Thyroid Fine-Needle Aspiration Indications and...
Transcript of Thyroid Fine-Needle Aspiration Indications and...
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Thyroid Fine-Needle AspirationIndications and Technique
Subcommittee membersZubair W. Baloch, MD, PhDMartha Bishop Pitman, MD
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Thyroid FNA Indication
• Clinical Thyroid Nodule (s) > 1 cm?• Hypo-functioning (cold)• History
– Age & Sex– Neck Irradiation– Family History of Cancer– Growth Pattern
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Thyroid Nodules
• Clinically apparent nodules affect 4-7% of US population.
• More common in women and up to 95% are benign.
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Prevalence of Thyroid Nodules
Ultrasound/autopsy
Palpation
Mazzaferri, 1993
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History and physical examination lack the sensitivity and specificity sufficient for
diagnosing thyroid cancer
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Sutton’s Law of
Medicine
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Go for the “Nodule”
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Initial Diagnostic Evaluationof Patients with Thyroid Nodules
FIRST STEPTSH
Not IndicatedRadionuclide scans
CT or MRIAntithyroid antibodies
T4, free T4, T3
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TSH assay is the optimal screening test in ambulatory healthy patients
TSH
HIGH>5.0mU/L
HYPOTHYROID
NORMAL0.5-5.0mU/L
EUTHYROID
LOW<0.5mU/L
HYPERTHYROID
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Hyperfunctioning “hot” left nodule
These “hot” nodulesdo not need to be aspirated
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95% of nodules are hypofunctioning “cold”
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Road to FNA
Check TSH
Normal
High
Low
FNA
FNA
Scan
T4 Rx
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Thyroid FNA Technique
• Manual• Guided
– Ultrasound– Other Imaging Modalities
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Thyroid Needle Biopsy
• Fine Needle Aspiration (FNA)– 23-25 gauge needle
• Large Needle Biopsy (LNB)– 16-18 gauge needle
• Core Needle Biopsy (CNB)– 14 gauge needle
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Recommended Thyroid FNA Technique
• Maximum 3 punctures/nodule– Use of thin 25 gauge (0.5 mm) needle– No local anesthesia
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ALL PATIENTS SHOULD HAVE ANALL PATIENTS SHOULD HAVE ANULTRASOUND
EITHER BEFORE OR AFTER FNAEITHER BEFORE OR AFTER FNA
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What is the role of ultrasound in the evaluation and management of
thyroid nodules?
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Ultrasound Use inNodular Thyroid Disease
• Multinodular consistency on exam• Hashimoto’s thyroiditis • Difficult neck exam• Surveillance in patients with known nodules or
thyroid cancer– Growth in nodule with previous benign FNA cytology– F/u of thyroid cancer to evaluate lymph nodes
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a) Are we truly feeling a nodule?
Of patients with one palpable nodule, 16% will have NO nodules found on ultrasound
Brander 1992, Marqusee 2000
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b) Is the nodule solitary?
A palpable solitary nodule is part of a multinodular thyroid gland on US in ~50% of patients. The size of the other nodules is usually <1.0 cm in the majority but 10-15% of patients will have a second nonpalpable nodule of >1.0cm
Brander 1992, Tan 1995, Marqusee 2000
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Palpable left nodule,Nonpalpable isthmus nodule
trachea carotid
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Specimen Preparation
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– Smears• Concentration direct (two) smears/puncture• On-site evaluation• Concentration processing remaining material
– Liquid Base Techniques• ThinPrep• Surepath
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Common On-site Cytosmears
• Direct smear– Thin and thick– Butterfly– Cobblestone– Splatter
• Concentration smear(Recommended )
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Types of Cytosmears
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Types of Cytosmears
Concentration Smear
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Problems: Cytopreparations
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References:
Altavilla G, Pascale M, Nenci I. Fine needle aspiration cytology of thyroid gland diseases. Acta Cytol. 1990;34:251-6. Aversa S, Pivano G, Vergano R et al. [The accuracy of the fine needle aspiration biopsy in 1250 thyroid nodules]. Acta Otorhinolaryngol Ital. 1999;19:260-4. Carpi A, Ferrari E, Sagripanti A et al. Aspiration needle biopsy refines preoperative diagnosis of thyroid nodules defined at fine needle aspiration as microfollicular nodule. Biomed Pharmacother. 1996;50:325-8. Hall TL, Layfield LJ, Philippe A, Rosenthal DL. Sources of diagnostic error in fine needle aspiration of the thyroid. Cancer. 1989;63:718-25. Hsu C, Boey J. Diagnostic pitfalls in the fine needle aspiration of thyroid nodules. A study of 555 cases in Chinese patients. Acta Cytologica. 1987;31:699-704. Kato A, Yamada H, Yamada T, Ishinaga H. [Fine needle aspiration cytology under ultrasonographic imaging for diagnosis of thyroid tumor]. Nippon Jibiinkoka Gakkai Kaiho. 1997;100:45-50. Vojvodich SM, Ballagh RH, Cramer H, Lampe HB. Accuracy of fine needle aspiration in the pre-operative diagnosis of thyroid neoplasia. J Otolaryngol. 1994;23:360-5.
Zardawi IM. Fine needle aspiration cytology in a rural setting. Acta Cytol. 1998;42:899-906.
Suen KC A-kF, Kaminsky DB, et al. Guidelines of the Papanicolaou Society of cytopathology for the examination of fine-needle aspiration specimens from thyroid nodules. Mod Pathol. 1996;9:710-715. Baloch ZW, Tam D, Langer J, Mandel S, LiVolsi VA, Gupta PK. Ultrasound-guided fine-needle aspiration biopsy of the thyroid: role of on-site assessment and multiple cytologic preparations. Diagn Cytopathol. 2000;23:425-9. Yang GC, Liebeskind D, Messina AV. Ultrasound-guided fine-needle aspiration of the thyroid assessed by Ultrafast Papanicolaou stain: data from 1135 biopsies with a two- to six-year follow-up. Thyroid. 2001;11:581-9.