Apropos of quality for fine-needle aspiration cytology of thyroid nodules with 22-, 23-, 25-, even 27-gauge needles and indeterminate cytology in thyroidology: an aide memory

Thyroidology, a dynamic discipline, deals with a crucial and, in the meantime, delicate butterfly-shaped gland, which may demand a gracious approach¹–⁶. Up-to-date management of nodular thyroid diseases necessitates the availability of several diagnostic and therapeutic modalities in order to obtain an accurate diagnosis and recommends appropriate treatment options. To this end, image-guided interventional techniques have globally been noticed and increasingly harnessed over the past four decades in thyroidology¹. Nevertheless, an optimal needle size in order to provide an adequate and accurate thyroid fine-needle aspiration (FNA) cytology has not been established distinctly to date. We read with a great deal and respect the article by Dong and colleagues⁷ entitled “Comparison of Ultrasound-Guided Fine-Needle Cytology Quality in Thyroid Nodules with 22-, 23-, and 25-Gauge Needles.” The authors compared the cytology quality of sonography-guided FNA in thyroid nodules with the 22-, 23, and 25-Gauge (G) needles prospectively in a total of 480 nodules in 437 consecutive outpatients for 17 months. They declared that the 25-G needles obtained the highest scores of FNA sample quality compared with 22- and 23-G needles. Herewith, they stated that the 25-G needle should be the first choice for thyroid FNA in routine work. To the best of our knowledge, a well-accepted universal guideline for an ideal procedural technique, such as US-FNA, US-guided fine-needle capillary sampling, US-guided core needle biopsy, and optimal needle size in FNA procedures, has not been declared in thyroidology to date. Therefore, a wide range of, 20–27-G in size, needles have been used for FNA applications in different geographic regions, that is, 25–27-G in most Western countries and 21–22-G in Japan⁸. Some authors propounded that the nondiagnostic/unsatisfactory, Category I, the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), rates of 22- and 25-G needles were 18.5 and 21.0%, respectively⁹. However, many authors have demonstrated no significant difference in the adequacy rates of the samples, achieved with finer and thicker needles¹⁰. We reported a retrospective study, a sum of 500 nodules in 425 eligible consecutive outpatients for 38 months, involving US-FNA with a surgeon-performed US (SUS) in thyroid nodules with 27-G fine-needles with a reasonable low rate, 9.0%, of Category I, TBSRTC¹¹. Although Dong et al.⁷ stated that they have determined the cytology/smear qualities with four parameters by Haddadi-Nezhad et al.¹², we demonstrated, as an output of a SUS-based serial, that the delicate needle with the finest gauge³ had possessed a reasonably low, 9.0%, nondiagnostic/unsatisfactory rate, which has been accepted globally as the crucial and significant marker for the quality of thyroid cytopathology, thereby thyroid FNA, utilizing TBSRTC, 1st¹³ and 2nd¹⁴ editions, and 2015 American Thyroid Association (ATA) Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer⁵ ([A11], Recommendation 9, [A12], Recommendation 10)¹⁵. For this, revisiting optimal needle size for thyroid FNA to display whether not much finer and less nondiagnostic is an essential issue in thyroidology⁴. The 27-G needle, minimum minimorum⁵, may provide cytologic quality, big gain⁶, while bringing peace and quiet, no pain⁶, particularly combining with our proposal of new terminology, Thy MIFNA²,⁶. Less is more?⁵ Volens nolens?⁵

In addition, Dong et al.⁷ stated that they had handled “indeterminate cytology” as Categories III and IV, TBSRTC. Nevertheless, many authorities, even the 2015 ATA Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer¹⁵, determined “indeterminate cytology” as thyroid nodules with the cytology of Categories III, IV, and V, TBSRTC, 2nd ed¹⁴, which additionally have the higher risk of malignancies (ROMs), regarding TBSRTC, 1st ed¹³, in thyroidology. A posteriori, would the mentioned outcomes of the respectable study be affected in case of incorporating the thyroid nodules with Category V, TBSRTC, which have a higher ROM, into their study design, initially, in terms of the terminology of “indeterminate cytology”? In fact, the issue of optimal needle size, hereinabove, merits further investigation. Ubi dubium ibi libertas. We thank Dong et al.¹ for their valuable study.

• Funding: none.

ACKNOWLEDGMENT

The authors thank all the participants in the article.

REFERENCES

• ¹
  Baloch Z, LiVolsi VA. Fifty years of thyroid pathology: concepts and developments. Hum Pathol. 2020;95:46-54. https://doi.org/10.1016/j.humpath.2019.09.008
  » https://doi.org/10.1016/j.humpath.2019.09.008
• ²
  Sengul I, Sengul D. Proposal of a novel terminology: minimally invasive FNA and thyroid minimally invasive FNA; MIFNA and thyroid MIFNA. Ann Ital Chir. 2021;92:330-1. PMID: 34312332
• ³
  Sengul I, Sengul D. Delicate needle with the finest gauge for a butterfly gland, the thyroid: is it worth mentioning? Sanamed. 2021;16(2):173-4. https://doi.org/10.24125/sanamed.v16i2.515
  » https://doi.org/10.24125/sanamed.v16i2.515
• ⁴
  Sengul I, Sengul D, Veiga ECA. Revisiting optimal needle size for thyroid fine-needle aspiration cytology: not much finer, less non-diagnostic? Rev Assoc Med Bras (1992). 2021;67(9):1213-4. https://doi.org/10.1590/1806-9282.20210671
  » https://doi.org/10.1590/1806-9282.20210671
• ⁵
  Sengul D, Sengul I. Minimum minimorum: Thy MIFNA, less is more concept? Volens nolens? Rev Assoc Med Bras (1992). 2022;68(3):275-6. https://doi.org/10.1590/1806-9282.20211181
  » https://doi.org/10.1590/1806-9282.20211181
• ⁶
  Sengul I, Sengul D. Big gain, no pain: Thyroid minimally invasive FNA (Thy MIFNA); Proposal of novelty in terminology. Rev Assoc Med Bras (1992). 2021;67(12):1749-50. https://doi.org/10.1590/1806-9282.20210922
  » https://doi.org/10.1590/1806-9282.20210922
• ⁷
  Dong YJ, Gao LL, Sui Y, Mao MJ, Zhan WW, Zhou ZQ. Comparison of ultrasound-guided fine-needle cytology quality in thyroid nodules with 22-, 23-, and 25-Gauge Needles. Anal Cell Pathol (Amst). 2021;2021:5544921. https://doi.org/10.1155/2021/5544921
  » https://doi.org/10.1155/2021/5544921
• ⁸
  Maeda H, Kutomi G, Satomi F, Shima H, Mori M, Hirata K, et al. Clinicopathological characteristics of thyroid cancer misdiagnosed by fine needle aspiration. Exp Ther Med. 2016;12(4):2766-72. https://doi.org/10.3892/etm.2016.3651
  » https://doi.org/10.3892/etm.2016.3651
• ⁹
  Tanaka A, Hirokawa M, Higuchi M, Kanematsu R, Suzuki A, Kuma S, et al. Optimal needle size for thyroid fine needle aspiration cytology. Endocr J. 2019;66(2):143-7. https://doi.org/10.1507/endocrj.EJ18-0422
  » https://doi.org/10.1507/endocrj.EJ18-0422
• ¹⁰
  Zhang L, Liu Y, Tan X, Liu X, Zhang H, Qian L. Comparison of different-gauge needles for fine-needle aspiration biopsy of thyroid nodules. J Ultrasound Med. 2018;37(7):1713-6. https://doi.org/10.1002/jum.14521
  » https://doi.org/10.1002/jum.14521
• ¹¹
  Sengul D, Sengul I, Egrioglu E, Ozturk T, Aydın I, Kesicioglu T, et al. Can cut-off points of 10 and 15 mm of thyroid nodule predict malignancy on the basis of three diagnostic tools: i) strain elastography, ii) the Bethesda System for Reporting Thyroid Cytology with 27-gauge fine-needle, and iii) histopathology? J BUON. 2020;25(2):1122-9. PMID: 32521915
• ¹²
  Haddadi-Nezhad S, Larijani B, Tavangar SM, Nouraei SM. Comparison of fine-needle-nonaspiration with fine-needle-aspiration technique in the cytologic studies of thyroid nodules. Endocr Pathol. 2003;14(4):369-73. https://doi.org/10.1385/EP:14:4:369
  » https://doi.org/10.1385/EP:14:4:369
• ¹³
  Cibas ES, Ali SZ. The Bethesda system for reporting thyroid cytopathology. Thyroid. 2009;19(11):1159-65. https://doi.org/10.1089/thy.2009.0274
  » https://doi.org/10.1089/thy.2009.0274
• ¹⁴
  Cibas ES, Ali SZ. The 2017 Bethesda system for reporting thyroid cytopathology. Thyroid. 2017;27(11):1341-6. https://doi.org/10.1089/thy.2017.0500
  » https://doi.org/10.1089/thy.2017.0500
• ¹⁵
  Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, 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):1-133. https://doi.org/10.1089/thy.2015.0020
  » https://doi.org/10.1089/thy.2015.0020

Publication Dates

• Publication in this collection
  19 Sept 2022
• Date of issue
  Aug 2022

History

• Received
  01 Apr 2022
• Accepted
  14 Apr 2022