Thyroid mass - Large Biopsy 3-6 cm

Biopsy

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FNAC/biopsy for histopathology.

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Thyroid Mass - Large Biopsy 3-6 cm

Why is it done?
- To obtain tissue samples from thyroid nodules measuring 3-6 cm in diameter for cytopathological and histopathological examination
- To determine the nature of the thyroid mass (benign vs malignant) and exclude thyroid cancer
- To guide clinical management decisions regarding the need for surgical intervention or conservative management
- Indicated when ultrasound or other imaging shows thyroid nodules with suspicious features (irregular margins, hypoechogenicity, microcalcifications, lymph node involvement)
- Performed when previous fine needle aspiration (FNA) biopsy is non-diagnostic, inconclusive, or shows atypia of undetermined significance (AUS)
- Obtained in patients with rapidly enlarging nodules, compressive symptoms, or clinical concern for malignancy
Normal Range
- Normal/Negative Result: Benign thyroid tissue with no evidence of malignancy, typically showing colloid nodule, adenoma, or non-neoplastic findings
- Bethesda System for Reporting Thyroid Cytopathology (BSRTC) Classification applies: Category I (Non-diagnostic/Unsatisfactory)
- Category II (Benign) - Colloid nodule, hyperplastic nodule, thyroiditis, adenoma; Malignancy risk: 0-3%
- Category III (Atypia of Undetermined Significance/AUS) - Abnormal cells but unclear significance; Malignancy risk: 10-30%
- Category IV (Follicular Neoplasm/Suspicious for Follicular Neoplasm) - Follicular pattern present; Malignancy risk: 25-40%
- Category V (Suspicious for Malignancy) - Features suggestive of cancer; Malignancy risk: 50-75%
- Category VI (Malignant) - Definite thyroid cancer; Malignancy risk: >99%
Interpretation
- Benign findings (Category II): Generally require clinical follow-up with ultrasound at 12 months. Annual ultrasound surveillance if stable. No surgical intervention typically needed unless compressive symptoms present.
- AUS (Category III): Intermediate category with uncertain malignancy risk. May require repeat biopsy, molecular testing (ThyroSeq, Afirma), or clinical correlation. Consider patient age, gender, and nodule characteristics.
- Follicular Neoplasm (Category IV): Cannot distinguish benign from malignant follicular lesions histologically. Typically requires thyroid lobectomy or hemithyroidectomy for definitive diagnosis (frozen section) and treatment.
- Suspicious for Malignancy (Category V): High probability of cancer. Typically warrants total thyroidectomy or lobectomy depending on extent and patient factors. Lymph node assessment and staging may be indicated.
- Malignant (Category VI): Confirmatory cancer diagnosis. Requires multidisciplinary team evaluation for surgical extent (total thyroidectomy typically), radioactive iodine therapy, hormone suppression therapy, and long-term surveillance.
- Specific cancer types identified may include: papillary thyroid carcinoma (PTC), follicular thyroid carcinoma (FTC), medullary thyroid carcinoma (MTC), anaplastic thyroid carcinoma (ATC), primary thyroid lymphoma, or metastatic disease.
- Factors affecting interpretation: Specimen adequacy, background cellularity, presence of colloid, architectural patterns, nuclear characteristics, mitotic activity, and specimen size all influence diagnostic accuracy.
Associated Organs
- Primary Organ: Thyroid gland - Located in anterior neck, produces thyroid hormones (T3, T4) regulating metabolism
- Regional Lymph Nodes: Central compartment (level VI), lateral cervical nodes, and upper mediastinal nodes may be affected by thyroid cancer metastasis
- Adjacent Structures at Risk: Recurrent laryngeal nerve, superior laryngeal nerve, trachea, esophagus, carotid artery
- Diseases/Conditions Associated with Abnormal Results: Papillary thyroid carcinoma (most common, 80-85% of cases), follicular thyroid carcinoma, medullary thyroid carcinoma, anaplastic thyroid carcinoma, primary thyroid lymphoma, squamous cell carcinoma, sarcoma
- Non-malignant findings may include: Nodular goiter, thyroid adenoma, benign follicular nodule, Graves' disease, Hashimoto's thyroiditis, thyroid cysts
- Potential Complications from Malignancy: Local invasion into surrounding structures, regional lymph node metastasis, distant metastasis (lung, bone, brain), vocal cord paralysis, dysphagia, dyspnea, superior vena cava syndrome
- Biopsy Procedure Risks: Bleeding (hematoma), infection, recurrent laryngeal nerve injury, vocal cord dysfunction, esophageal or tracheal perforation (rare with ultrasound guidance), vasovagal response
Follow-up Tests
- Thyroid Ultrasound: Baseline study for all patients with benign findings; follow-up at 6-12 months to assess nodule stability and survey contralateral lobe and cervical lymph nodes
- Molecular Testing (if Category III/IV): ThyroSeq Next-Generation Sequencing panel, Afirma Gene Expression Classifier, or other gene mutation analysis to refine malignancy risk stratification
- Thyroid Function Tests (TSH, Free T4): Assess thyroid function status preoperatively and postoperatively if thyroidectomy performed
- Serum Thyroglobulin (if malignancy): Baseline preoperatively; used for postoperative surveillance and detection of recurrence
- Calcitonin Level (if medullary carcinoma suspected): Screen for medullary thyroid carcinoma and familial medullary thyroid cancer syndrome; may require genetic testing (RET gene mutation)
- CT or MRI of Neck/Chest: If malignancy diagnosed to assess for local extension, lymph node involvement, or distant metastasis
- PET-CT Scan: For staging aggressive cancers (anaplastic, lymphoma) or if distant metastasis suspected
- Radioiodine Scan (if differentiated thyroid cancer): Performed after thyroidectomy and thyroid hormone withdrawal or recombinant TSH stimulation to detect radioiodine-avid metastatic disease
- Repeat Biopsy: If initial specimen non-diagnostic (Category I), consider repeat core biopsy or surgical biopsy for definitive diagnosis
- Monitoring Schedule: Benign findings - annual ultrasound for 1-2 years then as needed; Malignancy - TSH suppression therapy, thyroglobulin monitoring every 3-6 months initially, then annually for years; physical examination and imaging per tumor stage
Fasting Required?
- No fasting required for the biopsy procedure itself
- If local anesthesia planned: Fasting not required; patient may eat normally before procedure
- If sedation or general anesthesia planned: Follow standard NPO (nothing by mouth) guidelines - typically nothing to eat/drink after midnight or 6-8 hours before procedure
- Medications:
- Continue regular medications unless instructed otherwise by physician
- Anticoagulants (warfarin, aspirin, clopidogrel): Discuss with physician; may need to discontinue 3-5 days before procedure or manage INR levels
- NSAIDs (ibuprofen, naproxen): Generally avoid for 5-7 days before procedure to reduce bleeding risk
- Herbal supplements (ginkgo, ginseng, garlic): Discontinue 7-10 days before procedure to reduce bleeding risk
- Patient Preparation:
- Wear comfortable, loose-fitting clothing with easy access to neck
- Remove jewelry, necklaces, and metal objects from neck area
- Arrive 15 minutes early to complete paperwork and informed consent
- Inform provider of allergies (especially iodine or anesthetics) and bleeding disorders
- Arrange for transportation if sedation will be used; do not drive immediately after procedure
- Post-procedure: Apply ice pack for 15-20 minutes to reduce swelling; rest neck muscles; avoid strenuous activity for 24 hours; monitor for signs of bleeding, infection, or difficulty swallowing

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