International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - 5(2), January, 2013

Pages: 94-100

Date of Publication: 26-Jan-2013


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ACCURACY OF ULTRASOUND GUIDED FINE NEEDLE ASPIRATION CYTOLOGY IN THE EVALUATION OF THYROID NODULES

Author: Senthil Panneerselvam, Rajan K. Vaithianathan, Ramachandran Santhanam

Category: Healthcare

Abstract:Background: Thyroid nodules are a common problem which requires an accurate cytological diagnosis for proper management. An essential investigation modality is fine needle aspiration cytology (FNAC) with a sensitivity ranging between 80-90%. Recommendations vary regarding the use of ultrasound in improving the accuracy of free hand fine needle aspiration biopsy. Objective: The aim of our study was to investigate the role and accuracy of ultrasound guided fine needle aspiration cytology in the evaluation of patients with thyroid nodules. Methods: Forty four patients with nodular thyroid disease who were assessed by ultrasound guided fine needle aspiration cytology (US-FNAC) followed by thyroidectomy were identified. Retrospective analysis of data on the cytology specimens and histological results was carried out. Results: The sensitivity and specificity of US-FNAC for diagnosing thyroid neoplasms were 91.7% and 93.3% respectively. The diagnostic accuracy was 92.8%, with the rate of inadequate smears as 4.6%. Conclusions: Ultrasound guided fine needle cytology of thyroid nodules yields more accurate results, with a decrease in the number of inadequate sample category. Precise targeting of lesions in both palpable and non palpable thyroid nodules by the FNA needle under ultrasound guidance will increase the diagnostic accuracy, thereby avoiding or reducing the number of unnecessary thyroid surgeries.

Keywords: thyroid nodule, ultrasound guided, FNAC, neoplasm

Full Text:

INTRODUCTION

Nodular thyroid disease is found in approximately 5% of the population at palpation screening. Routine ultrasound screening of thyroid in clinically normal individuals suggests a prevalence rate of 50% for thyroid nodules 1, 2 . Fine needle aspiration cytology (FNAC) of the thyroid gland is over 50 years old and is the single most important method of establishing a diagnosis in both adults and children. Recent guidelines published by the British Thyroid Association/Royal College of Physicians and the American Association of Clinical Endocrinologists (AACE)/Association Medici Endocrinologi(AME) emphasize that FNAC should be considered as the early investigation of choice for thyroid nodules and specifically for thyroid cancer 4,5 FNAC requires careful aspiration technique and meticulous interpretation of the findings by a skilled cytologist. Studies have suggested a sensitivity and specificity for predicting thyroid malignancies averaging 83% and 92% respectively 5, 6 . Unfortunately, FNAC can miss malignancies with a false negative rate of approximately 5% . Current guidelines recommend the usage of ultrasound guided FNAC (US FNAC) to reduce this error 1,5 .Studies have shown that US FNAC significantly reduces the number of inadequate fine needle aspirates and improves the diagnostic yield for malignancies 1,10 US FNAC also improves the yield of cancer found at surgery 11 The aim of our study was to investigate the role and accuracy of ultrasound guided fine needle aspiration cytology in the management of patients with thyroid nodules.

PATIENTS AND METHODS

Two hundred and eighty two FNACs of thyroid nodules were carried out at Mahatma Gandhi Medical College and Research Institute and the results reviewed. Out of this, 44 patients had US FNAC for assessment of thyroid nodules followed by thyroidectomy. A retrospective analysis of the data was carried out that included patient demographics, US FNAC results and the final histopathological reports. All patients had baseline thyroid function tests followed by ultrasound examination and guided FNAC of the thyroid nodules. A high resolution 7.5 MHz probe was used to guide a 23/25 gauge needle attached to a syringe to obtain cellular aspirates from the lesions. Cytological diagnosis was correlated with histopathology and the accuracy of ultrasound guided FNAC

Study parameters:

  •  Demographic data
  •  Sensitivity, specificity
  •  Positive and negative predictive values
  •  Diagnostic accuracy rate
  •  Inadequate sample category

RESULTS

Data regarding 44 patients who had undergone US FNAC of the thyroid nodules followed by thyroidectomy was retrospectively analyzed. There were 3 men and 41 women in the study group, with age ranging from 18 to 51 years. The mean age was 39.6 years with male to female ratio of 1:13.7(Table 1). 29(63.6%) patients had non neoplastic lesions (nodular/colloid goiter, thyroiditis) and 14(31.8%) had neoplastic lesions on cytological examination. Overall, US FNAC yielded satisfactory cell samples in 42(95.4%) patients and inadequate material in 2(4.6%) patients (Table 2). An aspirate was considered adequate by the presence of 5 to 6 clusters of cells with each cluster containing 10 or more cells. Nodular goiter constituted the majority (55.2%) in the non neoplastic category and papillary carcinoma was the commonest (61.5%) cytological diagnosis in the neoplastic group as shown in Tables 3 and 4. On comparing the US FNAC reports of the 29 non neoplastic nodules with the final histological diagnosis, it was observed that 26 patients had same cytological diagnosis, 1 had papillary carcinoma (false negative) and 2 had Hashimoto’s thyroiditis (Table 5). The US FNAC results for the 13 neoplastic lesions were compared with the corresponding histological diagnoses. 8 patients had papillary carcinoma confirmed by histological study and out of 4 cases of follicular neoplasm, 2 were confirmed as follicular adenoma and 1 each of colloid goiter (false positive) and follicular carcinoma. One patient diagnosed as Hurthle cell neoplasm by US FNAC turned out to be Hashimoto’s thyroiditis on final histological study (false positive), Table 6. The sensitivity and specificity of US FNAC for diagnosing neoplastic lesions were 91.7% and 93.3% respectively. The diagnostic accuracy was 92.8%, positive predictive value (PPV) was 86.5% and negative predictive value (NPV) 96.5% (Table 7 and Table 8).

DISCUSSION

FNAC is considered as the gold standard in the evaluation of thyroid nodules. Major problems associated with free hand FNAC are significant false negatives (missed neoplasms) and difficulties in accurate identification of follicular lesions leading to wrong FNAC diagnoses 12 . Possible reasons cited for this include the technique of aspiration, smear preparation and experience of the cytopathologist. The AACE/AME has suggested that ultrasound should be employed routinely to detect features suspicious of malignancy in thyroid nodules and to identify lesions that would be suitable for FNAC . Ultrasound (US) is useful to guide the needle for fine needle aspiration of a thyroid nodule; it improves the quality of diagnosis in pre operative assessment of thyroid nodules and to appropriately select patients for thyroidectomy. Ultrasound guidance allows continuous visualization of the needle during insertion and sampling, which results in pinpoint accuracy with a high evel of safety. Some of the potential advantages of US FNAC in the evaluation of nodular thyroid disease are selecting the suspicious nodule for biopsy in a multinodular goiter and guiding the needle to take samples from nonpalpable nodules. A recent review of studies that evaluated the role of US FNAC in the detection of thyroid cancer revealed a sensitivity of 76%–98%, specificity of 71%–100%, false negative rate of 0%–5%, false positive rate of 0–5.7%, and overall accuracy of 69%–97% 13 23 . Another report based on a systematic review of 12 studies had shown a median sensitivity and specificity of 88% and 90.5% 24 . A large prospective cohort study had reported a marked increase in the diagnostic accuracy of FNAC from 85% to 95% when FNAC was combined with US guidance 25 . Our results have shown a sensitivity and specificity of US FNAC for diagnosing neoplastic lesions as 91.7% and 93.3% respectively. The false negative rate was 2.3%, PPV 86.5%, NPV 96.5% and the diagnostic accuracy was 92.8%. The accuracy of FNAC depends crucially on the technique, operator performing the aspiration and the cytopathologist analyzing it. Even under optimal conditions, the false negative rate for thyroid neoplasms can vary from 1% to 6% due to wrong diagnosis or sampling errors . Danese et al in their study have observed the false negative rate much lower for US FNAC when compared with free hand FNAC 27 . In our analysis, there was one patient who had cytological picture of nodular goiter whereas the histological study showed a small focus of papillary carcinoma in a background of multinodular goiter(false negative 2.3%). The majority of thyroid FNAC is now performed under US guidance and this has become mandatory at some of the centers. The major benefit of this technique is accurate sampling of small or multiple nodules 28 30 . Certain sonologic features of thyroid lesions are predictive of malignancy and hence such lesions can be accurately biopsied 31 . Another crucial benefit of using US FNAC is significant reduction in the number of inadequate aspirates 32 . Case series have reported rates of inadequate samples in the order of 15 30% for free hand FNAC. Many published studies have shown US FNAC to decrease the rate of inadequate samples from 15% to 3% when compared to free hand FNAC 17,33,34 . In a recent study, the authors have noted a prevalence rate of 8.5% for thyroid cancer in patients with inadequate samples and they recommended repeat aspirations by US FNAC technique 35 . It is possible that reduced number of inadequate aspirates may potentially lead to increase in the yield of cancer and the diagnostic accuracy of FNAC. The rate of inadequate specimens in our retrospective study was 4.5 % (2 out of 44 samples), which is comparable to the above quoted studies.

CONCLUSION

In conclusion, US FNAC greatly facilitates the precise and adequate sampling of tissues from thyroid lesions thus enabling the cytopathologist to make an accurate diagnosis. This may lead to the elimination of the cost and potential morbidity of unnecessary thyroidectomy.

Ultrasound guidance helps in the selection of the most suspicious focus within the nodule especially with a background of multinodularity. It is therefore desirable that practice guidelines recommend universal use of ultrasound guided FNAC for all nodular thyroid lesions, especially for inadequate smears from free hand FNAC, for small or nonpalpable nodules and multinodular goiters. US FNAC is the most accurate and cost effective method for diagnostic evaluation of thyroid nodules.

ACKNOWLEDGEMENTS

Authors acknowledge the immense help received from the scholars whose articles are citied and included in references of this manuscript. The authors are also grateful to authors/ editors/publishers of all those articles, journals and books from where the literature for this article has been review and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript. The authors also thank all the residents and staff in the Department of Surgery, Departments of Pathology and Radiology, Dean and Vice Chancellor of Mahatma Gandhi Medical College & Research Institute for their support.

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Awards, Research and Publication incentive Schemes by IJCRR

Best Article Award: 

One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

Emerging Researcher Award:

‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


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A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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