Guided Fine-Needle Aspiration Biopsy Research Articles

PSAT337 Thyroid Storm Triggered by Thyroid Nodule Fine-Needle Aspiration Biopsy

Abstract Background Thyroid storm is a severe and life-threatening thyrotoxicosis precipitated by an acute event such as thyroid gland manipulation, infection, trauma, or an acute iodine load. Patients with known hyperthyroidism or low TSH with the presence of multinodular goiter should undergo radionuclide thyroid scan before deciding on fine-needle aspiration (FNA) biopsy. We present a case of a patient with history of multinodular toxic goiter disease, who had a thyroid storm after she underwent an FNA thyroid biopsy, requiring emergent total thyroidectomy. Clinical Case 62-year-old female patient with history of multinodular goiter (MNG) disease diagnosed in another country one year prior to admission. She was on methimazole for a few months but was off the medication upon presentation. She was admitted for evaluation due to worsening compressive symptoms. On presentation, she was hypertensive, tachycardic, with dysphonic voice and had a large goiter palpated bilaterally with extension over the sternocleidomastoid muscle. Laboratory results confirmed that she had thyrotoxicosis. TSH was 0.05 mclU/mL, n: 0.27-4.2mclU/mL; FreeT4 > 7.77 ng/dL, n: 0.93-1.70ng/dL; T3 was 552 ng/dL, n: 80-200 ng/dL; TSI and TRAB were elevated: 476 and 23 respectively. In view of this, methimazole 40 mg daily, prednisone 20 mg daily, cholestyramine 4 mg four times a day, potassium iodine 50 mg three times per day, and propranolol were started. Chest CT demonstrated a thyroid gland that was heterogeneous in appearance and markedly enlarged with a right thyroid lobe measuring approximately 6.2×5.8 cm and the left lobe measuring approximately 5.5×5.0 cm. Patient underwent ultrasound guided FNA biopsy of the right thyroid lobule ordered by another team two days after the medication regimen was initiated. One day after procedure, patient had altered mental status, stridor, acute respiratory failure, worsening of hypertension and tachycardia, requiring intubation. It was not possible to place an oral gastric tube, so propylthiouracil 400 mg was given via rectal route every 8 hours and her steroid dose was increased. Her FreeT4 decreased to 3.99 ng/dL and T3 to 165 ng/dL the following day. However, patient condition continued to deteriorate, and she underwent emergent total thyroidectomy, despite not being euthyroid. Patient tolerated the procedure and was able to be extubated the following day without postoperative complications. At the time of discharge, patient was on Levothyroxine 150 mcg oral daily. Conclusion FNA biopsy of toxic thyroid nodules are rarely indicated due to the risk of thyroid storm in patients with underlying hyperthyroidism. Control of the hyperthyroid state should be the priority prior to FNA of any thyroid nodule. Total thyroidectomy may be performed in the hyperthyroidism state as a life-saving procedure when there is failure control hyperthyroidism, as is the case here. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Mediastinal sarcomas: experience using fine needle aspiration cytopathology.

Fine needle aspiration (FNA) cytology is a sparsely used diagnostic method in the evaluation of mediastinal sarcomas in most medical centers worldwide with most literature citations regarding this category of malignancies consisting of small series and individual case reports. Most of these published studies highlight vascular sarcomas such as epithelioid hemangioendothelioma, and angiosarcoma, various subtypes of liposarcoma including well-differentiated liposarcoma, myxoid liposarcoma, and pleomorphic liposarcoma, malignant peripheral nerve sheath tumor, and sarcomas of uncertain differentiation, primary synovial sarcoma and the Ewing sarcoma family of tumors. This paucity of cytopathology reports regarding mediastinal sarcomas is in marked contrast to the almost daily application of endobronchial ultrasound (EBUS)-guided FNA biopsy for sampling mediastinal lymph nodes and mediastinal masses for primary and metastatic carcinomas which, of course, are considerably more common that any type of sarcoma in this location. EBUS, endoscopic ultrasound-guided (EUS) needle biopsy, and percutaneous image-guided biopsy using either core needle, fine-needle, or both can serve a potentially useful role for diagnostic sampling of mediastinal sarcomas, be they primary or metastatic. This review catalogues much of the published data regarding FNA cytopathology and its application to mediastinal sarcomas. An attempt is made to primarily highlight case series rather than individual case reports; however, due to the paucity of these, case reports are cited and discussed where appropriate.

Thyroid nodules with nondiagnostic results on repeat fine-needle aspiration biopsy: which nodules should be considered for repeat biopsy or surgery rather than follow-up?

Purpose:The goal of this study was to assess the clinicopathologic and ultrasonographic features of thyroid nodules with nondiagnostic results on repeat ultrasonography (US)-guided fineneedle aspiration biopsy (FNAB) according to size and the number of suspicious findings and to determine the proper management of nodules with consecutive nondiagnostic results.Methods:This retrospective study included 297 nodules with nondiagnostic results on repeat FNAB that were evaluated by US over the course of at least 12 months of follow-up, a follow-up biopsy, or an operation. We compared clinical and US variables between benign and malignant nodules in thyroid nodules with repeat nondiagnostic results.Results:The comparison of benign and malignant nodules with repeat nondiagnostic results revealed that age, marked hypoechogenicity, irregular or microlobulated margins, microcalcifications, and nonparallel shape were significantly associated with malignancy. Multivariate logistic regression analysis in malignant nodules revealed that microcalcifications and irregular or microlobulated margins were independently associated with malignancy. Among them, only irregular or microlobulated margins were independently significant as a predictor of malignancy in repeatedly nondiagnostic nodules measuring >10 mm. Using receiver operating characteristic analysis, the best cutoff value for the “number of suspicious findings” between benign and malignant nodules was three in nodules of all sizes, three in nodules measuring ≤10 mm, and two in nodules measuring >10 mm.Conclusion:Irregular or microlobulated margins may be the most frequent US features in repeatedly nondiagnostic nodules >10 mm. The presence of “two or more suspicious findings” can be used as the cutoff for distinguishing benign and malignant nodules.

Endoscopic ultrasound-guided fine-needle aspiration biopsy coupled with a KRAS mutation assay using allelic discrimination improves the diagnosis of pancreatic cancer.

Mutation of the KRAS oncogene is present in 75% to 95% of pancreatic cancer tissues. This study aimed to evaluate whether endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), combined with analysis of the KRAS mutation, improves the diagnosis of pancreatic cancer in cases of inconclusive or doubtful cytopathologic analysis. We prospectively included 186 patients with a pancreatic mass (103 men; mean age: 62 y). Cytopathology and KRAS mutations, using TaqMan MGB allelic discrimination, were performed on EUS-FNA material. A final diagnosis was obtained from EUS-FNA analysis and/or a subsequent biopsy if necessary, and/or surgery, and follow-up: these were pancreatic adenocarcinoma (n=104), other malignant pancreatic tumors (n=22), and benign lesions (n=60, including 35 cases of chronic pancreatitis). Inconclusive or doubtful (low-grade dysplasia or atypia) cytopathology was found in 68 cases. Of these, 29 patients who had adenocarcinoma were subsequently diagnosed, including 19 cases with a former KRAS mutation. Sensitivity, specificity, positive and negative predictive values, and overall accuracy of cytopathology alone to diagnose adenocarcinoma were 73%, 100%, 100%, 75%, and 85%, respectively. When KRAS mutation analysis was combined with pathology, these values reached 88%, 99%, 99%, 89%, and 93%, respectively. The performance of EUS-FNA to diagnose malignancy was similarly improved after the KRAS-mutation assay (negative predictive value increased from 67% to 88%; accuracy increased from 85% to 94%). EUS-FNA plus KRAS-mutation analysis, using allelic discrimination, is accurate and improves the diagnosis of pancreatic adenocarcinoma when pathology is inconclusive or doubtful.

Ultrasound Guided-Fine Needle Aspiration Biopsy of Thyroid Nodules: 18 Months Retrospective Review of One Center Experience

The objective of this study is to elucidate the use of ultrasonography guided fine-needle aspiration biopsies (UG-FNAB) in the evaluation of thyroid nodules. The study population consisted of 790 UG-FNAB in 719 patients whom were admitted to the our endocrinology clinic. The cytological results were classified as benign, follicular lesion or suspicious for malignancy, malignant and non-diagnostic. The results of 790 UG-FNAB of 719 patients were as follows: 567 (71.77%) benign, 97 (12.28%) non-diagnostic cytology, 43 (5.44%) atypia with undetermined significance, 81 (10.25%) follicular lesion or suspicious for malignancy, 2 (0.25%) malignant. In our study, thyroid carcinoma rate was found to be lower than current literature. Of the malignant nodules which were reported as papillary thyroid carcinoma by UG-FNAB cytology, both were female, euthyroid and have single nodule in their thyroid gland. One of the patient (39 years old) had a micro nodule ( 1 cm diameter) that it had, hypoechoic pattern with irregular margin. None of them have calcifications in their nodules. Multidisciplinary approach including endocrinologists, radiologists and pathologists is essential for the management of patients with thyroid nodules to avoid missestimation of the risk of thyroid cancer.

Comparison of Sonography With Sonographically Guided Fine‐Needle Aspiration Biopsy and Core‐Needle Biopsy for Initial Axillary Staging of Breast Cancer

The purpose of this study was to determine the roles of sonography and sonographically guided fine-needle aspiration biopsy and core-needle biopsy for initial axillary staging of breast cancer. Of 220 patients with breast cancer who underwent preoperative or prechemotherapy sonography for axillary staging, 52 patients who underwent sonographically guided fine-needle aspiration biopsy and core-needle biopsy for cortical thickening or a compressed hilum of lymph nodes on sonography were prospectively enrolled. Sonography and fine-needle aspiration biopsy/core-needle biopsy findings were compared with final pathologic results from sentinel lymph node biopsy or axillary lymph node dissection. Forty-eight patients met the final study criteria; we excluded 4 who had received primary systemic chemotherapy and showed negative fine-needle aspiration biopsy/core-needle biopsy results and negative final postoperative pathologic results. The positive predictive value of axillary sonography was 54%. The sensitivity and specificity of fine-needle aspiration biopsy were 73% and 100%, respectively, and those of core-needle biopsy were 77% and 100%. Results did not differ significantly between sonographically guided core-needle biopsy and fine-needle aspiration biopsy. The complication rates of fine-needle aspiration biopsy and core-needle biopsy were both 4%, and fine-needle aspiration biopsy and core-needle biopsy cost $180 and $350, respectively. Both sonographically guided fine-needle aspiration biopsy and core-needle biopsy were useful for axillary staging of breast cancer with high sensitivity. However, fine-needle aspiration biopsy is recommended based on the advantages of low cost and minimal invasiveness.

The Diagnostic Accuracy of Ultrasound Guided Fine-Needle Aspiration Biopsy and Intraoperative Frozen Section Examination in Nodular Thyroid Disease

Objectives. To determine the diagnostic accuracy of combined ultrasound-guided fine needle aspiration biopsy (USG-FNAB) and intraoperative frozen section examinationin (FSE) in diagnosing malignant thyroid nodules. Methodology. Retrospective review of patients undergoing thyroidectomy with intraoperative frozen section examination following ultrasound guided fine-needle aspiration biopsy. Sensitivity, specificity, positive and negative predictive values and accuracy were calculated with respect to final histology. Results. A total of 2,239 nodules were subjected to USG-FNAB at the Diabetes, Thyroid and Endocrine Center, St. Luke’s Medical Center between January 2007 and December 2009. Two hundred fifty-one nodules were surgically excised following USG-FNAB. Frozen section examinations were taken from 90 of 251 nodules. The USG-FNAB yielded 90.3% (n=1,721) adequate specimens and 9.7% (n=185) inadequate specimens. The histologic examination of the 251 surgically excised nodules revealed 182 (73%) benign and 69 (27%) malignant nodules. The sensitivity, specificity, positive and negative predictive values and accuracy rate of USG-FNAB cytology are 70.3%, 92.8%, 76.5%, 90.4% and 87.2%, respectively. The diagnosis by frozen section was benign in 56 cases (62%), malignant in 10 cases (11%) and deferred in 24 cases (27%). By FSE, the sensitivity, specificity, positive and negative predictive values and accuracy rate are 83.3%, 100%, 100%, 96.4% and 96.7%, respectively. A diagnostic accuracy of up to 97.2% was achieved when USG-FNAB and FSE were combined and when their findings were concordant. When USG-FNAB and FSE diagnoses were discordant, the FSE showed superior accuracy (83.3%) than cytology (16.7%). In the group of nodules with indeterminate or inadequate cytology, the diagnostic accuracy of frozen section is 100%. Conclusion. Ultrasound guided fine-needle aspiration biopsy is an accurate preoperative test for the evaluation of nodular thyroid disease. It helps to distinguish malignant from benign lesions. The intraoperative frozen section is a valuable test for confirming the cytologic diagnosis. It is especially important in identifying malignant thyroid nodule in cases with indeterminate cytology. The combination of USG-FNAB and FSE greatly improves the accuracy rate in thyroid cancer detection.

16 Diagnosis of Secondary Follicular Center Cell Lymphoma to Pancreas With Endoscopic Ultrasound–Guided Fine-Needle Aspiration Biopsy Cytopathology No. C 08-8 (C-410)

16 Diagnosis of Secondary Follicular Center Cell Lymphoma to Pancreas With Endoscopic Ultrasound–Guided Fine-Needle Aspiration Biopsy Cytopathology No. C 08-8 (C-410)

Endoscopic Ultrasound Guided Fine-Needle Aspiration Biopsy in the Evaluation of Mediastinal Adenopathy Suspected of Extra-Pulmonary Tuberculosis

Endoscopic Ultrasound Guided Fine-Needle Aspiration Biopsy in the Evaluation of Mediastinal Adenopathy Suspected of Extra-Pulmonary Tuberculosis

The role of ThinPrep cytology in the investigation of lung tumors

The aim of this study was to evaluate the role of liquid-based cytology with the ThinPrep (TP) (Cytyc; Cytyc, Co, Boxborough, MA, USA) technique, using fine-needle aspiration (FNA) for sampling, in the investigation of suspicious pulmonary lesions. We performed percutaneous computed tomography (CT)-guided FNA biopsy of focal pulmonary lesions in 80 adult patients. Study subjects were all consecutive patients and potential candidates for surgery. The sample was then examined by both conventional smears (CS) and TP techniques. TP smears of all FNA were prepared from needle rinsing obtained following preparation of CS. All cytological diagnoses were correlated with the CS and/or thoracotomy histological diagnoses in order to evaluate the role of liquid-based cytology with the TP technique. Using TP technique diagnosis was successfully established in 75 patients out of 80, whereas using CS cytology diagnosis was established in 54 patients (p<0.001, z=3899). Inadequate material was observed in 5 cases (6.25%) with the TP technique and in 13 cases (16.25%) with the CS technique (z=-2.77, p<0.05). We believe that the TP technique has a good overall yield for the diagnosis of suspicious for malignant lung lesions. We found that the accuracy of determining lung cancer was excellent.

Diagnosis of Deep-Seated Lymphoma and Leukemia by Endoscopic Ultrasound–Guided Fine-Needle Aspiration Biopsy

We retrospectively studied the use of endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) as a tool for the diagnosis of deep-seated lymphoma. An on-site assessment at the time of EUS-FNAB was performed by a cytopathologist using Diff-Quik (American Scientific Products, McGraw Park, IL) stain. In addition, Papanicolaou stains were performed on EUS-FNAB smears, immunohistochemical stains were performed on cell blocks, and additional samples were sent for flow cytometric analysis. Final cytologic diagnosis was correlated with surgical pathology and/or clinical follow-up. We evaluated EUS-FNAB specimens of deep-seated lymph nodes, spleen, stomach, and pancreas, and 1 EUS-guided needle core biopsy specimen of a lymph node. Thirteen cases of deep-seated lymphoma were diagnosed, including non-Hodgkin lymphomas and Hodgkin lymphoma. One case of hairy cell leukemia was diagnosed. EUS-FNAB is a minimally invasive, cost-effective, and useful tool for the primary diagnosis or staging of deep-seated lymphomas.

Detection of lymph node micrometastases by gene promoter hypermethylation in samples obtained by endosonography- guided fine-needle aspiration biopsy.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become a fundamental procedure for gastrointestinal and lung cancer staging. However, there is growing evidence that micrometastases are present in lymph nodes, which cannot be detected with standard pathological methods. The aim of this study was to evaluate whether hypermethylation gene promoter analysis was feasible on samples obtained by EUS-FNA from lymph nodes, as well as to establish the usefulness of this strategy for the detection of micrometastases in patients with gastrointestinal and non-small cell lung cancer. Suspicious lymph nodes based on EUS findings from consecutive patients with esophageal, gastric, rectal, and non-small cell lung cancer were sampled by EUS-FNA. Hypermethylation analysis of the MGMT, p16(INK4a), and p14(ARF) gene promoter CpG islands were performed by methylation-specific PCR. Effectiveness of conventional cytology, methylation analysis, and their combination were established with respect to the definitive diagnosis. Twenty-seven patients were included, thus representing a total of 42 lymph nodes (esophageal cancer, n = 11; rectal cancer, n = 7; gastric cancer, n = 3; and lung cancer, n = 21). According to definitive diagnosis, 21 (50%) corresponded to metastatic lymph nodes. Sensitivity, specificity, and overall accuracy of conventional cytology were 76%, 100%, and 88%, respectively, whereas the corresponding values for the methylation analysis were 81%, 67%, and 74%, respectively. Combination of both techniques increased sensitivity (90%) but decreased specificity (67%) with respect to conventional cytology. In conclusion, it is feasible to detect occult neoplastic cells in EUS-FNA samples by hypermethylation gene promoter analysis. Moreover, addition of methylation analysis to conventional cytology may increase its sensitivity at the expenses of a decrease in its specificity.

Evaluation of linear scanning endoscopic ultrasonography guidedfine needle aspiration biopsy of sub- mucosal lesions

Objective To determine the value of EUS- guided fine needle aspiration biopsy (FNAB)for the diagnosis of submucosal lesions. Methods We found 28 patients with upper gastrointestinal tract solid submucosal lesions by endoseopies. EUS was performed to assess the lesions arised from the specific layer of the wall and the lymph node metastasis. After excluding extrinsic normal tissues compressing the gastrointestinaltract, EUS guided FNAB were carried out. Results Among these patients, two were extrinsic normal tissues compressing the gastrointestinal tract and all other 26 patients were examined by EUS guided FNAB. EUS- guided FNAB failed in only 3 patients. Among the other 23 patients, cytology demonstrated malignant tumors in 4 patients (lymphoma, n=2; leiomyosarcoma, n=2) and benign lesions in 19 patients (leiomyoma, n=1;lipoma, n=1 ). The results of EUS-guided FNAB were validated by surgery (n=20), endoscopic treatment (n=1) or clinical follow-up (n=7). Conclusion EUS guided FNAB is a safe and accurate method for di-agnosis of submucosal lesions.

Percutaneous fine-needle aspiration of gastrointestinal wall lesions with image guidance.

The fear of complications related to transgression of the bowel wall has limited the application of fine-needle aspiration (FNA) in gastrointestinal wall masses. We have undertaken a study examining our use of image-guided FNA in this setting, and evaluated diagnostic outcome and procedural risk. Twenty patients underwent percutaneous computed topography (CT) or ultrasound (U/S)-guided FNA biopsy of gastrointestinal wall masses over a 3-yr period. Hollow-bore needles were used to aspirate 8 gastric wall masses, 5 perirectal/distal sigmoid masses, 4 colonic masses, and 3 small-bowel masses. Lesions ranged in size from 1.5-13.0 cm (mean, 3.9 cm). One to five passes were made into each lesion (mean, 2.4). Immediate assessment for adequacy by a cytopathologist was performed in all cases. Neoplastic processes were identified in 15 cases (8 primary adenocarcinomas, 2 gastrointestinal stromal tumors, 3 metastases to the bowel wall, 1 Kaposi's sarcoma, and 1 primary lymphoma). Eleven of these 15 patients had histologic confirmation (all neoplastic lesions, excepting patients with metastases or Kaposi's sarcoma). Negative diagnoses (no evidence of malignancy) were obtained in the remaining 5 patients (2 benign colonic epithelium, 1 benign lymphoid population, 1 benign stroma, and 1 acute inflammatory process). A benign clinical course was followed in 4 patients, with 1 patient lost to follow-up. No acute or chronic postprocedural complications were identified. The earlier literature as well as this current study suggest that complications of FNA in this setting are rare. Diagnostic material may be obtained in a less invasive manner than open surgical biopsy.

THE STATUS OF MAMMOGRAPHICALLY GUIDED FINE NEEDLE ASPIRATION BIOPSY OF NONPALPABLE BREAST LESIONS

Mammographically guided needle biopsy is a promising technique for the evaluation of nonpalpable breast lesions. If proved accurate, it should lead to less discomfort and anxiety, fewer complications, less cosmetic disfigurement, and a significant decrease in cost when compared with conventional surgical biopsy. The use of FNAB should lead to surgery on a much more highly selected group of patients, thus producing higher true positive surgical biopsy rates for breast cancer than has been previously possible in this country. These incentives should serve to increase compliance with screening mammography guidelines by women and their physicians. Nevertheless, it is likely that stereotactic FNAB will be best suited to high volume practices in which a large number of biopsies are performed and in which experienced mammographers, cytopathologists, and breast surgeons use a team approach to manage each patient.