Thyroid Nodules and Cancer 101; New Guide to Use of Cutting Needle Biopsies (CNB )
Core Needle Biopsy of the Thyroid: 2016 Consensus
Statement and Recommendations from Korean Society
of Thyroid Radiology
Korean J Radiol 2017;18(1):217-237 Dong Gyu Na, et al
The physicians involved in Korea were thyroid specialists (radiology, internal medicine, surgery, nuclear medicine, cytopathology, family practice. There was no mention of any endocrinologists involved. This is unusual as they are the main physicians caring for thyroid patients in the USA.
Consensus Statement and Recommendations
Indication 1. CNB could be alternative to FNA in evaluation of thyroid nodules in selected cases
Device and procedure
2. Modern CNB devices, particularly 18–21-gauge, spring-activated, core needles, are recommended for procedure
The CNB needle with sample notch includes normal thyroid tissue the nodule and the nodule capsule.
3. Patients with bleeding tendency, such as those taking anticoagulation medications or with disorders
affecting coagulation cascade, should be thoroughly evaluated and any problems corrected before CNB
4A. CNB should be performed by experienced operators under US guidance
4B. Manual compression of biopsy site should be performed immediately after procedure for 20 to 30 minutes
5. CNB can be used as alternative to FNA for thyroid nodules with non-diagnostic cytology in previous FNA
6. CNB may be used as alternative to FNA for thyroid nodules with atypia (follicular lesion) of undetermined
significance in previous FNA
7A. CNB has advantages to differentiate encapsulated follicular neoplasm from non-neoplastic nodule
Microfollicular neoplasm with normal thyroid tissue and nodule capsule.
7B. CNB cannot differentiate follicular thyroid carcinoma from follicular adenoma
8. CNB may be used as alternative to FNA for calcified thyroid nodules
Paucicellular fibrotic nodule with calcification shows few atypical
follicular cells with nuclear atypia and can be diagnosed as papillary
9. CNB may achieve low rates of non-diagnostic and inconclusive results for initially detected thyroid nodules.
However, utility of CNB as first-line diagnostic tool for these nodules is uncertain based on current evidence
10A. CNB can be used as alternative to FNA in patients with clinical and radiological features of uncommon malignancies (anaplastic carcinoma, lymphoma, or medullary carcinoma)
10B. CNB can be used as alternative to FNA for thyroid nodules with US–cytology discordance in previous FNA
11. CNB is safe, well-tolerated, and associated with low incidence of complications when performed
by experienced operators
The indication for CNB is also still debatable.
Many articles suggested such CNB indications as thyroid nodules
with previously inconclusive FNA results, calcified thyroid
nodules, or suspicious US features, or even that it should
be used as a first-line diagnostic tool (15, 18, 43, 47, 50,59).
However, the evidence is still insufficient because of
the retrospective design of these studies and their small
patient populations. Large multicenter and/or multinational
prospective studies are necessary to establish the
indications for CNB of thyroid nodules.
A safe and effective CNB technique needs to be
established, which would consider the type and size
of the CNB needle, approach, route to nodule, number
of samplings, way of cutting the nodule and adjacent
parenchyma, and knowledge for minimizing procedurerelated
The cost of CNB may be substantially higher than that of
conventional FNA in some countries (124). Therefore, costeffective
analysis according to the individual country should
The KSThR has suggested these recommendations to
improve the efficacy and safety of CNB in the diagnosis of
thyroid nodules. The operators performing CNB should know
the basic CNB techniques and perithyroidal anatomy and
have experience with image-guided interventions
Image of a papillary thyroid cancer on CNB.
Case of classic papillary carcinoma. Specimen shows
papillary proliferative lesion with typical nuclear features of papillary