Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA.
Surgery. 2010 Dec;148(6):1294-9; discussion 1299-301. doi: 10.1016/j.surg.2010.09.029.
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.
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.
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).
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.
细针穿刺活检（FNA）无法可靠地区分滤泡性甲状腺癌与良性滤泡性肿瘤。鉴于恶性肿瘤的风险估计为 20%，许多不确定的 FNA 活检患者需要进行甲状腺切除术以明确诊断。一些中心发现，当第二位病理学家评估相同的 FNA 活检时，存在显著的不一致。我们旨在确定常规的二次细胞学检查是否可以减少诊断性甲状腺切除术的需求，尤其是在不确定的 FNA 活检患者中。
回顾性分析 2004 年至 2009 年期间我院从外部中心获得的 331 例甲状腺 FNA 活检标本。将 FNA 活检结果分为非诊断性（Bethesda I）、良性（Bethesda II）、不确定（滤泡/ Hurthle 细胞肿瘤、滤泡/ Hurthle 细胞病变；Bethesda III 和 IV）和恶性（乳头状或疑似乳头状或其他恶性肿瘤；Bethesda V 和 VI）。将二次细胞学检查与 331 例中的初始意见进行比较，并与 250 例进展为甲状腺切除术的患者的最终手术病理进行比较。
患者的平均年龄为 51 岁，女性占多数（79%）。所有 331 例 FNA 活检的总体细胞学一致性为 66%（218/331）。恶性 FNA 活检的一致性最高，为 86%（74/86）。在 129 例不确定的 FNA 活检患者中，一致性仅为 37%（48/129）。在 129 例不确定的 FNA 活检患者中，21%（27/129）的患者被重新阅读为非诊断性，42%（54/129）的患者被重新阅读为良性。22 例因非细胞学原因（如症状性结节和辐射暴露/高危）而进行良性的不确定 FNA 活检患者被重新阅读为良性，其中 95%（21/22）的患者在手术病理上为良性，阴性预测值为 95%。另外 11 例不确定的 FNA 活检患者被重新阅读为良性，并进行了随访 FNA 活检，结果均为良性。在初始细胞学上不确定的 FNA 活检的恶性率为 13%（17/129），而第二次细胞学检查的不确定的 FNA 活检的恶性率为 29%（14/48）。二次细胞学检查可提高 FNA 活检的准确性，从 60%提高到 74%。总体而言，二次细胞学检查避免了 25%（32/129）不确定的甲状腺 FNA 活检的诊断性手术。
常规的不确定甲状腺 FNA 活检二次细胞学检查可以潜在地避免 25%的患者进行诊断性甲状腺切除术，而不会增加假阴性率。
