Thyroid Biopsy: Fine-Needle Aspiration for Multinodular Goiter
Main Text
Thyroid nodules are common with a higher prevalence in women and the older population. They can be found in more than 50% of the older population. Malignancy risk is reported to be 7–15% depending on age, sex, radiation exposure history, and family history. Thyroid nodules can be detected either by palpation or incidentally by imaging done for irrelevant purposes. About 16% of chest CT scans show an incidental thyroid nodule. Subsequent ultrasound scans would evaluate the nodule size and characteristics. If the nodules meet the biopsy criteria based on TIRADS (Thyroid Imaging Reporting and Data Systems) criteria, referral for fine-needle aspiration biopsy (FNA) is necessary. This video delivers a thorough demonstration of the correct technique for ultrasound-guided thyroid FNA with rapid on-site cytology evaluation (ROSE).
Thyroid biopsy; thyroid; cytology.
This is a case of multinodular goiter, which was detected over a decade ago. The right inferior and isthmus nodules were biopsied soon after the diagnosis and found to be benign. Ultrasound surveillance had lapsed until the patient was seen by a new primary care physician. A recent ultrasound showed that the left middle thyroid lobe has a new 2.6-cm TIRADS-41 nodule that meets biopsy criteria. She is asymptomatic, clinically and biochemically euthyroid. The patient was referred to the thyroid biopsy clinic.
Ultrasound-guided FNA is a clean (but not a sterile) procedure, which can be performed in an office setting to obtain cells or fluid from a nodule by using fine or thin (22- to 27-gauge) needles. The patient is placed in a supine position with neck extension to expose the thyroid. A pillow is placed under the shoulders. After cleaning the neck with an antiseptic agent, skin is marked, and local anesthesia is applied. The patient needs to stay still and avoid swallowing or talking during the procedure.
The biopsy needle can be inserted perpendicular or parallel to the transducer. The entire needle can be seen with the parallel approach; however, only the needle tip can be seen with the perpendicular approach. Here we demonstrate the perpendicular approach. The syringe plunger is pulled back to the 2-mL mark prior to needle insertion. Once the needle tip is in the nodule, gentle rotation and vertical motion within the nodule allow cell dislodging. The specimen is squirted on a glass slide, gently spread and fixed. Typically, 3–4 passes are required per nodule for the cytology analysis and an additional pass for the molecular testing (if it will be obtained). When ROSE is available, cytologists would give immediate feedback regarding the sample adequacy. Satisfactory FNA requires cytologic adequacy (i.e., the presence of at least six groups of follicular cells, each group containing at least 10 epithelial cells, preferably on a single slide).2
Nondiagnostic samples accounted for 2–16% of all FNA samples in a large series. When a thyroid nodule’s FNA cytology is nondiagnostic, a repeat FNA with ultrasound guidance and, if available, on-site cytologic evaluation, is recommended and can increase diagnostic adequacy by 60–80%. Nodules with repeatedly nondiagnostic results but low suspicion on ultrasound should be monitored or considered for surgical excision, while nodules with high-risk features or significant growth may require earlier intervention. Additionally, core-needle biopsy and molecular testing may aid in assessing these nodules, though their clinical impact is still under evaluation.3
Once the adequate sample is obtained, firm pressure is applied on the biopsy site, which is then covered with a Band-Aid. Patients can resume daily activities and light exercise right away; however, strenuous exercise and heavy lifting should be avoided for 24 hours.
- 1% lidocaine
- 70% isopropyl prep pads
- Transducer cover
- Sterile ultrasound gel
- Sterile gauze
- Gloves
- 3-mL syringe with 27-gauge 0.5-inch needle for local anesthesia
- 10-mL syringes with 25-gauge 1.5-inch needles for the biopsy
- Glass slides, CytoLyt
- Molecular testing vial
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Tessler FN, Middleton WD, Grant EG, et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): white paper of the ACR TI-RADS Committee. J Am Coll Radiol. 2017 May;14(5):587-595. doi:10.1016/j.jacr.2017.01.046.
- Baloch ZW, LiVolsi VA, Asa SL, et al. Diagnostic terminology and morphologic criteria for cytologic diagnosis of thyroid lesions: a synopsis of the National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference. Diagn Cytopathol. 2008 Jun;36(6):425-37. doi:10.1002/dc.20830.
- Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016 Jan;26(1):1-133. doi:10.1089/thy.2015.0020.
Cite this article
Sahin-Efe AN, Misialek M. Thyroid biopsy: fine-needle aspiration for multinodular goiter. J Med Insight. 2024;2024(467). doi:10.24296/jomi/467.
Procedure Outline
Table of Contents
- 1. Introduction
- 2. Preparation
- 3. Initial Ultrasound and Marking
- 4. Inject Local Anesthetic
- 5. Initial Biopsy Specimens and Preliminary Examination by Pathologist
- 6. Additional Specimens as Deemed Necessary by Pathologist
- 7. Final Specimen for Molecular Testing
- 8. Applying Pressure and Bandage
- 9. Post-op Remarks
Transcription
CHAPTER 1
I am Dr. Ayse Sahin-Efe. I am the medical director of the thyroid biopsy clinic at Newton-Wellesley Hospital, which is part of the Mass General Brigham System. Here, we are running a multidisciplinary clinic with multiple endocrinologists and thyroid and neck surgeons. We perform over 300 biopsies a year. Thyroid fine-needle aspirations are office procedures that are performed under local anesthesia. Certain patient populations may require an anxiolytic medication or less commonly a conscious sedation. After obtaining the written consent form, the patient is placed in supine or semi-sitting position with a slight neck extension. Nodule location and characteristics are confirmed. Biopsy site is marked by the ultrasound. Skin is cleaned with an antiseptic solution and 2% lidocaine is applied. We use a 25-gauge, 1.5-inch needles with a 10-mL syringe. Plunger is pulled to 2 mL to provide gentle negative pressure without pulling back. Alternatively, capillary method, non-aspiration technique without an attached syringe could also be used. Minimal amount of ultrasound gel should be applied as it could clog the needle. Either perpendicular or parallel technique can be utilized. Only tip of the needle can be seen by the perpendicular technique, whereas the whole needle shaft can be seen with the parallel technique. During this biopsy, I use the perpendicular technique. Once the needle tip is visible on the screen, I do move it back and forth while rotating it. For each pass, the needle should stay roughly two to five seconds within the nodule. We typically perform three to four passes. The passes should attempt to sample different areas of the nodule. After skirting the sample on the slide, needle is rinsed in CytoLyt solution. An additional test is performed for molecular testing. Molecular sample is analyzed only if the cytology comes back in Bethesda category three and four. We have on-site cytology team who provides immediate feedback regarding the sample adequacy. After applying gentle pressure, aspiration site is covered with a Band-Aid. Ice pack is applied for five minutes. Then patients can leave the clinic.
CHAPTER 2
So this is just the alcohol pads. Cleanup.
CHAPTER 3
So that's the gel, but that's a sterile gel. So I'm just gonna mark it with a surgical pen. You can just wash it off tomorrow if you see a blue mark. Okay.
CHAPTER 4
So the lidocaine is a tiny needle, but it could burn a little bit like a bee thing, okay? But keep breathing through your nose, nice and easy. That's the needle. That's medicine. Okay, you're doing great. Now going in a little deeper. Okay. So done with the numbing part. You're doing okay? Mhm.
CHAPTER 5
That's the plastic cap to find the area. Okay. That's the needle. Keep breathing through your nose, nice and easy. Doing okay? Yeah. Thank you. That's again the plastic. That's the needle. Keep breathing through your nose, nice and easy. They have two groups of follicular cells in the first one. Thank you. Okay. That's the needle. Okay, we have follicular cells again. Okay. We're getting close to adequate. Okay.
CHAPTER 6
So we have some cells, but not quite adequate yet, okay? That's the needle. Just breathe through your nose, nice and easy. It's not bleeding, I don't - I'm putting pressure to minimize bruising, okay? Thank you. More follicular cells. I think one more will probably do it. Have you done the Afirma yet? No. Okay. That's the needle. So I'm gonna get the Afirma now.
CHAPTER 7
So this is gonna be the last one for the molecular testing. Okay? It's the same as the previous ones. I'll just put it in a different tube. That's the needle. Bloody probably on the last one, but I think we've got enough. I think we're good. Okay.
CHAPTER 8
Okay, we are done. I'll hold pressure for a minute and then we'll put a Band-Aid on. Okay. You take the Band-Aid off in about an hour. Okay. Okay. So sit up slowly. All right. Okay. Sit at the edge 'cause you may feel a bit dizzy. Okay? Yep. Yep. Just make sure that you're not getting dizzy. So then, you're gonna keep the ice pack for five minutes and then you're all set. Okay.
CHAPTER 9
So patients come in with a radiology report to here. Oftentimes, I do my own ultrasound and may biopsy a different nodule than what was recommended by the radiology. So radiology recommended two biopsies on the left side. But on my ultrasound assessment I found there are two nodules, which are very close to each other and they look exactly similar. So I'm going to biopsy only one of them. During the biopsy, we got five aspirations because a few of them didn't show enough cells. So we had to do maybe one or more passes than our usual biopsies today. So the nodules could be very solid. They may have lots of cells or they may have lots of small fluid pockets, which are made up of the colloid, the normal thyroid tissue fluid. So when the nodule doesn't have a ton of cells, the pathology team may not be able to count the six groups of cells that they need to generate an official report. So we had to keep doing extra passes till they gave us okay with a diagnostic sample. So we use very small needles, 25-gauge needles. I rarely use a 22-gauge needle - if, you know, if you're not getting enough cells after multiple passes. But with the thyroid biopsies, we absolutely don't wanna cause a lot of bleeding 'cause having too much blood also will make it difficult to see the thyroid cells. So patients often are able to go back to their usual life. No restrictions in their activity. I just tell them to avoid heavy lifting for 24 hours. Otherwise, no restrictions in activities. Occasionally, patients may develop like a small hematoma. It didn't happen today, but if I notice that they're developing a hematoma in the neck, then I may keep them here in the office for a couple more minutes, up to half an hour, to observe and maybe repeat a quick office ultrasound before they leave. But it's very, very rare. And if they get any bruising or small swelling, I reassure them it's gonna go away in five to seven days. And we do this procedure in people who are taking anticoagulants or blood thinners because we are are using a 25-gauge needle. But the practitioners should definitely check the medication list to make sure there are no blood thinners or anticoagulants, especially if they're not comfortable with, you know, doing this procedure with blood thinning medications.