This study examined 221 patients with clinical presentations of goiter who underwent fine needle aspiration cytology (FNAC). 76 of these patients subsequently had surgery and histopathological examination. The study aimed to determine the diagnostic accuracy of FNAC for goiter diagnosis by comparing pre-operative FNAC results to post-operative histopathology. Key findings were a diagnostic accuracy of FNAC for goiter of 96.05%, and cyto-histological concordance in diagnosis of 95.7% of cases. FNAC was found to be a simple, safe and reliable first-line investigation for goiter diagnosis.

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
containing 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
Age in Females Males Total
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

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

15. Table 3:Presenting Complaints
Presenting complaint No. %
Swelling front neck 82 37.1
Solitary
Diffuse 139 62.9
Pain 03 1.36
Dysphagia 06 2.71
Palpitation & Anxiety 27 12.22
Weight gain 11 4.98
Total 221 100

16. Table 4: Size of the swelling
Size No %
1-5 cm 157 71
6-10 cm 64 29
Total 221 100

17. Table 5: Hormone levels
TSH No %
Normal 177 80
Decreased 31 14
Increased 13 6
Total 221 100

18. Table 6: Adequacy of sample
Adequacy No %
Satisfactory 219 99
Unsatisfactory 2 1
Total 221 100

19. Table 7 : Nature of sample
Nature of aspirate No. %
Colloid 77 34.84
Hemorrhagic 39 17.65
Colloid admixed with 105 47.51
blood
Total 221 100

20. Table 8: Lesions on FNAC
Lesion No.
Benign 204
Follicular 10
Malignant 5
Inadequate 2
Total 221

21. Table 9: Benign lesions in present study
Disease No. %
Simple colloid goiter 67 33
Nodular colloid goiter 56 27
Hyperplastic goiter 11 5
Colloid goiter with cystic degeneration 50 25
Hashimoto’s thyroiditis 14 7
Lymphocytic thyroiditis 6 3
Total 204 100

22. Table 10: Simple colloid and nodular goiter on
cytological study with Age and Sex
Age in Females Males Total
years No. % No. % No. %
10-20 5 3 1 10 6 3
21-30 46 26 2 20 48 26
31-40 62 36 3 30 65 35
41-50 52 30 2 20 54 29
51-60 6 3 0 0 6 4
61-70 3 2 2 20 5 3
Total 174 100 10 100 184 100

23. Table 11: Histopathology results of 76 patients
Benign 72
Malignant 4
Total 76

24. Table 12: Distribution of malignant cases (n=4)
Papillary carcinoma 2
Follicular variant of papillary carcinoma 1
Follicular carcinoma 1
Total 4

25. Table 13: Histopathological diagnosis Vs Cytological diagnosis
Diagnosis Histology Cytology
Benign 72 75
Malignant 4 1
Total 76 76

26. 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

27. 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 51.32
Nodular goiter with cystic 28 36.84 26 34.21
degeneration
Hyper plastic goiter 03 3.95 03 3.95
Hashimoto’s Thyroiditis 02 2.63 02 2.63
Follicular neoplasm 02 2.93 00 00
Follicular adenoma 00 00 02 2.63
Papillary carcinoma 01 1.32 02 2.63
Follicular variant of papillary 00 00 01 1.32
carcinoma
Follicular carcinoma 00 00 01 1.32
Total 76 100 76 100

28. Table 16: Results of False negatives
Diagnosis FNAC Histopathological
diagnosis diagnosis
Nodular goiter Papillary carcinoma- 1.
with cystic
degeneration- 2 Follicular variant of
False negative=3 papillary carcinoma- 1
Adenomatous Follicular carcinoma- 1
goiter- 1

29. • 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%.

30. Fig 1: Colloid goiter. Abundant thick colloid with few
clusters of follicular epithelial cells(H&E, scanner view)

31. Fig 2: Colloid goiter. Varying sized follicles lined by
flattened epithelium filled with colloid (H&E,x 10)

32. Fig 3: Nodular colloid goiter. Clusters and sheets of
follicular cells with colloid background(H&E, x10)

33. Fig 4: Nodular colloid goiter. Monolayered sheet of follicular
cells(H&E,x 40)

34. Fig 5: Nodular colloid goiter with cystic degeneration. Cyst
macrophages(H&E,x 10)

35. Fig 6: Multinodular goiter. External surface showing
nodules of varying size

36. Fig 7: Multinodular goiter. Cut surface showing nodules of
varying size filled with colloid

37. Fig 7: Multinodular goiter. Multiple colloid filled nodules
separated by fibrous septa(H&E,x 10)

38. Fig 8: Nodular goiter with Cystic degeneration. Cyst wall
with adjacent normal thyroid (H&E,x 10)

39. Fig 9: Hyperplastic goiter. 3-D cluster of follicular cells
(H&E,x 40)

40. Fig 10: Hyperplastic goiter. 3-D fragments of follicular cells
(H&E, x40)

41. Fig 11: Hyper plastic goiter. Scalloping of colloid
(H&E,x 40)

42. Fig 12: Hashimoto’s thyroiditis. Lymphocytic infiltration of
follicular cells and hurthle cell change (H&E,x 40)

43. Fig 12: Hashimoto’s thyroiditis. Lymhocytic infiltration of
follicular cells and hurthle cell change

44. Fig 24: Hashimoto’s thyroiditis. Hurthle cells (H&E,x 40)

45. Fig 14: Hashimoto’s thyroiditis. Prominent lymphocytic
infiltration of thyroid follicles (H&E,scanner view)

46. Fig 15: Hashimoto’s thyroiditis. Normal follicular epithelium
along with follicular epithelium with hurthle cell change
(H&E,x 10)

47. Fig 15: Hashimoto’s thyroiditis. Hurthle cell change and
lymphocytic infiltration (H&E,x 40)

48. Fig 12: Follicular neoplasm. Cut surface showing a solitary
well encapsulated nodule

49. Fig 16: Follicular neoplasm. A repetitive acinar pattern
(H&E,x 40)

50. Fig 17: Follicular neoplasm. Repetitive acinar pattern
(MGG,x 40)

51. Fig 5: Microfollicular adenoma. Intact fibrous capsule
around a follicular adenoma (H&E,scanner view)

57. Fig 7: Papillary carcinoma. Branching papillae with
fibrovascular core (H&E,x 10)

58. Fig 8: Papillary carcinoma. Papillae lined by cuboidal
epithelium with optically clear nuclei (H&E,x 40)

59. Fig 9: Follicular variant of papillary carcinoma. Optically
clear nuclei (H&E,x 40)

60. Fig 12: Follicular carcinoma. Capsular invasion (H&E,x 10)

61. Fig 13: Follicular carcinoma. Capsular invasion (H&E,x 10)

62. 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.

63. • 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.

64. Table 17: Comparison of Age
Studies Range of age Median age
in years in 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

65. Table 18: Comparison of Sex
Studies Total 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

66. Table 19: Comparison of Age and Sex for
Simple and Nodular goiter
Studies Median age in Female to Male
years ratio
Handa et al 39 6:1
Charugupta et al 32 7:1
Present study 27 17:1

67. 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

68. Table 21: Comparison of Presenting Symptoms
Studies Swelling Pain Dysphagia Palpitation Weight Total
front of & Anxiety gain
neck
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

69. 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

70. 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

71. Table 24: Comparison of Individual Lesions on Cytology
Disease Nongrum Bhatta et al Mosawi et Mubarik et Present study
et al n=60 n=90 al n=78 al n=54 n=76
Simple & Nodular 34 58 52 38 40
colloid goiter
Nodular goiter with 0 13 4 5 28
cystic degeneration
Hyperplastic goiter 4 0 6 0 3
Hashimoto’s 14 6 3 1 2
thyroiditis
Follicular neoplasm 5 3 3 7 2
Papillary 2 9 4 1 1
carcinoma
Anaplastic 1 1 0 0 0
carcinoma
Undifferentiated 0 0 0 2 0
carcinoma
Suspicious 0 0 3 0 0
Non diagnostic 0 0 3 0 0

72. 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

73. 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%

74. • 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.

75. • 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.

76. Table 27: Comparison of diagnostic values in goiter
Studies Sensitivit Specificity Positive Negative Diagnostic
y predictive predictive accuracy
value value
Nongrum et 100% 50% 75% 100% 80%
al
Beneragama 82.25% 87.77% 82.25% 87.25% _
et al
Present study 100% 62.5% 95.7% 100% 96.05%

77. 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.

78. • 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.