Clinical presentation of various thyroid lesions in a study population attending a teaching hospital in North India

INTRODUCTION

Thyroid nodules are commonly encountered in clinical practice, with a prevalence of 2% to 5% for palpable thyroid nodules¹ and 19% to 46% for nodules detected by thyroid ultrasonography.² Thyroid nodules are more common in women, and the incidence increases with age, history of radiation and diet containing giotrogenic material.¹ Various studies have shown that the risk of malignant involvement of thyroid palpable nodules³ is 4% to 7%. Clinically thyroid lesions present as goitre or thyroid enlargement which can be nodular (solitary or multiple) or diffuse.³

Clinicians have used clinical examination, biochemical lab tests (T₃, T₄, TSH), transcutaneous ultrasonography, scintigraphy with (I-123 or Tc-99 mm) and Fine Needle Aspiration Cytology (FNAC) for the evaluation of thyroid nodules. FNAC has surpassed most of other tests.⁴

The procedure is regarded as a valuable method of distinguishing between malignant from those with benign nodules that can be followed clinically.⁵

FNAC is proposed as a pre-operative screening method to reduce the number of patients with benign nodules referred for surgery.⁶

As a diagnostic test, FNAC can be used to diagnose most benign nodular goitres, cysts, thyroiditis and neoplasms (papillary, medullary, anaplastic, poorly differentiated and metastatic malignancy) with high degree of accuracy based on cyto-morphological features.⁷

The diseases of thyroid form a major share of head and neck surgery. Clinical examination, although very accurate in most cases, is inadequate in some areas especially, in staging of thyroid malignancies and in detecting the multi-nodularity of the gland.

The reported incidence of thyroid nodules in children and adolescents is estimated to be between 1% and 2%. However, this incidence may be increasing because diagnostic radiological procedures are detecting incidental thyroid nodules in children.⁸

FNAC and USG are thus used in association with clinical features. The present study is undertaken to evaluate the different clinical presentations of thyroid lesions attending the OPD in a teaching hospital.

METHODS

The study was conducted in the postgraduate department of pathology of a teaching hospital in northern India for a period of 1 year. It was a prospective hospital based Study. In each case, a brief clinical history and physical examination along with evaluation of relevant investigation was carried out. Patient was explained about whole of the procedure & the consent for the procedure was taken in all patients.

Fine needle aspiration cytology of thyroid gland was done by (a) palpable method and (b) ultrasound guided. The radiologist and cyto-pathologist carried out ultrasound-guided FNAC. The slide smears were stained by May-Grunwald Giemsa (MGG) and Papnincolaou (PAP) staining method.

The results of FNAC were correlated with histopathology, wherever available. Statistical evaluation was done using SPSS 11.5 software.

RESULTS

Out of the 139 patients, 134 presented with swelling in the neck, 3 patients presented with pain in the neck while as 2 patients came with discomfort in the neck (Table 1).

Out of 139 patients, 74 patients have duration of swelling more than 2 years, 51 patients have duration upto 1 year, 10 patients have duration between 1 to 2 years and 4 patients have less than one month (Table 2).

Out of 139 patients, 110 patients have solitary swelling, 87 have swelling on right side, 119 presented with regular margins, 91 presented with firm consistency, 130 were mobile and 135 presented with non-tender (Table 3).

DISCUSSION

The study was a prospective hospital-based study conducted in 139 patients with thyroid swelling in the postgraduate department of pathology in a teaching hospital in Northern India for a period of 1 year. The present study aimed at studying the different clinical presentations of thyroid lesions & confirmed cytological features of thyroid lesions by free/ultrasound guided Fine needle aspiration. Furthermore, the cytological findings were confirmed with Histopathology examination (HPE), wherever it was available.

Fine Needle Aspiration Cytology (FNAC) is the fundamental method for evaluation of thyroid nodules. Examination of the material obtained by FNAC enables to differentiate between benign and malignant lesions. However, FNAC of thyroid has its own limitations. Ultrasound guidance allows continuous visualization of the needle during insertion and sampling which results in pinpoint accuracy with a high level of safety.

Bouvet et al.⁹ (1992) have found in their study that asymptomatic thyroid swelling was the commonest presenting complaint. In our study, the most common presenting complaint was swelling in the neck, which was present in 134 patients (95.80 %).Three patients complained of pain in the neck and two with throat discomfort.

The incidence of solitary and diffuse nodules was 79.1% and 20.8%, respectively in the present study. The right lobe was more frequently involved than the left lobe as reported by Psarras et al.¹⁰ (1972). In our study, the right lobe of the thyroid was involved in 62.5% of the cases and the left lobe in 37.4% of the cases.

The diagnosis is mainly based on clinical signs and symptoms corroborated by laboratory confirmation by T₃, T₄, TSH levels and radio-active iodine uptake tests in some. FNAC provides cytomorphologic parameters that certainly help in understanding the pathogenesis of the thyrotoxicosis & hypothyroid state.

In the present study, goitre was the commonest thyroid lesion accounting for 51(57.3%) by USG-guided FNAC. Similar observation was made by A. Martinek et al.¹¹ who reported 156 (50.4%) out of 309 cases. Harsuolis et al.,¹² (1986) performed fine needle aspiration biopsy cytology in 1100 patients (aged 14-80, 993 women), with nodular goiter. Khurana KK et al.,¹³ (1998) investigated the value of ultrasound-guided FNZC as a diagnostic tool in the management of non-palpable thyroid nodules as well as palpable thyroid nodules that were considered difficult to aspirate without guidance. Alexander EK et al.,¹⁴ (2002) collected data of all patients at the Brigham and women’s hospital thyroid nodule clinic like patient age, gender, nodule size, cystic content, solitary vs. multinodular thyroid, and nodule location were documented and evaluated. Handa U. et al.,¹⁵ (2008) studied 434 patients with thyroid lesions over a period of three years. The most frequently encountered lesion was the colloid goitre in 250 (57.60%).

CONCLUSION

The present study was conducted in the post-graduate department of pathology in a teaching hospital in Northern India. The study compromised of 139 patients of thyroid lesions who were subjected to USG-guided and conventional method Fine Needle Aspiration Cytology (FNAC). Majority of the patients presented after 2 years of illness i.e. 74. Only 4 patients presently acutely within 1 month of illness. The major complaint was swelling in neck i.e. in 134, rest presented with local pain and discomfort.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

REFERENCES

1. 1. Rojeski MT, Gharib H. Nodular thyroid disease. Evaluation and management. N Engl J Med. 1985 Aug;313(7):428-36.
2. 2. Brander A, Viikinkosi P, Tuuhea J, Voutilainen L, Kivisaari L. Clinical versus ultrasound examination of the thyroid gland in common clinical practice. J Clin Ultrasound. 1992;20(1):37-42.
3. 3. Mathur SR, Kapila K, Verma K. Role of fine needle aspiration cytology in the diagnosis of goiter. Indian J Pathol Microbiol. 2005;48(2):166-9.
4. 4. Jogai S, Al-Jassar A, Temmim L, Dey P, Adesina AO, Amanguno HG. Fine needle aspiration cytology of thyroid: a cytohistologic study with evaluation of discordant cases. Acta Cytologica. 2005;49(5):483-8.
5. 5. Ko HM, Jhu IK, Yang SH, Lee JH, Nam JH, Juhng SW, et al. Clinico-pathologic analysis of fine needle aspiration cytology of the thyroid. A review of 1,613 cases and correlation with histopathologic diagnoses. Acta Cytol. 2003 Sep-Oct;47(5):727-32.
6. 6. Hatada T, Okada K, Ishii H, Ichii S, Utsunomiya J. Evaluation of ultrasound-guided fine needle aspiration biopsy for thyroid nodules. Am J Surg. 1998 Feb;175(2):133-6.
7. 7. Suen KC. Fine needle aspiration biopsy of the thyroid. Can Med Assoc J. 2002;167(5):491-5.
8. 8. Izquierdo R, Arekat MR, Knudson PE, Kartun KF, Khurana K, Kort K, et al. Comparison of palpation-guided versus ultrasound-guided fine-needle aspiration biopsies of thyroid nodules in an outpatient endocrinology practice. Endocr Pract. 2006;12(6):609-14.
9. 9. Bouvet M, Feldman JI, Gill GN, Dillmann WH, Nahum AM, Russack V, et al. Surgical management of thyroid nodule: patient selection based on the results of fine needle aspiration cytology. Laryngoscope. 1992 Dec;102(12):1353-6.
10. 10. Psarras A, Papadopoulus SN, Livadas D, Pharmakiotis AD, Koutras DA. The single thyroid nodule. Br J Surg. 1972;59:545-8.
11. 11. A. Martinek, J. Dvorackovia, M. Honka, J. Horácek, P. Klvana. Importance of guided fine needle aspiration cytology (FNAC) for the diagnosis of thyroid nodules-own experience. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2004;148(1):45-50.
12. 12. Harsoulis P, Leontsinit M, Economout A, Gerasimidis T, Smbarounis C. Fine needle aspiration biopsy cytology in the diagnosis of thyroid cancer: Comparative study of 213 operated patients. Br J Surg. 1986;73:461-4.
13. 13. Khurana KK, Richards VI, Chopra PS, Izquierdo R, Rubens D, Mesonero C. The role of ultrasonography-guided fine-needle aspiration biopsy in the management of non-palpable and palpable thyroid nodules. Thyroid. 1998 Jun;8(6):511-5.
14. 14. Alexander EK, Heering JP, Benson CB, Frates MC, Doubilet PM, Cibas ES, et al. Assessment of nondiagnostic ultrasound-guided fine needle aspirations of thyroid nodules. J Clin Endocrinol Metab. 2002 Nov;87(11):4924-7.
15. 15. Handa U, Garg S, Mohan H, Nagarkar N. Role of FNAC in diagnosis and management of thyroid lesions: a study on 434 patients. J Cytol. 2008;25:13-7.