title: Management of nodules with initially nondiagnostic results of thyroid fine-needle aspiration: can we avoid repeat biopsy?
abstract: OBJECTIVE
  To identify demographic and ultrasonographic (US) features associated with malignancy after initially nondiagnostic results of fine-needle aspiration (FNA) to help clarify the role of repeat FNA, surgical excision, or serial US in these nodules.
  
  
  METHODS
  This study was HIPAA compliant and institutional review board approved; informed consent was waived. Thyroid nodules (n = 5349) that underwent US-guided FNA in 2004-2012 were identified; 393 were single nodules with nondiagnostic FNA results but adequate cytologic, surgical, or US follow-up. Demographic information and diameters and volume at US at first biopsy were modeled with malignancy as outcome through medical record review. Exact logistic regression was used to model malignancy outcomes, demographic comparisons with age were made (Student t test, Satterthwaite test), and proportion confidence intervals (CIs) were estimated (Clopper-Pearson method).
  
  
  RESULTS
  Of 393 nodules with initially nondiagnostic results, nine malignancies (2.3%) were subsequently diagnosed with repeat FNA (n = 2, 0.5%) or surgical pathologic examination (n = 7, 1.8%), 330 (84.0%) were benign, and 54 (13.7%) were stable or decreased in size at serial US (mean follow-up, 3.0 years; median, 2.5 years; range, 1.0-7.8 years). Patients with malignancies were significantly older (mean age, 62.7 years; median, 64 years; range, 47-77 years) than those without (mean age, 55.4 years; median, 57 years; range, 12-94 years; P = .0392). Odds of malignancy were 4.2 times higher for men versus women (P = .045) and increased significantly for each 1-cm increase in anteroposterior, minimum, and mean nodule diameter (1.78, 2.10, and 1.96, respectively). In 393 nodules, no malignancies were detected in cystic or spongiform nodules (both, n = 11, 2.8%; 95% CI: 1.4%, 5.0%), nodules with eggshell calcifications (n = 9, 2.3%; 95% CI: 1.1%, 4.3%), or indeterminate echogenic foci (n = 39, 9.9%; 95% CI: 7.2%, 13.3%).
  
  
  CONCLUSIONS
  Very few malignancies were diagnosed with repeat FNA following nondiagnostic FNA results (two of 336, 0.6%); therefore, clinical and US follow-up may be more appropriate than repeat FNA following nondiagnostic biopsy results.
authors.affiliation: From the Department of Diagnostic Imaging (T.J.T.A., M.K.A., D.J.G., J.J.C., M.D.B.) and Lifespan Biostatistics Core (G.L.B.), Rhode Island Hospital, 593 Eddy St, Providence, RI 02903.
authors.forename: Thomas J T
authors.initials: TJ
authors.lastname: Anderson
authors.forename: Michael K
authors.initials: MK
authors.lastname: Atalay
authors.forename: David J
authors.initials: DJ
authors.lastname: Grand
authors.forename: Grayson L
authors.initials: GL
authors.lastname: Baird
authors.forename: John J
authors.initials: JJ
authors.lastname: Cronan
authors.forename: Michael D
authors.initials: MD
authors.lastname: Beland
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D061765:Endoscopic Ultrasound-Guided Fine Needle Aspiration / Q000379:methods*; D005188:False Negative Reactions; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D016606:Thyroid Nodule / Q000000981:diagnostic imaging* / Q000473:pathology*; D019564:Unnecessary Procedures; D055815:Young Adult