Nondiagnostic Fine-Needle Aspiration Biopsy of Thyroid Nodules: Outcomes and Determinants

Background: Nondiagnostic results are common following fine-needle aspiration biopsy (FNAB) of thyroid nodules, but recommendations for the management of these patients vary. We sought to determine the outcomes and predictors of nondiagnostic FNABs in a single-center cohort of patients undergoing thyroid nodule evaluation. Methodology: We identified all first time ultrasound-guided FNABs performed between May 2007 and June 2013 at the Beth Israel Deaconess Medical Center Thyroid Nodule Clinic and examined demographic data, follow-up ultrasounds, repeated FNABs, and histopathologic findings. We examined the likelihood of diagnostic findings and of cancer with increasing numbers of nondiagnostic evaluations with their exact binomial confidence intervals [CIs] and potential predictors of nondiagnostic status using generalized estimating equations. Results: During the six-year period, 2234 unique individuals underwent ultrasound-guided FNAB of a thyroid nodule. The probability of obtaining a diagnostic biopsy declined from 84.4% [95% CI 82.8-85.8%] for initial FNABs to 57.6% [CI 50.8-64.2%] for the first re-FNAB and further to 42.4% [CI 25.5-60.8%] for second re-FNABs. Adjusted risk of nondiagnostic FNAB strongly increased with increasing numbers of previous biopsies and was also higher among whites. The overall rate of diagnosis of malignancy after a nondiagnostic FNAB was 8.1% [CI 4.2-13.7%] and was similar regardless of the number of previous nondiagnostic aspirations. Conclusion: Following an initial nondiagnostic FNAB, the probability of yielding a diagnostic result declines with each sequential repeat FNAB. Nonetheless, a tangible possibility of malignancy remains even after repeated nondiagnostic FNABs.