Reliability of benign fine needle aspiration cytology of large thyroid nodules

doi:10.1016/j.surg.2008.09.006

Surgery

Volume 144, Issue 6, December 2008, Pages 963-969

https://doi.org/10.1016/j.surg.2008.09.006 Get rights and content

Background

With increasing use of thyroid ultrasonography, thyroid nodules have been found to be extremely common. For over 25 years, fine needle aspiration (FNA) has been the pivotal diagnostic test to discriminate benign from potentially malignant thyroid nodules. Recently, false negative rates exceeding 10% have led to recommendations that thyroid nodules ≥4 cm should be resected regardless of cytology results. Our aim was to determine the false negative rate of FNA cytology on thyroid nodules ≥3 cm interpreted as benign at our institution.

Methods

A retrospective review was performed at Mayo Clinic from January 2002 through December 2006.

Results

From 6,921 ultrasonographic-guided thyroid FNAs, 742 were interpreted as benign and ≥3 cm. A definitive histologic diagnosis was available for 145 (20%) patients who underwent thyroidectomy: 1 (0.7%) was false negative. No additional thyroid malignancies were identified in 550 index nodules with average follow-up of 3 years.

Conclusion

With precise ultrasonographic-guided aspiration, strict adherence to guidelines for adequacy of the sample, proper cytologic preparation, and most importantly, expert cytologic analysis, a diagnosis of benign is extremely reliable for thyroid nodules, regardless of size. Resection for diagnosis is not necessary, and a size ≥3 cm should not be an independent indication for resection.

Section snippets

Methods

After approval by our Institutional Review Board, a retrospective chart review was conducted of patients who had undergone US-guided FNA at Mayo Clinic, Rochester, from January 2002 through December 2006. Patients were identified by a systematic search of the electronic medical record for all such procedures performed in our departments of Endocrinology or Radiology. The size of the nodule was measured precisely by US in all patients except one which was measured by computed tomography. The

Results

From 6,921 US-guided fine needle aspirations, 742 thyroid nodules ≥3 cm met benign cytologic criteria. A definitive histologic diagnosis was available for 145 (20%) patients who underwent thyroid lobectomy in 88 (61%) or bilobar resection in 57 (39%). Of the 597 patients who were not operated on following their benign FNA, 23 are deceased without clinical evidence of thyroid malignancy. Of the remaining 574 patients, 550 (96%) have been followed for a mean of 3.0 years (range, 6 months–6

Discussion

Thyroid FNA is designed expressly to reduce the number of thyroid resections when the single indication for operative intervention is discriminating benign from malignant nodules. To this end, it has been highly successful.11, 12 The critical corollary to this practice has been to insure that malignancies are not overlooked. Such confidence in the reliability of FNA prompted Hegedus to conclude that “if the cytology is benign, repeated biopsy is seldom indicated.”¹² Since the introduction in

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Thyroid US-guided FNA techniques: A prospective,randomized controlled study
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Thyroid nodules are common in the general population. Ultrasonography is the most efficient diagnostic approach to evaluate thyroid nodules. The US FNAC procedure can be performed using either the short axis (perpendicular), or a long axis (parallel) approach to visualize the needle as it is advanced toward the desired nodule. The main aim of this study was to compare the percentage of non-diagnostic results between the long and short axis approach.
A prospective study that included a randomized controlled trial and was divided into two arms—the short axis and the long axis—was conducted. A total of 245 thyroid nodules were collected through the fine needle aspiration cytology, performed with ultrasound, from march 2021 to march 2022. The patient's demographic information were collected and also nodules characteristics.
Of 245 nodules sampled, 122 were sampled with the long axis method, while 123 with the short axis method. There is not significantly less non diagnostic approach with either method compared to the other (11.5 % vs 16.3 % respectively).
Previous studies came to the conclusion that the long axis method yields fewer non diagnostic samples. This study evaluated the two FNA approaches which were proceeded by the same physician who is expert in both techniques.
The US FNAC performed in the long axis approach will not produce more conclusive results and less non diagnostic results (Bethesda category 1) than the short axis approach one.
Effect of thyroid nodule size on cytology reliability and incidence of malignancy: A large cohort of 1205 patients from a single center
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There is controversy about whether the rates of malignancy and of false-negative malignancy are greater in large nodules. The aim of this study was to determine the reliability of cytology in ≥ 4 cm nodules and to compare malignancy rates between ≥ 4 cm and < 4 cm nodules.
The study included 1205 patients who underwent biopsy and subsequent thyroidectomy with the diagnosis of nodular thyroid disease between 2014 and 2019. The patients were separated into two groups, ≥ 4 cm and < 4 cm, according to the size of the index nodule on ultrasonography.
Two hundred and eleven index nodules (17.5%) were ≥ 4 cm. Malignancy rate on definitive pathology was 51% in < 4 cm nodules and 30% in ≥ 4 cm nodules. Malignancy risk was significantly lower in ≥ 4 cm nodules than < 4 cm nodules (P < 0.001). When <1 cm nodules were excluded and 1–4 cm and ≥ 4 cm nodules were compared, malignancy risk was also significantly lower in ≥ 4 cm nodules (P = 0.001). On definitive pathology, there were 45 false-negative results among cytologically benign nodules. There was no difference in false-negative cytology rate between < 4 cm and ≥ 4 cm nodules (P = 0.209).
The present study found no decrease in the reliability of cytology in ≥ 4 cm nodules, and there may not be a linear relationship between nodule size and malignancy risk. Therefore, in asymptomatic cytologically benign ≥ 4 cm nodules, surgery may not be recommended based on nodule size alone.
SFE-AFCE-SFMN 2022 Consensus on the management of thyroid nodules : Follow-up: How and how long?
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The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians, surgeons, and other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with the follow-up of thyroid nodules, low-grade tumors and microcarcinomas.
Current Evaluation of Thyroid Nodules
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Surgeon-Performed Ultrasonographic Evaluation and Predication for Large Thyroid Nodules—A Case-Control Study
2019, Surgery (United States)
The management of large thyroid nodules remains unclear. Ultrasonography is a central tool in the assessment of thyroid nodules, yet its role in risk stratification of large thyroid nodules has been studied only seldomly.
The aim of this study was to determine the utility of ultrasonography in characterizing and risk-stratifying thyroid nodules ≥3.0 cm.
We performed a retrospective, case-control study of all thyroid nodules aspirated between January 2010 and May 2014. Sonographic features of nodules ≥3.0 cm were compared with nodules <3.0 cm. All nodules were assessed by a single high-volume thyroid surgeon. Data collected included size (cm), texture, echogenicity, shape, calcifications, border, spongiform appearance, and vascularity.
A total of 537 nodules were included in the study, with 137 nodules (25.5%) ≥3.0 cm comprising the study group, and 400 nodules (74.5%) as the control group. No differences were found between the 2 groups regarding age, sex, and risk factors. Nodules ≥3.0 cm were associated with an increased risk for malignancy (odds ratio 2.41 [1.08–5.38]). Microcalcifications (26.3% vs 17.5%, P = .039), hypoechogenicity (40.8% vs 23.4%, P < .001), and irregular borders (14.3% vs 3.6%, P = .001) were more prevalent in nodules <3.0 cm. Among the large nodules, hypoechogenicity (50% vs 22.8%, P = .043) and irregular margins (28.6% vs 0%, P < .001) were associated with malignancy. The specificity of irregular borders was greater in nodules ≥3.0 cm (100% vs 89.6%, P = .011).
Sonographic appearances of large nodules differ from those of smaller nodules. Hypoechogenicity and irregular borders were associated with malignancy and should direct management towards a more aggressive policy of fine needle aspiration and consideration of operative resections in large thyroid nodules.
Navigating Uncertainty in the Management of Incidental Findings
2019, Journal of the American College of Radiology
Citation Excerpt :
But when the outcomes are projected with incorporation of stochastic uncertainty, the favorable choice may change. The wide range of published probabilities of malignancy range from 0.7% to 20%, and if the collective distribution is non-normal with greater representation at the lower end of the probability range, these lower risks will be sampled frequently as a model simulates patients with these nodules [17-19]. Surgery may not optimize quality-adjusted life expectancy, particularly considering the short- and long-term harms of unnecessary surgery.
The lack of prospective outcomes studies for many types of incidental findings limits our understanding of both their natural history and the potential efficacy of treatment. To support decision making for the management of incidental findings, major sources of uncertainty in management pathways can be mapped and analyzed using mathematical models. This process yields important insights into how uncertainty influences the best treatment decision. Here, we consider a classification scheme, grounded in decision science, which exposes various levels and types of uncertainty in the management of incidental findings and addresses (1) disease-related risks, which are considered in context of a patient’s competing causes of mortality; (2) potential degrees of intervention; (3) strength of evidence; and (4) patients’ treatment-related preferences. Herein we describe how categorizing uncertainty by the sources, issues, and locus can build a framework from which to improve the management of incidental findings. Accurate and comprehensive handling of uncertainty will improve the quality of related decision making and will help guide future research priorities.

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: Presented at the 29th Annual Meeting of the American Association of Endocrine Surgeons, Monterey, California, April 6–8, 2008.

^∗: Affiliation at time of research.

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American Association of Endocrine SurgeonReliability of benign fine needle aspiration cytology of large thyroid nodules

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

The significance of non-toxic thyroid nodules. Final report of a 15-year study of the incidence of thyroid malignancy

Ann Intern Med

Incidence of carcinoma in thyroid glands removed at 1000 consecutive routine necropsies: 40th Am Coll Surgeons Clin Cong

Proceedings Surgical Forum

Prevalence of incidental nodular thyroid disease detected during high-resolution parathyroid ultrasonography

Aspiration biopsy cytology in diagnosis of thyroid cancer

World J Surg

American Thyroid Association guidelines taskforce: Management guidelines for patients with thyroid nodules and differentiated thyroid cancer

Thyroid

AACE/AAES medical/surgical guidelines for clinical practice: management of thyroid carcinoma: American Association of Clinical Endocrinologists: American College of Endocrinology

Endocr Pract

Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement

Radiology

Fine-needle aspiration may miss a third of all malignancy in palpable thyroid nodules: a comprehensive literature review

Ann Surg

American Association of Endocrine Surgeon
Reliability of benign fine needle aspiration cytology of large thyroid nodules