J Pathol Transl Med.  2015 Jul;49(4):288-299. 10.4132/jptm.2015.06.04.

Pathology Reporting of Thyroid Core Needle Biopsy: A Proposal of the Korean Endocrine Pathology Thyroid Core Needle Biopsy Study Group

• Jung CK
• Min HS
• Park HJ
• Song DE
• Kim JH
• Park SY
• Yoo H
• Shin MK
• Korean Endocrine Pathology Thyroid Core Needle Biopsy Study Group

• KMID: 2151138
• DOI: http://doi.org/10.4132/jptm.2015.06.04

Abstract

In recent years throughout Korea, the use of ultrasound-guided core needle biopsy (CNB) has become common for the preoperative diagnosis of thyroid nodules. However, there is no consensus on the pathology reporting system for thyroid CNB. The Korean Endocrine Pathology Thyroid Core Needle Biopsy Study Group held a conference on thyroid CNB pathology and developed guidelines through contributions from the participants. This article discusses the outcome of the discussions that led to a consensus on the pathology reporting of thyroid CNB.

Keyword

Thyroid nodule; Guideline; Image-guided biopsy; Preoperative period; Diagnosis

MeSH Terms

Biopsy, Large-Core Needle*
Consensus
Diagnosis
Image-Guided Biopsy
Korea
Pathology*
Preoperative Period
Thyroid Gland*
Thyroid Nodule

Figure

• 

  Fig. 1. Core needle biopsies of fibrotic nodules. The right column images represent the high-power views of the lesional area in the left column images. (A) The specimen consists of an acellular fibrotic lesion and adjacent normal parenchyma. (B) The fibrotic area contains no follicular cells, but contains a few lymphocytes and stromal cells. This lesion is classified in the nondiagnostic category. (C) The specimen shows a paucicellular structure with marked fibrosis and calcification. (D) Scattered atypical cells with suspicious morphological features of papillary carcinoma are embedded in the fibrosis. This lesion contains suspicious follicular cells and should therefore be diagnosed as suspicious for malignancy or as a malignancy, depending on the degree of nuclear atypia. (E) The specimen shows marked fibrosis and calcification. (F) The high-power view of the lesion shows relatively numerous benign-appearing follicular cells. This lesion can be diagnosed as a benign follicular nodule.

• 

  Fig. 2. (A, B) The ultrasound images show well-circumscribed solid, homogeneous, nodules with peripheral hypoechoic rims. (C, D) The core needle biopsies show only microfollicular proliferation. These specimens do not contain a fibrous capsule or adjacent normal tissue that is required to make a diagnosis of follicular neoplasm. (E, F) Images are the high-power views of Fig. 2C and D, respectively. No nuclear atypia is present. The left and right columns show the conventional and Hürthle cell types, respectively. Typical ultrasound features of follicular neoplasms, when present, can lead to the diagnosis of follicular neoplasms, even when specimens are not contained in a fibrous capsule.

• 

  Fig. 3. Core needle biopsy findings of a follicular neoplasm with a macrofollicular growth pattern. The images in the left column and the right column show the core needle biopsy specimen and the resected specimen, respectively. (A) The ultrasound image shows a well-circumscribed, isoechoic, ovoid nodule with a peripheral hypoechoic rim. A focal cystic change is present. (B) The surgical specimen exhibits a thick fibrotic capsule surrounding the nodule. (C) The core needle biopsy shows a macrofollicular proliferative lesion with a fibrous capsule (arrows). (E) The high-power view of the biopsy specimen shows benign-appearing follicular cells. The typical ultrasound features and thick fibrous capsule can lead to a diagnosis of follicular neoplasm, even in a macrofollicular lesion. The microscopic examination of the surgical specimen shows that the tumor is well encapsulated (D) and capsular invasion is minimal (F).

• 

  Fig. 4. (A) The core needle biopsy shows a microfollicular proliferative lesion and surrounding normal tissue. (B) The high-power view of the boxed area in Fig. 4A shows that the lesion has no nuclear atypia or fibrous capsule. This lesion should be diagnosed as a benign follicular nodule. (C, D) When microfollicular proliferative lesions show a definite fibrous capsule (arrows) in the core needle biopsy, the specimens should be diagnosed as a follicular neoplasm.

• 

  Fig. 5. The core needle biopsy of a follicular neoplasm with focal nuclear atypia. The images in the left and right columns show the findings of the core needle biopsy and the corresponding surgical specimen, respectively. (A) The ultrasound image shows a solid, homogeneous, hypoechoic, ovoid nodule with a peripheral halo. (B) The cut surface of the resected specimen corresponds to the ultrasound image in Fig. 5A. (C, D) The low-power view shows a follicular proliferative lesion with a fibrous capsule. (E) The high-power view of Fig. 5C reveals focal nuclear atypia. (F) The corresponding image in the surgical specimen more definitely shows the morphological features (e.g., nuclear enlargement, irregularity, clearing, and grooves) of a follicular variant of papillary carcinoma.

• 

  Fig. 6. The core needle biopsy shows a follicular proliferative lesion with nuclear atypia and diffuse strong immunohistochemical staining for galectin 3 and cytokeratin 19 in the tumor cells. Images in the left and right columns show the low magnification and high magnification views, respectively, of the samples.

• 

  Fig. 7. Core needle biopsies of malignant thyroid nodules. (A, B) The biopsy specimen maintains the typical morphological features of papillary carcinoma. Poorly differentiated carcinoma shows solid, trabecular, and insular growth patterns (C) and mitosis (arrow) (D) under the high-power view. The medullary carcinoma shows the typical morphological features under the low-power view (E) and the high-power view (F).

• 

  Fig. 8. Diagnostic pitfalls in thyroid core needle biopsy. Follicular cells are smaller and darker in core needle biopsies in comparison (A) to resected specimens (B). These images have been obtained from the same patient as those pictured in Fig. 6. (C) The core needle biopsy shows the histologic features of a benign follicular nodule. (D) The high-power view of the boxed area in Fig. 8C shows nuclear vacuoles that mimic intranuclear cytoplasmic pseudoinclusions in papillary carcinoma (arrows).

Reference

1. American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper DS, Doherty GM, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009; 19:1167–214.

2. Ali SZ. Thyroid cytopathology: Bethesda and beyond. Acta Cytol. 2011; 55:4–12.

3. Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference. The Bethesda System for Reporting Thyroid Cytopathology. Am J Clin Pathol. 2009; 132:658–65.

4. Lee SH, Kim MH, Bae JS, Lim DJ, Jung SL, Jung CK. Clinical outcomes in patients with non-diagnostic thyroid fine needle aspiration cytology: usefulness of the thyroid core needle biopsy. Ann Surg Oncol. 2014; 21:1870–7.

5. Hahn SY, Shin JH, Han BK, Ko EY, Ko ES. Ultrasonography-guided core needle biopsy for the thyroid nodule: does the procedure hold any benefit for the diagnosis when fine-needle aspiration cytology analysis shows inconclusive results? Br J Radiol. 2013; 86:20130007.

6. Trimboli P, Crescenzi A. Thyroid core needle biopsy: taking stock of the situation. Endocrine. 2015; 48:779–85.

7. Sung JY, Na DG, Kim KS, et al. Diagnostic accuracy of fine-needle aspiration versus core-needle biopsy for the diagnosis of thyroid malignancy in a clinical cohort. Eur Radiol. 2012; 22:1564–72.

8. Na DG, Kim JH, Sung JY, et al. Core-needle biopsy is more useful than repeat fine-needle aspiration in thyroid nodules read as nondiagnostic or atypia of undetermined significance by the Bethesda system for reporting thyroid cytopathology. Thyroid. 2012; 22:468–75.

9. Baek JH, Na DG, Lee JH, et al. Core needle biopsy of thyroid nodules: consensus statement and recommendations. J Korean Soc Ultrasound Med. 2013; 32:95–102.

10. Ha EJ, Baek JH, Lee JH, et al. Core needle biopsy can minimise the non-diagnostic results and need for diagnostic surgery in patients with calcified thyroid nodules. Eur Radiol. 2014; 24:1403–9.

11. Yeon JS, Baek JH, Lim HK, et al. Thyroid nodules with initially nondiagnostic cytologic results: the role of core-needle biopsy. Radiology. 2013; 268:274–80.

12. Trimboli P, Nasrollah N, Guidobaldi L, et al. The use of core needle biopsy as first-line in diagnosis of thyroid nodules reduces false negative and inconclusive data reported by fine-needle aspiration. World J Surg Oncol. 2014; 12:61.

13. Nasrollah N, Trimboli P, Rossi F, et al. Patient’s comfort with and tolerability of thyroid core needle biopsy. Endocrine. 2014; 45:79–83.

14. Baloch ZW, LiVolsi VA. Our approach to follicular-patterned lesions of the thyroid. J Clin Pathol. 2007; 60:244–50.

15. Min HS, Kim JH, Ryoo I, Jung SL, Jung CK. The role of core needle biopsy in the preoperative diagnosis of follicular neoplasm of the thyroid. APMIS. 2014; 122:993–1000.

16. Yassa L, Cibas ES, Benson CB, et al. Long-term assessment of a multidisciplinary approach to thyroid nodule diagnostic evaluation. Cancer. 2007; 111:508–16.

17. Bae JS, Choi SK, Jeon S, et al. Impact of NRAS mutations on the diagnosis of follicular neoplasm of the thyroid. Int J Endocrinol. 2014; 2014:289834.

18. Ustun B, Chhieng D, Van Dyke A, et al. Risk stratification in follicular neoplasm: a cytological assessment using the modified Bethesda classification. Cancer Cytopathol. 2014; 122:536–45.

19. Sillery JC, Reading CC, Charboneau JW, Henrichsen TL, Hay ID, Mandrekar JN. Thyroid follicular carcinoma: sonographic features of 50 cases. AJR Am J Roentgenol. 2010; 194:44–54.

20. Reading CC, Charboneau JW, Hay ID, Sebo TJ. Sonography of thyroid nodules: a “classic pattern” diagnostic approach. Ultrasound Q. 2005; 21:157–65.

21. Crescenzi A, Guidobaldi L, Nasrollah N, et al. Immunohistochemistry for BRAF(V600E) antibody VE1 performed in core needle biopsy samples identifies mutated papillary thyroid cancers. Horm Metab Res. 2014; 46:370–4.

22. Alshenawy HA. Utility of immunohistochemical markers in diagnosis of follicular cell derived thyroid lesions. Pathol Oncol Res. 2014; 20:819–28.

23. El Demellawy D, Nasr AL, Babay S, Alowami S. Diagnostic utility of CD56 immunohistochemistry in papillary carcinoma of the thyroid. Pathol Res Pract. 2009; 205:303–9.