Annals of Clinical Cytology and Pathology

Ultrasound-Guided Fine-needle Aspiration of the Thyroid in Cytology Practice

Research Article | Open Access

  • 1. Department of Pathology and Cytology at Södersjukhuset, Karolinska University Laboratoriet, Department of Woman and Child Health, KarolinskaInstitutet, Sweden
  • 2. Department of Pathology and Cytology at Södersjukhuset, Karolinska University Laboratoriet, Sweden
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Corresponding Authors
Eugenia Colón, Department of Pathology and Cytology at Södersjukhuset, Karolinska University Laboratoriet, Karolinska Institute, Stockholm, Sweden, Tel: 46-86164512

Background: Fine-needle aspiration (FNA) of the thyroid gland is a widely accepted and accurate method for triaging patients with thyroid nodules. The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is used to standardize terminology and convey the risk of malignancy.

Objective: The aim of the study is to analyze the benefit of ultrasound in our daily cytology practice and the utility of the TBSRTC to predict the malignancy risk. We correlated cytology and ultrasound findings with histology reports.

Methods: Data on patient cytology were retrieved by a retrospective search of all thyroid fine needle aspiration cytology (FNAC) reports issued at the Department of Cytopathology, Söder Hospital, Karolinska University from January 2012 to June 2013. A total of 619 specimens were reclassified according to the TBSRTC. When applicable the cytological diagnosis was compared with follow-up cytology and/or the histology report.

Results: Cytology results were nondiagnostic in 24 (3.87%) nodules, benign in 553 (89,33%), atypia of undetermined significance or follicular lesion of undetermined significance,6 (1 %), follicular neoplasm or suspicious for a follicular neoplasm 14 (2.26 %), suspicious for malignancy,5 (0.8%), and malignant in 17 cases (2,7 % of the lesions).FNA showed a sensitivity of 84.62%, a specificity of 99.33 %, with prevalence of a malignant disease in 4.15 %.Ultrasonography proved to be very useful in our daily cytology practice in order to achieve representative samples. A representative specimen was obtained in 95% of patients examined by ultrasound. When ultrasound was not used, only 87 % of the patients presented a representative cell sample. Papillary thyroid cancer accounted for 65% of the cancers, followed by follicular neoplasm (25%), anaplastic carcinoma (5%), and metastatic renal cancer (5%).

Conclusion: Ultrasound is an important diagnostic modality for the evaluation of thyroid lesions, providing crucial information about the nature of the lesion. Its use in cytology practice increases the chance of obtaining an adequate cytological specimen, reaching a correct diagnosis, and avoiding unnecessary surgery. This study also demonstrates that the ultrasound can be handled by the cytologist him/herself, which has obvious practical advantages.


Colón E, Herder A (2016) Ultrasound-Guided Fine-needle Aspiration of the Thyroid in Cytology Practice. Ann Clin Cytol Pathol 2(6): 1040.


•    Ultrasound
•    Thyroid
•    Bethesda classification
•    Fine-needle aspiration (FNA)


Ultrasonography has been used in recent clinical studies to assess thyroid size, vascularization, and calcifications, which has led to higher estimates of goiter prevalence than those of studies in which goiter was assessed by physical examination alone. This method is highly accurate in determining whether a lump is malignant (cancerous) or benign [1-3,5].

FNAC is the gold standard in the examination of thyroid nodules. Latest studies imply a high sensitivity and specificity for predicting thyroid malignancies averaging 83% [6] and 92% respectively [7]. However; FNAC has limitations and a false-negative rate of approximately 5% [6] in one study and in others between 0-29% [8]. In contrast the false-positive rate for a cytology reading of suspicious of malignancy or malignancy has been reported before in other series with about 10% [9].

Real-time ultrasound allows for continuous visualization of the needle during insertion and sampling, thus minimizing the risk of false-negative results. Historically, ultrasound guided-FNA (US-FNA) has been always performed by a radiologist in a designated radiology suite. With the development of smaller and more portable ultrasound machines, wireless, there has been a push for clinicians other than radiologists to perform this procedure [3-5].

During the last 6 years, US-FNA cytology has been performed at our institution in the Cytology Department in almost all patients with thyroid nodules. US-FNA of the thyroid can be done on an outpatient basis. It is a relatively painless and minimally invasive method that does not require local or general anesthesia. Recovery time is short, and a hospital stay is normally not required.

The objective of this retrospective study was to analyze the benefit of ultrasound of the thyroid in daily cytology practice, which allows for the simultaneous evaluation of clinical, macromorphological (ultrasound image), and micro-morphological (cytology) parameters to predict the risk of malignancy, as ultimately demonstrated in the histological specimens [1-5].

Early studies demonstrated the value of ultrasound, but correlation with histology was not always available [3,5]. This information is included in our study.


Data on patient cytology were retrieved by a retrospective search of all thyroid FNA cytology reports that were issued in the Department of Cytopathology at Söder Hospital, Karolinska Laboratory in Stockholm between January 2012 and June 2013. A total of 619 thyroid FNA cytology diagnoses were reclassified according to the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) [10].


FNA was performed with a 0,4mm, sometimes a 0,6mm, and occasionally a 0,7mm in diameter needle using the capillary method or vacuum-assisted method and usually guided by ultrasound [5]. The ultrasound guided FNAs were done and the smears were analyzed, by an experienced cytologist (Dr. A. Herder). When a surgery decision was taken a second opinion diagnosis was made by cytologists in another hospital (Karolinska Solna). In all cases, air-dried Giemsa-stained smears were evaluated, and sometimes the Papanicolaou staining was performed. The reclassified cytology results were subcategorized as unsatisfactory, benign, atypia of undetermined significance or follicular Lesion of undetermined significance, follicular neoplasm, suspicious for malignancy, or positive for malignancy (Table 1).


Most patients (95%) were evaluated by ultrasound previous to FNA, and the images were archived. The FNAs were subsequently guided by real time ultrasound - all in the same session. A small number of cases (5%) underwent FNA with palpation guidance alone.

The cytology doctor performed ultrasound with a linear multi frequency transducer of 14 MHz for morphological analysis (B-mode) and for power Doppler evaluation.

In some patients, the referred nodule was not obvious by palpation, and sampling for cytology was performed solely on the basis of the ultrasonographic image. Often, the cytological work-up included sampling from the other lobe and/or nodules other than the palpable one. Routinely, the thyroid was also ultrasonographically scanned and, if suspicious, sampled in the case of cystic, non-squamous (determined by quick-stain) metastases in the neck.

Solid or predominantly solid nodules with the following features were defined as “suspicious” by ultrasound: marked hypoechogenicity (compared with the adjacent strap muscle); calcifications (especially if irregular); hypoechogenicity combined with microlobulation, irregular margins, or a tallerthan-wide shape (greater in the anteroposterior dimension than in the transverse dimension); or predominantly or exclusively central vascularization. These definitions have been used in other institutions [3,5]. Clinical data were recorded and correlated with the cytological findings. The results of FNA cytology were compared to the corresponding histological diagnoses whenever surgery had been performed.

Malignancy evaluation according to ultrasound findings

The imaging characteristics of a mass (nodule type, site, margins, microcalcifications, macrocalcifications, echogenicity, size, vascularity) were identified at examination followed by FNA.

Criteria for malignancy according to cytology findings

The recommended diagnostic categories by TBSRTC, risk of malignancy and recommended clinical management are seen in Table (1).

Cytological criteria for papillary thyroid carcinoma were ultimately defined by nuclear cell characteristics as follows: A relatively large nuclear size, round to slightly oval nuclear shape, hypodense chromatin, intranuclear cytoplasmic inclusions (ground glass nuclei), nuclear overlapping, and nuclear grooves.

Comparison with histology Histological

outcomes were obtained from the pathology database.

Statistical analysis

Quantitative data were summarized and expressed as percent, whereas qualitative data were expressed with the number of cases. Groups included in the study were compared using the Pearson correlation test. Sensitivity and specificity were calculated. Significance was set at the value of less than 0.05 level.

Table 1: Risk of malignancy and recommended clinical management.

  TBSRTC: Recommended Diagnostic Categories Risk of Malignancy (%) Usual Management
Number Name of the Category    
I Non Diagnostic of Unsatisfactory 1-4 Repeat FNA with ultrasound guidance
Cystic fluid only    
Virtually acellular specimen    
Other (obscuring blood, collecting artifacts, etc)    
II Benign 0-3 Clinical follow-up
Consistent with a benign follicular nodule (includes adenomatoid nodule, colloid nodule, etc)    
Consistent with lymphocytic (Hashimoto) thyroiditis in the proper clinical content    
Consistent with granulomatous (subacute) thyroiditis    
III Atypia of undetermined significance or follicular lesion of undetermined significance 5-15 Repeat FNA
IV Follicular neoplasm or suspicious for follicular neoplasm 15-30 Surgical lobectomy
V Suspicious for Malignancy 60-75 Near total thyroidectomy or surgical lobectomy
Suspicious for papillary carcinoma    
Suspicious for medullary carcinoma    
Suspicious for metastatic carcinoma    
Suspicious for lymphoma    
VI Malignant 97-99 Near-total thyroidectomy
Papillary thyroid carcinoma    
Poorly differentiated carcinoma    
Medullary thyroid carcinoma    
Undifferentiated (anaplastic) carcinoma    
Squamous cell carcinoma    
Carcinoma with mixed features (specify)    
Metastatic carcinoma    
Non-Hodgkin’s lymphoma    



The most common thyroid disease in the community is simple physiological goiter but several studies show that the incidence of thyroid cancer is increasing widely [11-16]. This increase of malignancy cannot be satisfactorily explained as an artifact of changes in classification systems and likely reflects a real increase in incidence. Fine-needle aspiration (FNA) cytology has proven to be an important and widely accepted cost-effective, simple, and minimally invasive procedure for triaging patients with thyroid nodules. FNA cytology findings play a vital role in selecting patients for surgery.

Adequacy of cytology specimens

We obtained a diagnostic cell sample in practically all patients where the FNA was ultrasound-assisted. In the cases where sampling was done by physical examination alone the adequacy of the material was less, about 87.6%.

Complications during sampling are possible, like pain and hematoma but in the cases reviewed, no significant complications occurred. One explanation is the small size diameter needles used (0,4 mm, 0.6 mm, occasionally 0.7 mm). US-FNA also tends to ensure diagnostic cell material with fewer needle passes than the traditional palpation guided technique [17].

Cytology and classification according to the TBSRTC

The TBSRTC was used in all patients following Bethesda criteria (Table 1), and the results are presented in Tables (2) and (3). As in many other studies, the most common diagnosis was nodular goiter, followed by Hashimoto thyroiditis and hyperplasia classified as TBSRTC category II. Most of the patients were women with benign or malignant nodules, which is consistent with the results of other studies [18-20]. The diagnosis of TBSRTC category III in patients with an apparent mass was an important criterion for selecting patients for follow-up (Table 1,3). Five of the patients in the study were classified as Bethesda III, and were followed with a second cytological investigation, together with 109 other patients selected for follow up due to clinical considerations. Of these altogether 114 patients, 83 were diagnosed with nodular goiter in both the primary, and the secondary cytological investigation. 13 cases with Bethesda II (colloid goiter) were operated, and the histological diagnosis was also colloid goiter as showed in Table (3). Seven cases with Bethesda II (Lymphocytic thyroiditis) were followed, and 6 of these kept the same cytological diagnosis. In one case the follow up upgraded the diagnosis to a Bethesda IV and histology showed follicular neoplasm, Table (4).

One case with a follicular neoplasm (Bethesda IV) in the initial cytology showed papillary thyroid carcinoma in the second cytology, as well as in the subsequent histology (Table 4). The ultrasound showed Microcalcifications and rich vascularization, both, which are indicators of malignancy. The initial FNA was guided by palpation, but in the follow up ultrasound was used (Table 5).

The unexpectedly low rate of Bethesda III and IV cases in our study could be due to the use of ultrasound, which enhances cytology accuracy. The local tradition is also to do a repeat cytology if the first one is inadequate. An additional factor is perhaps the long experience of the examining cytologist (30 yrs). Finally the retrospective reclassification might have resulted in a skewed Bethesda grouping.

Correlation with histology

Histology is the best technique for final tumor classification; the relationship between cytology and histology results is presented in Tables (3,6). The patient age-span was 37 to 91 yrs, and 90% of the patients were women. In our study, the results of US-FNA cytology and histology in the malignant cases were correlated as seen in Table (6).

Three patients showed Bethesda V and 14 Bethesda VI.

These 17 cases were confirmed as malignant histologically (Table 6). The most common malignant lesion was papillary carcinoma, but anaplastic cancer and metastatic renal clear cell carcinoma was also found. There were no medullary carcinomas among the malignancies, which is however an uncommon tumor that accounts for 3-4% of all thyroid neoplasias. Both cytologically and histologically this neuroendocrine (calcitonin) neoplasm is a spindle and epitheloid cell tumour often containing amyloid, and in the cytological smears rather frequently displaying neuroendocrine granules. Except for a malignant lymphoma neither does this tumour series contain any small cell malignancies [21].

Correlation with ultrasound findings

Ultrasound findings are presented in Table (7). We found a good correlation between the tumour size as measured by ultrasound and the size in the histological specimen (Pearson correlation test with r=0,96).

Papillary thyroid carcinoma has a predilection for women as others have shown, and this is also the case in our study [18-20]. The diagnosis of thyroid cancer by US-FNA cytology correlated with suspicious ultrasound findings in 18 of 20 patients (90%). All lesions with Bethesda V and VI on FNA cytology were selected for surgery, and subsequently proved to be malignant.

In 55% of patients with malignancies, the tumor was located in the right side and had calcifications. Most tumors (70%) had irregular borders, and 50% were hypoechogenic, and 70% showed abnormal vascularization. Most (65%) of the malignant cases were diagnosed as papillary thyroid cancer.

Malignancy was associated with gender and sonographic features. The use of ultrasound evaluation of thyroid nodules increased the quality of the cytology specimen and provided important diagnostic information (Table 7), (Figure 1) [1-3]. Irregular borders, abnormal vascularization, and hypoechogenicity were the most common ultrasound features present in the patients with cancer.

The success of US-FNA in accurately detecting neoplastic changes in the thyroid on initial examination of patients with a palpable mass depends on several factors such as operator experience and tumor appearance. The standard sonographic features used to predict the malignant status of thyroid nodules include irregular calcifications, increased vascularisation, hypoechogenic areas, and irregular borders. Even when all features are present, the diagnostic accuracy of ultrasound alone is about 90%. Conversely, only 75% of malignant thyroid nodules will demonstrate at least three ultrasound features of malignancy. When most criteria for malignancy are fulfilled in the ultrasound evaluation, the added benefit of performing US-FNA is clear. All patients with TBSRTC category V-VI tumors in our study fulfilled most of the ultrasonographic criteria of malignancy (Table 6).

There are operator-dependent factors, such as the ability to visualize and categorize thyroid nodules based on sonographic features, selection of suspicious nodules for aspiration, and skill in achieving diagnostic material. The contribution of immediate, preliminary, cytological assessment (microscope and a quickstain in the room) in reducing the number of nondiagnostic cases is well established [5,17]. For a correct cytological diagnosis, in many cases, ultrasound guidence is mandatory.

Of great importance is, with the frequent use of ultrasound as described, that small, not palpable, and mostly papillary malignancies, other than the palpable lesion will be detected. In the present study this was the case in 2,74 % of the malignancies.

Training is needed to be able to perform an ultrasonographic examination, as well as the US-FNA, but this study, as others, shows that ultrasound is an invaluable tool in the daily cytology practice [5,17].

Table 2: The figure illustrates the age, gender and diagnoses according to Bethesda classification.

Diagnosis Number of Patients Age range, years Female Male
Nondiagnostic or unsatisfactory 24 42-75 20 4
Benign 553 13-87 482 71
Atypia of undetermined significance or follicular lesion 6 35-83 4 2
Follicular neoplasmn or suspicious 14 22-66 12 2
Suspicious for Malignancy 5 38-39 3 2
Malignant 17 36-87 16 1
Total 619 13-87 537 82

Table 3: Bethesda classification, cytology findings, follow up and final histology is showed in 27 cases with Bethesda II-IV in which surgery was performed as illustrated.

Cases Bethesda Cytology diagnosis Follow up Final histology
1 II Colloid goiter   Colloid goiter
2 II Colloid goiter Colloid goiter Colloid goiter
3 II Colloid goiter   Colloid goiter
4 II Colloid goiter Colloid goiter Colloid goiter
5 II Colloid goiter   Colloid goiter
6 II Colloid goiter   Colloid goiter
7 II Colloid goiter Colloid goiter Colloid goiter
8 II Colloid goiter   Follicular thyroid adenoma
9 II Colloid goiter   Oxyfilt thyroid adenoma and colloid goiter
10 II Colloid goiter   Colloid goiter
11 II Colloid goiter   Colloid goiter
12 II Lymphocytic thyroiditis Lymphocytic thyroiditis Lymphocitic thyroiditis
13 III Suspect adenoma   Lymphocitic thyroiditis
14 IV Follicular neoplasm (oncocytic type) Hurtlel cell adenoma Hurtlel cell adenoma
15 IV Follicular neoplasm (oncocytic type) Goiter (hyperplastic process) Hurtlel cell adenoma
16 IV Follicular neoplasm (oncocytic type)   Lymphocitic thyroiditis
17 IV Follicular thyroiditis and lymphome   Oxyfilt thyroid adenoma, colloid goiter and Lymphoma
18 IV Follicular neoplasm (oncocytic type)   Colloid goiter and Oxyfilt metaplasia
19 IV Follicular neoplasm (oncocytic type) Hurtlel cell adenoma Hurtlel cell adenoma
20 IV Follicular neoplasm (oncocytic type)   Hurtlel cell adenoma
21 IV Follicular neoplasm (oncocytic type)   Hurtlel cell adenoma
22 IV Follicular neoplasm (oncocytic type) Follicular neoplasia Follicular thyroid adenoma
23 IV Follicular neoplasm (oncocytic type)   Hurtlel cell adenoma
24 IV Follicular neoplasm (oncocytic type)   Follicular type with colloid goiter
25 IV Follicular neoplasm (oncocytic type) Follicular neoplasia Follicular adenoma
26 IV Follicular neoplasm (oncocytic type)   Hurtlel cell adenoma
27 IV Follicular neoplasm (oncocytic type)   Hurtlel cell adenoma

Table 4.The table illustrated cases with initial cytology and follow up and the cases that were upgraded.

Initial Cytology/Follow Up Diagnosis N
Initial cytology Colloid goiter 13
Follow Up Colloid goiter 13
Initial cytology Lymphocityc thyroidit 7
Follow Up Lymphocityc thyroidit 6
  Follicular neoplasm 1
Initial cytology Follicular neoplasm 1
Follow Up and histology Follicular neoplasm 1

Table 5: Ultrasound Findings.

Cases Ultrasound Findings FNA Clinical Follow Up
1 Microcalcifications, hipoechogenic Suspect follicular neoplasm Lymphocytthyroiditic
2 Microcalcifications, hypoechogenic, abnormal vascularization Suspect follicular neoplasm Papillar thyroid cancer and follicular cancer

Table 6: Cytology and histology findings of patients with malignant thyroid nodules, W: woman; M: male.

Case Age, years Sex Cytology Histology Metastasis Size ultrasound (mm) Size histology (mm)
1 37 W Papillar thyroid cancer Papillar thyroid cancer 0 of 10 10 8
2 83 W Papillar thyroid cancer Multifocal Hurtlel cell cancer 3 of 6 10 9
3 47 W Papillar thyroid cancer Papillar thyroid cancer 11 of 14 20 14
4 91 W Anaplastic thyroid carcinoma Papillar thyroid cancer - 40 x 50 43 x 26
5 39 W Suspect thyroid cancer Papillar thyroid cancer 14 of 15 - 19 x 10
6 53 W Suspect thyroid cancer Papillar thyroid cancer 0 of 1 15 22
7 67 W Metastasis renal carcinoma No surgery was performed - - -
8 45 W Papillar thyroid cancer Papillar thyroid cancer 1 of 7 6 6
9 66 W Follicular neoplasia with oncocytic metaplasia Follicular cancer 0 of 1 - 46
10 42 W Papillar thyroid cancer Multifocal thyroid cancer 11 of 14 20 18
11 59 W Papillar thyroid cancer Micropapillar thyroid cancer 4 of 30 40 44
12 38 W Suspect thyroid cancer Papillar thyroid cancer and follicular cancer - - -
13 38 W Papillar thyroid cancer Papillar thyroid cancer - 15 15
14 55 W Papillar thyroid cancer Micropapillar thyroid cancer 0 of 13 10 8
15 46 W Papillar thyroid cancer Micropapillar thyroid cancer 0 of 16 9 10
16 46 W Papillar thyroid cancer Papillar thyroid cancer 7 of 33 5 5 and 2
17 39 W Papillar thyroid cancer Papillar thyroid cancer 9 of 22 19 and 8 16 and 8

Table 7: Ultrasound findings in the 17 patients with malignant thyroid nodules. The table illustrates the localization of the nodule.

  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Site R R R L R R R L L R R L I R L R I
Margins R I I I R R I I I I R R I I I I I
Microcalcifications Y Y Y N N Y Y N N N N Y Y Y N Y Y
Irregular calcifications N Y Y N Y N N N N Y N N Y N Y Y N
Hypoechogenic Y Y N Y N Y N Y N Y Y Y N Y Y Y Y
Size (mm) 10 10 20 40X50 - 15 X 6 - 20 40 1 15 10 9 5 19
Abnormal vascularity Y N N Y Y Y Y Y Y N N N Y N Y Y Y
Abbreviations: R: Right, L: left; Margins: R: regulars, I: Irregulars; Microcalcifications; Hypoechogenic; Vascularity: Yes (Y): Present, Not (N): Not Present.



Ultrasound and fine needle aspiration cytology are important diagnostic modalities for the evaluation of thyroid lesions. These techniques can be used one by one, or together, enabling real time ultrasound needle guidance, thereby reducing the number of false negative results.

This study shows that both techniques, after some training, can be handled by the cytologist her/himself and thus minimizing the time lap between the primary medical examination, and the final diagnosis. In addition this approach reduces the number of patient health-care visits.

Compared to physical examination/palpation alone, ultrasound provides the cytologist with crucial diagnostic information, creating the basis for an optimal and precise diagnostic work. In the cytology suite, addition of ultrasound, and ultrasound guided FNAC, enables detection of malignancies other than the palpable nodule.


To Dr Peter Zickert for the support during the project.


1. Choi YJ, Baek JH, Ha EJ, Lim HK, Lee JH, Kim JK, et al. Differences in risk of malignancy and management recommendations in subcategories of thyroid nodules with atypia of undetermined significance or follicular lesion of undetermined significance: the role of ultrasound-guided core-needle biopsy. Thyroid. 2014; 24: 494-501.

2. Chen AY, Bernet VJ, Carty SE, Davies TF, Ganly I, Inabnet WB 3rd, et al. American Thyroid Association statement on optimal surgical management of goiter. Thyroid. 2014; 24: 181-189.

3. Kihara M, Ito Y, Hirokawa M, Masuoka H, Yabuta T, Tomoda C, et al. Role of ultrasonography in patients with cytologically follicular thyroid tumor. Auris Nasus Larynx. 2011; 38: 508-511.

4. Vaccarella S, Dal MassoL, Laversanne M, Bray F, Plummer M, Franceschi S. The Impact of Diagnostic Changes on the Rise in Thyroid Cancer Incidence: A Population-Based Study in Selected High-Resource Countries. Thyroid. 2015; 25: 1127-1136.

5. Andrioli M, Carzaniga C, Persani L. Standardized Ultrasound Report for Thyroid Nodules: The Endocrinologist’s Viewpoint. Eur Thyroid J. 2013; 2: 37-48.

6. Cobin RH, Gharib H, Bergman DA, Clark OH, Cooper DS, Daniels GH, et al. AACE/AAES medical/surgical guidelines for clinical practice: management of thyroid carcinoma. American Association of Clinical Endocrinologists. American College of Endocrinology. Endocr Pract. 2001; 7: 202-220.

7. Gharib H. Fine-needle aspiration biopsy of thyroid nodules: advantages, limitations, and effect. Mayo Clin Proc. 1994; 69: 44-49.

8. Morgan JL, Serpell JW, Cheng MS. Fine-needle aspiration cytology of thyroid nodules: how useful is it? ANZ J Surg. 2003; 73: 480-483.

9. Yoon JH, Kwak JY, Moon HJ, Kim MJ, Kim EK. The diagnostic accuracy of ultrasound-guided fine-needle aspiration biopsy and the sonographic differences between benign and malignant thyroid nodules 3 cm or larger.Thyroid. 2011; 21: 993-1000.

10. Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference. The Bethesda System For Reporting Thyroid Cytopathology. Am J Clin Pathol. 2009; 132: 658-665.

11. Okoye JO, Okoye FO. Fine Needle Aspirate; a vital technique in the characterization of Masses and Lesions. Ann Clin Cytol Pathol. 2015; 1: 1-7.

12. Pettersson B, Adami HO, Wilander E, Coleman MP. Trends in thyroid cancer incidence in Sweden, 1958-1981, by histopathologic type. Int J Cancer. 1991; 48: 28-33.

13. Dubey AK, Gupta U, Jain S. Breast cancer statistics and prediction methodology: a systematic review and analysis. Asian Pac J Cancer Prev. 2015; 16: 4237-4245.

14. National Cancer Institute, SEER Stat Fact Sheets: Thyroid Cancer USA. 2013.

15. Davies L, Welch HG. Current thyroid cancer trends in the United States. JAMA Otolaryngol Head Neck Surg. 2014; 140: 317-322.

16. Chen AY, Jemal A, Ward EM. Increasing incidence of differentiated thyroid cancer in the United States, 1988-2005. Cancer. 2009; 115: 3801-3807.

17. Krishnappa P, Ramakrishnappa S, Kulkarni MH. Comparison of Free Hand versus Ultrasound-Guided Fine Needle Aspiration of Thyroid with Histopathological correlation. J Environ Pathol Toxicol Oncol. 2013; 32: 149-155.

18. La Vecchia C, Malvezzi M, Bosetti C, Garavello W, Bertuccio P, Levi F, et al. Thyroid cancer mortality and incidence: a global overview. Int J Cancer. 2015; 136: 2187-2195.

19. Rinaldi S, Plummer M, Biessy C, Tsilidis KK, Østergaard JN, Overvad K, et al. Thyroid-stimulating hormone, thyroglobulin, and thyroid hormones and risk of differentiated thyroid carcinoma: the EPIC study. J Natl Cancer Inst. 2014; 106: dju097.

20. Negri E, Dal Maso L, Ron E, La Vecchia C, Mark SD, Preston-Martin S, et al. A pooled analysis of case-control studies of thyroid cancer. II. Menstrual and reproductive factors. Cancer Causes Control. 1999; 10: 143-155.

21. Mehdi G, Maheshwari V, Ansari HA, Sadaf L, Khan MA. FNAC diagnosis of medullary carcinoma thyroid: A report of three cases with review of literature. J Cytol. 2010; 27: 66-68.

Received : 02 Sep 2016
Accepted : 07 Oct 2016
Published : 11 Oct 2016
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ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
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