Thyroid Ultrasound and Ultrasound-Guided FNA

Hence, close consultation with the referring physician is essential. However, if it is inevitable that US-FNA of thyroid nodule will be performed under conditions with bleeding tendency, an experienced operator must carefully perform US-FNA using smaller needles with a limited number of passes after informing the patient about the slightly increased risk of bleeding 8 , Additionally, under such circumstances, the medical team must maintain compression over the puncture site for a longer period than usual Because most US-FNAs are well-tolerated and are not associated with significant patient pain or discomfort, routine use of local anesthesia has not been recommended 7 , 9 , 31 , However, some patients may complain of pain or discomfort, which can make the procedure less tolerable.

Therefore, local anesthesia can be used to improve the patient's compliance 7 , 9 , 31 , 32 , Alternatively, topical lidocaine cream can be used to minimize children's distress Regarding the benefit of local anesthesia during US-FNA, one study revealed that single needle puncture without local anesthesia did not cause significant pain, when compared to procedures with local anesthesia So we recommend the use of local anesthetic agents for deep, non-palpable thyroid nodules that may require two or more needle punctures to obtain the specimen 7 , 35 , Before performing US-FNA, the operator should verify the bleeding risk of the patient and previous cytologic results from medical records if available.

The operator should sit in front of the screen of the US equipment, usually on the right side of patient for ease of handling. The FNA procedure is performed with the patient supine, with a pillow placed under the shoulders to facilitate neck extension and optimize visualization of the area, using a high-resolution 7.

Ultrasound-Guided Fine Needle Aspiration Biopsy of the Thyroid

According to US-based recommendations for thyroid nodules proposed by the KSThR 38 and the American Thyroid Association 4 , the operator should preferentially select the thyroid nodule that shows at least one of the following malignant US findings: In contrast, US characteristics consistent with benignity include a pure cyst, a predominantly cystic or cystic nodule with reverberating artifacts and spongiform nodules 38 , In addition, color Dopper US can be used to reveal any blood vessels in and around the nodule so that vascular injury can be avoided during the procedure 1 , After the patient's neck is antiseptically swabbed, FNA is subsequently performed with the needle oriented either parallel or perpendicular to the US probe 1 , 9 , 31 , When the needle tip is placed appropriately within the target nodule, tissue samples is collected with 6 to 7 "to-and fro" needle movements over seconds, with mL suction applied Because the microscopic hemorrhage induced by negative pressure during FNA can hamper accurate cytologic interpretation, a repetitive back and forth motion of the needle without applying negative pressure, known as "capillary sampling", was proposed as an alternative method for obtaining less blood-contaminated specimens 9 , 12 , 17 , However, there have been concerns about the effectiveness of capillary sampling with regards to cellular adequacy.

Some studies demonstrated that capillary sampling yields higher quality specimens with fewer bloody stains compared with FNA 12 , 40 , whereas others indicated that there was no significant difference between the two techniques 41 , 42 , To achieve a better diagnostic yield, we recommend the "combined method": In this method, the operator moves the needle back and forth repeatedly without suction for a few seconds and sequentially applies a minimal amount of negative pressure if insufficient amount of aspirates is obtained. Biopsy specimens should be obtained from different quadrants of the nodule to ensure a representative sample 1 , 9.

When an appropriate amount of material has filled the needle hub, the syringe-needle unit is rapidly withdrawn after releasing the suction 1 , 9 , Releasing the suction before needle withdrawal forces the aspirated specimen into the needle, but not into the needle tract, which could prevent potential complications such as needle tract seeding 1 , 9 , To obtain a sufficient amount of specimen, the operator routinely uses a mL plastic syringe attached to a conventional gauge needle 1 , 7 , 9 , 31 , A syringe holder may or may not be used, according to the preference of the operator.

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The number of needle passes, ranging from 2 to 3, for each thyroid nodule is determined depending on the US characteristics of the thyroid nodule and the operator's preference To improve the cellular adequacy of FNA, several methods are recommended. For example, a gentler manipulating needle technique involving small needle size, capillary technique, and short needle dwell time, followed by manual compression would be effective for preventing bloody aspirates and procedure-related hematoma when targeting a hypervascular nodule 1 , 9 , 12 , For cystic or complex lesions, sampling could be done from the solid elements and from suspicious areas of complex lesions after drainage of the viscous colloid using a large needle 1 , 7 , In the parallel technique, the needle advances along the long axis of the probe and is visualized from the skin puncture to the thyroid nodule, allowing the operator to observe needle penetration, location of distal tip, and the entire pathway of the needle 31 , In the perpendicular technique, the nodule is positioned in the mid-portion of the screen and the point of needle insertion might be central, just over the nodule to be targeted 31 , The needle advances perpendicular to the probe footprint at an angle determined by the nodule's depth and only the tip of the needle is visualized when it enters the nodule.

Therefore, the needle tip should be continuously monitored by US to prevent vascular, tracheal or esophageal injury during the entire duration of the FNA. According to one study comparing parallel and perpendicular techniques with regard to specimen adequacy from thyroid nodules, the parallel technique significantly decreased the overall nondiagnostic sampling compared to the perpendicular technique However the sample size of the study was small and the two techniques were applied to different lesions. Cytologic details of samples will vary depending on the experience of the technical staff or laboratory facilities for handing specimens obtained by US-FNA, thus proper methods should be applied during smearing, fixation, and staining of samples to improve diagnostic yield 1.

For conventional smear preparations, the syringe-needle unit is disassembled first. The empty syringe is then filled with air, reconnected to the needle and the needle content is extruded onto glass slides. Sometimes, excessive pressure between the spreader slide and non-spreader slide results in crush artifacts which may interfere with evaluation of nuclear morphology 1 , 4.

Therefore, liquid-based cytology LBC , originally developed for gynecologic cervical smears, was recently introduced for the FNA of thyroid nodules due to its specific advantages including clear background, a monolayer cell preparation, and more convenient handling of specimens 1 , 45 , 46 , This method is based on a two-step procedure: However, several changes that occur during the cellular processing step of LBC, such as loss of cell artitecture, cytomorphologic changes of colloid, and decrease of inflammatory cells, were pointed out as the drawbacks of LBC.

Therefore, a dedicated training program would be necessary for cytopathologists to maintain the diagnsotic accuracy of US-FNA 1 , To summarize the advantages of two different cytologic preparation methods, cellular specimen processing by conventional smear techniques enables rapid, real-time assessment of sample adequacy and allows for a more accurate evaluation of cell architecture and colloids than LBC, whereas LBC enables rapid processing of samples with clearer backgrounds than conventional smears and the possibility of saving material for additional marker studies.

The role of immediate cytologic assessment is controversial 9. Many previous reports have stated that immediate assessment of cytologic adequacy at the time of FNA significantly decreased the numbers of nondiagnostic results and helped to avoid repeated FNAs 10 , 48 , 49 , 50 , However, others did not find a statistically significant difference in cytologic adequacy between FNAs of thyroid nodules with and without immediate cytological analysis, and stated that immediate cytological analysis considerably extended the cost and duration of the procedure It may not be necessary for the success of the procedure to perform an immediate assessment, especially if a highly-experienced operator with a relatively low nondiagnostic rate performs the US-FNA for the thyroid nodule Rather, immediate cytologic assessment can be reserved for the less-experienced operator and for repeat FNA of thyroid nodules with previous nondiagnostic results if available 50 , 51 , Generally, the risk of FNA-related bleeding diminishes with a few minutes of manual compression immediately after needle withdrawal Upon completion of the FNA procedure, the operator should examine the patient's neck to identify any bleeding-related manifestations, such as progressive swelling or ecchymosis.

In addition, it would be empirically recommended for the patient to manually compress the skin puncture site for an additional minute observation period after US-FNA and his or her neck should be ultrasonographically re-examined if FNA-related complications are suspected. This is especially important in patients with bleeding tendencies and these patients should be observed for minutes to detect any bleeding-related symptoms Local pain or bruising can be minimized by an ice pack.

The patient should be discharged with instructions to seek medical care if sudden swelling or unrelenting pain occurs In regard to complications related with US-FNA, there is limited epidemiological data on the incidence and the relation to techniques including needle size, number of passes or the technique used. However, the possibility and severity of complications, including hemorrhage, may be increased by a medical history of hemorrhagic risk factors, thicker needles, vigorous handling of the needle, or lack of operator experience 12 , Local pain and ecchymosis are the most frequent complications related to US-FNA, however, serious events are very rare 4 , 5 , 8 , 25 , Most of the complications related to US-FNA can be sufficiently managed if the physician is aware and the patient is informed 8 , 9.

Local pain and slight ecchymosis related to minor hematomas are relatively tolerable; however, if they persist, mild painkillers such as Tylenol or temporary application of an ice pack on the painful area can control the pain very well 9. Aspirin or aspirin substitutes Motrin, Naprosyn should not be taken within 48 hours after the procedure, although there is no direct evidence against them.

Intrathyroidal- or perithyroidal-hemorrhage after US-FNA might be caused by venous extravasation into or around the nodules. Clinical manifestations of hemorrhage include increased pain, swelling and ecchymosis of the neck, dyspnea, dysphonia and dysphagia 9 , If hemorrhage is suspected, the patient's neck should be sonographically examined to ensure stabilization prior to discharging the patient. Small to moderate-sized hematomas can be successfully managed in out-patient settings with manual compression as well as an ice-pack and they usually resolve spontaneously within days.

Only a few cases of uncontrolled hemorrhage, requiring hospital admission and more active intervention, have been reported in the literature 25 , 28 , 29 , Rarely, subendothelial carotid hematoma manifests as acute, persistent pain immediately after US-FNA To prevent bleeding around the thyroid glands or a potential complication such as pseudoaneurysm, firm pressure should be applied after confirming the presence of a hematoma.

Reduced activity and upper positioning of the head can be useful to decrease the spread of hematoma along the vessel wall. Usually, the hematoma absorbs spontaneously within a week. Some patients experience vasovagal reactions, such as light-headedness, nausea, sweating, clammy hands or seizure-like activity, due to pain or anxiety about the procedure, prior to, during, or after the procedure 9. Especially, seizure-like activities such as uncontrollable jerking movements of the arms or legs can make the patients feel very scared.

The symptoms usually last for minutes. It is advisable to calm the patient by placing them in a supine position with legs slightly elevated and cold compression applied to the forehead 8 , 9. Furthermore, we compared UG-FNAB specimens with histological results in a subgroup of patients in whom thyroidectomy was performed at a later date.

From July to July , patients were referred for this procedure and were studied prospectively. In patients Five patients were lost to follow-up after the procedure and were not included in the analysis. During the procedure, the patient was kept in the supine position with slight hyperextension of the neck. Local anesthetic was not routinely applied unless requested by the patient.

A to gauge needle was introduced next to the medial edge of the transducer, allowing visualization of the tip of the needle while it was guided to the biopsy site. Our initial approach was to perform a first biopsy with partial aspiration of the fluid, followed by a second biopsy of the solid part of the nodule 42 nodules. However, after a high rate of hemorrhage within the cavity of the nodule was observed after partial aspiration, it was decided not to aspirate the fluid and to proceed directly to biopsy the solid part of the nodule.

Once the needle was introduced into the solid part of the nodule, 3—5 ml of negative syringe pressure was applied. After aspiration, the smear was placed on slides and air-dried. One to three slides from each patient were stained with Wright-Giemsa stain to confirm the presence of follicular cells. If follicular cells were scanty or absent, the procedure was repeated until the number of cells was considered sufficient. To evaluate the diagnostic yield from simple aspiration, the fluid from the first 42 samples in which fluid was aspirated was stained with Papanicolaou stain after cytospin cytocentrifugation.

Interpretation of the slides was performed by one of two experienced cytopathologists. A subgroup of 14 patients were referred for surgery, and the surgical pathology was compared with preoperative UG-FNAB.

Ultrasound-Guided Fine Needle Aspiration Biopsy of the Thyroid

The mean age of the patients was The majority of the nodules were located in the right lobe Eighty-nine percent of the patients were euthyroid at the time of the procedure, and the average longest diameter of the nodules was 2. The average number of passes for each nodule was 1. No complications were seen during the procedure. In of the nodules, adequate number of cells were present for cytological diagnosis, yielding a diagnostic rate of Of these nodules, were benign and 2 were malignant.

Results were indeterminate in 7 nodules 6 follicular neoplasm and 1 suspicious for malignancy. Follicular cells were scanty or absent nondiagnostic aspirates in the other 7 nodules. Of the initial 42 nodules in which fluid aspiration was performed, 11 On UG-FNAB, 23 were confirmed to be benign colloid nodules, 1 was nondiagnostic, and 2 were diagnosed as indeterminate follicular lesion one of these patients was referred for surgery, and the surgical pathology showed colloid goiter.

Numbers in parentheses represent the number of patients. All patients with either a benign or a malignant diagnosis on UG-FNAB had confirmation of these cytological findings on surgical pathology.

What are some common uses of the procedure?

One patient with nondiagnostic cytology was found to have papillary carcinoma. The principles are similar to sonar used by boats and submarines. The ultrasound image is immediately visible on a video display screen that looks like a computer or television monitor. The image is created based on the amplitude loudness , frequency pitch and time it takes for the ultrasound signal to return from the area within the patient that is being examined to the transducer the device placed on the patient's skin to send and receive the returning sound waves , as well as the type of body structure and composition of body tissue through which the sound travels.

A small amount of gel is put on the skin to allow the sound waves to travel from the transducer to the examined area within the body and then back again.

INTRODUCTION

Ultrasound is an excellent modality for some areas of the body while other areas, especially air-filled lungs, are poorly suited for ultrasound. The physician inserts a fine gauge needle through the skin and advances it into the thyroid nodule. Samples of the cells are then obtained and put on a slide for review by the pathologist.

Image-guided, minimally invasive procedures such as fine needle aspiration of the thyroid are most often performed by a specially trained radiologist with experience in needle aspiration and ultrasound. The neck will be cleansed with antiseptic. Medicine to numb the area may or may not be used. An ultrasound transducer with a small amount of sterile water soluble gel will be placed on your neck over the thyroid nodule.

The radiologist will insert the needle through the skin under direct imaging guidance, advance it to the site of the thyroid nodule and aspirate samples of tissue. After the sampling, the needle will be removed. New needles will be reinserted if additional samples are required.

Several specimens may be needed for a complete analysis. Once the biopsy is complete, pressure will be applied to the area to decrease the risk of bleeding. A bandage may be placed if necessary. No sutures are needed. During the test, you will lie on your back with a pillow under your shoulders, your head tipped backward, and your neck extended. This position makes it easier for the radiologist to access the thyroid gland.

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You may feel some pressure on your neck from the ultrasound transducer and mild discomfort as the needle is moved to obtain the cells. You will be asked to remain still and not to cough, talk, swallow or make a sound during the procedure. Aftercare instructions vary, but generally you can resume normal activities and any bandage can be removed within a few hours.

The biopsy site may be sore and tender for one to two days. You may take nonprescription pain medicine, such as acetaminophen, to relieve any discomfort. A pathologist examines the removed specimen and makes a final diagnosis so that treatment planning can begin. Depending on the facility, the radiologist or your referring physician will discuss the results with you.