Animated floating bubbles (Intermediate) To reproduce the bubble shape effects on this slide, do the following: On the Home tab, in the Slides group, click Layout , and then click Blank . On the Home tab, in the Drawing group, click Shapes , and then under Basic Shapes select Oval (second option from the left). Press and hold SHIFT, and then click and drag to draw a circle shape. Select the circle (oval shape). On the Home tab, in the Drawing group, click the Format Shape dialog box launcher. In the Format Shape dialog box in the left pane, click Fill . In the Fill pane, click Gradient fill , and then do the following: Click the button next to Preset Colors and select Calm Wate r (second row, third option from the left). In the Type box, select Radial . Click the button next to Direction and select From Bottom Right Corner (first option from the left). Also in the Format Shape pane, in the left pane, click Line Color . In the Line Color pane, click Gradient Line , and then do the following: Click the button next to Preset Colors and select Calm Water (second row, third option from the left). In the Type box select Linear . In the Angle box, enter 90 . Also in the Format Shape pane, in the left pane, click 3-D Format and then in the 3-D Format pane, do the following: Under Bevel , click the button next to Top and select Circle (first option from the left). Next to Top , in the Width box, enter 50 pt, and in the Height box, enter 50 pt. Under Surface , click the button next to Material , and then under Translucent , select Clear . Click the button next to Lighting , and then under Special , select Glow (third option from the left). In the Angle box, enter 110 °. To reproduce the animation effects on this slide, do the following: On the slide select the oval. On the Animations tab, in the Advanced Animation group, click Add Animation , and then under Entrance click Appear. On the Animations tab, in the Timing group, in the Start list, select With Previous . On the Animations tab, in the Advanced Animation group, click Add Animation , and then click More Motion Paths. In the Add Motion Path dialog box, under Lines & Curves , click S Curve 1 , and then click OK. On the Animations tab, in the Timing group, in the Start list, select With Previous . On the Animations tab, in the Timing group, in the Duration box, enter 8 . On the slide, select the animation path. Click and drag the green rotation handle to the right to rotate the path until the right side of the path faces the bottom right corner of the slide. Click and drag the right side handle to lengthen the path until it extends about one inch off the bottom right edge of the slide. Click and drag the left side handle to lengthen the path until it extends about one inch off the top left edge of the slide. On the Animations tab, in the Animation group, click Effect Options , and then click Reverse Path Direction . On the Animations tab, in the Animation group, click Effect Options , and then click Edit Points . Click and drag the edit points and curve handles to make the path a smooth S-shaped curve from the bottom right to top left. On the slide select the oval. On the Animations tab, in the Advanced Animation group, click Add Animation , and then under Emphasis click Grow/Shrink. On the Animations tab, in the Timing group, in the Start list, select With Previous . On the Animations tab, in the Timing group, in the Duration box, enter 0.1 . On the Animations tab, in the Timing group, in the Delay box, enter 6 . On the Animations tab, in the Animation group, click Effect Options , and then click Larger . On the slide select the oval. On the Animations tab, in the Advanced Animation group, click Add Animation , and then under Exit click Fade. On the Animations tab, in the Timing group, in the Start list, select With Previous . On the Animations tab, in the Timing group, in the Duration box, enter 0.1 . On the Animations tab, in the Timing group, in the Delay box, enter 6 . To create the second bubble on this slide, do the following: Select the bubble. On the Home tab, in the Clipboard group, click the arrow to the right of Copy , and then click Duplicate. Select the new bubble. Press and hold SHIFT, and then drag the sizing handle to resize the shape. Drag the bubble to a different part of the slide. On the Animation tab, in the Advanced Animation group, click Animation Pane . In the Animation Pane , select the Appear effect for the second oval. On the Animations tab, in the Timing group, in the Delay box, enter 1.4 . In the Animation Pane , select the S Curve 1 effect for the second oval. On the Animations tab, in the Timing group, in the Delay box, enter 1.4 . On the Animations tab, in the Animation group, click Effect Options , and then click Edit Points . Click and drag the edit points and curve handles to make the path of the second oval different from the first one. In the Animation Pane , select the Grow/Shrink effect for the second oval. On the Animations tab, in the Timing group, in the Delay box, enter 7 . In the Animation Pane , select the Fade effect for the second oval. On the Animations tab, in the Timing group, in the Delay box, enter 7 . To reproduce the background on this slide, do one of the following: Note: You can save the background of this slide template as a picture and use it in your own slides. To use the same background as this slide, do the following: Right-click the water background on the original template, and then click Save Background . Save the file as a JPEG (.jpg) file format. On the Design tab, in the Background group, click Background Styles , and then click Format Background . In the Format Background dialog box, click Fill in the left pane, select Picture fill in the Fill pane, and then under Insert from click File . In the Insert Picture dialog box, select a picture, and then click Insert .
FNAC: A RELIABLE DIAGNOSTIC TOOL IN DIAGNOSIS OF SIMPLE AND NODULAR GOITER
INTRODUCTION• Thyroid nodules - common clinical findings - prevalence - 4% to 7% of adult population.• Common in women.• Incidence ↑’s- Age, h/o radiation exposure and a diet ontaining goitrogenic material.• Commonest enlargement- Adenomatous and colloid goiters.• Especially- iodine deficient goiter belt areas.• .Prevalence- 40%.
• Difficult by clinical evaluation alone to make a correct diagnosis. Hence it is essential that correct diagnosis is made as early as possible.• FNAC- simple, safe, minimally invasive, reliable outpatient procedure.• Performed in children, adults, aged and pregnant women.• First line of investigation in goiters and a reliable procedure to obtain accurate diagnosis avoiding diagnostic surgery.
AIMS AND OBJECTIVES• To study the advantage of FNAC as a simple procedure for the diagnosis of goiter and to utilize it on the patient’s first visit to the hospital.• To compare the preoperative FNAC with postoperative histopathology and to determine the diagnostic accuracy of this test in the diagnosis of goiter.• To study the age and sex incidence of goiter and to study the geographical distribution of the lesion.
MATERIALS AND METHODS• A prospective study was conducted at ASRAMS hospital, Eluru from June 2010 to May 2012.• 221 patients between ages of 10-60 years with clinical presentation of simple and nodular goiters were selected for FNAC. There was no sex distinction.• These cases comprised of a heterogenous population from various areas of West godavari & Krishna districts.• All the patients underwent complete history taking, physical examination and hormonal assay.
• Careful palpation of the thyroid was done to guide precisely the location for doing aspiration.• Details of the procedure were explained to the patients.• Aspiration was done with the patient lying comfortably in a supine position and the neck was extended with a pillow under the shoulder so as to make the thyroid swelling appear prominent.• Under aseptic precautions 23 gauge needle was inserted into the lesion without attachment of a syringe and to and fro movement performed quickly.
• The material gets collected in the bore by capillary suction. The needle hub was attached to air-filled syringe and the plunger was pushed down to expel the material onto a clean, labeled glass slide.• The same procedure was repeated at different sites depending on size of the swelling.• Several smears were made in each case, fixed in 95% ethyl alcohol and stained by H&E method and Pap method, other was air dried and stained with MGG stain.
• Out of 221 patients, 76 patients underwent surgeries like hemithyroidectomy, subtotal and near total thyroidectomies.• Histopathological examinations of these specimens were also done.• All the specimens were fixed in 10% formalin. Detailed gross examination was done and 3-10 tissue bits were selected from representative areas and all the bits were processed and stained with H&E stain.• Cytological diagnosis was correlated with histopathology and the efficacy of FNAC was estimated.
Results and Observations• Study design: The present study deals with the fine needle aspiration cytology of simple and nodular goiters and determination of diagnostic accuracy of aspiration cytology.• A total of 221 patients with clinical presentation of goiters were subjected to FNAC during a period of 2 years from june 2010 to may 2012.• Of these 76 patients underwent surgery subsequently and histopathological examination of the excised specimens was done.
• Pre-operative diagnosis by FNAC was compared with histopathology reports of the operative specimens.• The important observations of the study have been represented in tabular and graphial forms.
• Cyto-histological concordance in the diagnosis of goiter is 95.7%.(68/71 cases).• Analysis of the FNAC results obtained were compared with the histological findings in the cases of goiter yielded the following diagnostic values:• Sensitivity- 100%.• Specificity- 62.5%.• Positive predictive value- 95.7%.• Negative predictive value- 100%.• Diagnostic accuracy- 96.05%.
Fig 1: Colloid goiter. Abundant thick colloid with few clusters of follicular epithelial cells(H&E, scanner view)
Fig 2: Colloid goiter. Varying sized follicles lined by flattened epithelium filled with colloid (H&E,x 10)
Fig 3: Nodular colloid goiter. Clusters and sheets of follicular cells with colloid background(H&E, x10)
Discussion• Thyroid nodules are a common clinical problem.• In iodine deficient areas the incidence of goiters among thyroid nodules is much higher.• An accurate and reliable diagnosis of goiter is thus important to avoid unnecessary surgeries and impose burden on the healthcare system.
• The present study deals with the fine needle aspiration cytology of goiters in 221 patients of which 76 of them underwent surgery subsequently.• The results of the patients were compared wherever available to determine the diagnostic accuracy of FNAC in the diagnosis of goiter.
Table 17: Comparison of Age Range of age in Median age in Studies years yearsMahar et al 13-76 39Mubarik et al 20-60 41Saddique et al 10-70 35Basharat et al 10-70 33Handa et al 5-80 37Present study 10-70 35
Table 18: Comparison of Sex Total Studies Males Females M:F ratio casesMubarik et al 54 7 47 1:6.7Safirullah et al 300 30 270 1:9Saddique et al 60 8 52 1:6.5Haberal et al 260 42 218 1:5Handa et al 434 - - 1:6.3Present study 221 10 211 1:21
Table 19: Comparison of Age and Sex for Simple and Nodular goiter Median age in Female to Male Studies years ratioHanda et al 39 6:1Charugupta et al 32 7:1Present study 27 17:1
Table 20: Comparison of TSH levels Studies Normal Decreased Increased TotalBasharat et al 48 2 0 50Godinho- 109 11 4 124Matos et alHanda et al 80 25 15 120Present 177 31 13 221study
Table 21: Comparison of Presenting Symptoms Swelling Palpitatio Weight Studies front of Pain Dysphagia n& Total gain neck AnxietyGodinho- 144 8 11 11 4 144Matos et alHanda et al 434 10 6 15 6 434Present 221 3 6 27 11 221study
Table 22: Comparison of Size of the Swelling Studies 1-5cm 6-10cm Total Basharat et al 35 15 60 Present 157 64 221 study
Table 23: Comparison of lesions on FNAC Studies Benign Follicular Malignant Inadequate TotalHanda et al 381 14 17 22 434Charugupta 470 - 30 7 507et alBagga & 228 17 3 4 252MahajanMahar et al 63 44 15 3 125Present 204 10 5 2 221study
Table 24: Comparison of Individual Lesions on Cytology Nongrum Bhatta et al Mosawi et Mubarik et Present studyDisease et al n=60 n=90 al n=78 al n=54 n=76Simple & Nodularcolloid goiter 34 58 52 38 40Nodular goiter withcystic degeneration 0 13 4 5 28Hyperplastic goiter 4 0 6 0 3Hashimoto’sthyroiditis 14 6 3 1 2Follicular neoplasm 5 3 3 7 2Papillarycarcinoma 2 9 4 1 1Anaplasticcarcinoma 1 1 0 0 0Undifferentiatedcarcinoma 0 0 0 2 0Suspicious 0 0 3 0 0Non diagnostic 0 0 3 0 0
Table 25: Comparison of Cyto-Histological Concordance in the Diagnosis of Goiter Studies No. % Mathur et al 130/134 97 Schnurer et al 264/284 93 Hag et al 32/35 91.4 Saddique et al 29/30 96.7 Mubarik et al 40/43 93 Present study 68/71 95.7
Table 26: Comparison of False Negativity Rate Studies No. of FN cases FNR Mahar et al 6/125 3.78% Mathur et al 9/154 5.8% Saddique et al 3/60 5% Mubarik et al 1/54 1.85% Haberal et al 6/260 2.3% Bhatta et al 1/20 5% Present study 3/76 3.95%
• False negative rates reported in literature range from 1.5 to 9%.• The false negative FNAC results may occur because of: -Inadequate samples. -Geographic misses of lesion. -Dual pathology and errors of interpretations. -Presence of cystic neoplasm.
• Intermediate FNAC results and cytodiagnostic errors are unavoidable due to overlapping cytological features, particularly among hyperplastic adenomatoid nodules, follicular neoplasms and follicular variants of papillary carcinoma.
Table 27: Comparison of diagnostic values in goiter Positive Negative Diagnostic Studies Sensitivity Specificity predictiv predictiv accuracy e value e valueNongrum 100% 50% 75% 100% 80%et alBeneragama 82.25% 87.77% 82.25% 87.25% _et alPresent study 100% 62.5% 95.7% 100% 96.05%
CONCLUSION• It is concluded that FNAC is a simple, minimally invasive first line diagnostic procedure for evaluation of simple and nodular goiter with significant efficacy in differentiating malignant from benign lesions of thyroid.• FNAC thus is a fairly accurate and reliable modality for diagnosis of goiters and is a very useful tool to select patients who would require surgery, thereby reducing unnecessary surgeries.• Strict adherence to adequacy criterion and meticulous examination of all the smears are of paramount importance in achieving a high rate of diagnostic accuracy.
• FNAC is highly sensitive and specific diagnostic procedure. But it can give false negative result. So final diagnosis and treatment pattern should be based upon histopathology.• This study also concludes that these areas are endemic for thyroid disease as goiter is common presentation. It is because of low intake of iodized salt. Medical education should be given in these areas.