Thyroid nodules with microfollicular findings reported on fine-needle aspiration: invariably surgical treatment?

OBJECTIVE: To assess whether fine-needle aspiration (FNA) can be a diagnostic procedure for identification of malignant thyroid nodules when the smear reveals the cytologic (microfollicular) finding of "follicular neoplasm" (FN).
METHODS: We reviewed a group of 79 patients with FN who underwent surgical treatment and evaluated the possible significance of the cytologic features of anisokaryosis, amount of colloid, and nuclear overlapping (NO). We excluded from the study those patients with FN who had other highly suspicious cytologic features, such as sporadic grooves and sporadic pseudonucleoli.
RESULTS: In our series of 79 patients with FN at FNA, we found anisokaryosis in 49.4%, scant or no colloid in 31.6%, and NO in 5.1%. Thyroid cancer (TC)--follicular cancer or follicular variant of papillary cancer--was found in six patients (7.6%): four patients (10.2%) with anisokaryosis and two patients (5.0%) without anisokaryosis (P<0.5; chi2 test). All the patients with malignant lesions had scant or no colloid in the smears, and four of them were those with NO. Therefore, TC was found in 24.0% of nodules with scant or no colloid versus 0.0% of nodules with abundant colloid (P<0.001; chi2 test), and TC was found in 100% of nodules with NO versus 2.6% of nodules without NO (P<0.001; chi2 test).
CONCLUSION: Because of the high prevalence of thyroid nodules and the frequency of FN at FNA, the number of unnecessary interventions may be very high. FNA cannot be diagnostic in FN because invasion of the tumor capsule and blood vessels can be evidenced only at histologic examination. Although it is common opinion that microfollicular nodules should be surgically treated, simple cytologic features can help select patients at low risk who can be monitored and reassessed clinically and by FNA. Patients with high-risk cytologic features such as NO should be advised that a total thyroidectomy may be necessary.