Thy roid nod ules (TNs) are a com mon med i cal prob -

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1 /STRU^NI RAD UDK DOI: /ACI S Pre op er a tive Eval u a tion of Sol i tary Thy roid Nod ule in Patients with Ultrasound and Fine-Needle Aspiration Bi N. Savi} 1,*, Vesna D. Škodri}-Trifunovi} 2,3, Mihailo I. Stjepanovi} 3, Katarina Ili} 4, Mi lan D. Brajovi} 5, Nevena Kalezi} 2,6 1 Cen ter of Ra di ol ogy and Mag netic Res o nance, Clin i cal Cen tre of Ser bia, Bel grade 2 Fac ulty of Med i cine, Uni ver sity of Bel grade, Ser bia, 3 Clinic for Lung Dis eases, Clin i cal Cen ter of Ser bia, Bel grade 4 De part ment of Phar ma col ogy, Fac ulty of Phar macy, Univesity of Bel grade 5 Cen ter for Car dio vas cu lar Dis eases Zvezdara Introduction: Fine-needle aspiration biopsy (FNAB) re mains the cor ner stone of thy roid can - cer di ag no sis. The aim of this study was to find how much ul tra sound alone and jointly with FNAB, can differentiate benign from malignant nodules, in our cir cum stances. Patienets and meth ods: FNAB was per formed in 203 out of 290 (70 %) pa tients re ferred to the De part ment of En do crine Sur gery, Clin i cal Cen ter Bel grade in fouryear pe riod for ul tra sound eval u a tion of TNs with di - am e ter to or greater than 10 mm. All the pa tients with sus pi cious or ma lig nant FNAB find ings un der - went surgery. The Thyroid Imaging Reporting and Data Sys tem (TIRADS) clas si fi ca tion was used. Re - sults: Pa tients were aged be tween years (mean 49 years). Out of 203 pa tients, 49 had an in ad e quate FNAB, 87 were checked on months and found be nign. Due to in com plete data re quired for a test 38 pa tients were ex cluded. Out of the 116 nod ules un der - went FNAB, 53 found to be be nign, 30 sus pi cious and 33 malignant. At the final postoperative histopathologic ex am i na tions it was found 70 and 46 be nign and ma lig nant TNs, re spec tively The fre quency of ma lig - nant TNs was slightly higher in the nod ules with a di - am e ter over 10mm in di am e ter than in those un der 10mm (p<0.01). No sing pa ram e ter and even size nodules or microcalcifications is not suf fi cient to se cure the as sess ment of ma lig nancy or even FNAB is not enough but the ac cu racy in creases by us ing US guided FNAB. Con clu sion: In this study it was shown for the FNAB tech nique to be ac cu rate, ef fi cient and re li able in the diagnosis and evaluation of thyroid nodules. Histological type and lo cal ag gres sive ness are not more fa vor able in microcarcinomas than in larger thy - roid can cers. Keyword: TIRADS, FNAB, thy roid nod ules rezime INTRODUCTION Thy roid nod ules (TNs) are a com mon med i cal prob - lem. Prev a lence of TNs found by pal pa tion at neck ex am i na tion in pa tients with or with out sus pected thy roid dis ease is 3 8%, while prev a lence of non-pal pa ble thy - roid nod ules (i.e. <1 cm in di am e ter) de tected by thy roid ultrasonography in the gen eral pop u la tion is 20 76% 1,2, 3,4,5,6,7. In ad di tion, in about 50% of pa tients with a clin i - cally pal pa ble sol i tary nod ule one or more ad di tional non-pal pa ble thy roid nod ules may be found by thy roid ultrasonography, or de tected in ci den tally by im ag ing stud ies per formed for var i ous rea sons 3. Large thy roid nod ules may cause lo cal com pres sive symp toms or may be ac com pa nied with the symp toms and signs of hyperthyroidism. How ever, TNs are of ten asymp tom atic. Thus non-pal pa ble TNs are fre quently de - tected in ci den tally dur ing phys i cal or ra dio log i cal ex am i - na tion. How ever, given that a risk of thy roid ma lig nancy is 5 13% all thy roid nod ules need to be clin i cally eval u - ated. High-res o lu tion thy roid ul tra sound (US) has en - hanced eval u a tion of nod u lar thy roid dis ease. It is found that microcalcifications are as so ci ated with an in creased risk of thy roid gland ma lig nancy. None the less, none of these US find ings is di ag nos tic, and fine-nee dle as pi ra - tion bi opsy (FNAB) re mains the cor ner stone of thy roid can cer di ag no sis. Which nod ules ex actly should be tar - geted for FNAB re mains con tro ver sial. Ac cord ing to Amer i can Thy roid As so ci a tion (ATA) guide lines, FNAB should be rou tinely per formed for all the thy roid nod ules 10 mm or greater in di am e ter. Guide lines of the So ci ety of Ra di ol o gists in Ul tra sound (SRU) rec om mend FNAB when: TNs are 10 mm or greater in di am e ter only when microcalcifications are pres ent; TNs are 15 mm or greater in di am e ter if com pletely or pre dom i nantly solid or if coarse calcifications are pres ent; and TNs are 20 mm or greater if pre dom i nantly cys tic with a solid com - po nent. Based on the Amer i can As so ci a tion of Clin i cal

2 Savi} et al. ACI Vol. LX En do cri nol o gists (AACE) guide lines FNAB should be per formed on all hypoechoic nod ules 10 mm or greater with one or more of the fol low ing US char ac ter is tics: ir - reg u lar mar gins, cha otic intranodular vas cu lar spots, a more-tall-than wide shape, and microcalcifications. Rec - om men da tions of the Na tional Co op er a tive Can cer Net - work Thy roid Car ci noma Clin i cal Prac tice Guide lines are sim i lar to AACE guide lines 8. These guide lines dif fer - ences par tially re flect dis agree ment in es ti mat ing the mag ni tude of two pri mary risks: the risk of de lay ing ap - pro pri ate sur gi cal treat ment when thy roid can cer is pres - ent and the risk of un der go ing hemithyroidectomy/isth musectomy for a be nign, asymp tom atic thy roid nod ule. Thus, the ap proach to small (<10mm) thy roid nod ules could vary, de pend ing on the guide lines. Within the last ten years Ser bia re corded a dou bled num ber of thy roid can cer pa tients. In a large num ber of pa tients more and more ma lig nant and ag gres sive forms of this car ci noma were di ag nosed 9. It is dif fi cult to say is the in crease of pa tients with this type of car ci noma the con se quence of the Chernobyl di sas ter of the high bur den of stress last ing al ready two de cades (due to war and dis - in te gra tion of Yu go sla via, hy per in fla tion and sink ing of lo cal cur rency, de pleted ura nium ra di a tion re sult ing from NATO bomb ings). OB JEC TIVE The aim of this study is to find how much ul tra sound alone and how much ul tra sound jointly with FNAB, can dif fer en ti ate be nign from ma lig nant nod ules u in our work ing con di tions. PA TIENTS AND METH ODS A pro spec tive study was con ducted at the De part ment of En do crine Sur gery, Clin i cal Cen ter Bel grade, in fouryear pe riod, in ac cor dance with Good Clin i cal Prac tice and Dec la ra tion of Hel sinki. To be el i gi ble to par tic i pate in the study, pa tients had to be at least 18 years old and the pa tients were re ferred for ul tra sound eval u a tion of thy roid nod ules if: their am bu la tory phy si cian found neck lumps by pal pa tion, pa tients re quested fur ther ex - am i na tion due to im pres sion of neck swell ing, if they were treated due to hy per or hypothyroidism, and if they had a genetical pre dis po si tion. The ex clu sion cri te ria were: his tory of neck ir ra di a tion, cer vi cal lymphadenopathy, pa tients who un der went sur - gery and those who al ready knew their thy roid gland was malignant. In to tal 290 pa tients with sol i tary solid (or pre dom i - nantly solid) thy roid nod ules were in cluded in the study. All pa tients with sus pi cious or ma lig nant FNAB un der - went sur gery, and sur gery was also per formed on those 53 pa tients with benign FNABs. The FNAB were per formed by en do cri nol o gists or radiolologists with out an es the sia, us ing a gauge nee dle mounted on a sy ringe us ing a free hand tech nique. Ul tra sound in ves ti ga tions used an ultrasonographic scan ner (Toshiba SS 270A and Acuson XP 128) equipped with a 7, 5 MHz lin ear trans ducer for mor pho log i cal stud ies and for color-dopp - ler eval u a tion. The fol low ing ul tra sound pa ram e ters were as sessed in all nod ules: a) nod ule size (max i mum di am e ter as eval u ated by sagittal and trans verse scans); b) echographic struc ture (solid, mixed or cys tic); c) echogenicity (iso-, hy per-or hypoechoic); d) pres ence/ab sence of cal ci fi ca tion; e) le sion mar gins well-de fined or blurred f) as small nod ules up to 10 mm, over 10 mm as large nod ules. By ul tra sound char ac ter is tics, our pa tients were clas si - fied into two groups ac cord ing to TIRADS clas si fi ca tion: nor mal ul tra sound find ings nod ules in TIRADS 1 and 2 groups - they were re viewed by 6 and 12 months and three years later and there were no sig nif i cant changes in ap pear ance and size of nod ules; nod ules in the TIRADS 3 group sus pect to be ma lig nant; nod ules in TIRADS 4 and 5 groups proved ma lig nant. The FNAB were per - formed for all nod ules in the TIRADS 3, 4 and 5 groups. TIRADS Benign N=87 Figure 1 US (n=203) Suspicious N=49 Malignant N=67 FIGRE 1. ULTRASOUND EVALUATION : BENIGN, MALIGN, SUS - PECT US cri te ria may help to de cide cost-ef fec tive man age - ment. Our ob jec tive was to de velop a stan dard ized US char ac ter iza tion and re port ing data sys tem of thy roid le - sions for clin i cal man age ment: (TIRADS). In Horvath et al. 10 pro posed the thy roid im ag ing re port ing and data sys tem (TIRADS). They es tab lished six cat e go ries (TRI- ADS 1 to TIRADS 6) based on US pat terns and es ti - mated the in ci dence of ma lig nancy for each TIRADS class: 1. TIRADS 1 - nor mal find ings 2. TIRADS 2 - there is a change, but ma lig nancy risk is 0% 3. TIRADS 3 - ma lig nancy risk < 5% 4. TIRADS 4A - ma lig nancy risk 5-10% 5. TIRADS 4B - ma lig nancy risk 10-80% 6. TIRADS 5 - ma lig nancy risk over 80%

3 Br. 4 Pre op er a tive eval u a tion of sol i tary thy roid nod ule in pts. with US and fine-nee dle as pi ra tion biopsy 33 TABLE 2 FNAB COMPARED TO FINAL HISTOPATHOLOGY RESULTS No of patients Benign Susp malignant Malignant Malignant + susp UZ (42.86%) 49 (24.1%) 67 (33.00%) 166 (57.1%) FNAB (45.7) 30 (25.9% 33 (28.5%) PH (60.3% / 46 (39.7%) 66 (56.9%) 203 (32.5%) 46 (39.7%) 203 (22.7%) 7. TIRADS 6 change al ready PH ver i fied as 100% malig ant. They di ag nosed nod ules with TIRADS 4 or greater as sus pected of ma lig nancy; they com pared their clas si fi ca - tion re sults and FNAB find ings and showed that the sen - si tiv ity, spec i fic ity, PPV, and NPV were 88, 49, 49, and 88%, re spec tively. In both stud ies, follicular le sions ac - cord ing to FNAB find ings were clas si fied as sus pi cious of ma lig nancy. FNAB was per formed in all pa tients with sol i tary solid (or pre dom i nantly solid) nod ule with di am e ter to or greater than 10 mm, where US re sulted by sus pect or ma - lig nant find ings. Bi op sies were done un der sonographic guid ance. Cy to log i cal spec i mens were smeared ac cord ing to the Papanicolaou tech nique, and eval u ated by experienced cytopathologists. When the smear was in ad e quate (<6 clus ters with 10 cells each) 11, FNAB was re peated once; only tech ni cally satisfactory results were considered. Ad e quate cy to log i cal ma te rial was clas si fied as be nign (colloid nod ules, thy roid cysts, lymphocytic thyroiditis, cys tic goi ters, adenoma (-ex cept for follicular car ci noma and Hurthle cell car ci noma-), nor mal thy roid tis sue and be nign hy per pla sia.) as ma lig nant (pap il lary car ci noma, medullary car ci noma, Hurthle cell car ci noma and anaplastic car ci noma). Sus pi cious find ings in cluded atyp i cal follicular cells or Hurthle cells. Histopathological find - ings were re viewed by two in de pend ent pa thol o gists. All pa tients with be nign, sus pi cious or ma lig nant FNAB un - der went sur gery. The di ag no sis of can cer was based on the fi nal con fir ma tion of patho-histological find ings af ter sur gery 12. Five fac tors were an a lyzed when com par ing the pre op er a tive FNAB re sults with the fi nal histologic find ings: sen si tiv ity, spec i fic ity, ac cu racy, pos i tive and neg a tive pre dic tive val ues. Neo plas tic le sions out side the nod ule ex am ined by FNAB were con sid ered in ci den tal and not in cluded in theanalysis. Clin i cal, ul tra sound, cytological and histological find ings were sep a rately recorded and an a lyzed. The di ag nos tic value of ul tra sound criteria was also as sessed in terms of sen si tiv ity, spec i fic - ity, pos i tive/neg a tive pre dic tive value and ac cu racy 13. RE SULTS Out of 290 pa tients 49 (16.9%) were ex cluded from fur ther anal y sis due to in ad e quate cy to log i cal spec i mens af ter a sec ond round of FNAB and for 38 (13.1%) patients there were miss ing data ( such as size of nod ules, ul - trasound find ings, FNAB, or fi nal find ings of HP). Finally, a sin gle nod ule was ex am ined in 203 pa tients. Out of 203 ul tra sound ex am ined pa tients 127(62.6%) were fe males, 76(37.4%) males; 87(42.8%) nod ules were be nign (TIRADS 1 i 2), 67(33%) ma lig nant (TIRADS 4 i 5) and the re main ing 49(24.2%) sus pi cious (TIRADS 3). Pa tients were aged be tween 26 and 88 (mean age 49 years). Nod ule size (as eval u ated by ul tra sound) ranged from 6 to 30 mm (mean ± SD 16.7 ± 9.8 mm), 124 were clas si fied as large nod ules and the re main ing 79 as small. In ad e quate sam ples were sig nif i cantly more com mon for "small nod ules" (<10 mm in di am e ter) than for "large nod ules" (>10 mm) (cal cu lated only for pa tients with inadequate ma te rial for FNAB; 73,4%vs.26,6%,p< 0,001). Cy to log i cal and histological fea tures All cases un der went by FNAB were un der went sur gery and all were con firmed by the fi nal histologic eval u a tion. FNAB were un der went in 116 (57.2%) nod ules (all be - nign, sus pi cious or overtly ma lig nant nod ules un der went sur gery). 87 (42.8%) nod ules be nign on ul tra sound were not op - er ated, they were re viewed by 6 and 12 months and three years later and there were no sig nif i cant changes in ap - pear ance and size of nod ules. The prev a lence of can cer was lower in small than in large nod ules (p< 0,01). How - ever, follicular and medullary histotypes were more com - mon in small than in large nod ules (p = 0.01). Pre op er a tive (by FNAB) be nign le sions were di ag - nosed in 53 (45.7%) cases, but all of these mul ti ple en do - crine neoplasy (MEN-II) pa tients and pa tients with pos i - tive fam ily his tory both in sisted on surgery. Ma lig nancy (by FNAB) was in 33 (28.5%) spec i mens. The re main ing 30 (25.8%) cases were de fined as sus pi - cious.

4 Savi} et al. ACI Vol.LX From the 30 sus pi cious cases, 8 proved to be ma lig - nant, the re main ing 22 were be nign le sions, while 48 of the 53 le sions found be nign on pre op er a tive FNAB were ver i fied as such by histologic eval u a tion, while the re - main ing 5 were ma lig nant. All cases of pap il lary car ci - noma on FNAB were pos i tive ac cord ing to the fi nal histologic eval u a tion, two cases were found to be pap il - lary car ci noma, seven cases of follicular adenoma were found to be pap il lary car ci noma and one case of follicular adenoma proved to be follicular car ci noma. Fi nal his tol - ogy re sults showed that, of the 30 sus pi cious and 53 be - nign cases on FNAB, 13 cases proved to be ma lig nant. On fi nal histologic eval u a tion, 70 (60.3%) cases proved to be be nign le sions and 46 (39.7%) were found as ma lig - nant. The sen si tiv ity of FNAB was 72%, spec i fic ity 100%, pos i tive pre dic tive value 100%, neg a tive pre dic tive value 84% and ac cu racy 89%. DIS CUS SION Mar tin was in 1930s 14 a pi o neer in the ap pli ca tion of FNAB as pre op er a tive di ag nos tic tech nique in the as sess - ment of choice in pa tients with thy roid nod ules as can di - dates for sur gery treat ment. He first noted that FNAB with clin i cal find ings, lab o ra tory and im ag ing data, reduced the num ber of thyroidectomias 21% to 75%. FNAB has an ac cu racy be tween 69% and 95%, and a spec i fic ity be tween 58% and 90% 15, and be came a first-line tool in the in ves ti ga tion of nod u lar thy roid dis ease 16,17. Sol i tary nod ules are found in ap prox i mately 4-7% of adult pop u - la tion 18,19,20, ma lig nancy in ci dence in sol i tary thy roid nod - ules is up to 10%. In au top sies, thy roid gland car ci noma was found in 6% cases, mostly as a multifocal al ter ation in the gland while of ten also as neck metastase. These were in most cases small tu mors, 4 to10 mm in di am e - ter 21. Se lec tion of pa tients to un dergo sur gery is a very im por tant pre op er a tive histologic eval u a tion. De ci sions made in the past on the ba sis of thy roid glands scan ning were of poor spec i fic ity as a method 22, with a large num - ber of false pos i tive find ings and many cases of un nec es - sary sur gi cal in ter ven tions, where fi nal histologic eval u a - tion proved low ma lig nancy in ci dence 20. Mayo Clinic stud ies in di cate FNAB use ful ness as a rou tine di ag no sis in the treat ment of thy roid gland ma lig nan cies, and also a re duc tion of gland re sec tions in sus pect cases from 67% to 43%. Stud ies also showed a rise of ma lig nancy eval u a - tion in fi nal histologic eval u a tion from 14% to 25%, re - sult ing in a re duc tion of sur gi cal in ter ven tions and con se - quently a re duc tion of costs by 25% 23. Gar cia et al., 24 in - di cate that sur gi cal in ter ven tions on sus pect thy roid nod - ules were re duced by half in the pe riod from 1980 to 1993 and that can cer con fir ma tion rate in fi nal patho logic eval u a tion in creased from 14.7% to 32.9%. Most au thors in di cate FNAB sen si tiv ity from 80 to 95%, 25,26,27 spec i fic ity from 70 to 100% 5, and false pos i - tive and false neg a tive re sults in 5-25% cases 28,29. Ac cu - racy is es ti mated to be be tween 92% and 95% 30,31, and var ies ac cord ing to the histologic eval u a tion. In case of pap il lary car ci noma the ac cu racy is about 80% 32, due to pathognomonic fea tures on histologic specimen examination. In cases of follicular can cer, FNAB is lower and estimated to be be tween 10% and 40%, mainly be cause struc tural fea tures of cell groups and the cap sule of the nod ule are es sen tial to the di ag no sis, and are not seen on FNAB cy tol ogy 32,33. How ever, a few pa thol o gists were able to iden tify cy to logic fea tures cor re spond ing to follicular ma lig nancy 34. In follicular can cer cases, lack of tis sues for di ag no ses are in di cated as main fac tors of lower ac cu racy, which also goes for Hur tle cell carcinoma and follicular tu mors. In suf fi cient tis sue taken for FNAB was in about 13.3% cases, usu ally in cys tic le - sions with blood or fluid be ing pres ent, where FNAB should be re peated. In cases of follicular or Hur tle cell tu mors, the tis sue makes im pos si ble the dif fer en ti a tion be tween be nign and ma lig nant, so that FNAB is in suf fi - cient here. FNAB can not eval u ate pen e tra tion of blood ves sels or cap sule 35. The fre quency of histologically ma - lig nant le sions was slightly less in small than in large nod ules, but clin i cally rel e vant in ab so lute terms. Follicular and medullary car ci no mas, (histological types with a less fa vor able prog no sis) were more fre quent in small nod ules. Gharib et al., 36 re ported 17% sus pi cious re sults on their FNAB eval u a tion, 20-25% of which proved to be ma lig nant on fi nal histologic eval u a tion. In our re port, of 30 nod ule cases sus pect to be ma lig nant, 8 (26.6%) were ma lig nant in the fi nal histologic eval u a tion. Com pared to fine-nee dle bi opsy, ul tra sound-con trolled FNAB re sulted in better FNAB re sults but use ful ness was not con - firmed 36 ; a pos si ble rea son for this could be that the per - son car ry ing out the ul tra sound-con trolled bi opsy was poorly trained. In ul tra sound-con trolled bi opsy in this study, in 11 cases (9.5%) spec i fic ity was 100%, sen si tiv - ity 83.3%, pos i tive pre dic tive value 100%, neg a tive predictive value 83.3% and accuracy 90.9%. Small, deeply located nodules, where taking of material was very difficult, were the reason of poor accuracy. The dis crep ancy be tween the low prev a lence of clin i - cally ev i dent thy roid neo pla sia com pared with the high rate of can cers un der 10 15mm at au topsy 37, prompts many phy si cians to be lieve that in most cases oc cult thy - roid can cer has no clin i cal rel e vance. In ad di tion, sev eral re ports have sug gested that in ci den tally dis cov ered thy - roid pap il lary car ci no mas fol low an in do lent course 38,39,40,41. On the other hand, other stud ies sup port our find - ing that ev i dence of extrathyroidal spread and/or nodal me tas ta sis is equally com mon in large and small nod ules 41,42,43, and that no valid di men sional cut-off for neoplastic aggressive behaviour can be identified. CON CLU SION Many stud ies have in ves ti gated whether the ultrasonographic char ac ter is tics of thy roid nod ules are use ful in - di ca tors of histological ma lig nancy. The prev a lence of malignant le sions in thy roid nod ules re ferred for US-FNAB is now a gold stan dard in the eval u a tion of thy roid nod ules, but not sub stan tially dif fer ent in nod ules above 1 cm vs. be low 1 cm in size. In this study it was

5 Br. 4 Pre op er a tive eval u a tion of sol i tary thy roid nod ule in pts. with US and fine-nee dle as pi ra tion bi opsy 35 shown for the FNAB tech nique to be ac cu rate, ef fi cient and re li able in the di ag no sis and eval u a tion of thy roid nod ules. Histological type and lo cal ag gres sive ness are not more fa vor able in microcarcinomas than in larger thy roid can cers. A cost-ef fec tive ap proach to the use of FNAB should not de pend solely upon nod ule size; spe - cific ul tra sound pat terns (microcalcifications, blurred mar gins and hypoechoic ap pear ance) ap pear to be use ful in di ca tors. SUMMARY PREOPERATIVNA PROCENA SOLITALNIH TIROIDNIH NODULA KOD BOLESNIKA POMO]U ULTARZVUKA I IGLENE BIOPSIJE Uvod: FNAB-fina iglena biopsija ostaje kamen temeljac dijagnostike raka tireoidne `lezde. Cilj ove studije je bio da utvrdi koliko sam ultrazvuk i zajedno sa FNAB, mogu razlikovati benigne od malignih nodusa, u našim uslovima. Bolesnici i metod: FNAB je uè~injen kod 203 od 209 (70%) bolesnika, hospitalizovanih na Odeljenju za endokrinu hirurgiju Klini~kog centra Srbije, u periodu od è~etiri godine, uz ultrazvuè~nu procenu TNs pre~ènika ve}eg od 10 mm. Svi bolesnici sa sumnjivim ili malignim FNAB nalazom su operisani. Koriš}en je TIRADS sistem klasifikacije. Rezultati: Bolesnici su bili starosnog doba izmedju godina (prose~èno 49 godina). Od 203 bolesnika, 49 je imalo neadekvatnu FNAB, 87 su proveravani tj. pra}eni na meseci. Zbog nepotpunih podataka potrebnih za test 38 bolesnika je isklju~èeno iz istra`ivanja. Od ukupno 116 nodula kojima je u~èinjen FNAB, 53 su bili benignog porekla, 30 sumnjivog i 33 maligna. Na završnoj postoperativnoj histološkoj obradi utvrdjeno je 70 i 46 benignih i malignih TNs, odnosno u~èestalos malignih TNs je bio nešto ve}i u nodula preè~nika preko 10 mm nego kod onih ispod 10 mm (p < 0.01). Parametri kao što su veli~èina ili mikrokalcifikacije nisu dovoljni da obezbede procenu maligniteta ili ~èak i FNAB nije dovoljan, ali se ta~ènost pove}ava koriš}enjem ultrazvu~ènog vodjenja FNABa. Zakljuè~ak: U ovoj studiji je da FNAB tehnika mo`e biti precizna, efikasna i pouzdana u dijagnostici i evaluaciji tiroidnih nodusa. Histološki tip i lokalna agresivnost nisu dovoljni u mikrokarcinomatozi nego u ve}im karcinomima štitaste `lezde. Kljuè~ne re~èi: TIRADS, FNAB, štitna `lezda BIBLIOGRAPHY 1.Gharib H, Papini E, Valcavi R, Baskin HJ, Crescenzi A, Dottorini ME et al. Amer i can As so ci a tion of Clin i cal En do cri nol o gists and Associazione Medici Endocrinologi med i cal guide lines for clin i cal prac tice for the di ag no sis and man age ment of thy roid nod ules. Endocr Pract 2006 Jan-Feb;12(1): Burman KD. Micropapillary thy roid can cer: should we as pi rate all nod ules re gard less of size? J Clin Endocrinol Metab : Tan GH, Gharib H. 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