Thyroid Biopsy: Fine-Needle Aspiration for Multinodular Goiter

CHAPTER 1

I am Dr. Ayse Sahin-Efe. I am the medical director of the thyroid biopsy clinic at Newton-Wellesley Hospital, which is part of the Mass General Brigham System. Here, we are running a multidisciplinary clinic with multiple endocrinologists and thyroid and neck surgeons. We perform over 300 biopsies a year. Thyroid fine-needle aspirations are office procedures that are performed under local anesthesia. Certain patient populations may require an anxiolytic medication or less commonly a conscious sedation. After obtaining the written consent form, the patient is placed in supine or semi-sitting position with a slight neck extension. Nodule location and characteristics are confirmed. Biopsy site is marked by the ultrasound. Skin is cleaned with an antiseptic solution and 2% lidocaine is applied. We use a 25-gauge, 1.5-inch needles with a 10-mL syringe. Plunger is pulled to 2 mL to provide gentle negative pressure without pulling back. Alternatively, capillary method, non-aspiration technique without an attached syringe could also be used. Minimal amount of ultrasound gel should be applied as it could clog the needle. Either perpendicular or parallel technique can be utilized. Only tip of the needle can be seen by the perpendicular technique, whereas the whole needle shaft can be seen with the parallel technique. During this biopsy, I use the perpendicular technique. Once the needle tip is visible on the screen, I do move it back and forth while rotating it. For each pass, the needle should stay roughly two to five seconds within the nodule. We typically perform three to four passes. The passes should attempt to sample different areas of the nodule. After skirting the sample on the slide, needle is rinsed in CytoLyt solution. An additional test is performed for molecular testing. Molecular sample is analyzed only if the cytology comes back in Bethesda category three and four. We have on-site cytology team who provides immediate feedback regarding the sample adequacy. After applying gentle pressure, aspiration site is covered with a Band-Aid. Ice pack is applied for five minutes. Then patients can leave the clinic.

CHAPTER 2

So this is just the alcohol pads. Cleanup.

CHAPTER 3

So that's the gel, but that's a sterile gel. So I'm just gonna mark it with a surgical pen. You can just wash it off tomorrow if you see a blue mark. Okay.

CHAPTER 4

So the lidocaine is a tiny needle, but it could burn a little bit like a bee thing, okay? But keep breathing through your nose, nice and easy. That's the needle. That's medicine. Okay, you're doing great. Now going in a little deeper. Okay. So done with the numbing part. You're doing okay? Mhm.

CHAPTER 5

That's the plastic cap to find the area. Okay. That's the needle. Keep breathing through your nose, nice and easy. Doing okay? Yeah. Thank you. That's again the plastic. That's the needle. Keep breathing through your nose, nice and easy. They have two groups of follicular cells in the first one. Thank you. Okay. That's the needle. Okay, we have follicular cells again. Okay. We're getting close to adequate. Okay.

CHAPTER 6

So we have some cells, but not quite adequate yet, okay? That's the needle. Just breathe through your nose, nice and easy. It's not bleeding, I don't - I'm putting pressure to minimize bruising, okay? Thank you. More follicular cells. I think one more will probably do it. Have you done the Afirma yet? No. Okay. That's the needle. So I'm gonna get the Afirma now.

CHAPTER 7

So this is gonna be the last one for the molecular testing. Okay? It's the same as the previous ones. I'll just put it in a different tube. That's the needle. Bloody probably on the last one, but I think we've got enough. I think we're good. Okay.

CHAPTER 8

Okay, we are done. I'll hold pressure for a minute and then we'll put a Band-Aid on. Okay. You take the Band-Aid off in about an hour. Okay. Okay. So sit up slowly. All right. Okay. Sit at the edge 'cause you may feel a bit dizzy. Okay? Yep. Yep. Just make sure that you're not getting dizzy. So then, you're gonna keep the ice pack for five minutes and then you're all set. Okay.

CHAPTER 9

So patients come in with a radiology report to here. Oftentimes, I do my own ultrasound and may biopsy a different nodule than what was recommended by the radiology. So radiology recommended two biopsies on the left side. But on my ultrasound assessment I found there are two nodules, which are very close to each other and they look exactly similar. So I'm going to biopsy only one of them. During the biopsy, we got five aspirations because a few of them didn't show enough cells. So we had to do maybe one or more passes than our usual biopsies today. So the nodules could be very solid. They may have lots of cells or they may have lots of small fluid pockets, which are made up of the colloid, the normal thyroid tissue fluid. So when the nodule doesn't have a ton of cells, the pathology team may not be able to count the six groups of cells that they need to generate an official report. So we had to keep doing extra passes till they gave us okay with a diagnostic sample. So we use very small needles, 25-gauge needles. I rarely use a 22-gauge needle - if, you know, if you're not getting enough cells after multiple passes. But with the thyroid biopsies, we absolutely don't wanna cause a lot of bleeding 'cause having too much blood also will make it difficult to see the thyroid cells. So patients often are able to go back to their usual life. No restrictions in their activity. I just tell them to avoid heavy lifting for 24 hours. Otherwise, no restrictions in activities. Occasionally, patients may develop like a small hematoma. It didn't happen today, but if I notice that they're developing a hematoma in the neck, then I may keep them here in the office for a couple more minutes, up to half an hour, to observe and maybe repeat a quick office ultrasound before they leave. But it's very, very rare. And if they get any bruising or small swelling, I reassure them it's gonna go away in five to seven days. And we do this procedure in people who are taking anticoagulants or blood thinners because we are are using a 25-gauge needle. But the practitioners should definitely check the medication list to make sure there are no blood thinners or anticoagulants, especially if they're not comfortable with, you know, doing this procedure with blood thinning medications.