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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]. 1 Int J Res Med. 2016; 5(3); 1-6 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 e ISSN:2320-2742 p ISSN: 2320-2734 Thyroid Cytology Evaluation By Bethesda System 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. 2 Int J Res Med. 2016; 5(3); 1-6 e ISSN:2320-2742 p ISSN: 2320-2734 Thyroid Cytology Evaluation By Bethesda System 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% Int J Res Med. 2016; 5(3); 1-6 e ISSN:2320-2742 p ISSN: 2320-2734 Thyroid Cytology Evaluation By Bethesda System (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 4 Int J Res Med. 2016; 5(3); 1-6 e ISSN:2320-2742 p ISSN: 2320-2734 Thyroid Cytology Evaluation By Bethesda System 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. 5 Int J Res Med. 2016; 5(3); 1-6 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. e ISSN:2320-2742 p ISSN: 2320-2734 Thyroid Cytology Evaluation By Bethesda System 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. 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Role needle biopsy and cytological of fine needle aspiration cytology in diagnosis of thyroid lesions. the diagnosis of thyroid swelling. JPMI Switzerland: Karger; 1997. p. 61 - 184. 2004; 18(2) 6 Int J Res Med. 2016; 5(3); 1-6 e ISSN:2320-2742 p ISSN: 2320-2734 Thyroid Cytology Evaluation By Bethesda System 7 Int J Res Med. 2016; 5(3); 1-6 e ISSN:2320-2742 p ISSN: 2320-2734