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Thyroid Cytology Evaluation By Bethesda System
ORIGINAL ARTICLE
‘Thyroid Cytology Evaluation By Bethesda System
A Two Year Prospective Study’
Gharia Amit A.1*, Agravat Amit H.2, Dhruva Gauravi A3
13rd
year resident, 2(MD): Associate Professor, 3(MD): Professor & Head, Department of Pathology, PDU Medical College
Rajkot
ABSTRACT
BACKGROUND: Thyroid lesions are one of the common conditions encountered in clinical practice. It is
difficult to clinical evaluation & reach to correct diagnosis. Hence it is essential that a correct diagnosis is made as
early as possible. The present study was carried out in Department of Pathology, P.D.U Medical College and
Hospital, Rajkot OBJECTIVES OF THE STUDY: The objectives of present study are: To study various
cytological features of material aspirated from thyroid swelling and hence making a pre-operative cytological
diagnosis.1To categorize all the thyroid FNA’s according to the Bethesda system proposed by the National Cancer
Institute (TBSRTC), Bethesda, USA in 2007. 2To study the prevalence of various thyroid pathology by Bethesda
system. 3To correlate cytological features of thyroid swelling with the thyroid hormone profile.4To study age and
sex distribution of patient with thyroid pathology. METHODOLOGY AND MATERIALS USED: Materials
needed for aspiration are: Disposable needles, Glass slides – clean and grease free, Methanol as fixative, Reagents
for H&E stain and Giemsa stain, sterile gloves, gauze piece and spirit swab and through proper method of
aspiration & examination has been done. CONCLUSION: It is concluded that fine needle aspiration cytology is a
simple, cost effective, quick, and relatively less painful procedure which can be used as an outdoor patient
procedure or as a part of screening programme for the diagnosis of thyroid lesion. Bethesda system is very much
helpful in categorizing thyroid lesion and avoiding confusion as was associated with previous categorizing
methods.
Keyword: tumours, Thyroid Cytology Evaluation
INTRODUCTION
Thyroid lesions are one of the common
conditions encountered in clinical practice.
It is difficult to clinical evaluation & reach
to correct diagnosis. Hence it is essential
that a correct diagnosis is made as early as
possible. The majority of solitary thyroid
nodules are benign; the incidence of
malignancy being only 5-20% of
surgically excised thyroid nodules on
histopathology. In the management of
solitary thyroid nodule, the primary
challenge is to separate benign nodules
(the majority) from malignant lesions (the
minority). About 50% of clinically
apparent solitary thyroid nodules turn out
to be dominant nodule of multi-nodular
goiter.1 Percentage of solitary thyroid
*Corresponding Author:
Gharia Amit A
D-38, High Rise Building,
10th Floor, Jamtower chowk
Jamnagar Road,Rajkot- 360001
Contact No. 08140320435
E-mail: [email protected].
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nodule increased with age along with
increased prevalence of malignancy in
third, fourth and fifth decades of life.
Thyroid tumours are more prevalent in
females and papillary carcinoma is the
most common histological type of thyroid
tumours followed by follicular carcinoma,
medullary
carcinoma,
anaplastic
carcinoma, non Hodgkin's lymphoma and
unclassified tumours in order of frequency.
Fine Needle Aspiration Cytology (FNAC)
is a diagnostic tool in which cells are
extracted from a palpable swelling using
FNAC gun, syringe and fine needle. It is a
simple, speedy, safe, cost effective and
accurate technique being used worldwide.
Thyroid disease may be classified into
hyperthyroidism, hypothyroidism and
euthyroidism. Thyroid disease such as
goiter, thyroid adenoma and thyroid
carcinoma typically occurs in individual
who are euthyriod, while hyperthyroidism
is commonly associated with Grave’s
disease and primary hypothyroidism is
most commonly iatrogenic in origin.
Thyroid function test which includes
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quantitative estimation of T3, T4 and TSH
in any lobe of thyroid selected by clinical
have a diagnostic as well as prognostic
palpation (multinodular, solitary nodules,
role in thyroid disorders.2
diffuse goiter etc) and patients with
recurrent thyroid swellings after a previous
RATIONALE OF THE STUDY
This study is undertaken to study the
thyroid surgery in the age group of 10-80
cytology of palpable thyroid lesions to
years have been included.
minimize surgical intervention and
RESULTS & DISCUSSION
correlating the same with the thyroid
The results of the study were shown in
function test and histopathological
various tables.
examination to confirm the diagnosis and
Table 1: No. of FNAC from Thyroid
planning post surgical management of
Lesions
malignant thyroid lesions.
Duration
Total no. of
Total no of thyroid
OBJECTIVES OF THE STUDY
( 2 Years )
cytology done
cytology done
1st September 2012 5085 (100%)
409 ( 8.04 % )
The objectives of present study are:
to
 To study various cytological features of
31st August 2014
material aspirated from thyroid swelling
As shown in table no. 1 during the period
and hence making a pre-operative
of present study total 5085 of cytology
cytological diagnosis.
were done. This included fine needle
 To categorize all the thyroid FNA’s
aspiration cytology from the various
according to the Bethesda system
lesions. Out of total 5085 aspirates, 409
proposed by the National Cancer
were from thyroid fine needle aspiration
Institute (TBSRTC), Bethesda, USA in
cytology smears comprising of 8.04% of
2007
the total cases.
 To study the prevalence of various
Figure 1: Bar Diagram Showing The
thyroid pathology by Bethesda system.
Total Number Of Fna Done As Well As
 To correlate cytological features of
Thyroid Fna From 1st September 2012
thyroid swelling with the thyroid
To 31st August 2014
hormone profile.
 To study age and sex distribution of
patient with thyroid pathology.
METHODOLOGY AND MATERIALS
The present study was carried out in
cytopathology laboratory, PDU Medical
Table 2: Conventional Cytological
College and Hospital, Rajkot between
Diagnosis Method of Thyroid FNAC is
September 2012 to August 2014 during
as follows:
this period 5085 FNA is done, out of
which 200 cases were included for the
Cytological Diagnosis
No. of cases Percentage
purpose of study. Most of the patients in
Cystic lesion
12
6%
the institute are directly referred by
Inflammatory Lesions
21
10.5 %
Lymphocytic thyroiditis
11
(5.5 %)
Department of Surgery, Department of
Hashimoto’s thyroiditis
10
(5.0 %)
ENT and other clinical departments for
Benign lesions
133
66.5 %
FNAC in cytopathology laboratory.
Colloid goiter
113
(56.5 %)
Materials needed for aspiration are :
Hyperplastic thyroid lesion
20
(10 %)
Malignancy
29
14.5
%
Disposable needles of 22-24G with length
Follicular neoplasm
16
(8.0 %)
of 2.5-3.8 cm, Disposable plastic syringes
Papillary carcinoma
07
(3.5 %)
of 10-20 cc, Glass slides – clean and
Medullary carcinoma
04
(2.0)
Anaplastic carcinoma
02
(1.0 %)
grease free, Methanol as fixative, Reagents
Unsatisfactory
05
2.5 %
for H&E stain and Giemsa stain3, Sterile
Total
200
100 %
gloves, gauze piece and spirit swab and
As shown in the table no. 2, out of the total
through proper method of aspiration
200 cases of thyroid aspirates, 21 (10.5 %)
examination has been done. For the
cases were inflammatory lesions, 133
purpose of study both male and female
(56.5 %) cases were benign lesions, 29
patients presenting with thyroid swelling
(14.5%) cases were malignant aspirates.
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Unsatisfactory
The 5 (2.5%) cases were the unsatisfactory
Ii
Benign Thyroid Lesion
165
82.5%
aspirates, which could not be reported in
Iii
Atypia Of Undetermined
04
0.02%
spite of the repeated fine needle aspiration
Significance / Follicular
Lesion Of Undetermined
cytology.
Significance
Table 3: Age Wise Distribution of
Iv
Follicular Neoplasm Or
12
06 %
Suspicious Of Follicular
Thyroid Lesions is as follows:
Age Range (in years)
0 – 10
11 – 20
21 – 30
31 – 40
41 – 50
51 – 60
61 – 70
71 – 80
Total
No. of cases
00
25
48
46
40
27
11
03
200
Percentage
00
0.125 %
24 %
23 %
20 %
13.5 %
5.5 %
1.5 %
100%
NUMBER OF
CASES
As shown in the table no. 3, the maximum
incidence of thyroid lesions, are between
the ages of 21 - 30 years, i.e. 48 cases
(24%). There was no case reported in the 0
– 10 year age group and >80 years of age
during the present study.
Figure 2: Bar Diagram showing Age
Wise Distribution of Thyroid FNA
Cases
50
NUMBER OF CASES
NUMBER…
0
Neoplasm
Suspicious For
Malignancy
Malignant
Total
V
Vi
Percentage
88.5
11.5
100%
As shown in the table no. 4, the present
study of 200 cases comprised of 177 cases
(88.5%) from the female thyroid lesions
while 23 cases (11.5%) from the male
thyroid lesions.
Figure 3: Bar Diagram Showing Sex
Wise Distribution of Thyroid Cases
NUMBER OF
THYROID
CASES
Table 5: Cytological Diagnoses Of 200
Cases According To Bethesda System Is
As Follows:
Bethesda
Diagnostic
Category
I
3
Bethesda Description
Non Diagnostic Or
No Of Percentage Of
Cases Total Cases
05
1%
6%
2%
BETHESDA
CATEGORY
I
BETHESDA
CATEGORY
II
Table 6: Age and Sex Incidence of
Thyroid Lesion
As shown in the table no. 6, thyroid
lesions are more common in females. In
present study, only 23 cases were from the
male thyroid lesions. Maximum numbers
of cases were of (Benign thyroid lesion)
Age (In
Years )
NUMBER OF THYROID CASES
0
06 %
100 %
2% 6%
83%
Table 4: Sex Wise Distribution of
Thyroid Lesions is as follows:
200
12
200
NUMBER OF CASES
AGE RANGE IN YEARS
No. of cases
177
23
200
0.01%
As shown the table no. 5, out of 200
cytological diagnosed cases of thyroid
lesions,165 (82.5 % ) cases were of Benign
category II, 12 ( 06 %) cases were of
follicular neoplasm or suspicious of
follicular neoplasm category IV, 12 ( 06
%) cases were of Malignant nature
category VI, 05 (0.025% ) cases were Non
diagnostic or unsatisfactory, 04 (0.02 cases
were of Atypia of undetermined
significance / follicular lesion of
undetermined significance cystic lesions
and 02 cases were of Suspicious for
malignancy category V respectively.
Figure 4: Pie Chart showing Bethesda
Category Wise Distribution of Thyroid
FNA Cases
0 –1110
21
– 20
31
– 30
41
– 40
51
– 50
61
– 60
71
– 70
– 80
Sex
Females
Males
Total
2
0-10
11-20
21-30
31-40
41-50
51-60
61-70
71-80
Total
Sex
M
00
03
08
04
05
03
00
00
23
F
00
22
40
42
35
24
11
03
177
I
00
00
01
02
01
01
00
00
05
BETHESDA DIAGNOSTIC
CATEGORY
II
III
IV
V
VI
00
00
00
00
00
24
00
01
00
00
41
01
02
00
03
36
01
05
01
01
30
02
02
01
04
23
00
01
00
02
09
00
01
00
01
02
00
00
00
01
165 04
12
02
12
category II, followed by category IV
(Follicular neoplasm or suspicious of
follicular neoplasm) and category VI
0.025%
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(Malignant)
with
equal
number
DISCUSSION
respectively.
FNAC is a method where a very small
quantity of tissue, fluid and cells are
Table 7: Cytological examination of
aspirated from a lesion for cytological
thyroid lesion with hormonal
examination. Although needle aspiration
correlation
cytology
had
been
performed
BETHESDA
THYROID FUNCTION TEST
Hypothyroid Euthyroid Hyperthyroid
intermittently in the second half of the last
Bethesda Bethesda
century4, it was popularized by Martin,
Diagnostic Description
Ellis and Stewart at Memorial Hospital for
Category
I
Non
00
05
00
Cancer and Allied Diseases, New York in
diagnostic
the 19305. FNAC is now accepted as the
or unsatis
factory
cost effective, minimally invasive, low
II
Benign
03
150
12
complication, non operative diagnosis for
III
Atypia of
01
03
00
undetermin
most of the thyroid lesions and is highly
ed
successful in triaging the patients with
significance
/ follicular
solitary thyroid nodule in to non operative
lesion of
and operative group6. The location of
undetermin
ed
target lesion, careful searching for
significance
malignant cells and repeat FNAC is the
IV
Follicular
00
11
01
neoplasm or
key to successful diagnosis to plan proper
suspicious
surgical management in thyroid mass.7 The
of follicular
neoplasm
distinction of benign and malignant
V
Suspicious
00
02
00
thyroid nodules is fundamental, as
for
malignancy
malignancy necessitate surgery while strict
VI
Malignant
00
12
00
patient follow up is necessary in case of
Total
(200 Cases
04
183
13
)
benign thyroid mass. FNAC is considered
As shown in the table no. 7, 183 cases
to be gold standard in the selection of the
were euthyroid, 04 cases were hypothyroid
patients for surgery.7 During the present
and 13 cases were hyperthyroid. In present
study, no complication like hematoma,
study, out of total 200 cases of thyroid
transient laryngeal nerve palsy or
lesions, 165 cases were of benign thyroid
perforation of trachea was noted. For the
lesion Category II. Out of these 165 cases,
staining, the haematoxyline and eosin and
150 cases were euthyroid, 03 cases were
giemsa stain were done. But mainly the
hypothyroid and 12 cases were
haematoxyline and eosin was chosen
hyperthyroid. Out of 06 cases of
because of its familiarity and easily
hyperplastic thyroid lesion, 05 cases were
discernible cytomorphology.
diagnosed as Grave’s disease. (Primary
Table 8: Comparison of Age incidence
Thyrotoxicosis) and 01 case was
Studies
Range of age in Median age in
years
years
diagnosed as Secondary thyrotoxicosis, all
Tabaqchali et al8 8.5 - 85
48
of were hyperthyroid. All the malignant
(2000)
and cystic lesions were euthyroid while
Afroze N et al9 (2002) 16 – 78
40.2
Handa et al10 (2008) 5 – 80
37.69
cases of Hashimoto’s thyroiditis were
11 (2010)
Gupta
et
al
22
–
58
38.72
hypothyroid.
Sengupta et al7 (2011) 10 – 60
35
Figure 5: Bar Diagram Showing
Present Study (2014) 11 – 75
35
Thyroid
Hormonal
Status
and
Table no 1 shows the comparison of age
Bethesda Category
incidence in the present study with other
studies. In the present study median age
was 35 years. In Sengupta et al also
showed the same result. In Tabaqchali et al
and Afroze et al showed median age above
40 years. This variation is due to fact that
these studies were not performed in
particular age group or as a screening
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programmed, but randomly done on the
patients coming to the hospital with
Table 2 shows the sex distribution in
thyroid lesion.
thyroid
lesions.
There
was
the
predominance of female patients in all
Table 9: Comparison of sex wise
studies.
distribution of thyroid lesion
Studies
Tabaqchali et al
(2000)
Afroze N et al (2002)
Handa et al (2008)
Gupta et al (2010)
Sengupta et al (2011)
Present Study (2014)
Total cases Male Female Male:
Female
239
26 213
1:82
170
434
75
178
200
48
59
6
37
23
122
375
69
141
177
1:2.54
1:6.35
1:11.5
1:3.81
1:7.6
Table 10: Comparison of different thyroid
lesion
Studies
Cystic lesion Thyroiditis
Tabaqchli
(2000)
Afroze
(2002)
Handa
(2008)
Gupta
(2010)
Sengupta
(2011)
Present study
2
0.4%
0
0%
2
3.03%
0
0%
0
0%
3
3%
7
2.9%
10
5.88%
0
0%
3
4%
15
8.43%
6
6%
Colloid
goiter
136
56.9%
111
65.3%
45
68.2%
42
56%
135
75.8%
76
76%
Thyroid lesions
Follicular Papillary
Follicular
adenoma carcinoma
carcinoma
60
19
10
25.1%
7.9%
4.2%
27
11
07
15.88%
6.47%
4.11%
13
3
0
19.70%
4.55%
0%
15
12
3
20%
16%
4%
11
0
14
6.18%
0%
8.99%
4
2
2
4%
2%
2%
As shown in the above table, percentage of
incidence of various thyroid lesions of
present study is nearer to study of
Sengupta et al and Handa et al. In present
study predominate lesions were benign
while there were higher percentage of
malignant lesion in Tabaqchali et al and
Afroze et al studies.
Table 11: Comparison of non-neoplastic
to neoplastic ratio
Studies
NonNeoplastic A : B
neoplastic (A)
(B)
Tabaqchali (2000)
145
94
1.54 : 1
Afroze (2002)
121
49
2.47 : 1
Handa (2008)
47
19
2.48 : 1
Sengupta (2011)
150
32
4.68 : 1
Present Study
155
45
3.44 : 1
As shown in above table, there was higher
percentage non-neoplastic lesion in present
study. This study documented the fact that
the benign lesions of thyroid are the most
common lesions. Such lesions are more
common in young females. This increased
case of benign lesions indicates increase
awareness of patients. In such lesions the
reassurance is the main line of treatment
though close follow up is mandatory.
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Medullary Anaplastic carcinoma
carcinoma
3
1
1.3%
0.4%
02
02
1.18%
1.18%
2
1
3.03%
1.52%
0
0
0%
0%
0
7
0%
3.93%
0
1
0%
1%
Table 12: Comparison of thyroid lesion
with hormonal status correlation
Thyroid lesion
Thyroid cyst
Thyroiditis
Sang et al12 (2006)
Euthyroid (100%)
Euthyroid (100%)
Present study (2014)
Euthyroid (100%)
Hypothyroid (83.33%)
Hyperthyroid (16.66%)
Nodular goiter
Euthyoid (76.9%)
Euthyoid (81.70%)
Hypothyroid (2.88%)
Hypothyroid (7.31%)
Hyperthyroid (20.04%) Hyperthyroid (10.98%)
Malignant
Euthyroid (100%)
Euthyroid (100%)
lesion
As shown in above table, results of the
hormonal status of the patient were
comparable with study of Sang et al. In
present study 5 patients with thyroiditis
were hypothyroid while only 1 patient was
hyperthyroid. While in Sang et al study,
patients with thyroiditis were euthyroid.
Hormonal status reflects the functional
activity of the gland.
So time of
13,14,15
presentation is important
. In present
study, majority of nodular goiter (81.7%)
were euthyroid. In 6 cases, goiter
associated
with
hyperthyroidism,
investigated further and diagnosed as
primary thyrotoxicosis (Grave’s disease).
Malignant lesions were euthyroid.
Hormone study should be done to know
the functional status of the patient, it also
help us to support the diagnosis.
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5. Culling
CFA.
Handbook
of
CONCLUSION
It is concluded that fine needle aspiration
Histopathological and Histochemical
cytology is a simple, cost effective, quick,
technique
(including
museum
and relatively less painful procedure which
technique). 3rd edition. Butterworth;
can be used as an outdoor patient
1975. p. 29 - 220.
procedure or as a part of screening
6. Park K. Park's textbook of preventive
programme for the diagnosis of thyroid
and social medicine. 19th edition. 2007
lesion. FNAC can be utilized as a first line
p. 119 -120.
diagnostic procedure in patient presenting
7. Sengupta A, Pal R, Kar S et al. Fine
with thyroid swelling especially in
needle aspiration cytology as the
developing
countries
with
limited
primary diagnostic tool in thyroid
resources. FNAC diagnosis of malignancy
enlargement. Journal of Natural
is highly significant and such patients
science, Biology and Medicine 2011
should be subjected to surgery. A benign
January; 2(1): 113-118.
FNAC diagnosis should be viewed with
8. Tabaqchali MA, Hanson JM, Johnson
caution as false negative results do occur
SJ et al. Thyroid aspiration cytology in
and these patients should be followed up
newcastle: a six year cytology/
and any clinical suspicion of malignancy
histology correlation study. Ann R
even in the presence of benign FNAC
Coll Surg Eng 2000; 82: 149-155.
requires surgery. Bethesda system is very
9. Afroze N, Kayani N, Husain SH. Role
much helpful in categorizing thyroid lesion
of fine needle aspiration cytology in
and avoiding confusion as was associated
the diagnosis of papable thyroid lesion.
with previous categorizing methods.
Indian Journal of Pathology and
Hormone study should be done to know
Microbiology 2002; 45(3): 241-246.
the functional status of the lesions, it also
10. Handa U, Garg S, Mohan H, Nagarkar
help us to lead the diagnosis. When
N. Role of fine needle aspiration
combined with clinical examination,
cytology in diagnosis and management
hormone study and imaging technique,
of thyroid lesions: A study on 434
FNAC gives more accurate results which
patients. Journal of cytology 2008;
will help clinician for proper line of
25(1): 13-17.
treatment in the respective thyroid
11. Gupta M, Gupta S, Gupta VB.
pathology.
Correlation of Fine Needle Aspiration
Cytology with Histopathology in
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