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ORIGINAL ARTICLE Table of Contents   
Year : 2008  |  Volume : 25  |  Issue : 1  |  Page : 13-17
Role of fine needle aspiration cytology in diagnosis and ­management of thyroid lesions: A study on 434 patients

1 Department of Pathology, Government Medical College and Hospital, Chandigarh, India
2 Department of ENT and Head and Neck Surgery, Government Medical College and Hospital, Chandigarh, India

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Objectives: To evaluate the results of fine needle aspiration cytology (FNAC) in the diagnosis and management of thyroid lesions.
Materials and Methods: A review was conducted of FNAC of diffuse or nodular thyroid lesions performed on 434 patients over a period of three years. The cytological results were correlated with clinical features, biochemical investigations, and subsequent histopathological examination and management of the patients.
Results: The most frequently encountered lesion was the colloid goiter in 250 (57.60%) cases followed by thyroiditis in 119 (27.41%) cases, ten (2.30%) adenomatous goiters and two (0.004%) thyroglossal cysts. In the neoplastic group, 14 (1.38%) cases were reported as follicular/Hurthle cell neoplasms and 17 (3.91%) as malignant tumors. When compared with the clinical diagnosis, FNAC proved to be an improvement on the diagnosis of thyroiditis and malignancy when compared with that of goiter. FNA revealed a sensitivity of 97%, a specificity of 100%, a positive predictive value of 96% and a negative predictive value of 100%.
Conclusions: FNAC is a minimally invasive, highly accurate and cost-effective procedure for the assessment of patients with thyroid lesions. It also helps in differentiating lesions that require surgery from those that can be managed otherwise.

Keywords: Colloid goiter; fine needle aspiration cytology; thyroid; thyroid neoplasms; thyroiditis.

How to cite this article:
Handa U, Garg S, Mohan H, Nagarkar N. Role of fine needle aspiration cytology in diagnosis and ­management of thyroid lesions: A study on 434 patients. J Cytol 2008;25:13-7

How to cite this URL:
Handa U, Garg S, Mohan H, Nagarkar N. Role of fine needle aspiration cytology in diagnosis and ­management of thyroid lesions: A study on 434 patients. J Cytol [serial online] 2008 [cited 2021 Oct 18];25:13-7. Available from:

   Introduction Top

The diagnosis of thyroid lesions using aspiration cytology was first reported by Martin and Ellis in 1930. [1] The routine use of fine needle aspiration cytology (FNAC) in the assessment of thyroid nodules has reduced the number of patients subjected to thyroidectomy for benign diseases of the thyroid. [2],[3],[4],[5] As a result, the incidence of malignancy at thyroidectomy has increased from 5-10% to 30-50% in the recent years. [6] This relatively simple procedure has assumed a dominant role in determining the management of patients with thyroid nodules. [7],[8] However, the success of FNA is contingent upon several important contributing influences including aspirator experience, skillful cytological interpretation and a rational analysis based upon a synthesis of cytological and clinical information in the context of an individual patient.

The aim of this retrospective study was to evaluate the results of thyroid FNAC and correlate it with histology, wherever available. In particular, the present study was aimed at the impact of FNAC on the decreased rate of surgery in clinically suspect thyroid lesions.

   Materials and Methods Top

During the period from 2004 to 2006, FNAC was preformed on 434 patients with thyroid enlargement. Patients' data regarding history, clinical examination, thyroid function tests and clinical diagnosis were retrieved from the records.

The procedure was done by cytopathologists in all the cases. Prior to aspiration, a physical examination was carried out to note the mobility of the thyroid during swallowing and the presence of any enlarged cervical lymph node. The patients were made to lie supine with their necks stretched up. A 23-gauge needle attached to a Franzen's handle was used, either without or with aspiration by a 20 ml disposable syringe. Two to three passes were made in each case. In the case of cystic nodules, the cysts' contents were aspirated, centrifuged, and slides made from the sediment for cytological analysis. The slides were stained with May-Grünwald-Giemsa (MGG), hematoxylin and eosin (H and E) and papanicolau (Pap) stains. No major complications like penetration into the trachea, laryngeal nerve palsy, or hematoma were recorded. Only slight pain was reported by some patients.

Out of 434 patients, 66 (15.20%) patients were treated by surgery such as total, subtotal and hemithyroidectomy. Histopathological examination of these specimens was done. After noting the detailed gross examination, 3-10 tissue bits were selected from representative areas for routine paraffin sections, which were stained by H and E. The cytological results were correlated with clinical features, thyroid function tests, and histopathological examination. Descriptive statistics were done to evaluate our results.

   Results Top

The age of the patients ranged from 5 to 80 years with a mean age of 37.69 ± 14.93 years and the female: male ratio was 6.35:1. The major presenting symptom in all the patients was diffuse swelling and or nodular swelling of the thyroid. Other symptoms were less frequent - pain in the thyroid region in ten patients, dysphagia in six patients, and hoarseness of voice in ten and cough in seven patients. Cervical lymph nodes were palpable in four patients. Patients gave a history of swelling being present for more than one year in 270 (62.2%) cases, less than three months in 33 (7.6%) cases and between three months and one year in 29 (6.68%) cases. Family history of thyroid disease was positive in two cases.

Thyroid function tests were performed in 120 patients (27.64%). Eighty patients (66.66%) were found to be euthyroid, 25 hyperthyroid (20.83%), and 15 (13%) hypothyroid. Hyperthyroidism occurred in ten patients with solitary or multiple nodules, eight patients with diffuse swelling, six patients with thyroiditis, and one patient with malignancy. The results were compared with cytological findings.

FNAC of 434 patients resulted in the following diagnoses and are shown in [Table - 1]. Diagnoses for 22 cases with FNAC were inadequate because of the lack of cellularity.

Non neoplastic

Colloid goiter: A total of 250 patients were diagnosed to have colloid goiter by FNAC, out of which 40 were males and 210 were females, the female:male ratio being 5:1. The average age of these patients was 39.70 ± 15.19 years with a range of five to 77 years. The cytological features seen were follicular epithelial cells, cyst macrophages (59.4%), fire flares (6.34%), lymphocytic infiltrate (2.38%), and Hurthle cell change (1.58%). Nuclear inclusion and nuclear grooves were also seen in 1.4% patients. Fire flares were noted in 16 out of 18 patients of hyperthyroidism.

Adenomatous goiter: Out of 10 patients, 2 were males and 8 were females. The diagnosis was made when the smear showed a profusion of follicular epithelial cells distributed in sheets along with formation of follicles and moderate to scanty amount of colloid. These cases were correlated with clinical diagnosis and radiological findings.

Thyroiditis: In 119 patients, a diagnosis of thyroiditis was made. Lymphocytic and Hashimoto's thyroiditis were grouped together. One hundred and fifteen of these patients were females and four were males with a female to male ratio of 29:1. The mean age was 32.70 ± 11.85 years. The youngest patient was an eight year-old female. There was a diffuse swelling in 107 cases (89.91%), solitary nodules in six cases (5%) and multiple nodules in six cases (5%). Difficulty in breathing and change in voice was noted in two and three patients, respectively. The cytological findings included lymphocytic infiltrate destroying follicular epithelial cells [Figure - 1], Hurthle cell changes (40.3%), lymphoid tangles (25.2%), and epithelioid cells (11.8%). Multinucleate giant cells and fire flares were seen in 8.4 and 3.4% patients, respectively. Four out of six patients with increased levels of thyroid hormones showed the presence of fire flares.

Thyroglossal cyst: There were two cases of thyroglossal cysts. Fluid was aspirated and smears showed scanty cellularity with the presence of squamous cells and macrophages.


Follicular neoplasm/Hurthle cell neoplasm: Out of 14 patients, three were males and 11 were females. The diagnosis of follicular neoplasm was made when the smear showed a profusion of follicular epithelial cells distributed in follicular structures or sheets with a small quantity of colloid. If oxyphilic cells dominated, a diagnosis of Hurthle cell neoplasm was made. Histological examination was advised in cases of follicular/Hurthle cell neoplasm.

Malignant tumors of the thyroid: A comparative analysis of the clinical diagnoses and FNAC results was done as shown in [Table - 2].

Eleven cases of papillary carcinoma were diagnosed. Four cases had cystic changes and aspiration was repeated. The smears showed papillary clusters of cells with pale nuclei, intranuclear cytoplasmic invaginations, irregular nuclear outlines, and nuclear grooves [Figure - 2]. Hurthle cell changes were noted in five cases and psammoma bodies were seen in three cases. Thick colloid was present in three cases. A single case with increased levels of thyroid hormones did not show the presence of fire flares.

There were three cases of medullary carcinoma, which showed the presence of cuboidal to rounded cells with oval, eccentric, pleomorphic nuclei with abundant cytoplasm. Congo red-positive material was seen in one case. One case of anaplastic carcinoma showed the presence of large tumor cells with pleomorphic nuclei and moderate amount of cytoplasm in a background of necrosis. There was a single case of metastatic carcinoma, which showed the presence of clusters as well as singly scattered moderately pleomorphic tumor cells in a background of follicular epithelial cells and colloid. The patient was a known case of infiltrating duct carcinoma of the breast.

Surgery was preformed in 66 patients. [Table - 3] shows cyto-histological correlation in these cases.

Statistical analysis of our data shows the diagnostic accuracy of FNAC to be 98.48%. FNA showed a sensitivity of 97% and a specificity of 100%. The negative and positive predictive values were 100 and 96%, respectively.

   Discussion Top

Thyroid enlargement, whether diffuse or in the form of a nodule, leads to a battery of investigations, mainly to rule out the possibility of a neoplasm or thyroiditis. FNAC is usually the first line of investigation and other investigations like ultrasound (US) examination, thyroid function tests, thyroid scan, and antibody levels are done subsequently with an aim to select the patients who require surgery and those that can be managed conservatively. [9],[10]

FNAC of the thyroid is widely used as it is safe, rapid, inexpensive, and reliable in the diagnosis of thyroid nodules. [11] The sensitivity of the thyroid FNAC ranges from 80 to 98% and its specificity from 58 to 100%. [12],[13],[14],[15],[16],[17] In our study, the sensitivity was 97% and specificity 100%. The inadequacy rate in this study was 5.06%. Previous studies have shown the percentage of inadequate material to vary between 0 and 25%. [17],[18] Various studies have shown the role of US guidance which can detect circumscribed lesions as small as 1 mm in diameter. [19],[20] In addition, in mixed, solid-cystic lesions or difficult-to-palpate lesions, US-guided aspiration technique is clearly superior to palpation-guided aspiration. [21]

Thyroid enlargement is a common occurrence in most regions of the world. India has the world's biggest goiter belt in the sub-Himalayan region. In these iodine-deficient areas, the incidence of goiter among thyroid nodules is much higher as shown in our study (57.60%). The cytohistological concordance rate in our study in colloid goiters came out to be 90% (45 out of 50 cases). Various studies have shown concordance between cytology and histology to vary between 80 and 100%. [22],[23],[24],[25],[26],[27] A single false negative case was diagnosed cytologically as a colloid goiter. Histopathological examination revealed papillary carcinoma with colloid goiter. Here, the cytological smear consisted exclusively of thyroid follicular epithelial cells, leading us to believe that the needle did not puncture the actual 1.2 cm nodule seen on histological examination and that only the surrounding thyroid showing changes of colloid goiter was aspirated.

Five cases were diagnosed as colloid goiter with cystic degeneration on cytological investigation. On histological examination, four of these were diagnosed as follicular adenomas while one case was diagnosed as Hurthle cell adenoma with cystic change. This can be explained on the basis of the sampling of areas of cystic change rather than cellular areas. Occurrence of cystic change in thyroid lesions is a common diagnostic pitfall in cytology.

Marked cellularity of the smear is another problem inherent in thyroid FNA cytology. Increased cellularity of the smear and loss of cohesion may be present in hyperplastic/adenomatous goiter, adenoma, or in carcinoma. It is difficult to differentiate follicular/Hurthle cell adenoma from carcinoma on cytological assessment because cytology cannot evaluate the criteria of vascular or capsular invasion or of intrathyroid spread.

In our series, when FNAC was compared with the initial clinical diagnosis based on history and clinical examination of patient, it represented no improvement on the original clinical diagnosis of colloid goiters. Therefore, it can only be considered as an additional tool in these cases. On the other hand, it represented an improvement in the diagnosis of thyroiditis and malignancy in our patients. This is similar to the experience of other authors who found that up to 63% of thyroiditis patients had no clinical diagnostic features. [28]

The positive influence of FNAC on the management of thyroid disease is perhaps best highlighted in the low rate of surgical intervention (15.2% in this series). Surgery was avoided mainly in colloid goiter and thyroiditis. Thus, FNAC can be used as an initial modality in the evaluation of palpable thyroid nodules and helps in differentiating lesions that require surgery from those that can be managed otherwise.

   References Top

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Correspondence Address:
Sukant Garg
Department of Pathology, Govt. Medical College, Sector-32A, Chandigarh - 160 047
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9371.40652

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