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  In this article
 »  Introduction
 »  I. Indications f...
 »  II. Training and...
 »  III. Techniques ...
 »  IV: Diagnostic t...
 »  V. Utilization o...
 »  VI. Post FNA Opt...
 »  Competing interests
 »  Acknowledgements
 »  References
 »  Article Tables

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REVIEW
CytoJournal 2008,  5:6

The National Cancer Institute Thyroid fine needle aspiration state of the science conference : A summation


1 Department of Pathology. University of Pennsylvania Medical Center. Philadelphia, Pennsylvania, USA
2 Department of Pathology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
3 Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
4 Department of Pathology, University of Utah Hospital and Clinics, Salt Lake City, Utah, USA
5 Department of Pathology, University of California San Francisco, San Francisco, California, USA
6 Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
7 Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA

Date of Submission18-Mar-2008
Date of Acceptance07-Apr-2008
Date of Web Publication07-Apr-2008

Correspondence Address:
Andrea Abati
Chief, Cytopathology, National Cancer Institute/National Institutes of Health, Building 10 Room 2A19, Bethesda, MD 20892
USA
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© 2008 Baloch et al; licensee Cytopathology Foundation Inc.This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


DOI: 10.1186/1742-6413-5-6

PMID: 18394201

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How to cite this article:
Baloch ZW, Cibas ES, Clark DP, Layfield LJ, Ljung BM, Pitman MB, Abati A. The National Cancer Institute Thyroid fine needle aspiration state of the science conference : A summation. CytoJournal 2008;5:6

How to cite this URL:
Baloch ZW, Cibas ES, Clark DP, Layfield LJ, Ljung BM, Pitman MB, Abati A. The National Cancer Institute Thyroid fine needle aspiration state of the science conference : A summation. CytoJournal [serial online] 2008 [cited 2014 Sep 1];5:6. Available from: http://www.cytojournal.com/text.asp?2008/5/1/6/41200



 » Introduction Top


On October 22 and 23, 2007, the National Cancer Institute (NCI) hosted "The NCI Thyroid Fine Needle Aspiration (FNA) State of the Science Conference," a two-day gathering in Bethesda, Maryland. Its mission was to establish a comprehensive interdisciplinary informational dialogue dedicated to thyroid FNA. Preparations for the conference began 18 months earlier with the designation of a steering committee, the appointment of nine working committees, coordination with co-sponsoring organizations, and the establishment of a dedicated permanent web site. The function of the website was to serve as a permanent educational tool for health care practitioners and patients alike, as well as to foster on-line dialogue.

Six committees were charged with preparing summary documents based on literature reviews on the following subjects: 1. Indications/Pre-FNA requirements; 2. Training and Credentialing; 3. Technique; 4. Terminology and Morphologic Criteria; 5. Ancillary Studies; and 6. Post-FNA Options for Testing and Treatment. Three additional committees were formed, one each to oversee the website, publications ensuing from the conference and the establishment of an on-line educational cytopathology  Atlas More Details.

Literature reviews were limited to English language publications dating back to 1995, using PubMed as the search engine, with key words determined by the committee members. The first draft of the committees' summary documents ("Review and Conclusions") was posted on the web site and open for on-line forum discussion from May 1-June 30, 2007. There were several subsequent drafts and on-line discussion periods (Aug 15 - Sept. 30, 2007 and Nov. 30-Dec. 15, 2007). The documents underwent revision after each comment period prior to re-posting on the web. The two-day "live" conference in October, attended by 154 registrants, comprised of pathologists, endocrinologists, surgeons, and radiologists, gave the committees an in-depth opportunity to present their conclusions and debate controversial areas.

This is an abridged version of the topics reviewed at the conference and the website. This is not a "standards of practice" guideline, nor is it endorsed as such by the National Cancer Institute.


 » I. Indications for Thyroid FNA and Pre-FNA Requirements Top


A. Indications for performing an FNA of a thyroid nodule discovered by palpation

Every patient with a palpable thyroid nodule is a candidate for fine needle aspiration (FNA) and should undergo further evaluation to determine if an FNA is warranted[1]Thyroid nodules detected by palpation are usually at least 1.0 cm in dimension and are therefore clinically significant. Before a decision is made to perform an FNA, a complete history should be taken; a physical examination directed to the thyroid gland and cervical lymph nodes should be performed; and a serum thyrotropin level (TSH) and thyroid ultrasound (US) should be obtained [1,2].

Patients with a normal or elevated serum TSH level should proceed to a thyroid US to determine if an FNA needs to be performed (see section B below); those with a depressed serum TSH should have a radionuclide thyroid scan, the results of which should be correlated with the sonographic findings [1,2]. Functioning thyroid nodules in the absence of significant clinical findings do not require an FNA because the incidence of malignancy is exceedingly low [3]. A nodule that appears either iso- or hypo-functioning on radionuclide scan, however, should be considered for FNA based on US findings (see section B below) [1].

B. Indications for performing an FNA of a thyroid nodule discovered via imaging

A nodule not previously suspected or discovered clinically, but detected by an imaging study, is considered an incidental nodule ("incidentaloma"). Incidentalomas detected by 18 FDG-PET are unusual (2-3% of all PET scans) but have a higher risk of cancer (14-50%) compared to background incidence [4]. Therefore, a focal nodule that is 18 FDG-PET-avid is an indication for FNA. This applies only to focal lesions. Diffuse increased uptake on 18 FDG-PET does not warrant FNA unless thyroid sonography detects a discrete nodule.

All focal hot nodules detected on sestamibi scans and confirmed by US to be a discrete nodule should undergo FNA. Thyroid incidentalomas detected on sestamibi scans have a higher risk of cancer (22-66%) compared to baseline risk [5,6].

Incidentalomas detected by US (e.g., carotid Doppler scans or scans done for parathyroid disease) have a cancer risk of approximately 10-15% (0-29%) and should undergo dedicated thyroid sonographic evaluation [7-12]. Lesions with a maximum diameter greater than 1.0-1.5 cm should be considered for biopsy unless they are simple cysts or septated cysts with no solid elements. FNA may also occasionally be replaced by periodic follow-up for nodules of borderline size (between 1.0 and 1.5 cm in maximum diameter) if they have sonographic features that are strongly associated with benign cytology.

A nodule of any size with sonographically suspicious features can also be considered for FNA. Sonographically suspicious features include microcalcifications, hypoechoic solid nodules, irregular/lobulated margins, intra-nodular vascularity, and nodal metastases (or signs of extracapsular spread). This latter recommendation is controversial because it includes patients with microcarcinomas, in whom a survival benefit following an FNA diagnosis has not been documented. Nevertheless, the American Thyroid Association, the Academy of Clinical Thyroidologists and a collaborative effort of the American Association of Clinical Endocrinologists and the Associazione Medici Endocrinologi make this recommendation [1, 7, 13].

There are few direct data on the cancer risk of thyroid incidentalomas detected by computed tomography (CT) or magnetic resonance imaging (MRI). They are seen in at least 16% of patients evaluated by neck CT or MRI [14]. The risk of cancer in one study was predicted at 10%, but it included only a limited number of patients who went on to FNA[15]. CT and MRI features can not determine the risk of malignancy, except in very advanced cases that are unlikely to be incidental. Until more data are available, incidentalomas seen on CT or MRI should undergo dedicated thyroid sonographic evaluation. Any nodule with sonographically suspicious features (see above) should be considered for FNA. In addition, lesions that have a maximum diameter greater than 1.0-1.5 cm should also be considered for FNA (see above).

C. Indications for performing a thyroid FNA using palpation vs. ultrasound for guidance

In the evaluation of individual patients with nodular disease, there are occasions when either palpation or ultrasound-guided (US-guided) FNA of a thyroid nodule are reasonable to perform. Palpation-guided FNA can be performed with high levels of success in specific circumstances [16-18]. The benefits of palpation-guided FNA of thyroid nodules are its reduced cost in comparison to US-guided FNA as well as its logistical efficiency: the practitioner can perform the procedure without an US machine or assistance from other practitioners.

Published data from one study concludes that US evaluation changes the management of 63% of patients with palpable thyroid nodules [19]. US findings like irregular margins, microcalcifications, intra-nodular vascularity and the characteristics of other occult thyroid nodules can be used to identify nodules at risk that should be sampled [12,20]. In several studies US guidance was shown to reduce the rates of non-diagnostic (i.e., insufficient cells and/or colloid) and false-negative aspirates [16, 17, 21]. Re-evaluation of patients using US-guided FNA for those with initially benign results on palpation-guided FNA, led to the reclassification of patients and the diagnosis of 14% more cancers in one series [22]. Finally, there are US-specific findings that can be used to inform the results of the US-guided FNA (e.g. the benign sonographic appearance of a unilocular cyst explains why only cyst fluid was obtained by FNA).

A palpation-guided FNA can be considered when a thyroid nodule >1 cm in maximum diameter has been confirmed via US examination of the thyroid. The sonographic examination is important, because physical examination can be imprecise in determining nodule size, its origin from the thyroid rather than adjacent tissues, and the degree of cystic change. US-guided FNA is acceptable and is preferred for nodules that are not palpable, >25% cystic or have been biopsied before and yielded a non-diagnostic result [23,24].

D. The informed consent form for thyroid FNA

Legislation regulating the conditions under which consent must be obtained vary greatly by state [25-27]. Thus, providers (e.g., pathologists, radiologists, surgeons, endocrinologists, etc.) who perform thyroid FNA need to design informed consent policies and forms based on state regulations. For thyroid FNA, informed consent materials, including written documents, if used, should describe the FNA procedure and potential risks and complications. The possibility of the most frequently occurring complication, namely, hematoma, should be mentioned. Information should be presented in a manner to facilitate patient understanding. It might be useful to mention the possibility of a non-contributory result. Estimates of accuracy, such as false-negative and false-positive proportions, are not mandatory and should be considered only if the practitioner believes they would facilitate patient comprehension.

E. Information required on the requisition form that accompanies a thyroid FNA

Federal regulations in the United States require that specific identifying information be provided to laboratories with all specimens submitted for laboratory testing [28]. These include the name and address of the person requesting the test; the patient's name or unique identifier; the patient's gender; the patient's age or date of birth; the name of test to be performed; the specimen source; the date of specimen collection; and any additional relevant information. The purpose of this discussion is to consider what 'additional relevant information' a laboratory needs to properly evaluate a thyroid FNA specimen.

The location of the nodule (right vs. left; isthmus; upper pole, mid-pole, lower pole, etc.) should be specified on the requisition form to permit correlation with sonographic findings and subsequent histopathologic examination (if any). Such identification is often necessary because patients often present with multiple nodules (some but not all of which may be biopsied), or they may develop other nodules over time.

There is, at best, an imperfect correlation between the size of a nodule and the likelihood of malignancy, but larger nodules (>4 cm) may be associated with a higher malignancy risk, and therefore size should be included [29].

Benign cytologic changes that mimic malignancy, particularly papillary carcinoma, occur in some patients with autoimmune (Hashimoto's) thyroiditis. If not alerted to this history, a misdiagnosis can occur. Furthermore, nuclear alterations may be seen in patients with a history of I-131 therapy (for hyperthyroidism) or external radiation [30]. In some patients with Graves' disease, an FNA of a nodule may include pleomorphic cells from the extra-nodular Graves' thyroid parenchyma that can be a pitfall in cytologic interpretation [31].

It is important to note a personal history of malignancy because metastatic tumors to the thyroid can mimic the appearance of a primary thyroid neoplasm. Metastatic renal cell carcinoma mimics a follicular neoplasm; melanoma can mimic medullary carcinoma; metastatic lung cancer can mimic anaplastic carcinoma of the thyroid. Cytologists should be alerted to the possibility of a metastatic tumor in any patient with a history of malignancy.

Approximately 15% of medullary thyroid cancers are familial (familial MTC or MEN2a or 2b). Knowledge of family history can alert the pathologist to the possibility of medullary carcinoma. Recent data show that papillary thyroid cancer can also be familial, and thus knowledge of such family history can alert the pathologist to consider papillary carcinoma.

Therefore, at a minimum, the following data should appear on the requisition form that accompanies a thyroid FNA to the laboratory:

  1. Usual required data for lab test submission (see above)
  2. Location of the nodule
  3. Estimated size of the nodule
  4. History of hypothyroidism, autoimmune thyroiditis, or a positive test for anti-thyroid antibodies
  5. History of Graves' disease
  6. History of I 131 or external radiation therapy, accompanied by the dates of treatment
  7. Personal history of cancer
  8. Family history of thyroid cancer


The following information can be useful to the cytologist but is considered optional on the requisition form: 1. additional clinical history, e.g., that a prior FNA was done, or that the patient is undergoing levothyroxine therapy. Morphologic alterations due to a prior FNA can affect cytologic interpretation, and levothyroxine use can alter follicular cell morphology. 2. TSH level. If a patient has Hashimoto's hypothyroidism or Graves' disease, cytologic findings can be affected. A lower serum TSH level is also associated with a lower risk of thyroid cancer. 3. results of US examination. 4. results of nuclear medicine imaging studies [32,33].


 » II. Training and Credentialing for the Performance of a Thyroid FNA Top


A. Training for the Performance of Thyroid FNA

Diagnostic accuracy of thyroid FNA is highly variable [18,34-38]. The majority of diagnostic failures are due to non-diagnostic samples or pathologists issuing diagnosis on samples with inadequate material [39]. Efforts toward improvement in proficiency in FNA sampling and specimen preparation should be given high priority. Reports comparing the effectiveness of specific, defined training strategies for FNA procurement are lacking and there is little agreement on what the definition of adequate training is. Merely performing a large number of FNAs does not improve results when controlled for level of training[40]. There is, however, evidence that when FNA specimen procurement is concentrated in fewer hands and when the same physician both procures and microscopically examines the specimen, the results improve [41,42]. Training in procurement has significant impact on results regardless of the method of guiding the needle (ie palpation vs. ultrasound guidance). The consistent and timely feedback on specimen quality provided to physicians who both procure and examine specimens microscopically helps to improve results as well. Ultrasound (US) guidance of the sampling provides evidence that the needle is correctly placed within the target.

Two reviews of FNA state that the procurement of the samples is not as easy as generally perceived and stress the importance of obtaining an adequate sample in order for the test to be useful [41,43]. Suen makes the recommendation that "the procedure is carried out by a core group of dedicated physicians" [44]. In a 2003 editorial Kocjan discussed many of the problems associated with the current practice of FNA and stressed the importance of training in specimen collection and preparation regardless of the specialty of the operator[45].

A recent publication on the teaching of procedural skills indicates that the most important factor for mastering procedures is focused training with appropriate feedback by expert practitioners [46]. The previously widely held belief that simply performing a large number of procedures produces excellence does not appear to be true [47]. Given these observations it doesn't make sense to advocate that a specific number of procedures should be performed without specifying the circumstances. Reports comparing the effectiveness of specific, defined training strategies for FNA sampling are lacking in the literature. Such studies would be helpful in order to optimize training of operators in various settings and specialties.

In addition to the harvesting of diagnostic material, training for technical excellence in sample preparation cannot be overemphasized. Several options are available for the preparation and processing of FNA specimens. On-site sample adequacy assessments are performed with smears which may be stained with a modified Giemsa or a rapid Papanicolaou technique. In order to optimize on-site adequacy smears, appropriate training in smear technique is imperative in any FNA training program regardless of specialty. On-site evaluation of the specimen adequacy has lessened the percent unsatisfactory specimens and limited the number of passes per nodule sampled [48-50]. In all but one of these reports on-site evaluation of the specimens was one of several factors reported to improve accuracy, but was not calculated as a separate factor [50]. One report found on-site evaluation helpful in minimizing unsatisfactory samples only for less experienced radiologists procuring samples [51]. At the very least, it appears that on-site evaluation serves as an important educational tool for the physician performing the FNA in providing immediate feedback on the quality of the specimen.

Training in US imaging technique and interpretation is beyond the scope of this review.

Components of FNA procurement training:

  1. Studying of texts and DVD or similar teaching aids with moving images that explain the principles and show all required tasks including sampling and specimen preparation in detail. Lectures and demonstrations can also be helpful. A detailed instructional video done by Dr. Britt-Marie Ljung is available to all, sponsored by the Papanicolaou Society of Cytopathology on their website under the PSC Guidelines link.
  2. Bench practice of sampling and smearing on bovine liver or similar safe material, under supervision. Timely and precise placement of the needle tip under ultrasound guidance can be practiced with a model (for example turkey breast with a "target" inserted between the muscles or commercially available practice materials).
  3. Sampling of thyroid nodules guided either by palpation or US, supervised by a proficient operator, and followed by examination of all samples to provide timely feed back on quality of samples.
  4. Number of cases needed for achieving proficiency will vary depending on individual background and aptitude as well as case mix. Although it is best to start with easier cases, challenging cases need to be included. One should expect at least 90% diagnostic specimens before training is complete. The sampling of thyroid cysts devoid of follicular cells designated as "cyst fluid only" and categorized as " non-diagnostic" should not be considered "non-diagnostic" for credentialing purposes.


B. Credentialing and re-credentialing

Complete residency/fellowship training including FNA procurement or equivalent training in an alternative setting should suffice for initial credentialing.

For re-credentialing, documentation of the number of total FNA procedures per year, for an individual provider, in combination with a documented unsatisfactory sample rate (<10%) is a conservative measure of proficiency. The sampling of thyroid cysts devoid of follicular cells designated as "cyst fluid only" and categorized as " non-diagnostic" should not be considered "non-diagnostic" or "unsatisfactory" for credentialing purposes.


 » III. Techniques for the Performance of Thyroid FNA Top


A. Aspiration devices, needles and methods

A wide variety of needles of varying lengths and diameters are available for FNA. Commonly available 27-22 g needles are best used for thyroid FNA with 25-27 g needles being preferred for the initial biopsies and increasing needle size if needed; larger diameter needles are reserved for drainage of viscous colloid cyst contents. A variety of syringe holders are also available; among the oldest and most widely used pistol grip-like holders is the Cameco syringe gun. Other aspiration devices include the Tao instrument and the Inrad aspiration biopsy syringe gun.

The native suction provided by surface tension within smaller diameter needles often make devices for additional suction unnecessary [52]. When suction is needed, such as in the drainage of cyst contents, the Zajdela technique can still be used by having a section of IV tubing interposed between the needle held by the physician and the aspiration device held by an assistant.

The basic principals of thyroid FNA are described in detail elsewhere and are the same whether the needle is inserted into the lesion using manual palpation or ultrasound guidance [53]. As mentioned previously, a detailed instructional video is available at the website of the Papanicolaou Society of Cytopathology. When visualized with ultrasound, different areas of large masses should be sampled. If the nodule is complex, the wall, solid elements and suspicious calcified areas should be sampled avoiding cystic areas. Cellular material is obtained by the cutting action of the trailing edge of the needle (heel of the bevel) and is retained in the needle core by forward motion and capillary tension. As a starting point, a dwell time of 2-5 seconds within the nodule with 3 forward and back oscillations per second usually maximizes cellular yield, minimizes bloody artifacts, and efficiently produces 1-2 slides per biopsy pass.

Easily learned and very effective smearing techniques allow the aspirated material to be presented on the slides for optimal fixation, staining, and microscopic assessment [53]. Direct smears are necessary for immediate assessment at the time of biopsy. The failure or any significant flaw in smearing technique can limit or totally hinder microscopic evaluation, irrespective of how much material is obtained during the biopsy. Poor smear training and other logistical issues with respect to specimen transport to the laboratory have led to the utilization of a secondary means of specimen preparation, liquid based cytology (LBC), to be used in some laboratories [see specimen processing below].

Currently, the ideal physician to perform thyroid FNA in an institutional or office practice should be experienced, having repeatedly demonstrated appropriate judgment in nodule selection, technical excellence, and proficiency in obtaining aspirate material and preparing slides. For ultrasound guidance of FNA for either non-palpable or palpable nodules, this physician must have high resolution ultrasound imaging equipment with high frequency linear array transducers available, appropriate diagnostic skills, and documented experience in performing ultrasound-guided FNA.

B. Anesthesia

Most thyroid FNAs are well-tolerated and are not associated with significant patient discomfort or pain; however, the use of local anesthesia insures that the procedure will not be painful, and offers peace of mind, resulting in an overall more comfortable experience. For this reason, the trend among many experienced FNA physicians is to use local anesthesia for all thyroid FNAs[54]. However, local anesthetic may cause difficulty in subsequent sample evaluation. For deep, non-palpable thyroid nodules that may require more time and probing to reach the nodule, and for all biopsies using needles other than a fine needle, local anesthesia is recommended.

The local anesthetic of choice is 1% lidocaine or Lidocaine 2% Epi l:100,000. This may be performed through the injection of about 0.5 cc of the anesthetic utilizing a long bevel injection needle, (not a TB 27 g injector), slowly into the subcutaneous fat (not the dermis) thus allowing the anesthetic to back infiltrate the dermal nerves rather than make a painful intradermal wheal.

C. Core biopsy

There is limited literature regarding the use of modern biopsy needles, but so far it suggests that it is safe, well tolerated, and associated with a low incidence of complications. This is mainly due to the use of single action spring activated needles, i.e. Temno needle, which utilizes a non-advancing cutting action, or double action spring loaded needles (i.e. Monopty or Biopty gun) with a short throw device (11 mm excursion) [55,56].

FNA remains the best technique available to date for the initial evaluation of thyroid nodules. The slight increase in diagnostic accuracy obtained by CNB is outweighed by ease of use, cost effectiveness, and less patient discomfort associated with FNA [57]. Ultrasound-guided CNB should not be seen as a competitor of FNA, but rather as a complementary investigational tool. CNB under ultrasound guidance utilizing modern needles may be advantageous in cases rendered "unsatisfactory" by FNA, but offers no additional diagnostic value in separating a cellular hyperplastic nodule from follicular adenoma and follicular carcinoma [57] When cytopathology expertise is not available, CNB provides a small tissue sample for histologic examination.

D. Preparation of FNA material for Routine Evaluation

Aspirated tissue or cyst fluid may be directly smeared for air-dried and alcohol fixed preparations for staining with Romanowsky (Diff-Quik, Wright-Geimsa, Wright stains) and Papanicolaou stains, respectively. Direct smears can be processed alone or with a supplemental LBC or cellblock prepared. Likewise, liquid based processing can be utilized either alone or as a supplement to direct smears. Direct smears, however, are essential for immediate assessment. For LBC, the aspiration needle should be flushed with a small amount (~0.5 cc) of liquid (Cytolyt™, balanced saline or Hank's solution) and placed in a Falcon tube for transport to the lab. For remote transport or for specimens expected to have delayed processing, a fixative such as Preservcyt™ or CytoRich Red™ is necessary for optimal cellular preservation. This cell-rich liquid can also be used for cellblock preparation if needed. Residual cyst fluid may be submitted to the lab fresh or fixed for further processing, either by LBC or cellblock.

Immediate assessment is widely utilized. Some laboratories employ it routinely for all thyroid FNAs as it may decrease complications, improve triage of tissue and determines sample adequacy [23, 48, 51, 58-62]. One study found that immediate assessment as currently practiced, increases adequacy by up to 20%, but places a significant cost and burden on the laboratory [63].

E. Optimal number of passes

It is not possible to define a specific number of passes that should be used in every setting. Although studies show that the more passes performed the higher the adequacy, between 2 and 5 passes are a reasonable number of passes to perform to try and ensure an adequate sample [50, 63, 64]. There is no justification to recommend a different number of passes for a cystic lesion, unless the criteria for adequacy are different. A reasonable protocol is as follows: FNAs with rapid interpretation available: 2 biopsies from different areas of the lesion with a representative slide stained for adequacy. No more tissue is needed if a cyst is completely drained and no residual mass is identified, a specific malignancy is identified (and no ancillary tests are deemed necessary), or if the aspirate appears adequate. Additional biopsies are recommended if there is a residual mass after draining a cyst, cellularity is inadequate or to enrich a sample for cellblock or ancillary studies.

For FNAs without a rapid interpretation available: 2-5 biopsies from different sites with representative tissue from each pass smeared on a slide (or 2) and/or the tissue rinsed into a collection tube for either LBC or cellblock preparation.

F. Adequacy of Solid and Cystic lesions

Given that the purpose of thyroid FNA is to provide clinically useful information regarding the need for surgery, the FNA sample must be adequate enough for an interpretation that yields a low false negative rate. A thyroid FNA that is persistently inadequate may or may not result in surgery, depending on the clinical and ultrasounographic considerations [23,65].

Adequacy defines the quality and quantity of a sample, a definition that varies not only with respect to the site sampled, but also with respect to the type of lesion sampled. The cellularity of a specimen is influenced by the intrinsic nature of the lesion, and, as such, the same definition of adequacy does not apply to all specimen types [66].

All thyroid FNAs, however, must be technically adequate with well-preserved and well-prepared tissue for interpretation. Any cytological atypia precludes the interpretation of an inadequate sample and, although adequacy may be deemed "limited", an interpretation of "atypical" must be rendered, preferably with an explanation of the atypia.

An interpretation of an inflammatory process such as thyroiditis does not require a minimum number of follicle cells. An interpretation of a colloid nodule in which there is abundant, thick colloid present does not require a minimum number of follicle cells [66-68]. In solid nodules producing a follicular cell population with less than abundant colloid, a minimum number of 5-6 groups with a least 10 cells is recommended, preferably on a single slide [50, 69, 70]. Thyroid cysts with little to no follicular cells should be interpreted as "cyst fluid only" under the heading "nondiagnostic" and not "unsatisfactory". An optional recommendation for correlation with the cyst size, complexity, and ultrasonographic character may be added.


 » IV: Diagnostic terminology/classification scheme and morphologic criteria for cytologic diagnosis of thyroid lesions Top


A. Diagnostic terminology/classification scheme for thyroid fine-needle aspiration (FNA) interpretation

Several classification schemes have been suggested by various authors based on personal/institutional experiences and clinical organizations [9, 13, 66, 71-74]. A recent survey of pathologist and clinicians on the perceptions of diagnostic terminology and cytopathology reporting of thyroid FNA, showed a discord between pathologists and clinicians[75].

Many studies favor a tiered system for classifying thyroid FNA; this ranges from 3-6 (or more) diagnostic category schemes. The most favored one is a six category diagnostic scheme consisting of benign, lesion (atypia) of undetermined significance, follicular neoplasm, suspicious, malignant, and unsatisfactory [71-75]. A suggested scheme is as follows summarized in [Table 1]:

1. Benign

  1. Low risk of malignancy
  2. The diagnostic terms in this category include but are not limited to nodular goiter, chronic lymphocytic thyroiditis, hyperplastic/adenomatoid nodule in goiter and colloid nodule.
  3. Patients with a benign nodule are followed by clinical and periodic radiologic examination and some patients may undergo repeat FNA due to increase in the size of nodule.


2. Follicular Lesion of Undetermined Significance/Atypia of Undetermined Significance

  1. Risk of malignancy 5-10%.
  2. This is a heterogeneous category that includes cases in which the cytologic findings are not convincingly benign, yet the degree of cellular or architectural atypia is not sufficient for an interpretation of "Follicular Neoplasm" or "Suspicious for Malignancy".
  3. Some cases are placed in this category because of a compromised specimen (e.g. low cellularity, poor fixation, obscuring blood).
  4. This group can benefit from repeat FNA and correlation with clinical and radiologic findings.
  5. This category is optional and when utilized should ideally represent less than 7% of all thyroid FNA interpretations.


3. Follicular-Neoplasm/Suspicious for Follicular Neoplasm

  1. Low to intermediate risk of malignancy 20-30%.
  2. This category applies to non-papillary follicular patterned lesions/neoplasms and Hurthle cell lesions/neoplasms. A majority of studies have shown that up to 20% of the thyroid lesions classified as such are found to be malignant on surgical excision (the predictive value/relative risk of this diagnosis can be included in the report). This percentage may be higher in Hurthle cell lesions if the nodule is equal to or larger than 3.5 cm in greatest dimension.
  3. Other suggested diagnostic terms for this category are micro-follicular proliferation/lesion, suggestive of neoplasm and follicular lesion.
  4. Most patients with this diagnosis will undergo lobectomy/hemithyroidectomy and a definite diagnosis (adenomatoid nodule vs. adenoma vs. carcinoma) is rendered on surgical pathology examination.
  5. Some laboratories prefer the term "Suspicious for Follicular Neoplasm" may also be used for its clarity and for risk-management reasons.


4. Suspicious for Malignancy

  1. This term can be used as:

    1. Suspicious for papillary carcinoma (a majority of cases in this group (50-75%) are found to be follicular variant of papillary carcinoma).
    2. Suspicious for medullary carcinoma (applies to cases in which there is limited specimen to perform confirmatory immunostains for calcitonin. The cytology report should include a recommendation to assay serum calcitonin levels to confirm cytologic impression).
    3. Suspicious for other primary and secondary malignancies
    4. Suspicious for neoplasm because of total necrosis of the lesional cells (anaplastic carcinoma).




5. Malignant

6. Non-diagnostic

a. Specimen processed and examined, but non-diagnostic due to limited cellularity, no follicular cells or poor fixation and preservation. A repeat FNA can be recommended in these cases (see discussion on Post-FNA Testing and Treatment Options).

B. Morphologic Criteria

1. Morphologic criteria of benign, non-neoplastic conditions

Nodular Goiter:
The cytology specimen from a goiterous nodule (depending upon the preparation method) is characterized by:

  • Abundant watery colloid (usually appears bluish-pink magenta in color and shows a "chicken wire" artifact due to air-drying in smears stained with Romanowsky stain).
  • Follicular cells appear small, round to oval in shape with dark nuclei and are arranged in monolayer sheets, groups with follicle formation or as single cells [76,77]. Macrophages, usually filled with hemosiderin granules are also noted; however, their number depends upon the presence or absence of degenerative changes or a cystic component [77].


Autoimmune Thyroiditis/Chronic Lymphocytic Thyroiditis/Hashimoto's Thyroiditis

The FNA is usually performed in patients with thyroiditis who present with distinct nodules that are cold on thyroid scan. [78]The specimens from such cases usually show:

  • Scant colloid, Hürthle cells, follicular cells, lymphocytes and few plasma cells.
  • The lymphocytes are usually seen in the background, percolating between cell groups and in some cases one may see an intact lymphoid follicle. The Hürthle cells may display nuclear atypia and similarly follicular cells may show some chromatin clearing and nuclear grooves; however, one should refrain from interpreting these changes as malignant [78].
  • An extensive lymphocytic infiltrate can appear monotonous and mistaken for malignant lymphoma arising in lymphocytic thyroiditis [78,79]. If one suspects lymphoma it is advisable that an aliquot of specimen be submitted for flow cytometry to confirm the morphologic suspicion.


2. Morphologic criteria of follicular-patterned lesions

  • Fine-needle aspiration (FNA) is a screening test for follicular patterned lesions of the thyroid because it cannot distinguish between benign and malignant non-papillary follicular and Hurthle cell lesions. The cytopathologists often struggle with the diagnosis of follicular patterned lesions due to the lack of well-defined cytomorphologic criteria (both benign and malignant lesions appear similar in cytologic specimens) and standardized terminology [80,81]. This is further complicated by the lack of "meeting of minds" in the histologic diagnosis of these lesions [82]. To rely on cytologic atypia in follicular and Hürthle cells to differentiate between benign and malignant lesions has not proven to be a reproducible criterion [83]. A number of benign conditions such as thyroiditis, post treatment effects and adenomatoid nodules can show marked cellular atypia [78,79].


Follicular lesion of undetermined significance/atypia of undetermined significance

FNA specimens in this category include cases that partly display features of both hyperplastic/adenomatoid nodules and follicular neoplasm i.e. cellular specimen showing follicular cells arranged in cohesive groups and microfollicles with focal nuclear crowding and overlapping and monolayer sheets in a background of watery colloid admixed with thick colloid and few macrophages. The question arises as to how useful it may be to divide non-papillary follicular lesions into two separate categories; should all be diagnosed as indeterminate follicular lesions with the decision of how to manage being left to the clinician via either clinical follow-up and repeat FNA or surgical excision. Repeat FNA has been shown to play an important role in the management of thyroid nodules. Published experiences have shown that by repeating the FNA >50% of nodules which are non-diagnostic or indeterminate on initial cytologic diagnosis can latter be placed into definite diagnostic categories with repeat FNA [71,73].

Follicular neoplasm/Suspicious for follicular neoplasm

This term encompasses both benign and malignant tumors; i.e. follicular adenoma and carcinoma. The FNA of a follicular neoplasm usually shows:

  • Hypercellularity as compared to most aspirates of nodular goiter demonstrating a monotonous population of follicular cells with minimal or absent background colloid. The cells are usually arranged in three dimensional groups and microfollicles with prominent nuclear overlapping and crowding. Some cases may show nuclear atypia; however, this is not a diagnostic criterion of malignancy, since benign nodules can also show nuclear atypia [84].
  • The presence of microfollicles in an FNA specimens may be diagnostic of a follicular lesions neoplasm (adenoma or carcinoma) [85]. Some authors have proposed the term micro-follicular lesion [75]. However, various studies have shown that the interpretation of microfollicles suffers from inter-observer variability. Additionally, aspirates of normal thyroid and hyperplastic/adenomatoid nodules can show microfollicles [86]. Others have suggested that diagnosis of follicular neoplasm should only be used when a thyroid FNA specimen demonstrates a monotonous cell population arranged in cohesive groups with nuclear overlapping and crowding in a background if thick instead of watery colloid [80].


Hurthle cell neoplasm

FNA specimens of Hürthle cell lesions (benign and malignant) usually show:

  • Cellular aspirate comprising a single cell population of Hürthle cell in a background of minimal colloid. Cells can be arranged in monolayer sheets, follicular groups or as scattered single cells [87]. Some authors have suggested that cellular dispersion leading to single cells is more common in aspirates of Hurthle cell carcinoma than adenoma; however, this observation has not been validated [87]. Cellular atypia is also commonly observed in Hurthle cell lesion; this can be seen in the form of random nuclear enlargement, multi-nucleation, cellular pleomorphism and prominent nucleoli.
  • FNA specimens of neoplastic Hurthle cell lesions may show intra-cytoplasmic lumens and transgressing vessels [88].


Follicular Variant of Papillary Carcinoma

Similar to the histologic diagnosis the cytologic interpretation of FVPTC can also be difficult. The FNA specimens of FVPTC usually show:

  • Tumor cells arranged in monolayer sheets and follicular groups in a background of thin colloid. Thick colloid can also be present, however, much less as compared to classic PTC. The tumor cells show nuclear elongation, chromatin clearing and thick nuclear membranes; however, nuclear grooves and inclusions are rare. Nonetheless, chromatin clearing and nuclear membrane thickening is always seen in these cases [89,90].
  • If a thyroid FNA specimen focally shows cells with nuclear elongation, chromatin clearing and grooves but lacks nuclear inclusions, it may be diagnosed such as "follicular neoplasm with features suspicious for PTC.


3. Morphologic Criteria of Malignant Tumors

The well-differentiated thyroid carcinomas are the commonest form of malignant thyroid tumors. They are more common in young adults, whereas, the less differentiated and anaplastic tumors of the thyroid are prevalent in older age.

Cytology of Papillary Thyroid Carcinoma (PTC) and its variants

The cytologic features of PTC can be divided into major and minor diagnostic features; these are as follows:

  • Major Diagnostic Criteria : Enlarged, oval "and irregular" nucleus, eccentric and often multiple micro-nucleoli, fine, pale chromatin, longitudinal intranuclear grooves and intranuclear pseudo-inclusions [76,91].
  • Minor Diagnostic Criteria: Papillary cyto-architecture, syncytial monolayers, dense squamoid cytoplasm, "Bubble gum" colloid, psammoma bodies, multinucleated giant cells, histiocytoid cells and cellular swirls [92-94].


Follicular variant of papillary carcinoma : Refer to section on follicular patterned lesions of thyroid.

Tall cell variant of papillary carcinoma

Cytology specimens of this tumor usually show elongated cells with sharp cytoplasmic borders, granular eosinophilic cytoplasm and variably sized nuclei with nuclear features of papillary carcinoma. The nuclear features of papillary carcinoma are usually abundant and readily identifiable as compared to other variant of PTC [95].

Medullary Thyroid Carcinoma

The FNA specimens from MTC can show varied morphologic pattern similar to that seen in surgical pathology specimens. The majority of MTC cases show:

  • A cellular aspirate consisting of round to oval cells arranged mainly as single cells or loosely cohesive groups. The individual tumor cells show abundant eosinophilic granular cytoplasm and up to 20% of cells will demonstrate fine granules in Romanowsky-stained preparations. The nuclei are usually eccentric giving rise to a plasmacytoid appearance to tumor cells.
  • The nuclear chromatin is similar to that seen in neuroendocrine tumors; salt and pepper type with inconspicuous nucleoli. Intranuclear inclusions and multinucleated cells can also be seen.
  • In some cases of MTC the tumor cells are can assume a "spindle shape" and appear mesenchymal in origin. Amyloid may be observed as acellular material in the form of strings or as round to oval shaped fragments.
  • In cytology specimens the diagnosis of MTC can be confirmed by performing immunostains for Calcitonin. In cases with limited cellularity it is advisable to have a serum Calcitonin levels performed on the patient to confirm the diagnosis of MTC [76,96].


Anaplastic carcinoma

The aspirates from anaplastic carcinoma usually do not pose any diagnostic difficulties; they can be readily classified as malignant due to extreme cellular pleomorphism and obvious malignant features [97,98].


 » V. Utilization of Ancillary Studies in Thyroid FNA Top


A. Indications for ancillary studies in thyroid FNA

Medullary carcinoma and anaplastic carcinoma are the most common primary thyroid tumors that may require additional immunohistochemical studies to confirm the diagnosis. Although rare, metastatic tumors may occur in the thyroid and a history of a known primary along with a pertinent immunohistochemical panel would be helpful in making a final diagnosis. The utilization of ancillary studies to re-classify an indeterminate or suspicious FNA into a benign or malignant category or to refine the risk of malignancy within this category is controversial.

B. Specific ancillary studies to be performed for each of these indications

The ancillary studies with the widest utility involve the detection of specific proteins using immunologic techniques, typically immunohistochemistry on cell block preparations. Immunocytochemistry may also be utilized but only after careful validation of the protocols for this type of specimen. In cases of suspected medullary carcinoma, an immunohistochemical panel of calcitonin, thyroglobulin, CEA, and chromogranin can be confirmatory. Immunohistochemical findings should be correlated with serum calcitonin levels, particularly if there is insufficient FNA sample for ancillary studies [99-106]. Care should be employed in evaluating the results of calcitonin staining on cell block preparations of thyroid neoplasms with oncocytic features as cases of non-specific staining of oncocytic cells have been documented. Endogenous biotin in follicular cells may also cause non-specific staining.

Anaplastic carcinoma is often apparent based on its pleomorphic cytomorphology and aggressive clinical presentation. Anaplastic carcinoma often lacks TTF-1 and thyroglobulin staining. However, IHC for pan-cytokeratin may be utilized to distinguish anaplastic carcinoma from sarcomas. The clinical setting may also raise the possibility of a metastatic lesion [107-112]. The most common metastases to the thyroid arise from primary carcinomas of the kidney, lung, breast, colon, or malignant melanoma. The clinical history and presentation is important in determining the appropriate ancillary studies. One may initially employ TTF-1 and thyroglobulin IHC to narrow the primary site to thyroid, followed by further IHC characterization if these stains are negative [113].

One challenging area is excluding the possibility of lymphoma in the setting of Hashimoto's thyroiditis. All cases of Hashimoto's thyroiditis should not be automatically sent for flow cytometric immunophenotyping. In addition, immunophenotyping results from thyroid FNA samples should be interpreted with caution since Hashimoto's thyroiditis may yield κ/λ ratios that are skewed beyond normal values associated with reactive lymph nodes [114]. The indication for flow cytometric immunophenotyping should be based on cytomorphologic or clinical features that raise the suspicion of lymphoma. Parathyroid tissue can be extremely difficult to distinguish from thyroid tissue based on cytomorphologic features alone. In this setting, IHC for TTF-1, PTH, and chromogranin may be helpful. Neither the IHC nor the cytomorphology should be utilized to distinguish normal from abnormal parathyroid tissue. Chemical detection of PTH levels in FNA samples has been utilized, and may be considered following careful assay validation [115-120]. The identification of metastatic thyroid carcinoma to a lymph node in patients with a known history of thyroid carcinoma is often straightforward based on cytologic features. In challenging cases, IHC for TTF-1, calcitonin, and thyroglobulin may be useful in identifying the thyroid as a primary site for the nodal metastasis. Several studies have addressed the utilization of chemical assays for thyroglobulin on the FNA sample from neck lymph nodes [121,122]. Such an approach should be implemented with caution since clinical management of patients with benign or indeterminate lymph node FNAs containing detectable thyroglobulin remains undefined.

Ancillary studies that would permit re-classification of an indeterminate or suspicious thyroid FNAs into a benign or malignant category are highly desirable. Potential thyroid carcinoma-associated molecular markers include proteins (galectin-3, Cytokeratin-19, HBME-1), chromosomal translocations ( RET /PTC, PAX8 / PPARG ), and genetic mutations ( BRAF , RAS ) [123-125]. This review has focused on molecular markers that have proven efficacy for the above stated indication. The specificity of several markers for thyroid carcinoma is promising, but based on current limited evidence, widespread clinical use will require further studies.

The indications for performing ancillary studies and the current state of the science for ancillary studies in thyroid FNA are summarized in [Table 2].

C. Sample preparation for each type of ancillary study

If IHC is anticipated, one dedicated pass should be performed for cell block preparation from an FNA sample. The routine use of thyroid core biopsy to perform IHC is not supported. If lymphoma is suspected, at least one dedicated pass in a supportive medium should be obtained for flow cytometric analysis. Ancillary studies to detect genetic alterations may require dedicated passes and special processing protocols depending on the analyte (DNA or RNA) and the methodology (FISH, PCR, RT-PCR).


 » VI. Post FNA Options for Testing and Treatment Top


A. Follow-up of "Non-diagnostic" FNA Results

A universally accepted approach to "Non-diagnostic" thyroid FNAs is currently lacking. The strategy reviewed here is based on the American Thyroid Association's proposal, recent literature and the NCI Conference on Thyroid FNA [9,48]. Non-diagnostic aspirates obtained from cystic and solid nodules are treated differently in follow-up strategies. Aspirates composed of pure colloid and lacking a cellular component are considered benign, but require close clinical and ultrasound follow-up. Aspirates of cysts containing blood and histiocytes but no epithelial component need correlation with ultrasound findings [19]. Many cystic nodules contain only colloid surrounded by a thin rim of benign epithelium. These cysts are at very low risk for harboring malignancy. Many authors recommend these cysts be managed by nonsurgical follow-up. Other authors point to the low, but real incidence of papillary carcinoma in cysts and recommend surgical resection after two "Non-diagnostic" aspirations. The timing of repeat needle aspiration has not been established, but 6 to 18 months appears reasonable.

Cystic lesions with a "Non-diagnostic" aspirate should undergo repeat FNA if ultrasound demonstrates suspicious areas [12,126]. The repeat FNA should be under ultrasound guidance and, when possible, intraprocedural review of the aspirated material by a cytopathologist is recommended [48,19]. When repeat FNA yields "Non-diagnostic" material, correlation with family history, close clinical and ultrasonographic follow-up is suggested [19].

Solid nodules with a "Non-diagnostic" aspirate should be re-aspirated with ultrasound guidance with, if possible, intraprocedural review by a cytopathologist. If repeat smears are "Non-diagnostic," surgery ought to be considered. If the patient is likely to return for follow-up and the nodule is 1 cm or less in size, close clinical follow-up with ultrasound examination is a reasonable alternative to surgery [19]. When growth of the nodule is detected during surveillance, excision is suggested but repeat FNA is an acceptable approach. In general, for both solid and cystic "Non-diagnostic" aspirates a waiting period of at least three months should elapse between the initial "Non-diagnostic" aspirate and reaspiration. If suspicion for carcinoma is high based on clinical or ultrasonographic findings, a shorter waiting period may be appropriate.

B. Follow-up of "Benign" FNA Results

Management of patients with a "Benign" FNA diagnosis has varied between institutions. Because cytologically benign thyroid nodules are associated with up to 5% false negatives, these nodules require careful follow-up [16,127]. Patients with multiple thyroid nodules have the same risk of malignancy as those with a single nodule. Follow-up of patients with multiple nodules should be the same as those with a solitary nodule. Certain ultrasonographic characteristics (microcalcification, hypoechogenicity, intranodular hypervascularity) indicate a higher likelihood of malignancy [12,126]. Nodules with these features require more frequent clinical and ultrasonographic follow-up after a benign FNA. The false negative rate may be higher when FNAs are directed by palpation rather than by ultrasound [17, 128, 129]. Thus, palpation directed FNAs may require closer follow-up.

Medical suppressive therapy to confirm a benign cytologic diagnosis remains controversial. Multiple randomized trials have shown that thyroid hormone suppression may result in a decrease in nodule size in patient populations with borderline low iodine intake. The data are less convincing for populations ingesting sufficient iodine [130-132]. Rare examples of carcinomas suppressed by thyroid hormone have been reported. It is unclear that thyroid suppressive therapy is a reliable test for confirmation of a benign cytologic diagnosis of a solitary nodule.

Cytologically benign nodules can be followed clinically with interval ultrasound examination [19]. Benign nodules may be reaspirated or surgically removed when significant changes occur in their ultrasonographic appearance. Ultrasonography appears to be the best technique for detection of changes in nodule size[133]. There is no general agreement as to what constitutes a significant increase in nodule size. The American Thyroid Association (ATA) has suggested that a 20% increase in nodule diameter with a minimum increase in two or more dimensions of at least 2 mm is a reasonable definition for a significant change in nodule size [9]. The ATA has also recommended clinical follow-up of cytologically benign and easily palpable nodules occur at 6-18 month intervals. When nodules are not easily palpable, the recommendation is for serial ultrasound examinations at 6-18 month intervals [9].

Thyroid nodules cytologically diagnosed as benign require careful clinical follow-up. Easily palpable nodules may be followed clinically at 6-18 month intervals. Nodules which are not easily palpable should receive serial ultrasound examinations at 6-18 month intervals. The total duration of the follow-up period should be at least 3-5 years. When a 20% increase in nodule diameter or a minimum of 2 mm increase in two dimensions is detected, repeat FNA is performed. Repeat FNA should be performed if ultrasound abnormalities (irregular margins, central hypervascularization) develop. The repeat FNA should be under ultrasound guidance. Attendance of a pathologist at reaspiration is desirable. At this time, hormone suppressive therapy can not be recommended as a diagnostic maneuver for confirmation of benignity in a cytologically benign thyroid nodule. Ethanol ablation may be considered in selected patients.

C. Follow-up of FNA specimens diagnosed as "Follicular lesion/Atypical/Borderline"

A variety of terms are employed to convey uncertainty about the significance of some thyroid cytologic findings. Such changes do not rise to the level of a significant concern for a follicular neoplasm meriting lobectomy (see section D), nor do they fit a "Suspicious for Malignancy" interpretation. Because of cytologic or architectural atypia, neither can such cases be reliably called benign. A variety of diagnostic headings are used for such cases including "Atypical Follicular Lesion", "Cellular Follicular Lesion" and "Indeterminate" [73,134]. The term "Atypical/Borderline" will be used for this discussion. Approximately 5-10% of the "Atypical/Borderline" category are malignant neoplasms. Given that this diagnostic category is associated with low specificity and a low positive predictive value, the appropriate follow-up for this category remains controversial. Some authorities have recommended repeat FNAs, repeat ultrasound scans, or repeat radio-nucleotide uptake studies. A repeat FNA is benign in about one-half of patients, obviating the need for surgery [71]. Radiological correlation may aid in improving the overall positive predictive value of this category. Besides increasing size, ultrasonographic features such as hypoechogenicity, irregular border, calcifications and abnormalities of vascularization all favor a malignant diagnosis [54,135].

Outside expert cytopathology consultation may be considered in cases with an "Atypical/Borderline" cytologic diagnosis. In general, a conservative approach may be taken. After a single "Atypical/Borderline' interpretation, a repeat FNA should be considered in 3 to 6 months. If the repeat FNA is "Atypical/Borderline" or worse, a surgical consultation should be considered [71].

D. Follow-up of an FNA with the diagnosis of "Neoplasm (Follicular)"

This category has, in some reports, been termed "Suspicious for Follicular Neoplasm" [54,71]. The majority of cases in this category are adenomas, but 20 to 30% are carcinomas [73]. Patients with a diagnosis of "Follicular Neoplasm" should be referred for operative exploration. Usually a lobectomy is performed followed by histologic examination for capsular and vascular invasion.

The utility of frozen section evaluation for capsular or vascular invasion is controversial. Most participants at the NCI Meeting voiced the opinion that frozen section evaluation does not play a role in the separation of follicular adenoma from follicular carcinoma. Some surgeons may perform frozen section to determine the necessity for additional surgery, but there is no published data to support this practice. When frozen section is not utilized, initial surgery is lobectomy. If subsequent histologic examination discloses capsular or vascular invasion, the diagnosis of follicular carcinoma is made. Depending on the surgeon's discretion, histopathologic findings and clinical status of the patient reoperation with thyroidectomy may be performed.

E. Follow-up of FNAs with a diagnosis of "Suspicious for Malignancy"

Approximately 50-75% of lesions cytologically diagnosed as "Suspicious for Malignancy" are papillary carcinomas [71, 73, 134]. Less commonly, other malignancies such as medullary carcinoma are included in this category. Patients with an FNA diagnosis of "Suspicious for Malignancy" should be referred for thyroid lobectomy. Subsequent operative intervention depends on histological review.

F. Follow-up of "Malignant" FNA Results

This category refers to the histopathologic entities of papillary carcinoma, medullary carcinoma, lymphoma and anaplastic carcinoma. A comprehensive review of this subject concluded that the cytologic diagnosis of malignancy in a thyroid nodule should result in surgical consultation. Whenever possible, the type of carcinoma present should be stated in the cytology report. If a metastatic carcinoma is suspected, clinical and imaging studies should be undertaken to establish the primary site. At the surgeon's discretion, surgical intervention may initially be simple lobectomy or intraoperative frozen section examination to determine if total thyroidectomy should be performed. If frozen section is equivocal, the operative procedure is ended with lobectomy and further therapy is based on permanent sections. Depending on the surgeon's discretion and the characteristics of the malignancy, total thyroidectomy may be performed for a cytological diagnosis of papillary carcinoma. Controversy exists as to whether total thyroidectomy or unilateral lobectomy should be performed for papillary carcinoma. The selection of lobectomy versus thyroidectomy depends on the evaluation of the patient's clinical status and the size and nature of the papillary carcinoma. Total thyroidectomy may be accompanied by a central compartment dissection. For patients with large, bulky disease or recurrent laryngeal nerve dysfunction, preoperative cross sectional imaging should be considered as well as ultrasound imaging for lateral neck nodal disease.


 » Competing interests Top


The author(s) declare that they have no competing interests.


 » Acknowledgements Top


The authors of this document acknowledge the work of the various committee members who were responsible for the research that resulted in this publication: Pedro de Agustin, M.D., Ted Miller, M.D., Stephen Raab, M.D., William Faquin, M.D., Ph.D., Susan Mandel, M.D., Erik A. Alexander, M.D., William Middleton, M.D., Carol Benson, M.D., Gerard Doherty, M.D., Jerry Waisman, M.D., Yolanda Oertel, M.D., Ernest Mazzaferri, M.D., Jill Langer, M.D., Samuel A. Wells, M.D., Celeste N. Powers, M.D., Ph.D., John Abele, M.D., Syed Z. Ali, M.D., Tarik M. Elsheikh, M.D., Andrew Renshaw, M.D., Dan Duick, M.D., Helen Wang, M.D., R. Brooke Jeffrey, M.D., Leslie Scoutt, M.D., W. Jack Frable, M.D., Mary Sidawy, M.D., R.Mac DeMay, M.D., Philippe Vielh, M.D., Virgnia A. LiVolsi, M.D., Juan Rosai, M.D., Sylvia L. Asa, M.D., Maria L. Merino, M.D., Greg Randolph, M.D., Sanjay Logani, M.D., Armando C. Filie, M.D., Yuri E. Nikiforov, M.D., Ph.D., Kim Geisinger, M.D., Beatrix Cochand-Priollet, M.D., Jackie Abrams, M.D. Hossein Gharib, M.D., Frank Greenspan, M.D., Doug Evans, M.D., Michael Henry, M.D.

The authors would also like to thank Drs. Carlos Bedrossian and Vinod Shidham for supporting the publications that resulted from the conference.

The following medical societies are co-sponsors of the NCI Thyroid Fine Needle Aspiration State of the Science Conference and Website:

The American Cancer Society

College of American Pathologists

The American Society for Clinical Pathology

The American Society of Clinical Oncology

La Societe Francaise de Cytologie Clinique

The American Society of Cytopathology

The Papanicolaou Society of Cytopathology

The American Association of Clinical Endocrinologists

The American Association of Endocrine Surgeons

The American Thyroid Association

The Society of Radiologists in Ultrasound

The American College of Radiology

National Comprehensive Cancer Network

The American College of Endocrinology

 
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European Radiology. 2014;
[Pubmed]
14 Core needle biopsy can minimise the non-diagnostic results and need for diagnostic surgery in patients with calcified thyroid nodules
Eun Ju Ha,Jung Hwan Baek,Jeong Hyun Lee,Jin Kyoung Kim,Jae Kyun Kim,Hyun Kyung Lim,Dong Eun Song,Tae Yon Sung,Tae Yong Kim,Won Bae Kim,Young Kee Shong
European Radiology. 2014;
[Pubmed]
15 Atypia of undetermined significance on thyroid fine needle aspiration: surgical outcome and risk factors for malignancy
Young Jae Ryu,Youn Seung Jung,Hyun Chul Yoon,Min Jung Hwang,Sun Hyoung Shin,Jin Seong Cho,Ji Shin Lee,Hee Kyung Kim,Ho Cheol Kang,Hyo Soon Lim,Jung Han Yoon,Min Ho Park
Annals of Surgical Treatment and Research. 2014; 86(3): 109
[Pubmed]
16 Thyroid nodules with suspicious ultrasound findings: the role of ultrasound guided core-needle biopsy
Mingbo Zhang,Yan Zhang,Shuai Fu,Faqin Lv,Jie Tang
Clinical Imaging. 2014;
[Pubmed]
17 Fine-Needle Aspiration of the Thyroid: Correlating Suspicious Cytology Results with Histological Outcomes
Andrea L. Baynes,Andres Del Rio,Catriona McLean,Simon Grodski,Meei J. Yeung,William R. Johnson,Jonathan W. Serpell
Annals of Surgical Oncology. 2014;
[Pubmed]
18 Current role and value of fine-needle aspiration in nodular goitre
Zubair W. Baloch,Virginia A. LiVolsi
Best Practice & Research Clinical Endocrinology & Metabolism. 2014;
[Pubmed]
19 Thyroid Nodules with Benign Findings at Cytologic Examination: Results of Long-term Follow-up with US
Soo-Yeon Kim,Kyung Hwa Han,Hee Jung Moon,Jin Young Kwak,Woong Youn Chung,Eun-Kyung Kim
Radiology. 2014; : 131334
[Pubmed]
20 Thyroid fine-needle aspiration cytology: Performance data of neoplastic and malignant cases as identified from 1558 responses in the ASCP Non-GYN Assessment program thyroid fine-needle performance data
Stan G. Eilers,Paula LaPolice,Perkins Mukunyadzi,Umesh Kapur,Amy Wendel Spiczka,Ajay Shah,Husain Saleh,Adebowale Adeniran,Amberly Nunez,Indra Balachandran,Jennifer J. Clark,Larry Lemon
Cancer Cytopathology. 2014; : n/a
[Pubmed]
21 Annual financial impact of well-differentiated thyroid cancer care in the United States
Carrie C. Lubitz,Chung Y. Kong,Pamela M. McMahon,Gilbert H. Daniels,Yufei Chen,Konstantinos P. Economopoulos,G. Scott Gazelle,Milton C. Weinstein
Cancer. 2014; : n/a
[Pubmed]
22 Appropriate and accurate diagnosis of thyroid nodules: A review of thyroid fine-needle aspiration
Hambleton, C. and Kandil, E.
International Journal of Clinical and Experimental Medicine. 2013; 6(6): 413-422
[Pubmed]
23 Thyroid nodules with initially nondiagnostic cytologic results: The role of core-needle biopsy
Yeon, J.S. and Baek, J.H. and Lim, H.K. and Ha, E.J. and Kim, J.K. and Song, D.E. and Kim, T.Y. and Lee, J.H.
Radiology. 2013; 268(1): 274-280
[Pubmed]
24 The biopsy-proven benign thyroid nodule: Is long-term follow-up necessary?
Lee, S. and Skelton, T.S. and Zheng, F. and Schwartz, K.A. and Perrier, N.D. and Lee, J.E. and Bassett, R.L. and Ahmed, S. and Krishnamurthy, S. and Busaidy, N.L. and Grubbs, E.G.
Journal of the American College of Surgeons. 2013; 217(1): 81-88
[Pubmed]
25 Five top stories in cytopathology
Fischer, A.H. and Benedict, C.C. and Amrikachi, M.
Archives of Pathology and Laboratory Medicine. 2013; 137(7): 894-906
[Pubmed]
26 The value of preoperative PET-CT in papillary thyroid cancer
Kim, B.S. and Ryu, H.S. and Kang, K.H.
Journal of International Medical Research. 2013; 41(2): 445-456
[Pubmed]
27 Radiologic and clinical predictors of malignancy in the follicular lesion of undetermined significance of the thyroid
Carr, R. and Ustun, B. and Chhieng, D. and Schofield, K. and Theoharis, C. and Hammers, L. and Adeniran, A.J.
Endocrine Pathology. 2013; 24(2): 62-68
[Pubmed]
28 Sonographically suspicious thyroid nodules with initially benign cytologic results: The role of a core needle biopsy
Ha, E.J. and Baek, J.H. and Lee, J.H. and Song, D.E. and Kim, J.K. and Shong, Y.K. and Hong, S.J.
Thyroid. 2013; 23(6): 703-708
[Pubmed]
29 Ultrasonography-guided core needle biopsy for the thyroid nodule: Does the procedure hold any benefit for the diagnosis when fine-needle aspiration cytology analysis shows inconclusive results?
Hahn, S.Y. and Shin, J.H. and Han, B.-K. and Ko, E.Y. and Ko, E.S.
British Journal of Radiology. 2013; 86(1025)
[Pubmed]
30 Thyroid Bethesda reporting category, æsuspicious for papillary thyroid carcinomaæ, pitfalls and clues to optimize the use of this category
Mahajan, A. and Lin, X. and Nayar, R.
Cytopathology. 2013; 24(2): 85-91
[Pubmed]
31 Low malignancy risk of thyroid follicular lesion of undetermined significance in patients from post-endemic areas
Słowińska-Klencka, D. and Woźniak, E. and Wojtaszek, M. and Popowicz, B. and Sporny, S. and Klencki, M.
European Journal of Endocrinology. 2013; 168(4): 621-630
[Pubmed]
32 Are we ready to modify the bethesda thyroid fine-needle aspiration classification scheme?
Baloch, Z.W. and Mandel, S.J. and LiVolsi, V.A.
Cancer Cytopathology. 2013; 121(4): 171-174
[Pubmed]
33 Interobserver agreement for thyroid elastography value of the quality factor
Calvete, A.C. and Rodríguez, J.M. and De Dios Berná-Mestre, J. and Ríos, A. and Abellán-Rivero, D. and Reus, M.
Journal of Ultrasound in Medicine. 2013; 32(3): 495-504
[Pubmed]
34 Management of thyroid nodules with atypical cytology on fine-needle aspiration biopsy
Nagarkatti, S.S. and Faquin, W.C. and Lubitz, C.C. and Garcia, D.M. and Barbesino, G. and Ross, D.S. and Hodin, R.A. and Daniels, G.H. and Parangi, S.
Annals of Surgical Oncology. 2013; 20(1): 60-65
[Pubmed]
35 BRAFV600E mutation in papillary thyroid microcarcinoma: A genotype-phenotype correlation
Virk, R.K. and Van Dyke, A.L. and Finkelstein, A. and Prasad, A. and Gibson, J. and Hui, P. and Theoharis, C.G. and Carling, T. and Roman, S.A. and Sosa, J.A. and Udelsman, R. and Prasad, M.L.
Modern Pathology. 2013; 26(1): 62-70
[Pubmed]
36 Next-generation sequencing-based multi-gene mutation profiling of solid tumors using fine needle aspiration samples: promises and challenges for routine clinical diagnostics
Rashmi Kanagal-Shamanna,Bryce P Portier,Rajesh R Singh,Mark J Routbort,Kenneth D Aldape,Brian A Handal,Hamed Rahimi,Neelima G Reddy,Bedia A Barkoh,Bal M Mishra,Abhaya V Paladugu,Jawad H Manekia,Neda Kalhor,Sinchita Roy Chowdhuri,Gregg A Staerkel,L Jeffrey Medeiros,Rajyalakshmi Luthra,Keyur P Patel
Modern Pathology. 2013;
[Pubmed]
37 BRAFV600E mutation in papillary thyroid microcarcinoma: a genotype–phenotype correlation
Renu K Virk,Alison L Van Dyke,Alexander Finkelstein,Avinash Prasad,Joanna Gibson,Pei Hui,Constantine G Theoharis,Tobias Carling,Sanziana A Roman,Julie A Sosa,Robert Udelsman,Manju L Prasad
Modern Pathology. 2013; 26(1): 62
[Pubmed]
38 Relative sensitivity of thyroid fine-needle aspiration by tumor type and size
Vickie Y. Jo,Andrew A. Renshaw,Jeffrey F. Krane
Diagnostic Cytopathology. 2013; : n/a
[Pubmed]
39 Role of core needle biopsy for patients with indeterminate, fine-needle aspiration cytology
Woo Jung Choi,Jung Hwan Baek
Endocrine. 2013;
[Pubmed]
40 Sonographically Suspicious Thyroid Nodules with Initially Benign Cytologic Results: The Role of a Core Needle Biopsy
Eun Ju Ha,Jung Hwan Baek,Jeong Hyun Lee,Dong Eun Song,Jae Kyun Kim,Young Kee Shong,Suck Joon Hong
Thyroid. 2013; 23(6): 703
[Pubmed]
41 Radiologic and Clinical Predictors of Malignancy in the Follicular Lesion of Undetermined Significance of the Thyroid
Ryan Carr,Berrin Ustun,David Chhieng,Kevin Schofield,Constantine Theoharis,Lynwood Hammers,Adebowale J. Adeniran
Endocrine Pathology. 2013; 24(2): 62
[Pubmed]
42 Cost Effectiveness of Intraoperative Pathology Examination during Diagnostic Hemithyroidectomy for Unilateral Follicular Thyroid Neoplasms
Kyle Zanocco,Michael Heller,Dina Elaraj,Cord Sturgeon
Journal of the American College of Surgeons. 2013; 217(4): 702
[Pubmed]
43 Management of Thyroid Nodules with Atypical Cytology on Fine-needle Aspiration Biopsy
Sushruta S. Nagarkatti,William C. Faquin,Carrie C. Lubitz,Dieter Morales Garcia,Giuseppe Barbesino,Douglas S. Ross,Richard A. Hodin,Gilbert H. Daniels,Sareh Parangi
Annals of Surgical Oncology. 2013; 20(1): 60
[Pubmed]
44 Molecular diagnosis for indeterminate thyroid nodules on fine needle aspiration: advances and limitations
Xavier M Keutgen,Filippo Filicori,Thomas J Fahey
Expert Review of Molecular Diagnostics. 2013; 13(6): 613
[Pubmed]
45 Follicular lesion of undetermined significance in thyroid FNA revisited
Ann E. Walts,James Mirocha,Shikha Bose
Diagnostic Cytopathology. 2013; : n/a
[Pubmed]
46 The impact of implementing the bethesda system for reporting of thyroid FNA at an academic center
Constantine Theoharis,Adebowale J. Adeniran,Sanziana Roman,Julie Ann Sosa,David Chhieng
Diagnostic Cytopathology. 2013; : n/a
[Pubmed]
47 The Sonographic Appearance of Benign and Malignant Thyroid Diseases and Their Histopathology Correlate
Francisca Oyedeji,Ellen Giampoli,Daniel Ginat,Vikram Dogra
Ultrasound Quarterly. 2013; 29(3): 161
[Pubmed]
48 Thyroid Nodules with Initially Nondiagnostic Cytologic Results: The Role of Core-Needle Biopsy
J. S. Yeon,J. H. Baek,H. K. Lim,E. J. Ha,J. K. Kim,D. E. Song,T. Y. Kim,J. H. Lee
Radiology. 2013; 268(1): 274
[Pubmed]
49 Ultrasound-guided fine-needle aspiration for solid thyroid nodules larger than 10 mm: correlation between sonographic characteristics at the needle tip and nondiagnostic results
Hongxun Wu,Bingjie Zhang,Yaping Zang,Jun Wang,Beilin Zhu,Yuelong Cao,Qianyun Liu
Endocrine. 2013;
[Pubmed]
50 Are we ready to modify the Bethesda thyroid fine-needle aspiration classification scheme?
Zubair W. Baloch,Susan J. Mandel,Virginia A. LiVolsi
Cancer Cytopathology. 2013; 121(4): 171
[Pubmed]
51 Ultrasonography-guided core needle biopsy for the thyroid nodule: does the procedure hold any benefit for the diagnosis when fine-needle aspiration cytology analysis shows inconclusive results?
S Y Hahn,J H Shin,B-K Han,E Y Ko,E S Ko
The British Journal of Radiology. 2013; 86(1025): 20130007
[Pubmed]
52 Tract Recurrence of a Follicular Thyroid Neoplasm Following Transaxillary Endoscopic Thyroidectomy
Toni Beninato, David A. Kleiman, Theresa Scognamiglio, Thomas J. Fahey, Rasa Zarnegar
Thyroid. 2012; 22(2): 214
[VIEW]
53 Papillary thyroid carcinomas with and without BRAF  V600E mutations are morphologically distinct : BRAF V600E mutation in thyroid cancer
Histopathology. 2012; : no
[VIEW]
54 Prevalence of Malignancy in Thyroid Nodules with an Initial Nondiagnostic Result after Ultrasound Guided Fine Needle Aspiration
Anastasia L. Hryhorczuk, Tausha Stephens, Ronald O. Bude, Jonathan M. Rubin, Janet E. Bailey, Ellen J. Higgins, Giovanna A. Fox, Katherine A. Klein
Ultrasound in Medicine & Biology. 2012;
[VIEW]
55 Thyroid Bethesda reporting category, ‘suspicious for papillary thyroid carcinoma’, pitfalls and clues to optimize the use of this category : Use of the suspicious category for thyroid FNA: pitfalls and clues
A. Mahajan, X. Lin, R. Nayar
Cytopathology. 2012; : no
[VIEW]
56 Cost-effectiveness analysis of repeat fine-needle aspiration for thyroid biopsies read as atypia of undetermined significance
Michael Heller,Kyle Zanocco,Sara Zydowicz,Dina Elaraj,Ritu Nayar,Cord Sturgeon
Surgery. 2012; 152(3): 423
[Pubmed]
57 Follicular lesions of the thyroid: A retrospective study of 1,348 fine needle aspiration biopsies
ShouJin Wu,Richard M. DeMay,Pamela Papas,Benjamin Yan,Ward Reeves,Zubair Baloch
Diagnostic Cytopathology. 2012; 40(S1): E8
[Pubmed]
58 Ultrasound-Guided Fine-Needle Aspiration Biopsy of Clinically Suspicious Thyroid Nodules with an Automatic Aspirator: A Novel Technique
James Nagarajah,Sien-Yi Sheu-Grabellus,Jamshid Farahati,Kamer A. Kamruddin,Andreas Bockisch,Kurt Werner Schmid,Rainer Görges
Thyroid. 2012; 22(7): 695
[Pubmed]
59 Three-Gene Molecular Diagnostic Model for Thyroid Cancer
Thyroid. 2012; 22(3): 275
[VIEW]
60 Diagnostic accuracy of fine-needle aspiration versus core-needle biopsy for the diagnosis of thyroid malignancy in a clinical cohort
Jin Yong Sung, Dong Gyu Na, Kyu Sun Kim, Hyunju Yoo, Hunkyung Lee, Ji-hoon Kim, Jung Hwan Baek
European Radiology. 2012;
[VIEW]
61 Ultrasound-Guided Procedures for the Office
Russell B. Smith
Ultrasound Clinics. 2012; 7(2): 219
[Pubmed]
62 Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology
Erik K. Alexander,Giulia C. Kennedy,Zubair W. Baloch,Edmund S. Cibas,Darya Chudova,James Diggans,Lyssa Friedman,Richard T. Kloos,Virginia A. LiVolsi,Susan J. Mandel,Stephen S. Raab,Juan Rosai,David L. Steward,P. Sean Walsh,Jonathan I. Wilde,Martha A. Zeiger,Richard B. Lanman,Bryan R. Haugen
New England Journal of Medicine. 2012; 367(8): 705
[Pubmed]
63 Bethesda-Klassifikation der Feinnadelpunktion der Schilddrüse
R. Schäffer,K.W. Schmid,M. Tötsch
Der Pathologe. 2012; 33(4): 324
[Pubmed]
64 Yield of repeat fine-needle aspiration biopsy and rate of malignancy in patients with atypia or follicular lesion of undetermined significance: The impact of the Bethesda System for Reporting Thyroid Cytopathology
Chen, J.C. and Pace, S.C. and Chen, B.A. and Khiyami, A. and McHenry, C.R.
Surgery (United States). 2012; 152(6): 1037-1044
[Pubmed]
65 The Bethesda System thyroid diagnostic categories in the African-American population in conjunction with surgical pathology follow-up
Archuletta, P.A. and Gidwani, R. and Husain, M. and Johnson, T. and Shidham, V. and Alzohaili, O. and Bandyopadhyay, S. and Feng, J. and Shi, D. and Geng, L. and Tranchida, P. and Giorgadze, T.
CytoJournal. 2012; 9(1)
[Pubmed]
66 Prognosis of Thyroid Nodules in Individuals Living in the Zhitomir Region of Ukraine
Hayashida, N. and Sekitani, Y. and Takahashi, J. and Kozlovsky, A.A. and Gutevych, O.K. and Saiko, A.S. and Nirova, N.V. and Petrova, A.A. and Rafalskiy, R.M. and Chorny, S.A. and Daniliuk, V.V. and Anami, M. and Yamashita, S. and Takamura, N.
PLoS ONE. 2012; 7(11)
[Pubmed]
67 Preoperative diagnosis of benign thyroid nodules with indeterminate cytology
Alexander, E.K. and Kennedy, G.C. and Baloch, Z.W. and Cibas, E.S. and Chudova, D. and Diggans, J. and Friedman, L. and Kloos, R.T. and LiVolsi, V.A. and Mandel, S.J. and Raab, S.S. and Rosai, J. and Steward, D.L. and Walsh, P.S. and Wilde, J.I. and Zeiger, M.A. and Lanman, R.B. and Haugen, B.R.
New England Journal of Medicine. 2012; 367(8): 705-715
[Pubmed]
68 Diagnostic relevance of fine needle aspiration cytology in nodular thyroid lesions [Dijagnostička pouzdanost citoloških nalaza nodularnih lezija štitaste žlezde iz uzoraka dobijenih aspiracijom tankom iglom]
Knežević-Ušaj, S. and Eri, Z. and Panjković, M. and Klem, I. and Petrović, T. and Ivković-Kapicl, T. and Karapandžić, A. and Jelić, J.
Vojnosanitetski Pregled. 2012; 69(7): 555-561
[Pubmed]
69 Cytotechnologist-attended on-site adequacy evaluation of thyroid fine-needle aspiration: Comparison with cytopathologists and correlation with the final interpretation
Olson, M.T. and Tatsas, A.D. and Ali, S.Z.
American Journal of Clinical Pathology. 2012; 138(1): 90-95
[Pubmed]
70 Bethesda classification of fine needle punctures of the thyroid. Much ado about nothing really new? [Bethesda-Klassifikation der Feinnadelpunktion der Schilddrüse. Viel Lärm um wenig Neues?]
Schäffer, R. and Schmid, K.W. and Tötsch, M.
Pathologe. 2012; 33(4): 324-330
[Pubmed]
71 Croatian society for clinical cytology guidelines for thyroid cytology [Smjernice u citološkoj dijagnostici Štitnjače hrvatskoga društva za kliničku citologiju]
Mateša, N. and Knežević-Obad, A. and Ostović, K.T. and Kardum-Skelin, I. and Moslavac, S. and Vasilj, A. and Kojić-Katović, S. and Pauzar, B. and Irena Seili-Bekafigo
Lijecnicki Vjesnik. 2012; 134(7-8): 203-207
[Pubmed]
72 Ultrasound-guided fine-needle aspiration biopsy of clinically suspicious thyroid nodules with an automatic aspirator: A novel technique
Nagarajah, J. and Sheu-Grabellus, S.-Y. and Farahati, J. and Kamruddin, K.A. and Bockisch, A. and Schmid, K.W. and Görges, R.
Thyroid. 2012; 22(7): 695-698
[Pubmed]
73 Diagnostic yield of nondiagnostic thyroid nodules is not altered by timing of repeat biopsy
Lubitz, C.C. and Nagarkatti, S.S. and Faquin, W.C. and Samir, A.E. and Hassan, M.C. and Barbesino, G. and Ross, D.S. and Randolph, G.W. and Gaz, R.D. and Stephen, A.E. and Hodin, R.A. and Daniels, G.H. and Parangi, S.
Thyroid. 2012; 22(6): 590-594
[Pubmed]
74 Papillary thyroid carcinomas with and without BRAF V600E mutations are morphologically distinct
Finkelstein, A. and Levy, G.H. and Hui, P. and Prasad, A. and Virk, R. and Chhieng, D.C. and Carling, T. and Roman, S.A. and Sosa, J.A. and Udelsman, R. and Theoharis, C.G. and Prasad, M.L.
Histopathology. 2012; 60(7): 1052-1059
[Pubmed]
75 Thyroid fine needle aspirate: A post-Bethesda update
Bose, S. and Walts, A.E.
Advances in Anatomic Pathology. 2012; 19(3): 160-169
[Pubmed]
76 Follicular lesions of the thyroid: A retrospective study of 1,348 fine needle aspiration biopsies
Wu, S. and Demay, R.M. and Papas, P. and Yan, B. and Reeves, W.
Diagnostic Cytopathology. 2012; 40(SUPPL. 1): E8-E12
[Pubmed]
77 BRAF mutation analysis and sonography as adjuncts to fine-needle aspiration cytology of papillary thyroid carcinoma: Their relationships and roles
Moon, W.-J. and Choi, N. and Choi, J.W. and Kim, S.K. and Hwang, T.S.
American Journal of Roentgenology. 2012; 198(3): 668-674
[Pubmed]
78 Cytologic and molecular diagnosis of thyroid cancers is it time for routine reflex testing?
Hassell, L.A. and Gillies, E.M. and Dunn, S.T.
Cancer Cytopathology. 2012; 120(1): 7-17
[Pubmed]
79 Nodular thyroid cancer. Diagnostic value of real time elastography
Stoian, D. and Cornianu, M. and Dobrescu, A. and Lazǎr, F.
Chirurgia (Romania). 2012; 109(1): 39-46
[Pubmed]
80 Cost-effectiveness analysis of repeat fine-needle aspiration for thyroid biopsies read as atypia of undetermined significance
Heller, M. and Zanocco, K. and Zydowicz, S. and Elaraj, D. and Nayar, R. and Sturgeon, C.
Surgery (United States). 2012; 152(3): 423-430
[Pubmed]
81 Diagnostic Yield of Nondiagnostic Thyroid Nodules Is Not Altered by Timing of Repeat Biopsy
Carrie C. Lubitz,Sushruta S. Nagarkatti,William C. Faquin,Anthony E. Samir,Maria C. Hassan,Giuseppe Barbesino,Douglas S. Ross,Gregory W. Randolph,Randall D. Gaz,Antonia E. Stephen,Richard A. Hodin,Gilbert H. Daniels,Sareh Parangi
Thyroid. 2012; 22(6): 590
[Pubmed]
82 Thyroid Fine Needle Aspirate : A Post-Bethesda Update
Shikha Bose, Ann E. Walts
Advances in Anatomic Pathology. 2012; 19(3): 160
[VIEW]
83 Following the steps of Abu al-Qasim to Bethesda and beyond: The continuing deliberations in thyroid fine-needle aspiration
Zubair W. Baloch, Carlos Bedrossian, Zubair Baloch
Diagnostic Cytopathology. 2012; : n/a
[VIEW]
84 Fine-needle aspiration of follicular patterned lesions of the thyroid: Diagnosis, management, and follow-up according to thyroid bethesda system
Üstün, H. and Astarci, H.M. and Altunkaya, C. and Ylmaz, S. and Barn, A. and Ekici, S. and Çaydere, M.
Acta Cytologica. 2012; 56(4): 361-369
[Pubmed]
85 Core-Needle Biopsy Is More Useful Than Repeat Fine-Needle Aspiration in Thyroid Nodules Read as Nondiagnostic or Atypia of Undetermined Significance by the Bethesda System for Reporting Thyroid Cytopathology
Dong Gyu Na, Ji-hoon Kim, Jin Yong Sung, Jung Hwan Baek, Kyeong Cheon Jung, Hunkyung Lee, Hyunju Yoo
Thyroid. 2012; 22(5): 468
[VIEW]
86 Ultrasound-Guided Percutaneous Thyroid Nodule Core Biopsy: Clinical Utility in Patients with Prior Nondiagnostic Fine-Needle Aspirate
Anthony E. Samir, Abhinav Vij, Melanie K. Seale, Gaurav Desai, Elkan Halpern, William C. Faquin, Sareh Parangi, Peter F. Hahn, Gilbert H. Daniels
Thyroid. 2012; 22(5): 461
[VIEW]
87 The role of preoperative neck ultrasounds to assess lymph nodes in patients with suspicious or indeterminate thyroid nodules
Rashmi Roy, Guennadi Kouniavsky, Raghunandan Venkat, Erin A. Felger, Zita Shiue, Eric Schneider, Martha A. Zeiger
Journal of Surgical Oncology. 2011; : n/a
[VIEW]
88 Clinical outcome for atypia of undetermined significance in thyroid fine-needle aspirations: Should repeated FNA be the preferred initial approach?
Vanderlaan, P.A., Marqusee, E., Krane, J.F.
American Journal of Clinical Pathology. 2011; 135(5): 770-775
[Pubmed]
89 Thy3 cytology: What to do next?
Lakhani, R., Rourke, T., Jefferis, A., Perry, L., Ghiacy, S., Wood, S.
Annals of the Royal College of Surgeons of England. 2011; 93(3): 225-228
[Pubmed]
90 An examination of recently revised differentiated thyroid cancer guidelines
Miller, B.S., Doherty, G.M.
Current Opinion in Oncology. 2011; 23(1): 1-6
[Pubmed]
91 An Ultrasound Model to Discriminate the Risk of Thyroid Carcinoma
José Miguel Domínguez, René Baudrand, Jaime Cerda, Claudia Campusano, Carlos Fardella, Eugenio Arteaga, Francisco Cruz, Antonieta Solar, Tatiana Arias, Lorena Mosso
Academic Radiology. 2011; 18(2): 242
[VIEW]
92 Incidence of Malignancy in Thyroid Nodules Determined to be Follicular Lesions of Undetermined Significance on Fine-Needle Aspiration
Gilberto V. Teixeira, Horacio Chikota, Thiago Teixeira, Gabriel Manfro, Sara I. Pai, Ralph P. Tufano
World Journal of Surgery. 2011;
[VIEW]
93 The use of the Bethesda terminology in thyroid fine-needle aspiration results in a lower rate of surgery for nonmalignant nodules: A report from a reference center in Turkey
Ozluk, Y. and Pehlivan, E. and Gulluoglu, M.G. and Poyanli, A. and Salmaslioglu, A. and Colak, N. and Kapran, Y. and Yilmazbayhan, D.
International Journal of Surgical Pathology. 2011; 19(6): 761-771
[Pubmed]
94 Repeatedly nondiagnostic thyroid fine-needle aspirations do not modify malignancy risk
Jo, V.Y. and Vanderlaan, P.A. and Marqusee, E. and Krane, J.F.
Acta Cytologica. 2011; 55(6): 539-543
[Pubmed]
95 Nodule or pseudonodule? differentiation in Hashimotoæs thyroiditis with sonoelastography
Yildirim, D. and Gurses, B. and Gurpinar, B. and Ekci, B. and Colakoglu, B. and Kaur, A.
Journal of International Medical Research. 2011; 39(6): 2360-2369
[Pubmed]
96 Spectrum of risk of malignancy in subcategories of æatypia of undetermined significanceæ
Olson, M.T. and Clark, D.P. and Erozan, Y.S. and Ali, S.Z.
Acta Cytologica. 2011; 55(6): 518-525
[Pubmed]
97 Employing genetic markers to improve diagnosis of thyroid tumor fine needle biopsy
Cerutti, J.M.
Current Genomics. 2011; 12(8): 589-596
[Pubmed]
98 Cytologic features of focal papillary thyroid carcinoma arising within follicular adenoma: A masked cytomorphologic analysis of 17 cases
Ono, J.C. and Wilbur, D.C. and Lee, H. and Yang, J. and Krane, J.F. and Bongiovanni, M. and Faquin, W.C.
Acta Cytologica. 2011; 55(6): 531-538
[Pubmed]
99 The UK Royal College of pathologists thyroid fine-needle aspiration diagnostic classification is a robust tool for the clinical management of abnormal thyroid nodules
Lobo, C. and McQueen, A. and Beale, T. and Kocjan, G.
Acta Cytologica. 2011; 55(6): 499-506
[Pubmed]
100 Thyroid fine-needle aspiration: Does case volume affect diagnostic yield and interpretation?
Houlton, J.J. and Sun, G.H. and Fernandez, N. and Zhai, Q. and Lucas, F. and Steward, D.L.
Archives of Otolaryngology - Head and Neck Surgery. 2011; 137(11): 1136-1139
[Pubmed]
101 Pyrosequencing cut-off value identifying BRAF V600E mutation in fine needle aspiration samples of thyroid nodules
Yeo, M.-K. and Liang, Z.L. and Oh, T. and Moon, Y. and An, S. and Kim, M.K. and Kim, K.S. and Shong, M. and Kim, J.-M. and Jo, Y.S.
Clinical Endocrinology. 2011; 75(4): 555-560
[Pubmed]
102 Surgeon-performed ultrasound-guided needle biopsy of the thyroid: A safe and effective diagnostic procedure
Law, M.T. and Taylor, M. and Bennett, I.C.
World Journal of Endocrine Surgery. 2011; 3(3): 116-121
[Pubmed]
103 Current management of a thyroid nodule
Tufano, R.P. and Noureldine, S.I. and Kandil, E.H.
Otorinolaringologia. 2011; 61(3): 71-87
[Pubmed]
104 Microfilariae coexisting with a follicular lesion in thyroid aspirate smears in an uncommon case of a retrosternal thyroid mass, clinically presenting as malignancy
Rekhi, B. and Kane, S.V.
CytoJournal. 2011; 8(4)
[Pubmed]
105 Current state and future perspective of molecular diagnosis of fine-needle aspiration biopsy of thyroid nodules
Ferraz, C. and Eszlinger, M. and Paschke, R.
Journal of Clinical Endocrinology and Metabolism. 2011; 96(7): 2016-2026
[Pubmed]
106 The interobserver reproducibility of thyroid fine-needle aspiration using the UK Royal College of pathologistsæ classification system
Kocjan, G. and Chandra, A. and Cross, P.A. and Giles, T. and Johnson, S.J. and Stephenson, T.J. and Roughton, M. and Poller, D.N.
American Journal of Clinical Pathology. 2011; 135(6): 852-859
[Pubmed]
107 Value of ultrasound and cytological classification system to predict the malignancy of thyroid nodules with indeterminate cytology
Maia, F.F.R. and Matos, P.S. and Pavin, E.J. and Vassallo, J. and Zantut-Wittmann, D.E.
Endocrine Pathology. 2011; 22(2): 66-73
[Pubmed]
108 Is a five-category reporting scheme for thyroid fine needle aspiration cytology accurate? Experience of over 18000 FNAs reported at the same institution during 1998-2007
Piana, S. and Frasoldati, A. and Ferrari, M. and Valcavi, R. and Froio, E. and Barbieri, V. and Pedroni, C. and Gardini, G.
Cytopathology. 2011; 22(3): 164-173
[Pubmed]
109 Increasing diagnostic accuracy for thyroid nodules by an integrated multivariate approach: A methodological study
Consorti, F. and Cozza, V. and Loponte, M. and Mardente, S. and Milazzo, F. and Scardella, L. and Antonaci, A.
Clinica Terapeutica. 2011; 162(1): 31-35
[Pubmed]
110 The role of thyroid fine needle aspiration cytology and the Bethesda system for reporting thyroid cytopathology
Massimo Bongiovanni,Edmund S. Cibas,William C. Faquin
Diagnostic Histopathology. 2011; 17(3): 95
[Pubmed]
111 Predictive Value of Cytologic Atypia in Indeterminate Thyroid Fine-Needle Aspirate Biopsies
Meredith A. Kato, Daniel Buitrago, Tracy-Ann Moo, Xavier M. Keutgen, Raza S. Hoda, Joseph A. Ricci, Paul J. Christos, Grace Yang, Thomas J. Fahey, Rasa Zarnegar
Annals of Surgical Oncology. 2011;
[VIEW]
112 Pyrosequencing cut-off value identifying BRAFV600E mutation in fine needle aspiration samples of thyroid nodules : ROC curve of pyrosequencing for the BRAFV600E mutation in thyroid cancer
Min-Kyung Yeo, Zhe Long Liang, Taejeong Oh, Youngho Moon, Sungwhan An, Min Kyeong Kim, Koon Soon Kim, Minho Shong, Jin-Man Kim, Young Suk Jo
Clinical Endocrinology. 2011; 75(4): 555
[VIEW]
113 Guidelines of the French society of endocrinology for the management of thyroid nodules
Annales d Endocrinologie. 2011;
[VIEW]
114 Liquid-based cytology in fine-needle aspiration biopsies of the thyroid gland
Fadda, G., Rossi, E.D.
Acta Cytologica. 2011; 55(5): 389-400
[Pubmed]
115 Usefulness of diagnostic qualifiers for thyroid fine-needle aspirations with atypia of undetermined significance
VanderLaan, P.A., Marqusee, E., Krane, J.F.
American Journal of Clinical Pathology. 2011; 136(4): 572-577
[Pubmed]
116 Minimizing the diagnosis of "follicular lesion of undetermined significance" and identifying predictive features for neoplasia
Jing, X., Roh, M.H., Knoepp, S.M., Zhao, L., Michael, C.W.
Diagnostic Cytopathology. 2011; 39(10): 737-742
[Pubmed]
117 Utility and Interobserver Agreement of Ultrasound Elastography in the Detection of Malignant Thyroid Nodules in Clinical Care
S. Merino, J. Arrazola, A. Cardenas, M. Mendoza, P. De Miguel, C. Fernandez, T. Ganado
American Journal of Neuroradiology. 2011; 32(11): 2142
[VIEW]
118 Cytologic and molecular diagnosis of thyroid cancers : Is it Time for Routine Reflex Testing?
Lewis A. Hassell, Elizabeth M. Gillies, S. Terence Dunn
Cancer Cytopathology. 2011; : n/a
[VIEW]
119 Thyroid follicular lesion of undetermined significance: Evaluation of the risk of malignancy using the two-tier sub-classification
Matthew J. Horne, David C. Chhieng, Constantine Theoharis, Kevin Schofield, Diane Kowalski, Manju L. Prasad, Lynwood Hammers, Robert Udelsman, Adebowale J. Adeniran
Diagnostic Cytopathology. 2011; : n/a
[VIEW]
120 An Ultrasound Model to Discriminate the Risk of Thyroid Carcinoma
Domínguez, J.M., Baudrand, R., Cerda, J., Campusano, C., Fardella, C., Arteaga, E., Cruz, F., (...), Mosso, L.
Academic Radiology. 2011; 18(2): 242-245
[Pubmed]
121 Ultrasound-Guided Procedures for the Office
Smith, R.B.
Otolaryngologic Clinics of North America. 2010; 43(6): 1241-1254
[Pubmed]
122 Decision making for the extent of thyroidectomy in the patient with atypical cytologic results
Shah, M.D., Conrad, A., Ahmed, A., Eski, S., MacMillan, C., Freeman, J.L.
Archives of Otolaryngology - Head and Neck Surgery. 2010; 136(12): 1177-1180
[Pubmed]
123 Thyroid nodules; Interpretation and importance of fine-needle aspiration (FNA) for the clinician - Practical considerations
Sakorafas, G.H.
Surgical Oncology. 2010; 19(4): e130-e139
[Pubmed]
124 Diagnostic value and cost considerations of routine fine-needle aspirations in the follow-up of thyroid nodules with benign readings
Van Roosmalen, J., Van Hemel, B., Suurmeijer, A., Groen, H., Ruitenbeek, T., Links, T.P., Plukker, J.T.M.
Thyroid. 2010; 20(12): 1359-1365
[Pubmed]
125 Ultrasound-guided fine-needle aspiration of thyroid nodules: stratification of malignancy risk using follicular proliferation grading, clinical and ultrasonographic features
S. Rorive,N. DæHaene,C. Fossion,I. Delpierre,N. Abarguia,F. Avni,C. Decaestecker,I. Salmon
European Journal of Endocrinology. 2010; 162(6): 1107
[Pubmed]
126 Is a five-category reporting scheme for thyroid fine needle aspiration cytology accurate? Experience of over 18 000 FNAs reported at the same institution during 1998-2007 : Cytological classification of thyroid FNA
S. Piana, A. Frasoldati, M. Ferrari, R. Valcavi, E. Froio, V. Barbieri, C. Pedroni, G. Gardini
Cytopathology. 2010; : no
[VIEW]
127 Thyroid Fine Needle Aspiration Biopsies in Children: Study of Cytological-Histological Correlation and Immunostaining with Thyroid Peroxidase Monoclonal Antibodies
Victoria Hoperia, Alexander Larin, Kirk Jensen, Andrew Bauer, Vasily Vasko
International Journal of Pediatric Endocrinology. 2010; 2010: 1
[VIEW]
128 Fine-Needle Aspiration in the Work-Up of Thyroid Nodules
Edmund S. Cibas
Otolaryngologic Clinics of North America. 2010; 43(2): 257
[VIEW]
129 How to Interpret Thyroid Biopsy Results: A Three-Year Retrospective Interventional Radiology Experience
Jason D. Oppenheimer, Deepa Kasuganti, Ritu Nayar, Howard B. Chrisman, Robert J. Lewandowski, Albert A. Nemcek, Robert K. Ryu
CardioVascular and Interventional Radiology. 2010; 33(4): 800
[VIEW]
130 Indeterminate thyroid nodules: A challenge for the surgical strategy
Reza Asari, Barbara E. Niederle, Christian Scheuba, Philipp Riss, Oskar Koperek, Klaus Kaserer, Bruno Niederle
Surgery. 2010; 148(3): 516
[VIEW]
131 Ultrasound-Guided Procedures for the Office
Russell B. Smith
Otolaryngologic Clinics of North America. 2010; 43(6): 1241
[VIEW]
132 Retrospective evaluation of instituted standard adequacy criteria for on-site adequacy assessment of thyroid fine-needle aspiration
Xin Jing, Elizabeth Wey, Claire W. Michael
Diagnostic Cytopathology. 2010; : n/a
[VIEW]
133 Diagnostic Value and Cost Considerations of Routine Fine-Needle Aspirations in the Follow-Up of Thyroid Nodules with Benign Readings
Jeroen van Roosmalen,Bettien van Hemel,Albert Suurmeijer,Henk Groen,Teus Ruitenbeek,Thera P. Links,John T.M. Plukker
Thyroid. 2010; 20(12): 1359
[Pubmed]
134 Fine-needle aspiration of follicular patterned lesions of the thyroid: Diagnosis, management, and follow-up according to National Cancer Institute (NCI) recommendations
William C. Faquin, Zubair W. Baloch
Diagnostic Cytopathology. 2010; : NA
[VIEW]
135 Management guidelines for patients with thyroid nodules : Editorial
Jonathan Serpell
ANZ Journal of Surgery. 2010; 80(11): 765
[VIEW]
136 Diagnostic usefulness of tumor markers in the thyroid cytological samples extracted by fine-needle aspiration biopsy
Manuel, J., Sáaez, G.
Endocrine, Metabolic and Immune Disorders - Drug Targets. 2010; 10(1): 47-56
[Pubmed]
137 Translational research in surgical disease
Stojadinovic, A., Ahuja, N., Nazarian, S.M., Segev, D.L., Jacobs, L., Wang, Y., Eberhardt, J., Zeiger, M.A.
Archives of Surgery. 2010; 145(2): 187-196
[Pubmed]
138 Clinical and cytological features predictive of malignancy in thyroid follicular neoplasms
Lubitz, C.C., Faquin, W.C., Yang, J., Mekel, M., Gaz, R.D., Parangi, S., Randolph, G.W., (...), Stephen, A.E.
Thyroid. 2010; 20(1): 25-31
[Pubmed]
139 Thyroid Fine Needle Aspiration Biopsies in Children: Study of Cytological-Histological Correlation and Immunostaining with Thyroid Peroxidase Monoclonal Antibodies
Victoria Hoperia,Alexander Larin,Kirk Jensen,Andrew Bauer,Vasily Vasko
International Journal of Pediatric Endocrinology. 2010; 2010(1): 690108
[Pubmed]
140 Clinical and Cytological Features Predictive of Malignancy in Thyroid Follicular Neoplasms
Carrie C. Lubitz,William C. Faquin,Jingyun Yang,Michal Mekel,Randall D. Gaz,Sareh Parangi,Gregory W. Randolph,Richard A. Hodin,Antonia E. Stephen
Thyroid. 2010; 20(1): 25
[Pubmed]
141 Molecular diagnostics on thyroid fine-needle aspirations: The pathway to value creation
Clark, D.P.
Cancer Cytopathology. 2010; 118(1): 14-16
[Pubmed]
142 Decision making for the extent of thyroidectomy in the patient with atypical cytologic results
Shah, M.D. and Conrad, A. and Ahmed, A. and Eski, S. and MacMillan, C. and Freeman, J.L.
Archives of Otolaryngology - Head and Neck Surgery. 2010; 136(12): 1177-1180
[Pubmed]
143 Diagnostic value and cost considerations of routine fine-needle aspirations in the follow-up of thyroid nodules with benign readings
Van Roosmalen, J. and Van Hemel, B. and Suurmeijer, A. and Groen, H. and Ruitenbeek, T. and Links, T.P. and Plukker, J.T.M.
Thyroid. 2010; 20(12): 1359-1365
[Pubmed]
144 Thyroid nodules; Interpretation and importance of fine-needle aspiration (FNA) for the clinician - Practical considerations
Sakorafas, G.H.
Surgical Oncology. 2010; 19(4): e130-e139
[Pubmed]
145 Application of bethesda system for reporting thyroid aspiration cytology [Korean Source]
Lee, K. and Jung, C.-K. and Lee, K.-Y. and Bae, J.-S. and Lim, D.-J. and Jung, S.-L.
Korean Journal of Pathology. 2010; 44(5): 521-527
[Pubmed]
146 Management guidelines for patients with thyroid nodules
Serpell, J.
ANZ Journal of Surgery. 2010; 80(11): 765-766
[Pubmed]
147 Comparison between thyroidectomy and hemithyroidectomy in treatment of single thyroid nodules identified as indeterminate follicular lesions by fine-needle aspiration cytology
Dobrinja, C. and Trevisan, G. and Piscopello, L. and Fava, M. and Liguori, G.
Annali Italiani di Chirurgia. 2010; 81(6): 403-411
[Pubmed]
148 Thyroid carcinoma
Tuttle, R.M. and Ball, D.W. and Byrd, D. and Dilawari, R.A. and Doherty, G.M. and Duh, Q.-Y. and Ehya, H. and Farrar, W.B. and Haddad, R.I. and Kandeel, F. and Kloos, R.T. and Kopp, P. and Lamonica, D.M. and Loree, T.R. and Lydiatt, W.M. and McCaffrey, J.C. and Olson Jr., J.A. and Parks, L. and Ridge, J.A. and Shah, J.P. and Sherman, S.I. and Sturgeon, C. and Waguespack, S.G. and Wang, T.N. and Wirth, L.J.
JNCCN Journal of the National Comprehensive Cancer Network. 2010; 8(11): 1228-1274
[Pubmed]
149 Diagnosis and treatment of thyroid cancer - Polish guidelines [Diagnostyka i leczenie raka tarczycy - Rekomendacje Polskie]
Jarza̧b, B. and Sporny, S. and Lange, D. and Włoch, J. and Lewiński, A.
Endokrynologia Polska. 2010; 61(5): 518-521
[Pubmed]
150 Malignancy risk for fine-needle aspiration of thyroid lesions according to the Bethesda system for reporting thyroid cytopathology
Jo, V.Y. and Stelow, E.B. and Dustin, S.M. and Hanley, K.Z.
American Journal of Clinical Pathology. 2010; 134(3): 450-456
[Pubmed]
151 The patient with a thyroid nodule
Miller, M.C.
Medical Clinics of North America. 2010; 94(5): 1003-1015
[Pubmed]
152 Commentary to guidelines "Diagnosis and treatment of thyroid cancer" [Komentarz do rekomendacji "Diagnostyka i leczenie raka tarczycy"]
Jarza̧b, B. and Słowinska-Klencka, D.
Endokrynologia Polska. 2010; 61(5): 569-574
[Pubmed]
153 Fine needle aspiration - Is there a difference in indication for use based on gender?
Miller, B.S.
Journal of Surgical Research. 2010; 162(2): 165-167
[Pubmed]
154 Hashimoto thyroiditis: Part 2, sonographic analysis of benign and malignant nodules in patients with diffuse Hashimoto thyroiditis
Anderson, L. and Middleton, W.D. and Teefey, S.A. and Reading, C.C. and Langer, J.E. and Desser, T. and Szabunio, M.M. and Mandel, S.J. and Hildebolt, C.F. and Cronan, J.J.
American Journal of Roentgenology. 2010; 195(1): 216-222
[Pubmed]
155 Ultrasound-guided fine-needle aspiration of thyroid nodules: Stratification of malignancy risk using follicular proliferation grading, clinical and ultrasonographic features
Rorive, S. and DæHaene, N. and Fossion, C. and Delpierre, I. and Abarguia, N. and Avni, F. and Decaestecker, C. and Salmon, I.
European Journal of Endocrinology. 2010; 162(6): 1107-1115
[Pubmed]
156 Cytology diagnosis and clinical management of fine-needle aspiration for thyroid nodules
Zheng, J.-Y. and Bai, T. and Zhang, Y.-F. and Chen, A.-Q. and Huang, Q.
Chinese Journal of Pathology. 2010; 39(5): 349-352
[Pubmed]
157 Accuracy of fine needle aspiration biopsy with and without the use of tumor markers in cytologically indeterminate thyroid lesions
Mateša, N. and Šamija, I. and Kusić, Z.
Collegium Antropologicum. 2010; 34(1): 53-57
[Pubmed]
158 Differentiated thyroid cancers of follicular cell origin
Carty, S.E. and Yip, L.
Cancer Treatment and Research. 2010; 153: 35-56
[Pubmed]
159 Molecular diagnostics on thyroid fine-needle aspirations : The Pathway to Value Creation
Douglas P. Clark
Cancer Cytopathology. 2010; 118(1): 14
[VIEW]
160 The role of thyroid fine needle aspiration cytology and the Bethesda system for reporting thyroid cytopathology
Bongiovanni, M., Cibas, E.S., Faquin, W.C.
Diagnostic Histopathology. 2010; 17(3): 95-105
[Pubmed]
161 Minimizing the diagnosis of “follicular lesion of undetermined significance” and identifying predictive features for neoplasia
Xin Jing, Michael H. Roh, Stewart M. Knoepp, Lili Zhao, Claire W. Michael
Diagnostic Cytopathology. 2010; : n/a
[VIEW]
162 Thyroid fine needle aspiration cytology: a review of the National Cancer Institute state of the science symposium
L. J. Layfield, E. S. Cibas, Z. Baloch
Cytopathology. 2010; 21(2): 75-85
[Pubmed]
163 Application of Bethesda System for Reporting Thyroid Aspiration Cytology
Kyungji Lee, Chan-Kwon Jung, Kyo-Young Lee, Ja-Seong Bae, Dong-Jun Lim, So-Lyung Jung
The Korean Journal of Pathology. 2010; 44(5): 521
[VIEW]
164 Thyroid nodules; interpretation and importance of fine-needle aspiration (FNA) for the clinician – Practical considerations
George H. Sakorafas
Surgical Oncology. 2010; 19(4): e130
[VIEW]
165 Thyroid Aspiration Cytology
Status, C.
CA CANCER J CLIN. 2009; 59: 99-110
[Pubmed]
166 Thyroid fine-needle aspiration with atypia of undetermined significance: A necessary or optional category?
Shi, Y. and Ding, X. and Klein, M. and Sugrue, C. and Matano, S. and Edelman, M. and Wasserman, P.
Cancer Cytopathology. 2009; 117(5): 298-304
[Pubmed]
167 Differential expression of galectin-3, CK19, HBME1, and Ret oncoprotein in the diagnosis of thyroid neoplasms by fine needle aspiration biopsy
Saleh, H. and Feng, J. and Tabassum, F. and Al-Zohaili, O. and Husain, M. and Giorgadze, T.
CytoJournal. 2009; 6(18)
[Pubmed]
168 The many faces of follicular variant of papillary thyroid carcinoma
Livolsi, V.A. and Baloch, Z.W.
Pathology Case Reviews. 2009; 14(6): 214-218
[Pubmed]
169 The bethesda thyroid fine-needle aspiration classification system: Year 1 at an academic institution
Theoharis, C.G.A., Schofield, K.M., Hammers, L., Udelsman, R., Chhieng, D.C.
Thyroid. 2009; 19(11): 1215-1223
[Pubmed]
170 The bethesda system for reporting thyroid cytopathology
Cibas, E.S., Ali, S.Z.
Thyroid. 2009; 19(11): 1159-1165
[Pubmed]
171 The Many Faces of Follicular Variant of Papillary Thyroid Carcinoma :
Virginia A. LiVolsi, Zubair W. Baloch
Pathology Case Reviews. 2009; 14(6): 214-218
[Pubmed]
172 The Bethesda System for Reporting Thyroid Cytopathology
Edmund S. Cibas,Syed Z. Ali
Thyroid. 2009; 19(11): 1159
[Pubmed]
173 Cyclin D1 and D3 overexpression predicts malignant behavior in thyroid fine-needle aspirates suspicious for Hurthle cell neoplasms
Giancarlo Troncone, Marco Volante, Antonino Iaccarino, Pio Zeppa, Immacolata Cozzolino, Umberto Malapelle, Emiliano A. Palmieri, Giovanni Conzo, Mauro Papotti, Lucio Palombini
Cancer Cytopathology. 2009; : NA
[VIEW]
174 Thyroid Aspiration Cytology: Current Status
Layfield, L.J. and Cibas, E.S. and Gharib, H. and Mandel, S.J.
CA: A Cancer Journal for Clinicians. 2009; 59(2): 99
[Pubmed]
175 Hemosiderin laden macrophages and hemosiderin within follicular cells distinguish benign follicular lesions from follicular neoplasms
Jaffar, R. and Mohanty, SK and Khan, A. and Fischer, AH
CytoJournal. 2009; 6(1): 3
[Pubmed]
176 Thyroid fine-needle aspiration with atypia of undetermined significance
Yan Shi, Xin Ding, Melissa Klein, Chiara Sugrue, Sandra Matano, Morris Edelman, Patricia Wasserman
Cancer Cytopathology. 2009; 117(5): 298
[VIEW]
177 Development of a clinical decision model for thyroid nodules
Stojadinovic, A., Peoples, G.E., Libutti, S.K., Henry, L.R., Eberhardt, J., Howard, R.S., Gur, D., (...), Nissan, A.
BMC Surgery. 2009; 1(Art 12)
[Pubmed]
178 Thyroid fine needle aspiration
Bibbo, M.
Acta Cytologica. 2009; 53(5): 489-490
[Pubmed]
179 Improving prediction of malignancy of cytologically indeterminate thyroid nodules
Tysome, J.R., Chandra, A., Chang, F., Puwanarajah, P., Elliott, M., Caroll, P., Powrie, J., Simo, R.
British Journal of Surgery. 2009; 96(12): 1400-1405
[Pubmed]
180 Fine-needle aspiration of the thyroid: today and tomorrow
Baloch, Z.W., LiVolsi, V.A.
Best Practice and Research: Clinical Endocrinology and Metabolism. 2008; 22(6): 929-939
[Pubmed]
181 A Diagnostic Predictor Model for Indeterminate or Suspicious Thyroid FNA Samples
Nia D. Banks,Jeanne Kowalski,Hua-Ling Tsai,Helina Somervell,Ralph Tufano,Alan P.B. Dackiw,Michael R. Marohn,Douglas P. Clark,Christopher B. Umbricht,Martha A. Zeiger
Thyroid. 2008; 18(9): 933
[Pubmed]
182 Thyroid cancer: The impact of emerging technologies on clinical practice guidelines
Jeffrey I. Mechanick,Angelo Carpi
Biomedicine & Pharmacotherapy. 2008; 62(8): 554
[Pubmed]
183 Fine-needle aspiration of the thyroid: today and tomorrow
Zubair W. Baloch,Virginia A. LiVolsi
Best Practice & Research Clinical Endocrinology & Metabolism. 2008; 22(6): 929
[Pubmed]
184 CytoJournal′s move to the new platform: More on financial model to the support open-access charter in cytopathology, publication quality indicators, and other issues
Shidham, V. and Pitman, M. and Demay, R. and Atkinson, B.
CytoJournal. 2008; 5(15)
[Pubmed]
185 CytoJournalæs move to the new platform: More on financial model to the support open-access charter in cytopathology, publication quality indicators, and other issues
Shidham, VB and Pitman, MB and DeMay, RM and Atkinson, BF
CytoJournal. 2008; 5(1): 15
[Pubmed]
186 A Diagnostic Predictor Model for Indeterminate or Suspicious Thyroid FNA Samples
Banks, N.D. and Kowalski, J. and Tsai, H.L. and Somervell, H. and Tufano, R. and Dackiw, A.P.B. and Marohn, M.R. and Clark, D.P. and Umbricht, C.B. and Zeiger, M.A.
Thyroid. 2008; 18(9): 933-941
[Pubmed]
187 Thyroid cancer: The impact of emerging technologies on clinical practice guidelines
Mechanick, J.I. and Carpi, A.
Biomedicine \& Pharmacotherapy. 2008; 62(8): 554-558
[Pubmed]



 

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