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The combination of aspiration needle biopsy (ANB) with fine needle aspiration (FNA) in preoperative selection of thyroid tumors
245 THE COMBINATION OF ASPIRATION NEEDLE BIOPSY (ANB) WITH FINE NEEDLE ASPIRATION (FNA) IN PREOPERATIVE SELECTION OF THYROID TUMORS A. Carpi , A. Sagripanti , E. Ferrari , G. Cirigliano ,*G. Di coscio Istituti di Clinica Medica e di ‘Anatomia Patologica; Universid degli Studi di Piss.. Pisa Italia Since 1980 we have been performing preoperative selection of all palpable thyroid nodules in euthyroid subjects by adopting MA citology combined with ANB histology in the largest nodules. Up to 1992, 5,405 patients have been examined and 485 undergone surgery (8.9%). One hundred and sixty five cancers (3% of all the patients examined using needle aspiration techniques and 34% of all the operated patients) were postoperatively diagnosed. FNA citology played the principal role in achieving this high selection rate. We intend to give an up-to-date report on the main contribution of ANB for these results. Ah:B was performed with 18 or 16 gauge needles, without cutting the skin, in 1668 of the 5,405 examined patients (31%).A benign ANB diagnosis was obtained in 80 patients with inadequate FNA findings. ANB achieved complete evaquation of 25 cysts with very thick content which had not been aspirated by FNA. FNA missed 17 of the 165 excised cancers; ANB correctly identified 6 of these 17 cancers (preoperative FNA diagnosis indicated a benign nodule in 5 and it was inadequate in 1). Therefore, the sensitivity of needle aspiration techniques increased from 89% to 93% by combining ANB with FNA. One hundred and seventy-three nodules examined by adopting FNA and ANB were excised.
These nodules either had citological and histological diagnosis of benign nodule (Ben.) or had suspected cancer (S.C.). Each group of diagnosis at FNA (Ben. or SC.) has been divided into two series according to the preoperative ANB diagnosis. The incidence of malignant nodules at postoperative histology in the 2 MA groups with the same FNA diagnosis but with different ANB findings is shown and compared in the table GROUP FNA FNA
Ben,ANB Ben,ANB
PATIENTS Ben S.C.
no
Ca
75 8
INCIDENCE 5.3 % 25 %
FNA S.C.,ANB Ben 19 % FNA S.C.,ANB S.C. ;: 43 % Cancer incidence changes significantly (I’analysis,p~O.OOI) in each FNA group, according to the ANB findings. From 1984 to 1989, 144 patients with preoperative citological findings of microfollicular nodule underwent ANB histology. ANB showed a macrofollicular component in 55 nodules and a normal follicular structure in 15, it confirmed the microfollicular structure in 50 nodules (32%) and was inadequate in the remaining 24. Therefore, ANB significantly reduced the number of patients considered at some risk of malignancy These data show a very satisfactory preoperative selection of thyroid nodule patients by using needle aspiration techniques and indicate that the combination of ANB with FNA proved very beneficial to 101 patients (10% of al1 the ANB exams). Furthermore, they indicate that improvement of diagnostic accuracy can be expected by the combination of ANB with FNA.
The Value of Coarse Needle Glopsy In Evaluallng Thyrold Nodules. Paul Lo Gerfo, Professor of Surgery, Columbia Presbyterlan Medical Center, New York, N.Y.
FNA IN PREOPERATIVE NODULES
SELECrION
OF OXYPHIL-CELL
G. Di Cosc~o. I. Muchwi.
A. Aversa and A. Carpi..
At CPtlC the lncldence of thyroid cancer found al surgery (Cl) prior to 1950 was 3-41. The Cl gradually Increased to 29X In 1975 wlthout the use of needle biopsy. Fine needle biopsy (FNE) was Introduced In 1976. The Cl dld not change during the next 6 years but remalned stable at 27X In Patlent who dld not undergo coarse needle blopsy (CNG). The overall Cl uslng both FNB and CNB In 1964 was 42X and wllh CNG alone. 47X. Since that tlme extensive experience using both CNB and FNG has led to a Cl of SIX. The Cl ln patients who only received FNG remalns at 26X. In a review of 1625 patients who have undergone CNB there were 3 compllcatlons which repulred surgical Intervention (.016X). All of these were for bleeding 36-72 hours after CNB. These 3 patients underwent total thyroldectomy for folllcular cancer wlthout compllcatlons. There were no other slgnlflcant compllcatlons. The data suggested that ths Increase In Cl seen In patlents undergolng CNG occurred because thls procedure allowed the pathologlst to dlstlngulsh hyperplastlc lesions from mlcrofolllcular neoPlasms. Based on this. 70 patients, referred for surgery because of susp!clon of a folllcular neoplasm determlned on FNG alone, underwent CNB. 35 of these Patients were shown to have benign macro-micro folllcular leslons(hyperplastlc). This experlance leads me to belleve that CNG Is extremely useful In evaluating thyrold nodules and although there Is a small compllcatlon rate this Is offset by a large decrease (40X) In the number of patlents referred for operation. The primary value of CNB Is In dlflerentlatlng between true mlcrofolllcular
lsliluli dt Anatomic PlsJ. Il~li~
Palologic;l c di ‘Climca
Mcdica
Il.
THYROID
Univcrsilh
di
Oxyphil-cell ncoplasms represent one of the most imporumt diagnoslic problems in lhyroid nodules pathology. In this siudy we lried IO specify cylologic porame~crs which characterize these lumors in order to distinguish bclwecn malignanl ;Ind benign-t farms. We crnmined PNA soccimens from 50 patients (4 mrdcs and 46 females) who received cytologic dingnosis of &yphil-cell neoplasm. Al hystolugic vcrific.?lion WC found 34 adcnomas. I2 papillary carcinomas (5 mixed) and 4 lollicular cxcinonms. MCXI age was 51 years in lcn~alcs with ~dcnomn ;Ind 47 years in lcmalcs with carcinwna. All the 4 males (mean age ul 41 years) had carcinwws. Cytologic FNA specimens wcrc struincd according Lo Papsnicolwu .?nd Gicmsa methods. In the morphologic study we cvalutalcd PNA Ict~lurcs (well or poor ccllulatcd. cystic or necrotic): ccllul~r orgnnizalion (presence of fullicular. papillary or lrabccular masses or scallcrcd cclls~: ccllul.v rca:urcs SI*“CL”*CS. irrcgulu (large or small. polygonal. round or cylindric. bassophil or eusinophill: IIUCICUS morphology (dimcnsioss. shape. chromatln dislribution. prcscncc or Iwclcoli. mxro ur pscudowtclculi). Papillary s~ructurcs. pscudonuclcoli nnd cylindric cells wcrc present only in papillary carcinonms. in 33%. 334 nod 50% of cases &peclivcly: Mncronuclcoli were prcscm in 31% al carcinomas and in IS% 0r adcnomas. Cells were smell in 63% ur carcinomas and in 32% 0r adcnom;ls.Thc use or these psrrm~elcrs in a prcopcralivc selcclion allwcd to identify I.5 ol the I6 cxcinomY but did not wvid surgery in I3 p.LicnIs with bcnignw nodulnr palhulogy (69 or Ialsc negative and 38% of lalsc posilivc cnscr). Other mornholoaic rcatures considered were usclcss in the dilIcrential diagnosis of wmurs of this type. Marked cellular alypias. usually reprcscnling csscnlial criteria in cytologic diqworis. were present wilh the same rrcquency (38%) in hc~lignnnl and malignam nudules.
_
These nodules either had citological and histological diagnosis of benign nodule (Ben.) or had suspected cancer (S.C.). Each group of diagnosis at FNA (Ben. or SC.) has been divided into two series according to the preoperative ANB diagnosis. The incidence of malignant nodules at postoperative histology in the 2 MA groups with the same FNA diagnosis but with different ANB findings is shown and compared in the table GROUP FNA FNA
Ben,ANB Ben,ANB
PATIENTS Ben S.C.
no
Ca
75 8
INCIDENCE 5.3 % 25 %
FNA S.C.,ANB Ben 19 % FNA S.C.,ANB S.C. ;: 43 % Cancer incidence changes significantly (I’analysis,p~O.OOI) in each FNA group, according to the ANB findings. From 1984 to 1989, 144 patients with preoperative citological findings of microfollicular nodule underwent ANB histology. ANB showed a macrofollicular component in 55 nodules and a normal follicular structure in 15, it confirmed the microfollicular structure in 50 nodules (32%) and was inadequate in the remaining 24. Therefore, ANB significantly reduced the number of patients considered at some risk of malignancy These data show a very satisfactory preoperative selection of thyroid nodule patients by using needle aspiration techniques and indicate that the combination of ANB with FNA proved very beneficial to 101 patients (10% of al1 the ANB exams). Furthermore, they indicate that improvement of diagnostic accuracy can be expected by the combination of ANB with FNA.
The Value of Coarse Needle Glopsy In Evaluallng Thyrold Nodules. Paul Lo Gerfo, Professor of Surgery, Columbia Presbyterlan Medical Center, New York, N.Y.
FNA IN PREOPERATIVE NODULES
SELECrION
OF OXYPHIL-CELL
G. Di Cosc~o. I. Muchwi.
A. Aversa and A. Carpi..
At CPtlC the lncldence of thyroid cancer found al surgery (Cl) prior to 1950 was 3-41. The Cl gradually Increased to 29X In 1975 wlthout the use of needle biopsy. Fine needle biopsy (FNE) was Introduced In 1976. The Cl dld not change during the next 6 years but remalned stable at 27X In Patlent who dld not undergo coarse needle blopsy (CNG). The overall Cl uslng both FNB and CNB In 1964 was 42X and wllh CNG alone. 47X. Since that tlme extensive experience using both CNB and FNG has led to a Cl of SIX. The Cl ln patients who only received FNG remalns at 26X. In a review of 1625 patients who have undergone CNB there were 3 compllcatlons which repulred surgical Intervention (.016X). All of these were for bleeding 36-72 hours after CNB. These 3 patients underwent total thyroldectomy for folllcular cancer wlthout compllcatlons. There were no other slgnlflcant compllcatlons. The data suggested that ths Increase In Cl seen In patlents undergolng CNG occurred because thls procedure allowed the pathologlst to dlstlngulsh hyperplastlc lesions from mlcrofolllcular neoPlasms. Based on this. 70 patients, referred for surgery because of susp!clon of a folllcular neoplasm determlned on FNG alone, underwent CNB. 35 of these Patients were shown to have benign macro-micro folllcular leslons(hyperplastlc). This experlance leads me to belleve that CNG Is extremely useful In evaluating thyrold nodules and although there Is a small compllcatlon rate this Is offset by a large decrease (40X) In the number of patlents referred for operation. The primary value of CNB Is In dlflerentlatlng between true mlcrofolllcular
lsliluli dt Anatomic PlsJ. Il~li~
Palologic;l c di ‘Climca
Mcdica
Il.
THYROID
Univcrsilh
di
Oxyphil-cell ncoplasms represent one of the most imporumt diagnoslic problems in lhyroid nodules pathology. In this siudy we lried IO specify cylologic porame~crs which characterize these lumors in order to distinguish bclwecn malignanl ;Ind benign-t farms. We crnmined PNA soccimens from 50 patients (4 mrdcs and 46 females) who received cytologic dingnosis of &yphil-cell neoplasm. Al hystolugic vcrific.?lion WC found 34 adcnomas. I2 papillary carcinomas (5 mixed) and 4 lollicular cxcinonms. MCXI age was 51 years in lcn~alcs with ~dcnomn ;Ind 47 years in lcmalcs with carcinwna. All the 4 males (mean age ul 41 years) had carcinwws. Cytologic FNA specimens wcrc struincd according Lo Papsnicolwu .?nd Gicmsa methods. In the morphologic study we cvalutalcd PNA Ict~lurcs (well or poor ccllulatcd. cystic or necrotic): ccllul~r orgnnizalion (presence of fullicular. papillary or lrabccular masses or scallcrcd cclls~: ccllul.v rca:urcs SI*“CL”*CS. irrcgulu (large or small. polygonal. round or cylindric. bassophil or eusinophill: IIUCICUS morphology (dimcnsioss. shape. chromatln dislribution. prcscncc or Iwclcoli. mxro ur pscudowtclculi). Papillary s~ructurcs. pscudonuclcoli nnd cylindric cells wcrc present only in papillary carcinonms. in 33%. 334 nod 50% of cases &peclivcly: Mncronuclcoli were prcscm in 31% al carcinomas and in IS% 0r adcnomas. Cells were smell in 63% ur carcinomas and in 32% 0r adcnom;ls.Thc use or these psrrm~elcrs in a prcopcralivc selcclion allwcd to identify I.5 ol the I6 cxcinomY but did not wvid surgery in I3 p.LicnIs with bcnignw nodulnr palhulogy (69 or Ialsc negative and 38% of lalsc posilivc cnscr). Other mornholoaic rcatures considered were usclcss in the dilIcrential diagnosis of wmurs of this type. Marked cellular alypias. usually reprcscnling csscnlial criteria in cytologic diqworis. were present wilh the same rrcquency (38%) in hc~lignnnl and malignam nudules.
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