World J. Surg. 22, 575–580, 1998
WOR L D
Journal of
SURGERY
© 1998 by the Socie´te´
Internationale de Chirurgie
Role of Fine-needle Aspiration Biopsy and Frozen Section Examination in
Determining the Extent of Thyroidectomy
Jaap F. Hamming, M.D., Ph.D.,
1
Menno R. Vriens, M.D.,
2
Bernard M. Goslings, M.D., Ph.D.,
3
Ilfet Songun, M.D.,
1
Gert J. Fleuren, M.D., Ph.D.,
2
Cornelius J.H. van de Velde, M.D., Ph.D.
1
1
Department of Surgery, University Hospital Leiden, PO Box 9600, 2300 Leiden, The Netherlands
2
Department of Pathology, University Hospital Leiden, PO Box 9600, 2300 Leiden, The Netherlands
3
Department of Endocrinology, University Hospital Leiden, PO Box 9600, 2300 RC Leiden, The Netherlands
Abstract. Traditionally the extent of thyroidectomy in patients with
nodular thyroid disease has been based on peroperative frozen section
examination (FS). Fine-needle aspiration biopsy (FNAB) and FS were
evaluated with regard to the reliability to determine whether an operation
for cancer is necessary. Both methods were performed in 240 patients
operated for nodular thyroid disease and compared with the final
histology on paraffin sections. Altogether 72 (30%) patients were found to
have a malignant lesion on final histology. Only a malignant FNAB
diagnosis and a malignant FS diagnosis were considered positive results
for determining the extent of thyroidectomy. The test characteristics were
equal: the sensitivity of FNAB and FS was 67%, the specificity 99%, and
the accuracy 89%. The positive predictive value was 96% for FNAB and
98% for FS; the negative predictive values were 88% and 87%, respectively.
Further analysis of the results indicates that FS is not necessary for
patients with a malignant FNAB result. These patients should undergo a
therapeutic operation for malignancy. When the FNAB result is uncer-
tain, patients should undergo diagnostic surgery, and definitive surgery
should be based on the final histology. Routine use of FS can be omitted.
The incidence of cancer in patients operated for nodular thyroid
disease varies widely, ranging from less than 10% to more than
30% depending on the selection methods of patients for surgery
[1–4]. Fine-needle aspiration biopsy (FNAB) has proved useful
for preoperative evaluation of patients with nodular thyroid
disease and selecting patients for surgical exploration to exclude
malignancy [5–12]. The use of FNAB has reduced the number of
unnecessary diagnostic explorations by 50% or more [6, 10,
13–15], compared to the use of conventional selection methods
(e.g., clinical examination, scintigraphy, ultrasonography). These
methods are not sufficiently specific for selecting patients for
surgery [12]. In our institution FNAB plays an important role in
selecting patients for surgery, and our experience was reported
elsewhere [16, 17].
Usually the extent of thyroidectomy is determined during
surgery based on the frozen section examination (FS). If a
malignant lesion is confirmed by FS, a therapeutic operation for
thyroid cancer (mostly total thyroidectomy) can be performed at
the same session. The pathologist is not always able to give the
surgeon a definite diagnosis on the basis of FS [1, 18–20],
however, and a second operation is sometimes necessary when a
malignant lesion is found on final histologic examination of
paraffin sections. To avoid unnecessary two-stage operations,
some surgeons tend to disregard the peroperative FS results if the
FNAB is positive for malignancy [19, 20].
The results of FNAB and FS in patients operated for nodular
thyroid disease were evaluated in the present study and were
compared to assess the accuracy of these methods when applied to
the identification of patients with a malignant thyroid lesion and
determination of the extent of the operation. The role of these
diagnostic tools in the current operative management of patients
with nodular thyroid disease is discussed.
Materials and Methods
Patients
Since April 1977 FNAB has been used for preoperative evaluation
of patients with nodular thyroid disease at the Leiden University
Hospital, and up to July 1997 a total of 2164 FNABs had been
performed. During this period 240 patients operated for nodular
thyroid disease had an evaluable FNAB and peroperative FS. The
results were compared with the final histologic examination of
paraffin sections, which served as the gold standard. There were
179 females and 61 men (ratio 3:1) with a mean age of 58 years
(range 14–81 years).
Fine-Needle Aspiration Biopsy
The aspirations were performed with a 21-gauge needle without
local anesthesia by the endocrinologist or cytopathologist. The
smears were air-dried, fixed in methanol, and stained with Gi-
emsa. All smears were evaluated at the Department of Pathology,
This International Association of Endocrine Surgeons (IAES) article
was presented at the 37th World Congress of Surgery International
Surgical Week (ISW97), Acapulco, Mexico, August 24–30, 1997.
Correspondence to: J.F. Hamming, M.D., Ph.D., Department of Surgery,
Elisabeth Hospital, PO Box 90151, 5000 LC Tilburg, The Netherlands