DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.

ULTRASOUND EVALUATION OF THYROID NODULE

WITH PATHOLOGICAL CORRELATION
*Polisetti Ravi Babu, **Panil Kumar Be, ***Pasupala Renuka, ****Lanke Sowmya
*****Kota Sesha Brahma Sri Krishna Sasanka
Date of receipt of article -23-2-2016
Date of acceptance -2-5-2016
DOI-10.21176/ojolhns.2016.10.1.10
ABSTRACT
Objectives: To calculate the incidence of different types of thyroid nodules in rural people. To correlate ultrasound
diagnosis with operative and cytological/ histological diagnosis.
Study Design: Descriptive and prospective analytical study in a tertiary referral hospital.
Method: 100 patients with a clinical diagnosis of either solitary nodule or multinodular thyroid were included in
the study. The patient demographic data, ultrasound features, cytological diagnosis and operative procedure and
histological diagnosis were studied. Ultrasound features of nodules of patients were noted especially in respect
of nodule size, shape, echogenecity, composition (solid/ cystic), presence and type of calcifications, presence and
type of vascularity.
Results: In our study solitary nodules (56%) are common than multinodules (44%). Thyroid nodules are common
in female (94%) population and between the third decades to fifth decades. Mean size of the solitary nodule is 25
x 20 mm. Malignancy is seen in 20% of solitary nodules. 78% of well defined solitary nodules are benign and
60% ill defined nodules are malignant. Malignancy is seen in 16% of the nodules as per cytological examination.
Conclusion: In conclusion solitary nodules are more common than multinodules and nodules are more common
in female and ultrasound features are useful to identify benign from malignant nodules.

INTRODUCTION
Thyroid nodules are one of the most common
endocrine diseases in the world. They are seen
approximately 4 to 7% of the population in iodine
sufficient areas, with a markedly increased incidence in
iodine-deficient regions. Autopsy studies showed the
prevalence of multiple thyroid nodules (37.3%) is higher
than that of solitary nodules (12.2%). According to a
recent study in India the prevalence of a palpable
thyroid nodule in the community is about 12.2%.
Very few studies from India are available
correlating ultrasound features of thyroid nodules with
histopathology. The hospital from which the present
study was done caters hugely rural population and hilly
areas. Thyroid nodules are commonly observed in these
areas. Limited data is available about the incidence,
nature of the nodules, and the incidence of malignancy
in this population. Hence the study was undertaken to
study the incidence of various nodules in rural
population and correlate ultrasound features of the
thyroid nodules with cytology or histopathology.

AIMS AND OBJECTIVES

1. To calculate the incidence of different types of
thyroid nodules in rural people.
2. To correlate ultrasound diagnosis with
operative and cytological/ histological diagnosis.
MATERIAL AND METHODS
This descriptive and prospective analytical study
was done in the Ear, Nose and Throat Out Patient
Department from November 2013 to September 2015.
Inclusion criteria: All the patients presenting to
Department of Ear, Nose and Throat with either
Affiliations:
*Professor, ****Senior Resident, *****Junior Resident, Department
Of ENT, **Professor, Department Of Radiodiagnosis, Santhiram Medical
College, Nandyal, ***Senior Resident, Department Of Radiodiagnosis,
Kurnool Medical College, Kurnool
Address of Correspondence:
DR. P. RAVI BABU,
Professor
Department Of ENT, Santhiram Medical College Nandyal, 518502
E-mail : polisettir@yahoo.com,
Mobile : 9866308482

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Vol.-10, Issue-I, Jan-June - 2016

Keywords: Thyroid nodules, ultrasound, histopathology, malignancy.

Vol.-10, Issue-I, Jan-June - 2016

DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.1

solitary nodule or multinodular thyroid were included

in the study.
Exclusion criteria: The patients with diffuse
swelling of thyroid, thyroglossal cyst were excluded
from the study. In patients where Sonological
evaluations were done outside but the treatment under
taken in our hospital were excluded from the study..
The patient demographic data, ultrasound features,
cytological diagnosis and operative procedure and
histological diagnosis were studied. Ultrasound features
of nodules were noted especially nodule size, shape,
echogenecity, composition (solid/ cystic) , presence and
type of calcifications, presence and type of vascularity.
All the patients underwent sonological evaluation using
eSAOTE, SIEMENS ultrasound machines with
curvilinear probe of 5-10 MHz. Fine needle aspiration
cytology (FNAC) was done in each case. Apart from
general investigations which were required for fitness
of surgery no special investigations( antithyroid
antibodies) were done. Only few patients were operated
in our study even though indicated. Histological
diagnoses of the operated patients were noted. No
follow up study was done. Statistical analysis was done
by using Graph pad instat 3.0 version. Univariate
analysis by Fishers exact test was used.
RESULTS
In the present study nodules in the thyroid were
more common in female patients (n=94). Majority of
the patients were in the age group 21-40 years, followed
by the age group 41-60 years. The incidence of solitary
thyroid nodules is 56% and incidence of multinodules
is 44%. Out of 56 patients with solitary nodules
majority were found in the right lobe(31), followed by
left lobe (24). Out of the 44 patients with multinodules
majority were in both lobes (n=32) followed by six in
either lobes.
DISCUSSION
Thyroid nodular disease is characterized by the
presence of one or more palpable or non palpable
nodules within the substance of the thyroid gland. A
thyroid nodule is defined as a discrete lesion within
the thyroid gland that is distinguishable from the
adjacent parenchyma in Ultrasound study1.Thyroid
nodules are more common in women and elderly2,3. In
the present study 94% were women. Out of 100 patients
studied 53 were women in the age of 21-40 years, 29
patients were in the age of 41-60 years. Even though
male gender is considered risk factor for malignancy4
in the present study out of 6 patients, follicular
50

neoplasm is found in only in one patient. Mortensen

et al showed the prevalence of multiple thyroid nodules
(37.3%) is higher than that of solitary nodules (12.2%)5.
Our study showed the incidence of the solitary thyroid
nodules was 56% and the incidence of multinodular
thyroid was 44%. The probable reason for higher
incidence of solitary nodules than multinodules was
due to Ultrasound detection of early stage of
multinodules as solitary nodule which would eventually
become multinodules during its natural course. Out
of the 56 patients with solitary nodules 31 were found
in the right lobe, 24 were in the left lobe and one patient
had in the isthmus. Mean size of solitary nodule was
24.2 + 10.2 x 20.5 + 9.0 (mm).
Among the forty four multiple nodules , 32 were
found in both lobes, 6 patients had only in right lobe
and 6 patients in the left lobe. In patients with multiple
nodules, the cancer rate per nodule decreases, but the
decrease is approximately proportional to the number
of nodules so that the overall rate of cancer per patient
10%13%, is the same as that in patients with a solitary
nodule6. In the present study approximately 11% (5/
44) patients with multinodularity found on Ultrasound
were found to have follicular neoplasms on cytology.
Out of the 44 patients with multinodularity , 4 patients
found to have hashimotos thyroiditis on FNAC
analysis. The cytologic results were divided into two
categories: 1. Benign nodules 2. Malignant / probably
malignant nodules. Benign nodules include colloid
goiter, cystic nodule of thyroid, nodular goiter, nodular
goiter with cystic degeneration, Hashimotos
thyroiditis. The Malignant category includes follicular
neoplasms, papillary carcinoma, suspicious of neoplasm.
The final diagnosis was based on the cytologic result;
final pathologic confirmation was limited to the 21
resected thyroid specimens. Although there was no
Table no.I showing Incidence of malignancy of All
nodules.

DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.1

Table II: Incidence of malignancy

Table III : Shape of solitary nodules

Table IV : % microcalcification

Table V : % of central vascularity

The limitations of this study were that all the

patients included in the study were not operated in
our hospital, even though indicated, due to patients
denial .. Eventually most of the diagnoses were based
on cytology rather than histology. FNAC was done
only by palpation method so the suspicious nodule
could have been missed by this method. Nodule
characterization was done by different observers leading
to inter observer variability. Therefore we suggest to
correlate ultrasound features of nodules with
ultrasound guided FNAC, complete histological
diagnosis for better correlation.
CONCLUSIONS
Solitary nodules (56%) are common than
multinodules (44%). Thyroid nodules are common in
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discrepancy between the initial cytological result and

the final histological result in these resected specimens,
out of 13 follicular neoplasms only 4 were operated, 3
were adenoma on final histology and 1 was carcinoma.
The thyroid nodule is extremely common, found in
some autopsy series in as much as 50% of the general
population7.8. As shown in the table below most of these
nodules are benign; the incidence of malignancy is quite
low, 37% 11,12. In the present study based on the
cytology the incidence of malignancy was 16%. Two
were malignant in the 21 resected specimens constituting
10%.
In the present study the percentage of malignancy
with by illdefined margins was 60% which is almost
equal with Popilli et al 1 study. Poppili et al 1
demonstrated the sensitivity and specificity of an absent
or thick , irregular halo to be 70.4% and 65.8%,
respectively to detect malignancy. Out of 13 patients
with peri lesional halo 6 patients were found to have
benign lesions on cytology.
Out of the 8 patients with hypoechoic nodules ,
five patients (62%) were found to have malignant
cytology which is at par with the study of Lee et al 9
(64%).On comparison between presence or absence of
hypoechic nature ultrasound with cytology hypoechoic
is a feature of malignancy (p=0.004).A study done by
Poppili et al showed calcification occurred with greater
frequency in malignant nodules i.e., in 86.3% Vs 23.9%
benign nodules.
When central vascularity was compared with
cytological analysis, ultrasound should be able to
differentiate benign from malignant nodules based on
the presence or absence of central vascularity (p=0.010).

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female (94%) population. They are more common in

between the third decade to fifth decade. Solitary
nodules are more common in the right lobe and
multinodules are most common found in both
lobes.Malignancy is seen in 16% of the nodules as per
cytological examination.Only 10 % of nodules are
malignant as per histopathological examination. Mean
size of the solitary nodule is 25 x 20 mm. Majority of
solitary nodules are well defined (51/56), hyperechoic
(30/56), wider than tall (38/ 56) and benign on cytology
(45/56, 80%). Few solitary nodules showed calcification
(10/56), presence of halo (13/56), central vascularity (6/
56), peripheral vascularity (12/56).Malignancy was seen
in 20% of solitary nodules. Only few multinodules
showed calcification (7/44), central vascularity(3/44),
peripheral vascularity (3/44). 78% (43/51)of well
defined solitary nodules are benign, 60% (3/5) ill defined
nodules are malignant. Presence of halo was almost
equal in both benign and malignant solitary nodules.
67% (4/6) solitary nodules showing central vascularity
are malignant.100 %( 3/3) solitary nodules with taller
than wide shape are malignant. 63 % (5/8) hypoechoic
solitary nodules are malignant.
On univariate analysis ultrasound features like
well defined margins (p=0.04), wider than tall shape
(0.006) are features of benign nature in solitary nodules.
The presence of central vascularity (p=0.001) and
hypoechoic echogenicity (0.004) are features of
malignancy in solitary nodule.
In conclusion solitary nodules are more common
than multinodules and nodules are more common in
female and ultrasound features are useful to identify
benign from malignat nodules.
DISCLOSURES
(a) Competing interests/Interests of Conflict- None
(b) Sponsorships - None ,
(c) Funding - None
(d) No financial disclosures
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