The indeterminate thyroid fine‐needle aspiration

BACKGROUND:

To date, thyroid fine‐needle aspiration (FNA) has been used by clinicians as the screening test of choice to determine whether surgery is required and this is what the pathology report should communicate. Standard terminology for reporting thyroid FNA has not been implemented yet, and pathologists have used various reporting systems to communicate results. A significant source of confusion among both pathologists and clinicians has been the use of the indeterminate category. On the basis of an analysis of 1150 thyroid FNAs in 2000, this institution modified the reporting of thyroid biopsy results into 6 categories, including unsatisfactory. The indeterminate category was separated into 3 subroups: 1) indeterminate for neoplasia (IND), 2) follicular neoplasm (FN), and 3) suspicious for malignancy (SUSP). Repeat FNA in 6 months to 12 months was recommended for IND and surgery for FN and SUSP categories.

METHODS:

To determine the validity of this approach, the outcomes of this reporting system from July of 2000 to December of 2006 were analyzed. The IND category was used for 2 subsets of cases: (a) those that morphologically fall into the gray zone between adenomatoid nodule (AN) and FN, for Hurthle cell nodule (hyperplasia vs neoplasm), and chronic lymphocytic thyroiditis with concern for neoplasia; and (b) for suboptimal specimens due to low epithelial cellularity or collection artifacts.

RESULTS:

Among 5194 thyroid nodules, the IND category comprised 18%. FNA follow‐up was done in 21% of IND cases: 58% were benign/negative and did not require surgery based on cytology alone. Surgical follow‐up in 46% of IND showed 52% were benign/negative, and 42% were follicular/Hurthle cell adenomas. The surgical yield of malignancy in IND was low (6%) when compared with the FN category, which was 14% (more than 2× that of the IND category), and the SUSP category, which was 53% (almost 9× that of the IND category).

CONCLUSIONS:

A 6‐tier reporting system for thyroid FNA was effective for determining which patients needed surgery versus follow‐up FNA and also guided the clinician on the extent of surgery. Cancer (Cancer Cytopathol) 2009. © 2009 American Cancer Society.     

Diagnostic accuracy and limitations of fine‐needle aspiration cytology of bone and soft tissue lesions

BACKGROUND:

Fine‐needle aspiration (FNA) cytology is increasingly being used as a diagnostic modality for soft tissue and bone lesions. These diagnoses can be challenging because of a variety of factors, including interpretation and sampling issues. This study investigates the diagnostic utility of FNA biopsy, in addition to the diagnostic pitfalls, in soft tissue and bone cytopathology.

METHODS:

We retrospectively reviewed the soft tissue and bone FNAs over a 4‐year period (2004‐2008), along with available ancillary studies, pathological follow‐up, and clinical data. The cases with a cytologic‐histologic discrepancy were then reviewed.

RESULTS:

A total of 1114 soft tissue and bone FNAs were identified. Of the 1114 aspirates, 525 (47%) were positive for malignant cells, 505 (45.5%) were benign aspirates (including 189 benign lesions/neoplasms), 37 (3.5%) were inadequate, 34 (3%) had atypical cells, and 13 (1%) were suspicious for malignancy. Of the 586 cases (53%) with follow‐up, including 445 cases with histological follow‐up and 141 with ancillary studies, the overall sensitivity was 96%, the specificity was 98%, the positive predictive value was 99%, and the negative predictive value was 92%. A total of 15 false negatives and 3 false positives were identified with errors because of sampling (9 cases), interpretation (7 cases), and screening (2 cases).

CONCLUSIONS:

This large series demonstrates that there can be a high sensitivity and specificity in diagnosing bone and soft tissue lesions by FNA. Our data supports prior studies in the literature in showing that FNA cytology can be a valuable method for diagnosing these lesions. Cancer (Cancer Cytopathol) 2010. © 2010 American Cancer Society.     

Applications of molecular techniques to fine‐needle aspiration biopsy

The effectiveness of fine‐needle aspiration biopsy (FNAB) for rendering a specific diagnosis can be improved by applying several ancillary modalities. This review details several applications of molecular techniques using FNAB specimens with an emphasis on those used for patient care. A detailed search of the literature was conducted to collect all reports that used FNAB for different types of molecular tests. Several types of molecular tests, including in‐situ hybridization, polymerase chain reaction, Southern blotting, and gene microarrays using FNAB specimens have been reported. These tests have been used with different organ systems and different objectives, including the detection of cancer cells, diagnosis, distinction of benign and malignant disease, prediction of response to chemotherapy, risk assessment, and selection of patients for targeted therapy. Except for a few tests such as assessment of HER2/neu for gene amplification in breast cancer, detection of clonality in hematopoietic neoplasms, and specific chromosomal translocations in the former and in the diagnosis of soft tissue sarcoma, most of the molecular tests using FNAB specimens are currently investigational. The reported literature indicates the excellent potential of using material procured from FNAB for almost any type of molecular test. Whereas few of these tests alone are used for patient care, some of them have the potential for clinical use in the near future. Cancer (Cancer Cytopathol) 2007. © 2007 American Cancer Society.     

Interinstitutional consultation in fine‐needle aspiration cytopathology

BACKGROUND:

The importance of interinstitutional consultation (IC) has been documented across a variety of surgical pathology organ systems. However, to the authors' knowledge, few studies exist regarding this practice within cytopathology and specifically within fine‐needle aspiration cytology (FNAC).

METHODS:

All FNAC cases between September 2002 and January 2007 were reviewed. Original diagnoses and second opinion diagnoses (SODs) were categorized as either no diagnostic disagreement, or minor diagnostic disagreement, or major diagnostic disagreement, and the latter was defined as either a 2‐step deviation on a scale of “unsatisfactory, benign, atypical, suspicious, and malignant” or a change in treatment and/or prognosis. Outcome was determined by a review of the electronic medical record.

RESULTS:

Among 742 FNAC cases from outside laboratories, there were minor disagreements in 132 cases (17.8%) and major disagreements in 69 cases (9.3%) compared with the SODs from the authors' laboratory. Follow‐up was available for 60 of 69 major discrepancies. The SOD was supported on follow‐up in 65% of major discrepancies, and the initial diagnosis was supported better in 33% of major discrepancies. In 55% of cases in which the original institution diagnosis was supported better, either no case slides were received for examination or the slides contained material that was considered nondiagnostic by the authors. An SOD prompted a change in clinical management in 32 of 742 patients (4.3%). Aspirates that were most prone to change in management or therapy were from the thyroid (13 cases), neck (soft tissue and lymph nodes; 9 cases), salivary gland (2 cases), and liver (2 cases). Of 60 major diagnostic disagreements, board‐certified cytopathologists rendered an SOD in 44 cases, and 75% of the diagnoses were supported better by follow‐up, whereas pathologists who were not board certified in cytopathology had only 38% of SODs supported.

CONCLUSIONS:

Of 742 FNAC cases, 9.3% had major diagnostic disagreements; and, in 4.3%, patient management and therapy were altered. These results were similar to studies in surgical pathology emphasizing the importance of IC in FNAC. The authors concluded that FNAC IC benefits patient care. Cancer (Cancer Cytopathol) 2009. © 2009 American Cancer Society.     

Potential pitfalls of needle tract effects on repeat thyroid fine‐needle aspiration

BACKGROUND:

Fine‐needle aspiration (FNA) is a screening and diagnostic tool used in the evaluation of thyroid nodules. Its use has resulted in an increase in the ratio of malignant versus benign thyroid nodules undergoing surgical excision. However, the FNA procedure produces some histological and cytologic alterations, which may lead to misinterpretation on repeat FNA. The goal of the current study was to characterize FNA‐induced morphological alterations and their potential influence on interpretations in repeat FNA specimens.

METHOD:

Thyroidectomy specimens that had benign histological diagnoses and for which previous FNA specimens were available were retrieved. The FNA‐induced histological alterations were evaluated and grouped based on the interval between the FNA procedure and surgical excision. Repeat thyroid FNA specimens with a cytologic diagnosis of “atypical cells/follicular lesion” were reviewed. Worrisome cytologic features that might occur after the previous FNA procedure were discussed.

RESULTS:

Needle tracts were identified in 68 of the 96 thyroidectomy specimens studied. FNA‐induced histological alterations included hemorrhage, granulation, exuberant fibroblastic reaction, reactive follicular cells, infarction, and scarring. The presence of plump endothelial cells, myofibroblasts, and, particularly, reactive follicular cells with nuclear grooving and nuclear clearing are potential pitfalls in repeat FNA and these changes are reported to peak within 20 to 40 days after the FNA procedure. Sixteen of 152 repeat FNA cases were diagnosed as atypical cells/follicular lesion, and FNA‐induced changes might have contributed to the diagnosis in 2 of these 16 cases.

CONCLUSIONS:

Cytologists should be aware of atypical cellular changes caused by previous FNA procedures. Although uncommon, these changes may become potential pitfalls in the cytologic diagnosis of repeat thyroid FNA specimens. Cancer (Cancer Cytopathol) 2013. © 2012 American Cancer Society.     

Thin core needle biopsy crush preparations in conjunction with fine‐needle aspiration for the evaluation of thyroid nodules

BACKGROUND.

Fine‐needle aspiration (FNA) is widely accepted as the initial test to evaluate thyroid nodules; however, inadequate and suboptimal specimens have been 1 of its limitations. Unsatisfactory rates of 4.1% to 43% have been reported, but suboptimal specimens with adequate epithelial cells and other limiting factors, such as clotting, often are not addressed. The authors' institution has a low unsatisfactory rate, especially for thyroid biopsies performed under ultrasound in the Interventional Radiology (IR) Department. In addition to on‐site evaluation for all cases, they concomitantly use thin, 22/20‐gauge core needle biopsy (CB) crush preparations (CP) for unsatisfactory/suboptimal FNAs. The CB usually is done after 2 FNA passes and, in most cases, is exhausted by making an air‐dried CP, which is evaluated on site for adequacy; any residual tissue is processed for tissue sections. Experience is required to interpret CP on air‐dried smears. In this report, the authors describe a complementary approach to thyroid biopsy that has worked well.

METHODS.

All thyroid FNA and CB/CP that were performed in the IR Department during the year 2005 were reviewed. Follow‐up histology and records of all procedural complications were retrieved.

RESULTS.

Seven hundred thirteen thyroid biopsies qualified, 225 biopsies (31%) had FNA with CB/CP (85% had only CP for evaluation), and 488 biopsies (69%) had only FNA. The final unsatisfactory rate in IR for FNA was 8.7%; this was reduced to 3.4% with the use of CB/CP. The addition of CB also helped to obtain a more definitive diagnosis in suboptimal FNA specimens. Cytologic‐histologic correlation was comparable for FNA only cases and FNA/CB cases. There were no significant procedural complications in CB cases.

CONCLUSIONS.

FNA in conjunction with a thin CB/CP performed during the same procedure is a safe technique that can reduce the rate of unsatisfactory and suboptimal thyroid biopsy. Cancer (Cancer Cytopathol) 2008. © 2008 American Cancer Society.     

Cytology of endobronchial ultrasound‐guided transbronchial needle aspiration versus conventional transbronchial needle aspiration

BACKGROUND:

Conventional endoscopic transbronchial needle aspiration (TBNA) is a common procedure used to obtain samples for diagnosing and staging lung lesions. Recently, endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) has been developed and increasingly used by clinicians. Clinical data suggest that EBUS‐TBNA has higher sensitivity and specificity than conventional TBNA in staging lung cancers. In this study, the authors have investigated the cytological features and compared the diagnostic yield of these procedures in lung cancer patients.

METHODS:

A computer search of the cytopathology archives at The Johns Hopkins Hospital revealed 188 EBUS‐TBNA cases (308 lymph nodes; 47 lung lesions) and 74 TBNA cases (106 lymph nodes; 44 lung lesions) over a 28‐month period. All cytological material was correlated with available corresponding surgical material.

RESULTS:

The most frequently sampled lymph nodes were stations 4R and 7 in both TBNA and EBUS‐TBNA; in addition, the EBUS‐TBNA showed a wide range of lymph node sampling. EBUS‐TBNA had a significantly lower nondiagnostic rate (8.7%) compared with TBNA (28.3%, P < .05) in staging lung cancers. In lymph node sampling, the sensitivity and specificity were 54.5% and 100% in the TBNA group and 85.2% and 100% in the EBUS‐TBNA group. In lung specimens, the nondiagnostic rates of TBNA and EBUS‐TBNA were 6.8% and 4.3%, respectively (P > .05), and the sensitivity and specificity were 78.9% and 100% in the TBNA group; and 89.5% and 100% in the EBUS‐TBNA group.

CONCLUSIONS:

Findings indicated that EBUS‐FNA cytology is an optimal modality for diagnosing and staging in lung cancer patients, in comparison to conventional TBNA. Cancer (Cancer Cytopathol) 2010. © 2010 American Cancer Society.     

Ultrasound‐guided fine‐needle aspiration biopsy of thyroid bed lesions from patients with thyroidectomy for thyroid carcinomas

BACKGROUND:

To evaluate the efficacy and the limitation of fine‐needle aspiration (FNA) biopsy in thyroid bed lesions, a retrospective review was performed of the medical records of thyroid cancer patients who underwent ultrasound‐guided FNA biopsy of the thyroid bed at The University of Texas MD Anderson Cancer Center over a 5‐year period.

METHODS:

Data were reviewed on 220 FNA biopsies taken from thyroid bed lesions in 195 patients who had undergone thyroidectomy for thyroid carcinoma. Thyroid bed FNA results were compared with clinical follow‐up, including neck dissection results.

RESULTS:

Recurrent carcinoma was diagnosed by FNA biopsy in 139 of 220 (63%) cases. Neck dissections were performed for 112 sites identified by FNA biopsies, and recurrent carcinoma was confirmed in 110 sites. The concordance between positive and/or suspicious FNA diagnosis and positive neck dissection results was 98% (118 of 120 cases). A false‐positive FNA occurred in one patient with follicular thyroid carcinoma. The other discrepancy was attributed to failure to remove the lesion by neck dissection. The diagnostic accuracy of thyroid bed FNA was 100% in papillary and medullary thyroid carcinoma and 93% in follicular thyroid carcinoma. Suspicious and rare false‐negative FNA results were attributed to low cellularity and lack of characteristic cytomorphologic features of thyroid carcinoma.

CONCLUSIONS:

Ultrasound‐guided thyroid bed FNA biopsy is accurate and efficient in triaging patients who require post‐thyroidectomy follow‐up for recurrent thyroid carcinoma. Caution should be taken in the interpretation of FNA specimens that have low cellularity and lack characteristic cytologic features of thyroid carcinoma. Cancer (Cancer Cytopathol) 2013. © 2012 American Cancer Society.     

Spectrum of head and neck lesions diagnosed by fine‐needle aspiration cytology in the pediatric population

Fine‐needle aspiration cytology (FNAC) of the head and neck region is well accepted as a diagnostic procedure in the adult population. FNAC in the pediatric population is gaining acceptance as clinicians add this technique to the diagnostic armamentarium. An experience with FNAC of the head and neck region in the pediatric population is described from 2 large inner‐city hospitals. Eighty‐five cases were retrieved from patients age <18 years. In 52 cases, clinical or surgical follow‐up was obtained and among these cases the specificity and sensitivity of FNA was 93% and 100%, respectively. The high specificity of FNAC allows the clinician to be confident of malignancy in a clinically suspicious lesion of the head and neck in a pediatric patient. Cancer (Cancer Cytopathol) 2007. © 2007 American Cancer Society.