Specificity Of Fine Needle Aspiration Research Articles

Diagnostic tests for tuberculous lymphadenitis: fine needle aspirations using tissue culture in mycobacteria growth indicator tube and tissue PCR

Abstract Background: The diagnosis of tuberculous lymphadenitis (TBLN) ranges from therapeutic diagnosis to open biopsy with tissue culture. The open biopsies are accepted as the gold standard to diagnose TBLN, but it requires skin incision that leaves unwanted scars. Objective: Test the sensitivity and specificity of fine needle aspiration (FNA) using tissue culture in mycobacteria growth indicator tube (MGIT) and tissue polymerase chain reaction (PCR) for comparison with open biopsy using tissue culture. Subject and methods: Forty patients with clinically suspected cervical tuberculous lymphadenitis were recruited at King Chulalongkorn Memorial Hospital. The patients underwent FNA followed by open biopsies either excisional or incisional. Specimens from FNA were collected for tissue culture in MGIT and for tissue PCR. The specimens from open biopsies were divided into two portions for tissue culture in MGIT (the gold standard) and for hispathology. Results: FNA for tissue culture in MGIT had a moderate sensitivity (65%) but high specificity (83%) (73% positive and 76% negative predictive value). FNA for tissue PCR had a moderate sensitivity (53%) but very high specificity (96%) (90% positive and 73% negative predictive values). Combination of either FNA for tissue culture or FNA tissue PCR revealed an increase in sensitivity and specificity to 83.6% and 80.0%, respectively. However, a combination of both FNA for tissue culture and FNA tissue PCR revealed a decrease in sensitivity (34.5%) but a highly increase in specificity (99.0%). Conclusion: Either the FNA using tissue culture in MGIT or tissue PCR had a moderate sensitivity but high specificity. FNA using tissue culture or FNA tissue PCR may be used as an alternative test for diagnosis TBLN. The techniques may replace the open biopsies because of its effectiveness and low complication rate.

Efficacy of an in-house polymerase chain reaction assay for rapid diagnosis of Mycobacterium tuberculosis in patients with tubercular lymphadenitis: Comparison with fine needle aspiration cytology and conventional techniques

Tubercular lymphadenitis (TB-L) is the most common manifestation of extrapulmonary tuberculosis. Excisional biopsy with histopathological examination, Ziehl-Neelsen staining (ZNS) and culture and fine needle aspiration (FNA) cytology, although useful in the diagnosis of TB-L, cannot diagnose a substantial proportion of cases. We investigated the role of an in-house polymerase chain reaction (PCR) assay targeting the IS6110 gene from the FNA material in the diagnosis of the disease. The clinical profile of 150 patients with lymphadenopathy was noted and the fine needle aspirate was collected. After cytological processing, ZNS and culture on Lowenstein-Jensen media, mycobacterial DNA was isolated from the residual aspirate material and IS6110 gene PCR was performed. Results of cytology, ZNS, culture and IS6110 gene PCR were compared. There were 49 confirmed patients of TB-L based on laboratory parameters (either culture isolation of Mycobacterium tuberculosis or any two of cytology, ZNS, PCR positive) and clinical response to therapy. Sensitivity and specificity of FNA was 89.8% and 96%, of ZNS was 40.8% and 99%, of culture was 40.8% and 100% and of IS6110 gene PCR test was 100% and 92.1%. IS6110 PCR can be considered a valuable adjunct to cytology, ZNS and culture techniques in the diagnosis of TB-L.

A retrospective study of the diagnostic accuracy of fine‐needle aspiration for breast lesions and implications for future use

In recent years, the use of fine-needle aspiration (FNA) in the diagnosis of breast lesions has declined in many institutions. We sought to evaluate the role of FNA for breast lesions and the annual rate of the procedure at our institution over a 4(1/2) year period (May 2002-October 2006). A total of 831 FNAs were performed, with 258 (31%) having histologic follow-up. The number of FNAs obtained was 159 from 5/02 to 4/03, 192 from 5/03 to 4/04, 194 from 5/04 to 4/05, 191 from 5/05 to 4/06, and 95 from 5/06 to 10/06. Each case was placed into one of four categories: nondiagnostic (9%), benign (77.5%), atypical/suspicious (5.5%), or malignant (8%). Surgical tissue was available for 37% of nondiagnostic cases, 22% of benign cases, 80% of atypical/suspicious cases, and 72% of malignant cases. The overall sensitivity and specificity for FNA was 83 and 92% respectively. The overall positive and negative predictive values were 83 and 92% respectively. There were no false-positive cases, indicating a positive predictive value of 100% for a Dx of malignancy. For cases with surgical follow-up, the false-negative rate was 5.4%. Although there is a national trend away from FNAs of breast lesion, this has not been the experience at our institution. Although FNA may not be ideal in the initial evaluation of suspicious lesions, we argue that FNA for clinically benign palpable lesions and recurrent carcinomas has significant value.

Calcitonin Measurement in the Evaluation of Thyroid Nodules in the United States: A Cost-Effectiveness and Decision Analysis

European studies have shown that the use of routine calcitonin screening for detection of medullary thyroid cancer (MTC) in patients with thyroid nodules increases the detection of occult MTC and may improve patient outcomes. Calcitonin screening for MTC has not been recommended in recent U.S. practice guidelines. Our objective was to determine the cost-effectiveness (C/E) of routine calcitonin screening in adult patients with thyroid nodules in the United States. A decision model was developed for a hypothetical group of adult patients presenting for evaluation of thyroid nodules in the United States. Patients were screened using current American Thyroid Association guidelines only, or American Thyroid Association guidelines with routine serum calcitonin screening. Input data were obtained from the literature, the Surveillance Epidemiology and End Results and Healthcare Cost and Utilization Project's Nationwide Inpatient Sample databases, and the Medicare Reimbursement Schedule. Sensitivity analyses were performed for a number of input variables. C/E, measured in dollars per life years saved (LYS), was calculated. Addition of calcitonin screening to current American Thyroid Association guidelines for the evaluation of thyroid nodules would cost $11,793 per LYS ($10,941-$12,646). When extrapolated to the national level, calcitonin screening for MTC in the United States would yield an additional 113,000 life years at a cost increase of 5.3%. Calcitonin screening C/E is sensitive to patient age and gender, and to changes in disease prevalence, specificity of fine needle aspiration and calcitonin testing, calcitonin screening level, costs of testing, and length of follow-up. Routine serum calcitonin screening in patients undergoing evaluation for thyroid nodules appears to be cost effective in the United States, with C/E comparable to the measurement of thyroid stimulating hormone, colonoscopy, and mammography screening.

Clinical value of image-guided fine needle aspiration of retroperitoneal masses and lymph nodes in gynecologic oncology

Objective. Evaluation of the sensitivity and specificity of fine needle aspiration of retroperitoneal masses and lymph nodes in gynecologic oncology. Methods. Retrospective study of 101 punctures administered to 84 patients aged 23–86 years. The method's sensitivity and specificity were evaluated by clinical follow-up. Results. A satisfactory sampling was obtained in 89.1% of punctures, and a cytological diagnosis was made in 88.1%. The size of the lymph nodes punctured was less than 14 mm in 46.5%. This test has a sensitivity of 87.5%, specificity of 88.9%, positive predictive value of 98%, negative predictive value of 53.3%, and accuracy of 87.7%. Four patients presented complications: pain (2), hematoma (1), and right ureteral perforation (1). Conclusions. The fine needle aspiration technique has excellent positive predictive value and low morbidity. As a method of visualization, CT-scan, in combination with lymphography, allows the location of small lesions and the definition of their internal structures. The weak negative predictive value of fine needle aspiration might be correctible by laparoscopy-directed biopsy, and its potential is clearly ensured by the development of techniques for locating sentinel lymph nodes.

Screening high-risk populations for thyroid cancer.

Children treated with radiotherapy to the neck or exposed to environmental radiation are at risk for developing thyroid cancer later in life. The best method for screening these high-risk patients is unclear. We systematically reviewed evidence on the accuracy of ultrasound and palpation to detect thyroid nodules and of fine needle aspiration (FNA), a confirmatory test, to diagnose thyroid cancer. We searched the MEDLINE database for papers published since 1966, using the MeSH term thyroid neoplasms and terms related to diagnostic test performance. To supplement our MEDLINE searches, we searched reference lists from recent reviews and articles recommended by thyroid cancer experts. We recorded the tests used, the gold standard determination of disease, the test performance results, and the presence of biases that could affect the reported results. We also abstracted the number of patients who underwent surgery and the final diagnoses. We created two decision models: one for screening 10,000 medically irradiated patients, and one for screening 10,000 environmentally irradiated patients. Using ultrasound as the gold standard determination of the presence of a nodule, the sensitivity of palpation for all sized nodules was 10-41 percent, indicating that a high proportion of nodules detected by ultrasound are too small to be palpated. Sensitivity of palpation increased with nodule size. The specificity of palpation ranged from 95 to 100%. In studies from referral centers, the reported sensitivity and specificity of FNA were 71-95 and 52-99%, respectively. However, most authors excluded the proportion of patients (6-33%) who had inadequate or nondiagnostic FNA results when calculating sensitivity and specificity, even though 6-100% of these patients went on to have a diagnostic lobectomy. When each study was reanalyzed so that patients with nondiagnostic FNA results who went directly to surgery were reclassified as positive tests, sensitivity increased slightly, but specificity dropped by 4-20 percentage points per study. The decision model for screening 10,000 medically irradiated patients revealed that if ultrasound were used as an initial screen, 2,741 patients would have nodules at least 1 cm in size; assuming no patients with smaller nodules had surgery, 1,964 patients would have surgery; 275 patients would have a diagnosis of thyroid cancer. Screening with ultrasound as an initial test would detect an additional 150 cases of thyroid cancer compared to those screened with palpation. However, an additional 1,689 patients would have surgery for nonmalignant nodules (compared to 480 patients with nonmalignant nodules screened with palpation). The yield for screening 10,000 environmentally irradiated patients was several times smaller than for screening 10,000 medically irradiated patients. If 10,000 environmentally irradiated patients were screened initially with ultrasound, approximately 708 patients would have nodules at least 1 cm in size; 89 patients would have surgery; and 38 patients would be diagnosed with thyroid cancer. Regardless of type of exposure, testing initially with ultrasound detects several times more cases of thyroid cancer than palpation. However, when ultrasound is the initial test, many more patients also have surgery for nonmalignant nodules. Screening with palpation is not very reassuring, particularly to medically irradiated patients with negative tests, since almost half (46%) of these patients may have undetected nodules.

US-guided fine needle aspiration versus coarse needle biopsy of thyroid nodules

Objective: the aim of this study was retrospectively to evaluate ultrasound (US) guided fine-needle aspiration (FNA), in combination with US-guided coarse-needle biopsies, (CNB) from solitary or dominant thyroid nodules routinely performed during a 2 year period . Methods: seventy seven patients were biopsied using US-guided FNA and CNB. FNA was performed using a 21-Gauge needle and CNB using a 18-Gauge single action spring-activated needle biopsy system. The biopsies were performed with local anaesthesia. The Department of Pathology routinely examined the biopsy specimens. The retrieval rate in obtaining material for diagnostic evaluation was FNA (97%), CNB (88%), FNA and CNB (100%). Results: in all, 41 of the 77 patients underwent neck-surgery. The surgical specimens were used to determine the results of diagnosing neoplasia. The accuracy, sensitivity and specificity for FNA were 80, 83, and 77%. For CNB 86, 78, and 94%. For both FNA and CNB 80, 89 and 73%. The diagnostic value of the two methods showed no significant difference ( P<0.05). CNB revealed contrary to FNA, however, one additional cancer. Also a higher number of false positive findings was noticed using FNA. No serious complications were registered. Adequate biopsies were obtained in all the patients using the combination of US-guided FNA and CNB. No patient underwent rebiopsy. Conclusions: the study demonstrated that neither US-guided CNB nor the combination of US-guided FNA and CNB were superior to US-guided FNA. US-guided CNB is only recommended in few selected patients.

Thyroid cancer surgery.

The surgical management of thyroid cancer is complex, controversial, and categorized by divergent opinions based upon retrospective, self-fulfilling data. This chapter will review the role of the surgeon in the evaluation of thyroid nodules and the management of malignant thyroid disease. Patients who ultimately prove to have thyroid cancer generally present with 1) a thyroid nodule with or without preoperative cytologic evidence of malignancy, 2) a rapidly enlarging neck mass with or without symptoms and signs associated with local invasion, or 3) a positive history of familial thyroid cancer with or without a positive calcitonin stimulation test, or more likely, a positive RET protooncogene screening examination for medullary carcinoma of the thyroid. The initial surgical evaluation is focused on evaluating risk factors. A history of head or neck irradiation in childhood or a familial history of medullary carcinoma of the thyroid significantly impact surgical management. The physical examination needs to focus on evidence of local invasion, fixation to surrounding structures, recurrent laryngeal nerve involvement, regional nodal metastases, and systemic disease. In addition, it is the surgeon’s obligation to screen for nonthyroidal disease that could impact perioperative management. This includes a history of bleeding disorders, cardiac, pulmonary, hepatic or renal disease, a potentially difficult airway, as well as potential endocrinopathies including thyrotoxicosis, Addisonian crisis and pheochromocytoma. It is also important to perform a laryngeal examination in every surgical candidate to evaluate recurrent laryngeal nerve integrity by the demonstration of vocal cord function. Surgery is an important, but not the only essential component in the management of patients with thyroid cancer. It is a requisite that each surgeon who manages these patients has an integrated plan that operates in concert with cytopathologists, endocrinologists, and radiation oncologists. The sensitivity and specificity of fine needle aspiration (FNA) varies between institutions and even among individual cytopathologists. Since FNA is the single most important preoperative diagnostic procedure for the majority of patients with dominant thyroid nodules, every thyroid surgeon must be able to evaluate the reliability and accuracy of the FNA findings upon which critical clinical decisions are based.

Preoperative evaluation and predictive value of fine-needle aspiration and frozen section of thyroid nodules

Background: We sought to evaluate the predictive value of preoperative fine-needle aspiration (FNA) on surgical decision making by evaluating the final pathologic diagnosis and comparing it to the preoperative diagnosis. Further, we wished to calculate the predictive accuracy of each of several types of preoperative FNA diagnosis. Study Design: A retrospective chart review of 151 thyroid resections between July 1990 and April 1996 at the University of Virginia was undertaken. The mean age was 45 years (range, 11 to 85 years). Preoperative laboratory values, presenting symptoms, imaging studies, and predictive values of preoperative FNA and intraoperative frozen section were analyzed. Results: Symptomatology was poorly predictive of a benign versus malignant postoperative final pathologic diagnosis. Sensitivity, specificity, and accuracy of frozen section versus FNA was 86% versus 86%; 99% versus 93%, and 96% versus 92%, respectively, if the reading “cancer” or “suspicious” were predicted as positive for malignancy and “benign” or “follicular” were predicted as negative for malignancy. If only the reading “cancer” was predicted as positive for malignancy and only “benign” was predicted as negative for malignancy, sensitivity and specificity for FNA were 100% and 96%, respectively, and 100% and 99%, respectively, for frozen section. Forty-nine “follicular” lesions obtained by preoperative FNA resulted in 46 benign diagnoses after surgical resection. Conclusions: The use of preoperative FNA is a powerful diagnostic tool in the hands of skilled pathologists. There is increasing evidence that intraoperative frozen section adds little to intraoperative decision making in patients diagnosed with thyroid cancer by preoperative FNA. Less definitive interpretations decrease the sensitivity, specificity, and accuracy of the FNA diagnosis.

CT-Guided Fine Needle Aspiration and Needle Core Biopsy of Skeletal Lesions

To compare the diagnostic sensitivity and specificity of fine needle aspiration (FNA) to those of needle core biopsy (NCB) and to attempt to determine if a complementary role exists for the two modalities. Skeletal lesions in 144 patients were evaluated with concomitant FNA and NCB over a 21-year period. FNAs and NCBs were divided as diagnostic of neoplasm, normal or inflammatory (i.e., osteomyelitis), or unsatisfactory. The results of each modality were then reviewed and compared. In the 144 total cases, a diagnosis was possible in 79% (114) cases. FNA and NCB concurred in 73% (83) of diagnostic cases. Concurrence was 87% between diagnostic FNA (83) and NCB (95). The two modalities agreed in 78% of cases diagnosed as metastatic carcinoma and in 59% of primary malignant tumors of bone (17) (excluding Ewing's sarcoma). FNA alone was diagnostic in 8% (9) of cases, including 5 metastatic carcinomas, 2 chondrosarcomas, 1 Ewing's sarcoma and 1 case of osteomyelitis. This represented 24% of the 38 cases in which NCB was unsatisfactory (11) or normal (27). NCB alone was diagnostic in 19% (22) of cases, including 11 metastatic carcinomas, 3 osteosarcomas, 1 chondrosarcoma, 1 spindle cell sarcoma (not otherwise specified), 1 Ewing's sarcoma, 2 capillary hemangiomas and 3 cases of osteomyelitis. This represented 43% of the 51 cases in which FNA was misinterpreted (2), unsatisfactory (33) or normal (16). NCB more specifically typed a metastatic lesion or suggested a primary focus in 21% (12) of the 58 cases in agreement. It also more specifically subtyped 50% (5) of the 10 primary malignant tumors of bone. Given these findings, NCB is more specific in the evaluation, grading and typing of skeletal lesions in particular malignant primary bone tumors. Overall, there is excellent agreement between FNA and NCB, especially in the evaluation of benign primary bone tumors. Most important, FNA improved the diagnostic yield in 24% of cases when NCB was normal or unsatisfactory, obviating the need for rebiopsy. FNA should be performed concurrently with NCB in the evaluation of skeletal lesions since the two modalities are complementary.

Quality assurance in breast cancer screening cytology: a review of the literature and a report on the U.K. national cytology scheme.

The National Breast Screening Programme in the United Kingdom has had an external quality assessment (EQA) scheme for breast screening histopathology since 1990. Recently, it was decided, by the Cytology sub-group of the National Co-ordinating Committee for Breast Screening Pathology, to institute two forms of cytology quality assurance. An EQA scheme is planned with circulation of slides to pathologists, but this involves extra time and effort from the participants at a time when general pathology workloads are high. Because of this, a computer routine has been written to analyse the data already present within the National Breast Screening Computer Systems, to enable the calculation of sensitivity and specificity of fine needle aspiration, correlating the cytology results with subsequent histology or follow-up mammography for lesions where no biopsy is performed. This routine uses standardised terminology and calculations and, therefore, inter-unit comparisons can be made. Where problems are identified within a unit, the Quality Assurance team can investigate the cause and institute appropriate measures to correct the problem. This article details the procedures involved in this audit and reviews the literature, recalculating the parameters in a standard manner for a number of publications. The results of the cytology quality assurance routine from seven screening units in one health region in the U.K. are presented and the measures taken to improve the level of service are discussed.