Background
Follicular thyroid carcinoma cannot be distinguished reliably from benign follicular
neoplasia by fine needle aspiration (FNA) biopsy. Given an estimated 20% risk of malignancy,
many patients with indeterminate FNA biopsies require thyroidectomy for diagnosis.
Some centers have shown significant discordance when a second pathologist evaluates
the same FNA biopsy. We sought to determine whether routine second-opinion cytopathology
reduces the need for diagnostic thyroidectomy, especially in patients with indeterminate
FNA biopsies.
Methods
In all, 331 thyroid FNA biopsy specimens obtained from outside centers from 2004 to
2009 were reviewed at our institution. The FNA biopsy results were categorized into
nondiagnostic (Bethesda I), benign (Bethesda II), indeterminate (follicular/Hurthle
cell neoplasm, follicular/Hurthle cell lesion; Bethesda III & IV), and malignant (papillary or suspicious for papillary or other malignancy; Bethesda
V and VI). Second-opinion cytology was compared with the initial opinion in 331 cases
and with final operative pathology in the 250 patients who progressed to thyroidectomy.
Results
The average patient age was 51 with a predominant number of female (79%) participants.
The overall cytology concordance for all 331 FNA biopsies was 66% (218/331). Concordance
was highest at 86% (74/86) with malignant FNA biopsies. Concordance in the 129 patients
with indeterminate FNA biopsies was only 37% (48/129). Indeterminate FNA biopsies
were reread as nondiagnostic in 21% (27/129) of patients and as benign in 42% (54/129)
of patients. Twenty-two patients with an indeterminate FNA biopsy reread as benign
progressed to operative therapy for reasons other than cytology (eg, symptomatic nodule
and radiation exposure/high risk) and were found to be benign in 95% (21/22) of patients
on operative pathology for a 95% negative predictive value. An additional 11 patients
with an indeterminate FNA reread as benign had follow-up FNA biopsies, each of which
was benign. Indeterminate FNA biopsies on initial cytology had a malignancy rate of
13% (17/129) on operative pathology compared with 29% (14/48) for indeterminate FNA
biopsies from second opinion. A second opinion improved FNA biopsy accuracy from 60%
to 74%. Overall, second-opinion cytology of indeterminate FNA biopsies avoided diagnostic
operation in 25% (32/129).
Conclusion
Routine second opinion review of indeterminate thyroid FNA biopsies can potentially
obviate the need for diagnostic thyroidectomy in 25% of patients without increases
in false negatives.
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Article info
Publication history
Accepted:
September 16,
2010
Identification
Copyright
© 2010 Mosby, Inc. Published by Elsevier Inc. All rights reserved.
