DOI:10.2214/AJR.07.3530
AJR 2008; 190:1697-1699
© American Roentgen Ray Society
Simultaneous Fine-Needle Aspiration and Core Biopsy of Thyroid Nodules and Other Superficial Head and Neck Masses Using Sonographic Guidance
Edward B. Strauss1,
Alan Iovino1 and
Sunil Upender1
1 Department of Radiology, Norwalk Hospital, Maple St., Norwalk, CT 06856.
Received January 2, 2007;
accepted after revision December 12, 2007.
Address correspondence to E. B. Strauss
(edward.strauss{at}norwalkhealth.org).
Abstract
OBJECTIVE. The objective of our study was to conceive of and to
evaluate a simple system for simultaneous fine-needle aspiration (FNA) and
core biopsy of thyroid nodules when FNA alone has failed to yield tissue
adequate for diagnosis.
CONCLUSION. The use of a modified coaxial guiding needle and biopsy
gun is a simple, safe, and effective method for obtaining tissue from thyroid
nodules and is applicable to sampling other superficial masses as well.
Keywords: biopsy • core biopsy • fine-needle aspiration • head and neck masses • sonographic guidance • thyroid masses
Introduction
Fine-needle aspiration (FNA) for cytologic evaluation of thyroid
nodules has been established as a safe and reasonably efficacious technique
[1]. However, even with the
benefit of sonographic guidance, samples obtained in this manner are
inadequate for diagnosis in 15-20% of patients
[2]. Core needle and cutting
needle biopsy of thyroid nodules
[3] and nonthyroid lesions such
as lymph nodes [4] has been
reported with diagnostic yields of more than 90% but is used less commonly
than FNA because it is technically more difficult and still does not yield
tissue adequate for diagnosis in all cases. Some investigators have proposed
that, ideally, if it were not for the necessity to perform two procedures
requiring separate punctures, samples from both FNA and core biopsy would be
obtained [5]. In this report,
we describe a single-puncture technique that permits the rapid acquisition of
tissue samples by both FNA and core biopsy with high diagnostic yield.
Materials and Methods
Between November 2003 and November 2006, we used our technique to sample 81
thyroid nodules, all but one of which had undergone FNA performed with either
a 22- or 25-gauge needle that yielded nondiagnostic results, and to sample 30
nonthyroid lesions, including 19 lymph nodes, eight salivary gland masses, and
three neck masses of unclear origin, none of which had previously undergone
FNA. The morphology of the nodules is described in
Table 1.
All procedures were performed with sonographic guidance using a sonography
unit (ATL HDI 5000, Philips Medical Systems) equipped with a 5-12 MHz linear
array. We position the probe longitudinally over the center of the lesion and
mark the skin at either edge. The probe is 4 cm long, resulting in a skin site
2 cm medial or lateral to the target, the choice depending on the location of
blood vessels. This shallow approach, almost parallel to the transducer,
provides the best visualization of the needle, and the 2-cm offset is
particularly convenient with the guiding needle system we use.
A biopsy system (Adjustable Coaxial Temno, Allegiance Healthcare) is
supplied with a 6-cm 19-gauge guiding needle and a Tru-Cut (Baxter
Healthcare)-type 20-gauge biopsy gun. The throw is adjustable from 14 to 24
mm, and the device is a convenient size and length for biopsies of superficial
masses. This biopsy system is parti cularly easy to control with real-time
imaging such as sonography because the stylet is advanced manually and only
the outer cutting cannula is spring-loaded. If the inner solid trocar provided
with the guiding needle is replaced with a 10.2-cm 20-gauge rough surface
spinal needle (PTC Spine Needle, Havel's Incorporated), the highly echogenic
spinal needle will protrude 2 cm from the end of the 19-gauge guiding needle.
It is very easy to hold the three components together by simply gripping the
hub of the guiding needle between the second and third fingers while holding
the trocar of the spinal needle in place with the thumb.
After the selected entry site has been prepared in a sterile fashion and
2-3 mL of 1% lidocaine hydrochloride has been injected, the needle system is
advanced through the skin. No skin incision is required. The technologist
holds the probe longitudinally over the lesion while the physician advances
the needle system to the edge of the lesion and then through the lesion almost
to its far side (Fig. 1A). It
is, of course, the 20-gauge spinal needle, which extends 2 cm beyond the
19-gauge guiding needle, that touches the far edge of the lesion. The spinal
needle is then held in place while the guiding needle is advanced over it to a
position within the lesion (Fig.
1B).
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Fig. 1A —65-year-old man with right thyroid nodule detected
incidentally by PET scan. Sonogram shows spinal needle protrudes from guiding
needle (arrowheads) as coaxial needles are advanced into nodule.
|
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Fig. 1B —65-year-old man with right thyroid nodule detected
incidentally by PET scan. Sonogram shows guiding needle has been advanced into
nodule. Spinal needle was used to obtain tissue by fine-needle aspiration and
was then removed.
|
|
The trocar is removed from the spinal needle, and the spinal needle is then
used to obtain a tissue sample by FNA. We make several passes through the
lesion with minimal negative pressure and place the aspirate in preservative
and on slides.
The biopsy gun is then placed within the guiding needle. The stylet is
advanced under direct visualization to the far side of the lesion
(Fig. 1C), and then the
spring-loaded cannula is closed over it
(Fig. 1D). We usually obtain
three core samples in this manner and place them in formalin. In complex
cystic lesions, we attempt to target the solid portions.
Results
This combined FNA and core biopsy technique provided tissue adequate for
diagnosis of 79 (98%) of 81 thyroid nodules. During the same period, we
performed conventional FNA for 402 thyroid nodules with diagnostic tissue
obtained in 355 (88%). For the 30 nonthyroid lesions, the combined FNA and
core biopsy technique provided adequate tissue in all cases.
Of the 81 thyroid nodules, the samples obtained by both FNA and core biopsy
were diagnostic in 48 (59%). Of these, 53% were solid nodules. Samples
obtained by FNA were not diagnostic, whereas those obtained by core biopsy
were diagnostic in 26 cases (32%), nine of which had complex nodules and 17 of
which had solid nodules. In five cases (6%), the core biopsy specimens were
not diagnostic but the FNA specimens were. Of these nodules, three were
complex and two were solid. In two cases (2%), neither the FNA biopsy sample
nor the core biopsy sample was diagnostic. One of these two nodules was
complex and the other was solid. In one case, the samples showed only skeletal
muscle indicating operator error. In the other, we obtained scanty fragmented
samples containing only blood and inflammatory cells. Of the seven nodules in
which the core biopsy failed, four were complex and three were solid. The mean
size of the nodules was 2.2 cm.
In the group of 30 nonthyroid lesions, both the FNA and core biopsy were
diagnostic in 21 (70%) cases and only the core biopsy was diagnostic in nine
(30%). In no case was the FNA diagnostic when the core biopsy was not.
No complications resulted from any of the 111 procedures performed with
this technique. Of the 402 conventional FNAs we performed during the same
period, two patients had bleeding complications with palpable hematomas that
required compression and resulted in residual ecchymoses.
Discussion
In our practice, demand for sonographically guided cytologic evaluation of
thyroid nodules has increased considerably in recent years, as it seems to
have everywhere [6]. FNA offers
a rapid, low-cost, and usually effective technique that we use as a first-line
procedure in accordance with general recommendations
[7], but what should be done
when FNA fails?
For patients with nondiagnostic FNAs, whether performed by us or by
physicians at other centers, we began to explore core biopsy as a second-line
technique, but we found that the use of conventional biopsy devices is
surprisingly difficult for lesions that are superficial, small, and mobile.
The use of guiding needles and coaxial biopsy guns, which are so effective for
obtaining multiple tissue samples from other organs, did not seem as
applicable to thyroid nodules and other head and neck masses. In particular,
advancing a guiding needle through the resistant tissue of the thyroid gland
or into a mobile lymph node proved physically difficult. Using a simple
modification of the guiding needle coaxial approach, we overcame this
difficulty and at the same time that a guiding needle is positioned for core
biopsy, another needle is already in position for simultaneous FNA.
For thyroid nodules, the additional samples obtained using FNA have
increased our diagnostic yield over core biopsy alone, although this was not
the case for our nonthyroid lesions. Therefore, a combined technique, over
just a core biopsy, is most effective for thyroid masses.
In conclusion, the use of a long 20-gauge spinal needle inside a shorter
19-gauge guiding needle makes needle placement simple, even in resistant or
mobile lesions, and permits tissue samples to be obtained by both FNA and core
biopsy. Although the automated approach is slightly more costly than
conventional FNA, the cost is outweighed by the cost of a surgical procedure
that could otherwise be necessary for diagnosis. We do not necessarily
advocate our system as a first-line approach for thyroid nodules. Conventional
FNA is faster, is less expensive, and remains an established technique.
However, when FNA fails, we believe this technique is useful.
References
- Gharib H, Goellner JR. Fine-needle aspiration biopsy of the
thyroid: an appraisal. Ann Intern Med1993; 118:282
-289[Abstract/Free Full Text]
- Alexander EK, Heering JP, Benson CB, et al. Assessment of
nondiagnostic ultrasound-guided fine needle aspirations of thyroid nodules.
J Clin Endocrinol Metab 2002;87
: 4924-4927[Abstract/Free Full Text]
- Screaton NJ, Berman LH, Grant JW. US-guided core-needle biopsy of
the thyroid gland. Radiology 2003;226
: 827-832[Abstract/Free Full Text]
- Screaton NJ, Berman LH, Grant JW. Head and neck lymphadenopathy:
evaluation with US-guided cutting-needle biopsy.
Radiology 2002;224
: 75-81[Abstract/Free Full Text]
- Quinn SF, Nelson HA, Demlow TA. Thyroid biopsies: fine-needle
aspiration biopsy versus spring-activated core biopsy needle in 102 patients.
J Vasc Interv Radiol 1994;5
: 619-623[Medline]
- Ross DS. Nonpalpable thyroid nodules: managing an epidemic.
J Clin Endocrinol Metab 2002;87
: 1938-1940[Free Full Text]
- Frates MC, Benson CB, Charboneau JW, et al.; Society of
Radiologists in Ultrasound. Management of thyroid nodules detected at US:
Society of Radiologists in Ultrasound consensus conference statement.
Radiology 2005;237
: 794-800[Abstract/Free Full Text]
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Abstract
Introduction
