|Year : 2014 | Volume
| Issue : 2 | Page : 70-72
Multinodular goitre turning into follicular carcinoma thyroid after a latency of seven years
Mani Charan Satapathy, Dharitri Dash, Charan Panda, Ambuja Satapathy
Department of General Surgery, M.K.C.G. Medical College, Brahmapur, Odisha, India
|Date of Web Publication||31-Mar-2014|
Mani Charan Satapathy
Department of General Surgery, M.K.C.G. Medical College, Brahmapur, Odisha - 760 004
Source of Support: None, Conflict of Interest: None
Follicular carcinoma thyroid (FTC) is the second most common category after papillary variety with relative incidence estimated from 10-20%. Follicular thyroid carcinoma (FTC) rarely develops in a preexisting multinodular goiter (MNG) and tends to metastasize to lungs and bone through the blood-stream. The latency period for conversion varies significantly. We herein report a 48-year-old female presented with thyroid swelling since seven years with recent onset of multiple painful swellings over sternum and skull confirmed as a case of FTC on core needle biopsy. Considering her low socioeconomic status and advanced stage of the disease, she was treated with external beam radiotherapy (EBRT) and showing good response to EBRT at 6 months follow-up without any new bone secondaries thereafter.
Keywords: External beam radiotherapy, follicular carcinoma thyroid, multinodular goitre, thyroid
|How to cite this article:|
Satapathy MC, Dash D, Panda C, Satapathy A. Multinodular goitre turning into follicular carcinoma thyroid after a latency of seven years. Thyroid Res Pract 2014;11:70-2
|How to cite this URL:|
Satapathy MC, Dash D, Panda C, Satapathy A. Multinodular goitre turning into follicular carcinoma thyroid after a latency of seven years. Thyroid Res Pract [serial online] 2014 [cited 2019 Dec 12];11:70-2. Available from: http://www.thetrp.net/text.asp?2014/11/2/70/129732
| Introduction|| |
FTC occurs more commonly in women of over 50 years old. FTC can arise either de novo or in a pre-existing multinodular goitre (MNG). Thyroglobulin can be used as a tumor marker for well-differentiated FTC. Core needle biopsy now a days remains the investigation of choice taking advantage over fine needle aspiration cytology as the later cannot distinguish between follicular adenoma and carcinoma. Capsular invasion and vascular invasion by tumor cells are sine qua non features to establish histopathological diagnosis of follicular carcinoma.  Treatment is usually surgical, followed by radioiodine or radiotherapy (EBRT). But, her low socioeconomic status and advanced stage of the disease, prompted us to go for EBRT rather than radioiodine therapy as the 10-year survival rate is better with EBRT and less occurrence of local recurrences. 
| Case Report|| |
A 48-year-old female presented to surgical OPD of M.K.C.G. Medical College and Hospital, Brahmapur, Odisha with primary complaints of swelling in the neck since seven years, followed by recent onset of rapidly progressive swellings over sternum, right forehead, left parietal skull in last 2 months. She is a resident of goitre endemic belt of southern Odisha (Mohana of Gajapati dist.). Thyroid swelling [Figure 1] was of size 10 × 8 cm, non-tender, hard in consistency with irregular margin, nodular surface, fixed to underlying structures with lower border just palpable. Movement of swelling was restricted in all directions. Examination revealed no cervical lymphadenopathy and no toxic eye signs. Kocher's test was negative. Bilateral carotid pulsations were felt. There was no dysphagia or dyspnoea. Swelling over fronto-parietal region of scalp and sternum were of variable sizes ranging from 3 to 5 cm, tender, warm to touch, pulsatile in nature with bony erosion [Figure 2]. She was not taking any antithyroid drugs for the last seven years. Hematological investigations were within normal limits. Core needle biopsy of thyroid swelling gave impression of follicular carcinoma. The X-ray of skull showed multiple lytic lessions over frontal and parietal region. Ultrasonogram of abdomen was normal. Considering the low socioeconomic status and advanced stage IVC,  patient was referred to radiotherapy unit for EBRT. On follow-up, she is doing well.
| Discussion|| |
Incidence of FTC in MNG has been reported in several series as 5-10%. Lymphatic spread in FTC is nearly 10%. Hematogenous spreading to bone, lungs, liver are common metastases. Thyroid carcinoma metastasises to the skeleton was found in 33% of cases (Eddleston, 1980).  These metastases are, almost without exception, osteolytic in nature.  Bone secondaries are common in flat bones (owing to only red marrows in adult) like skull, sternum, rib, scapula. Skull is very commonly affected specifically fronto-parietal region. The scant literature on the latency period of conversion of MNG into FTC prompted us to report this case.
For papillary and follicular carcinomas, the stage grouping for patients older than 45 yrs has been revised. Stage III includes tumors with minimal extrathyroid extension. Stage IVA includes tumors of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve. Stage IVB includes tumors that invade prevertebral fascia, carotid artery, or mediastinal vessels. Stage IVC includes advanced tumors with distant metastasis. (IVC: Any T Any N M1).
The incidence of FTC is high in endemic goitrous areas, possibly as a result of TSH stimulation. The first case of thyroid follicular carcinoma in the exposed Belarussian children was diagnosed after a latent period of 6.5 years, as compared with 4 years of minimal latency for post-Chernobyl papillary carcinomas.  We found the latency period as 7 years.
In all differentiated cancers, providing sufficient doses of radiation are employed, one can obtain a regression of the tumour or arrest it. Radiotherapy proved effective in three patients with inoperable lesions; one of them living 8 years, one 10 years, and one continues to be well after 12 years of irradiation. 
The overall 5-year survival rate for follicular thyroid cancer is 91%, and the 10-year survival rate is 85%.  By overall cancer staging into stages I to IV, follicular thyroid cancer has a 5-year survival rate of 100% for stages I and II, 71% for stage III, and 50% for stage IV. 
After a follow-up of five years, survivals are similar in the various histologic or therapeutic subgroups whether they were treated by external radiotherapy or radioiodine. After 10 years, however, results are better after external radiotherapy in all subgroups. Effectiveness of EBRT should not be underestimated as the survival rate is 32.5% as in the series by Windeyer  in inoperable cases and bone metastases. Treated with radiotherapy, the only survival rate at 5 years was 3/15(25%) and at 10 years was 2/12(16%). 
| References|| |
|1.||Zidan J, Kassem S, Kuten A. Follicular carcinoma of the thyroid gland: Prognostic factors, treatment, and survival. Am J Clin Oncol 2000:23:1-5. |
|2.||Tubiana M, Lacour J, Monnier JP, Bergiron C, Gerard-Marchant R, Roujeau J, et al. External radiotherapy and radioiodine in the treatment of 359 thyroid cancers. Br J Radiol 1975;48:894-907. |
|3.||Thyroid gland. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7 th ed. New York, NY: Springer; 2010. p. 87-96. |
|4.||Eddleston B. Radiological assessment. In: Thyroid Cancer. In: Duncan W, editor. Berlin/Heidelberg/New York: Springer Verlag; 1980. p. 93-97. |
|5.||Sherman RS, Ivker M. Roentgen appearance of thyroid metastases in bone. Am J Roentgenol Radium Ther 1950;63:196-203. |
|6.||Nikiforov YE, Heffess CS, Korzenko AV, Fagin JA, Gnepp DR. Characteristics of follicular tumors and non neoplastic thyroid lesions in children and adolescents exposed to radiation as a result of the Chernobyl disaster. Cancer 1995;76:900-9. |
|7.||Tubiana M, Lalanne CM, Bergiron C, Monnier JP, and Gerard-Marchant R, et al. Results obtained with radiotherapy in cases of thyroid cancer. Thyroid Cancer, U.I.C.C. Monograph Series 12. Berlin: Springer-Verlag; 1969. p. 279-88. |
|8.||Grünwald F, Biersack HJ, GrŸunwald, Thyroid Cancer F. Numbers from National Cancer Database in the US. Berlin: Springer; 2005. p. 10. |
|9.||Thyroid Cancer By the American Cancer Society. In turn citing: AJCC Cancer Staging Manual. 7 th ed. Available from: http://www.Cancer.org. [Last accessed on 2013 Jun 15]. |
|10.||Windeyer BW. Cancer of the thyroid and radiotherapy. Mackenzie Davidson Memorial lecture. Br J Radiol 1954;27:537-52. |
[Figure 1], [Figure 2]