Afolabi, AO

Akanga, EEU

Akute, OO

Irabor, DO

Ogunbiyi, JO

Ogundiran, TO

Oluwasola, AO

English

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163Nigerian Journal of Clinical PracticeJune 2010 Vol. 13(2):163-166REVIEW OF FINE NEEDLE ASPIRATION CYTOLOGY IN THEMANAGEMENT OF GOITRES IN IBADAN, NIGERIA*AO Afolabi, **AO Oluwasola, *OO Akute, **EEU Akang, *TO Ogundiran, **JO Ogunbiyi, *DOIraborABSTRACTObjective:Method:Results:Conclusion:Key Words:Department of *Surgery, and **Pathology, College of Medicine, University of Ibadan, University CollegeHospital, Ibadan, Oyo State, Nigeria.(Accepted 16 April 2009)The use of Fine NeedleAspiration Cytology (FNAC) in the investigation of goitres was introducedinto our practice more than a decade ago. This is a review of its diagnostic accuracy for thyroid carcinoma sevenyears after the first evaluation and following the establishment of the 'FNAC Clinic'.This is a retrospective study of patients who had FNAC of goitres and the histopathology of theirthyroidectomy specimens between 1995 and 2004. The accuracy of the cytology reports were evaluated againstthe histology reports. The turnaround time of the patients for surgery was also determined.There were 130 females and 21 males with an age range of 7-86 years. The diagnostic accuracy of theprocedure for carcinoma was 89% with a sensitivity of 35%, specificity of 97%, positive predictive value of64%, and a negative predictive value of 91%. The average turnaround time for surgery was 178.7 ± 248.7 dayswith a range of five days to three and a half years.The diagnostic accuracy of FNAC of goitre for carcinoma improved in the period under review.However, the long surgery turnaround time may reduce the usefulness of the procedure. The accuracy may beimproved further by a protocol of ultrasound guidance, capillary collection with no-aspiration technique, on-site review of slides with a repeat of FNAas necessary.Fine needle aspiration cytology, Histology, Goitre, Accuracy, Surgery turnaround time.INTRODUCTIONFine Needle Aspiration Cytology (FNAC) of thethyroid gland is performed in the preoperativeevaluation of patients who present with goitres. Theoutcome of the test can be used to determine ifthyroidectomy is indicated in a patient and the extentof the procedure. It therefore plays a significant rolein the management of patients with thyroid lesions .This role is also enhanced by its simplicity and lowcost . The initial experience with the use of FNACfor the evaluation of goitre in our hospital has beendocumented . Fine Needle Aspiration (FNA) wasperformed by surgeons and pathologists when it wasintroduced into our centre. The need for qualitycontrol necessitated the establishment of the 'FNACClinic' and the performance of FNA exclusively bythe pathologists since 1994. The impact of this on theaccuracy of the procedure in the preoperativediagnosis of thyroid carcinoma is not known andthere has not been a re-evaluation of the proceduresince the first study. This study was thereforeconducted to review the accuracy of the procedureand its impact on the management of goitre patients;12, 3, 45Correspondence: Dr AOAfolabiE-Mail:aafolabi@comui.edu.ngwith the surgical turnaround time in the UniversityCollege Hospital, Ibadan, Nigeria.The study population included 151 patients who hadboth FNAC of goitres and histology of theirthyroidectomy specimens between 1995 and 2004 inthe hospital.The Fine Needle Aspirations were performed usingthe standard method described previously . Thereports of the cytology, performed by thepathologists, were sent to the surgeons who thenperformed thyroidectomy on the patients. Histologywas then performed on the paraffin-embeddedtissues of the thyroid specimens. The cytologyreports were classified according to the guidelines ofthe Papanicolaou Society of Cytopathology for theexamination of fine-needle aspiration specimensfrom thyroid nodules . One of the surgeons (AOA)compared the cytology reports with the histologyreports of the patients retrospectively. Theparameters studied include the age, gender,cytological diagnoses, the histological diagnoses ofthe patients and the interval between when the patientpresented and when surgery was performed.STUDYPOPULATIONMETHODS3, 4, 56, 7True Positives 7True Negatives 127False Positives 4False Negatives 13Sensitivity 35%Specificity 97%Positive predictive value 64%Negative predictive value 91%Accuracy 89%goitre, Graves' disease and thyroid cancer. In a seriesof patients, no clinically significant thyroid cancerswere found in the histology of the surgical specimensof the patients who did not undergo preoperativeFNAC. The authors therefore suggested that in thehands of experienced thyroid surgeons, FNAC couldbe utilized selectively based on the clinicalpresentation .The diagnostic accuracy of FNAC for carcinoma of89% in this study is an improvement on the accuracyof 80.6% obtained in the previous review of FNAC ofgoitre in our hospital . The specificity also improvedfrom 80% to 97%. However, there was a markedreduction in the sensitivity from 83% to 35% afterseven years. The recent accuracy compares well withthat of Ko of 84.4% . The lower sensitivity of35% and positive predictive value of 64% in ourstudy compared with their values of 78.4% and 99%respectively is attributable to the high rate of falsenegative results (65%) and of false positive results(36%). In practical terms, this low sensitivity may bedue to the 'blind' aspiration of the thyroid lesionswithout ultrasonic guidance, which has been shownto highly facilitate the detection of non palpablethyroid lesions, and the routine use of the procedurein all patients including those who had diffusegoitres. It may also be explained by the inter-observer variation in the interpretation-skill of thevarious cytologists since the result of FNAC isobserver-dependent.In a correlative study of FNA of the thyroid withhistopathology, Sclabas found that false-negative FNAC results were uncommon . Theynoted that in the patients with indeterminate biopsyresults, high-risk subgroups include patients withFNAC results suspicious for papillary carcinoma andfollicular neoplasms greater than 2cm in diameter.Total thyroidectomy is advised for the patients withFNAC report of indeterminate follicular lesions. Thisis because of the high prevalence of malignancy inthis category of patients . This is corroborated byBaloch who reported a malignancy rate of 49%on repeating FNAC in patients with thyroid nodulesdiagnosed on initial FNAC as non-diagnostic andindeterminate for neoplasm .Smith suggest that in follicular lesions of thethyroid, a benign FNAC report from an experiencedcytopathologist has a high positive predictive value.However, they warned that it may not be high enoughto preclude surgery and suggested that other factorsbe considered before recommending a non-operativemanagement approach . Despite the low sensitivityof FNAC in the diagnosis of follicular variant of85111121316et alet alet alet alFalse-negative diagnoses mayalso be due to inadequate samples, geographic missesof the lesion, dual pathology (e.g. a dominant benignnodule may obscure a smaller or more diffuselygrowing carcinoma) and errors in interpretation .9,10164Nigerian Journal of Clinical Practice June 2010, Vol.13(2) Afolabi et alFine Needle Aspiration CytologyHistological diagnosis n %‘Benign’ (nodular or colloid goitre,thyroiditis, hyperplasia) 125 82.78Hurthle cell adenoma 1 0.66Follicular adenoma 7 4.64Hurthle cell carcinoma 3 1.99Follicular carcinoma 7 4.64Papillary carcinoma 6 3.97Medullary Carcinoma 1 0.66Insular carcinoma 1 0.66Total 151 100165papillary thyroid carcinoma, it identifies patientswith suspicious lesions in whom intraoperativepathologic study may assist in determining theappropriate extent of thyroidectomy . The accuracymay be improved with the guidance of FNA byultrasonic and or radionuclide scanning to enhancethe asp i r a t ion of suspi c ious l es ions .Ultrasonography altered the clinical management for63% of a group of patients referred to the thyroidnodule clinic after abnormal results on thyroidphysical examinationThe combination of ultrasound guidance, capillarycollection with no-aspiration technique, and on-sitereview of slides, is an advantageous method forthyroid nodule fine-needle biopsy . Rizvirecommended that the non-aspiration techniqueshould be used alone or in tandem with FNAC forbetter diagnostic yield . They described it as simpleand easy to perform. It also produces better results inthe quality of the cellularity and less field obscurityby blood in lesions of the thyroid compared toFNAC.The negative predictive value of FNAC of goitre inthis study (91%) is higher than the 66.3% reported byKo . The probability of malignant goitre beingpresent in those patients with a negative result in ourseries is 9% compared to 33.7% in that series. Theprobability that a patient in our study does not have amalignant goitre when the FNAC report states so istherefore higher than in their own study. The higherdiagnostic accuracy of the FNAC for malignancy inthis study compared to the previous study isbeneficial to the patient. This enables the surgeon toperform a more effective therapeutic surgery on thepatient, thereby reducing the incidence ofhistological 'surprises'. The initial performance oftotal thyroidectomy will also resolve the dilemma ofthe management of patients with incidental thyroidcarcinomas.Hashimoto's thyroiditis is the second most commonthyroid lesion next to endemic goitre diagnosed onFNAC in iodine deficient areas . In this study, therewas a false positive cytological diagnosis and twomissed cases. The diagnosis of Hashimoto'sthyroiditis is likely to be missed in smears showingcytological evidence of hyperplasia or abundantcolloid. Multiple punctures and immunologicalinvestigations are advised to improve its diagnosticaccuracy.The delay of thyroidectomy for five days to three anda half years reduces the benefit of FNAC of goitres tothe patient. The common cause of the delay is usuallya lack of funds by the patients for furthermanagement. The out-of-pocket method of payingfor health services has a negative effect on effectivehealth care. The FNAC reports might have becomeobsolete by the time of thyroidectomy. This may lead171 318141512et alet alto an under treatment of patients, especially if lessthan total thyroidectomy had been performedinitially. The increasing performance of totalthyroidectomy even for benign goitres will offset thedisadvantages caused by the delay in surgery andavailability of histopathology reports. Moreimportantly, it may also make the routine use ofFNAC for the evaluation of goitres unnecessary.In conclusion, FNAC of the thyroid gland remains asimple and cost effective test for the initial evaluationof patients who present with goitre. The diagnosticaccuracy of the procedure for carcinoma improved inthe seven years after the first evaluation. Its accuracycan be improved by the combination of ultrasoundguidance, capillary collection with no-aspirationtechnique, and on-site review of slides. Theimmediate repeat of the procedure for the patientswith indeterminate and non-diagnostic results willfurther improve its accuracy. The introduction ofhealth insurance scheme to finance the managementof patients is recommended to reduce the surgeryturnaround time. This will enhance the benefit of theFNAC to the patients. It is also recommended thatFNAC should be performed selectively for patientswho have nodular goitre. It should not be performedin patients for whom total thyroidectomy is indicatedclinically. This selective utilization will reduce theoverall cost of treatment and the delay in definitivemanagement.Clinicopathologic analysis of fine needleaspiration cytology of the thyroid. A review of1 , 6 1 3 c a s e s a n d c o r r e l a t i o n w i thhistopathologic diagnoses. Acta Cytol 2003;47:727-732.Aspiration cytologyof Hashimoto's thyroiditis in an endemic area.Cytopathology 2002; 13:31-39.Fine needle aspiration (FNA) inthe management of palpable masses in Ibadan:impact on the cost of care. Cytopathology1999; 10:206-210.Fineneedle aspiration in the management ofperipheral lymphadenopathy in a developingcountry. Diagn Cytopathol 1999; 21:159-162.Fine needle aspiration in themanagement of thyroid enlargement- Ibadanexperience. EastAfr Med J 1998; 75:657-659.REFERENCES1. Ko HM, Jhu IK, Yang SH, Lee JH, Nam JH,et al.2. Kumar N, Ray C, Jain S.3. Thomas JO, Amanguno AU, Adeyi OA,Adesina AO.4. Thomas JO, Adeyi OA, Amanguno H.5. Thomas JO,Adeyi OA, Nwachokor FN, Olu-Eddo AO.Nigerian Journal of Clinical Practice June 2010, Vol.13(2) Afolabi et alFine Needle Aspiration Cytology6.7. Suen KC.8. Chen H, Dudley NE, Westra WH, Sadler GP,Udelsman R11. Sclabas GM, Staerkel GA, Shapiro SE,Fornage BD, Sherman SI, et al.12. Miller B, Burkey S, Lindberg G, Snyder IIIWH, Nwariaku FE.Guidelines of the Papanicolaou Society ofCytopathology for the examination of fine-needle aspiration specimens from thyroidnodules. The Papanicolaou Society ofCytopathology Task Force on Standards ofPractice. Mod Pathol 1996; 9(6): 710-715.Fine-needle aspiration of thethyroid. CMAJ 2002; 167(5):491-495.. Utilization of fine-needlea s p i r a t i o n i n p a t i e n t s u n d e rg o in gthyroidectomy at two academic centres acrosstheAtlantic. World J Surg 2003; 27:208-211.Fine-needleaspiration of the thyroid and correlation withhistopathology in a contemporary series of 240patients. Am J Surg 2003; 186:702-710.Prevalence of malignancywithin cytologically indeterminate thyroidnodules.Am J Surg 2004; 188: 459-462.9. Hamburger JI, Hamburger SW.10. Hsu C, Boey J.Fine needlebiopsy of thyroid nodules: avoiding the pitfalls.NYState J Med 1986; 86:241249.Diagnostic pitfalls in the fineneedle aspiration of thyroid nodules.Astudy of555 cases in Chinese patients.Acta Cytol 1987;31:699704.13. Baloch Z, LiVolsiVA, Jain P, Jain R,Aljada I,et al.14. Ceresini G, Corcione L, Morganti S, Milli B,Bertone L, et al.15. Rizvi SA, Husain M, Khan S, Mohsin M.16. Smith J, Cheifetz RE, Schneidereit N,Berean K, Thomson T.17. Kesmodel SB, Terhune KP, Canter RJ,Mandel SJ, Livolsi VA, et al.18. Marqusee E, Benson CB, Frates MC,Doubilet PM, Larsen PR, et al.Role of repeat fine-needle aspirationbiopsy (FNAB) in the management of thyroidnodules. Diagn. Cytopathol. 2003; 29:203-206.Ultrasound-guided fine-needle capillary biopsy of thyroid nodules,coupled with on-site cytologic review,improves results. Thyroid 2004; 14:385-389.Acomparative study of fine needle aspirationcytology versus non-aspiration technique inthyroid lesions. The Surgeon 2005; 3:273-276.Can cytologyaccurately predict benign follicular nodules?Am J Surg 2005; 189:592-595.The diagnosticdilemma of follicular variant of papillarythyroid carcinoma. Surgery. 2003; 134:1005-1012.Usefulness ofultrasonography in the management of nodularthyroid disease. Ann Intern Med. 2000;133:696-700.166Nigerian Journal of Clinical Practice June 2010, Vol.13(2) Afolabi et alFine Needle Aspiration Cytology

Review of fine needle aspiration cytology in the management of goitres in Ibadan, Nigeria

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Review of fine needle aspiration cytology in the management of goitres in Ibadan, Nigeria

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