81 year old male comes to see me for a second opinion. He was told he had a tumor of the thyroid called follicular neoplasm. He was told it was a 20 % chance it was cancer. As part of my routine evaluation, I obtained the biopsy material from the hospital. The physician was a general endocrinologist, at one of the top hospital centers in the USA. The smears were very poor. They was air dried artifact resulting in enlarged cells suggesting cancer. There was blood obscuring the cellular detail. Even more disturbing was the presence of Thin Prep material. Thin Prep is for cervical pap smears. They are not useful for thyroid FNA. The Thin Prep material was used to make a diagnosis pushing the endocrinologist to recommend surgery. The ( physician did not know that a thin prep was obtained. The pathologist told me they do it because the smears are commonly poorly done, yielding bloody unreadable material. She stated that the thin prep, made by washing the needle into a solution, is a fall back to try to save the case from an inadequate result. I told her she needed to get all her referral physicians to make better smears, rather than using another poor method. I repeated the FNA with smears only, with good technique, and the result was a benign thyroid nodule. This 81 year old did not need a surgery, with it's increase risks for hospital complications.
What should the endocrinologist do about the poor material he gets ?
They need to use the cytology version of the old real estate saw,"location,location,location", and substitute "smears,smears,smears".
( This was a quote from John Abele MD, expert thyroid cytologist )
What does the pathologist do?
They need to be up to date, and not use incorrect methods to correct a problem only solved by workshops on smearing technique.
What to do as a patient?
Always get another opinion on your thyroid FNA. There are many pitfalls in doing the FNA, making smears, and assuring that the material is properly handled by the pathology people. Finally reading thyroid smears is one of the hardest jobs for a pathologist. When told you need surgery, and before you see a surgeon, get the slides reviewed by an expert, during a second opinion visit to a clinical thyroidologist. Try www.thyroidologists for one of our members, or come to see me.
Until the next thyroid rounds,
Dr.G.
