are significantly associated with these three types of pathophysiological status. In order to examine their diagnostic ability, 289 serum samples from 124 MTC patients, 43 BTT patients, and 122 normal controls were randomly divided into the training set and validation set. A biomarker of PC(34:1) exhibited excellent diagnostic ability to differentiate both MTC and BTT patients from normal individuals, with an area under the receiver operating characteristic (ROC) curve value of 0.984, a sensitivity of 96.4 %, and a specificity of 92.7 %. A panel which included PA(36:3) and SM(34:1) could distinguish between MTC and BTT, with an area under receiver operating characteristic curve (AUC) of 0.961, a sensitivity of 87.8 %, and a specificity of 92.9 %. It is worth noting that a panel consisting of PC(34:1), PA(36:3), and SM(34:1) could differentiate MTC patients from both BTT patients and normal individuals, with an AUC of 0.841, a sensitivity of 86.6 %, and a specificity of 75.5 %.