Wednesday, November 29, 2023

Fine Needle Aspiration Of Thyroid

What Is The Evidence That Molecular Fna Diagnostics By Analyzing A Panel Of Somatic Mutations Can Alter The Follow

Thyroid FNA (Fine Needle Aspiration) Biopsy

It is commonly accepted that positive rule-in tests constitute an indication for surgery due to a substantial risk of malignancy . However, the important question arises of what to do when the FNA result is indeterminate and the panel of somatic mutations is positive only with respect to RAS mutation? Total thyroidectomy has been proposed for such cases due to a high risk of cancer . This is not supported by results of others who demonstrated that the presence of RAS mutation was associated with thyroid cancer in 19, 38, and 57% of cases while BRAF mutations were associated with cancer in 100% cancer samples . Even those who propose total thyroidectomy found that RAS mutations in benign thyroid adenomas do not require extensive surgery as for thyroid cancer . No data regarding the follow-up of patients with these nodules have been published.

The analysis of a panel of somatic mutations together with FNA in follicular lesions increased the diagnostic sensitivity from 60 to 80% in comparison with FNA alone. The risk of malignancy increased to 71% for mutation-positive FN and decreased to 18% for mutation-negative follicular lesions when compared to a 28% risk of malignancy evaluated by FNA only . Unfortunately, also in this study no data with reference to follow-up were given.

How The Test Is Performed

This test may be done in the health care provider’s office or in a hospital. Numbing medicine may or may not be used. Because the needle is very thin, you may not need this medicine.

You lie on your back with a pillow under your shoulders with your neck extended. The biopsy site is cleaned. A thin needle is inserted into your thyroid, where it collects a sample of thyroid cells and fluid. The needle is then taken out. If the provider cannot feel the biopsy site, they may use ultrasound or a CT scan to guide where to put the needle. Ultrasound and CT scans are painless procedures that show images inside the body.

Pressure is applied to the biopsy site to stop any bleeding. The site is then covered with a bandage.

What Are The Risks Of A Thyroid Fna

FNA is a very safe procedure and is considered very low risk for most people, because the needle that is used is so small.

There are two reasonably common risks and several rare risks that you should know about. The most common risk is an uncertain diagnosis, even after the tissue sample is looked at thoroughly by the pathologist. This happens up to 20% of the time.

The second most common risk is bleeding at the site of the FNA. This happens to approximately 1 in 10 people, and generally produces some local pain, tenderness and a lump. Simple pain medication available at the chemist is generally sufficient to help the pain and it settles with the swelling over a few days. It is best to avoid aspirin for pain relief unless you are taking this daily for other reasons. Aspirin makes it harder for blood to clot, so paracetamol is better if you need to take something for pain after the thyroid FNA.

Major haemorrhage, enough to cause compression of your airway and problems breathing, is very rare . You need to go to a hospital emergency department immediately if this happens, and sometimes surgery is needed to stop the bleeding, but this too is very rare.

Rarer complications after thyroid FNA include:

If any of these things happen to you, you should see your doctor.

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What Happens During A Thyroid Fine Needle Aspiration Biopsy

Some people, like children, might need a medicine to help them relax before the procedure. Most people will not need this, though.

In some cases, your healthcare provider might inject a local anesthetic to the area before inserting the needle. Because the needle is so small, this is often not necessary.

Your healthcare provider may perform the biopsy with the help of an ultrasound machine. This machine uses high-frequency sound waves to provide an ongoing image of the nodule. This enables your healthcare provider to guide the needle to exactly the right spot. It also prevents damage to other structures. A gel-like substance will be applied to your neck, where the ultrasound detector will be used.

After cleaning the area, your provider will insert the thin, fine needle into your thyroid gland. This may hurt a little. He or she will slowly advance the needle into the nodule itself, moving it back and forth several times.

The needle attaches to a syringe that can apply suction and remove some cells from the nodule. After the removal of the needle, these cells will be placed on a slide. Your healthcare provider might repeat this procedure a few times to obtain different samples from different parts of the nodule. Sometimes the lump will be all or mainly fluid. The fluid can be removed during the biopsy.

After the procedure, the cells will be sent to a pathology lab and analyzed for signs of cancer. A small bandage will be placed over the needle insertion site.

Indication And Goal Of Thyroid Fna


Thyroid nodular lesions are a common clinical problem. In the United States, 4 to 7% of the adult population have a palpable TN . The incidence of thyroid cancer in a clinically solitary TN or in a multinodular goiter is equal and about 5% in non-endemic areas . TNs constitute the main indication for FNA, and the goal of this diagnostic procedure is to detect thyroid neoplasms for surgical resection and to identify non-neoplastic lesions that may be managed conservatively . This method of clinical investigation has reduced the number of diagnostic thyroid surgeries for TNs by 6085%, and the difference in rates of thyroid surgery reflect the cytodiagnostic accuracy rates among different medical centers .

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Fine Needle Aspiration Biopsy Of Thyroid Nodules

Procedure and interpretation of results


A fine needle aspiration biopsy of a thyroid nodule is a simple and safe procedure performed in the doctors office. Typically, the biopsy is performed under ultrasound guidance to ensure accurate placement of the needle within the thyroid nodule. You will be asked to lie down on your back with your head tipped backwards, so that your neck is extended. Sometimes, a pillow is placed under your shoulders to help you get in the best position for the biopsy.

During the procedure you may feel some neck pressure from the ultrasound probe and from the needle. You will be asked to remain as still as possible and avoid coughing, talking and swallowing during the biopsy.

Possible Surgical Consequences Of Molecular Fna Diagnostic Results Of Thyroid Nodules

The preoperative knowledge of a verified thyroid carcinoma will have an impact on the surgical strategy and therefore will considerably increase the success of the oncologic treatment.

The clinical setting may lead to two different basic diagnostic approaches in the decision-making for thyroid surgery due to suspicious nodes:

  • Rule out malignancy in order to avoid surgery

  • Verify malignancy preoperatively and determine the type of thyroid cancer to optimize surgical strategy and treatment success, while avoiding secondary interventions

  • In order to comply with the rule-in and rule-out strategies the necessary NPV for rule-out tests should be > 95% according to the National Comprehensive Cancer Network guidelines , while the ideal PPV should be > 95% for rule-in strategies leading to more radical resections . However, apart from the indication for primary radical surgery a lower risk of malignancy prompts the recommendation for diagnostic resection. Current guidelines recommend total or near total thyroidectomy or lobectomy in case of FNA results suspicious for malignancy , which is associated with a 6075% risk of malignancy. Similarly lobectomy is recommended in case of Bethesda class IV with a risk of malignancy ranging from 15 to 30% .

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    How Is A Thyroid Fna Performed

    The neck will first be cleaned with an antiseptic. A local or topical anesthetic may be applied. For the biopsy, your doctor will use a very thin needle to withdraw cells from the thyroid nodule. The needle used is smaller in diameter than those used in most blood draws. Your doctor will insert the needle through the skin and into the thyroid nodule. After the sampling, which only takes several seconds, the needle will be removed. New needles are used for additional samples. Several samples of cells will be obtained, by sticking a fine needle in various parts of the nodule usually between two and six times . This assures a better chance to find cancerous cells if they are present. If there is fluid in the nodule, a syringe may be used to drain it.

    Once the biopsy is completed, pressure will be applied to the neck. The procedure usually lasts less than 30 minutes.

    Can Fine Needle Aspiration Be Used To Treat Thyroid Nodules

    Fine Needle Aspiration (FNA) of the Thyroid Gland

    Certain thyroid nodules may be treated by FNA technique. These include fluid-filled nodules, called thyroid cysts. In the case of thyroid cysts, the fluid is removed using FNA. Then sterile, medical-grade alcohol called ethanol is injected into the cyst. The ethanol is allowed to sit for a short period of time and is then removed. The ethanol irritates the lining of the cyst, decreasing the chance for fluid to reaccumulate. This procedure is called sclerotherapy.

    Injection of ethanol by fine needle may also be used to destroy small lymph nodes with metastatic papillary thyroid cancer.This procedure is called ultrasound-guided percutaneous ethanol ablation . In PEA, the ethanol volume is even smaller, and it is left in the lymph node after injection. The goal of PEA is to destroy the lymph node without additional surgery or radioactive iodine. For most patients, PEA involves two or more injections, usually 6 to 12 months apart. Your Thyroid Center provider and interventional radiologist will discuss these procedures with you if they feel your child would be a good candidate.

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    Are There Any After Effects Of A Thyroid Fna

    It is common to have some pain, swelling and even a little bruise where the needle was inserted into your neck. Simple pain medication available from the chemist, such as panadol or panadeine, can be taken for this. Pain and swelling should be minimal after 48 hours.

    It is important to avoid strenuous activity, particularly activity that involves bending over, straining or working over your head , as all of these activities can increase the chance of internal bleeding into the thyroid gland.

    It is uncommon to have any change in your voice, severe pain, general neck swelling, or difficulty breathing or swallowing after a thyroid FNA. If any of these things happens, you should phone the hospital or radiology practice where the procedure was carried out and let them know.

    If you are experiencing difficulty breathing after the procedure, you should go immediately to the nearest hospital emergency department.

    What Happens During The Procedure

    You may be asked to wear a hospital gown for the procedure.

    It is important to remember that the doctors carrying out your FNA are there to answer any questions you might have at any time and to ensure you remain as comfortable as possible. If you have any questions, this is the time to ask them.

    Once in the treatment room, you will be asked to lay back on the bed with a pillow to support your shoulders. You will be required to tilt your head backwards to enable the doctor to access the thyroid gland. Your neck will be cleansed and a local/topical anaesthetic may be applied. It is essential that you remain still, avoid swallowing, speaking, coughing or moving. The doctor will hold the lump with one hand and insert the needle into the lump.

    You may feel some pressure at this point but if you have had an anaesthetic this should reduce any pain. An ultrasound machine is sometimes used to help guide the needle safely into the lump/nodule enabling cells to be removed for further testing.2 You are not exposed to any radiation during this process.

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    Nodule Characterization In Ultrasonography

    In sonographic examination, the internal texture, echo structure, and presence of calcification in TNs were evaluated. The largest diameter was determined by three dimensional measurements of the nodules. The texture of the nodule was evaluated in three groups as solid, cystic, or mixed solid-cystic. Pure cystic nodules were excluded from the study. Echogenicity of TNs was grouped as hyperechoic, isoechoic, hypoechoic, and anechoic compared with normal thyroid parenchyma. In the presence of more than one nodule in the same patient, FNAB was performed on the largest sized dominant nodule and/or one with suspicious structures. Nodules with microcalcification, hypoechoic structure, irregular contour, and intranodular vascularization were preferred in addition to larger nodules under US to be biopsied . Attention was paid to take samples from the solid part of the semi-solid nodules.

    Ultrasonography image of a 28-year-old female patient. Transverse plan gray scale ultrasound image shows a hypoechoic solid nodule with microlobulated contour in the middle part of the thyroid right lobe, with punctate echogenic foci in the center. FNAB revealed a diagnosis of papillary thyroid carcinoma .

    Why Might I Need A Thyroid Fine Needle Aspiration Biopsy


    You might need the test to see whether your nodule is cancerous. You might have noticed the nodule yourself, or your healthcare provider might have noticed it during an exam or on another test.

    Researchers do not know what causes most thyroid nodules. They are very common, though. Certain problems with the thyroid gland, like Hashimoto thyroiditis, may increase your chances of getting a thyroid nodule. Thyroid nodules are much more common in women than in men. Nodules tend to grow during pregnancy. People who have had radiation treatments to their neck are also more likely to develop nodules. Your risk of developing thyroid nodules or thyroid cancer is increased if members of your family have already had thyroid and certain other cancers.

    Only a small percentage of thyroid nodules turn out to be cancer. It is important to identify a cancerous nodule as soon as possible, so that you can begin treatment quickly.

    Not everyone who has a thyroid nodule needs a fine needle aspiration biopsy. Your healthcare provider may start with an ultrasound or computed tomography scan of your neck. Sometimes, this provides enough information to know that the nodule isnt due to cancer. Blood tests of thyroid levels also may provide helpful information. If your healthcare provider cant tell for sure, youll probably need a thyroid fine needle aspiration biopsy.

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    What Will A Biopsy Tell Me

    Sometimes, a nodule or goiter just sits there and isnât dangerous.

    When they do cause problems, it could be something like:

    Cysts, fluid-filled nodules that can give you neck pain or make it hard to swallow. Theyâre very rarely cancer but still might need treatment.

    Gravesâ disease, which causes your thyroid to grow and make too many hormones.

    Hashimotoâs disease, where your thyroid is damaged by your immune system, so it makes fewer hormones than normal and then swells.

    Infection, where a virus causes pain and swelling in your thyroid.

    Large nodules or goiters that are an issue because of their size. They can push into surrounding body parts and make it harder to breathe or swallow.

    Toxic nodules or goiters, which are almost never cancer, can cause your thyroid to pump out too many hormones.

    Cancer, which makes up about 10% of cases.

    Adjunctive Diagnostic Value Of Ancillary Techniques

    Ultrafast Papanicolaou stain selectively swells the nuclei of papillary thyroid carcinoma, making their nuclear grooves disappear and making the swollen nuclei look like “watery grapes”, while this staining method has no effect on nuclei of a follicular adenoma . This artifactual change is due to the disorganization of nuclear lamins and permits a confident distinction between a follicular adenoma and a follicular variant papillary carcinoma . Immunostaining with thyroid peroxidase antibody has been reported to be of value in distinguishing these two lesions, as malignant and benign follicular cells commonly stain negatively and positively with this antibody, respectively .

    Ploidy determination has no value in distinguishing a follicular adenoma from a follicular carcinoma and immunostaining for p53, Ki-67 and Bcl-2 has no value in separating benign from malignant Hurthle cell tumors .

    At present, techniques such as microarray analysis are limited by the amount of RNA that can be retrieved from a sample, thereby often limiting analysis to surgically resected samples. However, refinement of these techniques may make them applicable to FNA, with extraction of RNA from a cell block from which molecular analysis of FNA material may have significant diagnostic benefit.

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    About Your Fna Procedure

    The thyroid gland is a small gland in the lower part of the front of your neck. Your thyroid makes hormones that control your metabolism .

    A fine needle aspiration is a procedure that uses a thin needle to take out cells from a nodule in your thyroid gland. Thyroid nodules are abnormal growths of tissue or fluid that may or may not be cancer. After your FNA procedure, the cells that were taken out are checked to see if they have cancer.

    Your FNA procedure can be done in your healthcare providers office or at a local radiology center.

    • If youre having your FNA done at Memorial Sloan Kettering , your healthcare providers office will help schedule this appointment.
    • On the day of your appointment, make sure you eat a light meal so you dont feel dizzy and lightheaded . You dont need to follow any special diet. Take all your usual medications too.
    • Tell your healthcare provider if youre taking aspirin or any anticoagulant medication, such as warfarin , dalteparin , or enoxaparin . Your healthcare provider may tell you to stop taking your medication several days before your procedure.
  • If youre having your FNA done at a local radiology center, your healthcare provider will give you a prescription. Check with the radiology center about what instructions they want you to follow before the procedure.
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