Who performs a Fine Needle Aspiration (FNA) in a thyroid nodule?

Who Performs Fine Needle Aspiration (FNA) in Thyroid Nodules

Fine needle aspiration (FNA) of thyroid nodules is typically performed by endocrinologists, radiologists, surgeons (particularly otolaryngologists), or pathologists with expertise in thyroid disorders, with the procedure ideally being performed by clinicians who regularly do the procedure and have appropriate training. 1

Types of Specialists Who Perform Thyroid FNA

• Endocrinologists - Often perform FNA as part of initial workup 2
• Surgeons/Otolaryngologists - Shown to perform safe, cost-effective FNA with accuracy comparable to other clinicians 3
• Radiologists - Particularly for ultrasound-guided FNA
• Pathologists - May perform FNA, especially in specialized centers

Procedure Setting and Guidance

• FNA is typically performed in an outpatient setting
• Ultrasound guidance is recommended for thyroid nodule FNA 1
• The procedure can be performed during the initial office visit 1

Factors Affecting Diagnostic Success

The diagnostic success of FNA depends on several factors:

• Operator experience - Experience level affects diagnostic rates (resident-performed FNAs have higher non-diagnostic rates) 3
• Nodule characteristics:
  • Cystic nodules have higher non-diagnostic rates (strongest independent predictor) 3
  • Nodules smaller than 1 cm have higher non-diagnostic rates 3
• Sampling technique - Proper technique is essential for adequate sampling

Diagnostic Accuracy Considerations

• Overall diagnostic accuracy of thyroid FNA ranges from 91-95% 4, 5
• Non-diagnostic rates range from 6-36% across different studies 3
• Surgeon-performed FNA has been shown to have similar diagnostic rates to FNA performed by other specialists 3

Clinical Pathway

1. Initial evaluation of thyroid nodule
2. Ultrasound of thyroid and central neck is recommended 1
3. FNA is recommended as the first diagnostic test before other imaging studies 1
4. Cytologic examination by a pathologist with expertise in thyroid disorders 1
5. Follow-up based on cytology results

Pitfalls to Avoid

• Inadequate sampling leading to non-diagnostic results (13-23% of cases) 2, 3
• Failure to have cytology reviewed by a pathologist with expertise in thyroid disorders 1
• Relying solely on reassuring FNA results when clinical findings are worrisome 1
• Not considering repeat FNA when initial results are non-diagnostic 6

For optimal patient outcomes in terms of morbidity and mortality, the FNA should be performed by a clinician with experience in the procedure, with ultrasound guidance when appropriate, and the samples should be interpreted by a pathologist with expertise in thyroid cytopathology.