- Douglas S Ross, MD
Douglas S Ross, MD
- Section Editor — Thyroid Disease
- Professor of Medicine
- Harvard Medical School
Thyroid nodules come to clinical attention when noted by the patient, or as an incidental finding during routine physical examination or a radiologic procedure, such as carotid ultrasonography or neck computed tomography (CT). Their clinical importance is primarily related to the need to exclude thyroid cancer, which is present in 4 to 6.5 percent of thyroid nodules overall but up to 15 percent of thyroid nodules in the older patient population. If a serum thyroid-stimulating hormone (TSH) is normal, the next step in the evaluation of a thyroid nodule is a palpation or ultrasound-guided fine-needle aspiration (FNA) biopsy.
This topic will review the techniques, utility, limitations, and complications of percutaneous thyroid biopsies. Ultrasound-guided thyroid biopsy, an atlas of cytopathologic findings, and overview of the diagnosis and treatment of thyroid nodules are discussed separately. (See "Ultrasound-guided thyroid biopsy" and "Atlas of thyroid cytopathology" and "Diagnostic approach to and treatment of thyroid nodules".)
The two most common methods used to obtain tissue from thyroid nodules are fine-needle aspiration (FNA), using a syringe, and fine-needle capillary sampling (FNC), which is done without aspiration. Biopsy can be guided by palpation only or by ultrasound.
Other techniques include large-needle aspiration biopsy and cutting-needle biopsy. The latter has shown to be particularly useful for repetitive nondiagnostic FNAs. (See 'Other techniques' below.)
Fine-needle aspiration biopsy — FNA is a simple and safe office procedure in which tissue samples are obtained for cytologic examination. FNA is performed with or without local lidocaine anesthesia , by repetitively moving a 23- to 27-gauge (most commonly 25- or 27-gauge) needle through the nodule. The needle is attached to a 10 mL syringe that may be contained in a holder designed to facilitate the application of constant or intermittent suction. The aspirated material is smeared directly on slides, fixed, and stained, or collected in a liquid preservative from which thin-layer preparations are made. (See 'Procedure' below.)
Subscribers log in hereLiterature review current through: May 2017. | This topic last updated: May 22, 2017.References
- Gursoy A, Ertugrul DT, Sahin M, et al. Needle-free delivery of lidocaine for reducing the pain associated with the fine-needle aspiration biopsy of thyroid nodules: time-saving and efficacious procedure. Thyroid 2007; 17:317.
- Boey J, Hsu C, Collins RJ, Wong J. A prospective controlled study of fine-needle aspiration and Tru-cut needle biopsy of dominant thyroid nodules. World J Surg 1984; 8:458.
- Nishiyama RH, Bigos ST, Goldfarb WB, et al. The efficacy of simultaneous fine-needle aspiration and large-needle biopsy of the thyroid gland. Surgery 1986; 100:1133.
- Gharib H, Goellner JR. Fine-needle aspiration biopsy of the thyroid: an appraisal. Ann Intern Med 1993; 118:282.
- 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; 36:425.
- Yassa L, Cibas ES, Benson CB, et al. Long-term assessment of a multidisciplinary approach to thyroid nodule diagnostic evaluation. Cancer 2007; 111:508.
- Rosen IB, Wallace C, Strawbridge HG, Walfish PG. Reevaluation of needle aspiration cytology in detection of thyroid cancer. Surgery 1981; 90:747.
- Mair S, Dunbar F, Becker PJ, Du Plessis W. Fine needle cytology--is aspiration suction necessary? A study of 100 masses in various sites. Acta Cytol 1989; 33:809.
- Kate MS, Kamal MM, Bobhate SK, Kher AV. Evaluation of fine needle capillary sampling in superficial and deep-seated lesions. An analysis of 670 cases. Acta Cytol 1998; 42:679.
- Romitelli F, Di Stasio E, Santoro C, et al. A comparative study of fine needle aspiration and fine needle non-aspiration biopsy on suspected thyroid nodules. Endocr Pathol 2009; 20:108.
- SODERSTROM N. Puncture of goiters for aspiration biopsy. Acta Med Scand 1952; 144:237.
- Crile G Jr, Hawk WA Jr. Aspiration biopsy of thyroid nodules. Surg Gynecol Obstet 1973; 136:241.
- Wang C, Vickery AL Jr, Maloof F. Needle biopsy of the thyroid. Surg Gynecol Obstet 1976; 143:365.
- Suh CH, Baek JH, Park C, et al. The Role of Core Needle Biopsy for Thyroid Nodules with Initially Indeterminate Results on Previous Fine-Needle Aspiration: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2017.
- Samir AE, Vij A, Seale MK, et al. Ultrasound-guided percutaneous thyroid nodule core biopsy: clinical utility in patients with prior nondiagnostic fine-needle aspirate. Thyroid 2012; 22:461.
- Carpi A, Nicolini A, Sagripanti A, et al. Large-needle aspiration biopsy for the preoperative selection of palpable thyroid nodules diagnosed by fine-needle aspiration as a microfollicular nodule or suspected cancer. Am J Clin Pathol 2000; 113:872.
- Gharib H, Papini E, Valcavi R, et al. American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract 2006; 12:63.
- 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; 26:1.
- Polyzos SA, Anastasilakis AD. Clinical complications following thyroid fine-needle biopsy: a systematic review. Clin Endocrinol (Oxf) 2009; 71:157.
- Polyzos SA, Anastasilakis AD. Systematic review of cases reporting blood extravasation-related complications after thyroid fine-needle biopsy. J Otolaryngol Head Neck Surg 2010; 39:532.
- Tomoda C, Takamura Y, Ito Y, et al. Transient vocal cord paralysis after fine-needle aspiration biopsy of thyroid tumor. Thyroid 2006; 16:697.
- Ha EJ, Baek JH, Lee JH, et al. Complications following US-guided core-needle biopsy for thyroid lesions: a retrospective study of 6,169 consecutive patients with 6,687 thyroid nodules. Eur Radiol 2017; 27:1186.
- Cibas ES, Ali SZ. The Bethesda System for Reporting Thyroid Cytopathology. Thyroid 2009; 19:1159.
- Oertel YC, Miyahara-Felipe L, Mendoza MG, Yu K. Value of repeated fine needle aspirations of the thyroid: an analysis of over ten thousand FNAs. Thyroid 2007; 17:1061.
- Yang J, Schnadig V, Logrono R, Wasserman PG. Fine-needle aspiration of thyroid nodules: a study of 4703 patients with histologic and clinical correlations. Cancer 2007; 111:306.
- Layfield LJ, Morton MJ, Cramer HM, Hirschowitz S. Implications of the proposed thyroid fine-needle aspiration category of "follicular lesion of undetermined significance": A five-year multi-institutional analysis. Diagn Cytopathol 2009; 37:710.
- Bongiovanni M, Crippa S, Baloch Z, et al. Comparison of 5-tiered and 6-tiered diagnostic systems for the reporting of thyroid cytopathology: a multi-institutional study. Cancer Cytopathol 2012; 120:117.
- Olson MT, Clark DP, Erozan YS, Ali SZ. Spectrum of risk of malignancy in subcategories of 'atypia of undetermined significance'. Acta Cytol 2011; 55:518.
- Cibas ES, Baloch ZW, Fellegara G, et al. A prospective assessment defining the limitations of thyroid nodule pathologic evaluation. Ann Intern Med 2013; 159:325.
- Olson MT, Boonyaarunnate T, Aragon Han P, et al. A tertiary center's experience with second review of 3885 thyroid cytopathology specimens. J Clin Endocrinol Metab 2013; 98:1450.
- Hegedüs L. Clinical practice. The thyroid nodule. N Engl J Med 2004; 351:1764.
- Gharib H, Goellner JR, Zinsmeister AR, et al. Fine-needle aspiration biopsy of the thyroid. The problem of suspicious cytologic findings. Ann Intern Med 1984; 101:25.
- Block MA, Dailey GE, Robb JA. Thyroid nodules indeterminate by needle biopsy. Am J Surg 1983; 146:72.
- Peng Y, Wang HH. A meta-analysis of comparing fine-needle aspiration and frozen section for evaluating thyroid nodules. Diagn Cytopathol 2008; 36:916.
- Nayar R, Ivanovic M. The indeterminate thyroid fine-needle aspiration: experience from an academic center using terminology similar to that proposed in the 2007 National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference. Cancer 2009; 117:195.
- Ohori NP, Nikiforova MN, Schoedel KE, et al. Contribution of molecular testing to thyroid fine-needle aspiration cytology of "follicular lesion of undetermined significance/atypia of undetermined significance". Cancer Cytopathol 2010; 118:17.
- Widder S, Guggisberg K, Khalil M, Pasieka JL. A pathologic re-review of follicular thyroid neoplasms: the impact of changing the threshold for the diagnosis of the follicular variant of papillary thyroid carcinoma. Surgery 2008; 144:80.
- Nikiforov YE, Ohori NP, Hodak SP, et al. Impact of mutational testing on the diagnosis and management of patients with cytologically indeterminate thyroid nodules: a prospective analysis of 1056 FNA samples. J Clin Endocrinol Metab 2011; 96:3390.
- Chudova D, Wilde JI, Wang ET, et al. Molecular classification of thyroid nodules using high-dimensionality genomic data. J Clin Endocrinol Metab 2010; 95:5296.
- Marchetti I, Iervasi G, Mazzanti CM, et al. Detection of the BRAF(V600E) mutation in fine needle aspiration cytology of thyroid papillary microcarcinoma cells selected by manual macrodissection: an easy tool to improve the preoperative diagnosis. Thyroid 2012; 22:292.
- Kitano M, Rahbari R, Patterson EE, et al. Evaluation of candidate diagnostic microRNAs in thyroid fine-needle aspiration biopsy samples. Thyroid 2012; 22:285.
- Prasad NB, Kowalski J, Tsai HL, et al. Three-gene molecular diagnostic model for thyroid cancer. Thyroid 2012; 22:275.
- Kim JM, Ryu JS, Kim TY, et al. 18F-fluorodeoxyglucose positron emission tomography does not predict malignancy in thyroid nodules cytologically diagnosed as follicular neoplasm. J Clin Endocrinol Metab 2007; 92:1630.
- Sebastianes FM, Cerci JJ, Zanoni PH, et al. Role of 18F-fluorodeoxyglucose positron emission tomography in preoperative assessment of cytologically indeterminate thyroid nodules. J Clin Endocrinol Metab 2007; 92:4485.
- de Geus-Oei LF, Pieters GF, Bonenkamp JJ, et al. 18F-FDG PET reduces unnecessary hemithyroidectomies for thyroid nodules with inconclusive cytologic results. J Nucl Med 2006; 47:770.
- Vriens D, de Wilt JH, van der Wilt GJ, et al. The role of [18F]-2-fluoro-2-deoxy-d-glucose-positron emission tomography in thyroid nodules with indeterminate fine-needle aspiration biopsy: systematic review and meta-analysis of the literature. Cancer 2011; 117:4582.
- Sangalli G, Serio G, Zampatti C, et al. Fine needle aspiration cytology of the thyroid: a comparison of 5469 cytological and final histological diagnoses. Cytopathology 2006; 17:245.
- Jain M, Khan A, Patwardhan N, et al. Follicular variant of papillary thyroid carcinoma: a comparative study of histopathologic features and cytology results in 141 patients. Endocr Pract 2001; 7:79.
- Jayaram G. Fine needle aspiration cytologic study of the solitary thyroid nodule. Profile of 308 cases with histologic correlation. Acta Cytol 1985; 29:967.
- Cichoń S, Anielski R, Konturek A, et al. Metastases to the thyroid gland: seventeen cases operated on in a single clinical center. Langenbecks Arch Surg 2006; 391:581.
- Chung AY, Tran TB, Brumund KT, et al. Metastases to the thyroid: a review of the literature from the last decade. Thyroid 2012; 22:258.
- Fine-needle aspiration biopsy
- Fine-needle capillary sampling
- FNA versus FNC
- Ultrasound guidance
- Other techniques
- Choice of technique
- SENSITIVITY AND SPECIFICITY
- DIAGNOSTIC CATEGORIES
- Atypia of undetermined significance or follicular lesion of undetermined significance
- Follicular neoplasm (microfollicular)
- - Hürthle-cell tumors
- Suspicious for malignancy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS