Worrisome histologic alterations following fine needle aspiration of the thyroid

OBJECTIVE: To investigate worrisome histologic alterations following fine needle aspiration (FNA) of the thyroid (WHAFFT). STUDY DESIGN: Of 1,890 FNA thyroid cases, 265 underwent surgical excision. The histologic sections of these cases were studied for WHAFFT lesions. Thirty control cases were also studied. RESULTS: WHAFFT lesions were present in 38.49% of cases. Acute lesions were seen in 30 and chronic in 72 cases. Control cases did not show WHAFFT lesions. The common lesions were hemorrhage and fibrosis. Worrisome lesions, like nuclear atypia, vascular changes, capsular pseudoinvasion and metaplasia, were present in 32 (12.07%) cases. CONCLUSION: Considering the large number of FNAs and reduction in the number of thyroid excisions, the advantages of FNA are manifold as compared to the few diagnostic problems. Misdiagnosis can be avoided with awareness of WHAFFT lesions.     

Fine needle aspiration cytology of vaginal cuff lesions

OBJECTIVE: To assess the usefulness of fine needle aspiration (FNA) of the vaginal cuff in various lesions in the female genital tract. STUDY DESIGN: Twenty-six FNAs of vaginal cuff lesions were performed at our institution from 1994 to 1998. All cases were reviewed. Data on clinical histories and follow-up, if available, were collected. Histologic material was reviewed. Fourteen gynecologic (cervicovaginal) smears performed on these patients within six months prior to the FNA were also reviewed. RESULTS: Two of twenty-six (7.7%) FNAs were non-diagnostic due to poor cellular yield. Four lesions were classified as benign (16.7%). The remaining 20 FNAs were classified as malignant (83%) and were consistent with the clinical history in all cases. CONCLUSION: The results show that FNA of the vaginal cuff appears to be a simple and accurate procedure for detecting benign and malignant lesions of the female genitourinary tract. Clinical indications, cytologic techniques and potential pitfalls are identical to those of FNAs at other sites.     

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.     

Correlation of cell counts and indices in testicular FNAC with histology in male infertility.

OBJECTIVE: To evaluate the value of percentage cell counts and cell indices in testicular fine needle aspiration cytology (FNAC) in male infertility and their correlation with histologic categories as seen in open testicular biopsies. STUDY DESIGN: Differential cell counts were performed, and cell indices, including spermatic index, Sertoli cell index and sperm-Sertoli cell index, were calculated in testicular fine needle aspiration (FNA) smears in 30 azoospermic males whose open testicular biopsies were classified as normal spermatogenesis in 10 cases, maturation arrest in 5, hypospermatogenesis in 6, Sertoli cell only syndrome in 5 and tubular/peritubular sclerosis in 4. RESULTS: In normal spermatogenesis, FNA smears showed up to 40% Sertoli cells, and spermatozoa were the predominant spermatogenetic cell type. There was a progressive increase in Sertoli cell percentage and Sertoli cell index and reduction in spermatozon percentage, spermatic index and sperm-Sertoli cell index with increasing severity of reduction in spermatogenesis in different histologic categories. The differences between mean counts and indices in normal spermatogenesis and other histologic categories were statistically significant (P < .01). CONCLUSION: The percent cell counts and cell indices in testicular FNAC correlate with histologic categories and are useful in evaluating male infertility.     

Percutaneous core needle biopsy vs. fine needle aspiration in diagnosing benign lung lesions.

OBJECTIVE: To determine the diagnostic value of percutaneous core needle biopsy (PCNB) in comparison with fine needle aspiration (FNA) in patients with benign pulmonary lesions. STUDY DESIGN: A retrospective review was undertaken of computed tomography-guided PCNBs and FNAs performed between 1988 and 1997. Both FNA and PCNB biopsies were carried out sequentially at the same visit in every patient. RESULTS: A specific benign diagnosis was made in 10/60 cases (16.7%) by FNA and in 49/60 (81.7%) by PCNB. PCNB findings resulted in significant modification of the diagnosis established by FNA. The only significant complication encountered was pneumothorax, at a rate of 11.7%, which is compatible with that reported in the literature for complications induced by FNA alone. CONCLUSION: Radiologically guided PCNB is a safe procedure, can provide sufficient histologic material for a specific diagnosis of peripheral lung disease and can avoid more-invasive surgical procedures in many cases. Our experience demonstrated that the histologic analysis provided by PCNB can greatly increase the diagnostic accuracy in benign pulmonary diseases as compared with the yield of FNA.     

Cytology and mRNA expression analysis of fine needle aspirates of thyroid nodules in an East German region with borderline iodine deficiency.

Fine needle aspiration cytology (FNAC) is widely recommended as an important tool for pre-operative identification of malignancy in patients with nodular thyroid disease. To assess the diagnostic contribution of FNAC and the potential of quantitative mRNA analysis in fine needle aspirates in daily practice, we conducted a prospective study in thyroid clinics (n=2) and endocrine practices (n=3), respectively in an East German region with borderline iodine deficiency. Two-hundred and forty-four consecutive FNACs were obtained over a period of 2 years (2002-2004) from euthyroid patients presenting for first evaluation of a solitary thyroid nodule. The mean nodule size for FNAC was 27 mm (range: 10-79 mm). In 55% of patients FNAC was performed after scintiscan detection of a cold or normal functioning thyroid nodule (CTN), while in the remainder FNAC was performed as a primary investigation. FNAC outcomes were: 57.8% benign, 22.1% indeterminate, 2.5% suspicious for malignancy, 17.6% non-diagnostic. Messenger RNA levels for a house keeping gene (beta-actin) and a thyroid specific marker (thyroglobulin, Tg) were studied as basic molecular markers using real-time PCR. Both in the IN VIVO and EX VIVO FNA series, beta-actin and Tg mRNA levels were positively correlated with the thyrocyte cell yield/respective FNA smear. However, subgroup analysis showed that FNAC with histologically confirmed follicular thyroid cancer and/or microfollicular adenoma exhibited significantly lower Tg mRNA expression despite high beta-actin levels. Sufficient mRNA quantities were obtained in >90% of FNA specimen to allow quantitative mRNA analysis of at least 5 further genes. In conclusion, quantitative mRNA analysis is feasible in FNA on a routine basis and provides a perspective for a molecular distinction of thyroid nodules, once specific marker genes have been defined for benign and malignant thyroid tumours respectively.     

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.     

Detection of medullary thyroid microcarcinoma using ultrasound‐guided fine needle aspiration cytology

G. C. H. Yang, K. Fried and P. H. Levine Detection of medullary thyroid microcarcinoma using ultrasound‐guided fine needle aspiration cytology Objective: Compared with incidental papillary thyroid microcarcinoma (microPTC), incidental medullary thyroid microcarcinoma (microMTC) is clinically more significant. The objective of the present study was to summarize our experience in detecting microMTCs. Methods: From 1995 to 2011, there were 10 825 thyroid fine needle aspirates (FNAs) guided using high‐resolution ultrasound with on‐site preparation and evaluation by a cytopathologist. Of the 140 microcarcinomas detected, 132 were microPTCs and eight were microMTCs, which are the subject of the present study. Results: All eight cases were incidentalomas and none of the five women and three men, age 37–70 years, had a family history of MTC. One patient had two FNAs at an interval of 10 months, two had a single lymph node metastasis and one had a 0.1‐cm tumour nodule near the main tumour. Four of five plasmacytoid cell microMCTs had irregular borders; two round cell and one rectangular cell tumours had smooth borders. In contrast, 17 larger MTCs diagnosed in the same period included seven plasmacytoid, four giant cell and six spindle cell types. All five plasmacytoid microMTCs were correctly diagnosed on FNA, but the round cell and rectangular cell tumours were undercalled as follicular lesions. Sampling of colloid from adjacent follicles was noted in microMTCs. Two were diagnosed on histology following recommended surgery and one was diagnosed on recommended repeat FNA. Conclusions: US‐guided FNA of thyroid lesions is a powerful tool in the detection of microMTCs, provided that cytopathologists are alerted to the pitfalls described in the present study.     

Nonaspiration fine needle cytology. Application of a new technique to nodular thyroid disease

The basic principle underlying fine needle aspiration (FNA) is the aspiration of cellular material from target masses, often utilizing fairly high suction pressures. The procedure requires a needle and a syringe, advisedly held in a syringe holder, enabling single-handed suction to be exercised. Mastery of the technique is variable, with few operators acquiring consistent skill. A new technique, pioneered in France but essentially unpublicized, eliminates active aspiration, replacing it by the principle of capillary suction of fluid or semifluid material into a thin channel (a fine needle). This nonaspiration sampling method was tested in a consecutive series of 50 solid thyroid nodules. Simultaneously performed conventional FNAs served as controls. Cell samples were cytologically assessed as unsuitable, diagnostic/adequate or diagnostic/superior, without knowledge of the sampling method employed. Diagnostically superior specimens were obtained significantly more frequently by the nonaspiration technique in 36 benign lesions and 13 neoplasms. The method of nonaspiration fine needle cytology ("cytopuncture") is described and illustrated, and the implications for its use in other sites are discussed.     

Clinicopathologic analysis of fine needle aspiration cytology of the thyroid. A review of 1,613 cases and correlation with histopathologic diagnoses

OBJECTIVE: To evaluate the accuracy of fine needle aspiration (FNA) of thyroid lesions at our institution and to ascertain its usefulness in determining the therapeutic approach. STUDY DESIGN: The authors reviewed the results of 1,613 cases of FNA cytology of thyroid nodules performed from 1999 to 2001 at the Department of Pathology, Chonnam National University Hospital. Cytologic diagnoses were compared with histologic diagnoses in 207 cases that included both FNA and thyroid surgery. RESULTS: The sensitivity for the detection of neoplasms (carcinoma and follicular adenoma) was 78.4% and the specificity 98.2%. A false positive diagnosis was made in 1 case (1.8%) and false negative ones in 28 cases (21.5%). The diagnostic accuracy was 84.4%, with a positive predictive value of 99.0% and negative predictive value of 66.3%. The predictive value of a cytologic diagnosis was 100% in papillary carcinoma. CONCLUSION: FNA is a useful test in determining the therapeutic approach of thyroid lesions.     

Endoscopically directed fine needle aspiration biopsy of gastric and esophageal lesions.

Endoscopically directed fine needle aspiration (FNA) has been reported to be a valuable adjunct to forceps biopsy in the evaluation of gastric and esophageal lesions. In our series of 38 cases with endoscopically detected mucosal and submucosal abnormalities, FNAs were obtained with a Stifcor transbronchial aspiration needle. Four cases were reported as insufficient. Five aspirates correctly documented the presence of a neoplasm, but three failed to identify a subsequently histologically confirmed adenocarcinoma. Two cases were falsely suspicious for adenocarcinoma. FNA correctly excluded lymphoma in 12 patients with thick gastric folds clinically suspicious for lymphoma. FNA is a useful adjunct to forceps biopsy of neoplastic and inflammatory lesions in both mucosal and submucosal locations within the upper gastrointestinal tract.     

Is a five‐category reporting scheme for thyroid fine needle aspiration cytology accurate? Experience of over 18 000 FNAs reported at the same institution during 1998–2007

S. Piana, A. Frasoldati, M. Ferrari, R. Valcavi, E. Froio, V. Barbieri, C. Pedroni and G. Gardini Is a five‐category reporting scheme for thyroid fine needle aspiration cytology accurate? Experience of over 18 000 FNAs reported at the same institution during 1998–2007 Objective: Fine needle aspiration (FNA) has long been recognized as an essential technique for the evaluation of thyroid nodules. Although specific cytological patterns have been recognized, a wide variety of reporting schemes for thyroid FNA results have been adopted. This study reports our experience with a five‐category reporting scheme developed in‐house based on a numeric score and applied to a large series of consecutive thyroid FNAs. It focuses mainly on the accuracy of thyroid FNA as a preoperative test in a large subset of histologically distinct thyroid lesions. Methods: During the 1998–2007 period, 18 359 thyroid ultrasound‐guided FNAs were performed on 15 269 patients; FNA reports were classified according to a C1–C5 reporting scheme: non‐diagnostic (C1), benign (C2), indeterminate (C3), suspicious (C4), and malignant (C5). Results: Non‐diagnostic (C1) and indeterminate (C3) FNA results totalled 2 230 (12.1%) and 1 461 (7.9%), respectively, while suspicious (C4) and malignant (C5) results totalled 238 (1.3%) and 531 (2.9%), respectively. Histological results were available in 2 047 patients, with thyroid malignancy detected in 840. Positive predictive value of FNA was 98.1% with a 49.0 likelihood ratio (LR) of malignancy in patients with a C4/C5 FNA report. Conclusions: This five‐category scheme for thyroid FNA is accurate in discriminating between the virtual certainty of malignancy associated with C5, a high rate (92%) of malignancy associated with C4, and a 98% probability of a histological benign diagnosis associated with C2. Further sub‐classifications of C3 may improve the accuracy of the diagnostic scheme and may help in recognizing patients eligible for a ‘wait and see’ management.     

The role of fine needle aspiration cytology in evaluation of epididymal nodular lesions

OBJECTIVE: To study the role of fine needle aspiration cytology (FNAC) in evaluation of nodular lesions of the epididymis. STUDY DESIGN: A retrospective study was done on 16 patients who reported with nodular lesions of the epididymis over a 1(1/2)-year period. FNAC was carried out in all cases. Histopathologic correlation was achieved in 10 cases. Cytologic features were studied in all cases and compared with histology results where available. RESULTS: Adequate material was obtained on FNAC in all cases. Cytologic features were adequate to establish a diagnosis in all cases and were confirmed as correct on histologic examination in the 10 cases in which biopsies were performed. Sperm granuloma was the most common lesion encountered. CONCLUSION: FNAC is a rapid, easily available technique for evaluation of nodular lesions of the epididymis. It helps in making a diagnosis and developing a management plan.     

Fine needle aspiration of breast lesions in women aged 30 and under

Fine needle aspiration (FNA) biopsies of 1,598 breast masses were performed between 1983 and 1989, and of them, 48 were from women aged 30 and under for whom a cytologic diagnosis was made by FNA and histologic follow-up was available. In 37 (77%) of the cases, both the cytologic and histologic diagnoses were benign. Fibroadenoma (20/37) and fibrocystic changes (14/37) were the most common benign lesions aspirated. Eight (17%) FNAs showed cytologic atypia. Four of these atypical lesions proved to be benign (two fibroadenomas, two fibrocystic changes). Epithelial proliferation in fibroadenomas and fibrocystic changes and cellular stroma in a fibroadenoma mimicking phylloides tumor were the causes of atypia in these biopsies. Four of the eight atypical lesions were shown to be carcinoma at biopsy (three infiltrating duct, one atypical medullary). Low cellularity, epithelial cohesiveness mimicking a fibroadenoma and background lactational changes in a pregnant patient were the causes of the atypical, rather than unequivocally malignant, diagnoses in these cases. In three patients (6%), a diagnosis of carcinoma was made by FNA and confirmed histologically (all were infiltrating duct carcinoma). Although most breast masses in women aged 30 and under are benign, cytologic atypia in a breast fine needle aspirate in this age group warrants a surgical biopsy. Clinical follow-up alone may be appropriate for young women with clinically nonsuspicious breast masses without cytologic atypia.     

Fine needle aspiration of parathyroid lesions

OBJECTIVE: To assess the cytologic features of parathyroid lesions and to determine if it is possible to differentiate between parathyroid hyperplasia (PH) and parathyroid adenoma (PA) based on fine needle aspiration (FNA). STUDY DESIGN: FNAs of 14 parathyroid lesions were performed during intraoperative consultation. Alcohol-fixed, Papanicolaou-stained smears and air-dried Diff-Quik-stained smears were prepared in each case. Cytologic features were evaluated. RESULTS: All cases, PA and PH, showed numerous bare nuclei in the background. Ninety percent of PA contained microfollicular groups in addition to sheets and syncytia, while PH was arranged primarily in sheets and syncytia without microfollicles. Nuclear pleomorphism was seen in 33% of PA and absent from PH. CONCLUSION: Careful evaluation of cytologic features might help to differentiate between PA and PH on FNA.     

Comparative cytology of mucocelelike lesion and mucinous carcinoma of the breast in fine needle aspiration

OBJECTIVE: To study the fine needle aspiration cytology (FNAC) features of mucocelelike lesion (MLL) of the breast and to compare them to those of mucinous carcinoma. STUDY DESIGN: The fine needle aspiration (FNA) smears of 7 cases of histologically proven MLL (2 malignant and 5 benign, including 4 associated with atypical ductal hyperplasia) were reviewed and compared to those of 14 mucinous carcinoma cases. RESULTS: In all cases, grossly visible thick, mucoid material was obtained from FNA. The most important features for distinguishing benign MLL from mucinous carcinoma were: (1) scant cellularity; (2) no or rare single, intact tumor cells; (3) tumor cells arranged in cohesive monolayers; and (4) absence of significant nuclear atypia. In contrast, mucinous carcinoma in general showed higher cellularity; abundant single, intact cells; three-dimensional cellular clusters in most cases; and nuclear atypia ranging from mild to severe. CONCLUSION: Mucinous lesions of the breast should be divided into MLL and frank mucinous carcinoma based on FNAC. However, FNAC diagnosis of malignant MLL has yet to be defined. Excisional biopsy is advised for all hypocellular cases for further separation into benign and malignant MLL and to rule out the possibility of hypocellular mucinous carcinoma.     

Ultrasound guidance improves the adequacy of our preoperative thyroid cytology but not its accuracy

AIMS: Our thyroid cytology audit results of 1990-1995 showed an unsatisfactory rate of 43.1% and prediction of neoplasia with a sensitivity of 86.8%. Increasingly, ultrasound scan (USS)-guided core sampling for cytology is proving a valuable tool instead of freehand fine needle aspiration (FNA) or following unsatisfactory freehand FNA. We present the results of freehand FNA and USS-guided core samples for cytology in two separate patient groups in our centre. METHODS: Patients who had a thyroid resection and preoperative thyroid cytology in our institution between 1996 and 2002 were included. The histological diagnoses were correlated with the preceding cytology results. RESULTS: A total of 450 FNAs were performed on 394 patients. Freehand FNAs were performed for 348 (77.3%) samples and USS-guided core for 102 (22.7%) samples; 121 (26.8%) were repeat aspirates performed on 45 patients. Using aspiration cytology (AC) grading, freehand FNA was cytologically inadequate (AC0 or AC1) in 34.8% cases whereas USS-guided core was inadequate in 17.6% cases (P = 0.001). Freehand FNA (AC3, AC4, AC5) predicted neoplasia with a sensitivity of 83.2%, specificity of 46.6%, accuracy of 63.0%, positive predictive value of 56.0% and negative predictive value of 77.1%. USS-guided core sample for cytology (AC3, AC4, AC5) predicted neoplasia with a sensitivity of 93.5%, specificity of 26.0%, accuracy of 51.9%, positive predictive value of 43.9% and negative predictive value of 86.7%. CONCLUSIONS: Although USS-guided core provides more satisfactory specimens than freehand FNA, in our centre it does not provide increased accuracy.     

Fine needle aspiration cytology of thyroid gland diseases

From 1982 to 1987, 2,433 lesions of the thyroid gland in 1,796 patients were examined by fine needle aspiration (FNA). Cytopathology classified 66.91% of the aspirates as benign, 10.76% as thyroiditis, 4.89% as suspected (unspecified) neoplasia, 1.31% as positive for malignancy and 16.11% (392) as unsatisfactory. The histologic diagnoses in 257 cases were compared with cytologic diagnoses to determine the accuracy of FNA cytology of thyroid lesions, yielding a sensitivity of 71.43%, a specificity of 100% and an accuracy of 95.09%. This data strongly supports thyroid FNA as an important preoperative diagnostic tool. Follicular carcinomas were difficult to cytologically differentiate from nonmalignant follicular neoplasms, and papillary thyroid carcinomas less than 2 cm in diameter in elderly patients were frequently misdiagnosed or diagnosed only as "suspect lesion."     

Secondary infection and ischemic necrosis after fine needle aspiration for a painful papillary thyroid carcinoma: a case report

BACKGROUND: Papillary thyroid carcinoma (PTC) is often asymptomatic and rarely presents as a painful goiter. Further, the thyroid gland is not easily infected. Therefore, acute suppurative thyroiditis (AST) is unusual. PTC is also seldom combined with AST. We report a case of painful PTC with secondary infection after fine needle aspiration (FNA). CASE: A 19-year-old girl complained of a painful goiter without skin change after an episode of upper airway infection. PTC was diagnosed according to the FNA cytology (FNAC) at another hospital. The goiter became more painful after FNA. The patient's second FNAC at our hospital revealed only many polymorphonuclear leukocytes (PMNs). Antibiotic treatment ameliorated the pain, but the goiter persisted. The third FNAC revealed some PMNs and papillary carcinomatous cells. After total thyroidectomy, pathology revealed ischemic necrosis with a focal PMN aggregation around the needle track and papillary carcinomatous cells nearby. According to the time sequence, secondary infection after FNA was suspected. CONCLUSION: A painful goiter is an unusual presentation of PTC. Although FNAC is feasible for studying a thyroid lesion, malignant cells might be missed when secoandary injection and ischemic necrosis occur after FNA. Therefore, aseptic procedures are necessary to prevent bacteria from seeding into the thyroid.     

Improving recognition of thyroid carcinoma in rapid-consultation specimens

OBJECTIVE: To improve recognition of thyroid carcinoma in rapid consultation on Diff-Quik-stained (Fisher Diagnostics, Middletown, Virginia, USA.) fine-needle aspiration (FNA) and rapid hematoxylin-eosin (H-E)-stained intraoperative scrape preparation (ISP) specimens by assessing 3 variables (anisokaryosis, nuclear overlap [NO] and scant/absent colloid) in cases of cellular follicular lesions (CFL), an indeterminate diagnostic category. STUDY DESIGN: Thirty-seven FNAs and 28 ISPs diagnosed as CFL, with histologic follow-up, were evaluated in blinded fashion by 3 cytopathologists assessing the 3 variables. RESULTS: Over 90% of the malignant cases showed NO in both FNA and ISP, while only 22% of the benign cases did; positive and negative predictive values (PPV and NPV) were 82% and 100%. All malignant cases showed significant anisokaryosis in both FNA and ISP in contrast to 24% of benign cases; PPV and NPV were 74% and 100%. Scant/absent colloid was seen in 87% and 39% of malignancies in FNA and ISP, respectively, as compared to 55% and 20% of the benign cases. PPV and NPV were 52% and 83% in FNA and 63% and 60% in ISP, respectively. CONCLUSION: Application of these variables improves recognition of thyroid carcinoma, particularly in fine needle aspirates, while additional material may be requested. With ISP, their absence supports recommending against further surgery. Together, optimal surgical planning and outcome may be obtained.