INTRODUCTION• Thyroid nodules - common clinical findings - prevalence -  4% to 7% of adult population.•   Common in women....
• Difficult by clinical evaluation alone to make a correct  diagnosis. Hence it is essential that correct diagnosis is  ma...
AIMS AND OBJECTIVES• To study the advantage of FNAC as a simple procedure  for the diagnosis of goiter and to utilize it o...
MATERIALS AND METHODS• A prospective study was conducted at ASRAMS  hospital, Eluru from June 2010 to May 2012.• 221 patie...
• Careful palpation of the thyroid was done to guide  precisely the location for doing aspiration.• Details of the procedu...
• The material gets collected in the bore by capillary  suction. The needle hub was attached to air-filled syringe  and th...
• Out of 221 patients, 76 patients underwent surgeries like  hemithyroidectomy, subtotal and near total  thyroidectomies.•...
RESULTS AND OBSERVATIONS• Study design:        The present study deals with the fine needle  aspiration cytology of simple...
• Pre-operative diagnosis by FNAC was compared with  histopathology reports of the operative specimens.• The important obs...
Table1:Age distribution with SexAge in    Females           Males            TotalYears         No.    %      No.         ...
Table2: Duration Of ComplaintsDuration of complaints          %                         No.    Upto 6 months         99   ...
Table 3:Presenting ComplaintsPresenting complaint    No.      %Swelling front neck     82    37.1SolitaryDiffuse          ...
Table 4: Size of the swellingSize            No       %1-5 cm          157      716-10 cm         64       29Total        ...
Table 5: Hormone levelsTSH           No       %Normal        177      80Decreased     31       14Increased     13        6...
Table 6: Adequacy of sample Adequacy         No    % Satisfactory     219   99 Unsatisfactory    2     1 Total            ...
Table 7 : Nature of sampleNature of aspirate       No.     %Colloid                  77     34.84Hemorrhagic              ...
Table 8: Lesions on FNAC        Lesion   No.Benign           204Follicular       10Malignant         5Inadequate        2T...
Table 9: Benign lesions in present study               Disease                    No.   %Simple colloid goiter            ...
Table 10: Simple colloid and nodular goiter on            cytological study with Age and SexAge in         Females        ...
Table 11: Histopathology results of 76 patients        Benign              72        Malignant           4        Total   ...
Table 12: Distribution of malignant cases (n=4)  Papillary carcinoma                         2  Follicular variant of papi...
Table 13: Histopathological diagnosis Vs Cytological diagnosis        Diagnosis               Histology   Cytology        ...
Table 14 : Cytological diagnosis in 76 patients         Diagnosis             No.   % Simple & nodular colloid      40    ...
Table 15 : Correlation of Cytological diagnosis with           final Histopathological diagnosis                          ...
Table 16: Results of False negativesDiagnosis             FNAC            Histopathological                     diagnosis ...
• Cyto-histological concordance in the diagnosis of goiter  is 95.7%.(68/71 cases).• Analysis of the FNAC results obtained...
Fig 1: Colloid goiter. Abundant thick colloid with fewclusters 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)
Fig 4: Nodular colloid goiter. Monolayered sheet of follicular                       cells(H&E,x 40)
Fig 5: Nodular colloid goiter with cystic degeneration. Cyst                macrophages(H&E,x 10)
Fig 6: Multinodular goiter. External surface showing               nodules of varying size
Fig 7: Multinodular goiter. Cut surface showing nodules of               varying size filled with colloid
Fig 7: Multinodular goiter. Multiple colloid filled nodules        separated by fibrous septa(H&E,x 10)
Fig 8: Nodular goiter with Cystic degeneration. Cyst wall        with adjacent normal thyroid (H&E,x 10)
Fig 9: Hyperplastic goiter. 3-D cluster of follicular cells                      (H&E,x 40)
Fig 10: Hyperplastic goiter. 3-D fragments of follicular cells                        (H&E, x40)
Fig 11: Hyper plastic goiter. Scalloping of colloid                   (H&E,x 40)
Fig 12: Hashimoto’s thyroiditis. Lymphocytic infiltration of    follicular cells and hurthle cell change (H&E,x 40)
Fig 12: Hashimoto’s thyroiditis. Lymhocytic infiltration of         follicular cells and hurthle cell change
Fig 24: Hashimoto’s thyroiditis. Hurthle cells (H&E,x 40)
Fig 14: Hashimoto’s thyroiditis. Prominent lymphocytic   infiltration of thyroid follicles (H&E,scanner view)
Fig 15: Hashimoto’s thyroiditis. Normal follicular epithelium  along with follicular epithelium with hurthle cell change  ...
Fig 15: Hashimoto’s thyroiditis. Hurthle cell change and          lymphocytic infiltration (H&E,x 40)
Fig 12: Follicular neoplasm. Cut surface showing a solitary                  well encapsulated nodule
Fig 16: Follicular neoplasm. A repetitive acinar pattern                      (H&E,x 40)
Fig 17: Follicular neoplasm. Repetitive acinar pattern                      (MGG,x 40)
Fig 5: Microfollicular adenoma. Intact fibrous capsule  around a follicular adenoma (H&E,scanner view)
Fig 7: Papillary carcinoma. Branching papillae with          fibrovascular core (H&E,x 10)
Fig 8: Papillary carcinoma. Papillae lined by cuboidal   epithelium with optically clear nuclei (H&E,x 40)
Fig 9: Follicular variant of papillary carcinoma. Optically                  clear nuclei (H&E,x 40)
Fig 12: Follicular carcinoma. Capsular invasion (H&E,x 10)
Fig 13: Follicular carcinoma. Capsular invasion (H&E,x 10)
Discussion• Thyroid nodules are a common clinical problem.• In iodine deficient areas the incidence of goiters among  thyr...
• The present study deals with the fine needle aspiration  cytology of goiters in 221 patients of which 76 of them  underw...
Table 17: Comparison of AgeStudies          Range of age   Median age                   in years      in yearsMahar et al ...
Table 18: Comparison of SexStudies            Total   Males   Females   M:F ratio                   casesMubarik et al    ...
Table 19: Comparison of Age and Sex for Simple and Nodular goiterStudies            Median age in   Female to Male        ...
Table 20: Comparison of TSH levelsStudies          Normal   Decreased   Increased   TotalBasharat et al     48         2  ...
Table 21: Comparison of Presenting SymptomsStudies       Swelling   Pain   Dysphagia Palpitation   Weight   Total         ...
Table 22: Comparison of Size of the Swelling  Studies          1-5cm   6-10cm   Total  Basharat et al    35       15      ...
Table 23: Comparison of lesions on FNACStudies       Benign   Follicular   Malignant Inadequate   TotalHanda et al    381 ...
Table 24: Comparison of Individual Lesions on CytologyDisease               Nongrum Bhatta et al Mosawi et   Mubarik et   ...
Table 25: Comparison of Cyto-HistologicalConcordance in the Diagnosis of Goiter  Studies          No.       %  Mathur et a...
Table 26: Comparison of False Negativity Rate     Studies          No. of FN cases   FNR     Mahar et al           6/125  ...
• False negative rates reported in literature range from 1.5  to 9%.• The false negative FNAC results may occur because of...
• Intermediate FNAC results and  cytodiagnostic errors are unavoidable due to  overlapping cytological features, particula...
Table 27: Comparison of diagnostic values in goiterStudies      Sensitivit Specificity Positive   Negative Diagnostic     ...
CONCLUSION• It is concluded that FNAC is a simple, minimally invasive  first line diagnostic procedure for evaluation of s...
• FNAC is highly sensitive and specific diagnostic  procedure. But it can give false negative result. So final  diagnosis ...
Thyroid paper
Thyroid paper
Thyroid paper
Thyroid paper
Thyroid paper
Thyroid paper
Thyroid paper
Thyroid paper
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Thyroid paper

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Thyroid paper

  1. 1. 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 containing goitrogenic material.• Commonest enlargement- Adenomatous and colloid goiters.• Especially- iodine deficient goiter belt areas.• .Prevalence- 40%.
  2. 2. • 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.
  3. 3. 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.
  4. 4. 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.
  5. 5. • 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.
  6. 6. • 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.
  7. 7. • 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.
  8. 8. 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.
  9. 9. • 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.
  10. 10. Table1:Age distribution with SexAge in Females Males TotalYears No. % No. % No. %10-20 08 3.79 01 10 09 4.0721-30 54 25.59 02 20 56 25.3431-40 71 33.65 03 30 74 33.4841-50 60 28.44 02 20 62 28.0551-60 14 6.64 00 00 14 6.3361-70 04 1.90 02 20 06 2.71Total 211 95.48 10 4.52 221 100
  11. 11. Table2: Duration Of ComplaintsDuration of complaints % No. Upto 6 months 99 44.80 6months to 1 year 89 40.27 1 to 10 years 30 13.57 >10 years 03 1.36 Total 221 100
  12. 12. Table 3:Presenting ComplaintsPresenting complaint No. %Swelling front neck 82 37.1SolitaryDiffuse 139 62.9Pain 03 1.36Dysphagia 06 2.71Palpitation & Anxiety 27 12.22Weight gain 11 4.98Total 221 100
  13. 13. Table 4: Size of the swellingSize No %1-5 cm 157 716-10 cm 64 29Total 221 100
  14. 14. Table 5: Hormone levelsTSH No %Normal 177 80Decreased 31 14Increased 13 6Total 221 100
  15. 15. Table 6: Adequacy of sample Adequacy No % Satisfactory 219 99 Unsatisfactory 2 1 Total 221 100
  16. 16. Table 7 : Nature of sampleNature of aspirate No. %Colloid 77 34.84Hemorrhagic 39 17.65Colloid admixed with 105 47.51bloodTotal 221 100
  17. 17. Table 8: Lesions on FNAC Lesion No.Benign 204Follicular 10Malignant 5Inadequate 2Total 221
  18. 18. Table 9: Benign lesions in present study Disease No. %Simple colloid goiter 67 33Nodular colloid goiter 56 27Hyperplastic goiter 11 5Colloid goiter with cystic degeneration 50 25Hashimoto’s thyroiditis 14 7Lymphocytic thyroiditis 6 3Total 204 100
  19. 19. Table 10: Simple colloid and nodular goiter on cytological study with Age and SexAge in Females Males Totalyears No. % No. % No. %10-20 5 3 1 10 6 321-30 46 26 2 20 48 2631-40 62 36 3 30 65 3541-50 52 30 2 20 54 2951-60 6 3 0 0 6 461-70 3 2 2 20 5 3Total 174 100 10 100 184 100
  20. 20. Table 11: Histopathology results of 76 patients Benign 72 Malignant 4 Total 76
  21. 21. Table 12: Distribution of malignant cases (n=4) Papillary carcinoma 2 Follicular variant of papillary carcinoma 1 Follicular carcinoma 1 Total 4
  22. 22. Table 13: Histopathological diagnosis Vs Cytological diagnosis Diagnosis Histology Cytology Benign 72 75 Malignant 4 1 Total 76 76
  23. 23. Table 14 : Cytological diagnosis in 76 patients Diagnosis No. % Simple & nodular colloid 40 53 goiter Nodular colloid goiter with 28 36 cystic degeneration Hyperplasic goiter 03 04 Hashimoto’s thyroiditis 02 03 Follicular neoplasm 02 03 Papillary carcinoma 01 01 Total 76 100
  24. 24. Table 15 : Correlation of Cytological diagnosis with final Histopathological diagnosis Cytological Histopathological Thyroid disease Diagnosis Diagnosis No. % No. %Simple & Nodular colloid goiter 40 52.63 39 51.32Nodular goiter with cystic 28 36.84 26 34.21degenerationHyper plastic goiter 03 3.95 03 3.95Hashimoto’s Thyroiditis 02 2.63 02 2.63Follicular neoplasm 02 2.93 00 00Follicular adenoma 00 00 02 2.63Papillary carcinoma 01 1.32 02 2.63Follicular variant of papillary 00 00 01 1.32carcinomaFollicular carcinoma 00 00 01 1.32Total 76 100 76 100
  25. 25. Table 16: Results of False negativesDiagnosis FNAC Histopathological diagnosis diagnosis Nodular goiter Papillary carcinoma- 1. with cystic degeneration- 2 Follicular variant ofFalse negative=3 papillary carcinoma- 1 Adenomatous Follicular carcinoma- 1 goiter- 1
  26. 26. • 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%.
  27. 27. Fig 1: Colloid goiter. Abundant thick colloid with fewclusters of follicular epithelial cells(H&E, scanner view)
  28. 28. Fig 2: Colloid goiter. Varying sized follicles lined by flattened epithelium filled with colloid (H&E,x 10)
  29. 29. Fig 3: Nodular colloid goiter. Clusters and sheets of follicular cells with colloid background(H&E, x10)
  30. 30. Fig 4: Nodular colloid goiter. Monolayered sheet of follicular cells(H&E,x 40)
  31. 31. Fig 5: Nodular colloid goiter with cystic degeneration. Cyst macrophages(H&E,x 10)
  32. 32. Fig 6: Multinodular goiter. External surface showing nodules of varying size
  33. 33. Fig 7: Multinodular goiter. Cut surface showing nodules of varying size filled with colloid
  34. 34. Fig 7: Multinodular goiter. Multiple colloid filled nodules separated by fibrous septa(H&E,x 10)
  35. 35. Fig 8: Nodular goiter with Cystic degeneration. Cyst wall with adjacent normal thyroid (H&E,x 10)
  36. 36. Fig 9: Hyperplastic goiter. 3-D cluster of follicular cells (H&E,x 40)
  37. 37. Fig 10: Hyperplastic goiter. 3-D fragments of follicular cells (H&E, x40)
  38. 38. Fig 11: Hyper plastic goiter. Scalloping of colloid (H&E,x 40)
  39. 39. Fig 12: Hashimoto’s thyroiditis. Lymphocytic infiltration of follicular cells and hurthle cell change (H&E,x 40)
  40. 40. Fig 12: Hashimoto’s thyroiditis. Lymhocytic infiltration of follicular cells and hurthle cell change
  41. 41. Fig 24: Hashimoto’s thyroiditis. Hurthle cells (H&E,x 40)
  42. 42. Fig 14: Hashimoto’s thyroiditis. Prominent lymphocytic infiltration of thyroid follicles (H&E,scanner view)
  43. 43. Fig 15: Hashimoto’s thyroiditis. Normal follicular epithelium along with follicular epithelium with hurthle cell change (H&E,x 10)
  44. 44. Fig 15: Hashimoto’s thyroiditis. Hurthle cell change and lymphocytic infiltration (H&E,x 40)
  45. 45. Fig 12: Follicular neoplasm. Cut surface showing a solitary well encapsulated nodule
  46. 46. Fig 16: Follicular neoplasm. A repetitive acinar pattern (H&E,x 40)
  47. 47. Fig 17: Follicular neoplasm. Repetitive acinar pattern (MGG,x 40)
  48. 48. Fig 5: Microfollicular adenoma. Intact fibrous capsule around a follicular adenoma (H&E,scanner view)
  49. 49. Fig 7: Papillary carcinoma. Branching papillae with fibrovascular core (H&E,x 10)
  50. 50. Fig 8: Papillary carcinoma. Papillae lined by cuboidal epithelium with optically clear nuclei (H&E,x 40)
  51. 51. Fig 9: Follicular variant of papillary carcinoma. Optically clear nuclei (H&E,x 40)
  52. 52. Fig 12: Follicular carcinoma. Capsular invasion (H&E,x 10)
  53. 53. Fig 13: Follicular carcinoma. Capsular invasion (H&E,x 10)
  54. 54. 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.
  55. 55. • 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.
  56. 56. Table 17: Comparison of AgeStudies Range of age Median age in years in 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
  57. 57. Table 18: Comparison of SexStudies Total 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
  58. 58. Table 19: Comparison of Age and Sex for Simple and Nodular goiterStudies Median age in Female to Male years ratioHanda et al 39 6:1Charugupta et al 32 7:1Present study 27 17:1
  59. 59. Table 20: Comparison of TSH levelsStudies 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
  60. 60. Table 21: Comparison of Presenting SymptomsStudies Swelling Pain Dysphagia Palpitation Weight Total front of & Anxiety gain neckGodinho- 144 8 11 11 4 144Matos et alHanda et al 434 10 6 15 6 434Present 221 3 6 27 11 221study
  61. 61. 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
  62. 62. Table 23: Comparison of lesions on FNACStudies 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
  63. 63. Table 24: Comparison of Individual Lesions on CytologyDisease Nongrum Bhatta et al Mosawi et Mubarik et Present study et al n=60 n=90 al n=78 al n=54 n=76Simple & Nodular 34 58 52 38 40colloid goiterNodular goiter with 0 13 4 5 28cystic degenerationHyperplastic goiter 4 0 6 0 3Hashimoto’s 14 6 3 1 2thyroiditisFollicular neoplasm 5 3 3 7 2Papillary 2 9 4 1 1carcinomaAnaplastic 1 1 0 0 0carcinomaUndifferentiated 0 0 0 2 0carcinomaSuspicious 0 0 3 0 0Non diagnostic 0 0 3 0 0
  64. 64. Table 25: Comparison of Cyto-HistologicalConcordance 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
  65. 65. 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%
  66. 66. • 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.
  67. 67. • 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.
  68. 68. Table 27: Comparison of diagnostic values in goiterStudies Sensitivit Specificity Positive Negative Diagnostic y predictive predictive accuracy value valueNongrum et 100% 50% 75% 100% 80%alBeneragama 82.25% 87.77% 82.25% 87.25% _et alPresent study 100% 62.5% 95.7% 100% 96.05%
  69. 69. 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.
  70. 70. • 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.

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