Fine Needle Aspiration Cytology in Diffuse or Multinodular Goitre Compared With Solitary Thyroid Nodules

Fine needle aspiration cytology in
diffuse or multinodular goitre

compared with solitary thyroid
nodules
J A Franklyn, J Daykin, J Young, G D Oates,
M C Sheppard
Thyroid Clinic,
Birmingham General
Hospital, and University
Departments of Medicine
and Pathology, Queen
Elizabeth Hospital,
Birmingham
J A Franklyn, reader in
medicine
J Daykin, research nurse
J Young, senior lecturer in
pathology
G D Oates, consultant
surgeon
M C Sheppard, professor of
medicine
Correspondence to:
DrJ A Franklyn,
Department of Medicine,
Queen Elizabeth Hospital,
Edgbaston, Birmingham
B15 2TH.
BMJ 1993;307:240
240
Comparison of final diagnosis in patients with solitary nodules and

diffuse or multinodular goitre
Rate of neoplasia
Rate of malignancy (benign+malignant)
Clinical diagnosis
Solitary nodule (n-321)

Diffuse goitre (n-68)
Multinodulargoitre (n-72)
59% (n- 19)

4-4% (n-3)
1-40/o (n- 1)
12-5% (n-40)
7-4% (n-5)
4-2% (n-3)
nant) in those with solitary nodules and diffuse goitre.

Rates of neoplasia were less in multinodular goitre,
only one malignant tumour being diagnosed.
Thyroid enlargement affects around 15% of the

population' but thyroid cancer is rare,2 so the challenge
is to identify the few patients with neoplastic disease.
Clinical features are unhelpful,3 but the likelihood of Comment
malignancy is reportedly higher in solitary thyroid
The overall accuracy of fine needle aspiration
nodules than in diffuse or multinodular goitre.4 Fine cytology in predicting neoplasia in our clinic accords
needle aspiration cytology is the investigation of choice with that in other centres.45 Only a quarter of the series
in solitary nodules,5 but its role in diffuse or multi- had thyroidectomy (two patients with lymphoma had
nodular goitre is unclear. We compared the results of only open biopsy), so that further false negative cases
fine needle aspiration cytology in patients with goitre may emerge. However, all patients were followed up
and solitary nodules and related the final cytological or for at least two years to allow repeat cytology prompted
histological diagnosis to findings on examination.
by further thyroid growth or symptoms.
In this series the rate of neoplasia (benign plus
malignant) was 12-5% (40/321 cases) in patients with
Patients, methods, and results
solitary thyroid nodules, which is similar to the rate
A total of 461 euthyroid patients presenting with (10%) reported elsewhere.45 Interestingly, a comparthyroid enlargement were studied prospectively, after able rate of neoplasia was evident in patients judged to
classification by JAF or MCS as cases of solitary have a diffuse goitre, which conflicts with reports that
thyroid nodule or diffuse or multinodular goitre. All neoplasia is uncommon in patients with diffuse thyroid
had fine needle aspiration cytology performed at the enlargement.4 Furthermore, we also identified a few
first clinic visit (aspirates from several sites (mean benign or malignant tumours in patients with multithree) were obtained in those with goitre), and nodular goitre, in which neoplasia is also reportedly
aspiration was repeated (in 33%) if the first specimen rare.4
was inadequate (n= 45) or if symptoms changed during
The discrepancy between the prevalence of goitre in
a minimum follow up of two years (n= 105).
the general population detected by screening' and the
Suspicious or malignant cytological features promp- low rate of malignancy in the general population2
ted surgery in 67 cases, a futher 55 patients with indicates that malignant disease is absent in most
satisfactory cytological appearances proceeding to patients in the community with thyroid enlargement.
partial thyroidectomy for upper airways obstruction or In the selected group presenting to a hospital clinic
cosmetic reasons. All reports of malignant cytological because of an increase in thyroid size, however, the
findings (n= 14) were confirmed histologically (two absence of suspicious clinical features in most patients
follicular, four papillary, two medullary carcinomas; with malignancy and comparison of the rate of
six lymphomas or anaplastic tumours). Of patients malignancy in those with solitary nodules and diffuse
with cytological appearances suspicious but, not or multinodular goitre indicate that fine needle
diagnostic of neoplasia (n=53), six had malignancy aspiration cytology should be performed in all.
(two follicular and four papillary carcinomas) and 22
benign follicular adenomas. Twenty five patients with
We thank Dr Scott Sanders for expert interpretation of
a suspicious cytological picture had simple colloid some ofthe cytological specimens.
goitres. Six neoplasms (three follicular adenomas,
three papillary carcinomas) which were not identified 1 Tunbridge WMG, Evered DC, Hall R, Appleton D, Brewis M, Clark F, et al.
The spectrum of thyroid disease in a community: the Whickham survey.
in the first adequate aspirate were diagnosed during
Clin Endocrinol 1977;7:481-93.
follow up; review showed the false negative finding to 2 Office
of Population Censuses and Surveys. Cancer statistics. Cases of diagnosed
cancer registered in England and Wales. London: HMSO, 1975. (Ser MBI,
reflect sampling error. Only four patients had clinical
No
5.)
features suspicious of malignancy (fixed or rapidly 3 Miller JM, Hamburger JI, Kini SR. Diagnosis of thyroid nodules: use of fine
enlarging lesions). All had solitary nodules, and
needle aspiration and needle biopsy. JAMA 1979;241:4814.
4 Rojeski MT, Gharib H. Nodular thyroid disease. Evaluation and management.
malignancy was confirmed in each case.
NEnglJMed 1985;313:428-36.
Comparison of outcome in terms of final cytological 5 Mazzaferri
EL. Management of a solitary thyroid nodule. N Engl J Med
1993;328:553-9.
or histological diagnosis in patients with solitary
nodules and diffuse or multinodular goitre (table)
indicated similar rates of neoplasia (benign or malig- (Accepted 21 May 1993)
BMJ VOLUME 307
24juLY 1993

Fine Needle Aspiration Cytology in Diffuse or Multinodular Goitre Compared With Solitary Thyroid Nodules

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Fine needle aspiration cytology in

diffuse or multinodular goitre

Comparison of final diagnosis in patients with solitary nodules and

Solitary nodule (n-321)

59% (n- 19)

nant) in those with solitary nodules and diffuse goitre.

Thyroid enlargement affects around 15% of the

BMJ VOLUME 307

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