Fine-needle Aspiration Biopsy Of Nodules Research Articles

7812 Community Practice Setting Experience in Evaluation of Incidental Thyroid Nodules

Abstract Disclosure: N. Abate: None. H. Rhodes: None. M. Horlavadi: None. B. Adams-Huet: None. M. Chandalia: Advisory Board Member; Self; Boehringer Ingelheim. Speaker; Self; Boehringer Ingelheim, Eli Lilly & Company, Novo Nordisk. Background: There is a significant increase in detection of incidental thyroid nodules due to increase in routine screening ultrasounds at church, workplace, and health fairs, increase in routine ultrasound in primary care clinics and incidental finding of thyroid nodule during carotid artery ultrasound. These patients are then referred for thyroid nodule fine needle aspiration biopsy. Aim of this study was to evaluate real world data in frequency of thyroid cancer in patients referred for incidental thyroid nodule to a nonacademic Endocrinology clinic utilizing centralized collection of cytology and molecular analysis. Method: Medical records were reviewed for consecutive FNA of incidental thyroid nodule in an Endocrinology clinic in greater Houston from 2021 to 2023. FNA was performed in patients selected based on ACR TI-RADS classification. Patients with Bethesda score of 3 or more had molecular testing with Thyroseq performed. Patients with intermediate or high probability of cancer on Thyroseq as well as Patients with Bethesda 4 and 5 on cytopathology were referred for surgery. Surgical pathology was obtained in patients who underwent surgery. Data was tabulated and analyzed using SAS. Results: A total of 304 subjects, 267 Female and 37 males, age 57 ± 13, nodule size 2.69 ± 1.4 (mean ± SD), had thyroid nodule FNA between 2021 and 2023. Of these FNA, 23 (7.5%) sample collections were insufficient, 233 (77.3%) were benign (Bethesda 2), 46 (15%) were Atypia of undetermined significance or Suspicious for malignancy. Of those subjects with Bethesda 3 or higher, 36 patients had molecular testing by Thyroseq Method. Fifteen patients had intermediate and high risk finding on Thyroseq. Thirty-four subjects had surgery and 8 patients had malignancy on surgical pathology. One patient was identified as Medullary Thyroid cancer on Thyroseq, confirmed by surgery. Frequency of malignancy in incidentally detected thyroid nodule in the whole group was 2.6%, those with Bethesda 3 and more was 17.4% and those with Thyroseq intermediate or high risk was 27%. Conclusion: Availability of centralized cytopathology and reflex molecular testing to Community practice settings helps reducing unnecessary thyroid surgeries in patients with incidental thyroid nodules. Presentation: 6/1/2024

6511 Provider Opinions on Holding Antiplatelet and Anticoagulant Drugs Prior to Thyroid Nodules FNA Biopsy: A Survey Study

Abstract Disclosure: M.D. Lundholm: None. P.P. Rao: None. Objective: It is thought that anticoagulant (AC) or antiplatelet (AP) therapy at the time of thyroid nodule fine needle aspiration biopsy (TNFNAB) may increase the risk of non-diagnostic results and post-procedure hematomas. However, interrupting a patient’s AC or AP can lead to procedural delays or have thrombotic consequences. Since there is currently no consensus on whether or not to hold these medications, this study aims to survey the expertise of our providers across multiple specialties. Methods: A survey was sent out to Cleveland Clinic providers who have performed TNFNABs for patients with an active prescription for AC or AP since 2010. Providers were asked if they routinely held a number of blood thinner medication classes and included a free response section for open-ended comments. Results: The survey responses represented 60 providers (of 68 invited, 88% response rate). Respondents were 51.7% medical endocrinologists, 30% interventional radiologists, 13% surgical endocrinologists, and 5% ENTs. Of respondents, 13.3% held aspirin 81 mg, 15.0% held aspirin 325 mg, 41.7% held other antiplatelet agents, 73.3% held warfarin, 43.3% held direct oral anticoagulants (DOACs), and 43.3% held heparin. No department was uniform in practice, with the least agreement (responses closest to 50%) amongst medical endocrinologists. In a subset of 15 providers who have performed ≥100 TNFNABs on patients with AC/AP, a consensus emerged not to hold aspirin at any dose, but there was no agreement in any other AC/AP categories (hold rates ranging 53.5-66.6%). Free response themes reiterated that the main concerns for continuing blood thinners are hematomas and non-diagnostic results. Other comments included consideration of the nodule features such as location as well as strategies used to lower risk for hematomas (i.e., small-gauge needles, ice, holding pressure). A couple responses referred to the Society of Interventional Radiology (SIR) and the International Society on Thrombosis and Haemostasis (ISTH) guidelines which offer INR and platelet goal recommendations prior to any procedure with a low bleeding risk. Discussion: A survey of Cleveland Clinic providers demonstrated that ≥85% continue aspirin therapies prior to TNFNAB. However, there is no such agreement in any other category of AC/AP medication, even amongst the most experienced providers. The closest guidelines available come from SIR and ISTH and rely on recent platelet and/or INR information, which may not be available in routine endocrinology practice. The caveat is that these recommendations are not specific to TNFNAB and do not take into account the nuances of this procedure. Conclusion: There is wide variation in provider opinions and practice patterns regarding AC and AP medications prior to TNFNAB. This highlights the need for further study into the safety and adequacy of TNFNAB performed on uninterrupted AC or AP therapy. Presentation: 6/3/2024

Lymphadenitis and meningoencephalitis resulting from Cryptococcus neoformans infection in HIV patients

Background: Lymphadenopathy can occur at any stage of HIV infection, with multiple aetiologies including reactive, infectious and malignant. An accurate and timely diagnosis has obvious implications for treatment. Case Description: We report cryptococcal lymphadenitis as the presenting manifestation of HIV infection. Clinical symptoms observed in the patient included headaches, fever, non-productive cough, nausea, vomiting, white patches on the tongue, nodules in the right and left jaw area, a weight loss of 10 kilograms within a month, and a decrease in consciousness in the middle of treatment. The diagnosis was eventually confirmed with a lymph node fine needle aspiration biopsy. Fine needle aspiration biopsy (FNAB) indicated chronic granulomatous inflammation with a fungal (yeast) infection, suggestive of Cryptococcus. Conclusion: Cryptococcosis is a major invasive fungal infection capable of causing widespread disease outbreaks in immunocompromised hosts, and even in seemingly immunocompetent individuals. Cryptococcal infection should be a diagnostic consideration for lymphadenopathy in every patient, regardless of known HIV infection.

Exploring the diagnostic value of ultrasound-guided lymph node fine-needle aspiration biopsy in the diagnosis of cervical lymph node tuberculosis: a medical discussion.

Exploring the diagnostic value of ultrasound-guided lymph node fine-needle aspiration biopsy in the diagnosis of cervical lymph node tuberculosis: a medical discussion.

Fine-needle aspiration biopsy of axillary lymph nodes: Areliable diagnostic tool for breast cancer staging.

Pathologic evaluation of sentinel lymph node biopsy (SLNB) samples is crucial for axillary staging in patients newly diagnosed with breast cancer. Patients with pathologic evidence of nodal metastasis scheduled for upfront surgery typically also undergo axillary lymph node dissection (ALND). Although SLNB is the gold standard method for detecting nodal metastasis, axillary lymph node fine-needle aspiration biopsy (FNAB) utility has not been thoroughly explored. Ultrasound-guided axillary lymph node FNAB samples along with concurrent ipsilateral breast tissue samples were searched and reviewed. The control group included histologic findings of axillary dissection or intraoperative SLNB results. A total of 354 axillary lymph node FNAB samples with matched histology were included. Of these, 187 (52.8%) were positive for metastatic carcinoma of breast origin; 143 (40.4%) were negative for metastasis; 12 (3.4%) showed atypical cells; six (1.7%) were suspicious for metastasis; and six (1.7%) were nondiagnostic because of a lack of lymphoid tissue and malignant cells. Of the 143 negative FNAB samples, 22 (15.4%) were positive on either intraoperative SLNB or ALND. When only the positive and negative FNAB samples were accounted for (n=330; 93.2%), overall diagnostic sensitivity and specificity were 89.4% and 99.2%, respectively. Although axillary SLNB is the standard procedure for detecting nodal metastasis of breast origin, axillary lymph node FNAB appears to be a suitable alternative in a significant proportion of patients. A standard SLNB should be performed in cases of negative axillary lymph node FNAB findings, particularly nodes with abnormal imaging findings.

The Application of the Proposed Sydney System for Reporting Lymph Node Cytopathology: A Five-Year Experience of an Academic Institution in South India

Introduction: Fine needle aspiration biopsy (FNAB) is a routinely used investigation in the evaluation of lymph node pathologies. However, there exists a lack of uniformity in cytopathology reporting owing to the nonavailability of standard guidelines. Recently, a novel system for reporting lymph node cytopathology has been proposed. The present study aimed to analyze the utility of the proposed system in cytopathology reporting in our institution. Materials: FNABs of lymph nodes performed over a period of 5 years were categorized as per the proposed Sydney system. The diagnoses on cytopathology were correlated with histopathologic diagnoses to assess the diagnostic accuracy. The rate of malignancy (ROM) for each category was calculated. Results: A total of 747 lymph node FNABs were included in the study. Histopathology was available in 262 cases. ROM in categories I–V was 26.3%, 7.2%, 76.9%, 82.3%, and 100.0%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of FNAB when considering category L3 to represent benign cytopathology were 84.2%, 97.5%, 97.1%, and 86.2%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of FNAB when considering category L3 to represent malignant cytopathology were 92.56%, 95.08%, 94.9%, and 92.8%, respectively. Conclusion: The study substantiates the usefulness of the proposed Sydney system in lymph node cytopathology in enhancing better communication between clinicians and cytopathologists. The use of ancillary techniques like immunocytochemistry and flow cytometry will aid in arriving at a more precise diagnosis.

Has the Diagnostic Accuracy of Thyroid Nodule Fine-Needle Aspiration Biopsy Improved? Results of a Systematic Review and Meta-Analysis

Clinical ThyroidologyVol. 34, No. 12 Thyroid NodulesHas the Diagnostic Accuracy of Thyroid Nodule Fine-Needle Aspiration Biopsy Improved? Results of a Systematic Review and Meta-AnalysisAndrea Ortiz Rocha and Naykky Singh OspinaAndrea Ortiz RochaDivision of Endocrinology, Diabetes & Metabolism, Department of Medicine; University of Florida College of Medicine, Gainesville, FL, U.S.A.Search for more papers by this author and Naykky Singh OspinaDivision of Endocrinology, Diabetes & Metabolism, Department of Medicine; University of Florida College of Medicine, Gainesville, FL, U.S.A.Search for more papers by this authorPublished Online:12 Dec 2022https://doi.org/10.1089/ct.2022;34.540-544AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetails Volume 34Issue 12Dec 2022 Information© Copyright 2022, Mary Ann Liebert, Inc.To cite this article:Andrea Ortiz Rocha and Naykky Singh Ospina.Has the Diagnostic Accuracy of Thyroid Nodule Fine-Needle Aspiration Biopsy Improved? Results of a Systematic Review and Meta-Analysis.Clinical Thyroidology.Dec 2022.540-544.http://doi.org/10.1089/ct.2022;34.540-544Published in Volume: 34 Issue 12: December 12, 2022PDF download

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.

A Retrospective Evaluation of the Diagnostic Performance of an Interdependent Pairwise MicroRNA Expression Analysis with a Mutation Panel in Indeterminate Thyroid Nodules.

Background: The addition of genetic analysis to the evaluation of thyroid nodule fine-needle aspiration biopsy samples improves diagnostic accuracy of cytologically indeterminate thyroid nodules (ITNs) with Bethesda III or IV cytopathology. We previously reported the performance of a multiplatform molecular test, referred to in this study as MPTXv1, that includes a mutation panel (ThyGeNEXT®) plus an algorithmic microRNA (miRNA) risk classifier (ThyraMIR®). Complex interactions of growth-promoting and -suppressing miRNAs affect the phenotype. We previously demonstrated that accounting for these interactions with pairwise miRNA expression analysis improves the diagnosis of medullary thyroid carcinoma. In this study, we assess the impact of pairwise miRNA expression analysis on risk stratification of ITNs. Methods: Pairwise expression analysis of 11 miRNAs was performed on a training cohort of histopathology-proven benign nodules (n = 50) to define the mean and standard deviation of each pairwise analysis and create a Benign/Malignant Profiler (MPTXv2), deviations from which predicted the malignancy risk. Clinical validation of MPTXv2 was assessed using a cohort of 178 ITN (Bethesda III and IV) samples from a multicentered, blinded retrospective study, previously evaluated by MPTXv1. Results: Compared with MPTXv1, MPTXv2 significantly improved the test performance. The receiver operating characteristic (ROC) areas under the curve (AUC) increased from 0.85 to 0.97 (p < 0.001), and the diagnostic accuracy at the positive threshold increased significantly (p < 0.05) from 83% [95% confidence interval (CI) = 76-88] to 93% [CI = 89-96]. The significant improvement in the ROC AUC and the diagnostic accuracy was due to a strong statistical trend for improvement in specificity at the positive threshold. At the positive threshold, the specificity for MPTXv1 was 90% [CI = 84-95] and improved to 98% [CI = 94-99] for MPTXv2. Using the MPTXv2, the Moderate-Risk cohort decreased from 50 samples (28% of the cohort) to 24 samples (13% of the cohort). This 52% decrease is statistically significant (p < 0.001) and clinically meaningful. Conclusion: As compared with MPTXv1, pairwise miRNA expression analysis used in MPTXv2 significantly improved the diagnostic accuracy of ITN risk stratification and reduced the size of the Moderate-Risk group. Prospective trials are indicated to confirm these findings in a clinical practice setting.

Intraoperative Sentinel Node Fine-Needle Aspiration Biopsy as a Substitute for Whole Sentinel Node Excisional Biopsy in Breast Cancer Patients. Initial Report

IntroductionSentinel Node Biopsy (SNB) is the choice procedure for axillary staging in Breast Cancer. Following the ACOSOG Z11 trial, axillary dissection is advised only in patients with more than 2 positive SNs. We aimed at exploring palpation-guided, intraoperative fine-needle aspiration biopsy of the SN as a replacement for whole SN excision in node-negative BC patients to minimize side-effects. Patients and MethodsWe included 80 patients with BC undergoing SNB between December 2020 and May 2022. After identification of the SN, the breast surgeon performed SN-FNAB. Results were compared with definitive pathological assessment. ResultsDiagnostic yield was 80%, including a “learning curve.” 58 of 64 patients with suitable samples tested negative. In this group, the Negative Predictive Value was 77.6% (IC 64.7%-87.5 %). If micro metastasis is disregarded, the NPV would increase to 86.2% (IC 74.6%-93.9%). If we accept the Z11 criterion for axillary dissection, the NPV would rise to 100%. Six patients had a positive SN-FNAB. They were all confirmed as having macro metastatic-positive SNs at the final pathological assessment, and 3 of them also displayed extra nodal extension (ENE). ConclusionWe believe that intraoperative SN-FNAB is highly accurate for swiftly depicting both low axillary tumor burden/negative cases, in whom axillary dissection is to be omitted, as well as high axillary tumor burden cases.

Development of a Molecular Assay for Detection and Quantification of the BRAF Variation in Residual Tissue From Thyroid Nodule Fine-Needle Aspiration Biopsy Specimens

Thyroid cancer, predominantly papillary thyroid carcinoma (PTC), is common, but an estimated 30% of ultrasonography-guided fine-needle aspiration (FNA) biopsies of thyroid nodules are indeterminate. BRAF variation, associated with poor clinicopathological characteristics, is a useful molecular marker for diagnostics. To develop a sensitive molecular assay for BRAF V600E detection in remaining tissue of thyroid FNA biopsies to identify patients with cancer carrying a BRAF variation. This diagnostic study used tumor tissue from surgical formalin-fixed, paraffin-embedded (FFPE) specimens and residual tissue from thyroid FNA biopsies for genomic DNA extraction. FFPE specimens served as the validation set, and residual tissue from FNA biopsies served as the test set. A molecular assay was developed for accurate detection of BRAF V600E variation using locked nucleic acid (LNA) probe-based droplet digital polymerase chain reaction (dPCR), and the assay was validated by BRAF V600E immunohistochemical staining (IHC). The study was conducted between February 2019 and May 2021. A total of 271 specimens, including 77 FFPE specimens (with a follow-up of 48 matched surgical specimens) and 146 residual FNA samples, were collected from 223 patients (mean [SD] age, 53.8 [15.3] years; 174 [78.0%] women; 49 [22.0%] men). The molecular assay by dPCR was first established to specifically and accurately detect and quantify wild-type BRAF and variant BRAF in DNA from human follicular thyroid carcinoma-derived FTC-133 and papillary thyroid carcinoma-derived BCPAP cells. The linearity of quantification of BRAF V600E was calculated (y = 0.7339x; R2 = 0.9996) with sensitivity at 0.02 copies/μL and reproducibility in detecting variant DNA at various dilutions(coefficient of variance in 0.3% DNA, 9.63%; coefficient of variance in 1.0% DNA, 7.41%). In validation testing, the dPCR assay and IHC staining exhibited 100% specificity in concordantly identifying BRAF V600E in PTCs (κ = 0.873; P < .001) and sensitivity of 32.0% (95% CI, 19.1% to 44.9%) in dPCR and 26.0% (95% CI, 13.1% to 38.9%) in IHC staining, with an improvement by 23.08% in dPCR compared with the IHC staining. The dPCR assay further detected BRAF V600E in 39 of 146 residual FNA specimens (26.7%). At short-term follow-up, 48 patients, including 14 of 39 patients with BRAF variation and 34 of 107 patients without BRAF variation on residual FNA specimens, underwent resection. The dPCR assay of BRAF status in the matched surgical specimens showed BRAF V600E variations in 12 patients and wild-type BRAF in 36 patients, with a high agreement to that in residual tissue of FNA specimens (κ = 0.789; P < .001). Among 14 patients with BRAF variations on residual FNA, 13 were diagnosed with PTC and 1 was diagnosed with anaplastic thyroid cancer at the thyroidectomy. This diagnostic study developed a sensitive molecular assay for detection and quantification of BRAF V600E variation in residual tissue from thyroid FNA biopsies to identify patients with cancer harboring BRAF V600E in a cost-effective manner, highlighting the clinical value of molecular assay of the remaining FNA tissue in the management of thyroid nodules.

Canine visceral leishmaniasis and Rhipicephalus sanguineus: evaluation and comparison of classical techniques.

The aim of this study was evaluating the association and correlation between the diagnostics tests used for Leishmania spp. detection in dogs and ticks. We evaluated 99 dogs and 990 Rhipicephalus sanguineus. In dogs, we used bone marrow aspirates and lymph node fine-needle aspiration biopsy (FNAB) for direct parasitological examinations and real time-polymerase chain reaction (RT-PCR) and collected blood samples for enzyme-linked immunosorbent assays (ELISA). In ticks, two laboratory techniques [immunohistochemistry to lipophosphoglycan (IHC) and RT-PCR] were performed in the intestine, ovaries and salivary glands. With respect to the measurement of diagnostic performance in dogs, lymph node RT-PCR proved to be the best test followed by ELISA and bone marrow RT-PCR. In ticks, intestine IHC were considered as a gold standard for diagnosis of leishmaniasis with intestinal RT-PCR being the best diagnostic test. To arrive at the correlation between laboratory techniques for dogs and their ticks, we evaluated the diagnostic test used for dogs with tests performed in R. sanguineus, which used lymph node FNAB as the gold standard. The intestine IHC technique showed strongest association. We demonstrated that the best tissue for Leishmania spp. detection in dogs was the lymph node and the intestine in case of ticks. As for laboratory techniques, the isolated analysis of each species presented a strong agreement between immunohistochemistry and RT-PCR when compared to its gold standard. In addition, we concluded that the immunohistochemistry of ticks' intestines was a better technique for diagnosing Leishmania spp. in R. sanguineus, thereby showing almost perfect correlation with the lymph node FNAB.

Role of the cytopathologist during the procedure of fine-needle aspiration biopsy of thyroid nodules

PurposeThis study aimed to conduct a diagnostic and cost-effective analysis of the cytopathology assistance in the ultrasound (US)-guided fine-needle aspiration biopsy (FNAB) for characterising thyroid nodules.Materials and methodsWe reviewed the reports relative to 9061 US-guided FNABs for the histologic definition of the nature of thyroid nodules: 45.4% completed with the cytopathologist assistance and 54.6% by the radiologist alone.We also performed the cost-effectiveness analysis (CEA) of the procedure with and without the cytopathologist assistance.ResultsWe found a significant positive correlation between the adoption/non-adoption of cytopathologist assistance and the number of indeterminate (TIR1) (Chi-square; z-score, Z = 10.22; critical value 5%, C = 1.96; p < 0.001). The cytopathologist's absence was correlated with the number of TIR 1 (Pearson correlation, product–moment correlation r = 0.059; critical value 5%, C = 0.008; p < 0.001).The total cost of the model's cytopathologist-assistance branch is 109.87€, while the total cost of the non-cytopathologist-assistance branch is 95.08€.ConclusionThe cytopathologist assistance resulted in fewer nondiagnostic results, thus excluding the procedure's repetition but involved a higher expense, mainly due to the professional cost of the pathologist's participation. These data may provide decision-makers in healthcare with a practical evidence based on the opportunity to include the cytopathologist assistance in the thyroid nodule's FNAB depending on the available resources and the population's expectance.

Impact of Electronic Consultation on Timeliness and Guideline Concordance of Workups Leading to Thyroid Nodule Fine-Needle Aspiration Biopsy

ObjectiveElectronic consultations (e-consults) are commonly used to obtain endocrinology input on clinical questions without a face-to-face visit, but sparse data exist on the resultant quality of care for specific conditions. We examined workups resulting in a thyroid nodule fine-needle aspiration (FNA) biopsy to investigate whether endocrinology e-consults were more timely and similarly guideline-concordant compared with endocrinology face-to-face visits and whether endocrinology e-consults were more guideline-concordant compared with workups without endocrinology input. MethodsWe retrospectively reviewed charts of 302 thyroid FNA biopsies conducted in the Veterans Affairs health system between May 1, 2017, and February 4, 2020 (e-consult, n = 99; face-to-face visit, n = 100; no endocrinology input, n = 103). We used t tests to compare timeliness, χ2 tests to compare the proportion of guideline-concordant workups, and multivariable linear and logistic models to control for demographic factors. ResultsFNAs preceded by an endocrinology e-consult had more timely workups compared with those preceded by endocrinology face-to-face visits in terms of days elapsed between referral and FNA biopsy (geometric mean 44.7 days vs 61.7 days, P = .01). The difference in the summary measure of guideline concordance across groups was not statistically significant (P =.38). ConclusionE-consults were faster than face-to-face consults and similarly guideline-concordant compared with both face-to-face consults and no endocrinology input for workups resulting in FNA. Decisions about the appropriate use of e-consults for thyroid nodules should take into account these data while also considering the potential benefits of direct patient-endocrinologist interaction for complex situations.

Pediatric adaptions are needed to improve the diagnostic accuracy of thyroid ultrasound using TI-RADS

Background/PurposeThyroid Imaging Reporting and Data System (TI-RADS) is validated in adults but not yet in children. The purpose of this study was to determine the sensitivity, specificity, and accuracy of TI-RADS in predicting thyroid malignancy for pediatric nodules, and to compare the diagnostic accuracy to the current American Thyroid Association (ATA) guidelines. MethodsA single institution retrospective review was performed of patients younger than 21 years who underwent thyroid nodule fine needle aspiration biopsy (FNAB). Two radiologists were blinded to the pathology and independently classified all biopsied thyroid nodules based on TI-RADS. ATA and TI-RADS guidelines were analyzed to determine the diagnostic sensitivity and specificity of both scoring systems. Results115 patients (median age 15.5 years, 90 females) with 138 nodules were scored using TI-RADS. There was moderate inter-rater agreement between radiologists (Kappa = 0.51; p < 0.0001). Evaluating several potential TI-RADS criteria, 23.2%-68.1% of nodules were recommended for FNAB, compared to 82.6% of nodules using ATA guidelines. Using TI-RADS ≥ 3 (without size cutoff) as an indication for FNAB had 100% sensitivity with no missed suspicious or malignant nodules on cytology or pathology. ConclusionsUsing TI-RADS for diagnostic management of pediatric thyroid nodules improves accuracy in predicting malignancy.

The Role of Nuclear Medicine in the Clinical Management of Benign Thyroid Disorders, Part 2: Nodular Goiter, Hypothyroidism, and Subacute Thyroiditis.

Part 2 of this series of Continuing Education articles on benign thyroid disorders deals with nodular goiter, hypothyroidism, and subacute thyroiditis. Together with Part 1 (which dealt with various forms of hyperthyroidism), this article is intended to provide relevant information for specialists in nuclear medicine dealing with the clinical management of patients with benign thyroid disorders, the primary audience for this series. Goiter, an enlargement of the thyroid gland, is a common endocrine abnormality. Constitutional factors, genetic abnormalities, or dietary and environmental factors may contribute to the development of nodular goiter. Most patients with nontoxic nodular goiter are asymptomatic or have only mild mechanical symptoms (globus pharyngis). Work-up of these patients includes measurement of thyroid-stimulating hormone, free triiodothyronine, free thyroxine, thyroid autoantibodies, ultrasound imaging, thyroid scintigraphy, and fine-needle aspiration biopsy of nodules with certain ultrasound and scintigraphic features. Treatment for multinodular goiter includes dietary iodine supplementation, surgery, radioiodine therapy (to decrease thyroid size), and minimally invasive ablation techniques. Hypothyroidism ranges from rare cases of myxedema to more common mild forms (subclinical hypothyroidism). Primary hypothyroidism often has an autoimmune etiology. Clinical presentations differ in neonates, children, adults, and elderly patients. Work-up includes thyroid function tests and ultrasound imaging. Nuclear medicine is primarily used to locate ectopic thyroid tissue in congenital hypothyroidism or to detect defects in iodine organification with the perchlorate discharge test. Treatment consists of thyroid replacement therapy with l-thyroxine, adjusting the daily dose to the individual patient's metabolic and hormonal requirements. Subacute thyroiditis is a self-limited inflammatory disorder of the thyroid gland, often associated with painless or painful swelling of the gland and somatic signs or symptoms. Inflammation disrupts thyroid follicles resulting in a rapid release of stored thyroxine and triiodothyronine causing an initial thyrotoxic phase, often followed by transient or permanent hypothyroidism. Although subacute thyroiditis is often related to a viral infection, no infective agent has been identified. Subacute thyroiditis may be caused by a viral infection in genetically predisposed individuals. Work-up includes lab tests, ultrasound imaging, and radionuclide imaging. Thyroid scintigraphy demonstrates different findings depending on the phase of the illness, ranging from very low or absent tracer uptake in the thyroid gland in the hyperthyroid phase to a normal appearance in the late recovery phase. Since subacute thyroiditis is self-limited, treatment is directed toward relief of pain. High-dose nonsteroidal antiinflammatory drugs are usually the first-line treatment. If severe pain persists, a course of corticosteroids may be necessary. Permanent hypothyroidism develops in up to 15% of patients with subacute thyroiditis, even more than 1 y after presentation.

Association of the Implementation of a Standardized Thyroid Ultrasonography Reporting Program With Documentation of Nodule Characteristics

Although most thyroid nodules are benign, the potential for malignant neoplasms is associated with unnecessary workup in the form of imaging, fine-needle aspiration, and diagnostic surgery. The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) is commonly used to assess the malignant neoplasm risk potential of thyroid nodules imaged by ultrasonography. However, standardized reporting of ACR TI-RADS descriptors is inconsistent. To increase the documentation rate of ACR TI-RADS thyroid nodule characteristics to 80% in 18 months. This prospective interrupted time series quality improvement study was conducted from December 1, 2018, to March 31, 2020, at a tertiary outpatient head and neck clinic among 229 patients who had at least 1 documented thyroid nodule identified on bedside clinic ultrasonography. Data analysis was performed throughout the entire study period because this was a quality improvement study with iterative small cycle changes; final analysis of the data was performed in April 2020. The primary outcome was the documentation rates of 6 ACR TI-RADS ultrasonographic descriptors. Secondary outcomes included nodule fine-needle aspiration biopsy rate and physician-reported clinic flow efficiency. A total of 229 patients had at least 1 documented thyroid nodule and were included in the analysis. Size was the most frequently documented nodule characteristic (72 of 74 [97.3%]) at baseline, followed by echogenic foci (31 of 74 [41.9%]), composition (23 of 74 [31.1%]), echogenicity (17 of 74 [23.0%]), margin (6 of 74 [8.1%]), and shape (1 of 74 [1.4%]). After 3 Plan, Do, Study, Act (PDSA) cycles, the final intervention consisted of a standardized ultrasonography reporting form and educational initiatives for surgical trainees. After the third PDSA cycle (n = 36), reporting of nodule size, echogenic foci, and composition increased to 100%. Similarly, reporting of echogenicity (34 of 36 [94.4%]), shape (28 of 36 [77.8%]), and margin (25 of 36 [69.4%]) all increased. This represented a cumulative 90.3% documentation rate (195 of 216), a 56.5% increase from baseline (95% CI, 50.0%-61.9%). The standardized reporting form was used in 83.3% of eligible thyroid ultrasonography cases (30 of 36) after PDSA cycle 3, demonstrating good fidelity of implementation. There were no unintended consequences associated with clinic workflow, as a balancing measure, reported by staff surgeons. This study suggests that implementation of an ACR TI-RADS-based reporting form in conjunction with educational initiatives improved documentation of ultrasonographic thyroid nodule characteristics, potentially allowing for improved bedside risk stratification and communication among clinicians.

Is there a place for measuring serum calcitonin prior to thyroidectomy in patients with a non-diagnostic thyroid nodule biopsy?

To verify the cytopathological Bethesda System classification of thyroid nodule fine-needle aspiration biopsy (FNAB) in MTC patients and to assess the role of preoperative serum calcitonin (CT) levels in the investigation of this neoplasm in medullary thyroid cancer (MTC) patients under observation at the Uopeccan (União Oeste Paranaense de Estudos e Combate ao Câncer). This is a cross-sectional review of medical records of patients monitored at the thyroid cancer outpatient clinic of Uopeccan. Clinical and demographic data, laboratory tests, ultrasound images, and cytopathological findings of MTC patients were evaluated. Among the 360 patients with thyroid cancer monitored in the outpatient clinic, 5.2% (n: 19/360) had MTC. The hereditary form was more prevalent (63.2%), and there was no sex preference. The most common ultrasound findings were hypoechogenicity, solid appearance and microcalcifications. The FNAB diagnoses showed a sensitivity of 47.1%, and the most common cytopathological report was Bethesda category III. Serum CT levels showed good sensitivity (84.6%) for the diagnosis of MTC, and sensitivity levels were directly associated with the size of the nodule and distant metastases. Bethesda category III was more prevalent in this group of MTC patients. Serum CT levels were more sensitive than cytopathology for diagnosis of this neoplasm and were able to identify all patients who could not be diagnosed by FNAB.

Thyroid Cancer Identified After Positron Emission Tomography (PET) Shows Aggressive Histopathology

BackgroundIncidental thyroid nodules with focal uptake on positron emission tomography (PET) have an increased risk for malignancy, with the majority being differentiated thyroid cancer (DTC). It is unclear whether these cancers have more aggressive histopathology compared with DTC diagnosed via other means. MethodElectronic medical record of two medical centers was queried for the period of 2001-2016 to identify patients who underwent PET imaging for nonthyroid-related indications and who were found to have focal thyroid uptake. Patients who underwent thyroid nodule fine needle aspiration biopsy (FNAB) and subsequent thyroidectomy with a final diagnosis of DTC were further reviewed. A comparison group, matched for age, tumor type, and tumor size, was selected from consecutive patients who underwent surgery for DTC. ResultsAmong 35,124 PET scans reviewed, 227 (0.6%) patients were found to have focal thyroid uptake and underwent FNAB: Fourty-seven (21%) were found to have cancer (36 papillary thyroid cancer (PTC), 9 metastases, and 2 lymphoma). Sixty-seven patients proceeded to surgery: Thirty-one with FNAB of PTC and the rest with indeterminate FNAB necessitating diagnostic thyroidectomy. Compared with the control group, the PET PTC patients involved more men (54% versus 26%, P = 0.003), had more advanced tumor stage (P = 0.03), and had increased BRAF mutation on final pathology (78% versus 42%, P = 0.05). ConclusionsThis study demonstrates that DTC detected on PET is most commonly of the papillary type. Despite the small sample size, the results suggest that these PTC may be more aggressive than PTC detected through other means and more frequently harbor BRAF mutations.

Impact of laboratory work-up of lymphoma guidelines on cytopathology practices

A multi-society expert panel recently published evidence-based guidelines and recommendations for the primary diagnosis and classification of lymphoma, which included a public comment period. The guideline concludes: "primary diagnosis and classification of lymphoma can be achieved with a variety of specimens." The guideline recommends that fine-needle aspiration biopsy (FNAB) cytomorphology not be used without ancillary testing, and that either flow cytometry or immunohistochemical immunophenotyping be performed for any type of specimen. Either excisional or core biopsy should be obtained when there is a high suspicion of lymphoma, and excision is recommended when feasible for Hodgkin lymphoma primary diagnosis. The use of cerebrospinal fluid to diagnose central nervous system lymphoma is discussed. For any patient with initial negative biopsy or fluid specimens and a high suspicion of lymphoma, additional tissue samples should be obtained. Additional molecular testing and good practice statements are summarized in the guideline. Cytopathologists should continue to advocate for judicious use of lymph node FNAB as an excellent triage tool that may require additional tissue biopsy for definitive diagnosis.