Introduction: Ultrasound guided Fine Needle AspirationIntroduction: Ultrasound guided Fine Needle...
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Transcript of Introduction: Ultrasound guided Fine Needle AspirationIntroduction: Ultrasound guided Fine Needle...
Introduction: Ultrasound guided Fine Needle Aspiration:
When and how
Teresa Rago
Unit of Endocrinoloy I
University of Pisa
International Course of Thyroid Ultrasonography and minimally invasive procedure
7-8 October 2016
University of Pisa, Italy
THYROID NODULE US
DIAGNOSTIC IMPORTANCE
Nodule size and position Suspicious US features Presence of other nodules/lymphnodes Increases FNAC accuracy
US characteristics
(references)
Sensitivity
(%)
Specificity
(%)
Positive Predictive
Value (%)
Negative
Predicitve Value
(%)
Microcalcifications
(1-5)
26-59 86-95 24-71 42-94
Hypoechogenicity
(2-5)
27-87 43-94 11-68 74-94
Irregular margins or no
halo (2-5)
17-78 39-85 9-60 39-98
Solid
(4-6)
69-75 53-56 16-27 88-92
Frates et al. Radiology 2005
1.Khoo et al. Head Neck 2002
2.Kim et al. Am J Roentgenol 2002
3.Papini et al. J Clin Endocrinol Metab
4.Rago et al. EJE 1998
5.Frates et al. Radiological Society of Noth America 2004
6.Frates et al. J Ultrasound Med 2003
Suspicious US features
Society of Radiologists in Ultrasound Consensus Statement
US features
MALIGNANT BENIGN
Hypoechogenic Absent halo Irregular margins Microcalcificazions
Anechogenic / hyperechogenic Thin Halo Regular margins Egg shell calcifications
10 US patterns with their malignancy risk and thyroid
imaging reporting and data system (TIRADS) category
Horvath et al., J Clin Endocrinol Metab, 2009
FNAB TIRADS 2 TIRADS 3 TIRADS 4 TIRADS 5
Benign 100 % 85,9 % 55 % 10,4 %
Cancer 0 % 3,4 % 14 % 86,5 %
Horvath et al, J Clin Endocrinol Metab, 2009
Correlation of TIRADS categories with the risk of cancer determined by FNAB and Histology
TIRADS: thyroid imaging reporting and data system
Haugen B. et al, ATA Guidelines on Thyroid Nodules and DTC, in press
ECON-ARM
US Features Example Risk Of Malignancy
0-1
Cystic, spongiform, iso-hyperechoic, complete halo sign, macrocalcifications, perinodular vascularization
Low
2-3
iso-hypoechoic with one of US pattern suggestive of malignancy,
Intermediate
4-5
hypoechoic, with 3 or more US pattern suggestive of malignancy, extrathyroid extension, presence of lymph nodes
High
Echographic Classification Of thyroid Nodules According to the Risk of Malignancy (ECON-ARM)
Teresa Rago, Maria Scutari, Francesco Latrofa, Ivo Marchetti, Rossana Romani, Agnese Proietti, Fulvio Basolo, Paolo VittI
TIR-1 TIR-2 TIR-3 TIR-4 TIR-5 Risk
1 1C A B
ECON-ARM n°
0-1 338 20 16 264 28 10 0 0 Low
2-3 166 13 1 108 29 7 3 6 Intermediate
4-5 18 1 / 0 1 2 3 11 High
Total 522 51 372 58 19 6 17
Low Risk was found in 64,75% : none had TIR 4-5 cytology and 11,2 % TIR 3 cytology.
Intermediate risk was found in 31,8%: 5,4% had TIR 4-5 cytology and 21,7% TIR 3 cytology.
High risk was found in 18%: 78% had TIR 4-5 cytology and 16% TIR 3 cytology.
Conclusions This new US classification of the risk of malignancy in the thyroid nodule allows to establish the strength of the indication to perform FNA in each thyroid nodule.
Echographic Classification Of thyroid Nodules According to the Risk of Malignancy (ECON-ARM)
Teresa Rago, Maria Scutari, Francesco Latrofa, Ivo Marchetti, Rossana Romani, Agnese Proietti, Fulvio Basolo, Paolo VittI
Strength of indication for FNA depending on US features
Cystic
spongiform
Mixed
Solid hypoechogenic
Microcalcificazions Irregular margins
Lymphadenopathy
More suspicious US findings
Ind
icat
ion
Strength of indication for fine-needle aspiration (FNA) biopsy of thyroid nodules on the basis of ultrasonography (US) findings.
Indications for FNA
Which nodules?
3.5.1. Indications for UGFNA
High-US-risk thyroid lesions ≥10 mm
Intermediate-US-risk thyroid lesions >20 mm
Low-US-risk thyroid lesions only when > 20 mm and increasing in size or associated with a risk history and before thyroid surgery or minimally invasive ablation therapy [BEL 2, GRADE A]
3.5.2. UGFNA of multinodular glands
We do not recommend the biopsy of more than 2 nodules when they are selected
on the basis of previously described criteria [BEL 3, GRADE C]
Gharib H. et al, AACE/AME Task Force on Thyroid Nodules, in press
Indications for FNA
US -Guided
US-Guided Fine Needle Aspiration
Authors
Patients FNA
Palpation / US
Not diagnostic (%)
FNA
Palpation / US
Cameci 1998
Danese 1998
497 370 / 127
9683 4986 / 4697
16 7
8,7 3,5
Palpation vs US guided FNA
US-Guided Fine Needle Aspiration
US-Guided Fine Needle Aspiration
US -Guided
necessary
Non palpable Nodules
Mixed / cystic Nodules
Nodules in MG
US-Guided Fine Needle Aspiration
450 non palpable nodules
94 operated: 20 Ca 8 < 1cm, 12 >1 cm
No correlation size / hystology Ca
Solid–hypoechogenic / hystology Ca p<0.0003
Adequacy of material / size p<0.0001
Indications and limits of ultrasound-guided cytology in the management of nonpalpable thyroid nodules.
Leenhardt L et al. JCEM, 1998
US-Guided Fine Needle Aspiration
Good compliance
Repeatable
Reproducible
Devoid of risk
Accurate Aspiration
21 22 23 Gauge
Thin needle
Capillarity
US-Guided Fine Needle Aspiration
Drawings: 2-4 in different areas
of the nodule
US-Guided Fine Needle Aspiration
Measurement Tg and CT
Immunocytochimistry
Molecular Characterization
Cytological examination
US-Guided Fine Needle Aspiration
Cytological examination
Adequate: 6 groups of 10-20 cells
Fixation, staining: preservation of nuclei
Hamburger, 1986,1988 Mazzaferri, 1988 Gharib, 2016
US-Guided Fine Needle Aspiration
Cytological examination
Stain
Papanicolaou
May-Grunwald-Giemsa
Classification of cytology
Results of cytology
Percentage
Non diagnostic 10-15
Benign 60-80
Indeterminate 10-20
Suspicoius or Malignant 3,5-10%
US-Guided Fine Needle Aspiration
US-Guided Fine Needle Aspiration
The combination of two or more of these features is
100% specific in detecting papillary thyroid
carcinoma.
Specificity Psammoma bodies: 100% Nuclear grooves: 88% Micronuclei: 86% Pseudo-inclusions: 88% Powdery chromatin: 59%
Cytological features of papillary thyroid tumor on fine-needle aspiration biopsy
US-Guided Fine Needle Aspiration
Problems
Non Diagnostic
Inderminate
Follicular Nodule / Hurthle cell Nodule
US-Guided Fine Needle Aspiration
Non Diagnostic Author aa Pz % Repeated FNA
D ND
% %
Tx
N°
Ca
%
Goernell 80-83 1299/6300 20 59 41 118 8
Livolsi 94-97 72/616 11 8 37
Block 81 3/121 2,5 3 33
Burch 95 156/504 31 125 4
Caraway 86-90 9/394 2,28 4 5 5 0
Altavilla 89 392/2433 16 257 12,5
Hing you 97 148/662 22 34 22.9
Predictivity of Cytology
Histology
N° pz 3.406
Benign – N° (%) Malignant– N° (%)
Non diagnostic (TIR 1) 247 165 (67) 82 (33)
Benign (TIR 2) 1295 1271 (98.2) 24 (1.8)
Indeterminate (TIR 3) 969 686 (70.7) 283 (29.3)
Suspicious (TIR4) 391 11 380 (97.2)
Indicative of ca (TIR 5) 504 0 504 (100)
Rago T. et al. EJE - 2010
Results of cytology
THE DILEMMA OF INDETERMINATE
TIR 3 CYTOLOGY RESULT
10-20 %
Follicullar lesions
Increased cellularity,
Small uniform follicule,
Scant watery colloid
Small nuclei
Regular chromatin
Nuclear atipias
Enlarged nuclei
Sparse or irregulary chromatin
Rare prominent nucleoli
Ocasional mitosis
Isolated or arranged in cohesive sheets
Scant colloid
Abundant, dense, finely granular cytoplasm
Eccentrical nuclei granular chromatin
Small single or multiple nuceloli
Hürthle cell nodules
Results of cytology
0
20
40
60
80
100
Classic Follicular Oxyphylic Tall cell Trabecular
0
20
40
60
80
100
Papillary Follicular Poorly differentiated
n= 308
n= 55
n= 8
n= 239
n= 47
n= 6 n=10 n= 6
Rago et al. JCEM 2013
Histological subtype of CA in 371/1520 (24%) Thy 3 nodules at cytology
Thyroid US
Combined clinical, thyroid ultrasound and cytological features help to predict thyroid malignancy
in Follicular and Hurthle cell thyroid lesions: results from a series of 505 consecutive patients
Rago et al. Clin Endocrinol, 2006
The only US pattern predictive of carcinoma is the presence of microcalcifications (p=0.0009)
Thyroid follicular neoplasms: can sonography distinguish between adenomas and carcinomas?
Seo HS et al. J Clin Ultrasound. 2009
US…… microcalcifications ……are more common in FC than in FA (p < 0.05 )
Histological subtype of CA in 371/1520 (24%) Thy 3 nodules at cytology
0
25
50
75
100
Thy 3A Thy 3B
Benign
Malignant
227/1170
144/350
p < 0,0001
(Atypias-) (Atypias+)
41%
19%
US-Guided Fine Needle Aspiration
Cytologic diagnosis
Measurement of Tg and CT
Immunochemical Examen
Molecular Characterization
US-Guided Fine Needle Aspiration
Histochemical Markers
……Many molecular markers have been evaluated to improve diagnostic accuracy for indeterminate nodules (34,35) but none can be recommended because of insufficient data…………
R.8…..the use of specific molecular markers ….. is not recommended.
US-Guided Fine Needle Aspiration
Conclusions
“Today”: US guided FNA accurate technique, reducing inadequate specimens for cytological examination
“Tomorrow”: Molecular diagnosis will help to improve diagnosis of CA in indeteminate and non diagnostic lesions in conventional cytology
Grazie
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