The diagnostic value of argyrophil staining of nucleolar organizer regions (AgNOR) was studied in 95 nonneoplastic and neoplastic follicular lesions of the thyroid. Different AgNOR parameters such as number, size, and distribution pattern were determined using digital image analysis. In addition, nuclear and nucleolar size as well as the percentage of nucleoli touching the nuclear membrane (nucleolar margination) were assessed. A stepwise increase in nuclear size and AgNOR counts from normal thyroid tissue to follicular adenoma as well as from differentiated follicular to anaplastic carcinoma was found (mean nuclear area [micron2]/mean AgNOR number per cell: 21.5/1.6 vs. 34.4/3.5 and 45.3/5.0 vs. 66.5/10.8, p < 0.01/p < 0.001). There was, however, no clear separation between these diagnostic groups. In contrast, an almost total discrimination between follicular adenoma and carcinoma was achieved by quantification of AgNORs per tumor cell nucleolus (AgNOR distribution score). In benign adenomas, 3.3% (range, 0-8.8%) of the cells showed nucleoli with at least five AgNOR dots within one focal plane, whereas in follicular carcinomas, the corresponding value was 34.1% (range, 12-75%). Two of four cases of so-called atypical adenomas showed values in the range of benign adenomas, and two were in the range of follicular carcinomas. In comparison with other nuclear and nucleolar parameters, the AgNOR distribution score proved the most valuable diagnostic criterion for the cytomorphological differentiation between follicular adenoma and carcinoma of the thyroid.