Fine Needle Aspiration Of Thyroid Nodules Research Articles

Metastatic Renal Cell Cancer to Thyroid Diagnosed by Endoscopic Ultrasound (EUS)-Guided Fine Needle Aspiration (FNA) Technique

Medical literature about the role of Endoscopic ultrasound (EUS) in identifying thyroid lesions is limited. We present a case of secondary thyroid cancer from renal cell carcinoma (RCC) metastasis, diagnosed by thyroid EUS-fine needle aspiration (FNA) approach that was done for staging of esophageal adenocarcinoma, in a patient with 11 years history of complete right nephrectomy for RCC. An 81 year old female patient presented to our facility with dysphagea to both solids and liquids. Initial EGD examination of the esophagus revealed a distal esophageal mass of 5 cm in length, that was biopsied, and the histopathologic results revealed esophageal adenocarcinoma. For staging, the patient underwent computed tomography (CT) of the chest, which showed the lower esophageal mass with mediastinal lymphadenopathy. Next, the patient underwent upper gastrointestinal (GI) EUS for assessment of the esophageal adenocarcinoma and the mediastinal lymph nodes. The EUS-FNA examination of the mediastinal lymph nodes revealed no lymphatic spread. A diagnosis of esophageal adenocarcinoma with stage of T3N0M0 was made. Upon withdrawing the EUS scope, examination of the thyroid revealed a hypoechoic, round, and well-demarcated mass that measured 26.9 mm x 21.9 mm in the right lobe (Image1A). The radial echoendoscope was then withdrawn and the Olympus video curvilinear array echoendoscope was advanced through the mouth into the proximal esophagus. Under echoendosonographic guidance, FNA with a 25-gauge needle (Expect EUS-FNA 25 G needle; Boston Scientific, Menomonie, WI, USA) was performed successfully without adverse events (Image 1B). Cytopathologist was present in the room and confirmed the adequacy of the sample. The thyroid FNA results showed renal cell carcinoma with positive Immunohistochemical stains for PAX8 and CAIX while negative for thyroid transcription factor-1 (TTF1), thyroglobulin and chromogranin (Image 2A-C). A diagnosis of metastatic RCC was made. The patient had a history of right renal cell carcinoma (RCC) status post right nephrectomy 11 years ago (Image 2D). The patient was referred for further oncology work up and management. In conclusion, diagnosis of metastatic RCC to thyroid by EUS-FNA approach during local staging of esophageal malignancy is feasible and safe.Figure: (A) EUS examination of the thyroid revealed a hypoechoic, round, and well-demarcated mass that measured 26.9 mm x 21.9 mm in the right lobe. (B) Under EUS guidance, FNA with a 25-gauge needle (Expect EUS-FNA 25 G needle; Boston Scientific, Menomonie, WI, USA) was performed successfully.Figure: (A) Cell block of thyroid nodule FNA is displaying multiple nests of clear cells, which have clear to eosinophilic cytoplasm. These nests are separated by delicate vascular network and surrounded by lymphocytic infiltrate (H&E stain, original magnification X 400). (B) Staining of Cell block with PAX-8 shows strong nuclear positivity (PAX-8 immunohistochemistry stain, original magnification X 200). (C) Staining the cell block with thyroid transcription factor-1 (TTF-1) shows negative staining (TTF-1 immunohistochemistry stain, original magnification X 200). (D) Kidney section is showing multiple nests of clear cells, which have clear to eosinophilic cytoplasm. These nests are separated by delicate vascular network (H&E stain, original magnification X 400).

Fine-needle Aspiration of Thyroid Nodules: Is it Worth Repeating?

The fine-needle aspiration has a significant role in assessing the malignancy risk of thyroid nodules. There is uncertainty regarding the value of repeat fine-needle aspiration in benign nodules. This study aims to evaluate the concordance of results in consecutive fine-needle aspiration and to study the relevance of repetition in benign results. Retrospective study of the 4800 thyroid nodules fine-needle aspiration held in Instituto de Patologia e Imunologia Molecular da Universidade do Porto between January 1, 2014 and May 2, 2016. Of the initial sample, we selected the repeated fine-needle aspiration on the same nodule. The first fine-needle aspiration result of the 309 nodules underwent revaluation was non-diagnostic in 103 (33.3%), benign in 120 (38.8%) and atypia/follicular lesion of undetermined significance in 86 (27.8%). The agreement between the first and second fine-needle aspiration was significantly higher in cases with an initial benign result (benign: 85.8%, non-diagnostic: 27.2% and atypia/follicular lesion of undetermined significance: 17.4%, p < 0.005). The fine-needle aspiration repeating motifs in initially benign nodules (n = 78) were repetition suggestion in 58, nodule growth in 17 and suspicious ultrasonographic features in 3. The fine-needle aspiration repetition in nodules with initial non-diagnostic and atypia/follicular lesion of undetermined significance result changed the initial diagnosis in a significant proportion of patients, modifying their therapeutic approach. The high concordance of results in initially benign nodules makes fine-needle aspiration repetition not cost-effective in most cases. The fine-needle aspiration should be repeated when the initial cytology result is non-diagnostic or atypia/follicular lesion of undetermined significance.

Malignancy Risk for Fine-Needle Aspiration of Thyroid Nodules according to the Bethesda System for Reporting Thyroid Cytopathology, at King Abdul-Aziz, National Guard Hospital

Malignancy Risk for Fine-Needle Aspiration of Thyroid Nodules according to the Bethesda System for Reporting Thyroid Cytopathology, at King Abdul-Aziz, National Guard Hospital

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

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). 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. 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. 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.

Next-Generation Sequencing Identifies Gene Mutations That Are Predictive of Malignancy in Residual Needle Rinses Collected From Fine-Needle Aspirations of Thyroid Nodules.

- Thyroid nodules have a prevalence of approximately 70% in adults. Fine-needle aspiration (FNA) is a minimally invasive, cost-effective, standard method to collect tissue from thyroid nodules for cytologic examination. However, approximately 15% of thyroid FNA specimens cannot be unambiguously diagnosed as benign or malignant. - To investigate whether clinically actionable data can be obtained using next-generation sequencing of residual needle rinse material. - A total of 24 residual needle rinse specimens with malignant (n = 6), indeterminate (n = 9), or benign (n = 9) thyroid FNA diagnoses were analyzed in our clinical molecular diagnostics laboratory using next-generation sequencing assays designed to detect gene mutations and translocations that commonly occur in thyroid cancer. Results were correlated with surgical diagnoses and clinical outcomes. - Interpretable data were generated from 23 of 24 residual needle rinse specimens. Consistent with its well-known role in thyroid malignancy, BRAF V600E mutations were detected in 4 malignant cases. An NRAS mutation was detected in 1 benign case. No mutations were detected from specimens with indeterminate diagnoses. - Our data demonstrate that residual thyroid FNA needle rinses are an adequate source of material for molecular diagnostic testing. Importantly, detection of a mutation implicated in thyroid malignancy was predictive of the final surgical diagnosis and clinical outcome. Our strategy to triage thyroid nodules with indeterminate cytology with molecular testing eliminates the need to perform additional FNA passes into dedicated media or to schedule additional invasive procedures. Further investigation with a larger sample size to confirm the clinical utility of our proposed strategy is underway.

Evaluation of the Afirma Gene Expression Classifier in Repeat Indeterminate Thyroid Nodules.

- Molecular testing in indeterminate thyroid nodules is a rapidly evolving field with variable reported outcomes. - To report our experience at a tertiary thyroid referral center with the Afirma Gene Expression Classifier (Veracyte, San Francisco, California) in repeat fine-needle aspirations of thyroid nodules with a previous indeterminate cytologic result. - Results of cytopathology and the Afirma test were collected from August 2013 to March 2015, as were diagnoses from surgical resection when performed. - One hundred and fifteen thyroid nodules were evaluated by Afirma. The fine-needle aspiration diagnostic categories for these nodules were 100 (87%) Bethesda III, 10 (9%) Bethesda IV, 3 (2%) Bethesda II, 1 (1%) Bethesda V, and 1 (1%) Bethesda I. Afirma results for 52 of the nodules (45%) were benign, 57 (50%) were suspicious, and 6 (5%) specimens yielded no result because of low messenger RNA content. Three of the benign nodules (6%) were treated surgically, and all were benign on final surgical pathology. Forty-six (81%) of the suspicious nodules were treated surgically; final surgical pathology revealed 30 (65%) were benign and 16 (35%) malignant, yielding a positive predictive value of 35%. - In our experience, 50% of the indeterminate nodules were classified as suspicious by Afirma, with a 35% rate of malignancy in these nodules at surgical resection, in comparison with a historical rate of malignancy at our institution of 11% for Bethesda III nodules and 23% for Bethesda IV. Our use of Afirma is consistent with prior reports in that it has a low positive predictive value in indeterminate thyroid nodules.

A Fresh Cadaver Model for the Instruction of Ultrasound-Guided Fine-Needle Aspiration of Thyroid Nodules.

Objective The aim of our study is to determine if a fresh cadaver model (FCM) for the instruction of ultrasound (US)-guided fine-needle aspiration (FNA) of thyroid nodules is a practical method for instruction. Study Design Pre- and postinstruction assessment of medical students' ability to perform US-guided FNA of artificially created thyroid nodules placed adjacent to the thyroid gland of a fresh cadaver. Setting University-based fresh cadaver laboratory. Subjects and Methods Study participants included a total of 17 first- and second-year medical students with minimal US training. Technical skills were assessed using a 10-item checklist. In addition, a cognitive assessment regarding the indications, contraindications, and complications of the procedure was completed. A postinstruction assessment was provided for participants 5 weeks after their initial assessment. Differences between pre- and postinstruction assessment scores of technical skills were analyzed using McNemar's test. The mean cognitive knowledge gain was analyzed using a paired 2-sample t test. Results Eight of 10 items on the skills checklist were statistically significant between pre- and postinstruction skills assessment ( P < .05). There was a statistically significant change in cognitive knowledge gain regarding the contraindications of the procedure ( P = .001), but not for indications or complications ( P = .104 and P = .111, respectively). Conclusion US-guided FNA continues to be an important diagnostic procedure in the workup of thyroid nodules, making it an essential skill to integrate into surgical skills lab. Our FCM for the instruction of US-guided FNA is the first of its kind, and this pilot study shows this is a viable method for instruction.

Elastography-targeted Thyroid Nodule Aspiration: A Novel Approach.

Objectives:Since 2009, the rate of nondiagnostic (ND) thyroid nodule fine-needle aspiration (FNA) has ranged from 2% to 20%. A ND result can cause further patient morbidity secondary to repeated procedures and delay in diagnosis. The use of real-time strain elastography (RTE) in determining nodule malignant risk has gained considerable focus recently. A less studied area where RTE may prove beneficial is its role in targeting areas for FNA. Our hypothesis is that FNA performed in concurrence with RTE will show a decreased rate of ND results leading to fewer repeated FNA.Materials and Methods:The Institutional Review Board approval was obtained. A retrospective review of all thyroid nodule FNA from January 1, 2011, to January 1, 2014, was performed with review of nodule size, presence of microcalcifications, vascularity, solid components, patient age, and gender. Cases were separated based if RTE was done before FNA or not. Pathology reports were reviewed to assess for specimen adequacy. Statistical comparison was performed using SAS analysis software.Results:A total of 221 specimens were reviewed, with RTE performed on 140 cases (63.4%). Both groups were similar in demographics and previously described nodule characteristics. The ND rate when RTE was not performed was 16% (13/68) compared to 10% when RTE was performed (14/126). The difference was not found to be statistically significant, P = 0.205.Conclusions:The presence of an elastogram failed to demonstrate a significant decrease in ND FNA rates although these results may be secondary to study design. Further evaluation with prospective trials using larger sample size may ultimately detect increased accuracy of RTE-targeted FNA.

Thyroid Ultrasound-Guided Fine-Needle Aspiration Cytology Results: Observed Increase in Indeterminate Rate over the Past Decade.

Objectives To evaluate changes in distribution of reported thyroid nodule fine-needle aspiration (FNA) cytopathology results since implementation of the Bethesda classification and revised 2015 American Thyroid Association (ATA) guidelines for selecting nodules for biopsy. Study Design Retrospective review. Setting Tertiary academic medical center. Subjects and Methods Evaluation of ultrasound (US)-guided thyroid FNA by a single surgeon using 2015 ATA nodule selection criteria and Bethesda reporting on 211 thyroid nodules in a 1-year period (2015). Comparison is made to an earlier sample wherein any nodule >1 cm underwent US FNA with cytology reported prior to Bethesda consensus (2006). Results The current cohort involved mostly women (79%); nodules ranged from 1 to 7 cm (mean ± SEM, 2.4 ± 0.07 cm). Mean ± SEM age was 53.5 ± 1.1 years. Bethesda reporting yielded 6% nondiagnostic, 57% benign, 3% malignant, and 34% indeterminate (27% atypia of undetermined significance [AUS]/follicular lesion of undetermined significance [FLUS], 4% follicular neoplasm [FN]/Hürthle neoplasm [HN], and 2% suspicious for malignancy [SFM]). The malignancy rate in indeterminate nodules was 26% (18% AUS/FLUS, 33% FN/HN, and 80% SFM). Age, sex, or nodule size did not correlate with indeterminate cytology. The comparator sample of 447 nodules had significantly different distribution, with 7% nondiagnostic, 80% benign, 5% malignant, and 8% indeterminate ( P < .00001). Conclusion We observed a significantly increased proportion of indeterminate cytology and corresponding decrease in benign nodules compared with an earlier sample, predominately from an increase in AUS/FLUS. Multiple factors are likely involved, including selection of sonographically suspicious nodules for biopsy based upon 2015 ATA guidelines coupled with cytopathological interpretation by a new generation of cytopathologists trained in the era of Bethesda reporting; further study is required to make a definitive conclusion.

Risk of Malignancy in Thyroid Nodules with Non-Diagnostic Fine-Needle Aspiration: A Retrospective Cohort Study.

Fine-needle aspiration (FNA) of thyroid nodules is commonly performed, and despite the use of ultrasound (US) guidance, the rate of non-diagnostic FNAs is still significant. The risk of malignancy of thyroid nodules with a non-diagnostic FNA is not clearly defined. However, most studies exclude the majority of patients without a repeat biopsy or surgery, thus increasing the likelihood of selection bias. The aims of this study were to determine the malignancy risk in nodules with an initial non-diagnostic FNA, and to identify the factors associated with malignancy. This was a retrospective cohort study of patients with thyroid nodules who underwent US-guided FNA between 2004 and 2010 and had a non-diagnostic result. Patients were followed until confirmatory diagnosis of the nature of the nodule was made. The outcome of malignant or benign disease was based on one of the following: (i) final surgical pathology following thyroidectomy; (ii) repeat biopsy; (iii) clinically, based on repeat ultrasound performed at least three years following biopsy; or (iv) report of thyroid status for patients without follow-up visits contacted by mail. There were 699 nodules from 665 patients included. The mean age was 59 ± 15 years, and 71.7% were women. There was complete follow-up of 495 nodules. After a median follow-up of 2.7 years, thyroid cancer was found in 15 nodules. The prevalence of malignancy was 3% (15/495). The presence of nodular calcifications was the strongest predictor of thyroid malignancy (odds ratio 5.03 [confidence interval 1.8-14.7]). Initial nodule size was inversely associated with malignancy (odds ratio 0.55 [confidence interval 0.28-0.93]). However, the 193 patients without follow-up had smaller nodules compared with those included in the analysis. None of the patients with repeatedly non-diagnostic results were diagnosed with thyroid cancer at follow-up. The prevalence of thyroid cancer in nodules with non-diagnostic results is lower than the malignancy rate in thyroid nodules in general, but not negligible. They should be followed as per guidelines with heightened suspicion for nodules containing calcifications. Nodules with repeatedly non-diagnostic FNA results especially in the absence of calcifications have a low risk of malignancy and may be observed.

Utility of Ultrasound Versus Gene Expression Classifier in Thyroid Nodules with Atypia of Undetermined Significance

Thyroid nodules with fine-needle aspiration (FNA) cytology categorized as atypia of undetermined significance (AUS) often undergo additional diagnostic analysis with the Afirma Gene Expression Classifier (GEC), which classifies these as either high probability of being benign (GEC-B) or suspicious for malignancy (GEC-S). Our goal was to assess the clinical validity and utility of GEC in the evaluation of AUS cytology and evaluate the performance of ultrasonography (USG) for predicting malignancy in this subset. We conducted a study with a retrospective cohort of patients from January 2012 to January 2014 who had FNA of thyroid nodules >1 cm in size with AUS cytology. Cleveland Clinic Florida has an overall prevalence of AUS of 5%. A total of 119 cases with nodules >1 cm in size were reported as AUS. Forty-eight (40.3%) had a GEC performed after the first FNA (AUS-1), and 27 of these were GEC-S. Of those 27, 21 went for surgery and 14 (66.6%) had thyroid cancer on histopathology. The remaining 71 with AUS-1 were sent for a second FNA: 19 nodules were benign and did not undergo further evaluation, while the remaining 52 were reported as AUS for the second consecutive time (AUS-2). AUS-2 samples were sent for GEC. Of these 52 AUS-2, 38 (73.1%) were reported as GEC-S. Thirty-five went for surgery and 32 (91.4%) had confirmed malignancy on histopathology. Positive predictive value (PPV) was 91.4% for AUS-2 and 66.6% for AUS-1. Moreover, AUS-2 nodules that were hypoechoic and solid on USG showed a PPV of 92% for malignancy. In our practice, the diagnostic accuracy to predict malignancy with GEC for AUS-1 nodules was poor (PPV, 66.6%). The PPV of GEC testing was markedly higher at 91.4% performed after two consecutive AUS cytologies. AUS-2 nodules that were solid and hypoechoic on USG also had a high probability to be malignant (PPV, 92%). We recommend repeat FNA on AUS-1 nodules rather than proceeding directly to GEC testing. Also, we suggest that among AUS-2 nodules, surgery can be recommended when USG shows solid and hypoechoic features with GEC testing reserved for the remainder. AUS = atypia of undetermined significance FNA = fine-needle aspiration GEC = gene expression classifier GEC-B = GEC-benign GEC-S = GEC-suspicious for malignancy NPV = negative predictive value PPV = positive predictive value USG = ultrasonography.

Cytologic and Molecular Identification of Parathyroid Tissue in Thyroid Nodule Fine Needle Aspiration Biopsies

Cytologic and Molecular Identification of Parathyroid Tissue in Thyroid Nodule Fine Needle Aspiration Biopsies

Long-Term Follow-Up of Patients with Fine-Needle Aspiration of Thyroid Nodules

Long-Term Follow-Up of Patients with Fine-Needle Aspiration of Thyroid Nodules

Low Vitamin D Status Is Not Associated With Thyroid Cancer Risk

Background: Low vitamin D status has been known to be associated with the increased prevalence and worse prognosis of several cancers. The aim of this study was to investigate the correlation between vitamin D insufficiency and the risk of malignancy of thyroid nodules and the prognosis of differentiated thyroid cancers (DTCs). Methods: This cross-sectional study included a total of 410 patients who submitted to simultaneous measurements of serum 25-hydoxyvitamin D (25(OH)D) and ultrasonography-guided fine-needle aspiration for thyroid nodules during the period from March 2005 to June 2009. Levels of serum free thyroxine, thyroid stimulating hormone, anti-thyroid antibodies, parathyroid hormone (PTH), calcium, and phosphorus were also measured. Vitamin D insufficiency was defined as a serum 25(OH)D level < 75 nmol/L. In addition, the clinicopathologic characteristics of 34 patients who underwent thyroidectomy for DTC were analyzed retrospectively. Results: The prevalence of vitamin D insufficiency was 40.2%. Serum 25(OH)D levels and the prevalence of vitamin D insufficiency showed no significant differences between benign (n = 366) and malignant (n = 44, 10.7%) thyroid nodules. Serum 25(OH)D levels showed a negative correlation only with serum PTH levels after adjusting for age, sex, body mass index, and sampling season. Among DTC patients, vitamin D insufficiency was not associated with disease stage or any other prognostic features. Conclusions: Vitamin D insufficiency was not associated with the development of thyroid cancer or the prognostic characteristics of DTC. J Endocrinol Metab. 2016;6(4):116-122 doi: http://dx.doi.org/10.14740/jem365w

Molecular Testing of Thyroid Nodules: A Review of Current Available Tests for Fine-Needle Aspiration Specimens.

- Fine-needle aspiration of thyroid nodules is a reliable diagnostic method to determine the nature of thyroid nodules. Nonetheless, indeterminate cytology diagnoses remain a diagnostic challenge. The development of multiplex molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. - To summarize the most common commercially available molecular testing in thyroid cancer, focusing on the technical features and test performance validation. - Peer-reviewed original articles, review articles, and published conference abstracts were reviewed to analyze the advantages and limitations of the most common tests used in the evaluation of thyroid needle aspirations. - The most common tests available include the Afirma Gene Expression Classifier, ThyGenX, and ThyroSeq. The excellent negative predictive value (NPV) of the Afirma test allows it to be used as a "rule out" test. ThyGenX analyzes a panel of DNA mutations and RNA translocation fusion markers to assess the risk of malignancy with good NPV and positive predictive value. ThyroSeq is a next-generation sequencing-based gene mutation and fusion test that has been reported to have the best NPV and positive predictive value combined, suggesting that it can be used as a "rule in" and "rule out" test. Molecular testing of cytology specimens from thyroid nodules has the potential to play a major role in the evaluation of indeterminate thyroid lesions.

Ultrasound-guided fine needle aspiration of thyroid nodules: factors affecting diagnostic outcomes and confounding variables.

Background The incidence of thyroid cancer is increasing in men and women. Fine needle aspiration (FNA) is an accepted technique to assess thyroid nodules but is associated with a high rate of non-diagnostic sampling. Purpose To assess the diagnostic performance of ultrasound-guided FNA of thyroid nodules and identify factors associated with non-diagnostic sampling. Material and Methods A retrospective review of thyroid FNAs was performed between 2006 and 2013. Patient demographics, nodule characteristics, procedural technique, cytology, and complications were recorded. Cytology was categorized THY1-5 based on the British Thyroid Association guidelines. Descriptive and multivariable analysis were conducted to identify factors associated with non-diagnostic sampling. Results A total of 724 procedures were identified with 597 (82.5%) in women, and an overall mean age of 40 years (age range, 17-87 years). Factors associated with a non-diagnostic outcome in the multivariable regression analysis included increasing lesion depth (OR, 1.05 per mm; 95% confidence interval [CI], 1.007-1.10), age (OR, 1.012 per year; 95% CI, 1.0-1.025) and number of FNA passes (1 vs. 4+; OR, 6.07; 95% CI, 2.27-16.21). The complication rate was 1.1% related to perilesional hematomas and vaso-vagal episodes. Conclusion Thyroid FNA is a safe and reliable procedure for cytological assessment of thyroid nodules. Deeper nodules and older patients are more likely to have non-diagnostic samples.

The Role of Core-Needle Biopsy for Thyroid Nodules with Initially Nondiagnostic Fine-Needle Aspiration Results: A Systematic Review and Meta-Analysis

This study evaluated the prevalence of nondiagnostic results, diagnostic performance, and complications of core-needle biopsy (CNB) compared with repeat fine-needle aspiration (FNA) for thyroid nodules with previous nondiagnostic FNA findings. The Ovid-MEDLINE and EMBASE databases were thoroughly searched for studies evaluating CNB or repeat FNA for thyroid nodules with initially nondiagnostic FNA results. Pooled proportions of nondiagnostic results of CNB and repeat FNA were calculated. A meta-analysis was performed to evaluate the diagnostic accuracy of CNB and repeat FNA for a diagnosis of malignancy using a bivariate random-effects model. Complication rates were also evaluated. A review of 52 articles identified 4 eligible articles, involving 1,028 patients with 1,028 thyroid nodules, which were included in the meta-analysis. CNB demonstrated significantly lower rates of nondiagnostic results (6.4%) than repeat FNA (36.5%) (P<.0001). In the 3 studies that analyzed the diagnostic accuracy of CNB in diagnosing malignancy, CNB demonstrated significantly higher summary estimates of sensitivity (89.8%) than repeat FNA (60.6%) (P = .022), but summary specificity did not differ between CNB (99.2%) and repeat FNA (99.0%) (P = .576). None of the patients who underwent CNB or repeat FNA experienced any major complications. CNB demonstrates lower rates of nondiagnostic results and higher diagnostic accuracy than repeat FNA. CNB, rather than repeat FNA, can be utilized to diagnose thyroid nodules previously nondiagnostic on FNA. CI = confidence interval CNB = core-needle biopsy FNA = fine-needle aspiration SROC = summary receiver operating characteristic US = ultrasound.

Fine-needle aspiration of thyroid nodules: our experience before and after Bethesda

Fine-needle aspiration of thyroid nodules: our experience before and after Bethesda

The Effect of Implementing Gene Expression Classifier on Outcomes of Thyroid Nodules with Indeterminate Cytology.

Thyroid nodules are classified into six cytological categories under the Bethesda classification system. Two of these categories, atypical of undetermined significance (AUS) and suspicious for a follicular neoplasm (SFN), are further labeled as "indeterminate" diagnosis. Starting in June, 2012, Kansas University-Wichita Endocrine clinic implemented Afirma® Gene Expression Classifier (AGEC) to evaluate the need for surgical resection of thyroid nodules in patients with an indeterminate diagnosis. Electronic medical records of patients who underwent thyroid nodule fine-needle aspiration from 2004-2014 were reviewed. The aim of this study was to find whether implementing AGEC was associated with decreased surgical recommendation rate, decreased cost, and increased incidence of thyroid malignancy diagnosed by surgery in patients with indeterminate diagnosis. A total of 299 consecutive patients' charts were screened. Sixty-one (20%) patients had an indeterminate diagnosis. Out of these, 27 (44%) patients underwent evaluation before and 34 (56%) patients underwent evaluation after AGEC implementation, respectively. Surgical recommendation for patients with indeterminate finding decreased from 81.5 to 50% (p = 0.01) after AGEC implementation. Surgical pathology was read as malignant in 20 and 85.7% (p < 0.01) of patients before and after AGEC implementation, respectively. Primary cost-benefit estimate showed implementing AGEC has saved $1048/patient in medical evaluation and initial management of patients with indeterminate diagnosis. AGEC implementation has decreased the number of surgical recommendations, has lowered financial burden, and has increased incidence of thyroid malignancy diagnosed by surgical pathology in patients with indeterminate diagnosis of thyroid nodules.

Impact of a gene expression classifier on the long-term management of patients with cytologically indeterminate thyroid nodules

Objectives: The gene expression classifier (GEC, Afirma) reclassifies as molecularly benign approximately one half of thyroid nodule fine-needle aspiration (FNA) biopsies with an initial indeterminate cytopathology diagnosis, facilitating clinical monitoring in lieu of diagnostic thyroid surgery. This study evaluated the long-term management patterns and thyroid surgery rates of GEC benign patients compared to a control group of cytopathology benign patients and also described the costs of thyroid surgery. Methods: This retrospective cohort study used laboratory test results linked to payer medical claims data. Patients who underwent FNA biopsy between 1 January 2011 and 31 July 2013 were selected. GEC benign patients were matched 1:3 to cytopathology benign patients on biopsy year, gender, nodule size and age. Outcomes measured included thyroid-related follow-up clinic visits, ultrasound examinations and surgeries. Results: Out of 2059 patients, matched groups consisting of 201 GEC benign patients and 603 cytopathology benign patients were evaluated over an average follow-up of 20 months. The proportions of GEC benign and cytopathology benign patients that underwent thyroid surgery (11.4% versus 10.1%, p = 0.594), and received a follow-up ultrasound exam (60.2% versus 61.7%, p = 0.706), respectively, were not significantly different. Average thyroid-related medical cost for the surgical episode and during 6 months following surgery were $10,432.00 (SD $8301) and $10,939.00 (SD $9656) respectively. Limitations: The study cohort included only patients whose diagnostic laboratory test results and administrative claims data were uniquely identifiable and could be linked on multiple identifiers; the rigorous matching and patient selection algorithms utilized improved the robustness and internal validity of the study. Claims were used as a proxy for clinical utilization without chart review confirmation. Conclusion: Patients with GEC and cytopathology benign diagnoses were managed similarly. The majority of patients in both groups did not undergo surgery and were managed with usual care, consisting of clinical follow-up and ultrasound exams.