The significance of FNAC in diagnosing differentiated thyroid cancer and the discrepancy between theory and practice - a multi-centre study.

INTRODUCTION: After non-invasive diagnostic modalities high risk thyroid nodules are investigated with fine needle aspiration cytology in order to find the right surgical strategy for suspected malignancies. Despite the clear recommendation by the European and the American associations (ETA, ATA) its clinical value is doubted and its importance in clinical practice not fully clarified. METHODS: A multicentric study of 119 patients with differentiated thyroid cancer operated on in 24 surgical departments was conducted. The aim was not only to evaluate the use of FNAC as a diagnostic tool, but also to investigate its diagnostic validity and compare it with that of other, non-invasive diagnostic methods. RESULTS: FNAC was used only in 25 % of malignant thyroid nodules. In these patients sensitivity of FNAC was 60 %. In 40 % with preoperative FNAC, the result had an impact on the surgical approach. 17 % underwent surgery only because of the FNAC result, and 23 % underwent a planned surgical resection with total thyroidectomy and lymphadenectomy on account of the FNAC result. In comparison to non-invasive diagnostics (ultrasonography in conjunction with scintigraphy with Na99mTcO4) FNAC reached the same sensitivity. DISCUSSION: The results of our study reveal a limited application of preoperative FNAC in diagnosing thyroid nodules as well as a limited conclusiveness in our study population if not performed according to standards. In order to increase the benefits of this diagnostic modality, it seems to be important to perform FNAC according to the guidelines and in a standardized manner. FNAC should always be conducted in combination with ultrasonography. An experienced cytopathologist should be consulted and the Bethesda classification system should be established.

Evaluation of thyroid nodules--combined use of (99m)Tc-methylisobutylnitrile scintigraphy and aspiration cytology to assess risk of malignancy and stratify patients for surgical or nonsurgical therapy--a retrospective cohort study.

OBJECTIVE: Thyroid nodules are a common clinical problem, and differentiation between benign and malignant nodules is essential. The aim of this study was to evaluate an approach for cold thyroid nodules including (99m)Tc-methylisobutylnitrile (MIBI) scintigraphy to assess risk of malignancy and stratify patients for therapy. DESIGN: Retrospective cohort study; 391 patients with at least one cold thyroid nodule were consecutively admitted (between 1 January 2004 and 31 December 2006) and recommended for surgical or nonsurgical therapy. MEASUREMENTS: Thyroid ultrasonography, (99m)Tc-pertechnetate scintigraphy, laboratory tests, fine needle aspiration cytology (FNAC) and MIBI scintigraphy. RESULTS: 57·3% (224/391) had one cold nodule, 17·9% (70/391) had several cold nodules, and 24·8% (97/391) had both cold and hot nodules. MIBI scintigraphy was classified into 'positive' (16·1%, 63/391), 'weakly positive' (19·2%, 75/391) or 'negative' (64·7%, 253/391). FNAC was classified into benign (87·9%, 247/281), nondiagnostic (6·8%, 19/281) or suspicious/malignant (5·3%, 15/281). 127 patients received surgery, revealing malignancy in 13·3% (17/127), predominantly papillary (64·7%, 11/17) and follicular carcinoma (23·5%, 4/17). MIBI scintigraphy was 'positive' (64·7%, 11/17) or 'weakly positive' (23·5%, 4/17) in most patients with malignant findings. FNAC was unavailable in 23·5% (4/17) with malignancy, positive in 38·5% (5/13) and negative in 61·5% (8/13). Among patients undergoing surgery, sensitivity, specificity, negative and positive predictive values for MIBI scintigraphy were 88·2%, 35·5%, 95·1% and 17·4%, for FNAC 38·5%, 90·6%, 90·6% and 38·5%, respectively, and for the combination (MIBI scan + FNAC) 92·3%, 30·6%, 96·3% and 16·9%. Benign MIBI-positive nodules were predominantly follicular adenomas (68%, 33/48). CONCLUSION: Evaluation of cold thyroid nodules by MIBI scintigraphy aids therapeutic decisions: MIBI-negative findings support nonsurgical management in about two-thirds of patients, while MIBI-positive findings have an increased risk of malignancy, supporting surgical therapy. However, the positive predictive value was low, which requires further research.

Eosinophilic fasciitis leading to painless contractures.

UNLABELLED: We report on an 11-year-old girl who developed multiple joint contractures over a period of 3 months. The disease presented with progressive involvement of the fingers, elbows, shoulders, knees and feet and was not accompanied by other symptoms. Laboratory investigations showed eosinophilia and hypergammaglobulinaemia. Muscle ultrasound and magnetic resonance imaging of the right forearm revealed thickened fascia and a full thickness biopsy confirmed the diagnosis of eosinophilic fasciitis. Following treatment with pulsed steroids, the contractures resolved. CONCLUSION: our case shows that eosinophilic fasciitis can present without skin involvement and arthritis and therefore has to be regarded as a differential diagnosis of contractures in childhood. Pulsed steroid treatment was effective and without side-effects.