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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 14
| Issue : 3 | Page : 106-111 |
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Thyroid cancer and nodular goiter of thyroid: An analysis of patients in rural South Tamil Nadu
Johnsy Merla, Shantaraman Kalyanaraman
Department of Pathology, Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India
| Date of Web Publication | 9-Oct-2017 |
Correspondence Address:
Shantaraman Kalyanaraman
Department of Pathology, Tirunelveli Medical College, Tirunelveli, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/trp.trp_18_17
Background: The aim of the study was to analyze the profile of nodular goiters of thyroid presenting with thyroid cancers in a tertiary hospital in rural South India.
Materials and Methods: This study was conducted for 2 years since 2010 in patients with thyroid enlargements. Patients with multinodular or solitary thyroid enlargements with ultrasonogram suspicious of malignancy, fine-needle aspirate suspicious of malignancy, or persons with clinical suspicious thyroid enlargements with equivocal ultrasonogram or cytology with or without symptoms of mass effect were selected for the study. The clinical, operative, cytological, and histological data were tabulated and statistically analyzed.
Results: Of 522 patients analyzed, 91.57% were females and 67.62% were between 21 and 40 years. Nearly 17.04% presented with hypothyroidism, 15.13% with hyperthyroidism, and 67.82% patients were euthyroid. Of the 522 patients, 425 (81.42%) had nodular thyroid enlargements, of whom 224 (42.91%) had multinodular goiters (MNGs), 201 (38.51%) had solitary thyroid nodules (SNT), and 97 (18.58%) had diffuse thyroid enlargements. The malignant tumors were present in 105 patients with papillary carcinoma, 20 patients with follicular carcinoma, and 6 with medullary carcinoma, of whom 76 (33.93%) had MNG and 54 (26.87%) had SNT.
Conclusion: Thyroid cancers are best diagnosed through concerted clinical, radiological, cytological, and histological analyses. All nodules of thyroid, whether solitary or multinodular, should be sampled in fine-needle aspiration under radiological assistance and similarly all nodules need to be studied for malignancy in histopathology. In this study, we observed that the incidence rates of malignancy were higher than that of the existing Indian data and these patients were from the coastal regions of Tirunelveli and Thoothukudi districts. We also observed that multinodular goiters had microscopic malignant foci. Keywords: Fine-needle aspiration cytology, histopathology, malignancy, papillary carcinoma, thyroid tumors
How to cite this article:
Merla J, Kalyanaraman S. Thyroid cancer and nodular goiter of thyroid: An analysis of patients in rural South Tamil Nadu. Thyroid Res Pract 2017;14:106-11 |
How to cite this URL:
Merla J, Kalyanaraman S. Thyroid cancer and nodular goiter of thyroid: An analysis of patients in rural South Tamil Nadu. Thyroid Res Pract [serial online] 2017 [cited 2022 Jan 24];14:106-11. Available from: https://www.thetrp.net/text.asp?2017/14/3/106/216206 |
| Introduction | |  |
Thyroid cancer is the third fastest rising cancer diagnosis in the United States with an annual rate of increase at 3% and with a doubling of incidence in the past 30 years.[1],[2] Globally, many autopsy studies have reported incidences of thyroid nodules of more than 50%, and presently with the use of high-resolution ultrasonography, the incidence reports are approximately 40% of patients with nonthyroidal illness.[3] In the Framingham study, ultrasonogram showed that 3% of men above the age of 60 years and 36% of women of age between 49 and 58 years had thyroid nodules.[4] The increasing incidence of goiter is associated with an increase in the incidence of thyroid cancer globally, attributed variably to better detection and diagnostic methods.[5] In India, there is a significant burden of thyroid diseases. A study on thyroid disorders estimated that about 42 million people in India suffer from thyroid diseases.[6] The Indian National Cancer Registry Program (Indian Council of Medical Research) reported a nationwide relative frequency of thyroid cancer among all the cancers of 0.1%–0.2% with a female-to-male ratio of 4:1. In the Wickham study, 26% of women had a goiter, compared to 7% of men.[3] Thyroid nodules are less frequent in men than in women, but when found, they are more likely to be malignant. The frequency of goiters decreases with advancing age. The decrease in frequency differs from the incidence of thyroid nodules, which increases with advancing age. The age-adjusted incidence rates of thyroid cancer are 1/100,000 for males and 1.8/100,000 for females (Mumbai Cancer Registry Data). A hospital cancer registry of 1185 cases of thyroid cancer has reported papillary thyroid carcinoma (PTC) to be most common, followed by follicular thyroid carcinoma.[7] We report here the profile of nodular goiters of thyroid presenting with thyroid cancers in a tertiary hospital.
| Materials and Methods | | |
This study, conducted for 2 years since 2010, included adult patients who presented to outpatient departments in the hospital with thyroid enlargements. These patients were registered, subjected to clinical examination, and investigated with radiological and basic laboratory tests including thyroid hormone assay and fine-needle aspiration cytology of thyroid. Patients who were found with cytological evidence of thyroid malignancy or metastatic deposits in cervical lymph node aspirates were excluded from the study. Patients with multinodular or solitary thyroid enlargements with ultrasonogram suspicious of malignancy, fine-needle aspirate suspicious of malignancy, or persons with clinical suspicious thyroid enlargements with equivocal ultrasonogram or cytology with or without symptoms of mass effect were selected for the study. Informed written consent was obtained, and these patients were given surgical resections based on hospital protocol and the thyroidectomy samples were sent for histopathological evaluation. The clinical, operative, cytological, and histological data were tabulated and statistically analyzed.
| Results | | |
Of the 522 patients analyzed, 91.57% were females [Table 1] and [Figure 1] (P< 0.001) which shows high significant difference between genders at 0.1% level. Nearly 67.62% of the patients were between 21 and 40 years, 20.88% were between 41 and 60 years, and 5.36% were above 60 years [Table 2] and [Figure 2]. P <0.001 shows high significant difference between age groups at 0.1% level.
The most common presenting complaint was swelling in the neck (76.96%), while 15.13% presented with hyperthyroidism, 17.04% with hypothyroidism, and 67.82% patients were euthyroid [Table 3] and [Figure 3]. P < 0.001 shows high significant difference between thyroid groups at 0.1% level. None of the patients had a history of irradiation.
Of the 522 patients, 425 (81.42%) had nodular thyroid enlargements, of whom 224 (42.91%) had multinodular goiters (MNGs), 201 (38.51%) had solitary thyroid nodules (SNT), and 97 (18.58%) had diffuse thyroid (DT) enlargements [Table 4] and [Figure 4].
A total of 171 patients had ultrasonographic evaluation for thyroid enlargement which revealed solitary lesions in seventy patients, three cases suspicion of malignancy, eight cases of malignant tumor, 21 cases of DT enlargement, and 69 cases of MNG [Table 5].
Of the 163 patients who underwent surgery for MNG, 77 were diagnosed with malignant tumors of thyroid (47.24%) while 54 of 138 (39.13%) of SNT were diagnosed with malignant tumors [Table 6] and [Figure 5]. Odds ratio (95% confidence interval) (P > 0.05) (1.39 [0.76–2.53]) revealed no significant difference between thyroid status at 5% level.
Of these 425 patients with nodular thyroids, 131 (24.90%) were diagnosed with malignant tumors of thyroid including 105 patients with papillary carcinoma, 20 patients with follicular carcinoma, and 6 with medullary carcinoma, of whom 76 (33.93%) had MNG and 54 (26.87%) had SNT. The MNG and SNT patients were considered separately and it was found that 59 of 224 (25.89%) patients who presented with MNG had papillary carcinoma while 46 of 201 (22.89%) of SNT were papillary carcinoma. Of the 224 patients with MNG, 12 (5.36%) had follicular carcinoma while 8 of 201 (3.98%) of SNT had follicular carcinoma. Medullary carcinoma was seen in 6 of 224 (2.68%) patients with MNG against none in SNT. Relative risk of malignancy in MNG was 1.2629 (95% confidence interval = 0.9428–1.6916). MNG has a 1.26 times more risk of developing malignancy when compared to SNT. Odds ratio (95% confidence interval) revealed papillary carcinoma (P > 0.05) (0.56 [0.26–1.21]). There was no significant difference between thyroid status at 5% level, and odds ratio (95% confidence interval) revealed follicular carcinoma (P > 0.05) (1.08 [0.47–2.48]) There was no significant difference between thyroid status at 5% level [Table 7] and [Figure 6], [Figure 7], [Figure 8], [Figure 9]. | Figure 7: Types of malignancy in histological diagnosis – papillary carcinoma
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 | Figure 8: Types of malignancy in histological diagnosis – follicular carcinoma
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 | Figure 9: Types of malignancy in histological diagnosis – medullary carcinoma
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The cytological and histological diagnoses were correlated in SNT patients. Among the 46 cases of papillary carcinoma, 28 cases were cytologically diagnosed as papillary carcinoma. Among the eight patients histologically diagnosed with follicular carcinoma, the cytological diagnosis was adenomatous hyperplasia (four cases), follicular neoplasm (two cases), and Hurthle cell neoplasm (one case) [Table 8]. | Table 8: Correlation of cytological and histological diagnosis - solitary nodule
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The cytological and histological diagnoses were correlated in MNG patients. Among the 59 cases of papillary carcinoma, 43 cases were cytologically diagnosed. About 12 patients had histological diagnosis of follicular carcinoma in which 11 cases were diagnosed cytologically as having follicular neoplasm. There were six cases of medullary carcinoma, among which five cases were diagnosed cytologically [Table 9]. | Table 9: Correlation of cytological and histological diagnosis - multinodular
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| Discussion | | |
Kalra et al., 2013, highlighted the lack of attention to thyroid disorders and included thyroid diseases in the list of noncommunicable diseases.[8] Thyroid enlargement, which is a common disorder in our region, commonly presents as multinodular thyroid swelling (48.80%). Hanumanthappa et al.[9] reported 220 cases of goiter, in which 100 (45.45%) were multinodular goiter. The most common presenting complaint in this study was swelling in the neck (76.96%), while Tarrar et al.[10] reported a finding of 100%. Solitary and multinodular goiters were more common in women (91.51%). Similarly, Hanumanthappa et al.[9] reported a striking female predominance in their study. Age distribution in this study showed a preponderance of patients in the second and third decades of life (67.27%) for both solitary and multinodular goiters. The mean age of our patients with nodular thyroid was 36.7 years. This is in variance to the other Indian reports, namely Hanumanthappa et al.[9] who reported a majority of patients in the third (35%) and fourth (30%) decades of life and Nikhil Nanjappa et al.[11] who reported a mean age of 47.4 years. Autopsy studies suggest a frequency of >50% for thyroid nodules; with high-resolution ultrasonography, the value approaches 40% of patients with nonthyroidal illness. In the Wickham study [3] from the United Kingdom, 16% of the population had a goiter. In the Framingham study, ultrasonography revealed that 3% of men older than 60 years had thyroid nodules, while 36% of women aged 49–58 years had thyroid nodules.[4] In the United States, most goiters are due to autoimmune thyroiditis (i.e., Hashimoto disease). The incidence of thyroid cancer has been rising worldwide. The reasons are unclear, but this trend may be related to better detection and diagnostic methods.[5] Worldwide, the most common cause of goiter is iodine deficiency. It has been estimated that goiters affect as many as 200 million of the 800 million people who have a diet deficient in iodine. No racial predilection exists. The female-to-male ratio is 4:1.
In the Wickham study, 26% of women had a goiter, compared to 7% of men.[3] Thyroid nodules are less frequent in men than in women, but when found, they are more likely to be malignant. The frequency of goiters decreases with advancing age. The decrease in frequency differs from the incidence of thyroid nodules, which increases with advancing age.
Of these 522 patients with thyroid goiters, 201 had SNT and 224 had MNG. Of the 101 papillary carcinomas diagnosed, 58 were multinodular thyroid and 46 were solitary nodules. Of the 201 solitary nodules, 54 (26.87%) were malignant. Nikhil Nanjappa et al.[11] reported a malignancy rate of 23.47% in solitary nodules. Of the 224 multinodular goiters analyzed, 76 (33.93%) were malignant. Nikhil Nanjappa et al.[11] reported a 18.18% malignancy rate in multinodular thyroid. In this study, the incidence of malignancy in MNGs is more and is possibly attributed to the possible iodine excess as documented by Chandrasekaran and Ramadevi.[12]
In this study, we observed that the incidence of malignancy in multinodular goiter was similar to that in solitary nodules. Thyroid goiters clinically and cytologically diagnosed as benign lesions had malignant tumors in histology, as the nodularity possibly masked the existence of a solitary focus of cancer. Hence, thyroid cancers are best diagnosed through concerted clinical, radiological, and cytological analysis. It is also important that all nodules of the thyroid, whether solitary or multinodular, should be sampled in fine-needle aspiration (FNA) under radiological assistance and similarly all nodules need to be studied for malignancy in histopathology.
In this study, we observed multinodular goiter with microscopic malignant foci in 14 (18.42%) patients of which 100% were papillary carcinoma while Pang and Chen, 2007,[13] reported 57 (21.2%) nodular goiters with malignant foci, of which 44 were papillary carcinomas (77.19%), 5 (8.77%) were follicular carcinoma, and 5 (8.77%) were medullary carcinomas. Stoffer et al.[14] and Pelizzo et al.[15] have also reported increased incidence of papillary carcinoma in MNGs. The incidence rates appear higher than the existing Indian data. Of these patients, 53.26% are from the coastal regions of Tirunelveli and Thoothukudi districts.
Familial PTC with MNG (f-PTC/MNG) is characterized by the presence of multiple benign thyroid nodules, increased risk of multifocal disease, worse prognosis than the usual sporadic nonmedullary thyroid cancer, local invasion, more likely to have intraglandular dissemination, more aggressive clinical behavior, increased local or regional recurrence, and lymph node metastases. FNMTC is an independent entity of shorter disease-free survival.[16],[17],[18],[19],[20] Are our patients having familial PTC with MNG (f PTC/MNG)?
Thyroid diseases are different from other diseases in terms of their ease of diagnosis and accessibility of medical treatment. Early diagnosis and treatment remains the cornerstone of management. With increasing population in India over the next decade, the disease burden is bound to increase exponentially. If the patients we are reporting here are f-PTC/MNG, they are associated of short disease-free survivals and hence require an early diagnosis.
| Conclusion | | |
This study concludes that thyroid goiters clinically and cytologically diagnosed as benign lesions had malignant tumors in histology, possibly due to the nodularity and hence it is concluded that:
- Thyroid cancers are best diagnosed through concerted clinical, radiological, and cytological analysis
- All nodules of thyroid, whether solitary or multinodular, should be sampled in FNA under radiological assistance and similarly all nodules need to be studied for malignancy in histopathology
- In this study, we observed that the incidence rates of malignancy were higher than the existing Indian data, and these patients were from the coastal regions of Tirunelveli and Thoothukudi districts. We also observed that multinodular goiters had microscopic malignant foci. Are these patients have a f-PTC/MNG? If yes, then are they associated with short disease-free survivals that require an early diagnosis? These questions need further study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Davies L, Ouellette M, Hunter M, Welch HG. The increasing incidence of small thyroid cancers: Where are the cases coming from? Laryngoscope 2010;120:2446-51.  |
| 2. | Hossein G, Enrico P, Ralf P, Daniel S. Duick, Roberto V, et al. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules – 2016 Appendix. Endocr Pract 2016;22:(Suppl 1):1. |
| 3. | Tunbridge WM, Evered DC, Hall R, Appleton D, Brewis M, Clark F, et al. The spectrum of thyroid disease in a community: The Whickham survey. Clin Endocrinol (Oxf) 1977;7:481-93. |
| 4. | Sawin CT, Geller A, Hershman JM, Castelli W, Bacharach P. The aging thyroid. The use of thyroid hormone in older persons. JAMA 1989;261:2653-5. |
| 5. | Cossu A, Budroni M, Paliogiannis P, Palmieri G, Scognamillo F, Cesaraccio R, et al. Epidemiology of thyroid cancer in an area of epidemic thyroid goiter. J Cancer Epidemiol 2013;2013:584768. |
| 6. | Unnikrishnan AG, Menon UV. Thyroid disorders in India: An epidemiological perspective. Indian J Endocrinol Metab 2011;15 Suppl 2:S78-81. |
| 7. | Gangadharan P, Nair MK, Pradeep VM, Thyroid cancers in Kerala. In: Shah AH, Samuel AM, Rao RS, editors, Thyroid Cancer – An Indian Perspective. Mumbai: Quest Publications; 1999. p. 17-32. |
| 8. | Kalra S, Unnikrishnan AG, Baruah MP. Thyroid: Disorders of a lesser gland. Thyroid Res Pract 2013;10:45-6. [Full text] |
| 9. | Hanumanthappa MB, Gopinathan S, Suvarna R. Incidence of malignancy in multi-nodular goiter: A prospective study at a tertiary academic Centre. J Clin Diagn Res 2012;6:267-70. |
| 10. | Tarrar AM, Wahla MS, Ilyas S, Khan OU, Waqas A, Raza A. Solitary thyroid nodule; Frequency of malignancy at combined military hospital Rawalpindi. Prof Med J 2010;17:598-602. |
| 11. | Nikhil Nanjappa BA, Mohanty A, Tirou Aroul T, Robinson Smile S, Kotasthane D. Thyroid carcinoma (TC) in nodular goiter. Thyroid Disorders Ther 2012;1:115. |
| 12. | Chandrasekaran M, Ramadevi K. Thyromegaly and iodine nutritional status in a tertiary care hospital in South India. Indian J Endocrinol Metab 2013;17:260-4. |
| 13. | Pang HN, Chen CM. Incidence of cancer in nodular goitres. Ann Acad Med Singapore 2007;36:241-3. |
| 14. | Stoffer RP, Welch JW, Hellwig CA, Chesky VE, Mccusker EN. Nodular goiter. Incidence, morphology before and after iodine prophylaxis, and clinical diagnosis. AMA Arch Intern Med 1960;106:10-4. |
| 15. | Pelizzo MR, Piotto A, Rubello D, Casara D, Fassina A, Busnardo B. High prevalence of occult papillary thyroid carcinoma in a surgical series for benign thyroid disease. Tumori 1990;76:255-7. |
| 16. | Frilling A, Liu C, Weber F. Benign multinodular goiter. Scand J Surg 2004;93:278-81. |
| 17. | Sherman SI, Angelos P, Ball DW, Byrd D, Clark OH, Daniels GH, et al. Thyroid carcinoma. J Natl Compr Canc Netw 2007;5:568-621. |
| 18. | Qureshi JN, Muneer A, Memon AS, Memon S, Hammad A. Malignancy in nodular goiter. J Surg Pak 2006;11:71-2. |
| 19. | Thomas WE. Neoplasm's of thyroid gland (including the solitary nodule). Surg Int 2004;64:296-300. |
| 20. | Ahmed I, Malik ML, Ashraf M. Pattern of malignancy in solitary thyroid nodule. Biomedia 1999;15:392-6. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]
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