Therefore, the needle tip should be continuously monitored by US to prevent vascular, tracheal or esophageal injury during the entire duration of the FNA. According to one study comparing parallel and perpendicular techniques with regard to specimen adequacy from thyroid nodules, the parallel technique significantly decreased the overall nondiagnostic sampling compared to the perpendicular technique However the sample size of the study was small and the two techniques were applied to different lesions.
Cytologic details of samples will vary depending on the experience of the technical staff or laboratory facilities for handing specimens obtained by US-FNA, thus proper methods should be applied during smearing, fixation, and staining of samples to improve diagnostic yield 1. For conventional smear preparations, the syringe-needle unit is disassembled first. The empty syringe is then filled with air, reconnected to the needle and the needle content is extruded onto glass slides.
Sometimes, excessive pressure between the spreader slide and non-spreader slide results in crush artifacts which may interfere with evaluation of nuclear morphology 1 , 4. Therefore, liquid-based cytology LBC , originally developed for gynecologic cervical smears, was recently introduced for the FNA of thyroid nodules due to its specific advantages including clear background, a monolayer cell preparation, and more convenient handling of specimens 1 , 45 , 46 , This method is based on a two-step procedure: However, several changes that occur during the cellular processing step of LBC, such as loss of cell artitecture, cytomorphologic changes of colloid, and decrease of inflammatory cells, were pointed out as the drawbacks of LBC.
Therefore, a dedicated training program would be necessary for cytopathologists to maintain the diagnsotic accuracy of US-FNA 1 , To summarize the advantages of two different cytologic preparation methods, cellular specimen processing by conventional smear techniques enables rapid, real-time assessment of sample adequacy and allows for a more accurate evaluation of cell architecture and colloids than LBC, whereas LBC enables rapid processing of samples with clearer backgrounds than conventional smears and the possibility of saving material for additional marker studies.
The role of immediate cytologic assessment is controversial 9. Many previous reports have stated that immediate assessment of cytologic adequacy at the time of FNA significantly decreased the numbers of nondiagnostic results and helped to avoid repeated FNAs 10 , 48 , 49 , 50 , However, others did not find a statistically significant difference in cytologic adequacy between FNAs of thyroid nodules with and without immediate cytological analysis, and stated that immediate cytological analysis considerably extended the cost and duration of the procedure It may not be necessary for the success of the procedure to perform an immediate assessment, especially if a highly-experienced operator with a relatively low nondiagnostic rate performs the US-FNA for the thyroid nodule Rather, immediate cytologic assessment can be reserved for the less-experienced operator and for repeat FNA of thyroid nodules with previous nondiagnostic results if available 50 , 51 , Generally, the risk of FNA-related bleeding diminishes with a few minutes of manual compression immediately after needle withdrawal Upon completion of the FNA procedure, the operator should examine the patient's neck to identify any bleeding-related manifestations, such as progressive swelling or ecchymosis.
In addition, it would be empirically recommended for the patient to manually compress the skin puncture site for an additional minute observation period after US-FNA and his or her neck should be ultrasonographically re-examined if FNA-related complications are suspected.
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This is especially important in patients with bleeding tendencies and these patients should be observed for minutes to detect any bleeding-related symptoms Local pain or bruising can be minimized by an ice pack. The patient should be discharged with instructions to seek medical care if sudden swelling or unrelenting pain occurs In regard to complications related with US-FNA, there is limited epidemiological data on the incidence and the relation to techniques including needle size, number of passes or the technique used.
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However, the possibility and severity of complications, including hemorrhage, may be increased by a medical history of hemorrhagic risk factors, thicker needles, vigorous handling of the needle, or lack of operator experience 12 , Local pain and ecchymosis are the most frequent complications related to US-FNA, however, serious events are very rare 4 , 5 , 8 , 25 , Most of the complications related to US-FNA can be sufficiently managed if the physician is aware and the patient is informed 8 , 9.
Local pain and slight ecchymosis related to minor hematomas are relatively tolerable; however, if they persist, mild painkillers such as Tylenol or temporary application of an ice pack on the painful area can control the pain very well 9. Aspirin or aspirin substitutes Motrin, Naprosyn should not be taken within 48 hours after the procedure, although there is no direct evidence against them.
Intrathyroidal- or perithyroidal-hemorrhage after US-FNA might be caused by venous extravasation into or around the nodules. Clinical manifestations of hemorrhage include increased pain, swelling and ecchymosis of the neck, dyspnea, dysphonia and dysphagia 9 , If hemorrhage is suspected, the patient's neck should be sonographically examined to ensure stabilization prior to discharging the patient.
What are some common uses of the procedure?
Small to moderate-sized hematomas can be successfully managed in out-patient settings with manual compression as well as an ice-pack and they usually resolve spontaneously within days. Only a few cases of uncontrolled hemorrhage, requiring hospital admission and more active intervention, have been reported in the literature 25 , 28 , 29 , Rarely, subendothelial carotid hematoma manifests as acute, persistent pain immediately after US-FNA To prevent bleeding around the thyroid glands or a potential complication such as pseudoaneurysm, firm pressure should be applied after confirming the presence of a hematoma.
Reduced activity and upper positioning of the head can be useful to decrease the spread of hematoma along the vessel wall. Usually, the hematoma absorbs spontaneously within a week. Some patients experience vasovagal reactions, such as light-headedness, nausea, sweating, clammy hands or seizure-like activity, due to pain or anxiety about the procedure, prior to, during, or after the procedure 9.
Especially, seizure-like activities such as uncontrollable jerking movements of the arms or legs can make the patients feel very scared. The symptoms usually last for minutes. It is advisable to calm the patient by placing them in a supine position with legs slightly elevated and cold compression applied to the forehead 8 , 9. Vital signs should be immediately monitored.
The incidence of needle track seeding following FNA of thyroid carcinomas is exceedingly rare and only a few cases have been reported in the literature Although the evidence is limited, several factors have been presumed to cause needle tract seeding, including larger needle size, excessive or vigorous needle manipulation, withdrawing the needle without releasing suction, and inherent characteristics of the lesion e. In all described cases, surgical treatment successfully removed the tumor seeding, and there was no evidence of recurrence during the follow-up period. Other rare complications are pseudoaneurysm, recurrent laryngeal nerve palsy, infection or post-FNA thyrotoxicosis 9 , Although US guidance ensures safe and exact targeting, the rates of nondiagnostic FNA results were highly variable and ranged between 0.
Considering the fact that the results of US-FNA have primarily supported the decision on whether to manage the thyroid nodule medically or surgically, its overall diagnostic yield, which reflects the operator's level of proficiency in this technique, should be continuously monitored 1 , Measuring technical proficiency in US-FNA ideally would include monitoring the frequency of nondiagnostic material leading to missed or delayed diagnoses of cancers.
However, this approach is quite difficult because it requires large numbers of cases and access to long term reliable follow-up in all cases, not just those referred to surgery soon after FNA. For these reasons, the nondiagnostic rate of each operator, documenting the number of nondiagnostic results divided by the number of total FNA procedures, may be used as a limited indicator for the level of proficiency So, nondiagnostic FNA results should not be regarded as simply benign.
In general, repeat US-FNA is recommended after a minimum interval of three months to prevent false-positive interpretations caused by reactive or reparative changes 1 , 4 , 6 , In contrast, two recent studies demonstrated that repeat FNAs within a shorter interval did not significantly influence the diagnostic yield of thyroid nodules with previously nondiagnostic results 58 , Therefore, a shorter waiting period may be possible in some patients if malignancy is highly suggested by clinical or US features Alternatively, a core needle biopsy is recommended as a complimentary tool to patients for whom previous FNA results are nondiagnostic to improve the diagnostic yield of US-FNA 60 , Apart from cytologic preparation and interpretation of FNA specimen, the diagnostic yield of US-FNA highly depends on both the US appearance of the thyroid nodule and the operator's experience Table 1 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , For example, certain US features such as cystic dominancy, macrocalcification, size less than mm, or hypoechogenicity, have been reported to increase the likelihood of nondiagnostic sampling despite highly variable nondiagnostic rates between studies 13 , 14 , 15 , 16 , 18 , 19 , 20 , 21 , 23 , 39 , 62 , 63 , Particularly, cystic dominancy and intranodular macrocalcification were reported to be independent findings that increase the possibility of nondiagnostic results, even when experienced operators performed US-FNA US guidance, gauge needle, four passes and preparation of samples four total smears: Especially for a nodule with peripheral calcification, it would be helpful to target the specific portion that favors the possibility of malignancy, such as the area with focal discontinuity or soft tissue rim, rather than an egg-shell like completely calcified rim 32 , 39 , Furthermore, previous studies indicated that approximately 2.
Therefore, FNA sampling should be specifically targeted to the internal solid portion that suggests malignancy after drainage of cystic content. Similar to other operator-dependent procedures, significant differences existed in nondiagnostic rates when US-FNAs were performed by highly experienced versus less experienced groups 13 , 14 , For example, nondiagnostic rates from one comparative study on operator experience were In a recent study, nondiagnostic US-FNA rate for radiology residents progressively declined with training levels.
Therefore, the researchers emphasized the role of early and continued participation in the procedures throughout residency To improve the skill of inexperienced operators, training should consist of an initial observation period to learn the indications and technical aspects of US-FNA as well as communication skills 1 , 14 , Only after this observation period should the trainee perform the procedure under the supervision of an expert radiologist 14 , Ultrasound-guided fine needle aspiration has been widely used as the main diagnostic method for patients with thyroid nodules, which have been increasingly detected following advancement of US technique.
However, the overall diagnostic yield of this method has been highly variable. To optimize patient care, safety, and the diagnostic yield of US-FNA, radiologists should understand the technical details, cytologic preparation, and procedure-related complications associated with US-FNA. National Center for Biotechnology Information , U. Journal List Korean J Radiol v. Published online Feb Follicular cells were scanty or absent nondiagnostic aspirates in the other 7 nodules. Of the initial 42 nodules in which fluid aspiration was performed, 11 On UG-FNAB, 23 were confirmed to be benign colloid nodules, 1 was nondiagnostic, and 2 were diagnosed as indeterminate follicular lesion one of these patients was referred for surgery, and the surgical pathology showed colloid goiter.
Numbers in parentheses represent the number of patients. All patients with either a benign or a malignant diagnosis on UG-FNAB had confirmation of these cytological findings on surgical pathology. One patient with nondiagnostic cytology was found to have papillary carcinoma. Among four patients with indeterminate results follicular neoplasm on cytology, one had a benign colloid nodule, one had a follicular adenoma, one had a papillary carcinoma, and one had a follicular carcinoma. Accuracy for the detection of malignancy was These data clearly suggest that complex nodules are better evaluated under ultrasound guidance.
For decades, simple aspiration of the fluid was the method of choice for the evaluation and treatment of cystic nodules, disregarding the fact that many of these nodules had a solid component. The high rate of acellular and nondiagnostic specimens in our study confirms the low diagnostic accuracy rate if simple aspiration is performed by C-FNAB. The mechanism by which fluid collects within a nodule is unclear. Pure cystic nodules are lined by a monolayer of epithelial cells 8 , which are probably responsible for the secretion of fluid.
Complex nodules are thought to result from degeneration of solid nodules 8 , 10 , 12 , with the accumulation of fluid probably resulting from intranodular necrosis and hemorrhage by rupture of the fragile vascular network 7 , 10 , This is supported by the observation of hemorrhage occurring soon after fluid aspiration, which probably occurs as a result of a sudden reduction in intranodular pressure 4. This may be the reason for the low recurrence rate of cystic nodules after percutaneous ethanol injection, which results in vascular thrombosis Complex nodules are considered to be among the main causes of nondiagnostic aspirates and diagnostic errors 11 , 15 on C-FNAB due to three reasons.
However, we demonstrated that hemorrhage was a frequent complication after fluid aspiration and, therefore, the palpable nodule may actually represent hemorrhage rather than the solid part of the nodule. Some authors have advocated applying pressure at the biopsy site for 5 min after aspiration of a cystic nodule 4 , 8.
Ultrasound-Guided Fine Needle Aspiration Biopsy of the Thyroid
However, this practice was later shown to be ineffective in preventing hemorrhage 17 , False-negative results attributable to either sampling errors or cytological misinterpretations are also mainly associated with complex nodules. The inconsistency in these results may be attributable to lack of uniform criteria in defining these lesions and for surgical referral. Many authors report their data on cystic nodules based on fluid aspiration alone when they may actually be describing complex nodules. Ultrasound guidance has been previously suggested to better evaluate complex nodules 2 , 15 , However, in that study, the nodules were not biopsied under direct ultrasound guidance.
We conclude that UG-FNAB is an excellent initial diagnostic method for the evaluation of complex thyroid nodules and also for the reevaluation of complex nodules previously found to be nondiagnostic by C-FNAB. We propose that complex nodules originate from solid nodules and that UG-FNAB is the best method to make a definitive diagnosis. Oxford University Press is a department of the University of Oxford.
It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. You will be asked to remain still and not to cough, talk, swallow or make a sound during the procedure. Aftercare instructions vary, but generally you can resume normal activities and any bandage can be removed within a few hours. The biopsy site may be sore and tender for one to two days.
You may take nonprescription pain medicine, such as acetaminophen, to relieve any discomfort. A pathologist examines the removed specimen and makes a final diagnosis so that treatment planning can begin. Depending on the facility, the radiologist or your referring physician will discuss the results with you.
Complications of thyroid biopsy are rare since the procedure is done under direct imaging guidance and with a fine needle. In some cases, the specimens may be inadequate and the procedure may have to be repeated in order to obtain diagnostic results.
Ultrasound-Guided Fine Needle Aspiration Biopsy of the Thyroid
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What are some common uses of the procedure? How should I prepare?
- What is Ultrasound-Guided Fine Needle Aspiration Biopsy of the Thyroid??
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What does the equipment look like? How does the procedure work? How is the procedure performed? What will I experience during and after the procedure? Who interprets the results and how do I get them? What are the benefits vs. Thyroid biopsy is used to find the cause of a nodule in the thyroid gland. Usually, no special preparations are required for this procedure.