It's my 6th week at my new practice, and so far I've done 14 ultrasound-guided thyroid biopsies. It's sometimes complex, deciding who you should biopsy and who you shouldn't. In younger patients with a hypoechoic, irregular nodule with microcalcifications it's a lot more obvious, but if your patient is older and has multinodular goiter with one suspicious looking goomba, but is likely not going to live for another 10 years, sometime it's a judgment call. Not mine, but the patient's. I tell them honestly; worst case scenario they have a focus of papillary thyroid cancer, but it's likely not going to kill them before their natural deaths.
The other challenge is not getting a slam-dunk 'positive for malignancy' or 'benign' report from the pathologist.
If you get a 'nondiagnostic' report (which occurs in 5-10% of cases, a limitation of the procedure) then you're back at square one. Do you rebiopsy? If so, when? Do you just monitor with U/S? Or do you consider lobectomy?
Or, the one I consider the bigger pain-in-the-ass is the 'suspicious' report. Ie, suspicious for follicular neoplasm, or something to that effect. It's a fact. The FNA is a powerful tool, but cannot distinguish a follicular neoplasm from a follicular carcinoma. The distinction is made from histology, evidence of vascular invasion. Something you just don't see with cytology. And you know that chances are, 85% of these suckers are going to be benign, but because of the 15% otherwise, you usually end up having to send a patient to the surgeon for lobectomy. I got one such case today.
Chances are, 32-year old Mrs. F will have a benign nodule. But, we won't know until the surgeon takes out a chunk of her thyroid. A minor procedure, but a surgery nonetheless, and something I wish I wouldn't have to subject my patients to unnecessarily.