American Head & Neck Society
Translational Research Meeting

April 21-22, 2015

AHNS Annual Meeting
April 22-23, 2015 during the
Combined Otolaryngology Spring Meetings

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Accuracy & Predictive Value Of Thyroid Nodule Fna: The Need For Institutional Introspection

Presentation: S016
Topic: Endocrine Surgery
Type: COSM
Date: Thursday, April 23, 2015
Session: 8:00 AM - 9:00 AM Scientific Session #4
Authors: Marcus J Magister, BS, Irina Chaikhoutdinov, MD, Brian Saunders, MD, David Goldenberg, MD
Institution(s): Penn State Hershey Medical Center
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The Bethesda system for reporting thyroid cytopathology has helped standardize the way thyroid nodules (TN) are classified.  The test characteristics of fine needle aspiration (FNA) biopsies of larger nodules are a source of controversy.  The objective of this study is to assess the accuracy and predictive value of pre-operative FNA biopsies preformed on thyroid nodules as compared to their final pathology.


Two hundred and fifty eight patients (268 primary nodules) were retrospectively identified. All underwent a pre-operative FNA followed by surgical excision between 2011 and 2013 at the Penn State Hershey Medical Center.  All FNA results were reviewed by the Department of Pathology and assigned a Bethesda classification of class I-VI.  FNA vs. final pathology comparisons were made based on Bethesda classification to determine the negative (NPV) and positive predictive values (PPV) of benign (class-II) and malignant (class-VI) TN, respectively.  Additionally, the rate of malignancy in indeterminate thyroid nodules (class-III-V) was also assessed.  All results were stratified by nodule size into groups of <2.0cm, 2-3cm, and ≥3cm.


The 258 patients were comprised of 202 females and 66 males; the mean age was 50 years old (σ=15).  Primary nodule size ranged from 0.4cm to 8.8cm with a mean of 2.06cm (σ=1.41cm).  Our data included 9 class-I, 59 class-II, 42 class-III, 70 class-IV, 23 class-V, and 66 class-VI TN.  Comparison of all class-II nodules to their final pathologies revealed a NPV of 93%.  Likewise, comparison of all class-VI nodules to their final pathologies revealed a PPV of 98%.  When stratified by size however, class-II nodules <2cm were 4.7 times more likely to show malignant changes on final pathology as compared to class-II nodules ≥2cm (14% vs. 3%).  Class-VI nodules showed no such pattern when stratified by size. Results from our subset analyses revealed rates of malignancy of 31%, 20%, and 83% for class-III, IV, and V nodules, respectively.  When these indeterminate nodules were stratified by size, class-III nodules <2cm were 2.2 times more likely to have malignant changes on final pathology as compared to nodules ≥2cm (40% vs. 18%).  Additionally, the rates of malignancy of the largest TN (≥3cm) did not significantly differ from those expected based on their Bethesda classification.


At our institution, we found class-II and III nodules <2cm have higher rates of malignancy than previously assumed.  Our data also did not find an increase in the false-negative rate with larger nodules (≥3cm), as suggested in some prior reports.  Therefore, thyroidectomy based solely on nodule size without prior FNA should be viewed with caution.

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