Fine needle biopsy of thyroid nodule: Aspiration versus nonaspiration method Poster No.: C-0486 Congress: ECR 2012 Type: Scientific Exhibit Authors: F. Campoy-Balbontín, M. D. C. Jurado-Gómez, A. RonquilloRubio; Sevilla/ES Keywords: Neoplasia, Biopsy, Ultrasound, Thyroid / Parathyroids DOI: 10.1594/ecr2012/C-0486 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. www.myesr.org Page 1 of 14
Purpose 1.Thyroid nodules are a common clinical problem, detected by Ultrasound (US) in 19-67% of individuals, with higher frequencies in women and the elderly (1). Its clinical importance rests with the need to exclude thyroid cancer which occurs in 5 to 15% of the biopsied nodules. 2. The clinical management of the thyroid nodule is based on US-fine needle biopsy (FNB). Most of them carried out by fine needle aspiration biopsy (FNAB). Nonetheless, some authors (2) support that fine needle non-aspiration biopsy (FNNAB) or capillary action technique, is better than FNAB for obtaining sufficient cytological material (SCM). 3.The purpose of this study is to determine, the best way of obtaining SCM when performing FNB of Thyroid nodules, comparing the cytological results got by the aspiration versus the non-aspiration technique (FNAB versus FNNAB). Methods and Materials Two groups of FNB retrospectively were compared taking into consideration their cytological results. The first group of FNB were done by a senior radiologist. And the second group of FNB were carried out by the pathology department. From January to March 2010, 168 patients underwent thyroid US and fine needle biopsy (FNB). 168 patients (159 women, 9 men, aged from 22 to 87 years old, mean age 54.4) with 168 nodules, were evaluated by ultrasound by a senior radiologist, who performed FNNAB according to an established guideline (3). US control was carried out with the perpendicular method (4).( Fig. 1 on page 4 ) During 2008, 389 Thyroid nodules FNAB were performed by different attending pathologists, according to nodule size criteria, with the election of the dominant nodule. The procedures were carried out in the same hospital, covering the same area population disease. FNNAB(Fine Needle Non-Aspiration Biopsy) Page 2 of 14
All the punctures carried out by the radiologist were FNNAB by capillary action (2) technique, with a needle gauge number 23(23G) (94%), 25 G (1.2%) and 21G (4.2%) of the nodules, with three passes for every nodule. US-Guided FNNAB technique The US control was carried out with the perpendicular method (4). The Radiologist is standing up to the left of the patient that is in decubitus supine. The US machine is in front of the Radiologist, to the left of the patient's head. The US control is performed with the right hand (dominant hand) and the puncture is performed with the left hand using the perpendicular method, to get the shortest distance to the nodule. Once the tip of the needle is in the nodule, with no change of hands, the radiologist's left hand does vigorous to and fro movements, while a movement of rotation in a clock-wise and counter-clockwise is maintained in the needle. ( Fig. 1 on page 4 ) At all times there is control of the tip of the nodule, always inside the nodule. ( Fig. 2 on page 4 ) Three passes were done in every nodule. FNAB(Fine Needle Aspiration Biopsy) The punctures had been performed by attending pathologists, guided by palpation and/ or a skin mark done by a radiologist, who previously had performed an US examination. The election of the nodule was mainly based in size criteria, and the puncture was performed in the dominant nodule. The needle used was 25 G. with an average of three passes. Cytological Analysis The collected material placed on glass slides, is allowed to air dry, and stained by Giemsa at the laboratory. The cytological results were adapted from the Bethesda classification (5). T1 (Non-diagnostic), T2 (Benign), T3 (Follicular lesion of uncertain significance), Page 3 of 14
T4 (Follicular neoplasm), T5 (Suspicious for malignancy) and T6 (Malignant). T means thyroid. Statistical Analysis The FNB cytological results performed by the radiologist and pathologist were confronted by #2(significance p#0.005). Images for this section: Fig. 1: FNNAB US-Guided by perpendicular technique. The right hand (dominant) holds the tranducer, with control of the needle tip in every moment. The left hand does vigorous to-and-fro movements, doing at the same time rotation of the needle in a clockwise and counterclockwise mode. Page 4 of 14
Fig. 2: This video nicely shows the tip of the needle in a small nodule. FNNAB US-Guided by the perpendicular method. The cytological result was T2 (benign). Page 5 of 14
Results The cytological results obtained by the radiologist were: T1, 35 nodules (20.8%); T2, 106 nodules (63.1%); T3, 11 nodules (6.5%); T4, 8 nodules (4.8%); T5, 8 nodules (4.8%); and T6, 0 nodules (0%). And The cytological results obtained by the pathologist were: T1, 77 nodules (19.8%); T2, 300 nodules (77.1%); T3, 2 nodules (0.5%); T4, 3 nodules (0.8%); T5, 7 nodules (1.8%); and T6, 0 nodules (0%) (Fig. 3 on page 7 ). There is no difference between T1 and T2 obtained by the radiologist and pathologist (Fig. 4 on page 8 ). The ICM rate is similar in both groups. FNNAB, performed by the radiologist obtained more T3, T4 and T5. ( Fig. 5 on page 9). When Cytological Results are grouped, the difference between the cytological results obtained by FNAB versus FNNAB increase ( Fig. 6 on page 10). T3 to T5 have an increased rate in those nodules punctured by the radiologist (p#0.005). According to Cytological Results (5) three groups are created, that determine different management: A Surgical Group with T4 and T5 nodules, that are going to be operated. A non-surgical group with T2, that are going to be followed up. And a third group formed by T1 and T3, where the puncture is going to be repeated (Fig. 7 on page 11 ). We compare the cytological findings from the radiologist (FNNAB) and pathologists (FNAB) with those from other authors (6) (Table). FNNAB (N=168) FNAB (N=389) FNAB*(N=1458) T1 20.8% 19.8% 13% T2 63.1% 77.1% 63% T3 6.5% 0.5% 5% T4 4.8% 0.8% 9.3% T5 4.8% 1.8% 5.5% T6 0% 0% 3.2% Table [*Alexander et al (6)] Page 6 of 14
In our study FNNAB detected more nodules that require interventional procedures. T3 were again going to be biopsied in three months and, T4 and T5 were going to be operated. According to previous papers FNNAB cytological results do not differ from those obtained by other authors (6) that used FNAB. Pathologist guideline for FNAB of the thyroid nodule, in our study, is exclusively based in size criteria, choosing the dominant nodule; while radiologist criteria was based in the US characteristics of the thyroid nodule, following a well established guideline, that one according to the Society of Radiologist in ultrasound (3). US played an important role in the needle control in FNNAB, targeting the nodule in the precise place, eluding cystic and non-vascularized parts of the nodule. And Probably many nodules escaped from the needle action in those biopsies performed without USguide (FNAB performed by the pathologists). Although FNNAB in our study detected more nodules that require interventional procedures, we cannot support that FNNAB has this particular effect. There are other factors that make these two compared groups very different, the different way of choosing the nodule to be punctured and, the use of US to guide the procedure. More studies with more homogeneous groups will be necessary to compare the capillary versus the aspiration technique. Nonetheless with similar results we recommend FNNAB, because it is easier to carry out, maintaining in every moment the tip of the needle inside the target. Images for this section: Page 7 of 14
Fig. 3: The cytological results (T3, T4 and T5) associated to posterior interventional procedures, are more often found by FNNAB. T=Thyroid. T1 to T5 are adapted from the Bethesda Classification (5) Page 8 of 14
Fig. 4: There is not difference between sufficient (SCM) and insufficient cytological material (ICM) obtained by the aspiration and capillary-action method. Page 9 of 14
Fig. 5: The bars corresponding to T3, T4 and T5 are taller in FNNAB. Although only T5 has statistical significance (p< 0.005) Page 10 of 14
Fig. 6: When T3,T4 and T5 are grouped, there is significant difference between FNAB and FNNAB. Page 11 of 14
Fig. 7: When surgical (T4, T5) and non-surgical (T1 to T3) groups are created, the significant difference is mantained between the aspiration and non-aspiration technique. Page 12 of 14
Conclusion 1. There is no difference between the sufficient and insufficient cytological material obtained by FNAB versus FNNAB. 2. FNNAB is at least as good as FNAB to obtain cytological material. FNNAB should be considered as the first step, considering FNAB as a second alternative, when scarce specimen is obtained in the first needle pass. 3. All thyroid FNB should be US-guided. 4.The management of the thyroid nodule should always follow a well established guideline. References 1. Cooper D.S et al. Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 2009; 19: 1167-121 2. Degirmency et al. Sonographically guided Fine- needle biopsy of thyroid nodules: the effect of nodule characteristics, sampling technique, and needle size in the adeccuacy of cytological material. Clin Radiol 2007; 62: 798-803 3. Frates et al. Management of thyroid nodules detected at US: Society of Radiologist in Ultrasound Concenssus Conference Statement. Radiology 2005; 237: 784-800. 4. Ming Fung et al. US-guided fine needle aspiration of thyroid nodules: Indications, techniques, Results. Radiographics 2008; 28: 1869-1889. 5. The Bethesda System for Reporting Thyroid Cytopathology Definitions, Criteria an Explanatory notes. In: Syed ZA, Cibas ES, eds. Springer New York Dordrecht Heidelberg London. 6. Alexander et al. Assessment of Nondiagnostic Ultrasound-Guided Fine Needle Aspirations of Thyroid Nodules. JCEM 2002; 87: 4924-4927. Page 13 of 14
Personal Information Dr. Francisco Campoy Balbontín (fcampoy2000@hotmail.com). Attending Radiologist at Valme Universitary Hospital. Department of Radiology. Seville, Spain. Dr. Maria del Carmen Jurado Gómez. Attending Radiologist, at Valme Universitary Hospital. Sevilla, Spain Dr. Araceli Ronquillo Rubio. Resident of the Pathology Department of Valme Universitary Hospital. Sevilla, Spain. Page 14 of 14