HEAD AND NECK ENDOCRINE SURGERY OCTOBER 22-23, 2010 THE MARK HOPKINS SAN FRANCISCO, CA THYROID FNA AND CYTOPATHOLOGY THEODORE R. MILLER, MD THE THYROID NODULE Prevalence of palpable nodule: Female ~ 6% Male ~1.5%, (actually more due to incidental discovery of non palpable nodules) Thyroid Carcinoma: Female 2-20/100,00020/100,000 Male 1-5/100,000 Clinical Features: Physical Findings Ultrasound Nuclear Scintigraphy CAT, MRI, PET FNA THYROID FNA DIAGNOSTIC TERMS & EXPECTATIONS. DIAGNOSTIC TERMS & REALITY. REASONS IT AIN T EASY. Gharib H, Goellner JR. Fine-Needle Aspiration Biopsy of the Thyroid: An Appraisal. Annals of Internal Medicine. 1993;118:282-289. 289. 1
THE NCI THYROID FNA STATE of the SCIENCE CONFERENCE: 2007 Mission: Establish a comprehensive interdisciplinary informational dialogue dedicated to thyroid FNA. Six committees were formed to cover specific subjects in the utilization of FNA in the triage of thyroid nodules. Gharib H, Goellner JR. Fine-Needle Aspiration Biopsy of the Thyroid: An Appraisal. Annals of Internal Medicine. 1993;118:282-289. 289. Indications/Pre-FNA requirements Training and Credentialing Technique Terminology and Morphologic Criteria Ancillary Studies Post-FNA Opinions for Testing and Treatment Bethesda System for Reporting (BSR) Nondiagnostic or unsatisfactory Benign Benign (state process i.e. MNG, CT, Sub Acute) Atypia of Undetermined Significance (FOLLICULAR LESION-architectural/CELLULAR ATYPIA lymphoid, follicular, other) Follicular-Neoplasia/Suspicious for Follicular-Neoplasia Suspicious for Malignancy, (state what type) Malignant, Malignant, (state what type) BSR: Implied risk of malignancy Nondiagnostic/Unsatisfactory? Benign 0-3% Atypia of US or FL of US 5-15% FN or Susp. for FN 15-30% Susp. For Malignancy 60-75% Malignant 97-99% 99% 2
COMPARSION: GHARIB & THEOHATIS BENIGN MALIGNANT SUSPICIOUS NON-DX SPECFICTY +PV THEOHATIS 74% 5% 10% 11% 93% 97% GHARIB 69% 4% 10% 17% 92% 97% Theohatis CGA et al 2009 The Bethesda Thyroid Fine-Needle Aspiration Classification System: Year 1 at an Academic Institution Thyroid 19:1215-1223. 1223. WHEN ARE WE GOOD? MULTINODULAR GOITER (MNG), AKA BTN. PAPILLARY THYROID CA. OTHER SPECFIC MALIGNANCIES. WHEN ARE WE NOT SO GOOD? FOLLICULAR (including those with Hürthle cell change) ADENOMAS/CARCINOMAS/HYPERPLASTIC NODULES. BENIGN THYROID NODULE = MNG = MACROFOLLIULAR ADENOMA ~3% FALSE NEGATIVE RATE 3
BENIGN THYROID NODULE = MNG = MACROFOLLICULAR ADENOMA PAPILLARY CARCINOMA <1% FALSE POSITIVE RATE PAPILLARY CARCINOMA METAPLASTIC CYTOPLASM NIC 4
PAPILLARY CARCINOMA PAPILLARY STRUCTURE WITHOUT VESSLE Papillary Ca Papillary Structures w/o VSLs FOLLICULAR LESIONS Source?? HYPERPLASIA ADENOMA CARCNOMA 5
FOLLICULAR LESIONS hyperplasia, adenoma, carcinoma Histological Diagnosis is based on presence or absence of a capsule (the capsule is not sampled on cyto) (the capsule is not sampled on cyto). Histological definition of true invasion is capricious at best. FNA & THE THYROID NODULE GROSS MNG FN FN Follicular Carcinoma is Invasive & Microfollicular Hazzard (Am J of Clin Path, 1954) HISTO FNA CYTO VAGUE CAPSULE WELL DEFINED CAPSULE MICROFOLLICLES, INVASION? Angioinvasive Follicular Carcinoma 34 Carcinomas (3.1% of 1114) 5/34 Embryonal 28/34 Fetal 0/34 Macrofollicular Warren (Arch Path, 1931) COLLOID, MACROFOLLICLES, SHEETS, NON-COMPLEX FRAGMENTS OPA /UCSF 6
BENIGN THYROID NODULE = MNG = MACROFOLLICULAR ADENOMA BTN: Macrofollicles > Monolayered Sheets OPA /UCSF 7
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THYROID FNA MICROFOLLICULAR DX: A PERSPECTIVE BENIGN 86% HYPERPLASIA, ADENOMA PARATHYROID ADENOMA BTN BENIGN THYROID NODULE (90%) MICROFOLLICULAR TUMOR ( 6%) MALIGNANT ( 4%) MALIGNANT (14%) FOLLICULAR CA FV PAPILLARY CA FV MEDULLARY CA 6% CA ANCILLARY DIAGNOSTIC TECHNIQUES Immunohistochemistry Flow cytometry Morphometry/image analysis Molecular techniques 9
Surgeon s View of Diagnostic Testing Reality for the Cytopathologist 10