Use of aspiration cytology and frozen section examination for management of benign and malignant thyroid nodules

Abstract

Between January 1980 and December 1988, 161 patients underwent thyroidectomy with intraoperative frozen section consultation after fine-needle aspiration (FNA) of a thyroid nodule. The FNA were insufficient in 15 instances (9%) and in error in 39 (24%). In 15 cases, the incorrect aspiration diagnosis could have led to excessive surgery and in ten cases to delayed therapy if it had been the only guide for therapy. The diagnosis was deferred to permanent section analysis in 30 (19%) frozen sections. Twenty-two errors (14% of cases) were made in the interpretation of frozen section material, and in an additional 15 patients (9%), the diagnosis suggested (but deferred at frozen section) was in error. In one patient, this error could have led to more extensive surgery than necessary; in 21 patients, the frozen section error could have led to undertreatment. When frozen section results were combined with those of FNA, no therapeutically important false-positive diagnoses were made. In five patients, the combination of both FNA and frozen section results would not have identified a carcinoma which, in three cases, was a small occult papillary carcinoma not found in the index nodule.

The Role of Fine-Needle Aspiration and Intraoperative Frozen Section in the Surgical Management of Solitary Thyroid Nodules

“…16,17 In up to 20% of cases, malignancy may only be discovered by final histology. 18 It is primarily this group of lesions that warrant additional informative studies to determine the definitive surgical procedure.…”

Role of Fine-Needle Aspiration Biopsy and Frozen Section Analysis in the Surgical Management of Thyroid Tumors

“…In papers that evaluated a similar population for high prevalence of malignancy, the quoted sensitivity ranges from 70% in follicular lesions only 6 to 100% in a mixed group, 8 and specificity of over 85% is common. 7-10 These reported numbers are based on either grouping the suspicious and or follicular results with the positive FNA results 11,12 or the negative FNA results, 5 or discounting them entirely. 9,10,13,28 Arranging the suspicious results in this way can yield a seemingly high positive or negative predictive value, accordingly.…”

“…When one compares the 46% of deferred patients who had a malignant tumor on final histology to the 70% malignancy rate in patients who had no frozen section, there is a tendency to question the utility of frozen section at all. Some authors report improved sensitivity and specificity for the detection of malignancy when FNA and FS are combined, and they recommend FS be used in every case, 5,11,13 whereas others have outlined the indications for a frozen section in an effort to improve its utility in thyroid surgery. 7,9,12,14 -17 They recommend frozen section to clarify a suspicious, unsatisfactory, or absent FNA result.…”

“…Our view differs from those published by other high-volume centers. 5,7,11,13,32 We do not advocate total thyroidectomy for every thyroid cancer. Each case is decided individually based on risk factors and intraoperative findings.…”

“…[3][4][5][6][7][8][9][10][11][12][13] Although FNA is a cost-effective and specific first test, up to 30% of patients with nodular thyroid disease will receive an FNA report that reads "follicular lesion" or "suspicious." Most of these patients will require surgical management, and the extent of resection will need to be planned without a preoperative diagnosis of malignancy.…”