Reducing non diagnostic thyroid cytology using on-site adequacy assessment performed by junior medical staff
Main Article Content
Abstract
Objective:To assess efficacy of bedside cytology assessment of thyroid fine needle aspirate samples performed by junior medical staff compared to cytologists.
Methods: Retrospective analysis was performed of 1490 thyroid fine needle aspirates. Samples were divided into three groups: cellular adequacy assessment performed by cytologists, interns, and no onsite adequacy assessment (blind). A 45-minute training session was provided to medical interns with the aim of identifying whether adequate cellular material was demonstrated, as defined by the Bethesda criteria. The primary outcome was the rate of nondiagnostic samples, and the secondary outcome was the number of fine needle aspirate passes required to reach sample adequacy.
Results: The incidence of non-diagnostic samples for the cytologist, blind, and intern groups were 6.90%, 17.1% and 14.0% respectively (p<0.001). There was no statistically significant difference in non-diagnostic rate between the blind and intern groups. Significantly more aspirates required more than two passes in the cytologist group (74.8%) and blind (94.7%) compared to the intern group (58.7%, p<0.001).
Conclusions: On-site adequacy assessment performed by cytopathologists is the gold standard for minimising non-diagnostic thyroid FNAs, however, medical staff with minimal anatomical pathology experience can be trained to perform on-site adequacy assessment and improve outcomes with the implementation of a simple targeted training program.
Keywords:
Thyroid nodule, Thyroid ultrasound, Cytology, Aspiration biopsy
Article Details
How to Cite
REN, Tianchi et al.
Reducing non diagnostic thyroid cytology using on-site adequacy assessment performed by junior medical staff.
Medical Research Archives, [S.l.], v. 11, n. 10, oct. 2023.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/4557>. Date accessed: 15 may 2024.
doi: https://doi.org/10.18103/mra.v11i10.4557.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Brander A, Viikinkoski P, Nickels J, Kivisaari L. Thyroid gland: US screening in a random adult population. Radiology. 1991;181:683-687.
2. Mazzaferri EL. Management of a Solitary Thyroid Nodule. New England Journal of Medicine. 1993; 328: 553-559. doi: 10.1056/ NEJM199302253280807
3. Carroll BA. Asymptomatic thyroid nodules: incidental sonographic detection. AJR Am J Roentgenol. 1982; 138:499-501. doi: 10.2214/ajr.138.3.499
4. Ezzat S, Sarti DA, Cain DR, Braunstein GD. Thyroid incidentalomas. Prevalence by palpation and ultrasonography. Arch Intern Med. 1994; 154:1838-1840. doi: 10.1001/ archinte.154.16.1838
5. Russ G, Leboulleux S, Leenhardt L, Hegedüs L. Thyroid incidentalomas: epidemiology, risk stratification with ultrasound and workup. Eur Thyroid J. 2014;3: 154-163. doi: 10.1159/000365289
6. Frates MC, Benson CB, Doubilet PM, Kunreuther E, Contreras M, Cibas ES, Orcutt J, Moore Jr FD, Larsen PR, Marqusee E. Prevalence and distribution of carcinoma in patients with solitary and multiple thyroid nodules on sonography. The Journal of Clinical Endocrinology & Metabolism. 2006; 91:3411-3417.
7. Hoang JK, Lee WK, Lee M, Johnson D, Farrell S. US Features of thyroid malignancy: pearls and pitfalls. Radiographics. 2007; 27:847-860.
8. Thyroid Incidentalomas: Management Approaches to Nonpalpable Nodules Discovered Incidentally on Thyroid Imaging. Annals of Internal Medicine. 1997; 126:226-231. doi: 10.7326/0003-4819-126-3-199702010-00009 %m 9027275
9. Kakkos SK, Scopa CD, Chalmoukis AK, Karachalios DA, Spiliotis JD, Harkoftakis JG, Karavias DD, Androulakis JA, Vagenakis AG. Relative risk of cancer in sonographically detected thyroid nodules with calcifications. Journal of Clinical Ultrasound. 2000;28:347-352. doi:https://doi.org/10.1002/10970096(200009)28:7<347::AID-JCU5> 3.0.CO;2-O
10. Hong Y-r, Wu Y-l, Luo Z-y, Wu N-b, Liu X-m. Impact of nodular size on the predictive values of gray-scale, color-Doppler ultrasound, and sonoelastography for assessment of thyroid nodules. Journal of Zhejiang University SCIENCE B. 2012; 13:707-716. doi: 10.1631/jzus.B1100342
11. Brito JP, Gionfriddo MR, Al Nofal A, Boehmer KR, Leppin AL, Reading C, Callstrom M, Elraiyah TA, Prokop LJ, Stan MN, et al. The Accuracy of Thyroid Nodule Ultrasound to Predict Thyroid Cancer: Systematic Review and Meta-Analysis. The Journal of Clinical Endocrinology & Metabolism. 2014; 99:1253-1263. doi: 10.1210/jc.2013-2928
12. Horvath E, Majlis S, Rossi R, Franco C, Niedmann JP, Castro A, Dominguez M. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. The Journal of Clinical Endocrinology & Metabolism. 2009; 94:1748-1751.
13. Tessler FN, Middleton WD, Grant EG, Hoang JK, Berland LL, Teefey SA, Cronan JJ, Beland MD, Desser TS, Frates MC, et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee. J Am Coll Radiol. 2017;14:587-595. doi: 10.1016/j.jacr.2017.01.046
14. Rojeski MT, Gharib H. Nodular thyroid disease: evaluation and management. New England Journal of Medicine. 1985; 313:428-436.
15. Yeung MJ, Serpell JW. Management of the solitary thyroid nodule. The oncologist. 2008; 13:105-112.
16. Hall TL, Layfield LJ, Philippe A, Rosenthal DL. Sources of diagnostic error in fine needle aspiration of the thyroid. Cancer. 1989; 63:718-725.
17. Zhu W, Michael CW. How important is on‐site adequacy assessment for thyroid FNA? An evaluation of 883 cases. Diagnostic cytopathology. 2007; 35:183-186.
18. Yeh MW, Demircan O, Ituarte P, Clark OH. False-Negative Fine-Needle Aspiration Cytology Results Delay Treatment and Adversely Affect Outcome in Patients with Thyroid Carcinoma. Thyroid®. 2004; 14:207-215. doi: 10.1089/105072504773297885
19. Alexander EK, Heering JP, Benson CB, Frates MC, Doubilet PM, Cibas ES, Marqusee E. Assessment of Nondiagnostic Ultrasound-Guided Fine Needle Aspirations of Thyroid Nodules. The Journal of Clinical Endocrinology & Metabolism. 2002; 87:4924-4927. doi: 10.1210/jc.2002-020865
20. Goellner JR, Gharib H, Grant CS, Johnson DA. Fine needle aspiration cytology of the thyroid, 1980 to 1986. Acta Cytol. 1987; 31:587-590.
21. Nondiagnostic Fine-Needle Aspiration Biopsy of Thyroid Nodules: Outcomes and Determinants. Thyroid®. 2020; 30:992-998. doi: 10.1089/thy.2019.0140
22. Kim MJ, Kim E-K, Park SI, Kim BM, Kwak JY, Kim SJ, Youk JH, Park SH. US-guided Fine-Needle Aspiration of Thyroid Nodules: Indications, Techniques, Results. RadioGraphics. 2008; 28:1869-1886. doi: 10.1148/rg. 287085033
23. Son JI, Rhee SY, Woo J-t, Park WS, Byun JK, Kim Y-J, Byun JM, Chin SO, Chon S, Oh S. Insufficient experience in thyroid fine-needle aspiration leads to misdiagnosis of thyroid cancer. Endocrinology and Metabolism. 2014; 29:293-299.
24. Rapid Onsite Evaluation Improves the Adequacy of Fine-Needle Aspiration for Thyroid Lesions: A Systematic Review and Meta-Analysis. Thyroid®. 2013; 23:428-435. doi: 10.1089/thy.2012.0211
25. 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. doi: 10.1186/1742-6413-5-6
26. Tan C, Lavender I, Naismith A, Nguyen Q, Ptasznik R, Nandurkar D, Wong J, Kumar B, Fuller PJ, Coombs PR, et al. Evaluation of a dedicated ultrasound fine needle aspiration service for thyroid nodules. Sonography. 2018;5:3-11. doi:https://doi.org/10.1002/sono.12135
27. Russ G, Bigorgne C, Royer B, Rouxel A, Bienvenu-Perrard M. The Thyroid Imaging Reporting and Data System (TIRADS) for ultrasound of the thyroid. Journal de radiologie. 2011;92:701-713.
28. Shin JH, Baek JH, Chung J, Ha EJ, Kim J-h, Lee YH, Lim HK, Moon W-J, Na DG, Park JS, et al. Ultrasonography Diagnosis and Imaging-Based Management of Thyroid Nodules: Revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations. Korean J Radiol. 2016; 17:370-395.
29. Xu T, Wu Y, Wu R-X, Zhang Y-Z, Gu J-Y, Ye X-H, Tang W, Xu S-H, Liu C, Wu X-H. Validation and comparison of three newly-released Thyroid Imaging Reporting and Data Systems for cancer risk determination. Endocrine. 2019; 64:299-307. doi: 10.1007/ s12020-018-1817-8
30. Kamran SC, Marqusee E, Kim MI, Frates MC, Ritner J, Peters H, Benson CB, Doubilet PM, Cibas ES, Barletta J. Thyroid nodule size and prediction of cancer. The Journal of Clinical Endocrinology & Metabolism. 2013; 98:564-570.
31. Chan BK, Desser TS, McDougall IR, Weigel RJ, Jeffrey RB, Jr. Common and uncommon sonographic features of papillary thyroid carcinoma. J Ultrasound Med. 2003; 22:1083-1090. doi: 10.7863/jum.2003.22.10. 1083
32. Papini E, Guglielmi R, Bianchini A, Crescenzi A, Taccogna S, Nardi F, Panunzi C, Rinaldi R, Toscano V, Pacella CM. Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab. 2002; 87:1941-1946. doi: 10.1210/jcem.87.5. 8504
33. Cibas ES, Ali SZ. The Bethesda system for reporting thyroid cytopathology. Thyroid. 2009; 19:1159-1165.
34. de Vos tot Nederveen Cappel RJ, Bouvy ND, Bonjer HJ, van Muiswinkel JM, Chadha S. Fine needle aspiration cytology of thyroid nodules: how accurate is it and what are the causes of discrepant cases? Cytopathology. 2001; 12:399-405. doi: 10.1046/j.1365-2303. 2001.00363.x
35. Ghofrani M, Beckman D, Rimm DL. The value of onsite adequacy assessment of thyroid fine-needle aspirations is a function of operator experience. Cancer. 2006; 108:110-113. doi: 10.1002/cncr.21715.
2. Mazzaferri EL. Management of a Solitary Thyroid Nodule. New England Journal of Medicine. 1993; 328: 553-559. doi: 10.1056/ NEJM199302253280807
3. Carroll BA. Asymptomatic thyroid nodules: incidental sonographic detection. AJR Am J Roentgenol. 1982; 138:499-501. doi: 10.2214/ajr.138.3.499
4. Ezzat S, Sarti DA, Cain DR, Braunstein GD. Thyroid incidentalomas. Prevalence by palpation and ultrasonography. Arch Intern Med. 1994; 154:1838-1840. doi: 10.1001/ archinte.154.16.1838
5. Russ G, Leboulleux S, Leenhardt L, Hegedüs L. Thyroid incidentalomas: epidemiology, risk stratification with ultrasound and workup. Eur Thyroid J. 2014;3: 154-163. doi: 10.1159/000365289
6. Frates MC, Benson CB, Doubilet PM, Kunreuther E, Contreras M, Cibas ES, Orcutt J, Moore Jr FD, Larsen PR, Marqusee E. Prevalence and distribution of carcinoma in patients with solitary and multiple thyroid nodules on sonography. The Journal of Clinical Endocrinology & Metabolism. 2006; 91:3411-3417.
7. Hoang JK, Lee WK, Lee M, Johnson D, Farrell S. US Features of thyroid malignancy: pearls and pitfalls. Radiographics. 2007; 27:847-860.
8. Thyroid Incidentalomas: Management Approaches to Nonpalpable Nodules Discovered Incidentally on Thyroid Imaging. Annals of Internal Medicine. 1997; 126:226-231. doi: 10.7326/0003-4819-126-3-199702010-00009 %m 9027275
9. Kakkos SK, Scopa CD, Chalmoukis AK, Karachalios DA, Spiliotis JD, Harkoftakis JG, Karavias DD, Androulakis JA, Vagenakis AG. Relative risk of cancer in sonographically detected thyroid nodules with calcifications. Journal of Clinical Ultrasound. 2000;28:347-352. doi:https://doi.org/10.1002/10970096(200009)28:7<347::AID-JCU5> 3.0.CO;2-O
10. Hong Y-r, Wu Y-l, Luo Z-y, Wu N-b, Liu X-m. Impact of nodular size on the predictive values of gray-scale, color-Doppler ultrasound, and sonoelastography for assessment of thyroid nodules. Journal of Zhejiang University SCIENCE B. 2012; 13:707-716. doi: 10.1631/jzus.B1100342
11. Brito JP, Gionfriddo MR, Al Nofal A, Boehmer KR, Leppin AL, Reading C, Callstrom M, Elraiyah TA, Prokop LJ, Stan MN, et al. The Accuracy of Thyroid Nodule Ultrasound to Predict Thyroid Cancer: Systematic Review and Meta-Analysis. The Journal of Clinical Endocrinology & Metabolism. 2014; 99:1253-1263. doi: 10.1210/jc.2013-2928
12. Horvath E, Majlis S, Rossi R, Franco C, Niedmann JP, Castro A, Dominguez M. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. The Journal of Clinical Endocrinology & Metabolism. 2009; 94:1748-1751.
13. Tessler FN, Middleton WD, Grant EG, Hoang JK, Berland LL, Teefey SA, Cronan JJ, Beland MD, Desser TS, Frates MC, et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee. J Am Coll Radiol. 2017;14:587-595. doi: 10.1016/j.jacr.2017.01.046
14. Rojeski MT, Gharib H. Nodular thyroid disease: evaluation and management. New England Journal of Medicine. 1985; 313:428-436.
15. Yeung MJ, Serpell JW. Management of the solitary thyroid nodule. The oncologist. 2008; 13:105-112.
16. Hall TL, Layfield LJ, Philippe A, Rosenthal DL. Sources of diagnostic error in fine needle aspiration of the thyroid. Cancer. 1989; 63:718-725.
17. Zhu W, Michael CW. How important is on‐site adequacy assessment for thyroid FNA? An evaluation of 883 cases. Diagnostic cytopathology. 2007; 35:183-186.
18. Yeh MW, Demircan O, Ituarte P, Clark OH. False-Negative Fine-Needle Aspiration Cytology Results Delay Treatment and Adversely Affect Outcome in Patients with Thyroid Carcinoma. Thyroid®. 2004; 14:207-215. doi: 10.1089/105072504773297885
19. Alexander EK, Heering JP, Benson CB, Frates MC, Doubilet PM, Cibas ES, Marqusee E. Assessment of Nondiagnostic Ultrasound-Guided Fine Needle Aspirations of Thyroid Nodules. The Journal of Clinical Endocrinology & Metabolism. 2002; 87:4924-4927. doi: 10.1210/jc.2002-020865
20. Goellner JR, Gharib H, Grant CS, Johnson DA. Fine needle aspiration cytology of the thyroid, 1980 to 1986. Acta Cytol. 1987; 31:587-590.
21. Nondiagnostic Fine-Needle Aspiration Biopsy of Thyroid Nodules: Outcomes and Determinants. Thyroid®. 2020; 30:992-998. doi: 10.1089/thy.2019.0140
22. Kim MJ, Kim E-K, Park SI, Kim BM, Kwak JY, Kim SJ, Youk JH, Park SH. US-guided Fine-Needle Aspiration of Thyroid Nodules: Indications, Techniques, Results. RadioGraphics. 2008; 28:1869-1886. doi: 10.1148/rg. 287085033
23. Son JI, Rhee SY, Woo J-t, Park WS, Byun JK, Kim Y-J, Byun JM, Chin SO, Chon S, Oh S. Insufficient experience in thyroid fine-needle aspiration leads to misdiagnosis of thyroid cancer. Endocrinology and Metabolism. 2014; 29:293-299.
24. Rapid Onsite Evaluation Improves the Adequacy of Fine-Needle Aspiration for Thyroid Lesions: A Systematic Review and Meta-Analysis. Thyroid®. 2013; 23:428-435. doi: 10.1089/thy.2012.0211
25. 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. doi: 10.1186/1742-6413-5-6
26. Tan C, Lavender I, Naismith A, Nguyen Q, Ptasznik R, Nandurkar D, Wong J, Kumar B, Fuller PJ, Coombs PR, et al. Evaluation of a dedicated ultrasound fine needle aspiration service for thyroid nodules. Sonography. 2018;5:3-11. doi:https://doi.org/10.1002/sono.12135
27. Russ G, Bigorgne C, Royer B, Rouxel A, Bienvenu-Perrard M. The Thyroid Imaging Reporting and Data System (TIRADS) for ultrasound of the thyroid. Journal de radiologie. 2011;92:701-713.
28. Shin JH, Baek JH, Chung J, Ha EJ, Kim J-h, Lee YH, Lim HK, Moon W-J, Na DG, Park JS, et al. Ultrasonography Diagnosis and Imaging-Based Management of Thyroid Nodules: Revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations. Korean J Radiol. 2016; 17:370-395.
29. Xu T, Wu Y, Wu R-X, Zhang Y-Z, Gu J-Y, Ye X-H, Tang W, Xu S-H, Liu C, Wu X-H. Validation and comparison of three newly-released Thyroid Imaging Reporting and Data Systems for cancer risk determination. Endocrine. 2019; 64:299-307. doi: 10.1007/ s12020-018-1817-8
30. Kamran SC, Marqusee E, Kim MI, Frates MC, Ritner J, Peters H, Benson CB, Doubilet PM, Cibas ES, Barletta J. Thyroid nodule size and prediction of cancer. The Journal of Clinical Endocrinology & Metabolism. 2013; 98:564-570.
31. Chan BK, Desser TS, McDougall IR, Weigel RJ, Jeffrey RB, Jr. Common and uncommon sonographic features of papillary thyroid carcinoma. J Ultrasound Med. 2003; 22:1083-1090. doi: 10.7863/jum.2003.22.10. 1083
32. Papini E, Guglielmi R, Bianchini A, Crescenzi A, Taccogna S, Nardi F, Panunzi C, Rinaldi R, Toscano V, Pacella CM. Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab. 2002; 87:1941-1946. doi: 10.1210/jcem.87.5. 8504
33. Cibas ES, Ali SZ. The Bethesda system for reporting thyroid cytopathology. Thyroid. 2009; 19:1159-1165.
34. de Vos tot Nederveen Cappel RJ, Bouvy ND, Bonjer HJ, van Muiswinkel JM, Chadha S. Fine needle aspiration cytology of thyroid nodules: how accurate is it and what are the causes of discrepant cases? Cytopathology. 2001; 12:399-405. doi: 10.1046/j.1365-2303. 2001.00363.x
35. Ghofrani M, Beckman D, Rimm DL. The value of onsite adequacy assessment of thyroid fine-needle aspirations is a function of operator experience. Cancer. 2006; 108:110-113. doi: 10.1002/cncr.21715.