Is one benign fine needle aspiration enough?

BACKGROUND: Fine needle aspiration (FNA) is used to diagnose thyroid nodules, but the follow-up of benign FNA is unclear. We sought to determine whether routine repeat FNAs after initial benign FNA reduces false negatives. METHODS: We identified 265 patients who had at least one benign FNA that either progressed to surgery or had at least one repeat FNA. We reviewed their ultrasonography, FNA cytology, and surgical pathology. RESULTS: Of 127 patients with initial benign FNA that had surgery, 13 had a malignancy, yielding a 10.2% false-negative rate. Of 22 patients who had surgery after at least two benign FNAs, one had a malignancy, yielding a 4.5% false-negative rate. Initially benign cytology (Bethesda II) was upgraded to a cytology requiring surgical intervention (Bethesda IV-VI) in 7 of 129 (5.4%) patients after two FNAs. Suspicious features on ultrasound, including size >4 cm, calcifications, or increased vascularity were found in 90% of patients with a false-negative FNA. CONCLUSIONS: The overall false-negative rate of thyroid FNAs is 10.2%, which is reduced to 4.5% with a second benign FNA. Ninety percent of patients with a false-negative FNA had suspicious sonographic features. Reaspiration should be considered in patients with sonographically suspicious nodules.

Athlete's hernia--a true, early direct inguinal hernia: diagnosis, pathophysiology, and surgical treatment.

Athlete's hernia (AH) is an activity limiting condition that presents as chronic inguinal pain in elite athletes. The diagnosis involves a thorough history and physical examination and can be aided by ultrasound interrogation of the groin. Operative treatment with a direct tissue repair of the inguinal floor successfully alleviates symptoms and allows for full return to activity. A retrospective analysis of patients with the diagnosis of AH from January 1998 to May 2010 who underwent operative repair was reviewed. Patients were evaluated based on age, gender, sport, time to presentation, subjective and objective physical findings, imaging findings, operative findings, length of follow-up, and return to activity. Ninety-six patients (6 females) with a median age of 22.6 years were evaluated. In the majority of these patients, operative exploration revealed a wide external ring with separation of the fibers of the external oblique aponeurosis and an unprotected and bulging transverses abdominis aponeurosis, very akin to an early direct inguinal hernia. The mean initial follow-up time was 6 weeks at which point all but two of the patients were able to resume their full level of activity without restrictions. The diagnosis of AH, although somewhat elusive, can be easily established with a high degree of suspicion after doing a thorough history and physical exam augmented with ultrasonography. AH is equivalent to an early direct inguinal hernia found in young athletes and can be surgically corrected allowing return to full activity.

Calcitonin-negative neuroendocrine tumor of the thyroid: a distinct clinical entity.

BACKGROUND: Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor (NET) that arises from the parafollicular cells (C-cells) of the thyroid gland which produces calcitonin (CT) and is, therefore, a serum and immunohistochemical biomarker of MTC. Here, we describe a patient with another form of NET arising with the thyroid gland. PATIENT FINDINGS: This is a forty-year-old woman who underwent total thyroidectomy for a thyroid nodule that had features of an NET on fine needle aspiration. Her serum CT and carcinoembryonic antigen were normal. Surgical pathology showed a well-differentiated NET with immunohistochemical stains positive for markers of follicular cells (thyroglobulin and synaptophysin), positive for neuroendocrine markers (neuron specific enolase and chromogranin A), but negative for CT, the defining marker of MTC. CONCLUSIONS: We describe a rare case of a nonmedullary NET of the thyroid gland arising from thyroid follicular cells, not parafollicular cells. We suggest that calcitonin-negative neuroendocrine tumor of the thyroid gland (CNNETT) may be an entity that has not been recognized in the literature. This distinction between MTC and CNNETT may be important, as the treatment and prognosis may differ.

Routine second-opinion cytopathology review of thyroid fine needle aspiration biopsies reduces diagnostic thyroidectomy.

BACKGROUND: Follicular thyroid carcinoma cannot be distinguished reliably from benign follicular neoplasia by fine needle aspiration (FNA) biopsy. Given an estimated 20% risk of malignancy, many patients with indeterminate FNA biopsies require thyroidectomy for diagnosis. Some centers have shown significant discordance when a second pathologist evaluates the same FNA biopsy. We sought to determine whether routine second-opinion cytopathology reduces the need for diagnostic thyroidectomy, especially in patients with indeterminate FNA biopsies. METHODS: In all, 331 thyroid FNA biopsy specimens obtained from outside centers from 2004 to 2009 were reviewed at our institution. The FNA biopsy results were categorized into nondiagnostic (Bethesda I), benign (Bethesda II), indeterminate (follicular/Hurthle cell neoplasm, follicular/Hurthle cell lesion; Bethesda III & IV), and malignant (papillary or suspicious for papillary or other malignancy; Bethesda V and VI). Second-opinion cytology was compared with the initial opinion in 331 cases and with final operative pathology in the 250 patients who progressed to thyroidectomy. RESULTS: The average patient age was 51 with a predominant number of female (79%) participants. The overall cytology concordance for all 331 FNA biopsies was 66% (218/331). Concordance was highest at 86% (74/86) with malignant FNA biopsies. Concordance in the 129 patients with indeterminate FNA biopsies was only 37% (48/129). Indeterminate FNA biopsies were reread as nondiagnostic in 21% (27/129) of patients and as benign in 42% (54/129) of patients. Twenty-two patients with an indeterminate FNA biopsy reread as benign progressed to operative therapy for reasons other than cytology (eg, symptomatic nodule and radiation exposure/high risk) and were found to be benign in 95% (21/22) of patients on operative pathology for a 95% negative predictive value. An additional 11 patients with an indeterminate FNA reread as benign had follow-up FNA biopsies, each of which was benign. Indeterminate FNA biopsies on initial cytology had a malignancy rate of 13% (17/129) on operative pathology compared with 29% (14/48) for indeterminate FNA biopsies from second opinion. A second opinion improved FNA biopsy accuracy from 60% to 74%. Overall, second-opinion cytology of indeterminate FNA biopsies avoided diagnostic operation in 25% (32/129). CONCLUSION: Routine second opinion review of indeterminate thyroid FNA biopsies can potentially obviate the need for diagnostic thyroidectomy in 25% of patients without increases in false negatives.