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One of our facilities keeps using locum radiologists and quite a few of them are doing core biopsies of the thyroid over FNA. Anyone have experience with this?
Thyroid Core bx instead of FNA
- Thread starter WEBB PINKERTON
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Annoyingly yes...if i can't get a dx (like obvious PTC) i put a snarky comment about needing aspirate smears...eventually the clinicians will catch on and put their feet down if the locums people won't listen.
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Thyroid is probably the number one organ to do an FNA instead of a biopsy.
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Usually only do core bx of thyroid when patient is a repeat biopsy due to first biopsy having inadequate cellularity AND rapid eval on the second FNA biopsy is also inadequate cellularity. We do a touch imprint of the core so there is still cytology slide to evaluate for nuclear features of papillary. Core biopsy is not ever the upfront way to evaluate thyroid.
How many of you totally despise thyroid FNA?! I am one, predominately due to inadequate sampling and secondarily because of follicular processes that are difficult to define. I feel like the evolution of thyroid cytology is now inappropriately the generally accepted means to either "lobectomy versus watchful waiting", which I believe is only appropriate in capable and confident hands. Needless to say, anything that crosses my desk that I'm uncomfortable with gets a very quick "CONSULT" stamp.
Thinking about it, Bethesda says that about 20% of category IV follicular lesions are neoplastic, which require lobectomy to adequately assess. Something about that other 80% of folk with only half of their thyroids left makes me uneasy.
Thinking about it, Bethesda says that about 20% of category IV follicular lesions are neoplastic, which require lobectomy to adequately assess. Something about that other 80% of folk with only half of their thyroids left makes me uneasy.
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Less of a problem now with ThyroSeq & Afirma. Do what you can with what you have, but don't step out on the limb too much (there was a recent lawsuit in Chicago area).
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I don't see anything in the literature about doing core biopsies up front yet they insist on it. Looks like it is common in South Korea.
There are definitely lot of crutches now with thyroid FNA. Just call it FLUS and send it off to Veracyt or whomever.
Think about how much money is now spent on investigating thyroid nodules now.
There are definitely lot of crutches now with thyroid FNA. Just call it FLUS and send it off to Veracyt or whomever.
Think about how much money is now spent on investigating thyroid nodules now.
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we do a fair amount of molecular, essentially any atypical FNA, particularly at request of clinicians...I don't mind them aside from the 20+ slide or bilateral nodules.
There are clinical & therapeutic (eg. size) criteria as well, and we're not necessarily involved in those discussions, which may have more of a bearing on surgical decisions than your diagnosis (unless malignancy)...
But in terms of calling "b9" on a core, I've found it hard to definitively establish adenoma vs adenomtoid hyperplasia (or for that matter foll Ca) on a core.
There are clinical & therapeutic (eg. size) criteria as well, and we're not necessarily involved in those discussions, which may have more of a bearing on surgical decisions than your diagnosis (unless malignancy)...
But in terms of calling "b9" on a core, I've found it hard to definitively establish adenoma vs adenomtoid hyperplasia (or for that matter foll Ca) on a core.
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I got to get these guys to quit doing cores. I am afraid some docs will get mad at some point and quit sending patients to these radiologists.
Don't need any more cytopathology specimens to get replaced. Cytopath is already on it's death bed. Without Thyroid FNA, what exactly is left? If you learn on lesson from this website, seriously think hard before going into cytopath.
Don't need any more cytopathology specimens to get replaced. Cytopath is already on it's death bed. Without Thyroid FNA, what exactly is left? If you learn on lesson from this website, seriously think hard before going into cytopath.
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Thyroid FNAs get easier after you spend more than 5 years doing them.
I have seen one thyroid core biopsy in the last 8 years, it was for a LARGE mass.
Personally, I have a bias against doing pure cytopath. I think cytopath should be integrated into general practice particularly with lung, GYN, and GU specimens.
I have seen one thyroid core biopsy in the last 8 years, it was for a LARGE mass.
Personally, I have a bias against doing pure cytopath. I think cytopath should be integrated into general practice particularly with lung, GYN, and GU specimens.
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We get frequent biopsies of thyroid nodules, I don't feel the radiologists are comfortable with FNA. They get mad when I say its non-diagnostic (skeletal m. common), but oh well. Problem is I don't think you can do Afirma testing on cores, need aspirate.
Hey Webb,
What's the issue with cytopath being on its deathbed? I'm considering doing a cytopath fellowship and there seems to be a lot of demand for cytopath fellowship trained folks now in the job market.
My friend working at Quest also mentioned the same thing (how marketable a cytopath fellowship is).
I've seen you post about negatively about cytopath (also LADoc mentioned the same as well I believe) but the demand in the marketplace is very good. So I'm confused.
What's the issue with cytopath being on its deathbed? I'm considering doing a cytopath fellowship and there seems to be a lot of demand for cytopath fellowship trained folks now in the job market.
My friend working at Quest also mentioned the same thing (how marketable a cytopath fellowship is).
I've seen you post about negatively about cytopath (also LADoc mentioned the same as well I believe) but the demand in the marketplace is very good. So I'm confused.
GYN is going away with more HPV only screening.
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I seriously would not do a cytopath fellowship. There is more going on in cytopath besides the death of gyn cytology. The future of FNA looks very uncertain to me. Our FNA volumes have plummeted over the years. Cores are replacing FNA. All you will see in real life are mediastinal lymph nodes, thyroid and some other sporadic sites. If they call you to come access the core, you look at one or two and throw them into formalin for histology.
There is NO demand in my neck of the woods for cytopath.
Two of the top 4 things pathologists are sued for are cytopath as well according to an article I read. It is a risky field that doesn't pay well. The time commitment for procedures in endoscopy is large and the reimbursement is not good. You are expected to perform magic off of paucicellular specimens. I saw a false positive cytology specimen lead to someone dying where I trained.
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deleted314957
They were disappearing 5years ago, and good riddance.
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What do you mean by this? There is no corresponding FNA smear to assess, they just want you to look at the core bx tissue fragments to confirm they are there, or do you actually make a TOUCH prep from the core bx?
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I don't do cyto, but I'm fairly certain our cyto guys are expected to make touch preps of the cores for a rapid assessment and evaluate for adequacy.
I think WEBB is spot on here. I think the walls are slowly closing in on cytopath. This subspecialty is at higher risk for becoming marginalized.
We know what is happening to Paps. You have a situation in which the Pap coexists with a competing test that eventually will take over and to a large degree replace it. I predicted this when I was starting out my career when the landmark article was published which stated that HPV testing was more sensitive and less specific than the Pap at catching high grade dysplasia/cancer. The cytopaths were in a furor but the truth is that this is what you want in a screening test. Furthermore, this drives up colpos which puts more money in the pockets of obgyns...so they are not going to be allied with cytopaths in defending the Pap.
We see other situations in which the cytopath interpretation can be called into question due to competing tests...bile duct brushing FISH and thyroid molecular testing. In the next ten years, I suspect that the landscape in cytopath when it comes down to this will be much evolved than today especially with thyroid FNAs which has become the new Pap smear in terms of volume. The only way this gets curbed is if one day it is exposed that thyroid FNA is not cost effective. Either way, cytopath loses.
With molecular testing, FNAs are shifting more to core biopsies. The only way cytopath wins is if cores are owned by cytopath and there is a paradigm shift in thought— that core biopsies are the new FNA. But in academic places and super specialized places this is a political battle between surg path and cytopath and I have heard of ugly battles that have swung both ways depending on the institution. Cytopath can keep cores though by having touch preps made since noncytopaths hate looking at smears.
This is a watershed moment for cytopath. I’m not a gambler and I don’t have faith that cytopath will win so it is in your best interest not to focus solely or mostly on cytopath as your practice.
We know what is happening to Paps. You have a situation in which the Pap coexists with a competing test that eventually will take over and to a large degree replace it. I predicted this when I was starting out my career when the landmark article was published which stated that HPV testing was more sensitive and less specific than the Pap at catching high grade dysplasia/cancer. The cytopaths were in a furor but the truth is that this is what you want in a screening test. Furthermore, this drives up colpos which puts more money in the pockets of obgyns...so they are not going to be allied with cytopaths in defending the Pap.
We see other situations in which the cytopath interpretation can be called into question due to competing tests...bile duct brushing FISH and thyroid molecular testing. In the next ten years, I suspect that the landscape in cytopath when it comes down to this will be much evolved than today especially with thyroid FNAs which has become the new Pap smear in terms of volume. The only way this gets curbed is if one day it is exposed that thyroid FNA is not cost effective. Either way, cytopath loses.
With molecular testing, FNAs are shifting more to core biopsies. The only way cytopath wins is if cores are owned by cytopath and there is a paradigm shift in thought— that core biopsies are the new FNA. But in academic places and super specialized places this is a political battle between surg path and cytopath and I have heard of ugly battles that have swung both ways depending on the institution. Cytopath can keep cores though by having touch preps made since noncytopaths hate looking at smears.
This is a watershed moment for cytopath. I’m not a gambler and I don’t have faith that cytopath will win so it is in your best interest not to focus solely or mostly on cytopath as your practice.
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Co-testing is what cervical cancer screening is going forward. I don't see HPV totally replacing morphology screening because tissue is such a horrible gold standard. You need that Pap to correlate with the tissue. Just think about all the HPV positive, negative biopsy cases you would have that are harboring a significant lesion. It is vital to be able to refer back to the Pap test to correlate. Physicians can client bill both specimens (in most states) so they will be more than happy to collect both. They will be on the side of co-testing.
Anyone should be able to handle looking at the occasional touch prep of a core or fna without doing a fellowship in cytopathology.
If Thyroid FNA is the "new" Pap, guess what you have a crutch with molecular testing. Got a tough case call it FLUS and send it off. There will be many crutches to use that even the playing field.
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What I am seeing is recent grads without cyto training becoming less and less comfortable doing cytology and more larger groups limiting cytology to only those with cyto boards. No doubt Pap volumes will continue to decline and/or primary screening with HPV testing with triage to Pap could become the norm, but this decrease in overall cyto volume will likely be more than offset by the trend toward limiting cytology to cyto boarded pathologists.
I can count on one hand the number of times our group has needed outside consultation on a cytology specimen. And we have ZERO cytology fellows. Stains, molecular, or rebiopsy/excise are all in play. We send out about 1-2% surgical cases and have various subspecialty fellowships.
Cytology fellowship == BIG WASTE
Cytology fellowship == BIG WASTE
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Thrombus, I was hoping you would say "FLEE CYTOPATHOLOGY NOW!".
When you do send out a tough cytology case, they call it some ambiguous diagnosis and recommend rebiopsy anyways. You can do that on your own. The best and brightest of cytopathology are NO better than old community pathologist guy or gal.
When you do send out a tough cytology case, they call it some ambiguous diagnosis and recommend rebiopsy anyways. You can do that on your own. The best and brightest of cytopathology are NO better than old community pathologist guy or gal.
Correct. All the cases I have sent out are because the clinician has asked. Comes right back with more ambiguity. Their guess is as good as mine. Anyone training a resident who cannot competently sign out cytology should lose their program!
Then use all 4 years to get good. Don’t blame others for lack of initiative!
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During residency my attendings always encouraged me to do touches on my frozens as a way to see more cytology. I think that worked pretty well.
