Trends in thyroid function testing, neck ultrasound, thyroid fine needle aspiration, and thyroidectomies in North-eastern Italy.

PURPOSE: Evidence of an increased diagnostic pressure on thyroid has emerged over the past decades. This study aimed to provide estimates of a wide spectrum of surveillance indicators for thyroid dysfunctions and diseases in Italy. METHODS: A population-based study was conducted in North-eastern Italy, including 11.7 million residents (20% of the total Italian population). Prescriptions for TSH testing, neck ultrasound or thyroid fine needle aspiration (FNA), surgical procedures, and drugs for hypo- or hyperthyroidism were extracted from regional health databases. Proportions and rates of selected examinations were calculated from 2010 to 2017, overall and by sex, calendar years, age, and region. RESULTS: Between 2010 and 2017 in North-eastern Italy, 24.5% of women and 9.8% of men received at least one TSH test yearly. In 2017, 7.1% of women and 1.5% of men were prescribed drugs for thyroid dysfunction, 94.6% of whom for hypothyroidism. Neck ultrasound examinations were performed yearly in 6.9% of women and 4.6% of men, with a nearly two-fold variation between areas. Thyroid FNA and thyroidectomies were three-fold more frequent in women (394 and 85 per 100,000) than in men (128 and 29 per 100,000) with a marked variation between areas. Both procedures decreased consistently after 2013. CONCLUSIONS: The results of this population-based study describe recent variations over time and between surrounding areas of indicators of 'diagnostic pressure' on thyroid in North-eastern Italy. These results emphasize the need to harmonize practices and to reduce some procedures (e.g., neck ultrasound and total thyroidectomies) in certain areas.

Breast Fine-Needle Aspiration Practice in 2019: Results of a College of American Pathologists National Survey.

CONTEXT.­: The College of American Pathologists surveys provide national benchmarks of pathology practice for laboratories. OBJECTIVE.­: To investigate breast fine-needle aspiration (FNA) biopsy practice in domestic and international laboratories in 2019. DESIGN.­: We analyzed data from the College of American Pathologists Breast FNA Practice Supplemental Questionnaire that was distributed to laboratories participating in the 2019 College of American Pathologists Non-Gynecologic Cytopathology Education Program. RESULTS.­: Sixty-one percent (499 of 816) of respondent laboratories routinely evaluated breast FNAs. Cystic lesions were the most common indication, and radiologists primarily performed FNAs in most settings. Forty-five percent (220 of 491) of laboratories performed ancillary studies on breast FNA samples, but 33.8% (70 of 207) did not report fixation time for breast biomarker studies. Only 54.5% (271 of 497) of laboratories had a standardized reporting system and only 16.8% (82 of 488) were aware of the International Academy of Cytology Yokohama Breast FNA Biopsy Cytology Reporting System. There were significant differences among different types of institutions in several aspects of breast FNA practice, including frequency of concurrent FNA and core needle biopsy for the same lesion, primary personnel who performed the FNA, etc. Significant differences existed between domestic and international laboratories in slide preparation, ancillary studies, fixation time reporting, standardized/descriptive diagnosis, and International Academy of Cytology Yokohama Reporting System awareness. CONCLUSIONS.­: This is the first survey from the College of American Pathologists Cytopathology Committee to investigate breast FNA practices. The data reveal significant differences in breast FNA practice among different types of institutions and between domestic and international laboratories, and provide a baseline for future breast FNA studies in a variety of practice settings.

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.

Review of different platforms to perform rapid onsite evaluation via telecytology.

There is increased utilisation of cytopathology to provide a rapid onsite evaluation (ROSE) of fine needle aspiration and touch preparations of small biopsies. A well-executed ROSE procedure can significantly impact the diagnostic quality and appropriate specimen triage of procured biopsy materials. To accommodate the demand for ROSE, telecytology has been increasingly implemented to facilitate ROSE occurring remotely. Telecytology can be categorised based on camera systems including eyepiece system, camera port system and robotic microscope/whole slide image scanner system. Image sharing methods include static images, broadcast only live video streaming, teleconferencing and whole slide image management system. In this review, we will discuss the advantages and disadvantages of each of these systems and deployment considerations.

Rates of Thy 1-non-diagnostic thyroid fine needle aspiration using the UK Royal College of Pathologists Thy Terminology. A systematic review of the literature comparing patients who undergo rapid on-site evaluation and those who do not.

INTRODUCTION: The UK Royal College of Pathologists (RCPath) Thy terminology is an internationally recognised system for reporting thyroid fine needle aspiration. The terminology has been used throughout the UK and Ireland, in some parts of Italy and Switzerland, and elsewhere in the world. There is no systematic review of the literature specifically addressing the use of the non-diagnostic for cytological diagnosis-Thy1/Thy 1c category in the UK RCPath terminology. METHODS: A comprehensive literature search of online databases was conducted in October 2019 specifically examining overall reported rates of Thy1 and Thy1c in aspirates classified according to the UK Thy terminology. RESULTS: Twenty-five articles were identified showing a Thy1 rate of 13.4% (2540/18 920). The studies were then stratified according to whether or not the patients underwent rapid on-site evaluation (ROSE): 6.0% (353/5841; range 3.0%-10.9%) of ROSE aspirates were Thy1 whereas 18.5% (2072/11 204; range 7.9%-43.3%) of non-ROSE patients were Thy1; (P < .05). Three studies from 2016 reported Thy1c rates of 5.4%, 6.5% and 10.6%, respectively, implying Thy1 rates excluding Thy1c aspirates of 20.9%, 8.7% and 12.7%, respectively. CONCLUSION: This systematic review of the literature shows relatively high rates of aspirates non-diagnostic for cytological diagnosis-Thy1 in the peer-reviewed published literature using the UK terminology. Utilisation of ROSE appears to produce lower rates of Thy1 aspirates and ROSE should be considered if rates of non-diagnostic for cytological diagnosis-Thy1/Thy 1c are high.

Dissemination of health technologies: Trends in the use of diagnostic test in breast cancer screening.

OBJECTIVE: To analyse trends in the use of diagnostic test in breast cancer screening programs in Spain. MATERIALS AND METHODS: Retrospective study of 542,695 women who had undergone at least one screening mammogram in any of the screening centres of three administrative regions in Spain, between 1996 and 2011. Process measures were: overall recall rate, overall invasive test rate, and rates of each type of invasive test (fine-needle aspiration biopsy, core-needle biopsy and surgical biopsy). As results measures were included detection of benign lesions rate, ductal in situ cancer rate and invasive cancer rate. Adjusted by age rates were estimated year by year for each measure and, also, the annual percent of change and its corresponding joint points. RESULTS: Core-needle biopsy rates decreased between 1996 and 1999 and changed trends in 1999-2011 with an increase of 4.9% per year. Overall recall rate declined by 4.6% from 1999 to 2004, invasive test rate declined between 1996 and 2004 by 24.3%. Fine-needle aspiration biopsy rate changes were: a 22.4% declined per year (1996-1998), and 13.5% declined per year (1998-2005). Benign lesions rate decreased from 1996 to 2011, 21.4% per year (1996-2001) and 6.0% (2001-2011). Ductal carcinoma in situ and invasive cancer had no-statistically significant changes. CONCLUSION: The introduction of core-needle biopsy was slow and not concurrent with the reduction in the use of other diagnostic tests, but also represented a reduction in the rate of overall diagnostic tests and in the detection rate of benigns lesions without affecting the cancer detection rates.

Punción aspiración con aguja fina y biopsia con aguja gruesa ecoguiada en dermatología: un paso adelante / Ultrasound-Guided Fine-Needle Aspiration Cytology and Core-Needle Biopsy in Dermatology: A Step Forward

No disponible

Thyroid cytopathology: updates and molecular testing.

The utility of fine needle aspiration (FNA) is well described in the context of evaluating thyroid lesions. Among the various international systems of classification of thyroid cytology, the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) has also provided a sound framework to standardize the reporting of FNA cytology results. New molecular evidence and clinical studies demonstrated the need for revision of the nomenclature resulting in introduction of new categories, such as the noninvasive follicular thyroid neoplasms with papillary-like nuclear features (NIFTP). Indeterminate thyroid cytology results pose a challenge for further management and the continued development of molecular markers may aid in the management of indeterminate thyroid lesions.

Impact of non-invasive follicular thyroid neoplasms with papillary-like nuclear features (NIFTP) on risk of malignancy in patients undergoing lobectomy/thyroidectomy for suspected malignancy or malignant fine-needle aspiration cytology findings: a systematic review and meta-analysis.

OBJECTIVE: The second version of The Bethesda System for Reporting Thyroid Cytopathology endorsed the introduction of non-invasive follicular thyroid neoplasms with papillary-like nuclear features (NIFTP) as a distinct entity with low malignant potential into clinical practice. Consequently, the risk of malignancy (ROM) of cytological diagnoses has changed, but the magnitude of the change remains uncertain. The present systematic review was undertaken to obtain more robust information about the true impact of NIFTP on the ROM among patients undergoing surgery following a fine-needle aspiration cytology (FNAC) diagnosis of suspicious for malignancy (Bethesda V) or malignant (Bethesda VI). As they are managed surgically, these two diagnostic categories are the primary entities that are clinically impacted by the advent of NIFTP. DESIGN: Systematic review and meta-analysis. METHODS: A comprehensive literature search of online databases was performed in November 2018. The search was conducted looking for data of histologically proven NIFTP with preoperative FNAC. RESULTS: One-hundred fifty-seven articles were identified and nine were included in the study. Overall, there were 13,752 thyroidectomies with a cancer prevalence of 45.7%. When NIFTP was considered non-malignant, the pooled risk difference for ROM was 5.5%. Applying meta-analysis, the pooled prevalence of NIFTP among nodules with FNAC of Bethesda V or Bethesda VI was 14 and 3%, respectively. CONCLUSION: This meta-analysis shows that the inclusion of NIFTP leads to a reduction in the ROM for the Bethesda V and Bethesda VI FNAC diagnostic categories by 14 and 3%, respectively. Clinicians should be aware of these data to avoid overtreatment.

Trends in Thyroid Fine-Needle Aspiration Cytology Practices: Results From a College of American Pathologists 2016 Practice Survey.

CONTEXT.­: The College of American Pathologists periodically surveys laboratories to determine changes in cytopathology practices. We report the results of a 2016 survey concerning thyroid fine-needle aspiration (FNA). OBJECTIVE.­: To provide a cross-sectional survey of thyroid cytology practices in 2016. DESIGN.­: In 2016, a survey was sent to 2013 laboratories participating in the College of American Pathologists Non-Gynecologic Cytology Education Program (NGC-A) requesting data from 2015-2016 on several topics relating to thyroid FNA. RESULTS.­: A total of 878 laboratories (43.6% of 2013) replied to the survey. Radiologists performed the most thyroid FNA procedures in most laboratories (70%; 529 of 756), followed by endocrinologists (18.7%; 141 of 756), and most of these were performed under ultrasound guidance (92.1%; 699 of 759). A total of 32.6% of respondents (251 of 769) provided feedback on unsatisfactory rates for nonpathology providers who performed FNA. Intraprocedural adequacy assessment was primarily performed by attending pathologists (77.4%; 490 of 633) or cytotechnologists (28.4%; 180 of 633). Most laboratories used the Bethesda System for Reporting Thyroid Cytopathology (89.8%; 701 of 781) and performed molecular testing based on clinician request (68.1%; 184 of 270) rather than FNA diagnosis. Correlation of thyroid excisions with prior cytology results most often occurred retrospectively (38.4%; 283 of 737) and was used for pathologist interpretive quality assurance purposes. CONCLUSIONS.­: These survey results offer a snapshot of national thyroid FNA cytology practices in 2016 and indicate that standardized cytology terminology is commonly used; pathologists perform most immediate adequacy assessments for thyroid FNA; laboratories use correlation statistics to evaluate pathologists' performance; and molecular tests are increasingly requested for indeterminate interpretations, but reflex molecular testing is rare.

A retrospective study of endobronchial ultrasound transbronchial needle aspiration versus conventional transbronchial needle aspiration in diagnosis/staging of hilar/mediastinal lymph node in lung cancer: Which role in clinical practice?

The conventional-trans bronchial needle aspiration (c-TBNA) has been the first procedure for sampling hilar/mediastinal lymph node for the diagnosis/staging of lung cancer. In the last decade the endobronchial ultrasound trans bronchial needle aspiration (EBUS-TBNA) was introduced in clinical practice and became the first-choice exam in diagnosis and staging of lung cancer. The aim of this study was to compare the diagnostic accuracy (DA), sensitivity and adequacy of c-TBNA and EBUS-TBNA. It was a retrospective and observational multicenter study. The first endpoint was diagnostic accuracy of EBUS-TBNA versus c-TBNA. The secondary end-points were sensitivity and adequacy. Two hundred and nine consecutive patients underwent the procedure, 99 EBUS-TBNA and 110 c-TBNA. When lymph nodes with short axis <2 cm the diagnostic accuracy for correct diagnosis was 94.2% in EBUS-TBNA group and 89.7% in c-TBNA group (p=0.01); the sample adequacy was 70.3% and 42%, respectively (p=0.01); the sensitivity was 93% (95% CI, 82-98%) and 86.4% (95% CI, 67.6-95.6%), respectively (p=0.002). In lymph nodes with short axis ≥2 cm the diagnostic accuracy was 95.7% in EBUS-TBNA group and 93% in c-TBNA group (p=0.939); the sample adequacy was 68.7% and 68.3%, respectively (p=0.889); the sensitivity was 95.1% (95% CI, 83-99%) and 92.1%, respectively (95% CI, 78.7-97.7%) (p=0.898). The EBUS-TBNA in patients with lymph nodes size <2 cm presented a statistically significant difference in the DA, adequacy and sensitivity compared to c-TBNA procedure, while there were no significant differences in the DA, adequacy and sensitivity between EBUS-TBNA and c-TBNA in patients with lymph node size ≥2 cm. The results of our study indicated that the EBUS-TBNA should be the first-choice procedure for the diagnosis/staging in lung cancer patients with lymph node size <2 cm. In patients with lymph node size ≥2 cm, instead, both procedures can be used for the diagnosis/staging of lung cancer.

Effect of Implementing Community of Practice Modified Thyroid Imaging Reporting and Data System on Reporting Adherence and Number of Thyroid Biopsies.

RATIONALE AND OBJECTIVES: Thyroid nodules are common in the population, although the rate of malignancy is relatively low (5%-15%). The purpose of this study was to determine if introducing a modified standardized reporting format and management algorithm (Thyroid Imaging Reporting and Data System [TI-RADS]) affects radiologist reporting adherence, number of thyroid biopsies, and other measurable outcomes. MATERIALS AND METHODS: All thyroid biopsies performed over two 6-month periods were evaluated at a tertiary care hospital with Research Ethics Board approval. The first period was before implementation of TI-RADS and the second was several months after implementation of TI-RADS (using a modified version made through a multidisciplinary collaboration). The number of biopsies performed was determined in each of the two periods as well as the percent of positive malignancy, wait times, and rates of non-diagnostic/unsatisfactory and inconclusive biopsies, which included atypia of undetermined significance (AUS) and follicular lesion of undetermined significance (FLUS). RESULTS: The average number of biopsies performed prior to implementing modified Kwak's TI-RADS was 74 thyroid biopsies per month and the average number of diagnostic ultrasounds was 271. After the introduction of modified Kwak's TI-RADS, the average number of thyroid biopsies decreased to 60 per month (an 18.9% reduction, P < .05), and the number of diagnostic ultrasound increased to 287 per month (a 5.9% increase from 2016 to 2017). The average wait time for a thyroid biopsy decreased from 5 to 3 weeks (P < .05). There was a slight increase in the rate of positive malignancy results (from 15% to 18%), although it was not statistically significant. The rate of non-diagnostic/unsatisfactory and inconclusive results (including AUS and FLUS) remained unchanged (18% AUS/FLUS/15% non-diagnostic/unsatisfactory before and 17% AUS/FLUS/15% non-diagnostic/unsatisfactory after TI-RADS introduction, P > .05). CONCLUSIONS: Introduction of a multidisciplinary-approved standardized reporting system with evidence-based management recommendations led to no statistically significant change in the number of diagnostic ultrasounds but a statistically significant reduction in the number of monthly thyroid biopsies and associated reduction in wait times.

Differentiating between benign and malignant thyroid nodules: An evidence-based approach in general practice

BACKGROUND: The widespread use of imaging techniques has led to more frequent detection of thyroid nodules, and while the majority are benign, the risk of malignancy in an adult ranges from 7% to 15%. General practitioners (GPs) must be able to evaluate thyroid nodules and refer cases when appropriate. OBJECTIVES: The aim of this article is to bring GPs up to date on the evidence-based management of thyroid nodules, with specific focus on neoplastic nodules, while highlighting significant changes in the 2015 American Thyroid Association guidelines. DISCUSSION: Thyroid nodules frequently occur in the general population. Differentiating between a benign and malignant nodule can be challenging, and community guidelines have standardised investigation, management and follow-up procedures. The key tests for risk stratification of thyroid nodules include serum thyroid-stimulating hormone testing, ultrasonography and fine-needle aspiration. GPs should be aware of the latest evidence-based recommendations for the appropriate management of a thyroid nodule.

Surgeon-performed thyroid ultrasound-proving utility and credibility in selecting patients for fine needle aspiration according to the American thyroid association guidelines. A retrospective study of 500 patients.

DESIGN: Case series with chart review. SETTING: Single academic centre. PARTICIPANTS: The data of all patients who underwent surgeon-performed ultrasound (SUS) between 7/2009 and 9/2012 were retrospectively reviewed. MAIN OUTCOME MEASURES: A correlation between sonographic features and a non-benign cytology\malignant pathology. RESULTS: Four hundred ninety-eight nodules were included. Solid texture, irregular margins, hypo-echogenicity and intranodular vascularity were significantly associated with malignancy when benign to non-benign cytology was compared, and when compared to malignant pathology. Lack of suspicious features was significantly associated with benign lesions, with a negative predictive value of 94%. Except for taller than wider shape, malignancy odds ratio was significantly higher for known suspicious features, reaching 4.81 for irregular borders (CI 2.42-9.55, P < .001). CONCLUSIONS: SUS has proven to be a reliable and consistent tool to assess the thyroid nodule risk stratification. Surgeons should recognise the potential of this tool and its implementation.

New Developments in Endoscopic Ultrasound Tissue Acquisition.

Endoscopic ultrasound (EUS)-guided tissue acquisition has greatly evolved since the first EUS-guided fine-needle aspiration was reported nearly 25 years ago. EUS-guided tissue acquisition has become the procedure of choice for sampling of the pancreas, subepithelial lesions, and other structures adjacent to the gastrointestinal tract. This review focuses on recent developments in procedural techniques and needle technologies for EUS-guided tissue acquisition.

Recent Advances in Endoscopy.

In this narrative review, invited by the Editors of Gastroenterology, we summarize recent advances in the field of gastrointestinal endoscopy. We have chosen articles published primarily in the past 2-3 years. Although a thorough literature review was performed for each topic, the nature of the article is subjective and systematic and is based on the authors' experience and expertise regarding articles we believed were most likely to be of high clinical and scientific importance.

Una nueva figura en la anatomía patológica actual: el patólogo intervencionista / The interventional pathologist: a new role in modern pathology

No disponible

Utilidad del control por parte del patólogo del material obtenido por punción aspiración con aguja fina bajo guía de ecoendoscopia: revisión de la bibliografía acerca de un tema controvertido / Utility of rapid on-site evaluation (ROSE) by a pathologist during endoscopic ultrasound-guided fine needle aspiration cytology: a review of the literature

Numerosas técnicas de imagen permiten visualizar y obtener material de órganos de difícil acceso de forma mínimamente invasiva. Es preciso un estudio citológico adecuado, porque el calibre habitual de las agujas no permite obtener material histológico. Por ello, ligado al uso de la ecoendoscopia se debe hablar de punción aspiración con aguja fina (PAAF). La PAAF es una técnica económica cuando se realiza sobre lesiones palpables, pero con control por técnicas de imagen su rentabilidad es dudosa por la variabilidad entre centros y el aumento del coste. El objetivo de este estudio es determinar si el control por el patólogo del material obtenido en PAAF con ecoendoscopia mejora la precisión diagnóstica (en relación con la biopsia), cuál es la mejor estrategia para esta prueba, quién debe hacerla y si resulta económicamente rentable. Dada la escasez de datos a nivel nacional sobre este tema, hemos optado por una revisión bibliográfica de la literatura publicada (AU)

New imaging techniques, allowing the visualization and minimally invasive sampling of organs that are difficult to access, are being used more and more frequently. A suitable, accompanying cytological study is required, as in the majority of cases the caliber of the needle used is not sufficient to obtain a histological sample. Therefore, endoscopic ultrasound is generally associated with fine-needle aspiration (FNA). The performance of FNA on palpable nodules is a cost-effective procedure. However, the cost-effectiveness of using FNA with endoscopic ultrasound guidance is controversial, due to interobserver variability and increase in costs. The object of this study is to determinate if rapid-on site evaluation by a pathologist during endoscopic ultrasound-guided FNA improves diagnostic accuracy (correlated with biopsy), what is the best methodology, who should do it and the cost-effectiveness of the procedure. Because of the lack of Spanish data, we reviewed the pertinent international literature (AU)