RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS OF DISSERTATION
1. / NAME OF THE CANDIDATEAND ADDRESS: / Dr.SIDA TAGORE
Dr. BR.R.AMBEDKAR MEDICAL
COLLEGE AND HOSPITAL,
KADUGONDANAHALLI,
BANGALORE 560045.
2. / NAME OF INSTITUTION: / Dr. B.R.AMBEDKAR MEDICAL
COLLEGE AND HOSPITAL
3. / COURSE OF STUDY AND
SUBJECT: / M.D PATHOLOGY
4. / DATE OF ADMISSION TO
COURSE: / 31.05.2012
5. / TITLE OF THE TOPIC: / CYTOLOGICAL STUDY OF THYROID LESIONS BY FINE NEEDLE ASPIRATION CYTOLOGY (FNAC).
6. / BRIEF RESUME OF THE
INTENDED WORK:
/ 6.1 Need of the study Annexure I
6.2 Review of literature Annexure II
6.3 Objectives of the study Annexure III
7. / MATERIALS , METHOD AND
DESIGN / 7.1 Source of data Annexure IV
7.2 Method of collection Annexure V
7.3 Study Design and Method AnnexureVI
7.4 Has ethical clearance been
obtained from the
Institution? AnnexureVII
8. / LIST OF REFERENCES / Annexure VIII
9. / SIGNATRE OF CANDIDATE
10. / REMARKS OF THE GUIDE
11.1 / NAME AND DESIGNATION
OF THE GUIDE / DR.JAYAPRAKASH HT
PROFESSOR,DEPT OF PATHOLOGY
11.2 / SIGNATURE
11.3 / NAME AND DESIGNATION OF THE CO-GUIDE
11.4 / SIGNATURE
11.5 / HEADOF THE DEPARTMENT / DR.MANJUNATHA YA
PROFESSOR AND HOD,DEPT OF PATHOLOGY
11.6 / SIGNATURE
12.1 / REMARKS BY THE CHAIRMAN & PRINCIPAL
12.2 / SIGNATURE
BRIEF RESUME OF THE INTENDED WORK
ANNEXURE I
6.1) NEED OF THE STUDY:
Solitary thyroid nodule is a common clinical problem, especially in females where it is four times as common as in men1.
Since cancer is known to occur more frequently in solitary toxic nodules than in multinodular goiter, solitary toxic nodules are conventionally viewed with suspicion.
Non-invasive screening techniques used in evaluating clinically solitary nodules include thyroid scinti-scanning and ultrasonography (USG ). These modalities do not always reliably distinguish benign nodules from malignant nodules. Therefore, there is a pressing need for a pre-operative investigative modality that can discriminate between benign and malignant nodules.
Before the advent of fine needle aspiration cytology, the incidence of malignancy in surgically excised thyroid nodules ranged from 15%-50% 2, 3. Thyroid surgery however entails considerable morbidity and mortality4.
Since the advent of FNAC as the first line investigation of thyroid nodules, the percentage of patients undergoing thyroid surgery in many centres around the world has been reported to have decreased by almost 50%5. Hence, it is clear that FNAC can reduce the number of unnecessary thyroidectomies.
It is also of value in diagnosing unsuspected thyroid malignancies in which the therapeutic protocol may otherwise have been delayed 6.
FNA has been shown to be superior to clinical, radionuclide or thyroid ultrasound assessment 7. It is a safe, reliable outpatient procedure, which is minimally invasive and cost effective and can be performed in aged and pregnant women.
In comparison with older, conventional methods of pre-operative morphological evaluation such as core biopsy, cytology has the advantage of being more rapid, less traumatic and less expensive. Sampling is also more representative (due to the ease of several needle passes), complications are practically non-existent and diagnostic accuracy is as good as or better than with core biopsy 8.
The sensitivity and diagnostic accuracy of thyroid cytology has been shown to be as high as 85-95% in experienced hands 9.
FNAC of thyroid is indicated for diagnosing solitary thyroid nodule as well as diffuse thyroid enlargements as in autoimmune thyroid lesions. The main purpose of thyroid fine needle aspiration is to distinguish between patients with malignant, or possibly malignant, thyroid nodules and those with benign nodules that can be followed up clinically 10.
The present study aims to diagnose all solitary thyroid nodules as well as diffuse thyroid swelling by FNAC.
ANNEXURE II
6.2) REVIEW OF LITERATURE
The fine needle aspiration method for studying the thyroid was first developed in Sweden in the Radiumhelmet Hospital of Stockholm during the 1950s.
The Swedish investigators established its utility in the diagnostic protocol of the patient with thyroid problems and its correlations with clinical manifestations 11.
In the United States, FNA came into common use at a later date 12, although its use was reported in Memorial Hospital for Cancer in New York, in 1930 13.
At present, FNA of the thyroid is a first-line procedure that is fully accepted in the diagnostic workup of patients in conjunction with more traditional methods 10.
The effectiveness, safety, patient and physician acceptability of FNA technique in the diagnosis of tumor and a variety of other conditions was confirmed in a study of 469 cases14.
Smears studied from 795 patients with adequate sampling, confirmed 100% sensitivity in the diagnosis of malignant neoplasms 15.
The presence of any thyroid pathology increases the risk of a second pathological process in the same gland 16.
FNAC is essential for the management of patients and malignant or ‘suspicious for malignancy’ cytology are absolute indicators for thyroidectomy 17.
FNAC helps in differentiating lesions that require surgery from those that can be managed otherwise 18.
FNAC is highly effective in detecting thyroid malignancy in STN with a sensitivity of 75% and
specificity of 97.6% 19.
FNAC is the gold standard for preoperative assessment of patients with thyroid nodules 20.
ANNEXURE III
6.3) AIMS AND OBJECTIVES
1. To study the cytomorphological features of thyroid swellings by FNAC.
2. To study the incidence of various thyroid disorders diagnosed by FNAC.
3. To study the age and sex incidence of various thyroid lesions diagnosed by FNAC.
ANNEXURE IV
7) MATERIALS, METHODS AND DESIGN
7.1 SOURCE OF DATA
A minimum of 100 cases of thyroid swellings will be studied from June 2012 to June 2014.
Study will be done in the Department of Pathology of Dr BR Ambedkar Medical College.
INCLUSION CRITERIA:
1) Both male and female patients in any age group
2) Patients presenting with thyroid swelling
EXCLUSION CRITERIA:
Patients who have received radiation to head and neck.
ANNEXURE V
7.2 METHOD OF COLLECTION
The thyroid swelling is aspirated using a fine gauge needle of 22 size attached to a 10ml syringe.
The aspirate is put on as many clean glass slides as possible and multiple smears are made.
Some of the slides are put into a jar of alcohol for Papanicolaou staining. Remaining slides are air dried and stained with MGG.
ANNEXURE VI
7.3 STUDY DESIGN AND METHOD
Prospective study.
Data will be analysed using appropriate statistical tests.
STAINING TECHNIQUE
The wet-fixed smears are stained with Papanicolaou stain and the air-dried ones are stained with May Grunwald Giemsa (MGG ).
PAPANICOLAOU STAIN 21
1. Smears are fixed (while still moist ) in 95% ethanol for 15-30 minutes.
2. Smears are rinsed in distilled water.
3. Stained in Harris Haematoxylin for 4 minutes.
4. Washed in tap water for 1-2 minutes.
5. Differentiated in acid alcohol (0.35% HCl in 50% alcohol )
6. Blued in tap water or 1.5% sodium bicarbonate.
7. Rinsed in distilled water.
8. Transferred to 70% then 95% alcohol for few seconds.
9. Stained in OG-6 for 1-2 minutes.
10. Rinsed in three changes of 95% alcohol for few seconds each.
11. Stained in EA-36 for 1-2 minutes.
12. Rinsed in three changes of 95% alcohol for few seconds each.
13. Dehydrated in absolute alcohol, cleared in xylol.
14. Mounted with DPX.
Interpretation
Thin colloid- Brown colour with cracking artefact
Thick colloid- Brownish/ greenish brown
Nucleus- Bluish in appearance
Cytoplasm- Light green/ dark green
MAY- GRUNWALD- GIEMSA STAIN (MGG) 22
1) Smears are air-dried and fixed in methyl alcohol for 5 minutes.
2) Transferred to May-Grunwald stain freshly diluted with 1 to 2 volumes of buffered (Ph 6.8) distilled
water.Left for 3-5minutes.
3) Transferred, without washing, to fresh diluted Giemsa and allowed to stain for 7-15 minutes.
4) Washed quickly in three changes of buffered (pH 6.8) distilled water and placed in a fourth change
of buffered water for 3-12 minutes for differentiation to take place.
5) Allowed to dry.
Interpretation
Thin colloid stains homogeneous pale violet.
Thick colloid stains dark violet.
Nucleus- purple
Cytoplasm- greyish/ greyish blue
ANNEXURE VII
7.4 Has ethical clearance been obtained from the institution?
ANNEXURE VIII
LIST OF REFERENCES
1.Tunbridge WM, Evered DC, Hall R, et al. The spectrum of thyroid disease in a community:
The Whickham survey.Clin Endocrinol 1977; 7: 481-493
2. Mazzaferri EL, Santos ET, Rofagha-Keyhani S. Solitary thyroid nodules: diagnosis
and management. Med Clin North Am 1988; 72: 1177-1210.
3.Katz AD, Bronson D. Total thyroidectomy: the indicators and results of 630 cases. Am J Surg 1978; 136: 450-45
4.Foster RS Jr. Morbidity and mortality after thyroidectomy. Surg Gynecol Obstet 1978; 146: 423-429.
5. Hawkins F, Bellido D, Bernal C, et al. Fine needle aspiration biopsy in the diagnosis of thyroid cancer and thyroid disease. Cancer 1987; 59: 1206-1209.
6.Gita Jayaram. Atlas and Text of Thyroid Cytology, 1st Edition 2006 Arya publications, New Delhi, 2.
7.Gharib H. Fine needle aspiration biopsy of the thyroid nodules; Advantages, Limitations and Effect. Mayo Clin Proc 1994; 69: 44-49.
8.De May RM. The art and science of cytopathology. Vol II. Aspiration cytology. Chicago, ASCP Press, 1996; 703-778.
9. Gharib H, Goellner JR. Evaluation of nodular thyroid disease. Endocrinol Metab Clin North Am 1988; 17: 511-526.
10. Bibbo. Comprehensive Cytopathology. 2nd Edition 1997, W.B Saunders Company, Philadelphia, 673.
11.Lowhagen T, Granberg PO, Lundell G, et al. Aspiration Biopsy Cytology in nodules of the thyroid gland suspected to be malignant. Surg Clin North Am 1979; 59: 3-18.
12.Miller JM, Hamburger JI, Kini SR. The impact of needle biopsy on the preoperative diagnosis of thyroid nodules. Henry Ford Hosp Med J 1980; 28: 145-148.
13.Martin HE, Ellis EB. Biopsy by needle puncture and aspiration.Ann Surg 1930; 92: 169-181.
14.Frable WJ. Thin needle biopsy, personal experience with 469 cases. Am J Clin Pathol
1976; 65: 168-171.
15. Hall TL et al. Sources of diagnostic error in fine needle aspiration of the thyroid. Cancer 1989; 63: 718-720.
16.Pio Zeppa et al. Association of different pathological processes of the thyroid gland in fine needle aspiration samples. Acta Cytol 2001; 45: 347-352.
17. Morgan JL, Serpell JW, Cheng MSP. Fine needle aspiration cytology of thyroid nodules. ANZ Journal of Surgery 2003; 73(7): 480-484.
18.Uma Handa, Sukant Garg, Harsh Mohan, Nitin Nagarkar. Role of fine needle aspiration cytology in diagnosis and management of thyroid lesions: A study on 434 patients. Journal of cytology 2008; 25(1): 13-17.
19. Muhammad Tariq, Muhammad ZI, Muhammad ZA, Muhammad ACH, Rao SK, Shumaila Irum. FNAC of thyroid nodule; Diagnostic accuracy of FNAC. Professional Med J 2010; 17(4) : 589-597.
20.Shirish C, Neha S, Harsh K, Pagaro P, Charusheela G, Mohit R. Clinicopathological correlation of thyroid nodules. Int J Pharm Biomed Sci 2012; 3(3): 97-102.
21.Guidelines of the Papanicolaou society of Cytopathology for the examination of fine needle aspiration specimens from thyroid nodules. The Papanicolaou society of Cytopathology Task force on Standards of Practice. Med Pathol 1996; 9(6): 710-715.
22.Lynch’s Medical Laboratory Technology. Basic hematologic techniques. Third Edition, 1976, WB Saunders Company, 1094.
To,
The Principal,
Dr.B.R.Ambedkar Medical College,
K.G.Halli
Bangalore-560045
Through proper channel
Respected Sir,
Subject: Proforma for registration of subject for dissertation.
I, Dr Sida Tagore, Post Graduate student in MD Pathology will be working on the topic titled “Cytological study of thyroid lesions by Fine Needle Aspiration Cytology (FNAC)”.
I kindly request you to forward it to Rajiv Gandhi University of Health Sciences, Bangalore and do the needful.
Thanking You
Yours faithfully,
(Dr.SIDA TAGORE)
Professor & Head of the Department of Pathology.
To,
The Ethical committee,
Dr.B.R.Ambedkar Medical College,
K.G.Halli
Bangalore-560045
Through proper channel
Respected Sir/Madam,
Subject: Proforma for registration of subject for dissertation.
I, Dr Sida Tagore, Post Graduate student in MD Pathology will be working on the topic titled “Cytological study of thyroid lesions by Fine Needle Aspiration Cytology (FNAC)”.
I kindly request you to give ethical clearance and forward it to Rajiv Gandhi University of Health Sciences, Bangalore and do the needful.
Thanking You
Yours faithfully,
(Dr.SIDA TAGORE)
Professor Head of the Department of Pathology.
Dr. B.R.AMBEDKAR MEDICAL COLLEGE AND HOSPITAL,
KADUGONDANAHALLI, BANGALORE 560045.
DEPARTMENT OF PATHOLOGY
To,
The Registrar,
RGUHS,
Jayanagar 4th Block,
Bangalore.
Through proper channel
Respected Sir/Madam,
Subject : Proforma for registration of subject for dissertation.
I, Dr Sida Tagore, Post Graduate student in MD Pathology will be working on the topic titled “Cytological study of thyroid lesions by Fine Needle Aspiration Cytology (FNAC)”.
I kindly request you to certify my topic of dissertation and do the needful.
Thanking You
Yours faithfully,
(Dr.SIDA TAGORE)
3