Biopsy of a thyroid gland

Description:

Now thyroid nodules come to light approximately at a half of women at the age of 50 years. At more advanced age thyroid nodules can be revealed and is even more often. Statistically, about 5-6% of nodes can be malignant. Other thyroid nodules are the high-quality formations of not tumoral nature which do not have ability "to regenerate" in cancer. The main objective of doctors is presently not removal of all thyroid nodules as it is impossible, and carrying out the exact diagnosis allowing to divide nodes into the high-quality, not demanding most often treatments, and malignant at which surgical intervention is necessary.

The fine-needle biopsy of thyroid nodules is the main diagnostic method of cancer of thyroid gland. The puncture of a thyroid nodule and the subsequent research of the received cytologic drugs allows to define type of a structure of a node and to formulate recommendations about further maintaining the patient. It is possible to tell with confidence that without high-quality performance of a fine-needle biopsy of a thyroid gland also high-quality treatment of patients with thyroid nodules is impossible.

Indications to a biopsy of a thyroid gland:

It is necessary to carry out a biopsy of a thyroid gland at identification of nodes of 1 cm in size and whether more. Nodes of the smaller size can be not subjected a biopsy as their clinical value is small, and even malignant nodes can seldom lead to serious effects for the patient. In some cases the biopsy of a thyroid gland can be carried out also at identification of nodes up to 1 cm in size – for example, in cases when the patient was irradiated during the life, or has the relatives having cancer of a thyroid gland. The doctor of ultrasonography diagnosis also can insist on carrying out a biopsy of a thyroid gland if the node found at ultrasonography of a thyroid gland has a number of the guarding signs forcing to suspect its malignant character.

Technology of carrying out biopsy of a thyroid gland:

Now the biopsy of a thyroid gland can be carried out only under ultrasonic control. TAB of thyroid nodules under ultrasonography control has considerably big accuracy, than the biopsy which is carried out under control of a palpation (palpation) of a thyroid gland.

For carrying out a biopsy of a thyroid gland syringes with a capacity of 10 or 20 ml with needles with a diameter of 23-21G are used. TAB of thyroid nodules with an ulterior motive is called a fine-needle biopsy - in our center needles 23G as the thinnest are applied to carrying out a biopsy of a thyroid gland. Use of such fine needles allows to reduce expressiveness of pain when carrying out a biopsy, and also to improve quality of the cytologic drug received at a biopsy due to decrease in quantity getting to a blood smear.

In most cases carrying out a puncture of a thyroid gland does not demand additional anesthesia as the experienced doctor can carry out a biopsy of a thyroid gland in 2-5 seconds, and diameter of a syringe needle is so small that the prick is felt very poorly. Practically all centers which are carrying out a biopsy of a thyroid gland do not use any additional anesthesia of skin. There is, however, a number of clinics where the fine-needle biopsy of thyroid nodules is carried out under anesthetic, however it is impossible to recognize such technique justified as the risk and pain connected with carrying out the general anesthesia considerably exceed risk and morbidity when carrying out a biopsy of a thyroid gland. In our center for patients with hypersensitivity of skin surface anesthesia of skin by EMLA cream on the basis of lidocaine and a prilokain, Lightdep cream or XYLOCAINE spray on the basis of xylocainum is used. Cream is applied on skin in 1 hour prior to carrying out a biopsy of a thyroid gland. The biopsy of a thyroid gland with use of a surface anesthesia does not reduce the accuracy of a research and allows to reduce expressiveness of pain at the patient.

For carrying out a puncture of a thyroid gland it is not obligatory for patient to starve at all – from that, the patient before a biopsy ate or not, the thyroid nodule will not change the nature. Carrying out a biopsy of a thyroid nodule takes about 10-15 minutes from which 99% of time are spent for registration of the patient, an explanation for it of a technique of carrying out a biopsy and data entry in the computer. The puncture of a thyroid gland as it was told earlier, takes only several seconds and is well transferred by all patients. Right after carrying out a fine-needle biopsy of a thyroid nodule the patient can leave the medical center and start the daily affairs.

Before carrying out a fine-needle biopsy of a thyroid nodule the doctor asks the patient to lay down on a back on a therapy table with adjustable height. Under a back of the patient the small pillow is enclosed that provides the sufficient extension of a neck necessary for convenient carrying out a biopsy of a thyroid gland. Skin of a neck is disinfected by an antiseptic agent and delimited by a sterile napkin.

The doctor who is carrying out a puncture of a thyroid gland will see off to the patient of ultrasonography during which he defines quantity, the size and an arrangement of thyroid nodules, and also selects the nodes demanding carrying out a biopsy. Then the puncture of a thyroid gland is carried out actually. It is important to note that at all stages of carrying out a biopsy it is necessary to observe sterility to avoid a possibility of infection of the patient with the infections which are transferred with blood (hepatitises, HIV). The "weak" place when ensuring sterility during such procedure as a puncture of a thyroid gland is disinfection of the ultrasonic sensor which is used for aiming at the node chosen for a biopsy. In the majority of the clinics which are carrying out a biopsy of a thyroid gland, the ultrasonic sensor after a biopsy plunges into the disinfecting solution for the purpose of destruction of the microorganisms and viruses which got on it. Unfortunately, similar processing is not enough for full disinfection of the sensor as infectious agents have high resistance to the disinfecting means which are used in medicine. When performing a puncture of a thyroid gland by a traditional method to several patients in a row during the day the probability of transfer of infectious diseases increases with increase in number of the patient in turn – the last patients in turn have the greatest risk to ache, in connection with hit of an infection from the ultrasonic sensor in the patient's organism.

Many clinics at a puncture of a thyroid gland use the nozzles on the sensor intended for targeting of a needle during a puncture. Use of puncture nozzles through which there passes the needle when carrying out a biopsy of a thyroid gland allows to facilitate hit of a needle in a node, but right there creates a new problem: at hit of blood in a narrow gleam of a puncture nozzle it is possible to remove it only by long processing with the subsequent sterilization by autoclaving from there that often is not made by the medical centers.

Full sterility of the procedure of a fine-needle biopsy of thyroid nodules in our center is provided in two ways: the technique of "a free hand" without use of a puncture nozzle is applied to a biopsy, and the ultrasonic sensor is protected by a sterile one-time cover. The biopsy of a thyroid gland using a technique of "a free hand" is carried out so: the doctor holds the ultrasonic sensor in one hand, and in another – an aspirating needle. Any additional guides a needle of devices it is not applied. Hit in a node in such conditions demands from the doctor of the fulfilled skill, but provides the best control of all process of a biopsy and allows to do without puncture nozzles which are difficult disinfected. The sterile cover which is utilized right after carrying out a biopsy of a thyroid gland that completely eliminates possible contact of the sensor with blood is put on the ultrasonic sensor in the presence of the patient.

After carrying out a puncture of a thyroid gland to the place of a prick the sterile ball which can be removed in 5 minutes is imposed.

Thus, the main distinctive features of a technique of carrying out a fine-needle biopsy of thyroid nodules in our center are:

use of needles of smaller diameter;
use of the anesthetizing cream;
full sterility of the procedure at all its stages.

Problems when performing a biopsy of a thyroid gland:

Today the general quality of carrying out a biopsy of a thyroid gland in Russia remains very low. At consultation by specialists of our center of the cytologic drugs made in other clinics, the diagnosis is exposed to change in 60% of cases. In some cases the drugs received for consultation admit not informative or having poor quality of performance that forces us to recommend to the patient a repeated biopsy in our medical center for the purpose of establishment of the true diagnosis.

The problems of quality of a biopsy of a thyroid gland existing in Russia are caused by two main reasons.

The first reason – in the Russian Federation doctors with the certificate in "Laboratory business" have the right to analyze the cytologic drugs received at a fine-needle biopsy of thyroid nodules. The specialists who had training on pathological anatomy and knowing a structure of tissue of thyroid gland in details are not allowed to cytologic diagnosis. Instead doctors whose main work is the analysis of blood smears, an urocheras and smears from a vagina are engaged in the analysis of the drugs received at a biopsy of a thyroid gland. Doctors-cytologists, according to the Russian legislation, can not have preparation on pathological anatomy and histology at all. It turns out that to guess a structure of a thyroid nodule on the separate cells received from it at a biopsy doctors who do not know a structure of the same most thyroid gland at all have to. At the same time the doctors-pathologists who are carrying out all the life behind a microscope and perfectly guided in a structure of tissue of thyroid gland are normal also at her various diseases, without obtaining the certificate on laboratory business cannot be allowed to cytologic diagnosis. At the existing system of the organization of cytologic diagnosis doctors-cytologists carry out primary analysis of a structure of thyroid nodules by results of a fine-needle biopsy, and the final diagnosis after removal of a node is established already by the doctors-patologanatomami having an opportunity to investigate all fabric of a node. Doctors-cytologists cannot even study at the mistakes as they never learn about them – the final research of a node is made already absolutely by other specialists. Around the world there is a uniform specialty – morphology which combines in itself both cytologic diagnosis, and histologic. The research of the cytologic drugs received at a biopsy of a thyroid gland is made by the same doctor who then, in case of need, estimates also a node structure after its removal. Similar approach provides the maximum accuracy of diagnosis as at all its stages the specialists who are perfectly understanding a structure of a thyroid gland and its nodes participate in work. Unfortunately, in our country similar approach to the organization of diagnostic process still is not standard.
The second important problem of the Russian practice of performance of a biopsy of a thyroid gland is use by doctors-cytologists of outdated classification of diseases of the thyroid gland comprising a number of the conclusions, very strange from a clinical point ("Follicular adenoma", "Atipichesky adenoma" and so forth). In all the world the classification of The Bethesda System for Reporting Thyroid Cytopathology dividing all possible versions of the cytologic conclusions into five main sections is standard:

cancer of a thyroid gland (with the tumor instruction);
follicular neoplasia (probability of existence of follicular cancer of thyroid gland);
high-quality node;
inflammatory center;
not informative material.
Use of modern classification allows to achieve a main goal of carrying out a biopsy of a thyroid gland – to accurately define clinical tactics.

Results of a biopsy of a thyroid gland:

From three to seven days the cytologic research of the material received at a biopsy lasts. Results can be formulated differently. For example, there can be following formulations:

"Nodal craw". It means that high quality of new growths makes 98%.
"Colloid", "blood" or "cells of a follicular epithelium". Such formulation means that these nodes are good-quality with probability in 95%.
Various formulations in which the word "carcinoma" sounds are an alarm signal. It means that the probability of a zlokachestvennost makes from 70% to 100%.
The small error anyway exists. It is connected with qualification of the personnel performing the procedure and with features of the body. At nodes of the small size it is not always possible to select on the analysis only node contents because in a needle there can be a blood impurity, and it impedes the exact implementation of the analysis.