Do endocrinologists perform thyroid fine‑needle aspiration biopsies in their outpatient practice, or do they refer patients to radiology or surgery?

Who Performs Thyroid Fine-Needle Aspiration Biopsies

Endocrinologists, otolaryngologists, surgeons, and radiologists all perform thyroid FNA biopsies in outpatient settings, though practice patterns vary by institution and individual physician training. The decision of who performs the procedure depends on local expertise, equipment availability, and physician comfort with ultrasound-guided techniques rather than specialty-specific guidelines.

Current Practice Patterns Across Specialties

Endocrinologists and Office-Based FNA

• Multiple guidelines developed by endocrinology societies explicitly discuss thyroid nodule management and FNA indications, but do not restrict who performs the procedure 1.
• Endocrinologists with appropriate training in ultrasound-guided techniques can and do perform thyroid FNA in their offices, though this requires investment in ultrasound equipment and cytopathology support 2.
• The availability of portable ultrasound machines has enabled more non-radiologist physicians to perform office-based ultrasound-guided FNA 2.

Radiologists as Traditional Providers

• Historically, ultrasound-guided FNA has been performed by radiologists in designated radiology suites, and this remains common practice in many institutions 2.
• Radiologists typically have extensive experience with image-guided procedures and immediate access to ultrasound equipment 3.

Otolaryngologists and Surgeons

• Trained otolaryngologists and endocrine surgeons perform office-based ultrasound-guided thyroid FNA with accuracy and specimen adequacy rates comparable to radiology literature (81.2% satisfactory specimens in one series of 271 biopsies) 2.
• One study demonstrated that a senior otolaryngologist performing 271 FNA biopsies achieved satisfactory specimens in 81.2% of cases, with only 9.6% unsatisfactory—results equivalent to radiology benchmarks 2.

Evidence Supporting Multi-Specialty Performance

Accuracy and Safety Data

• FNA biopsy has diagnostic accuracy approaching 95% regardless of which specialty performs it, provided the physician has proper training 4, 5.
• The procedure is safe, simple, and cost-effective when performed by trained physicians with proper technique 6, 5.
• Performance of FNA by physicians with faulty technique and interpretation by pathologists without proper training are detrimental to patient outcomes—the key is training, not specialty 6.

Advantages of Office-Based Performance

• Office-based ultrasound-guided FNA by the referring physician eliminates extra office visits, reduces healthcare costs, and allows the primary physician to be more knowledgeable about the patient's overall care 2.
• Real-time ultrasound allows continuous visualization of the needle during insertion and sampling, improving accuracy for non-palpable nodules 2.
• Having onsite cytotechnologist review for cellular adequacy at the time of biopsy reduces the need for repeat procedures 2.

Technical Considerations

Recommended Technique

• A non-suction technique with a 25- or 27-gauge needle is recommended for optimal specimen quality 6.
• Ultrasound guidance is superior to palpation-guided biopsy for accuracy, patient comfort, and cost-effectiveness, particularly for non-palpable nodules 2, 3.

Size Considerations

• Nodules less than 1.5 cm had lower unsatisfactory rates (6.3%) compared to nodules greater than 1.5 cm (12.6% unsatisfactory rate) in one office-based series 2.
• Guidelines recommend FNA for nodules >1 cm with suspicious ultrasonographic features 1, 7.

Clinical Implications for Referral Patterns

When Endocrinology Performs FNA

• Endocrinologists with ultrasound equipment and FNA training can perform the complete diagnostic evaluation in one visit, streamlining care 2.
• This approach works best when onsite cytopathology support is available for immediate adequacy assessment 2.

When Referral to Radiology is Appropriate

• Institutions without office-based ultrasound capability in endocrinology clinics typically refer to radiology 2.
• Complex cases requiring core needle biopsy or technically difficult nodules may benefit from radiology expertise 3.

When Referral to Surgery is Appropriate

• Patients with malignant or suspicious cytology (Bethesda V/VI) should be referred directly to endocrine surgeons for total or near-total thyroidectomy 7.
• Endocrine surgeons with FNA training may perform the biopsy themselves as part of surgical evaluation 2.

Common Pitfalls to Avoid

• Do not assume only radiologists can perform ultrasound-guided FNA—multiple specialties perform this procedure safely and effectively with proper training 2, 6.
• Avoid sending patients for multiple appointments across different departments when office-based FNA is available—this increases costs and delays diagnosis 2.
• Ensure whoever performs the FNA has proper training in both ultrasound-guided technique and specimen adequacy assessment—poor technique leads to high failure rates regardless of specialty 6.
• Recognize that the widespread use of cross-sectional imaging has dramatically increased detection of non-palpable nodules, making ultrasound-guided (rather than palpation-guided) FNA the standard of care 3.