Thyroid fine-needle aspiration trends before, during, and after the lockdown: what we have learned so far from the COVID-19 pandemic.

PURPOSE: Nowadays, the clinical management of thyroid nodules needs to be multi-disciplinary. In particular, the crosstalk between endocrinologists and cytopathologists is key. When FNAs are properly requested by endocrinologists for nodules characterised by relevant clinical and ultrasound features, cytopathologists play a pivotal role in the diagnostic work-up. Conversely, improper FNA requests can lead to questionable diagnostic efficiency. Recently, recommendations to delay all non-urgent diagnostic procedures, such as thyroid FNAs, to contain the spread of COVID-19 infection, have made the interplay between endocrinologists and cytopathologists even more essential. The objective of this study was to assess the impact of COVID-19 pandemic on our practice by evaluating the total number of FNAs performed and the distribution of the Bethesda Categories before, during, and after the lockdown. METHODS: We analysed the FNA trends before (1st January 2019 to March 13th 2020), during (March 14th to May 15th), and after (May 16th to July 7th) the lockdown. RESULTS: Although the total number of weekly FNAs dropped from 62.1 to 23.1, our referring endocrinologists managed to prioritise patients with high-risk nodules. In fact, in the post-lockdown, the weekly proportion of benign diagnoses dropped on average by 12% and that of high-risk diagnoses increased by 6%. CONCLUSIONS: The lesson we have learned so far from this pandemic is that by applying safety protocols to avoid contagion and by increasing the threshold for FNA requests for thyroid nodules, we can continue to guarantee our services to high-risk patients even in times of a health crisis.

Cost-effectiveness of fine-needle aspiration cytology (FNAC) and watchful observation for incidental thyroid nodules.

OBJECTIVES: A trial-based comparison of the use of resources, costs and health utility outcomes of fine-needle aspiration cytology (FNAC), and watchful observation for incidental small (< 2 cm) thyroid nodules was performed using data from the randomized controlled trial (RCT). METHODS: Using data from 314 patients, healthcare-related use of resources, costs, health utility, and quality-adjusted life years (QALYs) were estimated at 12 months after first presentation of incidental thyroid nodule(s) on an intention-to-treat basis with adjustment for covariates. Uncertainty about the incremental cost-effectiveness ratio for FNAC versus watchful management at 12 months of follow-up was incorporated using bootstrapping. Multiple imputation methods were used to deal with missing data. RESULTS: FNAC management was associated with greater use of healthcare resources and mean direct healthcare costs per patient (US$542.47 vs US$411.55). Lower mean 12-month QALYs per patient in FNAC was observed in comparison to watchful observation (0.752 versus 0.758). The probability that FNAC management was cost-effective compared with watchful management at a willingness-to-pay threshold of US50,000 per QALY gained was 26.5%. CONCLUSION: Based on 12-month data from RCT, watchful observation appeared cost-saving compared to FNAC in patients with incidental thyroid nodules that have a low-suspicion sonographic pattern and measure between 1.0 and 2.0 cm from healthcare provider perspective. CLINICALTRIALS. GOV IDENTIFIER: NCT02398721.

Ultrasound morphometric and cytologic preoperative assessment of inguinal lymph-node status in women with vulvar cancer: MorphoNode study.

OBJECTIVE: To assess the accuracy of preoperative ultrasound examination for predicting lymph-node (LN) status in patients with vulvar cancer. METHODS: This was a single-institution retrospective observational study of all women with a histological diagnosis of vulvar cancer triaged to inguinal surgery within 30 days following ultrasound evaluation between December 2010 and January 2016. For each groin examined, 15 morphological and dimensional sonographic parameters associated with suspicion for LN involvement were examined. A morphometric ultrasound pattern (MUP) was expressed for each groin, classifying the inguinal LN status into five groups (normal; reactive-but-negative; minimally suspicious/probably negative; moderately suspicious; and highly suspicious/positive) according to subjective judgment, followed by stratification as positive or negative for metastasis according to morphometric binomial assessment (MBA). In cases of positive MBA, fine-needle aspiration cytology was performed. Combining the information obtained from MUP and cytologic results, a binomial final overall assessment (FOA) was assigned for each groin. The final histology was considered as the reference standard. Comparison was performed between patients with negative and those with positive LNs on histology, and receiver-operating-characteristics curves were generated for statistically significant variables on univariate analysis, to evaluate their diagnostic ability to predict negative LN status. RESULTS: Of 144 patients included in the analysis, 87 had negative inguinal LNs and 57 had positive LNs on histology. A total of 256 groins were analyzed, of which 171 were negative and 85 showed at least one metastatic LN on histology. The following parameters showed the greatest accuracy, with the best balance between specificity and sensitivity, in predicting negative LN status: cortical (C) thickness of the dominant LN (cut-off, 2.5 mm; sensitivity, 90.0%; specificity, 77.9%); short-axis (S) length of the dominant LN (cut-off, 8.4 mm; sensitivity, 63.9%; specificity, 90.6%); C/medulla (M) thickness ratio of the dominant LN (cut-off, 1.2 mm; sensitivity, 70.4%; specificity, 91.5%), the combination of S length and C/M thickness ratio (sensitivity, 88.9%; specificity, 82.4%); and the FOA analysis (sensitivity, 85.9%; specificity, 84.2%). CONCLUSIONS: Preoperative ultrasound assessment, with or without the addition of cytology, has a high accuracy in assessing inguinal LN status in patients with vulvar cancer. In particular, the combination of two ultrasound parameters (S length and C/M thickness ratio) provided the greatest accuracy in discriminating between negative and positive LNs. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

The extent of lymph node yield in central neck dissection can be affected by preoperative and intraoperative assessment and alter the prognosis of papillary thyroid carcinoma.

BACKGROUND: Lymph node yield (LNY) was implemented in the stratification of papillary thyroid cancer (PTC) patients. The effect of LNY may be related to the extent of surgery. This study aims to identify influencing factors for LNY in central compartment neck dissection (CND). METHODS: Data of 13 712 consecutive PTC patients were analyzed retrospectively. Risk factors for LNY in CND and distribution characteristics of LNY were evaluated. Its relationship with prognosis was studied in another cohort of 136 cases. RESULTS: LNY in therapeutic CND was significantly higher than prophylactic CND (Unilateral: 5.55 ± 3.79 vs 3.41 ± 2.77; Bilateral: 8.90 ± 5.10 vs 6.47 ± 4.17, P < .001). Other independent factors included extranodal extension (ETE), tumor size, and concurrent Hashimoto's thyroiditis. The inconsistency distribution of LNY in bilateral CND was associated with preoperative and intraoperative assessment. Patients with significant difference between major and minor LNY suffered from poorer prognosis (10y-RFS: 58.3% vs 92.0%; HR = 6.719, 95%, P < .0001). CONCLUSIONS: CND surgical procedure, ETE, and Hashimoto's thyroiditis were independent factors of LNY. Inconsistent distribution of LNY was associated with prognosis of bilateral PTC patients. The impact of preoperative and intraoperative assessment on the actual extent of CND can be used to explain the relationship between LNY and PTC prognosis.

INCIDENTAL THYROID NODULES: RACE/ETHNICITY DISPARITIES AND OUTCOMES.

OBJECTIVE: Black patients have a significantly lower incidence of well-differentiated thyroid cancer (WDTC) compared to all other race/ethnic groups, while white patients appear to be at greater risk. This study examines incidental thyroid nodules (ITNs) to assess whether racial disparities in WDTC arise from a differential discovery of ITNs-perhaps due to socioeconomic disparities-or reflect true differences in thyroid cancer rates. METHODS: A retrospective review was performed of all patients who underwent fine-needle aspiration (FNA) of thyroid nodules by our academic medical center's endocrinology division between January 2006 and December 2010. Medical records were reviewed to identify whether the biopsied thyroid nodule was discovered incidentally through nonthyroid-related imaging or identified by palpation. RESULTS: FNAs were performed on 1,369 total thyroid nodules in 1,141 study patients; 547 (48%) were classified as white, and 593 (52%) were classified as nonwhite. Among this cohort, 36.6% of patients underwent biopsy for an ITN. White patients were 1.6 times more likely to have undergone a biopsy for a nodule that was incidentally identified compared to nonwhites ( P<.0001). Indicators of socioeconomic status (SES) did not have a significant association with ITNs. Within the ITN cohort, 4.9% of nonwhite patients were found to have a thyroid malignancy compared to 12.9% of white patients ( P<.01). CONCLUSION: The higher incidence of thyroid cancer in white patients appears to be not only due to diagnostic bias, but also to a true difference in cancer prevalence. ABBREVIATIONS: FNA = fine-needle aspiration; ITN = incidental thyroid nodule; SEER = Surveillance Epidemiology and End Results; SES = socioeconomic status; WDTC = well-differentiated thyroid cancer.

Head and Neck Surgical Oncology Choosing Wisely Campaign: imaging for patients with hoarseness, fine needle aspiration for neck mass, and ultrasound for odynophagia.

Choosing Wisely Canada, is a campaign designed to raise awareness regarding inappropriate or unnecessary tests and treatments. The Canadian Society of Otolaryngology - Head & Neck Surgery and the Canadian Association of Head and Neck Surgical Oncologists developed a Choosing Wisely Canada list to help promote high quality care for patients presenting with disorders of the head and neck: (1) Don't order imaging - computer tomography (CT) or magnetic resonance imaging (MRI) - as the initial investigation for patients presenting with a chief complaint of hoarseness, (2) Don't perform an open biopsy or excision of a neck mass without having first considered a fine needle aspiration (FNA) biopsy and, (3) Don't order neck ultrasound to investigate odynophagia (discomfort or pain with swallowing) or globus sensation.

Imaging Surveillance in Patients After a Benign Fine-Needle Aspiration Biopsy of the Thyroid: Associated Cost and Incidence of Subsequent Cancer.

OBJECTIVE: The objective of our study was to determine patterns and cost of imaging tumor surveillance in patients after a benign fine-needle aspiration (FNA) biopsy of the thyroid in a large teaching hospital as well as the rate of subsequent cancer detection. MATERIALS AND METHODS: This cohort study was approved by the appropriate institutional review board and complied with HIPAA. All patients who had a benign thyroid FNA biopsy between January 1, 1999, and December 31, 2003, were identified from an institutional pathology database. We gathered information from electronic medical records on imaging tumor surveillance and subsequent cancer detection. Cost was determined using the facility total relative value unit and the 2014 Hospital Outpatient Prospective Payment System conversion factor. RESULTS: Between January 1, 1999, and December 31, 2003, 1685 patients had a benign thyroid FNA biopsy, 800 (47.5%) of whom underwent follow-up imaging. These patients underwent 2223 thyroid ultrasound examinations, 606 ultrasound-guided thyroid FNA biopsies, 78 thyroid scintigraphy examinations, 168 neck CTs, and 53 neck MRIs at a cost of $529,874, $176,157, $39,622, $80,580, and $53,114, respectively, for a total cost of $879,347 or $1099 per patient. The mean length of follow-up was 7.3 years, during which time 19 (2.4%) patients were diagnosed with thyroid cancer at a cost of $46,281 per cancer. Seventeen (89.5%) were diagnosed with papillary carcinoma and two (10.5%) with Hurthle cell carcinoma. CONCLUSION: Over a 5-year period, about half of the patients who had a benign thyroid FNA biopsy underwent follow-up imaging at considerable cost with a small rate of subsequent malignancy.

Changing trends in tissue acquisition in malignant pancreatic neoplasms.

BACKGROUND AND AIM: To compare the frequency of use, hospital costs, and resource availability between endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), percutaneous, and surgical techniques for tissue acquisition in malignant pancreatic neoplasms. METHODS: This is a retrospective claims analysis of Medicare patients undergoing biopsy of malignant pancreatic neoplasms over 5 years (2006-2010). The primary outcome measure was to compare the utilization of EUS, percutaneous techniques, and surgery for performing pancreatic biopsies. The secondary outcome measures were to compare treatment costs and variations in availability of resources between the three techniques over a 1-year period (2010). RESULTS: Over 5 years, the use of EUS-FNA increased by 69.3% (7100 to 12 020) and the use of percutaneous biopsy by 1.8% (4480 to 4560) compared to decrease in surgical biopsy (720 to 420) by 41.7% (P < 0.0001). When compared to percutaneous and surgical biopsies ($9639 and $21 947, respectively) the median hospital cost/claim for EUS-FNA ($1794) was significantly lower (P < 0.0001). More EUS-FNA procedures were performed in urban and teaching hospitals compared to rural and non-teaching hospitals (P < 0.001). CONCLUSIONS: Although EUS-FNA is increasingly performed and is less costly, and the rate of surgical biopsies has declined precipitously, the utilization of percutaneous techniques remains prevalent. Training and education are required to disseminate the use of EUS-FNA outside major teaching institutions or foster referral of patients to EUS centers because of implications for patient care and resource use.

Triple assessment is not necessary in most young women referred with breast symptoms.

INTRODUCTION: A palpable lesion in the breast is usually subjected to triple assessment (clinical examination [CE], imaging and core biopsy [CB] or fine needle aspiration [FNA]) to minimise the risk of missing breast cancer. However, breast cancer is rare in young women, and triple assessment (especially CB) is invasive and expensive. Our aim was to see whether CB/FNA could be avoided in young women with benign findings on CE and imaging. METHODS: This study analysed data from a prospectively entered database on female patients aged under 25 years who attended a rapid diagnosis breast clinic over a 68-month period. RESULTS: Among 10,301 patients seen, 955 females (9.3%) were aged <25 years. The most common presenting complaint was a lump, followed by pain and nipple discharge. CE was normal or revealed benign findings in all except 15 patients, in whom it was indeterminate. Ultrasonography was performed in 692 patients (72%) and was normal (n=289) or benign (n=382) in all except 21 patients, in whom it was indeterminate. In six patients, both were indeterminate. A total of 317 patients (35%) had triple assessment: FNA in 106, CB in 239 and both in 9 cases. No cancers were diagnosed. CONCLUSIONS: It would appear safe to omit FNA/CB in patients aged under 25 years when clinical and ultrasonography findings are normal or benign. This approach would have avoided needle biopsies in all but 30 patients (3%) in the study.

Cost-effectiveness of molecular testing for thyroid nodules with atypia of undetermined significance cytology.

CONTEXT: Novel molecular diagnostics, such as the gene expression classifier (GEC) and gene mutation panel (GMP) testing, may improve the management for thyroid nodules with atypia of undetermined significance (AUS) cytology. The cost-effectiveness of an approach combining both tests in different practice settings in North America is unknown. OBJECTIVE: The aim of the study was to determine the cost-effectiveness of two diagnostic molecular tests, singly or in combination, for AUS thyroid nodules. DESIGN AND SETTING: We constructed a microsimulation model to investigate cost-effectiveness from US (Medicare) and Canadian healthcare system perspectives. PATIENTS: Low-risk patients with AUS thyroid nodules were simulated. INTERVENTIONS: We examined five management strategies: 1) routine GEC; 2) routine GEC + selective GMP; 3) routine GMP; 4) routine GMP + selective GEC; and 5) standard management. MAIN OUTCOME MEASURES: Lifetime costs and quality-adjusted life-years were measured. RESULTS: From the US perspective, the routine GEC + selective GMP strategy was the dominant strategy. From the Canadian perspective, routine GEC + selective GMP cost and additional CAN$24 030 per quality-adjusted life-year gained over standard management, and was dominant over the other strategies. Sensitivity analyses reported that the decisions from both perspectives were sensitive to variations in the probability of malignancy in the nodule and the costs of the GEC and GMP. The probability of cost-effectiveness for routine GEC + selective GMP was low. CONCLUSIONS: In the US setting, the most cost-effective strategy was routine GEC + selective GMP. In the Canadian setting, standard management was most likely to be cost effective. The cost of these molecular diagnostics will need to be reduced to increase their cost-effectiveness for practice settings outside the United States.

The changing face of outpatient bronchoscopy in 2013.

In 2013, the outpatient hospital payment from Medicare for a transbronchial needle aspiration more than doubled. At the same time, the recently updated American College of Chest Physicians guidelines for the diagnosis and management of lung cancer now recommend needle techniques, such as transbronchial needle aspiration, over surgical staging. The convergence of these two events will accelerate the existing forces of technology and economics that have been influencing both the practices of outpatient bronchoscopy and mediastinoscopy and the management of patients with lung cancer over the past 20 years.

Single-session endosonography and endoscopic retrograde cholangiopancreatography for biliopancreatic diseases is feasible, effective and cost beneficial.

BACKGROUND: Endoscopic ultrasonography (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP) are often required in patients with pancreaticobiliary disorders. AIMS: To assess the clinical impact and costs savings of a single session EUS-ERCP. METHODS: Patient and intervention data from April 2009 to March 2012 were prospectively recruited and retrospectively analyzed from a database at a tertiary hospital. Indications, diagnostic yield, procedure details, complications and costs were evaluated. RESULTS: Fifty-five scheduled combined procedures were done in 53 patients. The accuracy of EUS-fine needle aspiration for malignancy was 90%. The main clinical indication was a malignant obstructing lesion (66%). The ERCP cannulation was successful in 67%, and in 11/15 failed ERCP (73%), drainage was completed thanks to an EUS-guided biliary drainage: 6 transmurals, 5 rendezvous. Eight patients (14%) had related complications: bacteremia (n = 3), pancreatitis (n = 2), bleeding (n = 2) and perforation (n = 1). The mean duration was 65 ± 22.2 min. The mean estimated cost for a single session was €3437, and €4095 for two separate sessions. The estimated cost savings using a single-session strategy was €658 per patient, representing a total savings of €36,189. CONCLUSION: Combined EUS and ERCP is safe, technically feasible and cost beneficial. Furthermore, in failed ERCP cases, the endoscopic biliary drainage can be completed with EUS-guided biliary access in the same procedure.

An interinstitutional review of the value of FNAB in pediatric oncology in resource-limited countries.

Fine-needle aspiration biopsy (FNAB) has been widely accepted as a reliable diagnostic modality in the general pediatric population, but its role in pediatric oncology still remains elusive. With new treatment protocols subscribing to preoperative chemotherapy, the need for a quick, minimally invasive, and accurate diagnostic procedure has arisen. This study assesses the feasibility of FNAB in childhood malignancies to render a specific diagnosis on which treatment can be initiated. An 11-year retrospective study was done on FNABs in patients 19 years and under referred for clinically malignant mass lesions. Cases were confirmed with histology, immunocytochemistry, flow cytometry, or clinical follow-up. Of the 357 patients referred for FNABs, 36 patients were lost to follow-up and 31 FNABS were inadequate. A total of 290 cases were included in the study, of which 68 (23%) cases were benign and 222 (77%) were malignant. The most frequently occurring tumors were nephroblastoma (68), non-Hodgkin's lymphoma (39), rhabdomyosarcoma (22), Hodgkin's lymphoma (22), and neuroblastoma (22). The sensitivity of the procedure for neoplasia was 96.6%, the specificity 97.0%, positive predictive value 99.0%, and negative predictive value 90.1%, with a diagnostic accuracy of 96.7%. The ability of FNAB to enable a specific diagnosis to be made, that is correct and accurate subtyping of the tumor on which chemotherapy or radiotherapy could be commenced was 75.7%. This study shows that FNAB can be used with confidence to confirm malignancy in children. With clinicoradiological correlation and the aid of ancillary techniques, FNAB allows a rapid and accurate preoperative diagnosis for definitive therapy commencement in most cases.

Ultrasound guided percutaneous fine needle aspiration biopsy/automated needle core biopsy of abdominal lesions: effect on management and cost effectiveness.

AIMS: This prospective study was designed to determine whether ultrasound (US)-guided percutaneous fine needle aspiration biopsy (PFNAB)/US-guided percutaneous needle core biopsy (PNCB) of abdominal lesions is efficacious in diagnosis, is helpful in treatment choice, to evaluate whether various other investigations can be avoided, especially invasive ones, its time (shortening hospitalization) and cost-effectiveness. MATERIALS AND METHODS: A total 159 US-guided PFNAB (67) and US-guided automated PNCB (92) of abdominal lesions were performed percutaneously in 150 patients; the youngest patient was a 3-month-old female and eldest was a 75-year-old female. The patient selection was irrespective of age, sex, or location of the abdominal lesion. These patients presented with abdominal mass/lesions, suspected malignancy, jaundice, and in some cases, however, biopsy was performed to determine the nature of indeterminate lesion (malignant / benign versus abscesses). They were 47 hepatobiliary, 6 pancreas, 24 gastrointestinal tract (GIT), 20 kidneys and urinary bladder, 20 prostate, 3 lymph nodes, 4 adrenals, 8 retroperitoneal, 13 ovaries, and 9 other types of lesions. We used free-hand technique (without biopsy attachment) in 129 cases, and transrectal and transvaginal with biopsy attachment was used in 30 cases. RESULTS: In 91.99% of cases, US-guided PFNAB/US-guided PNCB contributed significantly to diagnosis in which US-guided PFNAB/US-guided PNCB was the diagnostic test in 23.33% cases. It confirmed a highly suspected diagnosis in 64% patients, and indicated a specific diagnosis that was not suspected in the remaining 36%. In 57.33% cases, the results of US-guided PFNAB/US-guided PNCB, did not alter treatment choice but increased physician confidence in the choice. US-guided PFNAB/US-guided PNCB was responsible in avoiding 107 planned investigations, including 8 laparotomies, with no significant complications and decreasing length of stay and resulting in 20% cost savings. CONCLUSIONS: Thus, the US-guided PFNAB/US-guided PNCB contributed significantly in diagnosis, and in most of the cases it did not change treatment choice but increased clinicians confidence in the choice. We can avoid the number of investigations, decrease morbidity and mortality, shorten hospitalization and cost by using these methods.

Telecytology: a tool for quality assessment and improvement in the evaluation of thyroid fine-needle aspiration specimens.

The objective of this study was to investigate the role of telecytology as a tool with increased quality standards in the optimal evaluation of thyroid fine-needle aspiration specimens prepared by the ThinPrep(R) technique (Cytyc Co., Boxborough, MA). The study was performed on 252 adequate specimens of 157 patients referred to the Cytopathology Department of University Hospital "Attikon" for preoperative evaluation of thyroid nodules. In all cases, surgical excision followed the initial cytological diagnosis. Three diagnostic categories of cytological reports were used. All cases were confirmed by histological diagnosis of surgical specimens. Ten characteristic images from each case were transferred via file transfer protocol to password-protected accounts for remote review by four independent cytopathologists. In addition to diagnosis, reviewers also commented on overall digital image quality. Contributor's and reviewer's diagnoses were collected, recorded and statistically evaluated. No significant difference in diagnostic accuracy could be detected between the diagnoses proffered on the basis of digitized images and conventional slides. Telecytology is a prompt and valid method for quality assessment and proficiency testing and can be integrated into daily workflow. The use of liquid-based cytology ensures that additional material is preserved for ancillary studies (if necessary) and that a sufficient number of replicate microscope slides can be produced. The use of telecytology in the daily workflow will ensure the reproducibility of cytological diagnoses and make feasible the production of digital educational material. Besides diagnostic accuracy, the implementation of a diagnostic telecytology system requires consideration of numerous financial, legal, professional, and ethical issues.

Fine needle aspiration cytology in Nigeria.

OBJECTIVE: Fine needle aspiration cytology (FNAC) is a simple, safe and cheap method for the screening and diagnosis of a variety of inflammatory and neoplastic conditions. Being a relatively new diagnostic technique in Nigeria, scant information had been published on it. We conducted a nationwide study to describe the availability, organization and utilization of FNA in the country. STUDY DESIGN: A descriptive cross-sectional survey was done to describe the current state of the develop ment of FNAC in Nigeria. The respondents were pathologists and heads of pathology departments in leading medical institutions. RESULTS: It was found that the practice of cytology is widely disseminated throughout the country, with a growing number of pathologists who have taken an interest in cytology. But FNA in Nigeria faces many important challenges, not the least of which is the lack of opportunities for local training and continuing education in cytology. CONCLUSION: In our opinion, there is an immediate need for a comprehensive approach to cytopathology education in Nigeria.

Frequency and rationale of fine needle aspiration biopsy conversion to core biopsy as a result of onsite evaluation.

OBJECTIVE: To measure the frequency and analyze the rationale and potential diagnostic benefits of converting the fine needle aspiration (FNA) procedure to core biopsy. STUDY DESIGN: The frequency of conversion to core biopsy was calculated over 13 months. Analysis of these cases was conducted in regard to the appropriateness for conversion and whether the core biopsy provided additional specific diagnostic information. RESULTS: During this period, the onsite triaging pathologist recommended FNA conversion to core biopsy in 31 of 821 procedures (3.7%). In 3 instances, the core biopsy could not be performed. The rationale for conversion in the remaining 28 cases (3.4%) included either scant aspirated material in 9 cases (32%) or an anticipated need for additional histologic material to further characterize the lesion in the other 19 (68%). In 27 cases (96%), the rationale for conversion was considered to be appropriate, and in 3 of these (11%) the core provided a change in diagnosis. Additional useful diagnostic information was identified in 12 cases (44%). CONCLUSION: Conversion to core biopsy during FNA is infrequent but justified in most cases. Appropriate utilization of this approach is helpful and may be cost effective.

Thyroid nodule evaluation: what have we really learned from recent clinical guidelines?

Recent guidelines for the evaluation of thyroid nodules clarify the diagnostic algorithm while also reporting important differences. The performance of fine needle aspiration (FNA) for cytological examination follows serum TSH determination and thyroid ultrasonography. Thyroid scintigraphy is recommended following a low TSH value and/or FNA yielding an indeterminate follicular cytology. The use of thyroid ultrasonography is the source of some controversy: though it is recommended as a principal first test, its real-time use to guide FNA ranges from routine to only following an FNA yielding an inadequate or nondiagnostic cytological result. In clinical practice, the proportion of physicians utilizing ultrasonography, scintigraphy and FNA varies and frequently deviates from recommended guidelines. The development of guidelines is necessary to bring about consistency and optimization to the diagnostic work-up of thyroid nodules. It is likely that novel diagnostic procedures, such as molecular markers, large needle aspiration biopsy and thyroid imaging with tracers beyond conventional radioactive iodine or (99m)Tc pertechnetate, will lead to improved performance and implementation of guidelines.