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ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 2  |  Page : 65-69

An analysis of management in papillary thyroid carcinoma in a tertiary care hospital


Department of surgery, TNMC and BYL Nair Ch. Hospital, Mumbai, Maharashtra, India

Date of Web Publication17-Jul-2018

Correspondence Address:
Sharanabasavaraj C Javali
Department of surgery, TNMC and BYL Nair Ch. Hospital, Mumbaicentral, Mumbai - 400 008
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/trp.trp_17_18

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  Abstract 


Background: Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy, this study was conducted to evaluate the epidemiological pattern of the disease and also to observe and analyze the peak age of occurrence of PTC. In this article, the importance of preoperative ultrasonography (USG) in evaluating thyroid lesions especially malignant lesions and also its usefulness in correlation with fine-needle aspiration cytology (FNAC) findings in PTC has been studied.
Materials and Methods: It was an Observational retrospective and prospective included 50 patients (>18 yrs) having histopathology proven papillary thyroid carcinoma. All these patients epidemiological parameters such as clinical presentation and management was studied. Data collection from Medical records office department in retrospective cases and analysed using SPSS software system
Results: Maximum occurrences the disease were in the age group being after 31 to 40 years (P = -0.0002). Mean age group was 36 years. Malignancy was significantly associated with female gender >86% of patients (P = -0.0001). Various USG features such as echogenicty, nodularity, microcalcification, resistivity index, height and width of tumour correlation was statistically significant with malignant potential.
Conclusion: Preoperative ultrasound and USG guided FNAC helped for early diagnosis and timely management. USG guided FNAC decreased the incidence of false negative and non diagnostic results. Pre op usg allows for the early detection of non palpable cervical lymph node metastasis, thereby potentially helps for overall surgical approach in these patients. Cold nodules on Tc 99 thyroid scan suggests malignancy. In future further developments in ultrasound and fnac may further improve diagnostic accuracy of PTC.

Keywords: Echogenicity, fine-needle aspiration cytology, histopathology, margins, papillary thyroid carcinoma, ultrasound


How to cite this article:
Mahey RK, Javali SC, Devlekar S, Dharap S. An analysis of management in papillary thyroid carcinoma in a tertiary care hospital. Thyroid Res Pract 2018;15:65-9

How to cite this URL:
Mahey RK, Javali SC, Devlekar S, Dharap S. An analysis of management in papillary thyroid carcinoma in a tertiary care hospital. Thyroid Res Pract [serial online] 2018 [cited 2018 Dec 11];15:65-9. Available from: http://www.thetrp.net/text.asp?2018/15/2/65/236699




  Introduction Top


Thyroid cancer is the most common endocrine malignancy.[1] Papillary thyroid carcinoma (PTC) is the most common malignant tumor among all thyroid cancers, accounting for an estimated 75%–85% of thyroid cancer,[2] and the most common form of thyroid cancer to result from exposure to radiation. In India and worldwide, it appears to be a major health problem. In the USA, the estimated new cases in 2015 were 62,450.[3]

In India, the National Cancer Registry Programme has reported the thyroid gland as the leading site of cancer accounting for 1.5% of all cancers in men and 3.3% in women.[4] The increasing incidence of thyroid cancer, especially PTC, is of concern and is more common in females, the peak age group being 30–50 years.[5] In the last few years, we have noticed it to be occurring more often in younger patients.

Papillary carcinoma appears as an irregular solid or cystic mass or nodule in a normal thyroid parenchyma. Despite its well-differentiated characteristics, papillary carcinoma may be overtly or minimally invasive.[6] Papillary tumours have a propensity to invade lymphatics but are less likely to invade blood vessels. The life expectancy of patients with this cancer is related to their age. The prognosis is better for younger patients (< 45 years).

Of patients with papillary cancers, about 11% present with metastases outside the neck and mediastinum. Some years ago, lymph node metastases in the cervical area were thought to be aberrant (supernumerary) thyroids because they contained well-differentiated papillary thyroid cancer, but occult cervical lymph node metastases are now known to be a common finding in this disease.[6],[7],[8],[9],[10],[11] Surgery is the definitive management of papillary thyroid cancer.


  Objectives of the Study Top


  1. To study use of clinical parameters such as history and clinical examination in diagnosing malignancy in thyroid nodules
  2. To study role of USG and FNAC in predicting thyroid malignancies
  3. To find correlation of FNAC with final histopathological outcome
  4. To know the completeness of surgery and the complications (i.e., surgical outcomes).



  Materials and Methods Top


Study design

It is an Observational retrospective and prospective study included 50 cases of histopathology proven papillary thyroid carcinoma patients.

Study site

The study was done in Department of Surgery in TNMC & BYL NAIR CH HOSPITAL, MUMBAI, it is a Bombay Municipal Corporation (BMC) Tertiary care hospital which receives many referral patients of thyroid disease within the city, state and different parts of the country.

Data analysis

Data collection from Medical records office department in retrospective cases, and analysis of data was done using SPSS software system. The study was done from January 2012 to September 2016 (5 years) with sample of 50 patients. The epidemiological parameters such as clinical presentation, age group, sex, use of ultrasonography in predicting malignancies, early detection by using USG guided biopsy in suspicious nodules were studied.

Inclusion criterion

Age>18 yrs Male and Female patients diagnosed with papillary carcinoma of thyroid.

Exclusion criterion

Not fit for general anaesthesia and Age less than 18 years.

Investigations and management

Thyroid function tests

All patients considered for the study had euthyroid status at the time of surgery.

Ultrasonography of neck and color Doppler

All patients' USG neck with color Doppler and various parameters such as size and extent of the gland, nodularity, echogenicity, calcification pattern, and vascularity were studied.

Fine-needle aspiration cytology

All patients with thyroid nodules were subjected to FNAC or USG-guided FNAC.

Indirect laryngoscopy

An indirect laryngoscopy done in all patients before surgery for vocal cord visualization for medicolegal purposes was studied.

Tc99 scan

Those patients having nodularity with hyperthyroidism and those with indeterminate FNAC findings subjected to a Tc99 thyroid scan.

Near-total thyroidectomy was done for malignant nodular goiters with or without various types of lymph node dissection. For patients with nodules suspicious of malignancy or indeterminate fine-needle aspiration findings, intraoperative frozen section was arranged, and depending on the report of frozen section, total thyroidectomy was done for malignant goiters. Patients who underwent hemithyroidectomy for multinodular goiter and who had histopathology report as papillary carcinoma were reoperated for total thyroidectomy with lymph node dissection.

If postoperative thyroid-stimulating hormone (TSH) was raised >30, radioactive iodine thyroid scan was done 3 weeks after surgery to know the completeness of surgery.


  Observation and Results Top


Age

On correlating age incidence with incidence of malignancy, there was significant association between age and incidence of malignancy in our study. Maximum occurrence being after 30 years (P = -0.0002).

Sex

Of the 50 patients in our series, females accounted for 43 (86%) patients while male patients were 7 (14% of total cases). In our study, malignancy was significantly associated with female gender (P = -0.0001).

Ultrasonography and various ultrasonography parameters

In our series of 50 patients with thyroid swelling, various USG parameters such as size of nodule, echogenicity, nodule margins, and presence of nodular microcalcification and resistivity index were evaluated.

On correlating the association of height > width of the nodule on USG with final histopathology report, in our study, nodules with height > width were significantly associated with malignancy (P = 0.048).

Echogenicity of nodule

On correlating the association of echogenicity of the nodule on USG with final histopathology report, in our study, hypoechoic lesions were significantly associated with malignancy (P = 0.0001).

Margins

On correlating the association of margin of the nodule on USG with final histopathology report, in our study, nodules with ill-defined margin were significantly associated with malignancy (P = 0.0001).

Calcification on ultrasonography

Nodule was evaluated for the presence of microcalcification on USG.

In our study, microcalcification was present in 88% of patients while it was absent in rest 12% of patients.

Resistive index

Among 50 patients in our study, 44 patients had resistive index >0.75 while 6 patients had this index below 0.75.

A statistically significant association was found between RI > 0.75 and malignancy in thyroid nodules (P = 0.0001).

Cervical lymphadenopathy

In our study 23, people had cervical lymphadenopathy. Pre operative USG identifies abnormal cervical lymph nodes suspicious for malignancy and it was statistically significant with malignancy rates (P = -0.0001).

Tc99 scan

In our study, cold nodules were significantly associated with malignancy (P = 0.0001).

Fine-needle aspiration cytology

On correlating the FNAC report with final histopathology report, in our study, FNAC and USG guided FNAC in doubtful diagnosis was significantly associated with malignancy (P = -0.0001).


  Discussion Top


In a retrospective and prospective study of over 5 years in a tertiary care institute, data were collected of 50 patients with histopathology-proven report of papillary carcinoma thyroid and followed up for any complication of surgery or the prior disease itself.

Age

The mean age in our study was 36 years.

This is similar to study conducted by Fenn et al. in which maximum incidence of malignancy was in the age group of 30–40 (35%).[12]

In a study by Acun et al.,[13] the mean age of presentation was 43 years.

The highest incidence of malignancy in our study was in the age group of 31–40 years and it was statistically significant (P = 0.002).

Sex

In our study, male patients were 7 (14%) while female patients were 43 (86%).

Incidence of malignancy was higher in females than in males, with the female: male ratio being 6:1 (P = 0.0001).

Ultrasonography and its correlation

Differentiated thyroid cancer namely PTC comprises of 90% of thyroid cancers and the increased detection rates of PTC in past 3 decades can be partly attributed to wide spread use of USG neck and USGguided biopsy of suspicious, and nonpalpabale nodules, cervical lymph nodes. There is evidence to suggest that a number of ultrasound characteristics whwn occurring together are associated with higer risk of malignancy.[14],[15]

There was statistically significant association between hypoechogenecity and malignant potential (P = 0.0001).[14] similar to studies done by Moon WJ et al.[15]

Malignant nodules, both carcinoma and lymphoma, typically appear solid and hypoechoic when compared with normal thyroid parenchyma. An ill-defined and irregular margin in a thyroid tumour suggests malignant infiltration of adjacent thyroid parenchyma with no pseudocapsule formation.[16],[17]

Presence of nodule with ill defined margin and height >width of the nodule on USG had statisically significant association with malignancy (P = 0.0001), the results were similar to studies done by Enrico Papini et al.[7] Microcalcification was noted in 44(88%) patients while it was absent in 6(12%) patients. presence of microcalcification was statistically significantly associated with malignancy (P = 0.0001). Ultrasound is superior to CT scan in evaluating cervical lymph nodes. Pre operative USG can identify suspicious cervical lymphadenopathy in 20-30% of cases, thereby potentially altering the extent of and overall surgical approach in these patients, In our study 23, people had cervical lymphadenopathy. Pre operative USG identifies abnormal cervical lymph nodes suspicious for malignancy and it was statistically significant with malignancy rates (P = -0.0001).[18]

Tc99 scan

In our study, 28 patients had a cold nodule on thyroid scan, significantly associated with malignancy (P = -0.0001).

Fine-needle aspiration cytology

IN patients with a thyroid nodule suspicious for PTCon USG guided FNAC and with USG features associated with malignancy, the risk of thyroid cancer is high 95% necessitating total thyroidectomy, usg guided fnac decreases the incidence of false negative results from needle misplacement and reduces the rate of non diagnostic results.

In our study FNAC and usg guided FNAC was successful in diagnosing 46(92%) out of 50 while 2 were diagnosed as follicular neoplasm and 2 as features consistent with multi-nodular goitre. Similar observationswere made by Carlo Cappelli et al.[19]

Postoperative complications

Postoperatively, 4 patients developed hypocalcemia, of which 1 had persistent hypocalcemia, 3 patients developed temporary hoarseness of voice, while 43 patients had no postoperative complications.

In a study by Pattou et al.,[20] postoperative hypocalcemia was observed in 5.4% of patients and 0.5% had persistent hypocalcemia.

All were subjected to radioiodine uptake scan to pick up residual tumour or distant metastasis after three weeks of postsurgery and also radioiodine uptake scan was done in patients in whom TSH levels were >30miu/l, to rule out reccurrence of the disease.

None was found to have distant metastasis or residual tumor till 1 month of follow-up.


  Conclusion Top


PTC is the most common thyroid malignancy and its incidence seems to be on a rise. There appears to be an increase in its incidence in the younger population, causing an epidemiological shift in the age distribution. Highest incidence of malignancy was in the age group of 31-40 years. Incidence of malignancy was higher in females than in males. Cold nodules on thyroid scan suggests malignancy. Preoperative ultrasound and USG guided FNAC helped for early diagnosis and timely management. USG guided FNAC decreased the incidence of false negative and non diagnostic results. Pre op usg allows for the early detection of non palpable cervical lymph node metastasis, thereby potentially helps for overall surgical approach in these patients. Cold nodules on Tc 99 thyroid scan suggests malignancy. In future further developments in ultrasound and fnac may further improve diagnostic accuracy of PTC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Unnikrishnan AG, Menon UV. Thyroid disorders in India: An epidemiological perspective. Indian J Endocrinol Metab 2011;15:S78-81.  Back to cited text no. 1
    
2.
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Jayaram G. Papillary Carcinoma. Atlas and Text of Thyroid Cytology. New Delhi: Arya Publications; 2006. p. 35-48.  Back to cited text no. 5
    
6.
Papini E, Guglielmi R, Bianchini A, Crescenzi A, Taccogna S, Nardi F, et al. Risk of malignancy in nonpalpable thyroid nodules: Predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab 2002;87:1941-6.  Back to cited text no. 6
    
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Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, et al. Management of thyroid nodules detected at US: Society of radiologists in ultrasound consensus conference statement. Radiology 2005;237:794-800.  Back to cited text no. 7
    
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Abdel-Razzak M, Christie JH. Thyroid carcinoma in an autonomously functioning nodule. J Nucl Med 1979;20:1001-2.  Back to cited text no. 8
    
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Kountakis SE, Skoulas IG, Maillard AA. The radiologic work-up in thyroid surgery: Fine-needle biopsy versus scintigraphy and ultrasound. Ear Nose Throat J 2002;81:151-4.  Back to cited text no. 9
    
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Bitterman A, Uri O, Levanon A, Baron E, Lefel O, Cohen O, et al. Thyroid carcinoma presenting as a hot nodule. Otolaryngol Head Neck Surg 2006;134:888-9.  Back to cited text no. 10
    
11.
De Rosa G, Testa A, Maurizi M, Satta MA, Aimoni C, Artuso A, et al. Thyroid carcinoma mimicking a toxic adenoma. Eur J Nucl Med 1990;17:179-84.  Back to cited text no. 11
    
12.
Fenn AS, Krishnan KV, Devadatta J, Mammen KE, Kashyap V. Solitary nodules of the thyroid gland: A review of 342 cases. Indian J Surg 1980;42:175-7.  Back to cited text no. 12
    
13.
Acun Z, Comert M, Cihan A, Ulukent SC, Ucan B, Cakmak GK, et al. Near-total thyroidectomy could be the best treatment for thyroid disease in endemic regions. Arch Surg 2004;139:444-7.  Back to cited text no. 13
    
14.
Bonavita JA, Mayo J, Babb J, Bennett G, Oweity T, Macari M, et al. Pattern recognition of benign nodules at ultrasound of the thyroid: Which nodules can be left alone? AJR Am J Roentgenol 2009;193:207-13.  Back to cited text no. 14
    
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Asteria C1, Giovanardi A, Pizzocaro A, Cozzaglio L, Morabito A, Somalvico F, et al. US-elastography in the differential diagnosis of benign and malignant thyroid nodules. Thyroid 2008;18:523-31.  Back to cited text no. 15
    
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Hoang JK, Lee WK, Lee M, Johnson D, Farrell S. US features of thyroid malignancy: Pearls and pitfalls. Radiographics 2007;27:847-60.  Back to cited text no. 16
    
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Takashima S, Fukuda H, Nomura N, Kishimoto H, Kim T, Kobayashi T. Thyroid nodules: Reevaluation with ultrasound. J Clin Ultrasound 1995;23:179-84.  Back to cited text no. 17
    
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Bhatki AM, Brewer B, Robinson-Smith T, Nikiforov Y, Steward DL. et al. Adequacy of surgeon-performed ultrasound-guided thyroid fine-needle aspiration biopsy. Otolaryngol Head Neck Surg 2008;139:27-31.  Back to cited text no. 18
    
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Cappelli C, Castellano M, Pirola I, Gandossi E, De Martino E, Cumetti D, et al. Thyroid nodule shape suggests malignancy. Eur J Endocrinol 2006;155:27-31.  Back to cited text no. 19
    
20.
Pattou F, Combemale F, Fabre S, Carnaille B, Decoulx M, Wemeau JL, et al. Hypocalcemia following thyroid surgery: incidence and prediction of outcome. World J Surg 1998;22:718-24.  Back to cited text no. 20
    




 

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