1. FNAC: A RELIABLE DIAGNOSTIC TOOL
IN DIAGNOSIS OF SIMPLE AND
NODULAR GOITER
2. 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%.
3. • 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.
4. 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.
5. 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.
6. • 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.
7. • 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.
8. • 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.
9. 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.
10. • 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.
11. Table1:Age distribution with Sex
Females Males Total
Age in
Years No. % No. % No. %
10-20 08 3.79 01 10 09 4.07
21-30 54 25.59 02 20 56 25.34
31-40 71 33.65 03 30 74 33.48
41-50 60 28.44 02 20 62 28.05
51-60 14 6.64 00 00 14 6.33
61-70 04 1.90 02 20 06 2.71
Total 211 95.48 10 4.52 221 100
12.
13.
14. Table2: Duration Of Complaints
Duration 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
39. • 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%.
40. Fig 1: Colloid goiter. Abundant thick colloid with few clusters of
follicular epithelial cells(H&E, scanner view)
41. Fig 2: Colloid goiter. Varying sized follicles lined by flattened
epithelium filled with colloid (H&E,x 10)
42. Fig 3: Nodular colloid goiter. Clusters and sheets of follicular
cells with colloid background(H&E, x10)
72. 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.
73. • 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.
74. Table 17: Comparison of Age
Range of age in Median age in
Studies
years years
Mahar et al 13-76 39
Mubarik et al 20-60 41
Saddique et al 10-70 35
Basharat et al 10-70 33
Handa et al 5-80 37
Present study 10-70 35
75. Table 18: Comparison of Sex
Total
Studies Males Females M:F ratio
cases
Mubarik et al 54 7 47 1:6.7
Safirullah et al 300 30 270 1:9
Saddique et al 60 8 52 1:6.5
Haberal et al 260 42 218 1:5
Handa et al 434 - - 1:6.3
Present study 221 10 211 1:21
76. Table 19: Comparison of Age and Sex for
Simple and Nodular goiter
Median age in Female to Male
Studies
years ratio
Handa et al 39 6:1
Charugupta et al 32 7:1
Present study 27 17:1
77. Table 20: Comparison of TSH levels
Studies Normal Decreased Increased Total
Basharat et al 48 2 0 50
Godinho-
109 11 4 124
Matos et al
Handa et al 80 25 15 120
Present
177 31 13 221
study
78. Table 21: Comparison of Presenting Symptoms
Swelling Palpitatio
Weight
Studies front of Pain Dysphagia n& Total
gain
neck Anxiety
Godinho-
144 8 11 11 4 144
Matos et al
Handa et al 434 10 6 15 6 434
Present
221 3 6 27 11 221
study
79. 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
80. Table 23: Comparison of lesions on FNAC
Studies Benign Follicular Malignant Inadequate Total
Handa et al 381 14 17 22 434
Charugupta
470 - 30 7 507
et al
Bagga &
228 17 3 4 252
Mahajan
Mahar et al 63 44 15 3 125
Present
204 10 5 2 221
study
81. Table 24: Comparison of Individual Lesions on Cytology
Nongrum Bhatta et al Mosawi et Mubarik et Present study
Disease
et al n=60 n=90 al n=78 al n=54 n=76
Simple & Nodular
colloid goiter
34 58 52 38 40
Nodular goiter with
cystic degeneration
0 13 4 5 28
Hyperplastic goiter 4 0 6 0 3
Hashimoto’s
thyroiditis
14 6 3 1 2
Follicular neoplasm 5 3 3 7 2
Papillary
carcinoma
2 9 4 1 1
Anaplastic
carcinoma
1 1 0 0 0
Undifferentiated
carcinoma
0 0 0 2 0
Suspicious 0 0 3 0 0
Non diagnostic 0 0 3 0 0
82. 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
83. 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%
84. • 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.
85. • 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.
86. Table 27: Comparison of diagnostic values in goiter
Positive Negative
Diagnostic
Studies Sensitivity Specificity predictiv predictiv
accuracy
e value e value
Nongrum
100% 50% 75% 100% 80%
et al
Beneragama
82.25% 87.77% 82.25% 87.25% _
et al
Present study 100% 62.5% 95.7% 100% 96.05%
87. 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.
88. • 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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