Management of Nodules with Initially Nondiagnostic Results of Thyroid Fine-Needle Aspiration: Can We Avoid Repeat Biopsy?

This retrospective review of followup results from patients with non-diagnostic ultrasound guided thyroid biopsy. Of the 393 nodules with non-diagnostic initial result, only 9 were subsequently diagnosed with malignancy with either repeat FNA or surgical excision, and a very low percentage (2/336) had a malignancy diagnosed on repeat sampling. As such the authors propose ultrasound followup in lieu of repeat biopsy.

They further identify higher risk features including size, male gender and increased age.

While the study is limited as it is a retrospective sampling, it does provide some evidence to guide management of a frequent clinical conundrum in the setting of a non-diagnostic FNA.

PICO Analysis:
Population: Patients with initial negative US guided FNA
Intervention: Repeat FNA
Comparison: Followup US
Outcome: Prevalence of missed malignancy

 Reference: Pubmed Full Text

Advanced-stage Hodgkin Lymphoma: US/Chest Radiography for Detection of Relapse in Patients in First Complete Remission—A Randomized Trial of Routine Surveillance Imaging Procedures

This intriguing study looks at alternatives to PET/CT and CT for followup of Hodgkin lymphoma. The study prospectively enrolled 300 patients into either F18 PET/CT or US + CXR at specified intervals. The US/CXR arm had higher specificity than PET/CT (96% vs 86%), and both arms had similar sensitivity (97.5% vs 100%).
This is an intriguing approach to reduce radiation dose (14.5 mSv per PET/CT vs 0.1 mSv per CXR) in this population who have a high baseline risk of second malignancy (as documented in this study, ~5% 5yr risk of secondary malignancy with no difference between the two arms). Further benefit is the reduced cost of the US/CXR approach, which in Italy was estimated at €1071 per PET/CT vs €103 per US/CXR. There were also lower secondary costs and fewer invasive procedures (eg mediastinoscopy) in the US/CXR arm.
The main limitation is the technical feasibility of performing US screening, in the study this was all done by one 'expert' radiologist, and its extension to other practices may be challenging but is worth considering.

PICO Analysis:
Population: advanced stage Hodgkin Lymphoma
Intervention: US + CXR f/u post initial tx
Comparison: PET/CT f/u post initial tx
Outcome: Sensitivity & specificity for relapse, time to recurrence and cost

Reference: Pubmed Full Text

Diagnostic accuracy and patient acceptance of MRI in children with suspected appendicitis

This prospective study compares 3 strategies for imaging suspected appendicitis. Ultrasound alone, US+conditional MRI and MRI alone. The sensitivity of MRI alone and US + conditional MRI was 100%, ultrasound alone was found to be significantly lower at 76%.
The specificity was found to be comparable among the three investigated strategies; MRI alone 89%, US + conditional MRI 80% and US alone 89%.

The study on a technical basis is quite good, with patients enrolled consecutively and prospectively. Surgical diagnosis or 3mo followup including contact of all patients primary physician was used for clinical followup. While no flowchart is provided in the text documenting the different arms it appears none were lost to followup and all 'positive' cases did proceed to surgery. The study population had a relatively high prevalence of appendicitis at 56%.

Limitations are that the US was performed by radiology residents, and the surgical management is not clear for all cases which makes assessment of the applicability of these results to different practices (such as in Canada or US) somewhat challenging, and may explain the relatively low sensitivity of US alone despite relatively high subjective quality evaluation of the US studies.

PICO Analysis:
Population: pediatric patients 4-18yo (mean 12yo)
Intervention: US alone, MRI alone or US + conditional MRI
Comparison: Surgical dx or 3mo clinical followup
Outcome: Sensitivity and Specificity

Reference: Pubmed Full Text

Thyroid Cancers Incidentally Detected at Imaging in a 10-year Period: How Many Cancers Would Be Missed with Use of the Recommendations from the Society of Radiologists in Ultrasound?

A large retrospective review of 2090 patients with thyroidectomy and comparison with the ultrasound findings. This confirms a low proportion of false negative results when the SRU guidelines are applied to thyroid ultrasounds. Furthermore the 'missed' cancers tended to be of lower grade than those that met the SRU guidelines.

PICO Analysis:
Population: 2090 patients with full or hemi-thyroidectomy
Intervention: thyroid ultrasound by SRU guidelines
Comparison: pathology
Outcome: False negative rate

Reference: Pubmed Full Text
Link: SRU Conference Statement (Radiology, 2005)