Ultrasound-guided thyroid biopsy
- Manfred Blum, MD, FACP
Manfred Blum, MD, FACP
- Professor of Medicine and Radiology
- New York University School of Medicine
High-resolution ultrasonography provides a detailed map of thyroid nodules and helps to characterize the nodules and adjacent structures in the neck. Thyroid ultrasound, in conjunction with fine needle aspiration (FNA) biopsy, plays an important role in the evaluation of a patient with a suspected thyroid nodule. The use of ultrasound-guided thyroid biopsy is reviewed here. Other clinical uses of thyroid ultrasonography and an overview of thyroid biopsy, including palpation-guided techniques, limitations, and complications, are discussed separately. (See "Overview of the clinical utility of ultrasonography in thyroid disease" and "Thyroid biopsy".)
Thyroid ultrasound should be performed in all patients with a suspected thyroid nodule or nodular goiter on physical examination or with nodules incidentally noted on other imaging studies (carotid ultrasound, CT, MRI, or FDG-PET scan). There is increasing evidence that the presence of suspicious ultrasound features is more predictive of malignancy than nodule size alone. The decision to biopsy a thyroid nodule should be based upon a combination of ultrasonographic features, a history of factors that increase the risk of thyroid cancer (such as radiation exposure during youth), recent enlargement sustained by the nodule, and nodule size. This topic is reviewed in detail separately. (See "Diagnostic approach to and treatment of thyroid nodules", section on 'Evaluation' and "Diagnostic approach to and treatment of thyroid nodules", section on 'Indications'.)
INDICATIONS FOR ULTRASOUND-GUIDED FNA
Fine needle aspiration (FNA) biopsy is the procedure of choice for evaluating thyroid nodules and selecting candidates for surgery. If the presence of a thyroid nodule and indication for FNA is confirmed by diagnostic ultrasound, and the nodule corresponds to what is palpated on physical examination, FNA can be performed directly without ultrasound guidance. However, ultrasound guidance is sometimes preferred [1,2]. Compared with palpation-guided FNA, the use of ultrasound improves the cytologic diagnostic accuracy rate and reduces the nondiagnostic rate [3-7]. In a retrospective evaluation of 9683 patients with thyroid nodules, 4986 and 4697 patients were evaluated by palpation and ultrasound-guided FNA, respectively . The nondiagnostic rate was significantly higher after palpation-guided FNA (14.1 versus 8.5 percent). Over a 15-year period, over 1000 nodules were resected because of suspicious or malignant cytology on palpation or ultrasound-guided FNA. The false negative rate was higher in nodules that were biopsied via palpation rather than ultrasound (2.3 versus 1 percent).
When available, we suggest ultrasound-guided FNA for the majority of nodules. Ultrasound-guided FNA is essential for those nodules that are:
- Nonpalpable or difficult to palpate
- Predominantly cystic
- Nondiagnostic after palpation-guided FNA
- Small and located in close proximity to blood vessels
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