Initial Fine-needle Aspiration Biopsy Research Articles

SAT558 Papillary Thyroid Carcinoma With Anaplastic Transformation in a Filipino Male Treated With Radioactive Iodine and Radiotherapy: A Case Report

Abstract Disclosure: A.A. Apa-ap: None. P. Abarquez: None. M.B. Sedurante: None. A. Ongbit: None. P. Carlos Miguel: None. F. Acenas: None. J. Gacula: None. V. Lee: None. S. Estreller: None. INTRODUCTION. Papillary thyroid carcinoma (PTC) is an epithelial malignancy showing follicular differentiation and distinctive nuclear features, with a generally excellent prognosis. On the other hand, anaplastic thyroid cancer (ATC) is rare and highly lethal, with an incidence of only 0.7% in the Philippines. CASE DESCRIPTION. This paper describes a 43year old Filipino male with a 3-year history of anterior neck mass with an initial fine needle aspiration biopsy read as probable PTC. He underwent total thyroidectomy and bilateral radical lymph node dissection and histopathology revealed conventional PTC, solid variant with 5% focal anaplastic transformation. Metastatic workup revealed multiple sub-centimeter pulmonary nodules and a tiny hypodense nodule on left adrenal gland on CT scan. Bone scintigraphy showed increased tracer uptake in the posterior 10th rib and the sphenoid's greater wing. While the multidisciplinary team wanted to proceed with Radiation therapy (RT) first to address the more aggressive histology, this was not possible logistically and thus RAI was performed first. This slight deviation from guidelines was deemed acceptable by Nuclear Medicine due to the possible decrease in iodine absorption from post radiation fibrosis. After a dose of 150 mci, 4 weeks after surgery, patient then completed 33 fractions of RT. Surveillance revealed stable pulmonary nodules and adrenal mass but increasing TSH-stimulated thyroglobulin and antithyroglobulin. Patient underwent another cycle RAI and is currently stable on his 16th month from diagnosis, 15th month post initial RAI, and 13th month post-RT. DISCUSSION. In several case series, patients with minor anaplastic component had 1- and 2-year survival rates of 88% and 43%, respectively with a median survival of 17 months. The overall prognosis of patients with PTC with minor ATC component points to the value of active surveillance compared to more aggressive treatment modalities in the setting of conventional ATC. Presentation Date: Saturday, June 17, 2023

Impact of initial biopsy type on the time to final diagnostic biopsy in patients with follicular lymphoma and suspected histologic transformation

Diagnosis of histologic transformation (HT) of follicular lymphoma (FL) requires tissue biopsy. While surgical biopsy represents the gold standard, less invasive procedures such as fine-needle aspiration biopsy (FNAB) and core needle biopsy (CNB) are frequently performed. In this retrospective multi-institutional study including 269 patients with FL and suspected HT, the median time from initial clinical suspicion to final diagnostic biopsy was similar whether the workup began with FNAB, CNB, or surgical biopsy (4, 9, and 6 days, respectively; p=.27), despite more subsequent biopsies performed following initial FNAB. Periprocedural complications were uniformly minimal. Biopsy-proven HT was more common in the initial surgery group and in workups including positron emission tomography/computed tomography (PET/CT). Our findings, derived from US academic centers with specialized procedural and pathology expertise, suggest that FNAB, CNB, and surgical biopsy are all viable initial diagnostic procedures that can inform clinical decision-making in select FL patients with suspected HT.

A Large Thyroid Fine Needle Aspiration Biopsy Cohort with Long-Term Population-Based Follow-Up.

Background: Prior studies evaluating thyroid fine needle aspiration biopsies (FNABs) have limited the calculation of risk of malignancy (ROM) to cytologic specimens with corresponding histologic specimens, and clinical follow-up for those patients who do not undergo immediate surgery has been largely disregarded. Moreover, there is marked variability in how researchers have approached thyroid FNAB statistical analyses. This study addresses the urgent need for information from a large cohort of patients with long-term clinical follow-up to more accurately determine the performance of thyroid FNAB and ROM for each diagnostic category. Methods: A retrospective review of the University of California, San Francisco (UCSF), pathology database for thyroid FNABs from January 1, 1997, to December 31, 2004, was performed. Diagnoses were coded using the 2017 The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), and patients were matched to both the UCSF cancer registry and California Cancer Registry. Data were analyzed using the Kaplan-Meier method, and stratified by TBSRTC diagnostic category. Kaplan-Meier curves were used to estimate incidence rates of malignancy, stratified by FNAB category. Cox proportional hazards models were used to determine the instantaneous ROM. Results: Initial FNABs from 2207 patients were included. Median follow-up period after the first thyroid FNAB was 13.9 years (range: 10.5-18.4 years). During follow-up, there were 279 confirmed diagnoses of thyroid malignancy. Estimates derived from Kaplan-Meier curves demonstrated that the risk of having a thyroid malignancy was low for nondiagnostic and benign categories, intermediate for atypia of undetermined significance (AUS), follicular lesion of undetermined significance (FLUS), AUS/FLUS combined, and follicular neoplasm, and high for suspicious and malignant categories. A total of 52/1575 false-negative cases (3.2%) were identified. Excluding papillary microcarcinomas, the false-negative rate was 1.5% (23/1575). No patients with a false-negative diagnosis died of thyroid cancer during the follow-up period. Conclusions: Asymptomatic patients with low-risk clinical and radiologic features and initially benign or unsatisfactory biopsy are unlikely to develop thyroid malignancy and highly unlikely to die of thyroid cancer. FNAB is highly accurate in detecting malignancy. Additional studies evaluating similar large data sets after the adoption of TBSRTC and the integration of molecular testing are needed.

Comparative Cytogenetic Abnormalities in Paired Choroidal Melanoma Samples Obtained Before and After Proton Beam Irradiation by Transscleral Fine-Needle Aspiration Biopsy and Endoresection.

This study compared the cytogenetic profiles of choroidal melanoma samples retrieved before and after proton beam irradiation. Twenty-four consecutive patients who underwent both fine-needle aspiration biopsy (FNAB) during tantalum clip positioning, and endoresection within three months of irradiation, were retrospectively included. Chromosome alterations were explored by array comparative genomic hybridization. Age at diagnosis was 50 ± 14 years, tumor thickness was 8.6 ± 1.7 mm and tumor diameter was 12.4 ± 2.3 mm. Six FNAB samples were non-contributive (25%), versus one endoresection sample (4%) (p = 0.049). Among 17 cases with paired contributive samples, the profiles of chromosomes 3 and 8 were identical in all cases, except one with partial chromosome 3 loss on the FNAB sample only. Three cases presented additional discordant aberrations on chromosomes other than 3 or 8q. Overall, we identified monosomy 3 in two cases, 8q gain in six cases, and both alterations in three cases. All cases presented GNAQ or GNA11 mutations assessed by a custom next-generation sequencing panel. Among the six cases with non-contributive initial FNAB, three cases presented abnormal 3 or 8q chromosomes detected on the endoresection material. These results demonstrate the higher rentability of endoresection material for cytogenetic analysis compared to FNAB, and provide clinical evidence of tumor heterogeneity in choroidal melanoma.

Spontaneous cutaneous endometriosis of the mons pubis: Diagnosis, treatment, and review of the literature

Background: Cutaneous endometriosis is usually associated with a preceding surgical scar; spontaneous cutaneous endometriosis is rare. We report on a case of spontaneous cutaneous endometriosis of the mons pubis as well as a review of the literature. Case: A 46-year-old woman with no surgical history presented to gynecology clinic with a 6-year history of a mass on the mons pubis causing severe cyclic pain with enlargement during menses. Initial fine needle aspiration biopsy was nondiagnostic; thus, pelvic ultrasound, magnetic resonance imaging, and a core needle biopsy were used to diagnose a mons endometrioma. The lesion was surgically excised with pathology confirming the diagnosis. The patient noted subsequent improvement in her symptoms. Conclusion: Spontaneous cutaneous endometriosis of the mons pubis can be successfully treated via surgical excision.

The diagnostic ability of core needle biopsy in nodular thyroid disease.

INTRODUCTION Non-diagnostic results of fine needle aspiration biopsy (FNAB) remain an important limitation of this technqiue. The aim of our study was to evaluate the results of core needle biopsy (CNB) of thyroid nodules and its effectiveness in non-diagnostic FNAB cases. METHODS CNBs were performed in 1,000 patients (154 male, 846 female; mean age: 50.2 years, range: 18-86 years) with a spring loaded 20G needle. Of these, 143 had initially had FNABs that were insufficient for evaluation. The CNB reports were reviewed. Patients with suspicious or malignant CNB results underwent total thyroidectomy. RESULTS When considering all 1,000 CNBs, the non-diagnostic rate was 1.5% (15/1,000). However, when the first 100 cases were eliminated as a learning curve, this reduced to 0.9% (8/900). Of the 143 cases with initial FNABs that were non-diagnostic, 0.7% (1/143) were also non-diagnostic on CNB. Twelve patients underwent surgery because of malignant CNB reports and all of these cases were confirmed as malignant by the postoperative pathology specimen results (100% accuracy). There were no major complications although three self-limiting minor complications were observed. CONCLUSIONS CNB is a safe and accurate method. It is more diagnostic than FNAB for nodular thyroid disease.

Radiotherapy for iris metastasis from esophageal carcinoma: A series of three cases.

Background:Description of three cases of metastatic esophageal carcinoma to the iris and focus on management strategies.Methods:A 48-year-old man (Case 1) with previously treated stage IV esophageal carcinoma presented with blurred vision in the left eye (OS) for 3 weeks. Initial fine needle aspiration biopsy (FNAB) was negative for malignant cells, so incisional biopsy was performed and confirmed metastatic carcinoma. A 53-year-old man (Case 2) with previously treated stage III esophageal cancer experienced 2 months of pain and 1 month of blurred vision OS. Documented tumor growth suggested esophageal carcinoma metastasis. A 65-year-old man (Case 3) with previously treated stage IV esophageal carcinoma developed hyphema in the right eye (OD), and FNAB confirmed metastatic carcinoma.Results:Case 1 was treated with external beam radiotherapy (EBRT), delivered over 16 days which resulted in complete tumor regression. Case 2 received stereotactic body radiotherapy (SBRT) over 21 days leading to complete tumor regression. Case 3 was treated with plaque radiotherapy over 4 days, resulting in complete tumor regression.Conclusions:In all three cases, radiotherapy was employed, and enucleation was avoided. Plaque radiotherapy achieved tumor control in a shorter period of time (4 days) compared to EBRT (16 days) or SBRT (21 days). Knowing the short life expectancy of these patients, plaque radiotherapy appears most favorable.

Risk factors associated with malignancy and with triage to surgery in thyroid nodules classified as Bethesda category III (AUS/FLUS)

BackgroundSelection of nodules for surgery diagnosed as Bethesda category III [atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) category] is very important. We aimed at to define the predictive factors for malignancy and factors associated with triage to surgery. MethodsThe records of all patients with nodules who underwent fine needle aspiration biopsy (FNAB) and classified by Bethesda reporting system as AUS/FLUS between 2011 and 2015 at our institution were reviewed. Univariate and multivariate analysis were performed to select independent factors associated with thyroid cancer and with triage to surgery. Using independent risk factors for malignancy predictive index categories were created. ResultsOf the 485 patients who were classified as AUS/FLUS on initial FNAB, 153 underwent surgery with the associated malignancy rate of 22.8%. The malignancy rates for AUS/FLUS patients with and without repeat FNAB were 37.5% and 16.2%, respectively. Multivariate logistic regression analysis revealed that solid structure, microcalcification, hypoechogenicity, increased vascularization, and irregular margin were found to be significant and independent risk factors associated for malignancy, and solid structure, microcalcifications, increased nodule size (≥2 cm) and younger patient age (<65 years) were associated with triage to surgery. ConclusionsOur findings showed that using predictive factors for malignancy in AUS/FLUS category as risk indices, an important proportion of patients (35%) who had nodules without any risk factors could be spared unnecessary surgery. We suggest that predictive indices should be considered for selection of the patients to triage to surgery.

Severe IgG4-Related Disease in a Young Child: A Diagnosis Challenge.

Immunoglobulin G4-related disease (IgG4-RD) is an increasingly recognized syndrome that can appear with multiple organ involvement, typically with tumor-like swelling, lymphoplasmacytic infiltrate rich in IgG4-positive plasma cells, and elevated serum IgG4 concentrations. We report the case of a 22-month-old female child with failure to thrive and recurrent respiratory tract infections since 8 months of age. Physical examination was normal except for pulmonary auscultation with bilateral crackles and wheezes. Laboratory tests revealed elevated erythrocyte sedimentation rate, and elevated serum IgG and IgG4 with polyclonal hypergammaglobulinemia. Thoracic CT and MRI showed multiple mediastinal lymphadenopathies and a nodular posterior mediastinal mass in right paratracheal location with bronchial compression. Initial fine needle aspiration biopsy was compatible with reactive lymphadenopathy but after clinical worsening a thoracoscopic partial resection of the mass was performed and tissue biopsy revealed lymphoplasmacytic infiltrate and increased number of IgG4-positive plasma cells and a ratio of IgG4/IgG positive cells above 40%. Glucocorticoids therapy was started with symptomatic improvement, reduction in the size of the mass, and decrease of serum IgG4 levels after 6 weeks. There are very few reports of IgG4-RD in children. Long-term follow-up is necessary to monitor relapses and additional organ involvement.

Repeat Fine-Needle Aspiration Biopsy within a Short Interval Does Not Increase the Atypical Cytologic Results for Thyroid Nodules with Previously Nondiagnostic Results

Objective: The purpose of this study was to determine whether the recommended waiting period of 3 months is necessary for repeat fine-needle aspiration biopsy (FNAB). Study Design: A retrospective review of 128 nodules from 126 patients with initial nondiagnostic (ND) results was performed for the period between January 2009 and December 2012. Demographic and clinical factors were recorded including age, sex, time interval between FNABs, and ultrasound (US) factors, i.e. nodule size, location, consistency, suspicious malignant findings and thyroiditis. The time interval was subdivided into </≥5, 10, 15 and 20 weeks after the initial FNAB. The effects on the nuclear atypia were analyzed using the Fisher exact test and the Mann-Whitney U test. Results: None of the demographic, clinical or US variables was significantly related to the atypical diagnosis of repeat FNAB. The time interval until repeat FNAB was also not related to the atypical diagnosis (p = 0.63, 0.57, 0.23 and 0.48 for 5, 10, 15 and 20 weeks, respectively). Conclusion: The timing of repeat FNAB for thyroid nodules with previous ND results did not increase the nuclear atypia on repeat FNAB.

Thyroid Nodules with Benign Findings at Cytologic Examination: Results of Long-term Follow-up with US

To investigate the natural history of thyroid nodules found to be benign at initial fine-needle aspiration biopsy (FNAB) to determine the percentage of nodules that increased in volume by more than 50% as being an indicator of malignancy. This retrospective observational cohort study was approved by the institutional review board, and the need to obtain informed consent was waived. The study included 854 FNAB-confirmed benign thyroid nodules. Suspicious ultrasonographic (US) features included marked hypoechogenicity, irregular or microlobulated margin, microcalcification, and taller-than-wide shape. Univariate and multivariate generalized linear mixed models were used to assess the association with nodule growth greater than 50% in volume. For the 854 nodules, the initial mean diameter was 19.92 mm (range, 3.10-60.00 mm), and the initial mean volume was 3.19 cm(3) (range, 0.01-4.64 cm(3)). The majority (682 [79.9%] of 854) of thyroid nodules with benign cytologic results at initial FNAB did not grow more than 50% in volume during 4 years of mean follow-up (range, 7-101 months). More than 4 years of follow-up time versus less than 2 years, younger age, a cystic component of less than 25%, and nodule size 1 cm or larger versus less than 1 cm were independently associated with growth. There was only one malignant nodule (0.6%) among 172 thyroid nodules with a volume increase of 50% or greater during the entire follow-up time. Ten malignant nodules (overall malignancy rate: 1.2%) were detected among the 854 total nodules, and eight of these 10 nodules showed suspicious features at US. Repeat FNAB for nodules showing more than 50% growth in volume is unlikely to result in a diagnosis of malignancy. A positive FNAB result for malignancy is significantly more likely in the presence of suspicious US features.

Anaplastic Thyroid Cancer: Ultrasonographic Findings and the Role of Ultrasonography-Guided Fine Needle Aspiration Biopsy

PurposeTo investigate the ultrasonographic (US) features of anaplastic thyroid cancer (ATC) and the diagnostic performance of US-guided fine needle aspiration biopsy (FNAB) therein.Materials and MethodsEighteen cases of ATC diagnosed between January 2001 and May 2011 were included. FNAB was performed in all cases. Initial FNAB results were divided into three groups: 1) the cytological ATC group, cytological diagnosis of ATC; 2) the underestimated group, cytological diagnoses of malignancy other than ATC; and 3) the false negative group, cytological diagnoses of atypical, benign and non-diagnostic lesions. We retrospectively reviewed US findings and compared treatment modalities between each group.ResultsAmong the 18 patients, there were nine in the initially cytological ATC group, four in the underestimated group and five in the false negative group. The most common US features of ATC were a solid (64.7%) and irregular shaped (88.2%) mass with lymph node involvement (76.4%). However, except for lymph node involvement (p=0.003), US findings for each group were not statistically different. The initial cytological diagnostic accuracy of ATC was 50% (9/18). Surgery was performed less in the ATC group (11%) and the false negative group (20%) than the underestimated group (75%).ConclusionThe US features of ATC were not especially different from other types of aggressive thyroid cancer. A correct diagnosis of ATC by initial US-FNAB was made in 50% of the patients, which is significant in that therapeutic surgery can be undertaken in lower numbers if correctly diagnosed.

Kimura’s Disease Initially Diagnosed as Malignancy then Extra-Pulmonary Tuberculosis

Objective: To describe a rare case of Kimura’s disease initially misdiagnosed as malignancy then tuberculosis.Methods: Design: Case report Setting: Tertiary Private Hospital Patient: OneResults: A 30-year-old male with a 6-year history of gradually-enlarging right infra-auricular mass revealed an enlarged mass in the right infraauricular area and multiple cervical lymphadenopathies on physical examination. Initial fine-needle aspiration biopsy was interpreted as pleomorphic adenocarcinoma but succeeding work-ups and imaging studies led to treatmentfor tuberculosis. Subsequent biopsies finally led to the proper histopathologic diagnosis of Kimura’s disease and the patient was shifted to appropriate treatment with oral prednisone.Conclusion: Kimura’s disease is rare and may be confused with other diseases such as malignancyor tuberculosis. Histopathologic diagnosis is necessary as its treatment differs from tuberculosisand other diseases.Keywords: Kimura’s disease, parotid gland tumor, angiolymphoid hyperplasia with eosinophilia

Evaluation of Breast Disorders with Ultrasound

A 45-year-old nonlactating female presented to the emergency department (ED) fast-track area with a chief complaint of breast pain associated with redness. The symptoms occurred over a period of weeks. There were no constitutional symptoms of fever, chills, or weight loss. The patient had no known personal or family history of breast cancer. On physical examination, there was a 6- by 3-cm confluent area of erythema involving both lower quadrants of the breasts without dimpling. There were no palpable masses, areas of fluctuance, or discharge expressed from the areola. However, it was notable that the patient had large nonaugmented breasts that were difficult to examine. These findings were thought to be most consistent with infectious mastitis, and the patient was started on antibiotics for observation in the ED. On reexamination of the patient, given the difficulty of direct manual evaluation, ultrasound of the breast was performed with a high-frequency linear array ultrasound probe. A 4- by 4-cm complex structure with both solid and cystic components was visualized 1 cm below the area of erythema (see Movie Clip, online only). The patient was then admitted for evaluation of possible breast cancer versus deep tissue abscess. Initial fine-needle aspiration biopsy revealed diffuse lymphocytic invasion that was nonspecific. However, a later ultrasound-guided core-needle biopsy revealed infiltrating ductal carcinoma. Distinguishing between breast pathologies, such as simple infectious mastitis, breast abscess, or a malignant condition, can be quite challenging in the ED. A recent study of 127 adult mastitis complaints revealed that only 25% actually represented true simple infectious mastitis. Another 40% were found to be an abscess, and 6% represented a malignant condition.1 Currently, there is a growing body of literature that identifies ultrasound as being a more sensitive modality in identifying more complicated conditions, such as malignancy, from simple mastitis.2–3 Mammography, while more specific, is often difficult to obtain from the ED. Furthermore, the National Comprehensive Cancer Network endorses ultrasound alongside mammography as a class IIA screening modality for breast cancer with breast skin changes in their 2010 guidelines.4 This case demonstrates that the potential use of bedside ultrasound by emergency physicians can be a rapid and helpful diagnostic tool in differentiating an uncomplicated infectious condition, mastitis, from more complex pathology, such as breast cancer, that was ultimately diagnosed in this patient.

On‐site adequacy evaluations performed by cytotechnologists

Practice patterns regarding on-site assessment of the adequacy of image-guided fine-needle aspiration biopsies (FNABs) vary among laboratories, but in many laboratories primary responsibility rests with the cytotechnologists. On-site evaluation provides feedback on the need for additional passes and facilitates triaging of the specimen for time-sensitive ancillary studies. Prior studies have suggested that cytotechnologists can assess the initially obtained specimens correctly, but they are few in number and limited by small size. The purpose of this study was to assess the frequency with which our cytotechnologists were able to correctly assess specimens as adequate using a large-scale database that included a wide range of image-guided FNABs. The frequency that on-site adequacy assessments of 5241 image-guided FNABs were correct was determined by correlating the cytotechnologists' assessments of adequacy with the final cytologic interpretation. An adequacy assessment was considered correct if the FNAB was ultimately reported as satisfactory and unequivocally benign or malignant. An adequate reading on a case that was ultimately reported as unsatisfactory, atypical, or suspicious was deemed "incorrect." The effect of imaging modality was also analyzed. Of 5241 FNABs, 2784 (53%) were interpreted as adequate on site. Of these, 2637 (95%) were correctly considered adequate. Of the common biopsy sites sampled, the adequacy assessments for liver FNABs demonstrated the highest frequency for being correctly considered adequate (97%) and those for kidney FNABs showed the lowest (90%). Imaging modality had no effect on accuracy. Cytotechnologists are almost always correct when assessing initial FNAB samples as adequate.

Adequate reimbursement is crucial to support cost-effective rapid on-site cytopathology evaluations

Sir, The majority of us who routinely practice fine needle aspiration biopsy (FNAB) understand the value of immediate on-site evaluation of adequacy/triage and interpretation of this procedure.[1–3] The clinical significance of such evaluations and the critical importance of having a cytopathologist available at the time of the procedure are shared by our nonpathologist colleagues.[4,5] The potential benefits of having cytopathologists evaluating initial FNAB smears and rendering an immediate opinion or preliminary diagnosis increases accuracy and decreases the number of inadequate and suboptimal procedures.[6–11] In one institution, the nondiagnostic rate was reported as 1% for FNABs with on-site evaluations as compared with 20% when on-site evaluation was not provided.[8] The authors estimated that if on-site evaluations were not performed, their direct institutional charges for repeating FNABs would have increased by an additional 2 million US dollars in a 5-year period.[8] Therefore, nondiagnostic FNAB will have two obvious disadvantages: (1) delay in diagnosis, with an obvious negative impact on patient care as well as potential legal consequences and (2) substantial increase in the cost of healthcare. Since the October 2009 National Coding Corrective Initiative (NCCI) policy manual publication, many of us have faced repeated inquiries about the appropriateness of using the CPT code 88172 pertaining to this immediate cytologic evaluation.[12] The question at hand is whether or not cytopathologists may use multiples of 88172 when remaining on-site for multiple passes by our clinical colleagues. Opinions have surfaced that multiple 88172 codes may not be allowable; some have reported being denied reimbursement for such multiple coding (personal communication). Our billing departments have made inquiries and, despite the fact that there is nothing concrete yet about this issue, the voices demanding clarification are increasing. As with any rejection from a payer, an adequate, accurate and timely appeal may circumvent a discussion pertaining to the propriety of any given procedure, be it 88172 or other. If the payer repeatedly rejects a particular code with a boilerplate denial, further investigation of the insurers’ manual of coding procedures may better direct the appeal process. If all fails, some states have review processes for rejections. This said, as the leading US cytopathology organization, the American Society of Cytopathology (ASC) is joining others in an attempt to express our professional assessment of this matter. Representing the ASC, The Economic and Government Affairs Committee was asked to render a professional opinion through a written editorial commentary on this issue. The body of evidence is strong that the time required for on-site assessments by cytopathologists is well spent. In a comprehensive cost analysis, Layfield et al. found that on-site interpretations consume between 35 and 56 min, exceeding the average time required for frozen section evaluations by approximately 16 min.[8] Not surprisingly, these investigators also found that the Medicare compensation rate for the 88172 code was low in comparison with the other codes performed during a procedure, i.e. 88331, 88332, 88333 and 88334. They calculated that the time costs exceeded compensation by at least $40–50 per case for cytopathologists performing rapid evaluation for adequacy during a procedure. In another extensive cost analysis review of 5,688 FNAB cases, Nasuti et al. documented that without on-site evaluation, the rate of inadequate aspirates would increase, resulting in substantial institutional cost for repeat procedures and testing.[9] While billing codes for repeat frozen section procedures (88332) and repeat intraoperative cytologic evaluation (88334) are allowed, it is reasonable to allow similar flexibility for immediate cytologic adequacy evaluations and interpretation when immediate evaluation is required on subsequent cytologic material from the same site, following determination that the prior sample was not adequate for diagnosis. Given this background and the related questions and uncertainty, it is worth noting that the College of American Pathologists (CAP) recently added a specific question about immediate adequacy assessments and initial interpretations and their documentation in the Laboratory Accreditation Program cytopathology section checklist effective June 2009 (# CYP. 05325). The cytopathology community has the obligation to clearly advocate for reimbursement policies that support cost-effective cytopathology services for patients. It is our hope that this editorial will encourage individual pathologists, our professional organizations and the greater medical community to adequately support cost-effective cytopathology services. Because of widespread confusion on the current correct billing among payers and members, the ASC and CAP submitted a proposed change to the CPT for code 88172 to more clearly define the unit of service. The Economic and Government Affairs Committee of the American Society of Cytology strongly supports a clear definition of the unit of service for CPT code 88172 that allows the appropriate use of multiple units when multiple procedures are separately evaluated to assure adequacy of the material for diagnosis. As of this writing, the Center for Medicare Services (CMS) is expected to issue additional written guidance on the issue around the November of 2010.

How to combine ultrasound and cytological information in decision making about thyroid nodules

The purpose of this study was to evaluate the role of sonographic-cytological correlation in determining which nodules should be reaspirated to reduce the false-negative rate of fine-needle aspiration biopsy (FNAB). A retrospective cohort study was performed on a database of 568 patients with 672 focal thyroid nodules. An independent two-sample t-test was used to compare the risk of malignancy according to clinical factors. We evaluated the risk stratification of malignancy according to US groupings and cytological results. Additionally, we calculated the false-negative rate of FNAB and investigated the cytological results of repeat aspiration. The malignancy rate (92.2-98.5%) was high in thyroid nodules designated "malignant" or "suspicious for papillary carcinoma" on FNAB, regardless of US features. In contrast, when focal thyroid nodules had "benign" readings on FNAB, the malignancy rate was lower for the "probably benign" US features (2.9%) than for the suspicious nodules (56.6%). The false-negative rate of FNAB was 5.8%. Repeat aspiration revealed "suspicious for malignancy" or "malignancy" results in 15 (93.8%) of 16 thyroid cancers with "benign" results on initial aspirate. This study demonstrated repeat FNAB should be performed on focal thyroid nodules with suspicious US features even when initial FNAB results are benign.

Comparison of cytological results obtained by repeated US‐guided fine‐needle aspiration biopsies of thyroid nodules: Focus on the rate of malignancy and diagnostic concordance

The debate still continues on the repeated fine-needle aspiration biopsies (FNABs) for thyroid nodule in clinical practice. In this study, we determined the rate of cytological change to malignancy and the diagnostic concordance of repeated FNABs when the same nodules were targeted under US-guidance. We retrospectively reviewed data for 187 thyroid nodules (173: twice, 14: three times) from 160 patients who underwent repeated US-guided FNABs, which were performed by one skillful radiologist targeting for the same nodules at a mean interval of 7.5 months. Their initial cytological findings were compared with second or third results and histopathologic follow-up. The initial FNABs findings of 187 nodules were unsatisfactory, benign, and indeterminate in 56, 52, and 79 cases, respectively. The rate of a second cytological diagnosis changed to malignancy was significantly higher in the unsatisfactory aspirates (10.7%; 6/56), when compared with those of the benign (0.0%; 0/52) or of indeterminate aspirates (3.8%; 3/79) (P = 0.022). However, there was no change to malignancy at third cytological findings of all 14 nodules. After the second US-guided FNABs, 30.8% (16/52) of the initially diagnosed as benign aspirates were reclassified as indeterminate, while 26.6% (21/79) of the initially diagnosed as indeterminate were reclassified as benign. In conclusion, to identify malignancies, repeated US-guided FNABs are recommended for thyroid nodules initially classified as unsatisfactory aspirates. However, although US-guidance is applied, a discrepancy might be unavoidable in the cytological interpretation of the nodules classified as benign or as indeterminate aspirates because of overlapping cytological criteria.

Fine needle aspiration biopsy: Role in diagnosis of pediatric head and neck masses

To assess the feasibility and role of fine needle aspiration biopsy (FNAB) as a diagnostic tool in children with neck masses. Retrospective chart review. Tertiary care children's hospital. Consecutive series of 71 children with a head and neck mass who underwent FNAB as the primary diagnostic modality. FNAB was performed and interpreted by a pediatric cytopathologist. Rapid on-site analysis was performed to allow immediate assessment of specimen adequacy and to attain a preliminary diagnosis, after which routine cytologic staining was performed. Flow cytometry was performed on cytological specimens when malignancy was suspected, and open biopsy was performed when the cytologic diagnosis was in question. Technical feasibility of FNAB in children, complications, cytopathological diagnoses, accuracy of rapid on-site analysis, need for subsequent diagnostic evaluations, clinical outcomes and follow-up. Mean age was 8.4 years (S.D. 5.3 years), with mean follow-up of 4.1 months (S.D. 9.6 months). FNAB was performed under general anesthesia in 54 cases (76%). There were no technical complications. On-site rapid interpretation was completed in 55 cases, 18/55 confirmed adequacy of specimen only, 37/55 yielded a preliminary diagnosis, and in 34/37 cases, was same as final cytopathologic result. Overall, FNAB biopsy demonstrated 64 benign lesions, 3 malignant diagnoses, 2 follicular thyroid neoplasms, and 2 non-diagnostic specimens. FNAB was the only pathological test performed in 54 (76%) cases. The most common diagnosis was reactive lymphoid hyperplasia (n = 39), followed by benign granulomatous disease (n = 8). Flow cytometry was performed on 7 specimens (non-diagnostic in 5, negative for malignancy in 2). Of the 15 cases with surgical specimens, 3 revealed a pathologic diagnosis different from initial FNAB. There were no cases in which FNAB missed a malignancy, and there were 2 cases where FNAB suggested malignancy, with benign disease subsequently found on open biopsy. Fine needle aspiration biopsy is developing into a feasible option in diagnosing pediatric neck masses, with its main advantage being its minimally-invasive nature and avoidance of an open surgical procedure for benign persistent lymphadenitis. On-site rapid interpretation can be used successfully to confirm specimen adequacy and to give an accurate preliminary diagnosis for concerned parents. Issues to consider include the need for a specialized pediatric cytopathologist familiar with pediatric differential diagnoses, the need for general anesthesia in many cases, and the possibility of inaccurate diagnosis requiring an open procedure.

Can cytology accurately predict benign follicular nodules?

Background The reliability of fine-needle aspiration (FNA) biopsy in differentiating benign from malignant follicular lesions of the thyroid has been the subject of renewed debate recently. Although surgical excision has been recommended for most follicular lesions identified by cytology, this approach may not be necessary in all cases. The goal of this study was to determine whether FNA could be used as a diagnostic tool to safely identify patients with follicular thyroid nodules who do not require immediate surgical intervention. Methods A retrospective review was performed on a sample of 24 patients diagnosed with either follicular adenoma or follicular carcinoma after surgical excision of a thyroid nodule. The initial FNA biopsies were independently reviewed by two experienced cytopathologists in a blinded fashion and subsequently compared with final histologic diagnoses. Results For pathologist A, overall accuracy was 58%. The positive predictive value (PPV) of a benign diagnosis was 82%; PPV of a malignant diagnosis was 38%. For pathologist B, overall accuracy was 63%. The PPV of a benign diagnosis was 83%; PPV of a malignant diagnosis was 42%. Conclusions This study suggests that in follicular lesions of the thyroid, a benign FNA biopsy report from an experienced cytopathologist has a high positive predictive value. The predictive value may not, however, be high enough to preclude surgery; other factors may need to be considered before recommending a nonoperative approach.