Psammoma bodies in fine needle aspirate of the thyroid in lymphocytic thyroiditis

Psammoma bodies are concentric, laminated microcalcifications that are regarded as nearly specific markers in the thyroid gland for the presence of papillary carcinoma. While psammoma bodies have been seen rarely in some benign thyroid diseases, there appear to be no reports of psammoma body formation in lymphocytic or Hashimoto's thyroiditis. We report a case of Hashimoto's thyroiditis in which psammoma bodies were identified in a fine needle aspiration specimen of the thyroid and in histologic sections of the right thyroid lobectomy; papillary carcinoma was not found in either specimen. We conclude that psammoma bodies may be seen in any benign process, such as nodular goiter or lymphocytic thyroiditis, that produces reactive papillary hyperplasia of thyroid epithelium, as well as in papillary carcinoma. However, the finding of psammoma bodies in a fine needle aspirate without corroborating cytologic evidence of papillary cancer is still an indication for surgical removal of the thyroid nodule since these structures are reliable markers for occult papillary carcinoma of the thyroid, despite the rarity of their formation in benign diseases.     

Atypical epithelial cells, cannot exclude papillary carcinoma, in fine needle aspiration of the thyroid

OBJECTIVE: Atypical epithelial cells, cannot exclude papillary thyroid carcinoma (AEC-PTC), in fine needle aspiration (FNA) of the thyroid is a controversial diagnostic category that might cause a dilemma in patient management. STUDY DESIGN: Eighty-eight thyroid FNA specimens from 86 patients with a diagnosis of AEC-PTC were retrieved from our files in a 10-year period from December 1996 to December 2006. Of the 86 patients, 57 had follow-up histologic diagnoses and were included in this study. The cytologic and histologic materials were reviewed and correlated. RESULTS: Of the 57 patients, all had cytologic atypical features suggestive of PTC. Twenty-five cases of PTC were identified at surgery (44%). Review of the cytologic materials identified the following cytologic features, either alone or in combination strongly associated with PTC at resection: rare intranuclear cytoplasmic invagination (INCI), squamoid cytoplasm and psammoma bodies. CONCLUSION: The most common reasons for rendering the diagnosis of AEC-PTC in FNA of thyroid include rare atypical cells in a cystic thyroid nodule or a background of Hashimoto's thyroiditis. The cytologic features of LNCI, squamoid cytoplasm and psammoma bodies should alert the pathologist. Focal cytologic features of PTC in FNA samples are strongly associated with papillary carcinoma on resection.     

Diagnostic dilemmas of hyalinizing trabecular tumours on fine needle aspiration cytology: a study of seven cases with BRAF mutation analysis

T. Kim, Y. L. Oh, K. M. Kim and J. H. Shin Diagnostic dilemmas of hyalinizing trabecular tumours on fine needle aspiration cytology: a study of seven cases with BRAF mutation analysis Objective: Hyalinizing trabecular tumours (HTTs) are rare follicular‐derived neoplasms that behave in an almost benign manner. HTT is frequently misdiagnosed as papillary carcinoma by fine needle aspiration (FNA) cytology or as papillary or medullary carcinoma on surgical resection. Methods: The authors examined FNA material from seven cases of histologically verified HTT. Cytological findings were reviewed and correlated with ultrasonographic and histological features. In addition, MIB‐1 and calcitonin immunostaining was performed on surgical specimens, and BRAF mutation analysis on three pre‐operative FNA specimens and seven histology specimens. Results: The original cytological diagnosis was either suspicious or positive for papillary carcinoma in all patients. The FNA‐based differential diagnoses included HTT, papillary carcinoma or, less likely, medullary carcinoma in two patients. Aspirates showed oval to spindle‐shaped cells with frequent intranuclear inclusions, isolated in loosely cohesive groups with a trabecular or syncytial pattern in a bloody background. Radiating arrangements of tumour cells surrounding hyaline stroma with serrated calcifications and a lack of papillary or sheet‐like fragments may suggest HTT on FNA. Spherical calcified bodies and possible psammoma bodies were frequently found in three cases. Retrospectively, six of the seven cases showed membranous immunoreactivity for MIB‐1, but none of the seven possessed the BRAF (V600E) mutation or showed calcitonin reactivity. Conclusions: Although the recognition of HTT on FNA cytology is difficult, because of its morphological similarities to papillary and medullary carcinoma, its characteristic cytological features along with ultrasonographic findings may suggest the diagnosis preoperatively and avoid surgical over‐treatment.     

Fine needle aspiration cytology in a case of diffuse sclerosing carcinoma of the thyroid

The fine needle aspiration (FNA) cytologic findings in a rare case of bilateral diffuse sclerosing carcinoma of the thyroid are described. Along with a generally papillary architecture, the FNA biopsy smears showed a number of features not usually seen in thyroid carcinomas: psammoma bodies, an abundance of squamous metaplasia and a dense inflammatory component. The FNA diagnosis was multifocal papillary carcinoma with squamous metaplasia; histopathologic examination made the final diagnosis.     

Prevalence of psammoma bodies in Papanicolaou-stained cervicovaginal smears

Reports from sequential series of 234,318 cervicovaginal smears from a period of three years were reviewed to ascertain the prevalence and significance of psammoma bodies. Seven smears contained psammoma bodies. Three of the seven were associated with benign conditions and four were associated with a cancer (two serous papillary endometrial adenocarcinomas, one ovarian serous cystadenocarcinoma and one serous papillary carcinoma of the peritoneum). The prevalence of psammoma bodies in benign cases was much higher than reported in previous studies, in which most findings of psammoma bodies were associated with malignancy, particularly ovarian carcinoma. A consistent and useful feature in distinguishing psammoma bodies associated with benign or malignant disease was the presence of a few adherent small bland-appearing glandular cells in benign disorders and adherent malignant glandular cells in cases of carcinoma. A more conservative work-up may be merited in young women with clearly benign cells associated with psamoma bodies in a cervicovaginal smear and an otherwise negative physical examination and noncontributory endometrial sampling.     

Thyromegaly secondary to simultaneous papillary carcinoma and histiocytosis X. Report of a case and review of the literature

The cytologic and histologic findings are reported in a case of papillary carcinoma arising within a thyroid gland pathologically enlarged by histiocytosis X. Fine needle aspiration (FNA) biopsies of a thyroid nodule in a patient with longstanding histiocytosis X produced a scanty amount of colloid, a moderately dense mixed inflammatory infiltrate and numerous small papillary fragments lined by cuboidal-to-columnar cells. Both the inflammatory cells and the epithelial cells showed nuclear grooves; the two populations of neoplastic cells were distinguished, and the correct diagnosis of the nodule was made, by recognizing the greater amount of granular cytoplasm of the mononucleated Langerhans' cells. The rare involve-of the thyroid by histiocytosis X is reviewed; this case, which appears to be the first reported instance of the co-occurrence of histiocytosis X and papillary carcinoma of the thyroid, indicates that patients with histiocytosis X should be observed for the development of thyroid carcinoma and that FNA biopsy can make the distinction between the two conditions.     

Value of fine needle aspiration cytology of the breast, with an emphasis on the cytodiagnosis of colloid carcinoma.

The fine needle aspiration (FNA) cytologic evaluation of 6,941 lesions of the breast was reviewed, with an emphasis on the cytodiagnosis of colloid carcinoma. The most common benign breast diseases in this series were fibroadenomas, cysts and fibrocystic conditions. All cases with an FNA diagnosis of suspicious were biopsied; a number of these were found to be carcinoma of the breast. In cases with an FNA diagnosis of carcinoma of the breast, a plan of management was immediately adopted on the basis of that diagnosis. Thirteen cases of colloid (mucinous) carcinoma of the breast were diagnosed by FNA cytology; in all, the cytodiagnosis was confirmed by the subsequent histologic diagnosis. The distinctive cytologic criteria that may be useful for making an FNA diagnosis of colloid carcinoma of the breast are discussed, and the FNA differences between the pure and mixed types of colloid carcinoma are noted.     

Papillary breast lesions diagnosed on cytology. Profile of 65 cases

OBJECTIVE: To analyze the cytologic features of nipple discharge and fine needle aspiration (FNA) cytologic smears from breast lesions reported as showing papillary features and to correlate them with histopathologic features. STUDY DESIGN: The study group consisted of FNA smears and/or nipple discharge smears from 65 breast lesions diagnosed on cytology as duct papilloma, papillary lesion, fibrocystic condition, fibroadenoma, papillary neoplasm or papillary carcinoma. Cytomorphologic features assessed included cellularity, cell pattern (clusters, papillary, 3-dimensionality, etc.) and cell characteristics (monomorphism, pleomorphism, apocrine change, plasmacytoid features). Histological material was available for review and cytohistologic correlation in all cases. RESULTS: Forty-six specimens were FNA smears, and 16 were nipple discharge smears; in 3 cases FNA and nipple discharge cytologic smears were available for review. Cytologic study could predict the presence of a papillary pattern in all neoplasms with pure or focal papillary differentiation. There was an overlap in cytomorphologic features between papillary and nonpapillary benign lesions as well as between benign and malignant papillary neoplasms. Frank blood in the aspirate, cell dissociation and atypia, however, were more frequent in the last. CONCLUSION: Overlap of cytologic features in nonneoplastic and neoplastic benign papillary lesions and between benign and malignant papillary neoplasms necessitates histologic evaluation in all cases diagnosed as papillary on cytology. Since 49.2% of lesions showing papillary features on cytology prove to be malignant, all cases reported as papillary on cytology should be excised urgently for histologic assessment.     

Peritoneal washings in ovarian tumors. Potential sources of error in cytologic diagnosis

Peritoneal washings were performed on 48 patients with suspected or known ovarian carcinoma. The procedure was part of the initial surgical staging in 27 patients with presumed stage I and II ovarian cancer and was performed during second-look operations in 21 other cases with proven ovarian malignancy. This paper presents the microscopic features of the washings, with particular emphasis on the cytologic differentiation between benign and malignant findings outside of the ovary. Thirty-four cases showed benign or reactive mesothelial cells and no evidence of peritoneal disease. The washings of six patient showed malignant cells, which were confirmed histologically. Notable atypia that mimicked ovarian carcinoma was found in eight patients who had benign or borderline lesions. These findings included papillary and glandlike epithelial structures, with varying degrees of cellular atypia and psammoma bodies. The histologic counterparts of these atypicalities were Müllerian inclusions, mesothelial proliferations and borderline serous tumors. The differential diagnosis between these entities is essential because false-positive cytologic diagnoses may alter postoperative treatment in some patients.     

Posters. P13 Cytohistological correlation in 212 FNAs of thyroid: analysis of discordant cases

Aim To detect major pitafalls in thyroid FNA and to confirm its in a clinical sensitivity and specificity. Methods A total of 9251 fine needle aspirations biopsy carried out at Bellaria Hospital in Bologna from 1991 to 2000 by a pathologist in the FNA Clinic or by a clinician under ultrasonic guidance using a small needle (25–27 G); at least two passes have been made for each nodule. The specimen was considered satisfactory if at least five groups of follicular cells with at least 10 cells each, were seen. The cytological results were tiered in a four categories classification: inadequate, negative, suspicious and positive. Cyto‐histological correlations were available in 212 cases: 127 benign lesions and 85 malignant lesions. An analysis of false positive cases and false negative cases was performed and discordant case reviewed according to the flowing criteria: architecture, cellularity, colloid, pseudoinclusions, nuclear groovings, chromatin pattern, nuclear membrane, cytoplasm, naked nuclei and lymphocytes. Results Diagnostic distribution in 9251 FNAs from the thyroid: 88.6% negatives, 2.8 suspicious, 2.4% positives and 6.2% inadequates. Specificity was 85.8% and sensitivity was 78.8%. Among the 18 false negative cases eight were papillary microcarcinomas, four papillary carcinomas, five follicular carcinoma and one a Hurtle cell carcinoma. Four false positive cases were found: three reported as papillary carcinomas and one as carcinoma NOS. Review of false positives showed that in three cases the colloid was fluid, in three cases nuclear grooving was rare or absent, in two cases degenerative vacuoles at MGG were interpreted as nuclear inclusions and in three cases benign naked nuclei were present in the background. Review of false negatives confirmed lack of malignant features in 13 (eight papillary microcarcinomas and five follicular carcinomas), five were interpretation errors (three papillary carcinomas, one follicular, one Hurtle cell). Conclusion FNAC of the thyroid is a sensitive and specific method of assessment for thyroid nodules but false negative and false positive cases do occur. Use of all and only few criteria enhances diagnostic accuracy.     

Cribriform-morular variant of papillary thyroid carcinoma. Report of a case showing morules with peculiar nuclear clearing

BACKGROUND: There have been only 4 reported cases of cribriform-morular variant of papillary thyroid carcinoma (CMVPTC) with cytologic findings from fine needle aspiration. In these reports, the cytologic findings do not fully reflect the histologic characteristics of this entity. We report a case of CMVPTC in which a cribriform pattern without colloid and epithelial morules with peculiar nuclear clearing (PNC) were present in smears, thus fulfilling the criteria for a cytologic diagnosis of CMVPTC. Protein truncation tests for APC molecule abnormality indicated the presence of germline mutation in the patient's APC gene. CASE: A 30-year-old woman had multiple thyroid tumors. Aspiration cytology revealed a large number of round to spindle-shaped atypical-cells showing sheet-like, cribriform, follicular, whorl-like and solid, 3-dimensional arrangements. The cribriform and follicular arrangements did not contain colloid in the lumen. The powdery chromatin pattern characteristic of papillary carcinoma was not observed, but there were scattered intranuclear cytoplasmic pseudoinclusions and grooved nuclei. The nuclei of the atypical cells presenting in the whorl formations showed enlargement, thickened nuclear membranes and entirely clear contents, consistent with PNC. Hyalinelike necrotic cells were also observed in the cell clusters or in the background. Histologic and immunohistochemical findings were typical of CMVPTC. CONCLUSION: The cribriform pattern without colloid, fascicular or whorl formation of spindle cells, and morules with PNC are identifiable on cytologic smears and are sufficiently distinctive to allow a cytologic diagnosis of CMVPTC.     

A low-power, "architectural," clue to the follicular variant of papillary thyroid adenocarcinoma in aspiration biopsy

OBJECTIVE: To search for low-power, or "architectural," clues to the diagnosis of the follicular variant of papillary thyroid adenocarcinoma (FVP) in Diff-Quik-stained aspiration biopsy smears in order to aid in the rapid diagnosis of FVP, especially as a complement to frozen sections. STUDY DESIGN: The smears of 23 cases, each with tissue-proven FVP, were compared to those of 23 cases of classic papillary thyroid adenocarcinoma (PTA), 23 cases of tissue-proven follicular neoplasms (FN) (i.e., adenoma or well-differentiated adenocarcinoma) and 23 samples of colloid nodules (CN). The low-power (10x) features of the four groups were studied and compared. RESULTS: Our study showed that FVP exhibited monolayered cellular sheets with branched, irregular contours, which can be distinguished from the uniform microfollicles with smooth contours formed in FN and the large, round or oval monolayered sheets of follicular cells found in CN. FVP shared all of the features of classic PTA except for the larger, complex sheets of epithelial cells and psammoma bodies found in the latter. CONCLUSION: The branched sheets of epithelial cells evident during low-power examination of Diff-Quick-stained smears of thyroid aspirates are a ready first clue to the rapid diagnosis of FVP. The diagnosis can be confirmed by subsequent careful evaluation of nuclei in Papanicolaou-stained smears and sections of tissue.     

Thyroid papillary microcarcinoma. Is it really a pitfall of fine needle aspiration cytology?

OBJECTIVE: To assess the role of fine needle aspiration (FNA) of the thyroid in the diagnosis of papillary microcarcinoma. STUDY DESIGN: Eight cases of papillary microcarcinoma were diagnosed by fine needle aspiration. On histologic examination they were found to be adjacent to larger nodules of interest. The microcarcinomas were inadvertently sampled when sampling the larger, dominant nodules. RESULTS: None of the eight dominant nodules were papillary carcinoma; seven were benign lesions, and one was an angioinvasive Hürthle cell carcinoma. In three cases the microcarcinomas were situated within the capsule of a hyperplastic nodule. On histologic examination, five cases had multifocal microcarcinomas, with one case having multiple lymph node metastases. Based on the clinical findings and morphologic features, there were no definitive cytologic findings that could distinguish between "incidental" microcarcinoma and clinically significant papillary carcinoma. CONCLUSION: The detection of microcarcinoma by FNA should not be considered a false positive finding since the exact nature of the lesion cannot be determined until complete histologic evaluation reveals it to be truly incidental and clinically insignificant.     

Coexistent disease as a complicating factor in the fine needle aspiration diagnosis of papillary carcinoma of the thyroid

The occasional coexistence of papillary carcinoma of the thyroid with nodular goiter or hyperparathyroidism may in some cases result in a significant discrepancy between the clinical impression and the fine needle aspiration (FNA) biopsy diagnosis, leading to the suspicion that a false-positive FNA diagnosis was obtained. Two such cases are presented in which consultation between the cytopathologist and the surgeon was helpful in achieving a correct diagnosis and ensuring proper therapy. Awareness of these variations in the clinical presentation of papillary carcinoma of the thyroid will aid the cytopathologist in the resolution of such apparent discrepancies.     

Follicular variant of papillary carcinoma of the thyroid. A cytologic study of 15 cases

OBJECTIVE: To study the cytologic findings of follicular variant of papillary thyroid carcinoma (FVPTC) and to compare them with the cytologic findings on other thyroid lesions. STUDY DESIGN: The study group consisted of aspirate smears from 15 cases of histologically proven FVPTC. The control group consisted of 152 cases, including adenomatous colloid goiter (70), usual papillary carcinoma (40), follicular adenoma (30), Hürthle cell neoplasm (7) and medullary carcinoma (5). RESULTS: The smears of FVPTC revealed numerous colloid balls in the background, multilayered microfollicles (rosettes), numerous nuclear grooves and inclusions in the monolayer sheets of follicular cells, very rare giant cells, absence of calcification and papillary clusters. Rosettelike microfollicles and numerous colloid balls were not seen in the control group. CONCLUSION: The combination of numerous colloid balls and rosettelike microfollicles was frequently seen in FVPTC. This combination was not observed in the control group.     

Cytologic criteria of cystic papillary carcinoma of the thyroid

OBJECTIVE: To establish differential cytologic criteria between benign and malignant thyroid cysts. STUDY DESIGN: The study was a retrospective, transverse, analytic, comparative one of 3 groups of patients with nonfunctional thyroid nodules subjected to fine needle aspiration biopsy (FNAB) and surgical resection of the lesions, with histologic study as the diagnostic gold standard. Fifteen cases of cystic papillary carcinomas (group 1) with initial false negative diagnoses, 42 goiters accompanied by cystic degeneration (group 2) and 15 noncystic papillary carcinomas (group 3) were studied. Independent variables were age and sex; dependent variables were the presence of tridimensional fragments, papillae, anisonucleosis, nuclear bars, pseudoinclusions, powdery chromatin, cytoplasmic vacuoles, metaplastic cytoplasm, psammoma bodies, autolysis, multinucleated giant cells, spindle cells, colloid, monolayered laminae and macrophages in FNAB specimens. Statistical analysis was performed by central tendency measures and the chi 2 test. RESULTS: The chi 2 test revealed a statistically significant difference between group 2 and the groups with papillary carcinoma based on the presence of tridimensional fragments, anisonucleosis, nuclear bars, pseudoinclusions, powdery chromatin, cytoplasmic vacuoles, metaplastic cytoplasm and autolysis. CONCLUSION: The above cytologic characteristics must be searched for systematically in the FNAB of every cystic lesion of the thyroid to rule out the presence of cystic papillary thyroid carcinoma and to decrease the rate of false negative results.     

Expression of CD44 and cyclin D1 in fine needle aspiration cytology of papillary thyroid carcinoma

OBJECTIVE: To compare the expression pattern of CD44 and cyclin D1 immunostaining in fine needle aspiration specimens of papillary carcinoma of the thyroid and nonpapillary lesions. STUDY DESIGN: The study was performed on 80 fine needle aspiration cytologic smears of thyroid lesion retrospectively using monoclonal antibodies and on histologic material from a proportion of cases. RESULTS: Most papillary carcinomas expressed intense cell membrane or diffuse cytoplasmic staining for CD44 (97.8%). Focal immunoreactivity was observed in follicular neoplasms (28.5%) and nodular goiter (4.7%). There was no difference in CD44 immunostaining between follicular carcinoma and adenoma. Cyclin D1 was expressed in the nuclei of most papillary carcinomas (79.2%). Focal nuclear immunoreactivity was noted in nodular goiters (23.5%) and follicular neoplasms (10%). In resected specimens, all papillary carcinomas (19 cases) showed intense membranous or granular CD44 immunoreactivity. Focal cyclin D1 expression was noted in 52.6%. There was no difference in CD44 and cyclin D1 expression between the group of papillary carcinomas with regional lymph node metastasis as compared to those without metastasis. Positive staining for both CD44 and cyclin D1 would strongly favor papillary carcinoma, although further studies on cytologic material are necessary to verify this diagnostic approach. CONCLUSION: Most papillary carcinomas express CD44 and cyclin D1, whereas it is less common in follicular neoplasms and nodular goiter. This may be helpful in diagnostically difficult cases.     

Galectin-3 is not useful in thyroid FNA

INTRODUCTION: Previous studies have suggested that galectin-3 immunohistochemistry may be useful in the fine needle aspiration (FNA) diagnosis of thyroid carcinoma as it has been reported to selectively stain carcinomas and not adenomas or goitres. METHODS: Fifty-one patients were included in a prospective study of galectin-3 in thyroid FNA; 88.2% were female and 11.8% male, mean age 53 years, range 25-87 years. Cell blocks were prepared and stained for galectin-3 if any cells were present in needle washings from the respective FNAs. RESULTS: Twelve of 51 (23.5%) of cell blocks contained epithelial cells. One benign and one inadequate FNA were negative for galectin-3 staining. One of five non-diagnostic FNA cases, a papillary carcinoma on final histology showed positive staining. Four follicular neoplasm/suspicious of carcinoma cases showed negative staining. One malignant FNA case, a papillary carcinoma showed positive staining with galectin-3 but three further carcinomas, two papillary and one follicular were galectin-3 negative. CONCLUSION: Galectin-3 immunohistochemistry does not appear to be a useful adjunct to diagnosis in thyroid FNA as it does not reliably distinguish malignant and benign lesions. Many thyroid aspirates are of low cellularity and are not suitable for cell block immunohistochemistry.     

Fine needle aspiration cytology and immunocytochemistry in a case of intrathoracic thyroid goiter

Fine needle aspiration (FNA) was performed in the case of a patient with an anterior mediastinal mass. Examination of the smears revealed individual and groups of benign nondiagnostic cells. Surgical removal and histologic examination indicated that the mass was a true intrathoracic thyroid goiter. Subsequent immunocytochemical studies on the FNA smears showed thyroglobulin in the cytoplasm of the aspirated cells. The cytologic findings are presented; while not diagnostic of a thyroidal origin in this case, they serve as a reminder of the wide range of cytologic appearances of colloid nodules and goiters. This case will hopefully heighten the awareness of cytologists and other physicians to the consideration of the possibility of intrathoracic goiter in the differential diagnosis of mediastinal lesions seen in fine needle aspirates.     

Association of different pathologic processes of the thyroid gland in fine needle aspiration samples

OBJECTIVE: To evaluate the possible significant association between different pathologic processes of the thyroid gland. STUDY DESIGN: From a series of 10,039 fine needle aspiration biopsies of the thyroid gland, a total of 1,330 cases were aspirated involving two or more palpable nodules. In 103 (1%) cases, two different pathologic processes were cytologically diagnosed. Statistical analysis was performed through four two-tailed chi 2 tests to evaluate the following events: (1) mononodularity and multinodularity vs. neoplasms, (2) colloid goiter and neoplasms, and (3) all neoplasms vs. colloid goiter and lymphocytic thyroiditis. All tests were performed using < .05 as the probability level. RESULTS: Simultaneous pathologic processes observed were: goiter and chronic lymphocytic thyroiditis (32), goiter and Hashimoto's thyroiditis (21), goiter and subacute granulomatous thyroiditis (8), goiter and follicular neoplasm (9), and goiter and papillary carcinoma (14). In 12 cases we found goiter and Hürthle cell tumor, goiter and medullary thyroid carcinoma (2), papillary thyroid carcinoma and Hashimoto's thyroiditis (2), Graves' disease and lymphocytic thyroiditis (2), and follicular neoplasm and lymphocytic thyroiditis (1). Statistical analysis showed significant association between multinodularity and neoplasms (P < .001), while the association between goiter and any type of neoplasia was not statistically significant. All the neoplasms taken together were associated with lymphocytic thyroiditis and goiter (P < .005). CONCLUSION: While there may be no statistically significant associations between the individual pathologies, it seems that having one pathology increases the risk of developing another. All the palpable nodules in the same gland should be investigated by fine needle aspiration in order to improve diagnostic sensitivity and to identify occult neoplasms.