Differential diagnosis of benign and malignant thyroid nodules at elastosonography.

PURPOSE: Ultrasound of the neck detects a large number of non-palpable thyroid nodules in the population, but it offers poor diagnostic accuracy (the presence of microcalcifications is the only statistically significant criterion indicative of malignancy). The aim of this study is to evaluate elastography, a technique which allows differentiation between pathological and normal tissue by determining its hardness and which could also prove useful in the characterisation of thyroid nodules. MATERIALS AND METHODS: In this prospective study, 51 thyroid nodules in 40 consecutive patients were examined (25 women, 15 men, mean age +/- SD, 54 +/- 13.4). Elastosonography was performed by real-time, free-hand technique, using Logos HiVision equipment with a 10 MHz transducer and lesions were classified and scored in 4 classes of hardness. All patients were also examined by grey scale high frequency ultrasound and colour Doppler. Final diagnoses were obtained from cytological and/or histological evaluation. RESULTS: Final diagnoses revealed 11 malignant and 40 benign nodules. Only in two cases ultrasound demonstrated signs useful for a differential diagnosis (intrinsic microcalcifications). Correct differentiation of malignant from benign nodules was obtained by elastosonography in 43 / 51 cases with 5 false positives (FP) and 3 false negatives (FN). Specificity, sensitivity and accuracy were 87.5 %, 81.8 % and 86.2 %, respectively. Predictive negative value (PNV) and predictive positive value (PPV) were 94.5 % and 64 % area under the curve (AUC) 0.86. CONCLUSION: Elastosonography provides an interesting contribution to the differentiation of malignant and benign thyroid nodules. Particularly worthy of mention is that an entirely elastic nodule pattern was observed only in relation to benign nodules, a result which would suggest that immediate recourse to FNAB might be avoided.

Accuracy of fine-needle aspiration cytology and frozen-section examination in patients with thyroid cancer.

In patients with solitary thyroid nodules (TN) undergoing surgery both fine-needle aspiration (FNA) and frozen-section examination (FSE) are currently performed, but their role is still controversial. We retrospectively analyzed a series of 606 patients with a nontoxic solitary thyroid nodule who underwent both FNAB and FSE prior to thyroidectomy. There were 118 (19.5%) men and 488 (80.5%) women, with a median age of 44 years (range 16-81 years). The results of both FNAB and FSE were compared against the final pathological examination. Definitive histology showed 500 (82.5%) benign nodules, including 239 (39.4%) follicular adenomas, and 106 (17.5%) carcinomas, of which 18 (17.0%) were follicular cancer. In differentiating between benign TN and thyroid tumors the sensitivity, specificity, and accuracy of FNAB were 93.6%, 98.9% and 95.9%, while in the detection of malignancy were 81.1%, 99.4% and 96.2% for FNAB, and 83.0%, 100% and 97.0% for FSE (P = NS), respectively. The combination of both techniques did not improve significantly (P = NS) the results. Both medullary and undifferentiated cancer, and 76 of 80 (95.0%) papillary carcinomas were correctly detected by FNAB. Three (0.5%) false-positive smears suggesting cancer were found. In conclusion, in patients with FNAB revealing thyroid cancer or a benign TN, the extent of thyroidectomy should be established by performing FSE. When FNAB suggests the presence of a follicular tumor, FSE may affect rarely the final intraoperative decision-making, and should be considered unnecessary. However, in patients with FNA revealing thyroid cancer, FSE is useful in confirming malignancy, and may avoid surgical overtreatments.

CT-scan, MRI and image-guided FNA cytology of incidental adrenal masses.

AIM: The aim of this study was to compare the usefulness of computed tomography (CT)-scan, magnetic resonance imaging (MRI), and fine-needle aspiration (FNA) cytology in patients with incidentally discovered adrenal masses. PATIENTS AND METHODS: Thirty-four consecutive patients (six men and 28 women, median age of 47 years, range 26-80) with non-functioning adrenal masses of 2 cm or more (median 3.5 cm, range 2-9) were studied. All patients underwent CT-scan, MRI, and image-guided FNA cytology using spinal-type narrow-gauge needles prior to further procedures. Nineteen patients underwent adrenalectomy. RESULTS: Final pathology showed 13 benign adrenal lesions, four adrenocortical carcinomas, and two unsuspected adrenal metastases. Fifteen patients who did not have surgery were considered definitively as having benign adrenal lesions since the mass was unchanged on CT-scans performed during follow-up. The sensitivity, specificity, and positive predictive value were 66.7, 85.7, and 50.0%, for CT-scan, 83.3, 92.9, and 71.4% for MRI, and 83.3, 100, and 100% (p<0.05) for FNA cytology, respectively. CONCLUSIONS: Image-guided FNA cytology is a safe and sensitive procedure that may reveal unsuspected adrenal malignancies, and should be performed in all patients with incidentally discovered adrenal masses of more than 2 cm in size.

Fine-needle aspiration cytology of adrenal masses in noncancer patients: clinicoradiologic and histologic correlations in functioning and nonfunctioning tumors.

BACKGROUND: Image-guided, fine-needle aspiration (FNA) cytology is performed currently in patients with malignant disease who have suspected adrenal metastases. The objective of this study was to evaluate the usefulness and safety of FNA cytology in patients with incidental adrenal masses and functioning tumors. METHODS: Computed tomography (CT)-guided or ultrasound-guided aspirates using 21-23-gauge needles were performed successfully in 70 patients with functioning (n = 38 patients) and nonfunctioning (n = 32 patients) adrenal masses (median size, 4 cm; range, 3-12 cm) that were detected previously by CT scans. RESULTS: Definitive histology was available in 68 patients (97.1%), showing 53 benign tumors (77.9%), 11 primitive malignant tumors (16.2%), and 4 unsuspected adrenal metastases (5.9%) in patients with unknown primary tumors. In two patients with aspirate reports that ruled out malignancy, the mass was unchanged on CT scan follow-up; thus, they were considered benign lesions. The benign masses were significantly smaller (P < 0.01), although seven malignant tumors (46.7%) measured 3-4 cm in greatest dimension, and eight benign lesions (14.5%) measured 5-6 cm in greatest dimension. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 66.7%, 96.4%, 83.3%, 91.4%, and 90.0%, respectively, for CT scan and 93.3%, 100%, 100%, 98.2%, and 98.6%, respectively, for FNA cytology. The morbidity rate of image-guided FNA cytology was 4.3% (two patients with self-limited, asymptomatic pneumothorax and one patient with spontaneously resolved adrenal hematoma). CONCLUSIONS: Adrenal FNA cytology represents a safe and specific procedure for evaluating patients with adrenal masses measuring > 2 cm in greatest dimension. FNA is able to reveal malignancies and unsuspected pheochromocytomas and should be performed in all patients with adrenal tumors whenever requested for surgical planning.

Fine needle aspiration cytology (FNAC) of adrenal masses.

Between 1992 and 1998 at the Pathology Section, Cytopathology Unit of the Department of Oncological and Surgical Sciences of the University of Padova, we performed one hundred and twelve FNACs of adrenal masses under radiological guidance and seven intraoperative scrape smears; histological follow-up was available in 55 cases. Immediate on-site assessment of smears revealed a satisfactory adequacy rate (92%). With a simple diagnostic tree, we have been able to classify all smears except one as benign or malignant correctly, (accuracy 97.6%), differentiation of primary tumours from metastatic depositions remaining the most difficult task. In our experience FNAC is a safe and accurate tool in the diagnostic characterization of adrenal masses.

Recurrent synovial cyst of deep soft tissues. A case report.

BACKGROUND: Cystic lesions of deep soft tissues are rare and usually are composed of a mesenchymal tumor undergoing necrosis or regressive changes. Benign cysts arising de novo are even more rare and may show features of different morphology, potentially leading to an inexact diagnosis. CASE: A 68-year-old male presented with a deep, firm mass in the upper part of the back from which a dense liquid was aspirated, with an inconclusive diagnosis. A second fine needle aspiration was performed, and the lesion was surgically biopsied. Immunohistochemical studies were also inconclusive, while ultrastructural studies suggested an origin in the synovia of the scapular bursa. CONCLUSION: The cytologic picture was suspicious for malignancy due to the presence of numerous pseudopapillary structures, reminding us of a secondary deposit from a renal or thyroid primary or mesenchymal neoplasm. However, the bland nuclear aspect suggested the benignity of the lesion, and the electron microscopic features confirmed the synovial origin.

Extramedullary hematopoiesis of the thyroid gland diagnosed by FNA cytology. A case report.

BACKGROUND: Extramedullary hematopoiesis (EMH) is the production of elements of erythroid and myeloid series at ectopic sites; when concomitant with agnogenic myeloid metaplasia, it is invariably seen in advanced disease. In EMH, involvement of the thyroid gland is extremely rare. CASE: An 82-year-old male with thyroid enlargement underwent fine needle aspiration (FNA) cytology with a diagnosis of malignancy. A month later another FNA cytology was performed and was consistent with EMH. A complete hematologic workup subsequently allowed the diagnosis of agnogenic myeloid metaplasia. CONCLUSION: The presence of EMH in the thyroid gland is an unusual finding, and, due to the presence of numerous giant cells, the cytologic presentation might be mistaken for anaplastic thyroid carcinoma. The differential diagnosis is based on the recognition of giant cells as megakaryocytes.

[Adrenal incidentaloma: proposal for a correct treatment]. / Incidentalomi surrenalici: proposta per un corretto trattamento.

BACKGROUND: The incidence of unsuspected adrenal masses (incidentalomas) based on CT-scan results to be higher than in the past. The aim for our study was to establish some guidelines for an appropriate management. METHODS: From 1986 to 1995, 61 patients with no history or clinical findings suggestive of adrenal mass or adrenal hyperfunction were discovered by radiologic examination to have an incidentaloma larger than 1 cm. In each patient basal biochemical evaluations were obtained to exclude the presence of adrenal cortical or medullary dysfunction. There were 28 men and 33 (54.1%) women, with a mean age of 53 years (range 16-74). 19 patients underwent CT-guided fine-needle biopsy to exclude metastatic tumors. Furthermore in 29 patients 75-Se-selenomethyl-norcholesterol was performed and 17 were studied by MRI. RESULTS: At CT-scan mean lesion diameter was 5.48 +/- 3.76 cm (range 2-23); 32 adrenal masses were right sided and 3 (4.9%) were bilateral. 17 patients had concordant scintigraphic imaging pattern, 6 bilateral uptake and 6 had discordant imaging. CT-guided FNAB showed malignancy in 9. Adrenalectomy was performed in 45 patients according to a score calculated by 4 parameters: age of the patients, size of the mass, scintigraphic pattern, MR imaging. Twenty-four had a score greater than 9 and in the remaining 21 patients in spite of a score lower than 10 adrenalectomy was performed based on: 1) increased size at CT scan follow-up (15 pts); 2) either suspected primitive malignant neoplasm at CT-guided FNAB or history of malignancy (6 pts); 3) elevated 24-hour dopamine (4 pts). In 12 (26.7%) patients a malignant tumor was found. There were not any statistically significant differences (p > 0.05) between the age of the patients with malignant neoplasms and those with benign masses, and between the size of the masses, which were 7.58 +/- 5.93 cm (range 2-23) and 5.03 +/- 2.81 cm (range 3-17) respectively. The difference in scores between the patients with malignant masses (12.17 +/- 2.95) and those with benign ones (9.09 +/- 1.33) was statistically significant (p < 0.01). CONCLUSIONS: Since adrenal incidentaloma have a malignancy rate higher than the other adrenal tumors, it is crucial to outlinesome criteria to sort out the patients at risk for whom adrenalectomy is to be warranted. Based on our results we believe that patients with a score > 9 should undergo adrenalectomy.

Ultrasonographic evaluation of superficial lymph node metastases in melanoma.

The aims of the present work were to assess the diagnostic accuracy of ultrasonographic evaluation of superficial lymph nodes in patients with cutaneous melanoma and to describe the sonographic characteristics which permit early detection of neoplastic nodal involvement. Eighty-seven patients (89 lymph node sites) were studied for approximately a 3-year period, with a minimal surveillance time of 1 year. The ultrasonographic imaging equipment utilized were a 10 MHz scanner with a mechanical and one with 10 MHz electronic linear probe. The characteristics considered indicative of possible metastatic involvement were: round shape (short to long axis ratio > 0.5), no central hilus, nodular areas within the lymph node, sinuosity of the lymph node edges and lymph node with regular morphology and echostructure but with maximum diameter greater than 3 cm. Generally inguinal and axillary lymph nodes are larger than cervical ones. Of the 89 sites explored, 32 were considered 'suspect'. All 32 of these were subjected to cytology using ultrasound-guided, fine needle aspiration. The remaining 56 came in for a periodic control examination during a year. Thirteen of the 32 'suspect' lymph nodes proved positive at the pathologic examination. Two patients whose ultrasound diagnosis was negative developed metastases within 2 to 4 months (ultrasound false negatives). Our study indicates that there are sonographic features indicative of lymph node metastases from melanoma even in the early stages of the disease. Ultrasound scanning, therefore, is a useful diagnostic tool in the follow-up of melanoma patients, identifying which should be subjected to further testing with needle biopsy.