Patterns and Outcomes of Nodular Thyroid Disease in Benghazi, Libya

Abstract

Background

Most studies on thyroid nodules in Libya have been conducted on histopathological samples. This study was conducted on patients attending endocrine clinics in Benghazi, Libya.

Objectives

This article aims to describe the clinical, radiological, biochemical, and pathological aspects and outcome of nodular thyroid disease in Benghazi, Libya.

Materials and Methods

A total of 227 patients with nodular thyroid disease who attended the endocrine clinics of Benghazi Medical Center and 7th October Hospital during the year 2023 were included in the study. Records were reviewed regarding age, sex, clinical presentation, history of previous head and neck radiotherapy, number and size of nodules, presence and site of lymphadenopathy, thyroid ultrasound features, thyroid-stimulating hormone (TSH), fine-needle aspiration cytology (FNAC) results, outcome (surgery and its type or follow-up), results of histopathology, and final diagnosis.

Results

Most of the studied group was females, 213 (93.8%). The mean age ± standard deviation (SD) was 52.3 ± 13.5 years. Multinodular goiter represented the highest percentage and accounted for 142 (62.6%). Mean nodule size ± SD was 2.4 ± 1.5 cm, and the median TSH level was 1.7 mIu/L. Regarding FNAC, most of the cases (110, 44.1%) were benign/colloid goiter, follicular neoplasm, or malignant (19, 8.3%). Among the 54 patients who had a histopathological diagnosis, 26 (48.1%) were proven to have thyroid carcinoma, and most of them had papillary carcinoma (24/26, 92.3%). Among 28 benign cases, 13 (24.5%) had Hashimoto's thyroiditis.

Conclusion

Nodular thyroid disease was more common in females; most cases had multiple nodules. FNAC was benign colloid in more than half of the cases, and malignancy or suspicious for malignancy was found in 10% of the cases. Half of the cases with histopathological diagnosis had thyroid carcinoma, and most of them were papillary thyroid carcinoma.

 

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Keywords

nodules - thyroid - nodular - TIRADS - fine-needle aspiration cytology - Benghazi - Libya

Introduction

Prevalence of thyroid nodules reaches up to 35% with the use of imaging. A thyroid nodule ranges from colloid cysts to malignant tissue. The majority of thyroid nodules derive from thyroid follicular cells. Benign follicular nodules, either solitary or as part of a multinodular goiter, are the most common lesions.[1] [2] [3] [4] Thyroid cancer occurs in 7 to 15% of thyroid nodules. Papillary and follicular (including Hürthle) thyroid cancer represent approximately 85 and 12% of thyroid cancers, respectively. Overall, thyroid cancer carries an excellent prognosis with a 5-year overall survival rate of 96.1%, and 98.2% for those patients who have survived 1 year after diagnosis.[5] This good prognosis is mainly for papillary thyroid carcinoma, with less favorable 5-year survival rates for follicular thyroid carcinoma and other thyroid cancers.[1] [2] [3] The main challenge in managing nodular thyroid disease is to identify malignant nodules while avoiding inappropriate excess use of thyroid sonography, fine-needle aspiration (FNA), and surgery.[6] [7] [8] [9] [10] [11] [12] Thyroid ultrasonography (US) is safe, simple, and painless that documents echogenicity of the nodule, composition (solid, cystic, mixed), shape, and margins, and also the presence of microcalcifications in cervical lymph nodes.[13] [14] Hypoechogenicity; infiltrative, irregular, or lobulated margins; intranodular microcalcifications; and a taller-than-wide shape and suspicious cervical lymph nodes suggest malignancy.[13] [14] [15] [16] Risk stratification scores include US scan-based risk score (Thyroid Imaging Reporting and Data System [TIRADS]) and the American Thyroid Association risk score.[17] [18]

Fine-needle aspiration cytology (FNAC) is the next step in the evaluation of suspicious nodules. It employs one of the recognized cytological classification systems. These include the Bethesda System[19] or the Thy classification system adopted by the Royal College of Pathologists of the United Kingdom.[20] However, FNAC can give false-positive, false-negative, nondiagnostic, or indeterminate results.[19] Cytology has limitations: it cannot distinguish between follicular hyperplastic or adenomatoid nodules, follicular adenomas, follicular carcinoma, and some cases of follicular variants of papillary thyroid carcinoma.[19]

Benign thyroid nodules requiring treatment are rare. For cytologically indeterminate nodules, lobectomy with isthmusectomy is generally the procedure of choice. However, thyroidectomy may be indicated in patients with larger indeterminate nodules (≥ 3–4 cm). In patients with 1- to 4-cm suspicious nodules, lobectomy or total thyroidectomy is both acceptable, whereas patients with large suspicious nodules, suspected extrathyroidal extension, or suspected metastases should undergo total thyroidectomy.

Regional variations in pathology and practices are worth studying. For instance, a 10-year retrospective survey of 618 thyroidectomy specimens shows that in the west of Libya simple goiter is the most common cause of thyroid enlargement. The incidence of thyrotoxicosis seems to be increasing and the proportion of malignant goiters is higher than is usually reported from other general hospitals.[21] Also, surveys of physicians revealed variations in their approach to various nodules.[22] Knowledge of the local patterns of pathology and management approaches gives insights into and a step toward quality improvement. The present study aimed to describe the clinical, radiological, biochemical, and pathological aspects and outcomes of nodular thyroid disease in Benghazi, Libya.

 

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Materials and Methods

Study Design and Settings

A retrospective cross-sectional study was conducted at the endocrine clinics of Benghazi Medical Center and 7th October Hospital, Benghazi, Libya, between January and June 2023.

 

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Study Population

A sample of 227 patients with nodular thyroid disease was included in the study. Charts with complete data were only included in the study. Records were reviewed regarding age, sex, clinical presentation, history of previous head and neck radiotherapy, number and size of nodules, presence and site of lymphadenopathy, ultrasound features, thyroid-stimulating hormone (TSH), FNAC results, outcome (surgery and its type or follow-up), results of histopathology and final diagnosis, and follow-up ultrasound results.

 

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Statistical Analysis

SPSS Statistical software version 24 and frequencies, means, standard deviations (SDs), and medians were calculated. The chi-square test was used to compare categorical variables, and the Fisher's exact test was used when the sample size was small and a cutoff level of significance was set at < 0.05. A logistic regression analysis was performed to determine predictors of a malignant nodule.

 

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Results

Demographic Characteristics

Among 227 cases with nodular thyroid, most of the studied group was females, 213 (93.8%). Mean age ± SD was 52.3 ± 13.5 years. The median nodule number was one. Single nodules accounted for 85 (37.4%), multinodular goiter represented the highest percentage and accounted for 142 (62.6%). There were 49 (21.6%) with a family history of nodular thyroid disease. Mean nodule size ± SD was 2.4 ± 1.5 cm, and the median TSH level was 1.7 mIu/L, range 0.01 to 77 mIu/L ([Table 1]).

Table 1 General characteristics of patients with nodular thyroid disease

Characteristics	Results
Age (mean ± SD)	52.3 ± 13.5 years
Sex [N (%)]
Male	14 (6.2)
Female	213 (93.8)
Nodule number [N (%)]
Solitary	85 (37.4)
Multinodular	142 (62.6)
Family history of thyroid disease [N (%)]
Yes	49 (21.6)
No	178 (78.4)
Nodule size (mean ± SD)	2.4 ± 1.5 cm
Serum TSH [median (number)]	1.7 (0.01–77) mIU/L

Abbreviations: SD, standard deviation; TSH, thyroid-stimulating hormone.

 

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Clinical Presentations

Most of the studied group presented with palpable goiter, which accounted for 161 (70.9%), 133 (58.6%) had no symptoms of thyroid hormone dysfunction, and 37 (16.3%) presented with compression symptoms ([Fig. 1]).

Fig. 1 Clinical presentation of the patients.

 

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Sonographic Characteristics of Nodules

Among the studied group, 35 (15.4%) solid, 92 (40.5%) cystic, 32 (14.1%) mixed solid and cystic were found; microcalcification accounted for 56 (24.7%) cases, hypoechoic 49 (21.6%), isoechoic 41 (18.1%), hyperechoic 12 (5.3%), and heterogeneous 10 (4.4%); and 39 (17.2%) had regular margins, 6 (2.6%) had irregular margins, nodule tall more than wide found in 3 (1.3%), and suspicious lymphadenopathy was found among 37 (16.3%) patients.

 

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FNA Cytology

In most cases, 110 (44.1%) FNA cytology results were benign/colloid goiter, follicular neoplasm, or malignant 19 (8.3%), suspicious for cancer 4 (1.8%), 21 (9.3%) were Hashimoto's thyroiditis, and among 82 (36.1%), FNA cytology was not indicated ([Fig. 2]).

Fig. 2 Fine-needle aspiration cytology results.

 

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Postsurgical Histopathology

Fifty-four patients had surgery on either lobectomy or thyroidectomy; histopathology results confirmed that 26 (48.1%) had thyroid carcinoma and 28 (51.9%) were benign. Most of the malignant nodules were papillary carcinoma, 24/26 (92.3%), and follicular carcinoma accounted for 2/26 (7.7%). Among 28 benign cases, 12 (22.6%) were colloid, 13 (24.5%) were Hashimoto's thyroiditis, 1.9% were Hürthle cell hyperplasia, and 3 (5.7%) were adenoma ([Table 2]).

Table 2 Postsurgical histopathological findings among 54 patients

	Number (%)
Malignant
Total number	26 (48.1)
Papillary	24 (92.3)
Follicular	2 (7.7)
Benign
Total number	28 (51.9)
Colloid nodules	12 (22.6)
Hashimoto's thyroiditis	13 (24.5)
Hürthle cell hyperplasia	1 (1.9)
Adenoma	3 (5.7)

 

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Comparison between Benign and Malignant Disease

Among 54 patients with a histopathological diagnosis, 26 (48.1%) proved to have thyroid carcinoma, and 28 (51.9%) were benign. All 7 males (100%) with a histopathological result had thyroid carcinoma and 19/47 (40.4%) of females had thyroid carcinoma, and this was statistically significant (p < 0.001). Most of the cases with thyroid malignancy, 19/26 (73.1%), were in the age group of 20 to 55 years and 7/26 (26.9%) in the age group above 55 years, while benign pathology, 20/28 (71.4%), in the age group of 20 to 55 years and 10/28 (35.6%) in the age group of > 55 years with no statistical significance. Regarding TIRADS scores 4 and 5, they were higher among malignant histopathology, 6/10 (60%) and 7/7 (100%), respectively. In contrast, scores 2 and 3 were higher among benign nodules, 9/15 (60%) and 4/15 (26.7%), respectively, and 6/15 (40%) of score 3 had malignancy, while 17 had no data; the difference was statistically significant (p = 0.024). Regarding FNAC results, 14/14 (100%) of malignant results proved to be malignant by histopathology, most of the suspicious FNAC proved to be malignant histopathology, 8/11 (72.7%), while most benign FNAC results proved to be benign by histopathology, 22/26 (84.6%), but still 4 (15.3%) had malignant histopathology and this was statistically significant (p < 0.0001) ([Table 3]).

Table 3 Comparison between benign and malignant nodules among 54 patients with histopathological diagnosis

	Benign	Malignant	p-Value
Number	28	26
Sex
Male	0	7 (100%)	0.003
Female	19	19 (40.4%)
Age group
< 55 years	20 (71.4%)	19 (73.1%)	0.3
> 55 years	10 (35.6%)	7 (26.9%)
TIRADS score	15 (53.6%)	19 (73.1%)
TIRADS 2	9 (60%)	0 (0%)	0.024
TIRADS 3	4 (26.7%)	6 (40%)
TIRADS 4	0 (0%)	6 (60%)
TIRADS 5	0 (0%)	7 (100%)
No data	13 (46.4%)	7 (26.9%)
FNAC results
Benign (26)	22 (84.4%)	4 (15.3%)	< 0.0001
Suspicious (11)	3 (27.3%)	8 (72.7%)
Malignant (14)	0 (0%)	14 (100%)

Abbreviations: FNAC, fine-needle aspiration cytology; TIRADS, Thyroid Imaging Reporting and Data System.

 

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Predictors of Malignant Nodules

By a nominal regression analysis, male sex, TIRAD score, and malignant FNAC were independent risk factors for malignant nodules. Further, by a logistic regression analysis, TIRADS scores 3, 4, and 5 were risk predictors for malignancy with odds ratio (OR) of 1.1, 2.5, and 11.7, respectively. Also, malignant FNAC was a predictor of malignancy with an OR of 2.6.

 

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Discussion

Thyroid nodules are commonly encountered in clinical practice, and their evaluation was highly subjective and dependent on the experience of the evaluating radiologist and pathologist, making it difficult for the physician to make the correct decision without risking missing a malignancy at the expense of unnecessary intervention and follow-up.

The mean age in this study was comparable to previous studies in Benghazi and elsewhere, where patients were typically in their fourth to fifth decades.[23] [24] [25] [26] More than 90% of cases were females, and nodular thyroid disease was more common in female sex in many studies.[9] [10] Mean nodule size was 2.4 ± 1.5 cm, which was similar to a study by Elbalka et al.[22] Most of the nodules were multinodular, which was the same as Elbalka et al and Al-Hakami et al studies, where 63.8 and 57.4% had multiple nodules, respectively.[24] [25] The explanation of that might be explained by iodine deficiency as well as an underlying Hashimoto's disease.

In this study, only 21.6% had a positive family history of thyroid nodules. Thyroid nodules run in families, especially when there was a state of iodine deficiency; iodine status in Libya was considered insufficient. Most cases were euthyroid and the common presenting feature was a palpable goiter. In Al-Hakami et al study, euthyroidism was found in most patients (93.9%). Regarding median TSH, similar results were reported by other studies.[25] [26]

Ultrasound neck was one of the most sensitive tools to evaluate thyroid nodules. Many suspicious features on an ultrasound scan correlated well with the risk of malignancy. In the present study, in more than half of the cases, there was no good description of the nodules, which might lead to an unnecessary FNAC. The shape of the nodule was mentioned only in three patients, and it was suspicious, with no comment on vascularity. In Benghazi city, an ultrasound scan of the neck was performed by radiologists only and FNAC by pathologists.

Regarding FNAC, malignant results were found in 8.3%. This was lower than the Elbalka et al study, where FNAC was benign in 45.8% of patients and the remaining were malignant.

Among 54 cases that were operated on, nearly half of the cases had thyroid carcinoma, of which the papillary type was the most common. This was higher than the Elbalka et al study, where thyroid carcinoma was found among 33.8% of cases, and higher than a study done in Benghazi by Amer et al, where 24.6% had papillary thyroid carcinoma. Among benign pathologies, Hashimoto's thyroiditis and colloid goiter were the most common types, according to Amer et al's study.[23]

All males in the histopathological results had thyroid carcinoma, and this was significantly higher than in females; male sex was significantly associated with malignancy in this cohort. No significant difference regarding the age range of 20 to 55 years or > 55 years. All TIRADS 5 and most of TIRADS 3 had thyroid carcinoma, and it was statistically significant. This was similar to other studies.[20] [23] All malignant FNAC and most suspicious FNAC and 15.3% of benign cytology had malignant histopathology results, and this was statistically significant. Similar results were found in the Elbalka et al study. This determined the weakness in the scoring systems used to evaluate thyroid nodules, as neck ultrasound was highly dependent on the experience of the operator. FNAC was benign among four patients who had malignancy. This was probably related to poor technique of FNA, as it might not have been taken under an ultrasound guide, and the aspirate was from the thyroid tissue rather than from the suspicious nodule.

The TIRADS score and FNAC were independent predictors of malignancy, as mentioned in the literature. Interestingly, TIRADS score 3 was an independent predictor of malignancy in the present study.

The study is limited by its retrospective design; therefore, much data was missing from files, which affected sampling, as many files were excluded from the study due to insufficient data. Being a single-center study limits its generalizability.

 

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Conclusion

The study revealed that nodular thyroid disease was more common in females, most cases had multiple nodules, and most of them presented with goiter and were euthyroid. Suspicious ultrasound features were determined in less than half of the cases. FNAC was benign colloid in more than half of the cases, and malignancy or suspicious for malignancy was found in 10% of the cases. Half of the cases with histopathological diagnosis had thyroid carcinoma, and most of them were papillary thyroid carcinoma. Male sex, TIRADS score, and FNAC were predictors for malignancy.

Further studies in the present and similar settings need improved techniques and reporting standards of thyroid ultrasound. Endocrinologists need more in-depth training in performing and interpreting thyroid ultrasound and FNAC categories and their implications. All FNACs must only be performed under ultrasound guidance to verify suspicious sites and to take samples correctly.

 

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Conflict of Interest

None declared.

Authors' Contributions

T.A.M.: Data collection, statistics, and writing. N.O.B.: Research question and writing. S.A.L.: Writing and statistics. M.G.T.: Revision. A.M.A.: Revision. All authors approved the final version of the manuscript and take collective responsibility for its contents.

Compliance with Ethical Principles

The ethical research board at Benghazi Medical Center, Benghazi, Libya approved the study.

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Publication History

Article published online:
22 September 2025