Advantages of thyroid core needle biopsy: an emerging selective first-line biopsy modality

CNB as selective first-line modality

Article information

Ultrasonography. 2026;45(3):205-217

Publication date (electronic) : 2026 April 22

doi : https://doi.org/10.14366/usg.25201

Jae Ho Shin ¹

, Yeseul Kim ²

, Min Kyoung Lee ³

, Jung Hwan Baek ⁴

, So Lyung Jung^,⁵

¹Department of Radiology, Korea University Anam Hospital, Seoul, Korea

²Department of Pathology, Korea University Anam Hospital, Seoul, Korea

³Department of Radiology, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

⁴Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

⁵Department of Radiology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Correspondence to: So Lyung Jung, MD, Department of Radiology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon 16247, Korea Tel. +82-1577-8588 Fax: +82-2-599-6771 E-mail: sljung1@catholic.ac.kr

Received 2025 October 3; Revised 2026 January 30; Accepted 2026 February 7.

Abstract

Ultrasound-guided fine needle aspiration biopsy (FNAB) for thyroid lesions has proven safe and effective; however, FNAB has limitations, including the frequent occurrence of nondiagnostic and inconclusive results and technical challenges in specific clinical scenarios. To address these limitations, core needle biopsy (CNB) was introduced, and substantial advancements have been made in CNB devices and techniques. Evidence from large patient cohorts indicates that CNB is not only safe and reliable but also provides superior diagnostic accuracy compared with FNAB. This review discusses recent advancements in CNB techniques to optimize tissue sampling, the diagnostic performance of CNB, and patient-centered perspectives, highlighting the potential of CNB as a selective first-line biopsy modality.

Keywords: Thyroid; Ultrasonography; Biopsy

Introduction

Advancements in high-resolution ultrasound (US) have considerably improved image quality and overall detection of thyroid nodules, contributing to an increase in the number of thyroid biopsies. Fine needle aspiration biopsy (FNAB) of thyroid nodules has been widely regarded as a reliable and cost-effective diagnostic tool [1–4]. In addition to its high sensitivity for differentiating malignant from benign nodules, FNAB’s straightforward capillary-sampling mechanism, combined with procedural efficiency, makes it well suited for outpatient practice and a preferred first-line biopsy modality [2,5,6]. Nevertheless, a major limitation of FNAB is the frequent occurrence of inconclusive results, including nondiagnostic outcomes and atypia of undetermined significance [7–12].

Core needle biopsy (CNB) has undergone substantial advances in devices and techniques, and its use has expanded beyond that of an alternative biopsy modality because of better diagnostic performance than FNAB [13–16]. For example, several studies reported that CNB outperformed repeat FNAB in the re-evaluation of inconclusive FNAB results and outperformed FNAB in challenging scenarios, such as nodules with rim calcification, macrocalcifications, or cystic components [17–20]. In addition, major progress in CNB practice has been shaped by two guideline documents published in 2017 by the Korean Society of Thyroid Radiology and in 2020 by the Korean Thyroid Association [21,22]. Both guidelines provide evidence-based practical recommendations aimed at improving the efficiency, safety, and diagnostic performance of CNB.

This review highlights technical innovations and improvements addressed in the two major guideline publications from the Korean Society of Thyroid Radiology and the Korean Thyroid Association, along with advancements and findings that may not have been fully covered in those documents [21,22]. The review also provides a comprehensive overview of the diagnostic performance of CNB, management of complications, and patient-centered perspectives, thereby highlighting the emerging role of CNB as a selective first-line biopsy modality.

Historical Overview of CNB Devices

Before the development of modern thyroid-dedicated CNB, the Vim-Silverman needle (MacGregor Instrument Co., Camas, WA, USA) and large-bore needles (e.g., 14-gauge needles) were used to obtain thyroid nodule specimens through the 1980s [21–24]. The Vim-Silverman needle consisted of a stylet for puncture, a cannula to guide the target tissue, and a bifid needle for specimen retrieval. Biopsies were typically performed under palpation guidance, with solid portions targeted for sampling, whereas cystic regions were aspirated using a syringe with a thinner needle (21–23G) [23]. In essence, early CNB techniques involved puncturing and nicking the tissue.

Concerns have been raised regarding the invasiveness of CNB and the potential for increased hemorrhage risk due to the use of thick needles. Modern CNB devices with thinner calibers (18G–21G) have been developed to address these concerns [21]. Nasrollah et al. [25], for example, demonstrated the feasibility of CNB using a 21-G device (Menghini cutting needle; diameter, 0.514 mm) in 40 consecutive indeterminate nodules previously assessed with FNAB. In that study, 21-G CNB achieved a high specimen adequacy rate (97.5%) without major complications and enabled identification of 35% of benign lesions.

Modern thyroid-dedicated CNB devices typically have shorter needle lengths than liver or lung biopsy devices and are categorized by two main features: the location of the cutting mechanism and the type of spring-action mechanism. The cutting mechanism may be side-cutting or end-cutting, with side-cutting devices now standard for head, neck, and thyroid biopsies. End-cutting needles use a hollow trocar to extract cylindrical specimens, with the cutting action occurring at the tip [26,27]. Automatic CNB devices use a “double-action” mechanism in which the inner needle is propelled by a spring for penetration, followed by spring-powered advancement of the outer cutting cannula to obtain a tissue sample [21]. In contrast, semi-automatic devices use a “single-action” mechanism in which the inner stylet is advanced manually, followed by spring-powered firing of the cutting cannula. Owing to this single-action mechanism, semi-automatic devices have limitations in penetrating hard tissue, fibrotic components, and calcified nodules. Nevertheless, semi-automatic devices offer distinct advantages, including greater maneuverability for adjusting the needle trajectory and finer control of the cutting cannula, thereby enhancing procedural safety. Park et al. [28] reported comparable rates of nondiagnostic results with semi-automatic CNB devices (0.7%) and automatic CNB devices (1.8%). Furthermore, the overall complication rate remained low, with only 2.4% minor complications. Although that study suggested that both CNB device types are effective and safe, device selection requires careful consideration of factors such as thyroid nodule size, characteristics, location, and operator experience.

Standard CNB Techniques

Standard CNB techniques are widely practiced in Korea and recommended by guidelines published by the Korean Society of Thyroid Radiology and the Korean Thyroid Association [21,22]. US-guided CNB consists of vessel mapping, injection of 1% lidocaine, puncture, targeting, and specimen sampling [22]. Meticulous vessel mapping is a critical preparatory step before puncture and insertion of the CNB device through the thyroid gland (Fig. 1). A 1% lidocaine solution is injected into the puncture site and perithyroidal region to provide local analgesia. For safe and effective CNB, the needle should be oriented parallel to the US plane to ensure visualization of the entire needle length (Fig. 2). Although a transisthmic approach is preferred because of a shorter distance and lower risk of hematoma formation, the approach may vary depending on factors such as nodule composition (e.g., the solid portion in mixed nodules), nodule location, and vascular distribution (e.g., intranodular or perinodular vessels) [21].

Fig. 1.

Pre-biopsy vessel mapping and lateral approach.

A. A 31-year-old woman with endometrial cancer underwent core needle biopsy (CNB) for a large, 2.1-cm hypoechoic nodule with an irregular border, macrocalcification, and punctate echogenic foci in the left thyroid gland. B. Microvascular imaging demonstrated a traversing superior thyroid artery in the isthmus (arrow), precluding the conventional transisthmic CNB approach. C. A CNB trajectory with minimal vascularity (dashed line) was planned to minimize complications such as hematoma and pseudoaneurysm formation. D. CNB via a lateral approach was performed successfully without complications. CNB and surgical pathology confirmed papillary thyroid carcinoma.

Fig. 2.

Application of standard core needle biopsy (CNB) technique after a previous nondiagnostic fine needle aspiration biopsy (Bethesda category I).

A. A 52-year-old woman underwent CNB after a nondiagnostic fine needle aspiration biopsy result. A 6-mm hypoechoic nodule with rim calcification was present in the right thyroid gland, showed a nonparallel orientation, and was classified as Korean Thyroid Imaging Reporting and Data System 5. B. Using a transisthmic approach, a spring-activated CNB device successfully penetrated the rim-calcified nodule and obtained an adequate specimen, leading to a diagnosis of papillary thyroid carcinoma. C. The conventional CNB technique primarily targets the intranodular solid portion. D. Histopathology confirmed papillary thyroid carcinoma (H&E, ×100).

Standard CNB Technique: Marginal Targeting

In earlier years, the optimal specimen-sampling method for accurate diagnosis was debated. Marginal targeting was introduced in 2013 by Nasrollah et al. [25]. CNB sampling is performed such that the cutting notch includes three components: nodular tissue, the nodular margin, and perinodular normal thyroid tissue (Fig. 3). This approach may help differentiate nodular hyperplasia from follicular neoplasm in indeterminate nodules [25,29]. Furthermore, Hahn et al. [30] reported that two marginal-targeting passes are adequate for predicting thyroid neoplasm and malignancy in thyroid nodules with low- and intermediate-suspicion features. In that study, marginal targeting demonstrated high diagnostic performance, with 100% accuracy in differentiating non-tumors from tumors and 88.8% accuracy in differentiating benign from malignant lesions among low- and intermediate-suspicion nodules. However, for malignancies such as classic papillary thyroid carcinoma and thyroid metastasis, a single intranodular sample is typically sufficient rather than multiple biopsies, because pathological assessment primarily depends on nuclear and cytoplasmic characteristics [30–32].

Fig. 3.

Application of marginal-targeting biopsy technique after indeterminate fine needle aspiration biopsy (Bethesda category III).

A. A 77-year-old woman underwent core needle biopsy (CNB) for a 17 mm×19 mm isoechoic nodule with punctate echogenic foci and macrocalcification in the right thyroid gland, suggestive of Korean Thyroid Imaging Reporting and Data System 4. B, C. The modified CNB technique should ensure that the cutting notch includes three components: (1) intranodular tissue, (2) the nodular margin, and (3) perinodular normal thyroid tissue. D. Histopathology confirmed a follicular neoplasm with a thin tumor capsule and mild nuclear atypia (H&E, ×100).

Standard CNB Techniques: Elevating Maneuver

An effective standard CNB technique for nodules in difficult locations is the elevating maneuver. The consensus statement and recommendations of the Korean Society of Thyroid Radiology endorsed its use for small nodules located deep in the posterior thyroid [21]. Although no studies have evaluated its efficacy, this maneuver is frequently used not only for deeply located nodules but also to enable safe and effective biopsy of nodules close to critical anatomical structures, such as the common carotid artery (Fig. 4). After firing, the stylet is lodged in the target nodule. If necessary, the stylet may be carefully advanced through the nodule to facilitate elevation; otherwise, shallow penetration may lead to slip-off during the elevating maneuver. The device is then gently tilted to elevate the nodule away from adjacent critical structures before firing the cutting cannula.

Fig. 4.

Application of elevating maneuver after indeterminate fine needle aspiration biopsy (Bethesda category III)

A. An 80-year-old woman underwent core needle biopsy (CNB) for an 11-mm isoechoic nodule with punctate echogenic foci and a hypoechoic rim in the right thyroid gland, suggestive of Korean Thyroid Imaging Reporting and Data System 4. B. Because the CNB trajectory aligned with the right common carotid artery (CCA) (solid line), the elevating maneuver was used. C, D. After the CNB stylet was lodged in the target nodule, the device was gently elevated to displace the nodule upward and away from the original trajectory (dotted line). Note that the CNB trajectory (solid line) no longer aligns with the CCA because of upward elevation (arrow). CNB was performed for marginal targeting: (1) intranodular tissue, (2) the nodular margin, and (3) perinodular normal thyroid tissue. E. Histopathology confirmed a follicular neoplasm with a thin tumor capsule and nuclear atypia (H&E, ×150).

Advanced CNB Techniques: Hydrodissection

CNB has traditionally been considered less versatile than FNAB because of its larger needle size and limited maneuverability. In radiofrequency ablation of thyroid nodules, hydrodissection is an essential technique that involves fluid injection to create a safe distance between the target nodule and adjacent critical anatomical structures [33]. Similarly, hydrodissection can facilitate sampling in previously challenging locations, such as small nodules near critical structures. Ebrahiminik et al. [34] suggested injecting 0.9% saline solution via a 19-gauge spinal needle between the target thyroid nodule and critical structures, such as the common carotid artery, trachea, esophagus, and tracheoesophageal groove. In all cases in that study, specimen acquisition was technically successful, demonstrating the reliability and safety of hydrodissection-assisted CNB. Hydrodissection can also be performed using thinner needles (21–25 gauge). Gradual injection of solution (generally at a rate of 1–2 mL/s) along the thyroid capsule is performed (Figs. 5, 6). During this process, it is essential to maintain a parallel orientation to the thyroid capsule to optimize separation between the true and false capsules. If resistance is encountered and saline cannot be injected smoothly, the needle position and orientation should be adjusted. In the referenced study, the authors reported using an average of 25.9 mL of saline to separate the target nodule from surrounding critical structures by at least 10 mm [34]. In the authors’ experience, hydrodissection was successfully performed in most cases using a thin 25-gauge needle and less than 10–15 mL of normal saline; however, a larger volume may be required for posteriorly located thyroid nodules.

Fig. 5.

Application of hydrodissection-assisted core needle biopsy (CNB) technique.

A. A 55-year-old woman underwent hydrodissection-assisted CNB for a 10-mm hypoechoic nodule with an irregular margin (arrows) in the right thyroid gland, suggestive of Korean Thyroid Imaging Reporting and Data System 5. B, C. Approximately 10 mL of a lidocaine–normal saline mixture was injected along the right thyroid capsule (dashed line), separating the true from the false capsule to create a safety margin (arrow) between the target nodule and the right common carotid artery (CCA). D. CNB was performed for marginal targeting: (1) intranodular tissue, (2) the nodular margin, and (3) perinodular normal thyroid tissue. T, target nodule.

Fig. 6.

Application of hydrodissection-assisted core needle biopsy (CNB) of a densely calcified nodule.

A. A 46-year-old woman underwent CNB of a 14-mm mildly hypoechoic nodule with thick macrocalcification in the right thyroid gland, suggestive of Korean Thyroid Imaging Reporting and Data System 4. B. Hydrodissection was used prophylactically to change the CNB trajectory away from the right common carotid artery and to secure a safety margin in case of device overshooting or ricochet. C. Spring-activated CNB was used to provide greater thrust than a semi-automatic CNB device. The cutting notch is not visible because of pronounced posterior acoustic shadowing. D. Histopathology confirmed a benign nodule with stromal fibrosis and dystrophic calcification (H&E, ×100).

Advanced CNB Techniques: Calcified Nodules

Calcified thyroid nodules, particularly those that are entirely calcified, pose substantial challenges for FNAB and often yield nondiagnostic results. The main reasons include difficulty penetrating dense calcification and limited maneuverability for capillary sampling. One CNB strategy is to identify “weak” points within a calcified nodule (e.g., areas of interrupted calcification) and advance the stylet with a strong thrust. If penetration remains ineffective, a drilling motion of the stylet at a fixed point may be a useful alternative (Fig. 7) [35]. Once a weak point is identified, the stylet is fired from a safe distance. After the stylet is lodged at the weak point, the CNB device is advanced slowly with alternating rotational motion, mimicking drilling (Video clip 1). Another factor complicating biopsy of densely calcified nodules is prominent posterior acoustic shadowing, which can obscure visualization of the needle and cutting cannula. In this setting, it is important to estimate the position of the cutting notch based on its initial placement before making the final cut. Rather than relying solely on a powerful thrust, a drilling motion should be considered because it may reduce the risk of device ricochet or overshooting. Nevertheless, there is a risk of inadvertently sampling adjacent thyroid parenchyma rather than the intended calcified tissue. To address this issue, visual inspection of the CNB specimen is a simple and effective way to assess sample adequacy; whitish calcified material can be seen grossly in an adequate specimen [21,35]. However, when the specimen is bloody or contains mostly whitish-gray soft tissue, visual inspection may be equivocal. In such cases, a case report investigated the potential use of mammography as an adjunct imaging technique to confirm that the CNB device sampled the calcified component and to provide additional assurance regarding specimen retrieval accuracy [36].

Fig. 7.

Application of core needle biopsy (CNB) for a nodule with macrocalcification.

A. A 63-year-old man underwent CNB for an 8 mm×9 mm hypoechoic nodule with punctate echogenic foci and dense macrocalcification, suggestive of Korean Thyroid Imaging Reporting and Data System 5. B, C. After the stylet was fired from a safe distance, the CNB device was advanced slowly with alternating rotational motion, mimicking drilling. Histopathology suggested papillary thyroid carcinoma.

Diagnostic Performance of CNB

The first published diagnostic report on US-guided CNB was a study by Quinn et al. [37] in 1994, in which the authors demonstrated high diagnostic performance in a cohort of 102 patients. Similarly, a 2003 study reported relatively high diagnostic performance, with 92% accuracy for differentiating neoplastic from non-neoplastic lesions and 96% accuracy for identifying malignant neoplasms [38]. CNB outperforms FNAB because it yields larger specimens, preserves architectural histologic detail, and allows immunohistochemical staining [21,39,40]. Specifically, molecular markers such as Gal-3, HBME-1, CD20, and cytokeratin 19 can be applied to CNB specimens to enhance diagnostic accuracy (Figs. 8, 9) [40].

Fig. 8.

Thyroid lymphoma presenting as sudden neck swelling.

A. A 64-year-old man with a history of left hemithyroidectomy for papillary thyroid carcinoma was admitted for sudden swelling of the right thyroid gland. Axial computed tomography revealed a right thyroid mass measuring approximately 53 mm×51 mm, with substantial mass effect and displacement of the trachea and adjacent vessels. B. Ultrasound demonstrated a large hypoechoic mass replacing the right thyroid parenchyma. C. Core needle biopsy (CNB) was performed safely and effectively. D. Histopathology confirmed diffuse large B-cell lymphoma (H&E, ×250). E, F. Additional immunohistochemical staining, including CD20 and Ki-67, was performed (×250). The larger tissue yield of CNB, compared with fine needle aspiration biopsy, facilitated comprehensive immunohistochemical analysis.

Fig. 9.

Recurrent thyroid lymphoma without neck swelling.

A. An 80-year-old woman with a history of extranodal marginal zone B-cell lymphoma was admitted because of abnormal fluorodeoxyglucose uptake on positron emission tomography–computed tomography. The right thyroid gland demonstrated diffuse low echogenicity without mass effect, mimicking chronic lymphocytic thyroiditis. B, C. Core needle biopsy was performed on the right thyroid gland. D, E. Histopathology confirmed recurrent lymphoma with atypical B-lymphocytic infiltration (H&E, ×8, ×130). F. Immunohistochemical staining confirmed CD20 positivity (×130).

Diagnostic Performance of CNB: First-Line Biopsy Modality

One key study supporting CNB as a first-line biopsy modality is the meta-analysis by Chung et al. [41]. Thirteen studies were included, comprising 13,585 nodules from 9,166 patients who underwent CNB as a first-line biopsy. The overall nondiagnostic rate for first-line CNB was 3.5%, substantially lower than that reported for FNAB (>10% for initial FNAB and up to 50% for repeat FNAB) [41–43]. Similarly, the rate of inconclusive results was 13.8% for first-line CNB, again lower than rates reported for FNAB (>30%) [10,41]. When Bethesda category VI was considered positive, first-line CNB showed a sensitivity of 80.0% and a specificity of 100% for differentiating malignancy [41]. In contrast, a meta-analysis of FNAB in 16,597 patients—using Bethesda categories III–VI as positive—reported comparable sensitivity (85.6%) but substantially lower specificity (71.4%) [2]. As a first-line modality, CNB yielded few or no false-positive results while maintaining consistently low nondiagnostic and inconclusive rates.

Additional evidence supporting CNB as a first-line biopsy modality has been provided by several studies. Hong et al. [44] conducted a prospective study evaluating the potential role of CNB as a first-line biopsy modality and provided practical insights into nodule-specific use. The study used visual assessment of CNB specimens to determine the need for additional sampling, particularly for small nodules prone to mistargeting; nodules >3 cm or those with heterogeneous internal components; and nodules with macrocalcification or fibrosis. Using this approach, CNB demonstrated superior diagnostic performance across nodule sizes. Chen et al. [45] performed FNAB and CNB simultaneously and reported that CNB was a promising first-line biopsy modality, increasing sensitivity and accuracy for predicting malignancy. Notably, CNB showed higher sensitivity for malignancy even in small nodules ≤1.0 cm. Finally, a large cohort-based propensity score analysis by Suh et al. [9] reported higher sensitivity for diagnosing malignancy and a lower nondiagnostic rate for first-line CNB than for FNAB, with Bethesda category VI used to define malignancy.

Diagnostic Performance of CNB: Diffusely Infiltrative Lesions

Diffuse infiltrative lesions are currently categorized as Korean Thyroid Imaging Reporting and Data System (K‑TIRADS) 4 (intermediate suspicion). Overlapping US features, such as hypoechoic lesions with ill-defined margins, can pose diagnostic challenges, particularly in patients with malignancy [46]. In a study by Choi et al. [47], CNB demonstrated 100% sensitivity and 100% specificity for diagnosing thyroid metastasis. Compared with FNAB, CNB showed superior sensitivity (100% vs. 58.6%), making it the preferred biopsy modality in patients with cancer—particularly those with renal cell cancer, lung cancer, or breast cancer—who present with diffusely infiltrative thyroid lesions. Furthermore, patients with cancer who receive adjuvant radiation therapy to the supraclavicular region are at increased risk of radiation-induced hypothyroidism and thyroiditis because of incidental irradiation of the thyroid gland [48]. If radiation-induced thyroiditis mimics metastasis on US, CNB is recommended, particularly when FNAB yields inconclusive results.

Diagnostic Performance of CNB: Calcified Nodule

Thyroid nodules containing macrocalcifications (punctate echogenic foci >1 mm) may have a malignancy rate as high as 35.3%, necessitating biopsy when the nodule meets biopsy criteria [49,50]. In addition, entirely calcified nodules are associated with a low to intermediate malignancy risk (11.4%–16.1%) [35]. According to the updated K-TIRADS, entirely calcified nodules are classified as intermediate suspicion, and biopsy is recommended when the nodule size meets the criteria [51]. In such cases, a spring-activated CNB device offers an advantage because it provides greater thrust than FNAB or semi-automatic CNB devices, facilitating penetration through dense calcification. In a study comparing the diagnostic efficacy of FNAB and CNB in entirely calcified nodules, CNB outperformed FNAB, yielding fewer nondiagnostic results (7.7% vs. 53.8%) and fewer inconclusive results (15.4% vs. 57.7%) [35]. Similarly, another study reported superior performance of CNB over FNAB in nodules with macrocalcification, with a lower nondiagnostic rate (3.7% vs. 33.3%) [50].

Diagnostic Performance of CNB: Rare Tumors

Sudden neck bulging and swelling are an uncommon clinical presentation, for which underlying causes range from de Quervain thyroiditis to rare but aggressive entities such as thyroid lymphoma and anaplastic carcinoma. A meta-analysis of 17 studies reported that CNB is recommended over FNAB in patients with suspected lymphoma or anaplastic carcinoma [52]. Pooled estimates showed that CNB achieved a sensitivity of 94.3% and a specificity of 100% for diagnosing thyroid lymphoma and a sensitivity of 80.1% and a specificity of 100% for diagnosing anaplastic cancer, thereby reducing the need for unnecessary excisional biopsy. Similarly, Ha et al. [53] supported CNB as a first-line modality, reporting that it outperformed FNAB for diagnosing thyroid lymphoma and anaplastic cancer, with higher sensitivity (87.5% vs. 50.6%).

Presented with US features such as scattered parenchymal punctate echogenic foci, the diffuse sclerosing variant of papillary thyroid carcinoma is a rare, aggressive subtype compared with classic papillary thyroid carcinoma [54]. In a study by Yim et al. [54], CNB demonstrated higher sensitivity (96.9% vs. 81.4%) and negative predictive value (90.0% vs. 57.9%) than FNAB, while both modalities showed statistically comparable diagnostic accuracy. Given the sensitivity of 96.9% for differentiating malignancy in the setting of diffuse parenchymal punctate echogenic foci, CNB may serve as a first-line modality in this clinical context to reduce false-negative results.

Patient’s Perspective

When CNB is discussed with patients during the consent process, three concerns are commonly raised: cost-effectiveness, pain, and potential complications. CNB is sometimes perceived as unnecessary, with greater discomfort and higher complication risk than FNAB, particularly among patients who previously received nondiagnostic FNAB results or had painful FNAB experiences. Nevertheless, understanding the diagnostic accuracy of CNB—particularly when performed by an experienced operator—is important, as this benefit outweighs the low risk of major complications. This section addresses three key patient perspectives on CNB: cost-effectiveness, tolerability, and complications.

Cost-Effectiveness of CNB

Trimboli et al. [55] reported in 2015 that CNB of nodules previously classified as indeterminate on FNAB prevented unnecessary diagnostic thyroidectomies and substantially reduced hospital costs. In that study, a theoretical cohort of patients with indeterminate nodules was analyzed for cost-effectiveness. If all patients had undergone diagnostic thyroidectomy, the estimated cost would have been approximately 636,400 euros. By reducing unnecessary surgery in patients with benign pathology, CNB reduced expenses by 215,000 euros, representing cost savings of nearly one-third. Furthermore, repeated FNAB may increase overall patient costs, including transportation expenses and income loss due to hospital visits [56,57].

There is no strong recent evidence or comparative study evaluating the cost-effectiveness of CNB by thyroid nodule characteristics or patient demographics, or directly comparing CNB and FNAB cost-effectiveness. Nevertheless, repeated FNAB has limitations: up to 31% of patients still receive Bethesda category III results after prior nondiagnostic or Bethesda III outcomes, and a third FNAB is often less diagnostic for nodules with repeated nondiagnostic results [20,58]. Another study reported that a first repeat FNAB after an initially nondiagnostic result yielded a diagnosis in 58% of cases, whereas a second repeat FNAB achieved a 50% diagnostic rate [43]. Considering the diagnostic performance of CNB as a complementary modality, CNB may offer more favorable cost-effectiveness than FNAB because it reduces the likelihood of repeated FNAB or diagnostic lobectomy [59]. Moreover, implementing CNB as a selective first-line biopsy modality may lower overall health care costs and improve procedural efficiency, particularly for nodules prone to nondiagnostic results.

Tolerability and Procedure Time

Concerns about discomfort and pain may be barriers to accepting CNB; however, when performed appropriately, CNB has not been associated with greater pain or discomfort than FNAB. Jeong et al. [60] compared tolerability and pain in 100 consecutive patients undergoing FNAB with a 23-G needle and 100 consecutive patients undergoing CNB with an 18-G needle using a 10-cm visual analog scale. The study reported comparable median pain scores for both procedures, with high tolerability (100% for FNAB and 97% for CNB). Notably, CNB performed without lidocaine injection did not increase procedure-related pain; 70% of patients underwent CNB without local lidocaine injection.

When performed by an experienced operator, FNAB and CNB can be completed quickly and accurately. A study of 212 consecutive CNB procedures reported a median procedure time—defined as the interval between skin puncture and device withdrawal—of less than 2 minutes per nodule (approximately 102 seconds), with a 100% technical success rate [44]. In that study, CNB showed consistent time efficiency regardless of nodule size, with nondiagnostic results in <1% of patients and no major complications [44]. Therefore, high tolerability and short procedure time support CNB as an ideal selective first-line biopsy modality in outpatient settings.

Complications

Complications associated with CNB can be classified as minor or major, depending on severity and the need for medical intervention. Major complications include active bleeding caused by puncture of major vessels that necessitates unexpected hospitalization or surgical intervention. Minor complications are transient, self-limiting adverse events (e.g., hematoma) that require only conservative management [61]. Contrary to the conventional perception that CNB is difficult to manage and associated with more severe complications than FNAB, the overall complication rate of CNB is low [62]. Retrospective studies have reported extremely low major complication rates, whereas the most frequent minor complications are vascular injury–related hematomas and hemorrhages that typically resolve with manual compression without additional hemostatic procedures (Fig. 10) [62,63]. Specifically, large retrospective series reported low minor complication rates (0.79%–2.2%) and extremely low major complication rates (0%–0.09%) [9,62,63]. In addition, no patients with minor or major complications experienced serious morbidity or irreversible disability among 6,687 CNB procedures [62]. Patient-related factors (age and sex), nodule-related factors (location and size), and procedure-related factors (number of attempts and needle cutting length) were not associated with CNB-related complications [62]. A 2018 meta-analysis also reported that CNB is safe regardless of nodule size, with a pooled major complication proportion of <0.1% and a pooled minor complication proportion of 1.08% [64].

Fig. 10.

Perinodular and intrathyroidal hemorrhage after core needle biopsy (CNB).

A. A 56-year-old woman underwent CNB for a 13 mm×22 mm isoechoic nodule in the right thyroid gland, suggestive of Korean Thyroid Imaging Reporting and Data System 3. B, C. Immediately after the procedure, sharp pain was reported, and perinodular hemorrhage (arrow) and crack-like intrathyroidal hemorrhage were noted. Color Doppler showed no evidence of pseudoaneurysm or active arterial bleeding. D. After 45 minutes of manual compression, ultrasound demonstrated interval regression of perinodular and intrathyroidal hemorrhage. The patient was instructed to continue manual compression for at least 1 hour and was discharged after symptom improvement. E. At 6-month follow-up, ultrasound demonstrated no sequelae of the prior hemorrhage.

Complication Management

For safe procedures, adherence to guidelines and operator experience are important [21,22]. Prevention of hemorrhage is also a critical component of safe CNB. In patients receiving antithrombotic therapy, discontinuation is generally recommended, and decisions should be made after a careful benefit–risk assessment in consultation with the treating physician. For example, discontinuation of aspirin and clopidogrel bisulfate is typically recommended 7–10 days before biopsy [21]. Preprocedure vessel mapping should be performed meticulously to evaluate the location of critical vessels, including the common carotid artery and the superior and inferior thyroid arteries, as well as any anatomic variants that may compromise CNB safety [21]. After the procedure, manual compression for at least 20 minutes should be performed routinely, even if there are no definite signs of hemorrhage. When complications occur, most are minor and can be managed conservatively.

Rare but serious complications, such as iatrogenic pseudoaneurysm caused by CNB, are classified as major because of the potential to compress the upper airway and exacerbate hematoma formation. Noninvasive approaches such as manual compression can induce thrombosis; however, manual compression may be ineffective, particularly for larger or deeply located pseudoaneurysms. Minimally invasive approaches have emerged as effective options for managing iatrogenic pseudoaneurysms. Ham et al. [65] reported that pseudoaneurysms can be treated safely and effectively with US-guided bovine-derived thrombin injection, with a high technical success rate. Jun et al. [66] reported a promising effect of radiofrequency ablation for treating iatrogenic pseudoaneurysm. In that study, a short ablation time (mean, 13.5 seconds) was sufficient to induce thrombosis and facilitate closure of the pseudoaneurysm neck.

Challenges to be Solved

Although CNB has numerous advantages over FNAB, several important challenges and limitations remain unresolved. The first limitation is the absence of global standardization of pathologic diagnostic criteria specific to thyroid CNB, despite publication of pathology reporting guidelines by the Korean Endocrine Pathology CNB Study Group [22]. Interobserver variability—particularly in the diagnosis of follicular-pattern lesions, interpretation of architectural or nuclear atypia, and determination of the presence or absence of a tumor capsule—continues to present diagnostic challenges [39,67]. The second limitation is the lack of global standardization of CNB techniques. The third limitation is the absence of clearly established essential and appropriate indications for using CNB as a first-line modality, although the 2016 Consensus Statement and Recommendations from the Korean Society of Thyroid Radiology recommend first-line CNB for patients with suspected rare malignancies such as thyroid lymphoma and anaplastic thyroid carcinoma [21]. In addition, because technical success depends on operator experience, the quality of retrieved CNB specimens and institutional indications for first-line CNB may vary across institutions and clinical settings [14,45].

Conclusion

FNAB has long been recognized as a reliable first-line modality. Initially introduced as a complementary tool, CNB now plays a key diagnostic role because of its diagnostic performance, safety, and efficiency. Future work should include large-scale studies and standardization of advanced CNB techniques and complication management. Future CNB guidelines should also define essential and appropriate CNB indications. Finally, international efforts to standardize pathologic diagnostic criteria for CNB are necessary.

Notes

Author Contributions

Conceptualization: Shin JH, Kim Y, Lee MK, Baek JH, Jung SL. Data acquisition: Shin JH, Jung SL. Data analysis or interpretation: all authors. Drafting of the manuscript: Shin JH, Kim Y, Baek JH, Jung SL. Critical revision of the manuscript: Shin JH, Kim Y, Lee MK, Baek JH, Jung SL. Approval of the final version of the manuscript: all authors.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Supplementary Material

Video clip 1.

A 63-year-old male patient underwent core needle biopsy (CNB) for an 8 mm×9 mm hypoechoic nodule with punctate echogenic foci and dense macrocalcification, suggestive of Korean Thyroid Imaging Reporting and Data System 5. After the stylet was fired from a safe distance, the CNB device was advanced slowly with alternating rotational motion, mimicking drilling. Histopathology suggested papillary thyroid carcinoma (https://doi.org/10.14366/usg.25201.v001).

usg-25201-Supplementary-Video-1.mp4

References

1. Gharib H. Fine-needle aspiration biopsy of thyroid nodules: advantages, limitations, and effect. Mayo Clin Proc 1994;69:44–49. 10.1016/s0025-6196(12)61611-5. 8271850.

2. Hsiao V, Massoud E, Jensen C, Zhang Y, Hanlon BM, Hitchcock M, et al. Diagnostic accuracy of fine-needle biopsy in the detection of thyroid malignancy: a systematic review and meta-analysis. JAMA Surg 2022;157:1105–1113. 10.1001/jamasurg.2022.4989. 36223097.

3. Lee YH, Baek JH, Jung SL, Kwak JY, Kim JH, Shin JH, et al. Ultrasound-guided fine needle aspiration of thyroid nodules: a consensus statement by the Korean Society of Thyroid Radiology. Korean J Radiol 2015;16:391–401. 10.3348/kjr.2015.16.2.391. 25741201.

4. Cha YJ, Pyo JY, Hong S, Seok JY, Kim KJ, Han JY, et al. Thyroid fine-needle aspiration cytology practice in Korea. J Pathol Transl Med 2017;51:521–527. 10.4132/jptm.2017.09.26. 29017314.

5. Singh Ospina N, Brito JP, Maraka S, Espinosa de Ycaza AE, Rodriguez-Gutierrez R, Gionfriddo MR, et al. Diagnostic accuracy of ultrasound-guided fine needle aspiration biopsy for thyroid malignancy: systematic review and meta-analysis. Endocrine 2016;53:651–661. 10.1007/s12020-016-0921-x. 27071659.

6. Ha EJ, Lim HK, Yoon JH, Baek JH, Do KH, Choi M, et al. Primary imaging test and appropriate biopsy methods for thyroid nodules: guidelines by Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency. Korean J Radiol 2018;19:623–631. 10.3348/kjr.2018.19.4.623. 29962869.

7. Joo L, Baek JH, Lee J, Song DE, Chung SR, Choi YJ, et al. Superior diagnostic yield of core needle biopsy over fine needle aspiration in diagnosing follicular-patterned neoplasms: a multicenter study focusing on Bethesda IV results. Korean J Radiol 2025;26:604–615. 10.3348/kjr.2024.1022. 40288894.

8. Anderson TJ, Atalay MK, Grand DJ, Baird GL, Cronan JJ, Beland MD. Management of nodules with initially nondiagnostic results of thyroid fine-needle aspiration: can we avoid repeat biopsy? Radiology 2014;272:777–784. 10.1148/radiol.14132134. 24749714.

9. Suh CH, Baek JH, Choi YJ, Kim TY, Sung TY, Song DE, et al. Efficacy and safety of core-needle biopsy in initially detected thyroid nodules via propensity score analysis. Sci Rep 2017;7:8242. 10.1038/s41598-017-07924-z. 28811482.

10. Cho S, Han K, Yoon JH, Park VY, Rho M, Yoon J, et al. Inconclusive cytology results of fine-needle aspiration for thyroid nodules: the importance of strict guideline implementation. Ultrasonography 2025;44:285–293. 10.14366/usg.24216. 40495594.

11. Park KT, Ahn SH, Mo JH, Park YJ, Park DJ, Choi SI, et al. Role of core needle biopsy and ultrasonographic finding in management of indeterminate thyroid nodules. Head Neck 2011;33:160–165. 10.1002/hed.21414. 20848434.

12. Hahn SY, Shin JH, Oh YL, Park KW, Lim Y. Comparison between fine needle aspiration and core needle biopsy for the diagnosis of thyroid nodules: effective indications according to US findings. Sci Rep 2020;10:4969. 10.1038/s41598-020-60872-z. 32188891.

13. Hong MJ, Na DG, Kim SJ, Kim DS. Role of core needle biopsy as a first-line diagnostic tool for thyroid nodules: a retrospective cohort study. Ultrasonography 2018;37:244–253. 10.14366/usg.17041. 29113031.

14. Ahn HS, Youn I, Na DG, Kim SJ, Lee MY. Diagnostic performance of core needle biopsy as a first-line diagnostic tool for thyroid nodules according to ultrasound patterns: comparison with fine needle aspiration using propensity score matching analysis. Clin Endocrinol (Oxf) 2021;94:494–503. 10.1111/cen.14321. 32869866.

15. Choe J, Baek JH, Park HS, Choi YJ, Lee JH. Core needle biopsy of thyroid nodules: outcomes and safety from a large single-center single-operator study. Acta Radiol 2018;59:924–931. 10.1177/0284185117741916. 29137498.

16. Jung CK, Baek JH. Recent advances in core needle biopsy for thyroid nodules. Endocrinol Metab (Seoul) 2017;32:407–412. 10.3803/enm.2017.32.4.407. 29271614.

17. Lee SH, Kim MH, Bae JS, Lim DJ, Jung SL, Jung CK. Clinical outcomes in patients with non-diagnostic thyroid fine needle aspiration cytology: usefulness of the thyroid core needle biopsy. Ann Surg Oncol 2014;21:1870–1877. 10.1245/s10434-013-3365-z. 24526545.

18. Choi SH, Baek JH, Lee JH, Choi YJ, Hong MJ, Song DE, et al. Thyroid nodules with initially non-diagnostic, fine-needle aspiration results: comparison of core-needle biopsy and repeated fine-needle aspiration. Eur Radiol 2014;24:2819–2826. 10.1007/s00330-014-3325-4. 25038860.

19. Yi KS, Kim JH, Na DG, Seo H, Min HS, Won JK, et al. Usefulness of core needle biopsy for thyroid nodules with macrocalcifications: comparison with fine-needle aspiration. Thyroid 2015;25:657–664. 10.1089/thy.2014.0596. 25851539.

20. Na DG, Kim JH, Sung JY, Baek JH, Jung KC, Lee H, et al. Core-needle biopsy is more useful than repeat fine-needle aspiration in thyroid nodules read as nondiagnostic or atypia of undetermined significance by the Bethesda system for reporting thyroid cytopathology. Thyroid 2012;22:468–475. 10.1089/thy.2011.0185. 22304417.

21. Na DG, Baek JH, Jung SL, Kim JH, Sung JY, Kim KS, et al. Core needle biopsy of the thyroid: 2016 consensus statement and recommendations from Korean Society of Thyroid Radiology. Korean J Radiol 2017;18:217–237. 10.3348/kjr.2017.18.1.217. 28096731.

22. Jung CK, Baek JH, Na DG, Oh YL, Yi KH, Kang HC. 2019 Practice guidelines for thyroid core needle biopsy: a report of the Clinical Practice Guidelines Development Committee of the Korean Thyroid Association. J Pathol Transl Med 2020;54:64–86. 10.4132/jptm.2019.12.04. 31964112.

23. Ahn DS, Park CW, Rhee YC, Lee MK, Ho C, Cha H, et al. Differential diagnosis of thyroid nodules by Vim-Silverman needle. Korean J Med 1986;31:221–229.

24. Silverman JF, West RL, Finley JL, Larkin EW, Park HK, Swanson MS, et al. Fine-needle aspiration versus large-needle biopsy or cutting biopsy in evaluation of thyroid nodules. Diagn Cytopathol 1986;2:25–30. 10.1002/dc.2840020107. 3720480.

25. Nasrollah N, Trimboli P, Guidobaldi L, Cicciarella Modica DD, Ventura C, Ramacciato G, et al. Thin core biopsy should help to discriminate thyroid nodules cytologically classified as indeterminate: a new sampling technique. Endocrine 2013;43:659–665. 10.1007/s12020-012-9811-z. 23070753.

26. Yuen HY, Lee Y, Bhatia K, Wong KT, Ahuja AT. Use of end-cutting needles in ultrasound-guided biopsy of neck lesions. Eur Radiol 2012;22:832–836. 10.1007/s00330-011-2323-z. 22080282.

27. Diederich S, Padge B, Vossas U, Hake R, Eidt S. Application of a single needle type for all image-guided biopsies: results of 100 consecutive core biopsies in various organs using a novel tri-axial, end-cut needle. Cancer Imaging 2006;6:43–50. 10.1102/1470-7330.2006.0008. 16766268.

28. Park JY, Yi SY, Baek SH, Lee YH, Kwon HJ, Park HJ. Diagnostic efficacy, performance and safety of side-cut core needle biopsy for thyroid nodules: comparison of automated and semi-automated biopsy needles. Endocrine 2022;76:341–348. 10.1007/s12020-022-02980-6. 35032314.

29. Han S, Shin JH, Hahn SY, Oh YL. Modified core biopsy technique to increase diagnostic yields for well-circumscribed indeterminate thyroid nodules: a retrospective analysis. AJNR Am J Neuroradiol 2016;37:1155–1159. 10.3174/ajnr.a4650. 26846928.

30. Hahn SY, Shin JH, Oh YL, Park KW. Ultrasound-guided core needle biopsy techniques for intermediate or low suspicion thyroid nodules: which method is effective for diagnosis? Korean J Radiol 2019;20:1454–1461. 10.3348/kjr.2018.0841. 31544370.

31. Harahap AS, Jung CK. Cytologic hallmarks and differential diagnosis of papillary thyroid carcinoma subtypes. J Pathol Transl Med 2024;58:265–282. 10.4132/jptm.2024.10.11. 39557408.

32. Hahn SY, Shin JH, Oh YL. What is the ideal core number for ultrasonography-guided thyroid biopsy of cytologically inconclusive nodules? AJNR Am J Neuroradiol 2017;38:777–781. 10.3174/ajnr.a5075. 28154123.

33. Park HS, Baek JH, Park AW, Chung SR, Choi YJ, Lee JH. Thyroid radiofrequency ablation: updates on innovative devices and techniques. Korean J Radiol 2017;18:615–623. 10.3348/kjr.2017.18.4.615. 28670156.

34. Ebrahiminik H, Chegeni H, Jalili J, Salouti R, Rokni H, Mohammadi A, et al. Hydrodissection: a novel approach for safe core needle biopsy of small high-risk subcapsular thyroid nodules. Cardiovasc Intervent Radiol 2021;44:1651–1656. 10.1007/s00270-021-02838-w. 33970309.

35. Na DG, Kim DS, Kim SJ, Ryoo JW, Jung SL. Thyroid nodules with isolated macrocalcification: malignancy risk and diagnostic efficacy of fine-needle aspiration and core needle biopsy. Ultrasonography 2016;35:212–219. 10.14366/usg.15074. 26810196.

36. Shin JH. Strategies for safe and effective core needle biopsy of thyroid nodules with macrocalcification. Int J Thyroidol 2023;16:195–199. 10.11106/ijt.2023.16.2.195.

37. Quinn SF, Nelson HA, Demlow TA. Thyroid biopsies: fine-needle aspiration biopsy versus spring-activated core biopsy needle in 102 patients. J Vasc Interv Radiol 1994;5:619–623. 10.1016/s1051-0443(94)71565-7. 7949720.

38. Screaton NJ, Berman LH, Grant JW. US-guided core-needle biopsy of the thyroid gland. Radiology 2003;226:827–832. 10.1148/radiol.2263012073. 12601219.

39. Jung CK. Reevaluating diagnostic categories and associated malignancy risks in thyroid core needle biopsy. J Pathol Transl Med 2023;57:208–216. 10.4132/jptm.2023.06.20. 37460395.

40. Song S, Kim H, Ahn SH. Role of immunohistochemistry in fine needle aspiration and core needle biopsy of thyroid nodules. Clin Exp Otorhinolaryngol 2019;12:224–230. 10.21053/ceo.2018.01011. 30531651.

41. Chung SR, Suh CH, Baek JH, Choi YJ, Lee JH. The role of core needle biopsy in the diagnosis of initially detected thyroid nodules: a systematic review and meta-analysis. Eur Radiol 2018;28:4909–4918. 10.1007/s00330-018-5494-z. 29789911.

42. Alexander EK, Heering JP, Benson CB, Frates MC, Doubilet PM, Cibas ES, et al. Assessment of nondiagnostic ultrasound-guided fine needle aspirations of thyroid nodules. J Clin Endocrinol Metab 2002;87:4924–4927. 10.1210/jc.2002-020865. 12414851.

43. Orija IB, Pineyro M, Biscotti C, Reddy SS, Hamrahian AH. Value of repeating a nondiagnostic thyroid fine-needle aspiration biopsy. Endocr Pract 2007;13:735–742. 10.4158/ep.13.7.735. 18194930.

44. Hong MJ, Na DG, Lee H. Diagnostic efficacy and safety of core needle biopsy as a first-line diagnostic method for thyroid nodules: a prospective cohort study. Thyroid 2020;30:1141–1149. 10.1089/thy.2019.0444. 32228167.

45. Chen Z, Wang JJ, Guo DM, Zhai YX, Dai ZZ, Su HH. Combined fine-needle aspiration with core needle biopsy for assessing thyroid nodules: a more valuable diagnostic method? Ultrasonography 2023;42:314–322. 10.14366/usg.22112. 36935592.

46. Stasiak M, Michalak R, Lewinski A. Thyroid primary and metastatic malignant tumours of poor prognosis may mimic subacute thyroiditis: time to change the diagnostic criteria: case reports and a review of the literature. BMC Endocr Disord 2019;19:86. 10.1186/s12902-019-0415-y. 31387553.

47. Choi SH, Baek JH, Ha EJ, Choi YJ, Song DE, Kim JK, et al. Diagnosis of metastasis to the thyroid gland: comparison of core-needle biopsy and fine-needle aspiration. Otolaryngol Head Neck Surg 2016;154:618–625. 10.1177/0194599816629632. 26908554.

48. Roberson J, Huang H, Noldner C, Hou W, Mani K, Valentine E, et al. Thyroid volume changes following adjuvant radiation therapy for breast cancer. Clin Transl Radiat Oncol 2023;39:100566. 10.1016/j.ctro.2022.100566. 36582422.

49. Shin HS, Na DG, Paik W, Yoon SJ, Gwon HY, Noh BJ, et al. Malignancy risk stratification of thyroid nodules with macrocalcification and rim calcification based on ultrasound patterns. Korean J Radiol 2021;22:663–671. 10.3348/kjr.2020.0381. 33660454.

50. Kim S, Shin JH, Ihn YK. Biopsy strategies for intermediate and high suspicion thyroid nodules with macrocalcifications. Curr Med Res Opin 2023;39:179–186. 10.1080/03007995.2022.2146404. 36369696.

51. Ha EJ, Chung SR, Na DG, Ahn HS, Chung J, Lee JY, et al. 2021 Korean Thyroid Imaging Reporting and Data System and imaging-based management of thyroid nodules: Korean Society of Thyroid Radiology consensus statement and recommendations. Korean J Radiol 2021;22:2094–2123. 10.3348/kjr.2021.0713. 34719893.

52. Vander Poorten V, Goedseels N, Triantafyllou A, Sanabria A, Clement PM, Cohen O, et al. Effectiveness of core needle biopsy in the diagnosis of thyroid lymphoma and anaplastic thyroid carcinoma: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2022;13:971249. 10.3389/fendo.2022.971249. 36204100.

53. Ha EJ, Baek JH, Lee JH, Kim JK, Song DE, Kim WB, et al. Core needle biopsy could reduce diagnostic surgery in patients with anaplastic thyroid cancer or thyroid lymphoma. Eur Radiol 2016;26:1031–1036. 10.1007/s00330-015-3921-y. 26201291.

54. Yim Y, Park HS, Baek JH, Yoo H, Sung JY. Parenchymal microcalcifications in the thyroid gland: clinical significance and management strategy. Medicine (Baltimore) 2023;102e34636. 10.1097/md.0000000000034636. 37565926.

55. Trimboli P, Nasrollah N, Amendola S, Crescenzi A, Guidobaldi L, Chiesa C, et al. A cost analysis of thyroid core needle biopsy vs. diagnostic surgery. Gland Surg 2015;4:307–311. 10.3978/j.issn.2227-684X.2015.06.05. 26312216.

56. Borget I, Vielh P, Leboulleux S, Allyn M, Iacobelli S, Schlumberger M, et al. Assessment of the cost of fine-needle aspiration cytology as a diagnostic tool in patients with thyroid nodules. Am J Clin Pathol 2008;129:763–771. 10.1309/h86km785q9kbwpw5. 18426737.

57. Lee YH, Baek JH, Jung SL, Kwak JY, Kim JH, Shin JH, et al. Ultrasound-guided fine needle aspiration of thyroid nodules: a consensus statement by the korean society of thyroid radiology. Korean J Radiol 2015;16:391–401. 10.3348/kjr.2015.16.2.391. 25741201.

58. Eun NL, Yoo MR, Gweon HM, Park AY, Kim JA, Youk JH, et al. Thyroid nodules with nondiagnostic results on repeat fine-needle aspiration biopsy: which nodules should be considered for repeat biopsy or surgery rather than follow-up? Ultrasonography 2016;35:234–243. 10.14366/usg.15079. 27068131.

59. Choi YJ, Baek JH, Suh CH, Shim WH, Jeong B, Kim JK, et al. Core-needle biopsy versus repeat fine-needle aspiration for thyroid nodules initially read as atypia/follicular lesion of undetermined significance. Head Neck 2017;39:361–369. 10.1002/hed.24597. 27704650.

60. Jeong EJ, Chung SR, Baek JH, Choi YJ, Kim JK, Lee JH. A comparison of ultrasound-guided fine needle aspiration versus core needle biopsy for thyroid nodules: pain, tolerability, and complications. Endocrinol Metab (Seoul) 2018;33:114–120. 10.3803/enm.2018.33.1.114. 29589393.

61. Cardella JF, Kundu S, Miller DL, Millward SF, Sacks D, ; Society of Interventional Radiology. Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol 2009;20(7 Suppl):S189–S191. 10.1016/j.jvir.2009.04.035. 19559998.

62. Ha EJ, Baek JH, Lee JH, Kim JK, Choi YJ, Sung TY, et al. Complications following US-guided core-needle biopsy for thyroid lesions: a retrospective study of 6,169 consecutive patients with 6,687 thyroid nodules. Eur Radiol 2017;27:1186–1194. 10.1007/s00330-016-4461-9. 27311538.

63. Paja M, Del Cura JL, Zabala R, Korta I, Ugalde A, Lopez JI. Core-needle biopsy in thyroid nodules: performance, accuracy, and complications. Eur Radiol 2019;29:4889–4896. 10.1007/s00330-019-06038-6. 30783787.

64. Ha EJ, Suh CH, Baek JH. Complications following ultrasound-guided core needle biopsy of thyroid nodules: a systematic review and meta-analysis. Eur Radiol 2018;28:3848–3860. 10.1007/s00330-018-5367-5. 29589112.

65. Ham T, Lee JY, Jeon YH, Choi KS, Hwang I, Yoo RE, et al. Safety and efficacy of ultrasound-guided thrombin injection for pseudoaneurysms arising after ultrasound-guided biopsy of thyroid nodules. AJNR Am J Neuroradiol 2025;46:166–169. 10.3174/ajnr.a8428. 39510805.

66. Jun YK, Jung SL, Byun HK, Baek JH, Sung JY, Sim JS. Radiofrequency ablation for iatrogenic thyroid artery pseudoaneurysm: initial experience. J Vasc Interv Radiol 2016;27:1613–1617. 10.1016/j.jvir.2016.06.005. 27670995.

67. Noh BJ, Kim WJ, Kim JY, Kim HY, Lee JC, Shim MS, et al. Risk stratification of thyroid nodules diagnosed as follicular neoplasm on core needle biopsy. Endocrinol Metab (Seoul) 2025;40:610–622. 10.3803/enm.2024.2256. 40426309.

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Notes

Key points

Core needle biopsy has established an important diagnostic role in the evaluation of thyroid nodules, and significant advancements have been made in core needle biopsy (CNB) devices and techniques. This review provides an overview of innovative techniques, diagnostic performance, and patient perspectives, highlighting the emerging role of CNB as a selective first-line biopsy modality.