Imaging-cytology correlation of thyroid nodules with initially benign cytology

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1 Imaging-cytology correlation of thyroid nodules with initially benign cytology Poster No.: C-1815 Congress: ECR 2013 Type: Scientific Exhibit Authors: S. H. Hwang, E.-K. Kim, J. Y. Kwak; Seoul/KR Keywords: Cancer, Biopsy, Ultrasound, Thyroid / Parathyroids DOI: /ecr2013/C-1815 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12

2 Purpose Repeat fine needle aspiration (FNA) has been considered to reduce false negative diagnosis of a thyroid nodule when the nodule with benign cytology shows any suspicious feature on the initial ultrasound (US) (1-4). However, each suspicious US feature may not be considered as an equal risk factor for malignancy because of its variable probability of cancer (5-7). Imaging-pathology correlation after biopsy has been found to be useful in validating biopsy results of breast lesions (8-10). Based on different malignancy rates of suspicious US features in thyroid nodules and approaching steps in management of breast lesions, we conjecture that the post-biopsy correlation of US features with cytologic results can be a better diagnostic approach in determining whether the nodule should be re-aspirated to confirm its cytology or not. The purpose of this study is to determine the role of imaging-cytology correlation for reducing false negative results of FNA at thyroid nodules, compared with the use of initial US features. Methods and Materials Patients We included 1085 nodules in 1052 patients (men: 126, women: 925) underwent US examinations and US-guided FNA (US-FNA) at our institution from March 2006 to December 2006, which fulfilled the inclusion criteria: see Fig 1. Imaging Analysis and US-guided Fine Needle Aspiration 1. Initial report - suspicious US feature : marked hypoechogenicity, microlobulated or irregular margin, microcalcifications, taller than wider shape (11-13). - "initial positive US" : thyroid nodules with 1 or more of the suspicious US features. - "initial negative US" 2. US-FNAs - by the same radiologist who performed the US examinations. Page 2 of 12

3 - on either thyroid nodules with initial positive US or the largest nodule among nodules with probably benign assessment on US. 3. Imaging-cytology correlation and post-aspiration management The radiologist who performed FNA routinely reviewed the initial US images within a week of the FNA after knowing the cytologic results. For benign cytologic results, we added an additional report whether the findings were concordant or discordant with the imaging findings. Follow-up FNA was usually recommended for discordant benign thyroid nodules after 6-12 months (14). Statistical Analysis #2 test and Fisher's exact test were used to compare the malignancy risk between benign and malignant nodules and between concordant and discordant nodules. Logistic regression analysis and generalized estimating equation were used to assess the odds ratio for the risk of malignancy and to compare the risk of malignancy in thyroid nodules classified into subgroups according to the initial US features and imaging-cytology correlation. Images for this section: Page 3 of 12

4 Fig. 1: Flow chart of case enrollment. Page 4 of 12

Fig. 2: US scans (Fig2, transverse; Fig3, longitudinal) in a 50-year-old female who has a history of lobectomy for benign nodule in the left thyroid gland show a 9-mm hypoechoic nodule with

5 Fig. 2: US scans (Fig2, transverse; Fig3, longitudinal) in a 50-year-old female who has a history of lobectomy for benign nodule in the left thyroid gland show a 9-mm hypoechoic nodule with microlobulated margin and mix calcifications in the mid pole of the right lobe of the thyroid gland. Initial cytologic result was negative for malignancy which was concordant to US findings in imaging-cytology correlation after biopsy. During parathyroidectomy, right lobectomy was performed and the thyroid nodule was confimed as adenomatous hyperplasia. Page 5 of 12

Fig. 3: US scans (Fig2, transverse; Fig3, longitudinal) in a 50-year-old female who has a history of lobectomy for benign nodule in the left thyroid gland show a 9-mm hypoechoic nodule with

6 Fig. 3: US scans (Fig2, transverse; Fig3, longitudinal) in a 50-year-old female who has a history of lobectomy for benign nodule in the left thyroid gland show a 9-mm hypoechoic nodule with microlobulated margin and mix calcifications in the mid pole of the right lobe of the thyroid gland. Initial cytologic result was negative for malignancy which was concordant to US findings in imaging-cytology correlation after biopsy. During parathyroidectomy, right lobectomy was performed and the thyroid nodule was confimed as adenomatous hyperplasia. Page 6 of 12

Fig. 4: US scans (Fig4, transverse; Fig5, longitudinal) in a 36-year-old male show a 8mm hypoechoic nodule with irregular margin and taller than wider shape in the mid pole of the left lobe of the

7 Fig. 4: US scans (Fig4, transverse; Fig5, longitudinal) in a 36-year-old male show a 8mm hypoechoic nodule with irregular margin and taller than wider shape in the mid pole of the left lobe of the thyroid gland. Initial cytologic result was adenomatous hyperplasia which was regarded as discordanat when considering the US features of the nodule. Papillary carcinoma was suspected in repeat FNA. Surgical pathology confirmed papillary carcinoma. Page 7 of 12

Fig. 5: US scans (Fig4, transverse; Fig5, longitudinal) in a 36-year-old male show a 8mm hypoechoic nodule with irregular margin and taller than wider shape in the mid pole of the left lobe of the

8 Fig. 5: US scans (Fig4, transverse; Fig5, longitudinal) in a 36-year-old male show a 8mm hypoechoic nodule with irregular margin and taller than wider shape in the mid pole of the left lobe of the thyroid gland. Initial cytologic result was adenomatous hyperplasia which was regarded as discordanat when considering the US features of the nodule. Papillary carcinoma was suspected in repeat FNA. Surgical pathology confirmed papillary carcinoma. Page 8 of 12

9 Results Among 1085 nodules with initially benign cytologic results, 1051 nodules were benign (97.9%) and 34 nodules were malignant (3.1%) based on cytopathology. The risk of malignancy was higher in initial US-positive nodules (17.3%, 26/150) than in initial USnegative nodules (0.9%, 8/935) (P < 0.001). When reviewing images after obtaining initial FNA results, the rate of malignancy was significantly higher in the discordant group (28.9%, 22/76) than in the concordant group (1.2%, 12/1009) (P < 0.001). When comparing the risk of malignancy between cytology alone and combinations of cytology with initial US findings or concordance, all combinations were significantly different from cytology alone (Tables 1 and 2). Also, when comparing the risk of malignancy between the combination of cytology with discordant US and the combination of cytology with initial positive US, the former (28.9%, 22/76) was significantly higher than the latter (17.3%, 26/150). However, there was no significant difference in the risk of malignancy between the combination of cytology with concordant US (1.2%, 12/1009) and the combination of cytology with initial negative US (0.9%, 8/935, P = 0.104). Images for this section: Table 1 Page 9 of 12

10 Table 2 Page 10 of 12

11 Conclusion The result of this study lets us conclude that imaging-cytology correlation is a more effective approach than using initial US features alone when deciding follow-up management in patients with benign thyroid nodules without a statistical increase in missing malignancy. Another implication of our result is that the frequency of FNA can be reduced by nearly 50%, from 150 aspirations in nodules with initial positive US to 76 times in discordant nodules, with a statistically insignificant increase in false negative rates. In conclusion, FNA can be effectively repeated in patients with cytologically benign thyroid nodules showing discordance in imaging-cytology correlation after initial biopsy, which can result in reducing unnecessary repeat aspirations as well as decreasing false negative results. References 1. Kwak JY, Kim EK, Kim HJ, Kim MJ, Son EJ, Moon HJ 2009 How to combine ultrasound and cytological information in decision making about thyroid nodules. Eur Radiol 19: Kwak JY, Koo H, Youk JH, Kim MJ, Moon HJ, Son EJ, Kim EK 2010 Value of US correlation of a thyroid nodule with initially benign cytologic results. Radiology 254: van Roosmalen J, van Hemel B, Suurmeijer A, Groen H, Ruitenbeek T, Links TP, Plukker JT 2010 Diagnostic value and cost considerations of routine fineneedle aspirations in the follow-up of thyroid nodules with benign readings. Thyroid 20: Chernyavsky VS, Shanker BA, Davidov T, Crystal JS, Eng O, Ibrahim K, Kwong J, Trooskin SZ 2012 Is one benign fine needle aspiration enough? Ann Surg Oncol 19: Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, Cronan JJ, Doubilet PM, Evans DB, Goellner JR, Hay ID, Hertzberg BS, Intenzo CM, Jeffrey RB, Langer JE, Larsen PR, Mandel SJ, Middleton WD, Reading CC, Sherman SI, Tessler FN 2005 Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology 237: Kwak JY, Han KH, Yoon JH, Moon HJ, Son EJ, Park SH, Jung HK, Choi JS, Kim BM, Kim EK 2011 Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiology 260: Page 11 of 12

12 7. Kwak JY, Jung I, Baek JH, Baek SM, Choi N, Choi YJ, Jung SL, Kim E-K, Kim J-A, Kim J-h, Kim KS, Lee JH, Lee JH, Moon HJ, Moon W-J, Park JS, Ryu JH, Shin JH, Son EJ, Sung JY, Na DG, Korean Society of Thyroid Radiology (KSThR), Korean Society of Radiology 2013 Thyroid Imaging Reporting and Data System for Ultrasound Features of Thyroid nodules: Multicentric Korean Retrospective Study. Korean J Radiol 14: Shah VI, Raju U, Chitale D, Deshpande V, Gregory N, Strand V 2003 False-negative core needle biopsies of the breast: an analysis of clinical, radiologic, and pathologic findings in 27 concecutive cases of missed breast cancer. Cancer 97: Youk JH, Kim EK, Kim MJ, Ko KH, Kwak JY, Son EJ, Choi J, Kang HY 2011 Concordant or discordant? Imaging-pathology correlation in a sonography-guided core needle biopsy of a breast lesion. Korean J Radiol 12: Son EJ, Kim EK, Youk JH, Kim MJ, Kwak JY, Choi SH 2011 Imaging-histologic discordance after sonographically guided percutaneous breast biopsy: a prospective observational study. Ultrasound Med Biol 37: Kim EK, Park CS, Chung WY, Oh KK, Kim DI, Lee JT, Yoo HS 2002 New sonographic criteria for recommending fine-needle aspiration biopsy of nonpalpable solid nodules of the thyroid. AJR Am J Roentgenol 178: Yoon JH, Moon HJ, Kim EK, Kwak JY 2011 Inadequate cytology in thyroid nodules: should we repeat aspiration or follow-up? Ann Surg Oncol 18: Moon HJ, Son E, Kim EK, Yoon JH, Kwak JY 2012 The diagnostic values of ultrasound and ultrasound-guided fine needle aspiration in subcentimeter-sized thyroid nodules. Ann Surg Oncol 19: Moon WJ, Baek JH, Jung SL, Kim DW, Kim EK, Kim JY, Kwak JY, Lee JH, Lee JH, Lee YH, Na DG, Park JS, Park SW 2011 Ultrasonography and the ultrasound-based management of thyroid nodules: consensus statement and recommendations. Korean J Radiol 12:1-14. Personal Information Department of Radiology, Severance Hospital Yonsei University 50 Yonsei-ro, Seodaemun-gu, Seoul , Korea Page 12 of 12

Ethanol ablation of benign thyroid cysts and predominantly cystic thyroid nodules: factors that predict outcome.

Ethanol ablation of benign thyroid cysts and predominantly cystic thyroid nodules: factors that predict outcome. Poster No.: C-0322 Congress: ECR 2014 Type: Authors: Keywords: DOI: Scientific Exhibit J.