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Accuracy of Fine Needle Aspiration Cytology (FNAC) in comparison to

histopathological examination for the diagnosis of thyroid swellings

Article  in  International Journal of Medical Science and Public Health · January 2017

DOI: 10.5455/ijmsph.2016.30042016536

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 Research Article

Accuracy of fine needle aspiration cytology (FNAC) in

comparison to histopathological examination for the
diagnosis of thyroid swellings
Divyesh Goswami, Preeti Agrawal, Princy Shinde
Department of Pathology, Pacific Medical College and Hospital, Udaipur, Rajasthan, India.
Correspondence to: Divyesh Goswami, E-mail: [email protected]

Received April 30, 2016. Accepted June 21, 2016

Abstract

Background: Fine needle aspiration cytology (FNAC) is simple, readily available, reliable, time saving, and minimally
invasive procedure. Hence, it is widely accepted as a diagnostic tool in recent years. Histopathological examination of
surgically excised thyroid swelling is also one of the accurate ways to determine the pathology. However, it requires prepa-
ration and long procedure like anesthesia, hospitalization, and sometime even over treatment.
Objectives: Primary objective of this study was to evaluate the result of FNAC in diagnosis of various thyroid lesions and
correlate the result of FNAC with histopathological examination in diagnosis of various thyroid lesions.
Material and Methods: A prospective study was carried out for the duration of 2 years. Data collected were detailed
history of participants, general physical examination, and local examination. Investigations like thyroid function test, FNAC
and whenever it was possible histopathological examination was done. Correlation of FNAC with histopathological exam-
ination was done in those patients.
Results: Out of total 150 recruited patients 132 (82%) were female. Common age group of presentation was 21–40 years
of age with > 60% were presented during this period. Non-neoplastic non-inflammatory lesions were common (76.67%)
with common lesion were colloid goiter (36.67%), benign cystic lesion (10.67%), and adenomatous goiter (10.67%).
Briefly, 15 (10%) cases diagnosed as inflammatory lesion and 15 (10%) were neoplastic lesions. While 5 lesions were
undiagnosed. Out of 60 correlated cases of FNAC with histopathological examination four were incorrectly diagnosed.
The sensitivity of the FNAC was 85.71% and specificity was 96%. While positive predictive value (PPV) was 85.71% and
negative predictive value was 96%.
Conclusion: FNAC could be considered as a primary investigational tool for diagnosis and to differentiate thyroid lesions
and so for the selection of patients for surgery.
KEY WORDS: Thyroid swellings, fine needle aspiration cytology (FNAC), histopathological examination

Introduction thyroid tumors from the harmless thyroid lesions, so that a

definitive preoperative tissue diagnosis of the malignancy
Thyroid diseases are common problem of enormous mag- allows planning of appropriate surgery and relevant patient
nitude now a day all over the world. And it is necessary in counseling.
the clinical practice is to distinguish reliably the few malignant Fine needle aspiration cytology (FNAC) is simple, readily
available, reliable, time saving, and minimally invasive pro-
Access this article online cedure.[1] Hence, it is widely accepted as a diagnostic tool in
Website: http://www.ijmsph.com Quick Response Code: recent years. Various literatures and articles have been pub-
lished during the last 50years, which have put the cytology
DOI: 10.5455/ijmsph.2017.30042016536 in first line. In 1993, Stewart had stated that “diagnosis by
FNAC is reliable as combined intelligence of the clinicians and
pathologists make it”.[2] It is useful for diagnosis of pathological
lesions of multiple organs such as lymph node, breast, thyroid,
etc. Being superficial and easily accessible thyroid is an ideal

International Journal of Medical Science and Public Health Online 2017. © 2017 Divyesh Goswami. This is an Open Access article distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format
and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

6 International Journal of Medical Science and Public Health | 2017 | Vol 6 | Issue 1
 Goswami et al.: Accuracy of FNAC in diagnosis of thyroid lesions

organ for FNAC. Moreover, it has a wide range of pathologi- True negative: Negative for malignancy with subsequent
cal behaviors. It is vital for surgeon to know the morphological benign confirmation by final histopathological examination.
nature of the lesion before any surgery. With FNAC, thyroid False positive: Positive for malignancy or suspicious diagno-
function tests are also helpful in diagnosis in thyrotoxicosis sis for malignancy with no evidence of malignancy on final
and thyroiditis. It also helps in deciding the line of treatment histopathological examination.
and taking decision about the surgical procedure.[3] False negative: Negative for malignancy but diagnosed as
Another procedure, like histopathological examination of malignant by final histopathological examination.
surgically excised thyroid swelling is also one of the accurate
Accuracy, sensitivity, specificity, positive predictive value
ways to determine the pathology. However, it requires prepa-
(PPV), and negative predictive value were calculated.
ration and long procedure like anesthesia, hospitalization and
sometime even over treatment.[4]
Primary objective of this study was to evaluate the result Results
of FNAC in diagnosis of various thyroid lesions and correlate
the result of FNAC with histopathological examination in diag- Within 2 year of the study duration total 150 patients of
nosis of various thyroid lesions. thyroid swelling could be included. FNAC was performed in
all patients; while histopathological examination could be per-
form in only 60 patients. And correlation of FNAC and histo-
Material and Methods
pathological examination wasdone only in those patients. In
A prospective study carried out at P.D.U. Medical College 5 patients inadequate FNAC material was obtained. Hence,
and Hospital, Rajkot. Institutional ethics committee permis- they were undiagnosed by FNAC examination.
sion was taken before starting the study. The incidence of non-inflammatory non-neoplastic lesions
All the patients with thyroid enlargement visiting surgery was 115 (76.66%). Among them colloid goiter was 36.66%
and other departments were included in the study. There followed by benign cystic lesion (24.66%), and adenoma-
were no any specified exclusion criteria. During study dura- tous goiter (10.66%). Inflammatory lesion like thyroiditis was
tion of 2 year, a total of 150 patients with thyroid enlargement seen in 15 (10%) patients. Neoplastic lesions were seen in
were recruited in the study. Informed written consent from all 15  (10%) patients. Among them 11 (7.33%) cases were of
patients was taken before recruitment in the study. benign and malignant follicular lesions. Out of which 6 cases
Detailed history of participants like demographic data, his- were follicular adenoma and 2 cases were adenomatous
tory of present thyroid swelling, weight loss, diplopia, mood, goiter. While 3 cases required histopatholigical confirmation.
and drug history were taken. Patients’ general examination and The frequencies of malignant thyroid tumors like papillary
local examination of swelling was performed. Routine investi- carcinoma (1.33%), medullary carcinoma (0.66%), and ana-
gations and thyroid function test like Serum T3, T4, and TSH plastic carcinoma were (0.66%) (Table 1). Among 55 cases of
as well as FNAC examination was performed in each patient. goiter 35 were euthyroid, 10 were hyperthyroid, and 10 were
Among all participants only 60 participants undergo operative
procedure. Histopathological examination of the tumor could Table 1: Distribution of various lesions diagnosed by FNAC
be done only in operated patients. Correlation of FNAC with
histopathological examination was done in those patients. Thyroid lesions No. of cases Percentage

Non-neoplastic non-inflammatory 115 76.67

FNAC diagnosis was classified in following categories: lesions
1. Non-neoplastic and non-inflammatory lesion: Colloid Colloid goiter 55 36.67
goiter, adenomatous goiter, benign cystic lesion, hyper- Adenomatous goiter 16 10.67
plasia, thyroglossal cyst, thyrotoxicosis. Benign cystic lesions 37 24.67
2. Inflammatory lesion: Thyroiditis. Thyrotoxicosis 5 3.33
3. Neoplastic lesion: Follicular neoplasm including benign Thyroglossal cyst 2 1.33
and malignant Inflammatory lesion 15 10
a. Intermediate: All follicular neoplasm and lesions ­having Thyroiditis 15 10
suspicious cells with atypical features. Neoplastic lesions 15 10
b. Malignant: Carcinoma and follicular neoplasm with Follicular neoplasm: benign and 11 7.33
malignant cytology. malignant
4. Non-diagnostic: Material was inadequate for diagnosis. Malignant tumors 4 2.67
For correlation of FNAC diagnosis and histopatholog- Papillary carcinoma 2 1.33
ical diagnosis of lesion following criteria were used:[5] Medullary carcinoma 1 0.67
Anaplastic carcinoma 1 0.67
True positive: Positive for malignancy or suspicious for malig-
Non-diagnostic 5 3.33
nancy with subsequent confirmation by final histopatho-
Total 150 100
logical examination.

International Journal of Medical Science and Public Health | 2017 | Vol 6 | Issue 1 7
 Goswami et al.: Accuracy of FNAC in diagnosis of thyroid lesions

hypothyroid. Among 37 cases of benign cystic thyroid lesion Out of total 150 cases 50 undergo surgery and classifi-
patients 30 were euthyroid, 4 were hyperthyroid, and 3 were cation by histopathological examination of the lesion is given
hypothyroid. While out of 16 patients of adenomatous goiter 14 in Table 6. Non-neoplastic non-inflammatory lesions were the
were euthyroid and 2 were hyperthyroid. Among 11 patients of commonest type of lesion. Among them colloid goiter was the
follicular neoplasm 8 were euthyroid and 3 were hyperthyroid. most common followed by benign cystic lesion. Other com-
Patients diagnosed with medullary and anaplastic carcinoma mon lesions were benign tumors (8), inflammatory lesions (6)
were euthyroid. While among 2 cases of papillary carcinoma and malignant tumors (4). Figure 1 shows pseudopapillae for-
1 was euthyroid and 1 was hyperthyroid. mation in adenomatous goiter. Figure 2 shows lymphocytes
Age-wise distribution shows that most of the patients with with Hurthle cells in Hashimoto’s thyroiditis. Figure 3 shows
thyroid disease (i.e., nearly 70%) presented during 3rd and nuclear crowding and overlapping in papillary carcinoma.
4th decade of life (Table 2). Non-neoplastic non-inflamma- The correlation of diagnosis was carried out between his-
tory lesions like goiter shows same distribution with highest topathological examination and FNAC as seen in Table  7.
number of patients presented during 21–40 years of age. Total 60 cases diagnosed by HPE correlated with FNAC
Same result was seen with adenomatous goiter and benign examination. Among NNNI lesions, out of total 55 cases of
cystic lesion. Neoplastic lesions shows highest incidence dur- colloid goiter, histopathological correlation done in 20 cases.
ing 31–40 years of age with commonest tumor was follicular Out of 16 cases of adenomatous goiter, 4 cases were con-
neoplasm. Table 3 shows gender-wise distribution of all thy- firmed by HPE, while 2 cases were incorrect, in which final
roid lesions. It shows that the ratio of male:female was 1:7.3. diagnosis was follicular adenoma. All other types of NNNI and
Tables 4 and 5 show both age- and gender-wise distribution inflammatory lesions were correctly diagnosed by FNAC as
of thyroid lesions. The most common age group for thyroid compared with histopathological examination. In neoplastic
lesion was 31–40 years of age in both male and female. lesions HPE was performedin 12 cases out of 15 cases. All

Table 2: Age-wise distribution of various thyroid lesions diagnosed by FNAC

Age in years 1–10 11–20 21–30 31–40 41–50 51–60 61–70 71–80 Total Percentage

NNNI lesions 1 12 32 42 13 12 2 1 115 76.67

Colloid goiter – 7 13 23 3 7 1 1 55 36.67
Adenomatous goiter – 3 8 3 2 – – – 16 10.67
Benign cystic lesions – 2 8 14 7 5 1 – 37 24.67
Thyrotoxicosis – – 2 2 1 – – – 5 3.33
Thyroglossal cyst 1 – 1 – – – – – 2 1.33
Inflammatory lesion – 4 3 6 2 – – – 15 10.00
Thyroiditis – 4 3 6 2 – – – 15 10.00
Neoplastic lesions – 2 3 5 3 1 1 – 15 10.00
Follicular neoplasm – 2 2 4 2 1 – – 11 7.33
Malignant tumors – – 1 1 1 – 1 – 4 2.67
Papillary carcinoma – – 1 1 – – – – 2 1.33
Medullary carcinoma – – – – 1 – – – 1 0.67
Anaplastic carcinoma – – – – – – 1 – 1 0.67
Non-diagnostic – – 2 3 – – – – 5 3.33
Total 1 18 40 56 18 13 3 1 150 100.00
Percentage 0.67 12.00 26.67 37.33 12.00 8.67 2.0 0.07 100

Table 3:Gender-wise distribution of thyroid lesions diagnosed by FNAC

Non-inflammatory Neoplastic lesions
non-neoplastic Inflammatory
Gender lesions lesions Follicularneoplasm Malignant neoplasm Total Percentage

Male 14 1 2 1 18 12
Female 101 14 9 3 127 (+5)* 88
Total 115 (76.67%) 15 (10%) 11 (7.33%) 4 (2.77%) 150 100
M:F ratio 1:7.21 1:14 1:4.5 1:3 1:7.3

*Undiagnosed by FNAC because of inadequate sample.

8 International Journal of Medical Science and Public Health | 2017 | Vol 6 | Issue 1
 Goswami et al.: Accuracy of FNAC in diagnosis of thyroid lesions

Table 4: Age- and gender-wise distribution in non-neoplastic non-inflammatory and inflammatory lesions
Gender-wise distribution

Adenomatous Benign cystic Thyroglossal

Colloid goiter goiter lesion Thyrotoxicosis cyst Thyroiditis
Age-wise
distribution M F M F M F M F M F M F Total

1–10 – – – – – – – – 1 – – – 1
11–20 – 7 – – – 2 – – – – – 4 16
21–30 – 13 2 3 1 7 – 2 – 1 1 2 35
31–40 5 20 – 6 3 9 – 2 – – – 6 48
41–50 – 3 – 3 1 6 – 1 – – – 2 15
51–60 – 6 – 2 1 5 – – – – – – 12
61–70 – – – – – 2 – – – – – – 2
71–80 – 1 – – – – – – – – – – 1
Total 5 50 2 14 6 31 0 5 1 1 1 14 130
M:F ratio 1:10 1:7 1:5.1 – 1:1 1:14

Table 5: Age- and gender-wise distribution in neoplastic lesions

Gender-wise distribution

Follicular neoplasm Papillary carcinoma Medullary carcinoma Anaplastic carcinoma

Age-wise distribution M F M F M F M F Total

1–10 – – – – – – – – –
11–20 – 2 – – – – – – 2
21–30 – 2 – 1 – – – – 3
31–40 1 3 – 1 – – – – 5
41–50 1 1 – – – 1 – – 3
51–60 – 1 – – – – – – 1
61–70 – – – – – – 1 – 1
71–80 – – – – – – – – –
Total 2 9 0 2 0 1 1 0 15
M:F ratio 1:4.5 – – –

Table 6: various types of thyroid lesions diagnosed by histopatho-

logical examination
Thyroid lesions No. of cases Percentages

Non-neoplastic 42 71.67
non-inflammatory lesions
Colloid goiter 20 33.33
Adenomatous goiter 6 10
Benign cystic lesions 10 16.67
Thyrotoxicosis 4 6.67
Thyroglossal cyst 2 3.33
Inflammatory lesion 6 10
Thyroiditis 6 10
Neoplastic lesions 12 20
Benign tumors 8 13.33 Figure 1: Pseudopapillae formation – adenomatous goiter
Follicular adenoma 8 13.33
Malignant tumors 4 6.67
Papillary carcinoma 2 3.33 malignant lesions were correctly diagnosed by FNAC, while
Medullary carcinoma 1 1.67 out of 8 follicular neoplasms diagnosed by FNAC, 6 turned out
Anaplastic carcinoma 1 1.67 correct while 2 were incorrect while compare with HPE. They
Total 60 100
turned out adenomatous goiter by HPE.

International Journal of Medical Science and Public Health | 2017 | Vol 6 | Issue 1 9
 Goswami et al.: Accuracy of FNAC in diagnosis of thyroid lesions

In the present study, the sensitivity of the FNAC found out Discussion
85.71% and specificity 96%. While positive predictive value
(PPV) was 85.71% and negative predictive value was 96%. Clinical assessment of thyroid lesions by means of phys-
ical examination, hormone study, and ultrasonography is not
completely reliable. A surgeon must have knowledge about
nature of lesion before performing total or subtotal thyroid-
ectomy for any type of thyroid lesion. As diagnosis of thyroid
lesion concern FNAC and histopathological examination
(HPE) are common investigation.[6] Among them FNAC is
commonly used as primary investigation for diagnosis.
In the present study, total 150 patients were aspirated for
FNAC and out of them 60 underwent surgery. Operative treat-
ment was avoided in many patients after performing FNAC.
It was helpful in segregating those cases of thyroid nodule
which can be followed clinically, from those requiring surgical
intervention.
In present study, it was observed that the frequency of
thyroid lesions was maximum during 3rd and 4th decades of
Figure 2: Hurthle cells with lymphocytes in Hashimoto’s thyroiditis
life, and mean age of patient was 33 years. In the study per-
formed by different researchers, mean age of patients were
ranging from 34 to 54 years. Most of the studies from outside
India had mean age of more than 40 years like study by Hall,[7]
Godhinos-Matos et al,[8] and Rodriguez et al[9] had mean age
of 45, 51, and 41 years, respectively. However, most of the
Indian studies have mean age is less than 40 years like Bapat
et al,[10] Prasad,[11] and Mira and Pathak[12] had mean age of
presentation for thyroid lesion are 35, 34.54, and38 years,
respectively. Gender-wise distribution shows that thyroid
lesions are predominant in female with ratio of M:F and in the
present study it was 1:7.3. Most of the other studies also have
same findings with M:F ratio ranges from 1:3.84 to 1:11.2.
As seen in Table 7, in the present study, 56 cases were
diagnosed as non-malignant lesion and 4 malignant lesions
Figure 3: Nuclear crowding and overlapping in papillary carcinoma by FNAC. On comparison with HPE examination, all malignant

Table 7: FNAC correlation with histopathological examination for various types of thyroid lesions
Thyroid lesions No. of cases Histopathological Cytological diagnosis Accuracy
by FNAC examination
Correct Incorrect

Non-neoplastic non-inflammatory lesions 115 42 40 2 95.23

Colloid goiter 55 20 20 – 100
Adenomatous goiter 16 6 4 2 66
Benign cystic lesions 37 10 10 100
Thyrotoxicosis 5 4 4 100
Thyroglossal cyst 2 2 2 100
Inflammatory lesion 15 6 6 100
Thyroiditis 15 6 6 100
Neoplastic lesions 15 12 10 2 83.33
Follicular neoplasm 11 8 8 2 75
Malignant tumors 4 4 4 100
Papillary carcinoma 2 2 2 100
Medullary carcinoma 1 1 1 100
Anaplastic carcinoma 1 1 1 100
Non-diagnostic 5 – – –
Total 150 60 56 4 93.33

10 International Journal of Medical Science and Public Health | 2017 | Vol 6 | Issue 1
 Goswami et al.: Accuracy of FNAC in diagnosis of thyroid lesions

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Conclusion How to cite this article: Goswami D, Agrawal P, Shinde  P.

Accuracy of fine needle aspiration cytology (FNAC) in
The results of the present studyshow that the FNAC could comparison to histopathological examination for the diagnosis
be consider as primary investigational tool for diagnosis and of thyroid swellings. Int J Med Sci Public Health 2017;6:6-11
to differentiate thyroid lesions and so for the selection of Source of Support: Nil, Conflict of Interest: None declared.
patients for surgery.

International Journal of Medical Science and Public Health | 2017 | Vol 6 | Issue 1 11

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