THYROID
Volume 18, Number 5, 2008
ª Mary Ann Liebert, Inc.
DOI: 10.1089=thy.2007.0341
Appropriate Administration of Fine-Needle Aspiration (FNA)
Biopsy on Selective Parathyroid Adenomas Is Safe
Dear Editor:
The article by Norman et al. (1) titled ‘‘Diagnostic aspiration
of parathyroid adenomas causes severe fibrosis complicating
surgery and final histologic diagnosis’’ raises several concerns
as described below.
The collective reference of large bore needles such as 18–22-
gauge needles along with fine bore needles (25–27 gauge) is
inaccurate and misleading. Despite the obvious differences
in the outcomes, the authors conclude by calling for cessation
of the practice of fine-needle aspiration (FNA) of suspected
parathyroid adenomas. The distinction in the size of the
needles should have been defined in the study particularly
since comparisons in the outcomes between the needles have
been made. Large bore needle biopsies are associated with
greater risk of bleeding in the case of thyroid biopsy (2,3). The
use of large bore needles for performing biopsy on endo-
crine glands in the neck has largely been abandoned. In con-
trast, a quarter century use of FNA of the thyroid gland
using fine bore needles has a remarkable safety record and
utility (4).
It is also evident that the study is retrospective where
several operators using differing techniques have been in-
volved and hence the outcomes cannot be compared between
the techniques or the needles used (1). Also, the number of
passes performed is clearly far too many. We have never
found the need for any more than one or two passes with 27-
gauge needles on suspected parathyroid adenomas, and none
of these subjects developed fibrosis (5).
In this reported series of patients who developed fibrosis
reaction, none of the subjects received the 1 to 2 passes that
are sufficient to obtain adequate samples (1). In the majority
of subjects (17=30), either large bore needles were used or the
needle size was not known. Also, the 5 out of 13 subjects in
whom fibrosis followed the use of 25- to 27-gauge needles
have received an excessive number of attempts at aspiration
(mean number of passes ¼ 6) per individual procedure (1). To
summarize, what Norman et al. has reported in this journal is
a surgical series of parathyroid adenomas that have under-
gone traumatic biopsies by several operators (number of
FNAs performed ¼ 30) of unknown skill levels and possibly
practicing different aspirating techniques. Moreover, the use
of large bore needles along with the excessive number of
passes induced tumor damage and bleeding leading to de-
layed macroscopic and microscopic fibrosis reaction (1). De-
spite the administration of what appears to be traumatic
biopsy techniques with excessive number of passes using
mostly large bore needles, only 2 of the 30 patients even
581
LETTERS TO THE EDITOR
showed fibrosis during surgery when 27-gauge needles had
been used. The safety of FNA of parathyroid adenomas
using fine bore needles has been observed by several inde-
pendent groups of researchers (5–8). This fact has been over-
looked and not discussed in a balanced manner by Norman
et al.
We agree that all parathyroid adenomas visualized by
ultrasound (US) may not need biopsy confirmation. We find
biopsy confirmation to be especially valuable in Tc99 MIBI
negative subjects, in patients with multiple enlarged parathy-
roid glands, prior failed surgery, differentiating parathyroid
adenomas from posterior thyroid nodules, atypical location,
and nonfunctioning parathyroid incidentalomas. As and ad-
ded benefit, the use of US localization also enables the iden-
tification of incidental thyroid tumors and cancer that coexist
in patients with primary hyperparathyroidism that can ef-
fectively be addressed during the same surgery (5). Minimally
invasive parathyroid surgery is not applicable in those pa-
tients who have coexisting thyroid cancers or nodules with
suspicious cytology.
The authors’ concern that FNA might cause false positive
histology findings, suggesting carcinoma is farfetched since
that diagnosis would be suspected based on clinical and
biochemical findings prior to the surgery.
We conclude that US evaluation of parathyroid adenomas
with biopsy confirmation when used appropriately in select
cases is a safe technique that yields valuable information and,
therefore, cannot be discarded.
1
Dev Abraham, M.D.
2
Daniel S. Duick, M.D.
H. Jack Baskin, M.D., M.A.C.E
1
Division of Endocrinology, University of Utah,
Salt Lake City, UT
2
Endocrinology Associates, PA, Phoenix, AZ
References
1. Norman J, Politz D, Browarski E 2007 Diagnostic aspiration
of parathyroid adenomas causes severe fibrosis complicat-
ing surgery and final histologic diagnosis. Thyroid 17:1251–
1255.
2. Jones MK 2001 Management of nodular thyroid disease. BMJ
323:293–294.
3. Liu Q, Castelli M, Gattuso P, Prinz RA 1995 Simultaneous
fine-needle aspiration and core-needle biopsy of thyroid
nodules. Am Surg 61(7):628–632; discussion 632–633.
582
4. Baskin HJ, Duick DS 2006 The endocrinologists’ view of
ultrasound guidelines for fine needle aspiration. Thyroid
16(3):207–208.
5. Abraham D, Sharma P, Bentz J, Gault PM, Neumayer L,
McClain DA 2007 Utility of ultrasound-guided FNA of
parathyroid adenomas for localization before minimally in-
vasive parathyroidectomy. Endocr Pract 13:333–337.
6. Erbil Y, Salmaslioğlu A, Kabul E, Is¸ sever H, Tunaci M,
Adalet I, Bozbora A, Ozarmağan S 2007 Use of preoperative
parathyroid fine-needle aspiration and parathormone assay
in the primary hyperparathyroidism with concomitant thy-
roid nodules. Am J Surg 193(6):665–671.
7. Kiblut NK, Cussac JF, Soudan B, Farrell SG, Armstrong JA,
Arnalsteen L, Biechlin A, Delattre AA, Proye CA 2004 Fine
needle aspiration and intraparathyroid intact parathyroid
hormone measurement for reoperative parathyroid surgery.
World J Surg 28(11):1143–1147.
8. Frasoldati A, Valcavi R 2004 Challenges in neck ultraso-
nography: lymphadenopathy and parathyroid glands. En-
docr Pract 10(3):261–268.