218 / 232
GA (6.3 vs 8.5 years,
P
= .006), our experience was that
many children of all ages were able to successfully undergo
FNAB in the clinic with topical anesthesia alone. We there-
fore feel that general anesthesia is unnecessarily overused
and that there is even the opportunity to perform thyroid
FNAB with ultrasound guidance in an awake child or ado-
lescent, as is common practice in adults. Nevertheless, par-
ental preference, coordination with other procedures, or a
perceived inability to tolerate an awake FNAB can drive the
desire for a higher level of anesthesia in the OR or IR suite.
Surgical Decision Making
If the fundamental goal of FNAB is to provide a diagnosis
that will influence management, there is a significant gain
to be made in avoiding unnecessary surgery and associated
complications in children with benign or nonsurgical condi-
tions. Over the course of the 7-year study, surgery occurred
only 9 times following the 191 negative FNAB results.
Stated alternatively, negative FNAB results assisted in
avoiding unnecessary surgery in 95.3% of patients in whom
it was not indicated. In these 9 cases, the decision to pro-
ceed with surgery was guided by parental concern or the
clinical judgment of the treating physician. Final histo-
pathology concurred with the initial FNAB cytopathology in
all 9 of these cases. Six of the cases occurred in the first 4
years of the study, whereas only 3 were in the last 3 years,
indicating a possible increased clinician (and conceivably
parental) confidence in FNAB results.
Aside from the avoided morbidity and mortality of sur-
gery, the cost savings are potentially significant. For exam-
ple, our institution charges $320.00 for an FNAB and
$1203.00 for a simple excisional lymph node biopsy,
excluding the cost of anesthesia ($550.00/hour), OR time
($740/hour), and a hospital room ($1017.10/day). The cost
differences are obviously more pronounced when the sur-
gery being considered is a total thyroidectomy or superficial
parotidectomy.
Limitations
This study has several limitations that are inherent in its retro-
spective nature. First, the lack of standardization of the enrolled
patients is reflective of both the diversity of pediatric HNM and
the variable diagnostic and treatment approaches by different
physicians. For example, in the routine lateral neck mass consis-
tent with BLN, there was significant variation in the use, dura-
tion, and timing of antibiotic treatment, making uniform
indications for FNAB challenging in the retrospective study. In
these instances, FNAB was only offered once the child was
deemed a potential surgical candidate, had an atypical presenta-
tion, or had an unclear diagnosis. Another limitation to this
study is the lack of universal follow-up. All patients with nega-
tive FNAB results are instructed to follow up if the HNM per-
sists or concerns remain. If no follow-up in our system was
pursued, the child was assumed to have resolution and was
counted as a clinical true negative. Even still, if these cases are
excluded from the analysis, the overall specificity of FNAB is
96.2%. Despite these limitations, this study was able to
demonstrate that FNAB in children is highly accurate and safe
in a wide range of head and neck anatomic locations, diagnoses,
and ages.
Conclusion
Fine-needle aspiration biopsy is a safe, well-tolerated, and
accurate means of diagnosing pediatric HNM of thyroid and
nonthyroid origin. Given that few nonthyroid pediatric
HNMs are malignant, FNAB plays an important role in pro-
viding reassurance to obviate the need for unnecessary sur-
gery in benign HNM. Pediatric thyroid malignancies, on the
other hand, are not infrequent, and TBSRTC should be
applied to the pediatric population with the caveat that a
higher degree of suspicion should be present when FNAB
result is indeterminate. When this triage or stratification of
pediatric HNM is employed, it potentially reduces both sur-
gical morbidity and the burden on health care resources.
Acknowledgments
We thank Li Wang and Dan Winger.
Author Contributions
Phillip Huyett
, study design, data acquisition, analysis and inter-
pretation, manuscript drafting, final manuscript approval;
Sara E.
Monaco
, study design, data acquisition and interpretation, manu-
script drafting and revisions, final manuscript approval;
Sukgi S.
Choi
, data interpretation, manuscript drafting and revisions, final
manuscript approval;
Jeffrey P. Simons
, study design, data interpre-
tation, manuscript drafting and revisions, final manuscript approval.
Disclosures
Competing interests:
None.
Sponsorships:
None.
Funding source:
The statistical analysis performed in this project
was supported by the National Institutes of Health through grant
UL1TR000005.
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