Underwent Thyroid Fine Needle Aspiration Research Articles

Sterile gown and drape, and bouffant cap for thyroid FNA: preventing infections or producing unnecessary medical waste?

Ultrasound-guided fine needle aspiration (FNA) is a very low-risk procedure. Despite this, there remains great variability in the use of protective equipment. Given the monetary and environmental costs of protective equipment, the difference in infection rates with full versus limited protective equipment was assessed. A total of 857 consecutive patients were retrospectively reviewed after undergoing thyroid FNAs at the main hospital and outpatient clinic siteperformed from 12/1/2020 to 11/30/2023. The hospital site operated with full protective equipment (bouffant, sterile gown, sterile gloves, and full body sterile drape), and the outpatient site with limited (sterile gloves, limited sterile paper drape) protective equipment. Two patients were excluded as no procedure was performed. Review for signs of infection within 30days of procedure was performed using medical records, which was blinded to the extent of protective equipment utilization. No infections were identified in either group, with 0/629 (0%, 95%CI 0-1%) in the full protective equipment group vs. 0/226 (0%, 95%CI 0-2%) in the limited protective equipment group. There was no statistically significant difference in infection rate between full and limited protective equipment use in thyroid FNA in the included 855 procedures (95%CI 0-1%). Two patients out of 629 (0.3%) in the full protective equipment group developed mild allergic reaction to topical antiseptic. The 226 procedures with limited protective equipment represent a saving of at least 204,530g of CO2 equivalents, equivalent to driving a car for almost 3000 miles. Reducing the extent of protective equipment does not adversely affect the infection rate in thyroid FNAs. Given the inherent costs involved in the procurement and waste of protective equipment, reducing protective equipment use is warranted to reduce both the monetary and environmental impacts of waste.

Clinical risk factors and cancer risk of thyroid imaging reporting and data system category 4 A thyroid nodules

PurposeBeyond the Thyroid Imaging Reporting and Data System (TIRADS) classification of thyroid nodules, additional factors must be weighed in the decision to perform fine needle aspiration (FNA). In this study, we aimed to identify risk factors for malignancy in patients with ultrasound-classified Chinese-TIRADS (C-TIRADS) 4 A nodules.MethodsPatients who underwent thyroid FNA at our institution between May 2021 and September 2022 were enrolled. We collected demographic data, including age, sex, previous radiation exposure, and family history. An in-person questionnaire was used to collect lifestyle data, such as smoking habits and alcohol consumption. Body mass index (BMI) was calculated. The serum levels of thyroid stimulating hormone (TSH), thyroid peroxidase antibody (TPOAb), and thyroglobulin antibody (TGAb) were measured. Prior to FNA, ultrasonic inspection reports were reviewed. The cytologic diagnoses for FNA of thyroid nodules followed the Bethesda System for Reporting Thyroid Cytopathology (2017).ResultsAmong the 252 C-TIRADS 4 A nodules, 103 were malignant. Compared to those in the benign group, the patients in the malignant group had a younger age (42.2 ± 13.6 vs. 51.5 ± 14.0 years, P < 0.001). Logistic regression showed that advanced age was associated with a lower risk of malignancy in C-TIRADS 4 A nodules (OR = 0.95, 95% CI 0.93 ~ 0.97, P < 0.001). We demonstrated a decreased risk of malignancy in patients with 48.5 years or older.ConclusionAdvanced age was associated with a decreased risk of malignancy in patients with C-TIRADS 4 A nodules. This study indicated that in addition to sonographic characteristics, patient age should be considered when assessing the risk of malignancy.

Does the Adoption of Molecular Testing Cause Decreased Thyroidectomy Rates in a National Cohort? A Quasiexperimental Study of High- Versus Low-Adoption States.

Background: Over the last decade, the utilization of molecular testing (MT) for the evaluation of thyroid nodules has increased. Rates and patterns of adoption of MT and its effect on thyroidectomy rates nationally are unknown. Varying rates of MT adoption at the state level provide an opportunity to study the effects of MT on thyroidectomy rates using a quasiexperimental study design. Methods: We performed a retrospective analysis of American adult patients in the Merative™ MarketScan® Research Databases who underwent thyroid fine-needle aspiration (FNA) from 2011 to 2021. MT included commercially available DNA and RNA platforms and traditional targeted mutational analysis. Interrupted time series analysis was used to evaluate the inflection of MT adoption and thyroidectomy rates after 2015. Difference-in-differences (DID) analysis was used to causally analyze the effect of MT adoption on thyroidectomy rates in high-adoption (at least a 10% increase in MT utilization) versus low-adoption states (no more than 5% increase in MT utilization) from 2015 to 2021. Results: We identified 471,364 patients who underwent thyroid FNA. The utilization of MT increased over the study period from 0.01% [confidence interval, CI: 0.00% to 0.02%] to 10.1% [CI: 9.7% to 10.5%], in 2021, with an immediate (β2 = 1.61, p = 0.002) and deeper (β3 = 0.6, p < 0.001) increase in MT adoption after 2015. Utilization of MT was lower in black patients, the elderly, rural areas, and patients with Medicaid (p < 0.05). Thyroidectomy rates were inversely correlated with MT utilization (r = -0.98, p < 0.0001). From 2015 to 2021, the average MT utilization rate increased from 2.4% to 15.3% in high-adoption states and 1.6% to 5.6% in low-adoption states. In low-adoption states, thyroidectomy rates decreased more but to similar levels (18.5-13.2%) compared with high-adoption states (15.9-13.4%) with an adjusted DID rate of -3.3% [CI -5.6% to -0.8%]. Conclusions: The acceleration in adoption of MT after 2015 likely coincides with the publication of American Thyroid Association guidelines. Black, elderly, and rural patients are less likely to receive MT. Although thyroidectomy rates were inversely correlated with MT utilization, our study suggests that this correlation is not causal. The effect of MT on thyroidectomy rates may be overshadowed by decreasing aggressiveness of thyroid nodule evaluation.

Postoperative recurrence of diffuse sclerosing thyroid cancer in an adolescent patient: A case report.

Papillary thyroid cancer is an inert malignant tumor with a good response to surgical treatment, low recurrence and metastasis rate, and good prognosis. Diffuse sclerosing thyroid cancer is an invasive subtype that is more common in young people, with a higher rate of lymph node metastasis and recurrence, and a relatively poor prognosis. A 13-year-old girl underwent radical surgery for diffuse sclerosing thyroid cancer. Eight years later, due to a large number of lymph node metastases, she underwent another radical surgery on her neck lymph nodes. The patient thyroid ultrasound and neck enhanced CT indicated that the patient had multiple enlarged lymph nodes in the neck with irregular morphology and structure, and the possibility of metastatic lymph nodes was high. Subsequently, the patient underwent thyroid fine-needle aspiration and the results showed that cancer cells were detected in both cervical lymph nodes. The patient was diagnosed with bilateral cervical lymph node metastases after thyroid surgery. After the second surgery, the patient recovered well, and no residual or focal iodine uptake tissue was found on the enhanced CT examination. As diffuse sclerosing thyroid cancer is prone to lymph node and recurrent metastases, once it is diagnosed, radical treatment should be actively performed. Postoperative adjuvant radiation therapy should be administered according to the patient condition and regular follow-ups should be conducted to monitor neck lymph node metastasis.

Assessing the Frequency of Deferrable Thyroid Nodule Biopsies to De-escalate Low-Value Care

ObjectiveThyroid nodules are common, yet fewer than 1 in 10 harbors malignancy. When present, thyroid cancer is typically indolent with excellent survival. Therefore, patients who are not candidates for thyroid cancer treatment due to comorbid disease may not require further thyroid nodule evaluation. The goal of this study was to determine the rate of deferrable thyroid nodule biopsies in patients with limited life expectancy. MethodsWe identified patients who underwent thyroid fine needle aspiration (FNA) between 2015 and 2018 at our institution. The primary outcome was the number of deferrable FNAs, defined as FNAs performed in patients who died within 2 years after biopsy. Secondary outcomes included cytologic Bethesda score, procedure costs, and final diagnosis on surgical pathology. Multivariable logistic and Cox proportional hazards regressions were used to evaluate factors associated with FNA in patients with limited life expectancy. ResultsA total of 2565 FNAs were performed. Most patients were female (79%), and 37 (1.5%) patients died within 2 years. Nonthyroid specialists were significantly more likely to order deferrable FNAs (odds ratio 4.13, P < .001). Of the patients who died within 2 years, most (78%) had a concomitant diagnosis of nonthyroid cancer, and 4 went on to have thyroid surgery (Bethesda scores: 3, 4, 4, and 6). Spending associated with deferrable FNAs and subsequent surgery totaled over $98 000. ConclusionsOverall, the rate of deferrable thyroid nodule biopsies was low. However, there is an opportunity to reduce low-value biopsies in patients with a concurrent nonthyroid cancer by partnering with oncology providers.

Effect of Music on Anxiety and Pain Levels of Patients Undergoing Thyroid Fine Needle Aspiration Biopsy: A Randomized Controlled Study

Despite being a minimally invasive procedure, biopsy can cause pain and anxiety in patients. Therefore, it is important to reduce the pain and anxiety levels of patients. The present study aims to investigate the effect of music on patient anxiety and pain levels during thyroid fine needle aspiration biopsy. In this randomized controlled single-blind study, a validated State-Trait Anxiety Inventory (STAI) consisting of 40 questions in total was used to evaluate patient anxiety rates. The STAI consists of two sections: the state anxiety scale (SAS) measuring instant anxiety and the trait anxiety scalemeasuring general anxiety. Patients were divided into two groups: Group 1 those who did not listen to music during a biopsy and group 2 those who listened to music. The Visual Analogue Scalewas used to evaluate patient pain levels. Group 1 consisted of 46 patients and Group 2 consisted of45 patients. After the procedure, the mean SAS scores of Groups 1 and 2 were not significantly different (p=0.24). However, The state anxiety scale differences, which represents the decrease in pre-procedure and post-procedure anxiety levels (SAS1-SAS2) was statistically different among the groups (p=0.01). There was a significant difference between the two groups in terms of VAS score distribution (p=0.01). Music therapy is an easily applicable, cheap, and safe method that can be used to decrease anxiety and pain levels in patients during thyroid biopsy as evidenced by this research.

Performance of ACR TI-RADS and the Bethesda System in Predicting Risk of Malignancy in Thyroid Nodules at a Large Children's Hospital and a Comprehensive Review of the Pediatric Literature.

While thyroid nodules are less common in children than in adults, they are more frequently malignant. However, pediatric data are scarce regarding the performance characteristics of imaging and cytopathology classification systems validated to predict the risk of malignancy (ROM) in adults and select those patients who require fine-needle aspiration (FNA) and possibly surgical resection. We retrospectively reviewed the electronic medical records of all patients 18 years of age or younger who underwent thyroid FNA at our institution from 1 July 2015 to 31 May 2022. Based on surgical follow-up from 74 of the 208 FNA cases, we determined the ROM for the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) ultrasound risk stratification system and The Bethesda System for Reporting Thyroid Cytopathology and added our results to those of pediatric cohorts from other institutions already published in the literature. We found the following ROMs for 1458 cases using ACR TI-RADS (TR): TR1. Benign: 2.2%, TR2. Not Suspicious: 9.3%, TR3. Mildly Suspicious: 16.6%, TR4. Moderately Suspicious: 27.0%, and TR5. Highly Suspicious 76.5%; and for 5911 cases using the Bethesda system: Bethesda I. Unsatisfactory: 16.8%, Bethesda II. Benign: 7.2%, Bethesda III: Atypia of Undetermined Significance: 29.6%, Bethesda IV. Follicular Neoplasm: 42.3%, Bethesda V. Suspicious for Malignancy: 90.8%, and Bethesda VI. Malignant: 98.8%. We conclude that ACR TI-RADS levels imply higher ROMs for the pediatric population than the corresponding suggested ROMs for adults, and, in order to avoid missing malignancies, we should consider modifying or altogether abandoning size cutoffs for recommending FNA in children and adolescents whose thyroid glands are smaller than those of adults. The Bethesda categories also imply higher ROMs for pediatric patients compared to adults.

The impact of classical music on anxiety and pain perception during a thyroid fine needle aspiration biopsy.

To determine the impact of classical music on the anxiety and pain perception of patients who underwent thyroid fine-needle aspiration biopsy (TFNAB) for the first time. In a prospective randomized controlled design, TFNAB patients were randomized into the intervention and control groups. The State Anxiety Inventory (SAI) before and after the procedure and the visual analog scale (VAS) after procedure were used for measuring anxiety and pain. A total of 82 patients were included. There was no significant difference between the music intervention group (n = 41) and control group (n = 41) in terms of age, gender, work status, highest education level, SAI score before TFNAB, and duration of the procedure (p > 0.05). It was observed that the anxiety level before TFNAB was higher in women in all patient groups (p = 0.009). While the SAI score decreased significantly in the music intervention group (Z = - 3.62, p < 0.001), there was no significant difference in the control group (Z = - 1.41, p = 0.157) after TFNAB. However, no significant difference was found in terms of VAS between two groups (p = 0.075). The duration of the TFNAB procedure was correlated with the change in the SAI score (r = 0.382, p < 0.001). This is the first study to examine the impact of music on patients' anxiety and pain perception during the TFNAB procedure. Despite the fact that classical music intervention did not decrease pain perception, it significantly reduced patient anxiety. Music is an easy-to-implement intervention that can be considered as an effective method for reducing patient anxiety during TFNAB.

Analgesic efficacy of local anesthesia during thyroid fine-needle aspiration biopsy: A PRISMA-compliant systematic review and meta-analysis of randomized controlled trials

ABSTRACT Aim The objective of this study is to evaluate the analgesic efficacy of local anesthetic (LA) agents on pain severity among patients undergoing thyroid fine needle aspiration biopsy (FNAB). Design A systematic review and meta-analysis of randomized controlled trials (RCTs). Methods Digital databases, including PubMed, Scopus, Cochrane, Web of Science, and Google Scholar, were systematically screened from inception till December 2022. The Cochrane risk of bias tool (ROB 2) was used to evaluate the quality of each RCT. The primary outcome (pain severity) was gathered as a mean difference (MD) with a 95% confidence interval (Cl), under the random-effect model. Results Overall, 444 patients were enrolled in five RCTs. Regarding pain severity via the visual analogue scale (VAS) assessment tool, the overall effect size showed no substantial difference between LA and control groups (n = 4 RCTs,MD = −8.45, 95% CI [−27.41, 10.52], p = 0.38). Regarding pain severity via the numerical rating scale (NRS) assessment tool, the overall effect size showed no substantial difference between LA and control groups (n = 3 RCTs,MD = −0.85, 95% CI [−3.14, 1.45], p = 0.47). Conclusion We have found that the pain levels between the LA and control-receiving groups were comparable. Hence, we concluded that LA before FNAB provides no benefit, especially for one needle puncture and sampling.

Increased workload without clinical benefit: Results following implementation of the ACR-TIRADS system for thyroid nodules.

The ACR-TIRADS system for stratifying thyroid nodule malignancy risk has been widely promoted and implemented. We audited its introduction at a large public hospital in Auckland, New Zealand. Audit of outcomes following thyroid nodule fine needle aspiration (FNA) before/after ACR-TIRADS. Individuals undergoing thyroid FNA 2017-2019. From medical records, we obtained details from the pre-FNA ultrasound (nodule size, TIRADS points/levels, radiologist recommendation for FNA), Bethesda (B) cytology classification, histology and post-FNA follow-up. Four hundred and twenty-two individuals had 564 FNAs, 163 had surgery and 54 (13%) had cancer in the primary nodule. 37/54 (69%) cancers were papillary thyroid carcinoma (median size 25 mm, 87% ≥10 mm, 61% ≥20 mm). Following ACR-TIRADS introduction, FNA recommendations increased greater than twofold, FNAs performed by 71%-83%, and the monthly rate of FNAs and operations by 60% and 40%, respectively. However, the proportion of cancers/FNA remained similar (9.9% post-TIRADS vs. 8.7% pre-TIRADS). The proportions of FNA results remained stable for B2-B4 categories, but doubled (11% vs. 5%) for B5-B6: 15 FNAs were needed to identify an additional B5/B6 lesion. TIRADS-5 nodules had a higher proportion of B5/B6 (20%) and a lower proportion of B2 (30%) than TIRADS-3 (2%, 57%, respectively) and TIRADS-4 (9%, 56%) nodules. About 5 additional cancers/year were diagnosed, but they were more often small (49% vs. 8% <2 cm, 17% vs. 0% <1 cm). ACR-TIRADS introduction increased workload (FNAs and operations), without increasing the proportion of cancers/FNA. It led to a few more cancers being diagnosed, but many were small and of uncertain clinical significance.

COVID-19 pandemisi öncesinde ve sırasında tiroid ince iğne aspirasyon sitolojisi sonuçlarının karşılaştırılması: pandeminin etkisi

Purpose: The aim of this study was to compare the Bethesda classification to report the distribution of thyroid cytology diagnostic categories and total thyroid fine needle aspiration cytology numbers before and during the pandemic.&#x0D; Materials and Methods: This study was planned in two phases: (1) before the pandemic, from March 15, 2018, and 29 February 2020, and during the pandemic period, from 1 March 2020 to 12 March 2022. Each period consisted of 24 months. The total number of thyroid fine needle aspiration cytology performed before the pandemic and during the pandemic dates and histopathological data were obtained from the hospital database.&#x0D; Results: 432 thyroid fine needle aspiration biopsies were performed in the pre-pandemic period and 351 during the pandemic. There was no significant difference considering age and gender in patients who underwent thyroid fine needle aspiration cytology before and during the pandemic. According to the Bethesda classification, those who were benign were 70.8% (n:306) and 59.0% (n:207) respectively before pandemia and during the pandemia. According to the Bethesda classification, malignant lesions were 4.4%(n:19), and 9.1%(n:32) before and during the pandemia, respectively. During the pandemic, malignant lesions were detected significantly more than before the pandemic.&#x0D; Conclusion: Malignant lesions were detected significantly more in the thyroid fine needle aspiration cytology results according to the Bethesda classification during the pandemic period compared to before the pandemic period.

Effects of Rapid On-Site Evaluation on Diagnostic Accuracy of Thyroid Fine-Needle Aspiration

Introduction: Fine-needle aspiration (FNA) is well-established for the evaluation of suspicious thyroid nodules. However, a significant proportion is nondiagnostic. Rapid on-site evaluation (ROSE) has been proposed to improve the overall adequacy of FNA. Methods: Retrospective cohort study comparing adequacy of thyroid FNA findings pre- and postimplementation of ROSE at a tertiary center in Switzerland. Patients undergoing thyroid FNA from January 2016 to December 2019 were included. The primary outcome was the rate of nondiagnostic findings (Bethesda System for Reporting Thyroid Cytopathology category I). Results: In total, 410 thyroid nodule FNAs were performed. Of those, 309 with standard FNA and 101 with ROSE. The majority of patients were female (71%), with a median age of 56 years (IQR 46–68) and a nodule diameter of 1.9 cm (IQR 1.2–2.9). Implementation of ROSE led to a decrease in nondiagnostic findings from 41.1% to 23.8%, with an odds ratio of 0.42 (95% CI: 0.24–0.72; p = 0.002). Implementation of ROSE was associated with significantly higher rates of Bethesda category III (27.7% vs. 19.1%), category IV (15.8% vs. 5.5%), and Bethesda category VI (6.9% vs. 2.3%). Repeated FNA was performed in 29.1% before and 20.8% after implementation of ROSE (p = 0.18). The mean number of FNA per nodule was reduced from 1.4 (0.6) to 1.2 (0.4) with ROSE (p = 0.04). Conclusions: Implementation of ROSE of thyroid nodule specimen improved diagnostic adequacy of FNA, reducing nondiagnostic findings. However, due to increased equivocal findings (Bethesda category III), there was no significant reduction of repeat FNA.

Clinical significance and cytological detection of tracheal puncture following thyroid fine-needle aspiration: A retrospective study.

BackgroundThere have been no detailed reports on tracheal puncture after thyroid fine‐needle aspiration (FNA). This study aimed to discuss the cytological differential diagnoses of tracheal puncture after thyroid FNA and clarify its clinical significance.MethodsTracheal puncture was defined as aspiration of tracheal components, including ciliated cells, chondrocytes, and goblet cells. A history of air suction or cough during aspiration was also considered tracheal puncture. Among the 18,480 nodules from 13,813 patients that underwent thyroid FNA, 70 (0.38%) nodules with tracheal puncture were retrospectively examined. Eleven thyroglossal duct cysts (TGDCs) and seven bronchial cysts that could exhibit ciliated cells were included in the study to compare the cytological findings.ResultsSixty‐six (94.3%) nodules had no clinical evidence of complications during and after FNA. Of the nodules with tracheal puncture, 64.3%, 48.6%, and 51.4% nodules were <1.0 cm in size, located in the isthmus, and associated with calcification. Cytological examination showed that chondrocytes and ciliated cells were present in 94.3% and 32.9% nodules, respectively. Ciliated cells seen in nodules with tracheal puncture and TGDCs were non‐degenerative, whereas those in bronchial cysts were degenerative.ConclusionTracheal puncture after thyroid FNA is rarely noticed clinically, does not cause serious conditions, and spontaneously resolves. This complication more likely occurs in small‐calcified nodules in the isthmus. Chondrocytes are more reliable diagnostic clues than ciliated cells to indicate tracheal puncture cytologically.

Effect of an Information Video before Thyroid Biopsy on Patients' Anxiety

Aim To investigate the effects of video-based information on the anxiety of patients who underwent ultrasound-guided thyroid fine-needle aspiration biopsy. Methods Fifty consecutive patients who underwent thyroid fine needle aspiration biopsy were included in the study prospectively. Patients were divided into two groups before the biopsy. 25 patients in Group 1 received only written information about thyroid biopsy. In Group 2, 25 patients received video-based information along with written information. Baseline anxiety of all the patients was evaluated prior to procedure using STAI-S and STAI-T questionnaires. After the written information was provided to the patients in group 1, the STAI-S questionnaire was repeated. In the same way, group 2 patients were asked to repeat the STAI-S questionnaire after written and video-based information were provided. All patients were asked to evaluate pain during biopsy using visual analog scale (VAS). Results There was no significant difference between the groups in terms of age and gender. Although the VAS score was lower in group 2, there was no statistically significant difference between the two groups. When the groups were compared in terms of basal anxiety scores, STAI-T was similar in both groups (p = 0.708). Although STAI-S values were similar in pre and post-information patients in Group 1, the STAI-S values in group 2 were statistically significantly decreased. Conclusion The video based information provided prior to thyroid biopsy draws the attention as an effective and easy to apply method to decrease the anxiety of the patients.

Patient Discomfort in Relation to Thyroid Nodule Fine-Needle Aspiration (FNA) Performed with or without Parenteral and/or Topical Anesthetic

There is much reported variation in the impact of local anesthesia on thyroid fine-needle aspiration (FNA) related discomfort. We compare patients undergoing thyroid FNA with subcutaneous injection or topical anesthetic to no anesthetic. We conducted a retrospective review of 585 sequential ultrasound guided thyroid FNA procedures in Mayo Clinic. Group 1 (n = 200), no anesthetic; Group 2 (n = 185), subcutaneous injection anesthetic; and Group 3 (n = 200), topical anesthetic. Patient demographics, number of FNA passes, needle gauge, and cytopathology were recorded plus a discomfort score (0 to 10) before and immediately post procedure in all 3 groups and peak discomfort during the FNA in Groups 1 and 2. There were no differences among the 3 groups in age, sex, FNA sufficiency rate, cytopathology, and FNA passes number. There was no significant difference between Groups 1 and 2 in peak discomfort score during the FNA: 0 (45%, 42.2%), 1 to 2 (19%, 24.9%), 3 to 5 (23.5%, 20.5%), 6 to 8 (9.5%, 10.8%), 9 to 10 (3%, 1.6%), respectively. Discomfort score post procedure: 0 (78.5%, 77.8%, 53.5%), 1 to 2 (13%, 13%, 36.5%), 3 to 5 (7%, 7%, 9%), 6 to 8 (1.5%, 2.2%, 1%), 9 to 10 (0%, 0%, 0%) for groups 1, 2, and 3, respectively. There were no significant differences among the 3 groups for a discomfort score ≥3. FNA associated patient discomfort was comparable during and after the procedure regardless of the use of anesthetic or the type utilized. Approximately 90% of patients experienced mild to moderate discomfort during the procedure. And 90% reported no more than a level 2 discomfort post procedure. End = endocrinology; FNA = fine-needle aspiration; MCF = Mayo Clinic Florida; MCR = Mayo Clinic Rochester.

Hürthle Cells on Fine-Needle Aspiration Cytology Are Important for Risk Assessment of Focally PET/CT FDG Avid Thyroid Nodules.

Simple SummaryPET/CT fluorodeoxyglucose (FDG) scans are routinely used in patients to detect signs of malignant tumours or evidence of inflammation in the body. A total of 1–2% of patients show focal thyroid gland FDG uptake and 35–40% are malignant. FDG also detects metabolically active lesions containing mitochondria, known as Hürthle cells. Over 3 years, 47 patients in one hospital were found to have focal thyroid gland uptake. A total of 18 (38.2%) of the patients had malignancy, 15 (31.9%) had benign lesions that contained Hürthle cells and 14 (29.8%) had focally increased thyroid gland FDG PET/CT uptake with no cause identified. Exclusion of the Hürthle cell patients increased the risk of malignancy of the remaining PET-positive nodules from 38% to 68%. It is important to recognize Hürthle cells on FNA cytology in FDG PET/CT-positive nodules as this affects the risk of malignancy and the clinical management of focally FDG PET/CT-positive nodules.This study assesses the role of [18F] FDG PET/CT, fine needle aspiration (FNA) cytology and ultrasound in the 1–2% of patients with focally positive thyroid nodules on FDG PET/CT. All FDG PET/CT scans with focally increased thyroid FDG PET/CT uptake performed over 37 months in one institution were matched to patients undergoing thyroid FNA. Diffuse FDG PET/CT uptake patients were excluded. A total of 47 patients showed focally increased thyroid uptake. Consistent with previous studies, 18 (38.2%) patients had malignancy—12 primary thyroid carcinoma, 1 parathyroid carcinoma, 3 metastatic carcinoma to the thyroid and 2 lymphoma. A total of 15 (31.9%) lesions categorized as non-malignant contained Hürthle cells/oncocytes. A total of 14 lesions (29.8%) had focally increased FDG PET/CT uptake with no specific cytological or histopathological cause identified. No focally PET avid Hürthle cell/oncocytic lesions were found to be malignant. Exclusion of oncocytic lesions increased the calculated risk of malignancy (ROM) of focally PET avid nodules from 38% to 68%. It may be useful to exclude focally FDG PET/CT avid Hürthle cell/oncocytic lesions, typically reported as follicular neoplasm or suspicious for a follicular neoplasm, Hürthle cell type (Oncocytic) type, RCPath Thy 3F: Bethesda IV or sometimes Thy 3a: Bethesda III FNAs) from ROM calculations. Oncocytic focally PET/CT FDG avid lesions appear of comparatively lower risk of malignancy and require investigation or operation but these lesions should be readily identified by FNA cytology on diagnostic work up of focally PET avid thyroid nodules.

Quality of Life Following Molecular Marker Testing for Indeterminate Thyroid Nodules

Thyroid cancer has a disproportionately negative effect on the quality of life (QOL) compared to malignancies with a worse prognosis. The QOL of patients with indeterminate thyroid nodules has not been previously evaluated. We aimed to assess the impact of molecular test results on the QOL of patients with indeterminate thyroid nodules. A short version of the Thyroid-Related Patient-Reported Outcome (ThyPro-39) was used to assess the QOL of patients who underwent thyroid fine needle aspiration (FNA) biopsy throughout UCLA Health from May, 2016, to June, 2017. All patients with indeterminate biopsy results underwent molecular testing with either Afirma Gene Expression Classifier or ThyroSeq v2 at the time of the initial biopsy. The QOL associated with symptoms of goiter, anxiety, depression, and impaired daily life were analyzed. Of 825 consented patients, 366 completed the assessment (44.4% response rate). FNA results included 76% benign, 7% malignant, and 17% indeterminate. There were no differences in QOL between patients with a benign FNA and patients with an indeterminate result with benign molecular testing. In patients with an indeterminate FNA, symptoms of goiter (20.5 versus 10.4; P = .033) and depression (33.3 versus 21.0; P = .026) were worse for patients with suspicious versus benign molecular test results; however, no significant differences were observed in anxiety or impaired daily life. A benign molecular test result may provide reassurance for patients with indeterminate thyroid nodules that the risk of malignancy is low. Long-term follow-up is necessary to determine if benign molecular test results maintain improved QOL.

Predictors of malignancy in high-risk indeterminate (TIR3B) cytopathology thyroid nodules.

The classification of indeterminate cytopathology at thyroid fine-needle-aspiration (FNA) has been updated to reduce the number of unnecessary surgery; the 2014 Italian classification introduced the low-risk (TIR3A) and high-risk (TIR3B) subcategories. Aim of this study was to identify the ultrasonographic (US), clinical and cytological predictors of malignancy among TIR3B nodules from a single institution. A prospective observational study including 1844 patients who underwent thyroid FNA from June 2014 to January 2019. Ultrasonographic, clinical and cytological features were recorded. All TIR3B diagnoses were referred to surgery. According to final histology, patients were divided into thyroid cancer (TC) or benign nodules. Chi-square test, or Fisher exact test when appropriate, were used to compare groups and logistic regression analyses were used to determine independent predictors of malignancy. Of 1844 FNAs, 96 (5.2%) were TIR3B. Histology report was available in 65. Among them, 25 (38.5%) were TC. Predictors of TC were nodule size < 20mm [Odds Ratio (OR) = 5.88, 95% CI 1.91-18.11, p = 0.002], absence or weak intralesional flow [OR = 0.3, 95% CI 0.09-0.77, p = 0.015], microcalcifications [OR = 6.5, 95% CI 1.90-21.93, p = 0.003] at US; nuclear inclusions [OR = 25.3, 95% CI 1.34-476.07, p = 0.031] and chromatin clearing [OR = 3.7, 95% CI 1.27-10.99, p = 0.017] at cytopathology. Patients aged < 55years had a significantly higher risk of TC [OR = 9.7, 95% CI 2.79-34.07, p < 0.001]. In multivariate analysis, age < 55 and nodule size < 20mm resulted as independent risk factors. Patients < 55years receiving a diagnosis TIR3B on nodules < 20mm, with microcalcifications, showing specific nuclear atypia at cytopathology are more likely to have TC. Combining US, cytological and clinical features could help determining which patients with a TIR3B diagnosis should be referred to surgery.

Cytopathology-histopathology correlation and the effect of nodule diameter on diagnostic performance in patients undergoing thyroid fine-needle aspiration biopsy.

Although thyroid fine-needle aspiration biopsy (FNAB) is established to have a good overall sensitivity and specificity, various outcomes have been reported on its performance in large nodules. The aim of the study was to evaluate the diagnostic performance of FNAB and the effect of the nodule diameter on its diagnostic performance. The outcomes of a total of 7319 patients who underwent FNAB over the course of 5 years were analyzed retrospectively and 648 patients who had undergone post-FNAB thyroidectomy or lobectomy were included in the study. FNAB results were classified according to the Bethesda system. After evaluating the compatibility between cytology and pathology results, all-nodules and diameter-based (<4 cm and ≥4 cm) sensitivity, specificity, false positivity, false negativity, and accuracy rates of FNAB were calculated. Sensitivity of FNAB was 85.4% for all nodules, 88.3% for nodules <4 cm, and 75.8% for nodules >4 cm (P < 0.001). Specificity was 58.4% for all nodules, 49.3% for nodules <4 cm, and 75.1% for nodules >4cm (P < 0.001). While false positivity was 41.6% for all nodules, it was 50.7% for nodules smaller than 4 cm and was 24.9% for nodules larger than 4 cm (P < 0.001). False negativity was 14.6% for all nodules and was 11.7% for nodules smaller than 4 cm and 24.2% for nodules larger than 4 cm (P < 0.001). Finally, among the entire set of nodules, the accuracy was 64.4%, which was 59.2% in nodules smaller than 4 cm, and 75.2% in nodules larger than 4 cm (P < 0.001). Despite a higher rate of false negativity, FNAB has higher specificity and accuracy in large nodules than those in the small nodules. Nodule diameter should not be used alone as a criterion to recommend thyroidectomy to the patient.

Evaluation of Incidental Thyroid Nodules in Cancer Patients

ObjectiveFrequency of thyroid cancer in incidental thyroid nodules identified by imaging techniques in cancer patients is higher than that in the normal population. In the retrospective study, we have both investigated the incidence of thyroid cancer in incidentally identified nodules and compared the imaging techniques to determine whether there is any difference between them in detection of malign nodules. MethodsA total of 7319 patients who underwent thyroid fine-needle aspiration biopsy (FNAB) were included in the study. The data of 174 patients who had previously been diagnosed with a hematologic or solid malignancy prior to the FNAB procedure and had incidentally identified thyroid nodules were evaluated retrospectively. ResultsEighty-six (49.5%) of the incidental nodules were identified with ultrasonography (USG), 62 (35.6%) with positron emission tomography (PET) or PET/computed tomography (PET/CT), and 26 (14.9%) with CT. As a result of thyroidectomy, papillary carcinoma was identified in 8 (4.6%) patients, and metastasis to the thyroid of a primary cancer was found in 3 (1.7%) patients. While the papillary carcinoma proportion in the nodules identified by USG was 3.4%, PET/CT was 8.9%. A cut-off maximal standardized uptake value of 11.6 in PET/CT indicated malignancy achieving a sensitivity of 83.3% and a specificity of 91.1%. ConclusionWhether the nodule in the incidental thyroid nodules of cancer patients is identified using USG or PET/CT, the risk of thyroid cancer is similar. However, cancer risk is higher in the event of a higher focal uptake in the nodules identified by PET/CT.