thyroid fine needle aspiration biopsy (fnab): inside the eye of a cytopathologist ian jaffee, md...
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Thyroid Fine Needle Aspiration Biopsy (FNAB):
Inside the Eye of a Cytopathologist
Ian Jaffee, MD FCAP
Director of Cytopathology
California Pacific Medical Center
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Outline of Discussion• Utility of FNAB
• Applications to thyroid nodules
• Cytology…
• Understanding the cytopathology report
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FNA of the Thyroid Gland
• Safe, widely accepted, and cost-effective
• Accurate “triage” of the thyroid nodule
• Current estimates of ~30,000,000 people in U.S. with thyroid nodules > 1 cm
• ~30,000 with malignant thyroid nodules
• Goal: Identify patients who require surgical intervention
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Good practice in cytopathology
• Direct communication
• Collaboration with endocrinologist, surgeon (general vs ENT), radiologist, and PCP
• Follow-up correlation with final surgical pathology
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Good practice in cytopathology
• Benign• Malignant• The in betweens…• Suboptimal samples (quality/quantity)• Diagnostic guidelines
– Papanicolaou Society of Cytopathology Task Force– American Thyroid Association– None have been necessarily universally accepted
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Diagnostic approach
• Non-diagnostic
• Benign
• Atypical follicular lesion of undetermined significance (AFL-US)
• Suspicious for follicular neoplasm/follicular lesion
• Suspicious for malignancy
• Malignant
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Non-diagnostic
• Findings– Blood only– Absence of colloid– Insufficient cellularity (“6/10 rule”)– Colloid only (cyst contents)
• Management: Follow-up U/S and repeat FNA• Repeated non-diagnostics and risk of malignancy
– “quite low” (<5%)
» McHenry CR, Walfish PG, Rosen IB. Non-diagnostic fine-needle aspiration biopsy: a dilemma in management of nodular thyroid disease. Am Surg. 1993;59:415-419.
» Renshaw A, Significance of repeatedly non-diagnostic thyroid FNAs. Am J Clin Pathol 2011;135:750-752
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Benign
• “Most things in the thyroid are benign”
• Risk of malignancy (~3%)
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Benign Thyroid Nodules (BTN)
• Management: Clinical follow-up
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Atypical follicular lesion of undetermined significance (AFL-US)• I don’t use it
• Poorly defined category
• Theoretical risk of malignancy is 5-15%
• Management: Repeat FNA or molecular triage (more later)
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Follicular lesions
• Suspicious for follicular neoplasm
• Follicular neoplasm
• Follicular lesion
• Hürthle cell lesion
• Risk of malignancy: ~15-20%
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Cytology of follicular lesions
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Follicular adenoma
• Capsule; no vascular invasion
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Follicular carcinoma
• Capsular invasion
• Vascular invasion
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Follicular lesions
• Management Options:– Lobectomy– Lobectomy with frozen section– Total thyroidectomy– Molecular testing (more later…)
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Malignant
• Suspicious for malignancy (risk of malignancy 60-75%)– Management: Lobectomy vs total thyroidectomy
• Malignant (risk of malignancy 99%)– Management: Thyroidectomy
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Malignant
• Papillary thyroid carcinoma
• Follicular carcinoma
• Medullary carcinoma
• Anaplastic carcinoma
• Poorly differentiated carcinoma
• Lymphoma
• Metastatic carcinoma
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Papillary thyroid carcinoma
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PTC: Surgical pathology
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Molecular triage of FNA samples
• 60-70% of thyroid malignancies harbor at least one genetic mutation– BRAF– RAS– RET/PTC– PAX8-PPARγ
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Molecular triage of FNA samples
• Indeterminate by cytology– AFL-US– Follicular category
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Available tests
• VeraCyte (Afirma)– mRNA gene expression classifier– High NPV (>90%) but modest specificity (50+%)
• Asuragen– Reportedly specific (rule-in/confirmatory)– RNA-based assay (RAS, BRAF, RET/PTC, and
PAX8-PPARγ)
• Quest
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Bonus
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Final comments
• FNAB is highly accurate with high sensitivity and specificity• Accuracy in diagnosing thyroid abnormalities
– dependant on the expertise of the cytopathologist interpreting the biopsy specimen
– physician performing the biopsy• Categorization of samples
– Non-diagnostic– Benign– AFL-US– Follicular (Suspicious for) lesion/neoplasm– Suspicious for malignancy– Malignant
• FNA cannot reliably distinguish benign from malignant follicular neoplasm
• New molecular triage testing (lukewarm)
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Tzanck you