Nondiagnostic Aspiration Research Articles

Cytologic Categorization with Risk Stratification of Endoscopic Ultrasound-Guided Fine Needle Aspiration from Pancreatic Lesions Based on Guidelines of the Papanicolaou Society of Cytopathology: 12-Year Tertiary Care Experience.

BACKGROUND AND AIMS: Pancreatic malignancy is an important cause of cancer mortality worldwide. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) plays a crucial role in the pre-operative diagnosis of pancreatic lesions. In this study, we have analyzed the cytological spectrum of pancreatic lesions in the Indian population over 12 years, categorized them according to the Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology (PSCPC), and assessed the risk of malignancy (ROM) for each of the categories. METHODS: A computerized data search from January 2008 to December 2019 revealed 581 pancreatic EUS-FNA samples, among which surgical follow-up was available for 73 cases. All cytological specimens were reviewed and prospectively classified into one of the six diagnostic categories proposed by the PSCPC. Subsequently, a cytohistological correlation was performed and the ROM was calculated for each category. RESULTS: The cytologic diagnoses included 50 nondiagnostic (category I), 175 negative for malignancy (category II), 19 atypical (category III), 27 neoplastic:benign (category IVA), 30 neoplastic:other (category IVB), 26 suspicious (category V), and 254 malignant (category VI) cases. ROM for non-diagnostic aspirates, nonneoplastic benign specimens, atypical cases, neoplastic:benign, neoplastic:other, suspicious for malignancy, and the malignant category was 16.7%, 7.1%, 33.3%, 0.0%, 20.0%, 100%, and 78.6%, respectively. CONCLUSION: We document an increased risk of malignancy from category I to category VI of the PSCPC. The malignancy risk for category VI (malignant) was statistically significant in our study but was lower in comparison to the values reported by other authors. Nonetheless, such an approach would establish transparent communication between the pathologist and the clinician, as well as aid the clinician in decision making, particularly in intermediate categories.

Nondiagnostic Fine-Needle Aspiration Biopsy of Thyroid Nodules: Outcomes and Determinants.

Background: Nondiagnostic results are common following fine-needle aspiration biopsy (FNAB) of thyroid nodules, but recommendations for the management of these patients vary. We sought to determine the outcomes and predictors of nondiagnostic FNABs in a single-center cohort of patients undergoing thyroid nodule evaluation. Methodology: We identified all first time ultrasound-guided FNABs performed between May 2007 and June 2013 at the Beth Israel Deaconess Medical Center Thyroid Nodule Clinic and examined demographic data, follow-up ultrasounds, repeated FNABs, and histopathologic findings. We examined the likelihood of diagnostic findings and of cancer with increasing numbers of nondiagnostic evaluations with their exact binomial confidence intervals [CIs] and potential predictors of nondiagnostic status using generalized estimating equations. Results: During the six-year period, 2234 unique individuals underwent ultrasound-guided FNAB of a thyroid nodule. The probability of obtaining a diagnostic biopsy declined from 84.4% [95% CI 82.8-85.8%] for initial FNABs to 57.6% [CI 50.8-64.2%] for the first re-FNAB and further to 42.4% [CI 25.5-60.8%] for second re-FNABs. Adjusted risk of nondiagnostic FNAB strongly increased with increasing numbers of previous biopsies and was also higher among whites. The overall rate of diagnosis of malignancy after a nondiagnostic FNAB was 8.1% [CI 4.2-13.7%] and was similar regardless of the number of previous nondiagnostic aspirations. Conclusion: Following an initial nondiagnostic FNAB, the probability of yielding a diagnostic result declines with each sequential repeat FNAB. Nonetheless, a tangible possibility of malignancy remains even after repeated nondiagnostic FNABs.

Fine-needle aspiration specimens of 3 cases of intra-abdominal Rosai-Dorfman disease with comprehensive review of the literature

Rosai-Dorfman disease (RDD) is a rare usually self-limited non-Langerhans cell histiocytosis of unknown etiology. Nodal and extranodal RDD appear to represent distinct conditions with different molecular alterations and prognosis. They also pose different diagnostic challenges on biopsies and fine-needle aspiration (FNA) cytology. The aim of this study was to report on 3 cases of intra-abdominal RDD and perform an extensive review of the literature on FNA findings of RDD. We reviewed FNA specimens from cases diagnosed histologically or cytologically as RDD during the past 10 years. We searched the PubMed and Google Scholar databases for cases of RDD sampled by FNA. We identified 3 cases of intra-abdominal RDD, involving the kidney, periportal lymph node, and pancreas. FNA of the latter was hypocellular with fibrosis and was nondiagnostic. FNA of the first 2 yielded hypercellular smears that were diagnosed as RDD due to the identification of emperipolesis occurring in large uni- or binucleated histiocytes with large nuclei, fine chromatin, and prominent nucleoli in smears and cell-block sections. Immunohistochemistry showed positive staining for S100 and CD68 and negative staining for CD1a. The large histiocytes with emperipolesis were more difficult to identify histologically and their demonstration required immunohistochemical stains. Our experience and an extensive review of the literature suggest that extranodal RDD can be diagnosed on FNA, and that the recognition of histiocytes with emperipolesis may be less challenging cytologically than histologically. The fibrosis frequently seen in extranodal RDD may lead to nondiagnostic aspirates, however.

Feasibility of fine-needle aspiration for assessing responses to chemotherapy in metastatic nodes marked with clips in breast cancer: A prospective registry study.

Clips are often placed to mark axillary nodes with biopsy-confirmed metastases in patients with breast cancer. The evaluation of clipped nodes after chemotherapy can identify patients who have eradication of nodal disease. The goal of this study was to determine whether preoperative fine-needle aspiration (FNA) of clipped nodes after neoadjuvant chemotherapy (NAC) could predict the presence of residual disease. This prospective registry study enrolled 50 patients with a clip placed to mark nodes with biopsy-confirmed metastases who had completed NAC. Participants underwent FNA of the clipped node before seed-localized lymph node excision. FNA pathology was compared with surgical pathology. There were 36 patients (72%) with residual disease on surgical pathology: 3 (8%) had a nondiagnostic aspirate, carcinoma was seen in 14 (39%), and 19 (53%) had a false-negative result. The sensitivity of FNA was 42.4%, its specificity was 100%, and its negative predictive value was 40.6%. In a univariate analysis, the odds of a true-positive result increased significantly with the mean initial size of the clipped node (odds ratio [OR], 4.3; P = .004) and the size of the metastatic focus after NAC (OR, 1.3; P = 0.003), whereas normalization of nodes after chemotherapy (OR, 0.1) and a lack of response on ultrasound (OR, 0.11) were associated with a false-negative result (P = .01). FNA of marked nodes after chemotherapy has a high false-negative rate. This highlights the need for surgical staging of the axilla after NAC to assess the response.

Cyto-Histo-Biochemical And Ultrasonographic Correlation of Thyroid Lesions –A Multidisciplinary Approach: An Experience at Rural Tertiary Care Hospital in Southern coast of India

Introduction: Thyroid lesions are one of the most common palpable lesions subjected for FNAC.Fine Needle Aspiration Cytology (FNAC) of the thyroid gland is now a well-established first-line diagnostic test for the evaluation of diffuses thyroid lesions as well as of thyroid nodules with the main purpose of confirming benign lesions and thereby, reducing unnecessary surgery.Apart from cytology, other investigations like ultrasonography (USG),thyroid function tests(TFTs) play a supportive for better understanding of thyroid nodules under evaluation.Also, there is some gray of thyroid cytology where the diagnostic efficacy of FNA declines sharply.Radioimaging (ultrasonography) can be helpful in grey areas of indeterminate lesions and non-diagnostic aspirates. Though USG features alone cannot predict malignancy or benignity, but techniques that combine USG features and FNA cytology are most effective and most accurate for predicting malignancy. Aims and Objectives:We aimed to evaluate cytological features of palpable thyroid lesions and to correlate with histopathological , radiological and thyroid function tests wherever available, at a rural tertiary health care institute in southern coastal region of India. Materials /methods:This study was analysis of 156 cases of palpable diffuse and nodular thyroid lesions subjected to FNAC over a period of one and half year at a rural tertiary health care Institute. Results:Thyroid lesions constituted 19.3% of total lesions subjected to FNAC in study period.Age group ranged from 13 - 77 years, maximum cases belonged to 5th decade with female preponderance . Clinically, nodular swelling accounted for 86% cases.Benign lesions detected were 75.6%. Malignant lesion accounted for 7.7% cases.Cyto-histo correlation overall was noted in 72.2% cases with benign lesions showed 76.92% were as malignant lesion showed 100% correlation. Sensitivity, specificity , positive predictive value, negative predictive value and diagnostic accuracy was 40%, 100%,100%, 78.6% and 81.3% respectively. Similarly, Overall Radio- cytological concordance was 81.03%. In hormonal correlation, majority (59%) were euthyroid. In these lesions, 60.9% were goitres whereas in cases with hypothyroidism, majority (56%) had thyroiditis. Conclusion: FNAC is simple, cost-effective, more specific than sensitive procedure for evaluating thyroid masses, further evaluation of thyroid nodule for thyroid function status and radiological support especially in grey zone area of indeterminate lesion has a definitive role to play.

Impact of Noninvasive Follicular Thyroid Neoplasm With Papillary-Like Features on Adequacy Criteria and Risk of Malignancy of Thyroid Fine-Needle Aspiration.

The impact of noninvasive follicular thyroid neoplasm with papillary-like features (NIFTP) on nondiagnostic and benign diagnoses is not well characterized. The results of all thyroid fine-needle aspirates (FNAs) performed from 1997 to June 2016 with corresponding resections were reviewed. From 12,764 aspirates, there were 8,106 (64%) benign diagnoses with 412 (5%) resections and 1,888 (14.8%) nondiagnostic diagnoses with 329 (17%) resections. Before the use of NIFTP, there were 18 (4.3%) malignancies in the benign aspirates and 39 (11.9%) malignancies in the nondiagnostic aspirates. There were 12 NIFTP cases on review. After reclassification using NIFTP, there were 10 of 412 (2.4%) malignancies in the benign aspirates. When cases with 10 to 60 benign follicle cells without atypia or Hürthle cell change were reclassified as benign rather than nondiagnostic, the malignancy rate for a benign aspirate decreased (12/506, 2.3%; P = 1.0) when NIFTP cases were recognized. With NIFTP, reducing the threshold for adequacy from 60 to 10 cells led to nonsignificant decrease in the risk of malignancy of a benign diagnosis (2.4% to 2.3%). Thyroid fine-needle aspirates with 10 to 60 benign cells without atypia or Hürthle cell change should be diagnosed as benign.

Role of endoscopic ultrasound in undiagnosed pleural effusion

Background and Objectives:Thoracocentesis is the first diagnostic procedure for pleural effusion (PE). If diagnosis after thoracocentesis remains uncertain, pleural biopsy either computed tomography (CT)/ultrasonography (USG)-guided or thoracoscopy is required for definitive diagnosis. Overall, access to thoracoscopy is limited in many parts of the world as significant resources and expertise are required. We present the data about evaluation of undiagnosed PE by endoscopic ultrasound (EUS)-guided pleural aspiration or fine needle aspiration cytology (FNAC) of the lymph nodes/pleural deposits. This is first case series regarding EUS-guided FNAC of pleural deposits.Methods:During 2 years, 11 patients of undiagnosed PE were evaluated by EUS. Aspiration of PE was done if fluid sampling was required and EUS-FNA with rapid on-site evaluation (ROSE) was done if FNAC from PE deposit or lymph node was required.Results:Seven patients had right sided and four had left PE. Three cases had unsuccessful attempts/complications at US-guided aspiration. A single pass was successful in diagnostic aspiration in these cases and the aspirated fluid was suggestive of tuberculosis. The remaining eight cases had nondiagnostic aspiration and FNAC with ROSE (average two passes) was done from mediastinal lymphadenopathy or pleural deposits. Four cases with mediastinal lymphadenopathy had granulomatous lesions. Four cases with pleural deposits had malignancy. In this series, EUS was selected as the last diagnostic option for three indications: nontappable PE (3 cases), PE with mediastinal nodes (4 cases) and PE with pleural deposits (4 cases).Conclusion:EUS-guided imaging introduces a totally different path/technique of imaging for inspection of the pleural space. EUS-FNA can be performed as safe procedure in undiagnosed PE. At present, it appears that EUS-guided evaluation is an alternative modality for the evaluation of undiagnosed PE, in the cases who are unfit for thoracoscopy and as an alternative or adjunct to USG/CT-guided aspiration or biopsy.

Endoscopic ultrasound-guided evaluation of undiagnosed pleural effusion

Background and Objectives:Thoracocentesis is the first diagnostic procedure for pleural effusion (PE). If diagnosis after thoracocentesis remains uncertain pleural biopsy, either computed tomography/ultrasonography (CT/USG) guided or thoracoscopy is required for definitive diagnosis. We present the data about evaluation of undiagnosed PE by endoscopic ultrasound (EUS)-guided pleural aspiration or fine needle aspiration cytology (FNAC) of the lymph nodes/pleural deposits. This is the first case series regarding EUS-guided FNAC of the pleural deposits or nodules.Methods:Eleven patients of undiagnosed PE were evaluated by EUS. The CT/USG reports were reviewed before EUS. The PE aspiration was performed by EUS needle. The EUS-FNA of the mediastinal nodes or pleural deposits was done by a 22-gauge needle.Results:Seven patients had right-sided and four had left-sided PE. Three cases had unsuccessful attempts/complications at US-guided aspiration. A single pass was successful in diagnostic aspiration and the aspirated fluid was suggestive of tuberculosis (TB). The remaining eight cases had nondiagnostic aspiration, and FNAC with rapid on-site evaluation was done from mediastinal lymphadenopathy or pleural deposits. Four cases with mediastinal lymphadenopathy had granulomatous lesions. Four cases with pleural deposits had malignancy.Conclusions:EUS-guided imaging introduces a totally different path/technique of imaging for inspection of the pleural space. EUS-FNA can be performed as a safe procedure in undiagnosed PE. At present, it appears that EUS-guided evaluation is an alternative modality for evaluation of undiagnosed PE, in the cases who are unfit for thoracoscopy and as an alternative or adjunct to USG/CT-guided aspiration or biopsy. Further studies will be required to clarify its exact role in pleural diseases.

A Different Perspective on Evaluating the Malignancy Rate of the Non-Diagnostic Category of the Bethesda System for Reporting Thyroid Cytopathology: A Single Institute Experience and Review of the Literature.

ObjectiveTo determine the malignancy rate in the non-diagnostic (ND) category of the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) based on a different approach in relation to histopathology diagnoses.Study DesignAll ND fine needle aspirations (FNAs) that were performed under ultrasound guidance by an interventional radiologist with rapid on-site evaluation were included in the study. Slides were reevaluated to identify the cause of inadequacy as “qualitative” or “quantitative.” The malignancy rate of the ND category was assessed. Nodule/patient characteristics were compared between benign and malignant cases within the study cohort.ResultsThe study cohort consisted of 192 ND aspirations. Overall there were 156 (81.3%) women and 36 (18.7%) men with a mean age of 50.6 years (range 24–82 years). The malignancy rate was 4.7%. None of the nodules (size, consistency, and number) or patient characteristics (gender and age) were found to be predictive of malignancy.ConclusionThe malignancy rate of the ND category was high when compared to BSRTC predictions, but at the low end of the reported malignancy rates in the literature. Our results revealed that cyto-histopathologic correlation and method of malignancy rate estimation could have an effect on a wide range of reported malignancy rates. Furthermore, patient/nodule dependent factors were not statistically found to be predictive of malignancy.

Role of Fine Needle Aspiration Cytology as a Diagnostic Tool in Orbital and Adnexal Lesions.

Purpose:To evaluate the role of fine needle aspiration (FNAC) as a diagnostic tool in cases of orbital and ocular adnexal masses. Cytological findings were correlated with histopathological diagnosis wherever possible.Methods:FNAC was performed in 29 patients of different age groups presenting with orbital and ocular adnexal masses. Patients were evaluated clinically and investigated by non-invasive techniques before fine needle aspiration of the masses. Smears were analyzed by a cytologist in all cases. Further, results of cytology were compared with the histopathological diagnosis.Results:The age of patients ranged from 1 to 68 years (mean: 29.79±19.29). There were 14 males and 15 females with a male to female ratio of 0.93:1. Out of 29 cases, 26 aspirates were cellular. Cellularity was insufficient in three (10.34%) aspirates. Out of 26 cellular aspirates, 11 were non-neoplastic while 15 were neoplastic on cytology. Subsequent histopathologic examination was done in 21/26 cases. Concordance rate of FNAC in orbital and ocular adnexal mass lesions with respect to the precise histologic diagnosis was 90%.Conclusion:When properly used in well-indicated patients (in cases where a diagnosis cannot be made by clinical and imaging findings alone), FNAC of orbital and periorbital lesions is an invaluable and suitable adjunct diagnostic technique that necessitates close cooperation between the ophthalmologist and cytologist. However, nondiagnostic aspirates may sometimes be obtained, and an inconclusive FNAC should not always be ignored.

The Impact of CEA Fluid Analysis Over Negative and Non-diagnostic Pancreatic Cysts Aspirates: A 5-year Single Institutional Experience

The Impact of CEA Fluid Analysis Over Negative and Non-diagnostic Pancreatic Cysts Aspirates: A 5-year Single Institutional Experience

Malignancy risk associated with the EBUS-FNA diagnostic categories nondiagnostic, benign, atypical, suspicious for malignancy, and malignant for mediastinal lymph node aspirate specimens

Endobronchial ultrasonography-guided transbronchial fine-needle aspiration (EBUS-TBFNA) is used for preoperative staging of primary lung carcinomas. Published sensitivity and specificity are up to 86% and 100%, respectively. Diagnostic categories used by many cytopathologists are nondiagnostic, benign, atypical, suspicious, and malignant. Little information exists about the risk of malignancy associated with each of these categories. Records of the Department of Pathology at the University of Utah were searched for all EBUS-TBFNAs of mediastinal and pulmonary hilar lymph nodes. Only cases with surgical follow-up were included in this study. For each diagnostic category (nondiagnostic, benign, atypical, suspicious, and malignant), the percentage of cases proven to be malignant was calculated following correlation of cytologic and surgical diagnoses. Positive and negative predictive values were calculated. For calculation of accuracy statistics, atypical cases were considered benign and suspicious cases were classified as malignant. For this study, 136 EBUS-TBFNAs of lymph nodes were obtained with adequate surgical follow-up. Risk of malignancy for nondiagnostic specimens was 42%, benign specimens 32%, atypical specimens 40%, suspicious specimens 83%, and malignant specimens 84%. Positive predictive value was 84%, and negative predictive value was 68%. The categories stratified malignancy risk ranging from a low of 32% for benign to 84% for malignant. The categories suspicious and malignant had similar malignancy risks. Atypical aspirates had a higher malignancy risk than benign aspirates did. Nondiagnostic aspirates had a malignancy risk similar to that of atypical aspirates. This scoring system may aid in treatment planning and patient counselling.

Follow up Analysis of Non-diagnostic Fine Needle Aspiration of the Thyroid in the African-American Population

Introduction: It has been suggested that African Americans (AA) suffer from a more aggressive thyroid disease despite a lower rate of thyroid malignancies. The aim of this study is to analyze non-diagnostic (ND) aspirates and their follow up pathology diagnosis and compare the implied risk of malignancy in the African American (AA) versus non-African American (NAA) population. Materials and Methods: Thyroid FNA cytology reports and corresponding follow up findings were retrospectively reviewed between March 2006 and December 2012. 179 patients met our inclusion criteria. The patients were categorized as AA and NAA. Aspirates were labeled as ND based on adequacy criteria listed in the in the Bethesda System for Reporting Thyroid Cytolopathology (TBS-Thy). The follow-up cytology and surgical pathology diagnosis were used for the final categorization. Results: We studied 179 patients with ND aspirates: 85 AA and 94 NAA. The mean age of AA and NAA was not significantly different (AA 56.5 13.9 yrs. vs. NAA 56.3 15.2, pZ0.95). 91.8% of AA were females compared to 85.1% of NAA (pZ0.17). With respect to the outcomes of ND aspirates, loss of follow up was comparable in both AA and NAA: 71.8% and 77.7%, respectively. Two patients in the NAA group (2.1%) were diagnosed with papillary thyroid carcinoma (PTC) upon follow up compared to 0% in AA. The incidence of benign and atypical thyroid lesions was comparable between these two populations (Table 1). The distribution of benign versus malignant diagnosis on follow up cytology and surgical pathology was examined across TBS-Thy classes. Table 1

Atlas of thyroid cytopathology with histopathologic correlations

Preface 1. Overview of Diagnostic Terminology and Reporting 2. Normal Cytology, Extra-thyroidal Contaminants, Nondiagnostic Aspirates 3. Radiologic Characteristics of Thyroid Disease 4. Benign (Non-neoplastic Nodules, Thyroid Cysts) 5. Atypia of Undetermined Significance / Follicular Lesion of Undetermined Significance 6. Follicular Neoplasms / Suspicious for a Follicular Neoplasm 7. Hurthle Cell Neoplasm / Suspicious for a Hurthle Cell Neoplasm 8. Suspicious for Malignancy 9. Papillary Thyroid Carcinoma and Variants 10. Medullary Thyroid Carcinoma 11. Poorly Differentiated Thyroid Carcinoma 12. Undifferentiated (Anaplastic) Carcinoma 13. Rare Primary Carcinoma and Mesenchymal Neoplasms 14. Metastatic and Secondary Cancers

Clinical Outcomes in Patients with Non-Diagnostic Thyroid Fine Needle Aspiration Cytology: Usefulness of the Thyroid Core Needle Biopsy

Patients with non-diagnostic thyroid fine needle aspiration cytology (FNAC) results undergo repeat FNAC or core needle biopsy (CNB) for definite diagnosis or surgical resection, or are followed up by clinical and ultrasound surveillance. We aimed at evaluating the risk of malignancy in patients with non-diagnostic FNACs and their clinical outcomes according to the follow-up modality. We retrospectively reviewed 1,496 (8.8%) cases with a non-diagnostic result on a first aspiration among 17,045 thyroid FNACs performed between October 2008 and August 2012. Of the non-diagnostic FNACs, 389 patients underwent a second FNAC; 125, CNB; and 89, thyroidectomy by clinical indication. The remaining patients were clinically followed up. The rate of a second non-diagnostic result was significantly higher on repeat FNAC than on CNB (33.2 vs. 2.4%; p<0.001). There was no significant difference in the malignancy risk among patients initially non-diagnostic, twice non-diagnostic, and thrice or more non-diagnostic, nor did this differ from the rate following CNB. No further malignancy was found in cases with ≥2 non-diagnostic CNBs. The malignancy risk was 51% in those who underwent thyroidectomy. The sensitivity for detecting malignancy was 65and 70% for repeat FNACs and first CNBs, respectively, with no false positives seen in either test. Approximately one-third of repeat FNACs after an initial non-diagnostic aspirate are non-diagnostic on repeat examination, and the malignancy risk may not reduce following repetitively non-diagnostic FNACs. However, a single CNB may be enough to exclude malignancy risk for patients with a non-diagnostic aspirate.

Role of endoscopic ultrasound fine-needle aspiration evaluating adrenal gland enlargement or mass.

To report the clinical impact of adrenal endoscopic ultrasound fine-needle aspiration (EUS-FNA) in the evaluation of patients with adrenal gland enlargement or mass. In a retrospective single-center case-series, patients undergoing EUS-FNA of either adrenal gland from 1997-2011 in our tertiary care center were included. Medical records were reviewed and results of EUS, cytology, adrenal size change on follow-up imaging ≥ 6 mo after EUS and any repeat EUS or surgery were abstracted. A lesion was considered benign if: (1) EUS-FNA cytology was benign and the lesion remained < 1 cm from its original size on follow-up computed tomography (CT), magnetic resonance imaging or repeat EUS ≥ 6 mo after EUS-FNA; or (2) subsequent adrenalectomy and surgical pathology was benign. Ninety-four patients had left (n = 90) and/or right (n = 5) adrenal EUS-FNA without adverse events. EUS indications included: cancer staging or suspected recurrence (n = 31), pancreatic (n = 20), mediastinal (n = 10), adrenal (n = 7), lung (n = 7) mass or other indication (n = 19). Diagnoses after adrenal EUS-FNA included metastatic lung (n = 10), esophageal (n= 5), colon (n = 2), or other cancer (n = 8); benign primary adrenal mass or benign tissue (n = 60); or was non-diagnostic (n = 9). Available follow-up confirmed a benign lesion in 5/9 non-diagnostic aspirates and 32/60 benign aspirates. Four of the 60 benign aspirates were later confirmed as malignant by repeat biopsy, follow-up CT, or adrenalectomy. Adrenal EUS-FNA diagnosed metastatic cancer in 24, and ruled out metastasis in 10 patients. For the diagnosis of malignancy, EUS-FNA of either adrenal had sensitivity, specificity, positive predictive value and negative predictive value of 86%, 97%, 96% and 89%, respectively. Adrenal gland EUS-FNA is safe, minimally invasive and a sensitive technique with significant impact in the management of adrenal gland mass or enlargement.

Thyroid Nodules with Macrocalcification: Sonographic Findings Predictive of Malignancy

PurposeTo analyze which sonographic features of thyroid nodules with macrocalcifications were predictable of thyroid malignancy.Materials and MethodsWe reviewed sonographic findings of 854 macrocalcified thyroid nodules in patients who underwent fine needle aspiration biopsy between December 2009 and January 2011. There were 171 non-diagnostic aspirations, 34 nodules with category 3, 4, 5 based on Bethesda system, which were not confirmed by surgery, and these nodules were excluded from the analysis. Sonographic characteristics of the macrocalcifications including its thickness, interruption, and existence of soft tissue rim outside the macrocalcification were analyzed. Other sonographic characteristics of nodules such as shape, margin, composition, echo pattern, vascularity, and underlying parenchymal echogenicity were also evaluated. The correlation of sonographic features with cytopathologic results and the diagnostic performance of sonographic features for the prediction of malignancy were analyzed.ResultsAmong 649 nodules, 179 (27.6%) nodules were malignant and 470 (72.4%) nodules were benign. Among the features of the macrocalcification, interruption, irregular thickness, or the presence of soft tissue outside calcification rim were associated with malignancy (p<0.001). A high sensitivity and negative predictive values for the prediction of malignancy was found in sonographic characteristics of irregular thickness (92.2% and 91.0%, respectively) and the presence of soft tissue (88.5% and 88.8%, respectively).ConclusionSonographic characteristics of macrocalcification such as interruption, irregular thickness and the presence of soft tissue rim were associated with malignancy in thyroid nodules with macrocalcifications.

Thyroid fine‐needle aspiration cytology: Is there a place to virtual cytology?

Telecytology has been used for education, training, and consultation. Cytological studies from gynecological, nongynecological and fine-needle aspiration cytology (FNAC) specimens (including studies of thyroid FNAC) analyzed the diagnostic accuracy and reproducibility of telecytology-based predominantly on static digital images. The aim of this study was to evaluate the diagnostic reproducibility of virtual cytology by measuring intraobserver and interobserver agreements among two cytopathologists, using the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) nomenclature. 502 glass slides from 222 cases of thyroid FNAC were retrieved and scanned by a high-resolution scanner generating whole slides images (virtual cytology). Conventional and virtual cytology were analyzed by a skilled cytopathologist and the intraobserver agreement rate was 77.5% with the corresponding κ value of 0.54, suggesting a moderate agreement between both methods. A second cytopathologist analyzed the same slides only by virtual cytology and the interobserver agreement rate was 80.2% with the corresponding κ value of 0.57, suggesting a moderate agreement between both cytopathologists. The virtual cytology resulted in a higher proportion of aspirates classified as nondiagnostic (20.3 and 14.9% for the first and second cytopathologist, respectively) as compared to conventional cytology (8.1%). Regarding specific diagnostic categories as defined by the BSRTC nomenclature, the follicular lesion of undetermined significance category presented the lowest concordance rates, corresponding to 5.9% intraobserver agreement and no (0.0%) interobserver agreement. We suggest that virtual cytology can be an alternative to conventional cytology in assessment of thyroid FNAC specimens, but nondiagnostic aspirates obtained by virtual cytology should be reassessed by conventional cytology.

Seeking Help From ShadowsThe Author’s Reply

To the Editor The article by Renshaw1 expressed the views that nondiagnostic thyroid fine-needle aspiration should be followed by repeat aspiration and that patients with 2 sequential nondiagnostic aspirations have a very low risk of malignancy. We agree with this view. However, the difficulty arises in the case of cystic thyroid lesions. We are of the view that while doing a repeat aspiration it is better to correlate with ultrasonographic findings and better aspirate from a solid area under guidance. According to Moon et al,2 shape, margin, echogenicity, and presence of calcification are helpful ultrasound criteria for the discrimination of malignant …

Repeatedly Nondiagnostic Thyroid Fine-Needle Aspirations Do Not Modify Malignancy Risk

Objective: Thyroid nodules with nondiagnostic (ND) fine-needle aspirations (FNA) typically undergo repeat sampling. While repeat FNA is often diagnostic, little is known regarding the significance of repeatedly ND aspirates. Limited data suggest there is very low, if any, risk of malignancy for repeatedly ND FNAs. Study Design: We performed a retrospective analysis of ND thyroid FNAs over a nearly 6-year period at our institution to further address this question. Results: There were 834 ND thyroid FNAs, representing 694 distinct thyroid nodules. Repeat FNA was performed after an initial ND aspirate in 52% of cases (363/694); 19% (70/363) had at least one additional ND diagnosis on repeat FNA. Surgical follow-up was available for 57 cases. Malignancy was identified histologically in 21% (9/42) of nodules after a single ND FNA and in 20% (3/15) of nodules with 2 or more repeatedly ND aspirates. Accounting for all benign cytologic follow-up, the overall risk of malignancy was 4% [12/303; 3.5% (9/255) following a single ND FNA and 6.3% (3/48) after repeated ND FNAs]. Conclusion: We observed no modification of malignancy risk when repeated FNAs were ND. Clinical management for an ND aspirate should remain repeat aspiration along with clinical and sonographic correlation.