The accuracy of clinical diagnosis and fine-needle aspiration biopsy (FNAB) was evaluated in 169 patients surgically treated for nodular thyroid disease. Patients were divided into three groups with high, moderate, or low suspicion of malignant neoplasms on clinical grounds without previous knowledge of cytologic or histologic results. Histologic examination revealed an overall malignant neoplasm rate of 23%; the rate was 71%, 14%, and 11% for the groups with high, moderate, and low suspicion, respectively. The FNAB diagnostic interpretations of malignant and uncertain were considered positive. Overall sensitivity, specificity, and accuracy for FNAB were 92%, 71%, and 75%, respectively. Sensitivity in the high-, moderate-, and low-suspicion groups was 95%, 89%, and 88%, respectively; specificity was 88%, 72%, and 67%, respectively; and accuracy was 93%, 75%, and 69%, respectively. In our opinion, all patients in the group with high clinical suspicion need surgical treatment whatever the FNAB result; those with lower degrees of clinical suspicion and malignant or uncertain FNAB result [corrected] should also undergo surgery.

The value of fine-needle aspiration biopsy in patients with nodular thyroid disease divided into groups of suspicion of malignant neoplasms on clinical grounds.

The term “follicular neoplasm” is broadly applied to a heterogeneous group of thyroid tumors characterized by a proliferation of thyroid epithelial cells growing in a follicular pattern. Because this group encompasses both benign and malignant tumors, treatment decisions and prognosis ultimately rely on more specific classification. Regrettably, further classification is often not possible by fine-needle aspiration (FNA). In the case of follicular and Hurthle cell carcinomas, FNA is ineffectual in recognizing tumor invasion, an obligatory diagnostic feature. 1,2 In the case of the follicular variant of papillary carcinoma, FNA tends to underappreciate specific nuclear alterations because of their focal and random distribution. 3,4 The probability of malignancy in a thyroid lesion demonstrated by FNA to be a follicular neoplasm is approximately 20%. 2,5 Accordingly, excision is recommended for patients harboring this heterogeneous group of nodules.

Confusion surrounding optimal patient management is compounded in the operating room. Many surgeons perform an ipsilateral thyroid lobectomy and isthmusectomy and then rely on intraoperative frozen-section analysis to establish a more precise diagnosis. If the lesion is found to be malignant, a one-stage total thyroidectomy is advocated. If the lesion is benign, most surgeons and endocrinologists believe that an ipsilateral thyroid lobectomy is adequate treatment. 6,7 Unfortunately, intraoperative frozen-section evaluation can rarely distinguish benign from malignant neoplasms. 1,2,5,8–11 The focal nature of tumor invasion may elude detection because of the limited sampling inherent to frozen-section evaluation. Moreover, the artifact and cellular distortion induced by tissue freezing may mask the subtle morphologic atypia that characterizes the follicular variant of papillary carcinoma. As a result, some have called into question the standard practice of frozen-section evaluation as a reliable means to guide the surgical management of thyroid nodules. 1,2,8,11,12

In a large retrospective study, we previously showed that intraoperative frozen section failed to render useful information in 87% of patients with follicular neoplasms of the thyroid. 2 Further, frozen section appropriately modified the surgical procedure in only 4 of 120 (3.3%) patients. Likewise, Hamburger and Hamburger 11 showed that only 3 of 359 (0.8%) frozen-section analyses contributed decisively to surgical treatment; Shaha et al 13 reported similar limitations of frozen-section analysis for follicular neoplasms. Based on these results, we questioned the routine use of intraoperative frozen section as a useful and cost-effective diagnostic tool for classifying follicular neoplasms of the thyroid. 2 Although most investigators agree with this recommendation, some believe that this technique is a useful routine intraoperative diagnostic adjunct. 9,14 In addition, clinical factors such as age, sex, and tumor size may not be helpful in differentiating benign from malignant follicular neoplasms. 10

Despite growing concern regarding its efficacy, frozen-section analysis remains entrenched as a standard practice in the surgical management of thyroid nodules. Many surgeons are reluctant to abandon this ritualistic, albeit dubious, exercise in the absence of randomized prospective studies that either confirm or contest retrospective observations. With this in mind, we designed a randomized prospective trial evaluating the clinical utility of intraoperative frozen-section analyses for follicular neoplasms of the thyroid.

Randomized Prospective Evaluation of Frozen-Section Analysis for Follicular Neoplasms of the Thyroid

OBJECTIVE: The authors determined the usefulness of frozen section (FS) evaluation in the operative management of follicular lesions of the thyroid. SUMMARY BACKGROUND DATA: Fine-needle aspiration (FNA) cannot reliably discriminate between benign and malignant follicular lesions of the thyroid. Accordingly, FS evaluation is used routinely to guide intraoperative management. METHODS: One hundred twenty-five consecutive patients with follicular thyroid lesions who underwent surgical exploration at the Johns Hopkins Hospital were reviewed. RESULTS: Frozen sections were categorized in 104 of 120 patients (87%) as "follicular lesion, defer to permanent section," rendering no useful clinical information. In only 4 of 120 patients (3.3%) did FS evaluation correctly modify the operative procedure. Notably, in six cases (5.0%), an incorrect FS evaluation misled the surgeon, resulting in four misguided operations. CONCLUSION: Frozen section evaluation is of minimal diagnostic value for follicular thyroid lesions, rendering no additional information 87% of the time; it prolongs the operation, increases costs, and leads to misguided interventions. Until a more definitive diagnostic tool exists for follicular thyroid lesions, FS evaluation could be omitted, resection of the lobe with the nodule could be performed, and the definitive operative management could be based on the final permanent histology.

Follicular lesions of the thyroid. Does frozen section evaluation alter operative management

Background: We sought to evaluate the predictive value of preoperative fine-needle aspiration (FNA) on surgical decision making by evaluating the final pathologic diagnosis and comparing it to the preoperative diagnosis. Further, we wished to calculate the predictive accuracy of each of several types of preoperative FNA diagnosis. Study Design: A retrospective chart review of 151 thyroid resections between July 1990 and April 1996 at the University of Virginia was undertaken. The mean age was 45 years (range, 11 to 85 years). Preoperative laboratory values, presenting symptoms, imaging studies, and predictive values of preoperative FNA and intraoperative frozen section were analyzed. Results: Symptomatology was poorly predictive of a benign versus malignant postoperative final pathologic diagnosis. Sensitivity, specificity, and accuracy of frozen section versus FNA was 86% versus 86%; 99% versus 93%, and 96% versus 92%, respectively, if the reading "cancer" or "suspicious" were predicted as positive for malignancy and "benign" or "follicular" were predicted as negative for malignancy. If only the reading "cancer" was predicted as positive for malignancy and only "benign" was predicted as negative for malignancy, sensitivity and specificity for FNA were 100% and 96%, respectively, and 100% and 99%, respectively, for frozen section. Forty-nine "follicular" lesions obtained by preoperative FNA resulted in 46 benign diagnoses after surgical resection. Conclusions: The use of preoperative FNA is a powerful diagnostic tool in the hands of skilled pathologists. There is increasing evidence that intraoperative frozen section adds little to intraoperative decision making in patients diagnosed with thyroid cancer by preoperative FNA. Less definitive interpretations decrease the sensitivity, specificity, and accuracy of the FNA diagnosis.

https://www.journalacs.org/article/S1072-7515(98)00221-X/pdf

Preoperative evaluation and predictive value of fine-needle aspiration and frozen section of thyroid nodules

AIMS: To evaluate the correlation of fine needle aspiration (FNA) cytology and frozen section biopsy in the diagnosis of thyroid nodules. METHODS: The medical records of 662 patients who underwent FNA cytology of the thyroid and thyroid surgery were analysed. Frozen section biopsies were taken from 586 of the 662 patients. The diagnostic correlations of FNA cytology, frozen section, and both FNA cytology and frozen section with definitive histological assessment were evaluated. RESULTS: Among the 662 patients who received FNA cytology, there were 356 cases (53.8%) diagnosed as benign, 114 cases (17.2%) as malignant, 148 cases (22.4%) as indeterminate, and 44 cases (6.6%) as unsatisfactory. The positive predictive value for the detection of malignancy by FNA cytology was 92.1% and the negative predictive value was 95.2%. The incidence of malignancy in the indeterminate cytological diagnosis was 23%. The diagnosis from frozen sections was benign in 445 cases (75.9%), malignant in 134 cases (22.9%), and deferred in 7 cases (1.2%). By frozen section, the positive and negative predictive values were 97% and 95.5%, respectively. Diagnostic accuracy up to 98% was achieved when FNA cytology and frozen section diagnoses were in agreement. No false positives were observed when FNA cytology and frozen sections were both positive for malignancy. When FNA cytology and frozen section diagnoses were discordant, frozen section showed a higher accuracy (78.9%) than FNA cytology (21.1%). In the face of an indeterminate or unsatisfactory cytological diagnosis, the diagnostic accuracy of frozen sections reached 92.6%. CONCLUSIONS: The results confirm that FNA cytology is a useful tool in the initial evaluation of thyroid nodules. Intraoperative frozen section is a valuable procedure to confirm the cytological diagnosis and identify malignancy in patients with indeterminate or unsatisfactory cytological diagnosis. With reliance on frozen sections as an intraoperative guide of thyroid surgery, the possibility of unnecessary extensive surgery and the need for the second operation are considerably lower.

https://jcp.bmj.com/content/jclinpath/50/12/1005.full.pdf

Correlation of fine needle aspiration cytology and frozen section biopsies in the diagnosis of thyroid nodules.

Accuracy and significance of fine-needle aspiration and frozen section in determining the extent of thyroid resection.

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Accuracy and significance of fine-needle aspiration and frozen section in determining the extent of thyroid resection.