FNA
as An Indication for Thyroid Surgery without the
Need for Further Investigations
.........................................................................................................................
1. Mohammed Almulaifi MD, JBS
2. Khaled Ajarma MD, JBS
3. Waseem al Mefleh MD, JBS
4. Ashraf Shabatat MD, JBS
5. Khaled Khalayleh MD
6. Ibtihaj Habashneh RN
7. Ali Al-Ebous, FRCS
Correspondence:
DR. Waseem al Mefleh
Department of surgery, King Hussein Medical
Centre.
Phone No: 00962-777745674
E-mail: wozbi@yahoo.com
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ABSTRACT
Content:
Palpable solitary thyroid nodule is a
common reason
for thyroid surgery.
The recent investigations, namely fine
needle aspiration (FNA) decrease
dramatically the number on whom it is
mandatory to do surgery.
Objective:
To evaluate FNA as an indication for thyroid
surgery.
Patients and
method:
100 patients with clinical thyroid nodules
were studied
over 4 years. The study included thyroid
function test, thyroid ultrasound and
F.N.A.
Results:
95% were euthyroid, 5% had hyperthyroidism.
Ultrasound showed solid nodule in 44 patients,
cystic nodule in 35 patients,
Multinodular goiter in 15 patients, diffuse
enlargement in 6 patients.
FNA showed follicular neoplasm in 11 patients,
hurthle cells in 3 patients,
Papillary carcinoma in 13 patients, benign
in 58 patients, autoimmune in
13 patients and not diagnostic in 13 patients.
Thyroid surgery has been done for 88 patients.
Post-operative histopathological examination
was studied which proved that F.N.A had
a sensitivity of 96% and specificity of
98%.
Conclusion:
F.N.A is reliable, highly accurate and
aids in selection of patients for thyroid
surgery and decreases also the need for
other investigations, namely thyroid isotope
scan.
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Palpable solitary thyroid nodule is a common
reason for seeking medical advice all over the
world(6). The incidence is 5% in the general
population(7).
Thyroid nodules are more common in women; the
incidence increases with age, a history of radiation
exposure, and a diet containing goitrogenic
material.
Solitary thyroid nodule has been considered
by many clinicians as an absolute indication
for surgical resection. Only recently has this
policy been changed to a rather more selective
approach.
Availability of more practical easily performed
and well accepted procedures to obtain tissue
diagnosis is a consideration on one side as
well as the low incidence of thyroid cancer
which ranges from 11-20%(8). On the other side
it is more reasonable to select certain patients
with thyroid nodules for surgery. In addition,
thyroid surgery is associated with a definitive
morbidity and should not be undertaken lightly.
Conservative management of the thyroid nodules
is appropriate when malignancy can be safely
excluded.
Neoplasms of the thyroid encompass a wide spectrum
of phenotypes, which range from benign follicular
lesions to violently aggressive anaplastic cancers(3).
Papillary carcinoma is the most common malignancy
of the thyroid, and its pathologic diagnosis
is based on demonstration of characteristic
cytohistologic features(2).
The commonest presentation of medullary thyroid
carcinoma is a painless lump in the thyroid
gland and might be mistaken for a primary thyroid
tumor(5).
Total thyroidectomy is considered the preferable
initial surgical approach for papillary thyroid
cancers when there is no evidence of lymph node
metastases(4).
The overall morbidity of total thyroidectomy
included temporary hypocalcaemia 23%, permanent
hypocalcaemia 1%, temporary recurrent nerve
palsy 3%, permanent recurrent nerve palsy 1%,
haemorrhage 3%, tracheomalacia 5% and wound
infection 3%(1).
One hundred patients with clinical thyroid
nodule were retrospectively studied over a period
of 4 years. Mean age was 45 years with a female
to male ratio of 5:1.
Each patient had the following investigations:
1. Thyroid function test: free thyroxine, free
triiodo-thyronine and thyroid-stimulating hormone.
95% were euthyroid and 5% were hyper thyroid.
2. Thyroid ultrasound.
|
Ultrasound diagnosis |
Number |
Surgery |
Cancer |
|
Solid nodule |
44 |
41 |
14(31%) |
|
Cystic nodule |
35 |
31 |
1 |
|
Multi nodular goiter |
15 |
12 |
1 |
|
Diffuse enlargement |
6 |
4 |
0 |
3. Fine needle aspiration (F.N.A).
This was done by the pathologist and the specimen
was examined by the medical cytologist and cytopathologist.
The results are shown in the table below.
|
F.N.A-diagnosis |
Number |
Surgery |
Histopathology |
|
Follicular neoplasm |
11 |
11 |
3 Follicular carcinoma |
|
Hurthle cell tumor |
2 |
2 |
Same |
|
Papillary carcinoma |
13 |
13 |
1 Benign |
|
Benign |
58 |
49 |
1 Follicular carcinoma |
|
Auto immune |
3 |
0 |
------- |
|
Not diagnostic |
13 |
13 |
All benign |
|
Total |
100 |
88 |
Cancer =16Benign =72 |
Surgery was done as hemithyroidectomy in 54%
of patients and total or subtotal thyroidectomy
in 34% of patients.
Revision of the accuracy of the thyroid ultrasound
and fine needle aspiration (F.N.A) revealed
that the finding of a solid nodule by ultrasound
had a sensitivity of 98% but a higher specificity
of 31%.
(F.N.A) had a similar sensitivity; however.
Its specificity was 98%. There was one patient
diagnosed to have benign neoplasm by F.N.A.
who proved to have follicular carcinoma at surgery;
still the majority of patients sent for surgery
had benign lesions (72%).
Although Fine Needle Aspiration (F.N.A) is
the best investigation we depend on for selection
of patients for surgery and has the highest
sensitivity and specificity in comparison with
isotope SCAN and ultrasound(9); however, there
are certain pitfalls.
Firstly, it is a cytological examination; so
patients diagnosed as having Follicular neoplasm
had to be sent for Surgery because Follicular
- carcinoma couldn't be excluded.(10) Secondly,
it is person dependent, so certain centers can
achieve excellent results compared to others.
Thirdly; the potential for false negative diagnosis
is still there and can be maintained as low
as 6 %.
Reviewing our policy at (King Hussein centre).
Strict policy for selection of patients with
thyroid nodule for Surgery is not well established.
This can be attributed to the fact that some
surgeons still have not been acquainted with
the reliability of (F.N.A). A second reason
may be that most of the patients who do not
need surgery remain under the care of their
physicians.
From our study it is evident that fine needle
aspiration is:
- reliable.
- aids the selection for surgery of patients
with thyroid nodules.
- reduces the overall number of individuals
subjected to surgery and consequently increases
the proportion of cancer among those undergoing
thyroidectomy.
- decreases the need for other investigations.
- Anjali Mishra et al. Total thyroidectomy
for differentiated thyroid cancer. Eur J surg
2002; 168: (283-287).
- Virginia A. Livolsi et al. follicular neoplasms
of the thyroid. Adv Anat Pathol 2004; 11:
(279-287).
- Hani B. Abdul-Jabar et al. the surgical
management of thyroid cancer. Nuclear Medicine
communications 2004; 25(869-872).
- R. Bellantone et al. Video assisted thyroidectomy.
Surg Endosc 2003; 17(1604-1608).
- Erik G. Cohen et al. Medullary thyroid carcinoma.
Acta otolaryngol 2004; 124 :( 544-557).
- Mc Grath PC, Sloan DA, Schwartz RW, Kenady
DE: Diagnosis and management of thyroid malignancy.
Current opin on col 1994; 6 :( 60-71).
- danese D, sciacchitanu S. the thyroid nodule:
diagnostic consideration, Minerva Endocrinol,
1993; 18 :( 129-137).
- Psarras et al. The single thyroid nodule.
Br.j.surgery, 1972; 59 :( 545-548).
- Horvath et al. preoperative diagnosis of
thyroid nodule.
Minerva Chin, 1993; 48: (1279-81)
- Gharib.Fine needle aspiration Biopsy of
thyroid nodule: Advantages, limitations and
effects. Mayo Clinic Proc, 1994; 69 :( 44-49).
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