ULTRASOUND GUIDED FNA: WHEN, HOW, AND WHY

Transcription

1 ULTRASOUND GUIDED FNA: WHEN, HOW, AND WHY Marika Russell, MD, FACS Assistant Professor, UCSF OHNS Disclosures: none Overview Background Indications Technique Outcomes Survey Office-based ultrasound? USG-FNA? On-site cytopathology? 1

2 Background High-resolution ultrasonagraphy is widely-used imaging modality for evaluation of cervical masses Office-based ultrasound (US) is becoming increasingly common In evaluation of head and neck masses, performing US is instrumental component of physical exam Surgeon performed US enhances understanding of anatomy and informs surgical plan Background Fine needle aspiration biopsy (FNAB) is safe, simple, cost-effective diagnostic tool FNAB is gold standard for diagnosis in evaluation of neck mass, thyroid nodule Ultrasound guidance (USG) allows visual confirmation of sampling region Smith, RB. Otolaryngol Clin Am 2010 Background: Case example Left thyroid nodule measuring 1.9 cm. Further evaluation with ultrasound is recommended. Background: Case Example Palpation-guided FNAB: A limited physical exam of the patient' s neck demonstrated a palpable thyroid nodule in the left lobe of the thyroid gland at approximately the mid pole. Fine needle aspiration biopsy of the nodule demonstrated resistance to the needle on biopsy with a firm consistency. Three passes were performed, all of which yielded dense tissue. On review of the permanent stained smears, the specimen consists of fragments of cartilage. 2

3 Background Compared with palpation, use of USG improves diagnostic capability in certain settings Higher rates of adequate specimen achieved with USG Cesar et al. Thyroid 2006 Sensitivity, specificity, accuracy increased with USG Hatada et al. Am J Surg 1998 Takashema et al. J Clin Ultrasound 1994 Koike et al. Eur J Surg 2001 Background Benefits to surgeon-performed USG-FNA Patient centered; reduction of multiple visits Performed by individual familiar with head and neck anatomy Ensures appropriate/accurate sampling Potential for earlier triage to surgery Bohacek et al. Ann Surg Oncol 2012 Indications Neck mass (even palpable) Thyroid Lymph node Salivary gland Parathyroid Indications: Thyroid US features Kangelaris et al. Otolaryngol Clin N Am

4 Indications: Thyroid US Features Indications: Thyroid US Features Hypoechoic, irregular shape Microcalcifications Peripheral vascularity Central Vascularity Kangelaris et al. Otolaryngol Clin N Am 2010 Kangelaris et al. Otolaryngol Clin N Am 2010 Indications: Thyroid US Features Indications: ATA Recommendations Benign spongiform appearance Benign cystic degeneration 2009 ATA Thyroid Nodule Guidelines 4

5 Indications: ATA Recommendations Indications: ATA Recommendations High risk patient with suspicious US features (>5mm) Abnormal cervical lymph nodes (all) Microcalcifications (>1cm) Solid, hypoechoic nodule (>1cm) Mixed cystic/solid nodule with suspicious US features (>1.5cm) 2009 ATA Thyroid Nodule Guidelines 2009 ATA Thyroid Nodule Guidelines Indications: Lymph nodes US features Technique: Supplies Size >1cm Rounded shape Absence of hilum Calcifications Non-hilar pattern of vascularity 10 cc syringe (barrel removed) aspirator Giacomini et al. Semin Ultrasound CT MR 23g 1.5 inch needle 5

6 Technique: Supplies Technique: Supplies Technique Skin anesthetic (yes vs. no) Capillary sampling (French technique) vs. aspiration Similar sample adequacy rates Number of passes Technique: Long axis vs. Short Axis Lee et al. J Ultrasound Med 2009 Langer et al. Semin Ultrasound CT MR

7 Diagnostic Efficacy: sample adequacy Robitschek et al Randomized controlled trial 81 patients, palpable neck mass <3cm Surgeon-performed USG-FNA vs palpation guided- FNA Tissue adequacy rate 84% vs. 58% (p<0.014) Results significant only for thyroid, not lymphoid or salivary sites Supports office-based surgeon performance of USG- FNA Diagnostic Efficacy: accuracy Bohacek et al surgeon-performed USG-FNA thyroid nodule 451 with operative histology Sensitivity 83.3% Specificity 98.8% Positive predictive value 97.0% Negative predictive value 92.5% Robitscheck et al. Otolaryngol Head Neck Surg 2009 Bohacek et al. Ann Surg Oncol 2012 Diagnostic efficacy: on-site cytopathology On site cytopathologist applies, fixes, stains specimen Provides immediate assessment of tissue adequacy Allows for preliminary diagnostic information to be addressed with patient Diagnostic efficacy: on-site cytopathology Witt and Schmidt, 2013 Meta-analysis: benefit of rapid onsite evaluation (ROSE) Inclusion criteria: 2 arms (with and without ROSE) at single center 7 full studies, 1 abstract Adequacy: 83% without ROSE vs 92% with ROSE Improvement in adequacy dependent on initial adequacy rate Witt and Schmidt, Thryoid

8 Diagnostic efficacy: on-site cytopathology Bathki et al., surgeon performed USG-FNA No on-site cytopathology 92.6% adequacy rate Bohacek et al., surgeon performed USG-FNA No on-site cytopathology 94.4% adequacy rate Potential Barriers Perceived steep learning curve Previous absence of training in head and neck residency programs Time required to perform procedure Potential conflicts with radiologists and/or pathologists regarding scope of practice Bathki et al., Otolaryngol Head Neck Surg 2008 Bohacek et al. Ann Surg Oncol 2012 Conclusion USG-FNA is safe and effective in the hands of head and neck surgeons We are uniquely positioned to perform this service Patient-centered Rewarding experience 8