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Official Journals By StatPerson Publication

Table of Content - Volume 12 Issue 3 - December 2019


 

A clinical study on incidence of malignancy in solitary nodule of thyroid in rural area of Tamil Nadu

 

Jeyaganesh R1, Vijaiaboobbathi Sathiah2*

 

1Senior Resident, 2Assistant Professor, Department of General Surgery, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, INDIA.

Email: vijaiaboobbathi@gmail.com

 

Abstract               Background: An impalpable gland which present as discrete swelling is called solitary nodule of thyroid which is commonest presentation of thyroid diseases. Most patients with solitary nodule will have benign lesions, however thyroid cancer must be considered in all patients. The objective of the study is to identify pattern and distribution of solitary thyroid nodule, occurrence of malignance and to assess the risk factors for malignancies. Method: A total of 50 patients of both sex were randomly selected and included in the study. The data was collected from patients admitted with a diagnosis of solitary nodule using a pretested semi structured questionnaire was administered to the study participants, which includes sociodemographic profile, details regarding solitary nodule, malignancy and clinical examination. Duration of study was two years (September 2014 to August 2016). Results: In the present study females outnumbered males. There were totally 10 males and 40 females, giving male to female ratio of 1:4. Most of the patients are with peak incidence in 21 – 30 years of age group. 5 patients with more than one-year duration proven with malignancy. 5patients present with Hard nodules are proven malignant. Conclusion: 50 cases of clinically solitary nodule was studied, of which Papillary carcinoma constituted 3 cases, 1 case of Follicular neoplasm/ suspicious follicular lesion and 1 case of anaplastic carcinoma. Hashimoto’s thyroiditis was reported on histopathology in one case. Hemithyroidectomy was the common procedure performed in our study.

Key words: Dysphagia, Serum Thyroglobulin, Hemithyroidectomy, Papillary carcinoma of thyroid.

 

INTRODUCTION

Among various endocrinal disorders thyroid disorders are most common among clinical practice. An impalpable gland which presents as a discrete swelling is called solitary nodule of thyroid which is the commonest presentation of thyroid diseases2. For centuries likely from the second millennium BC, thyroid had its history in the Chinese literature when ancient Chinese employed ground sheep’s thyroid for goitre and cretinism. This gland has fascinated surgeons for centuries. In India, its incidence is between 0 .8 – 2 per 1,00,000 population1. United states have reported approximately a 2 .4 - fold increase in the yearly incidence from 1973 to 2002 and this trend appears to be continuing. In U.K its incidence is about 0 .5 % of all cancers and is responsible for fewer than 0.5 % of all deaths due to cancer. Prevalence may be as high as 50% around 60 years from near zero at 15 years on sonography. Ultrasonography can detect 67%of nodule of any size in the general population, when considered against palpation 3. Only 5 - 20% of nodules are true neoplasm while most of the lesions are benign hyperplastic 4., mostly 10% of these nodules are palpable even by experienced clinicians. 5 At autopsy, up to 30% of thyroid nodule harbor malign ant nodules under 1cm, termed microcarcinomas. 6 A nodules is more likely to be a carcinoma in a MEN.7 Many solitary nodules are found asymptomatically, but because of their size and position can result in obstructive symptoms of trachea and oesophagus (dyspnoea and dysphagia).5 The major concern relates to the potentiality for malignancy of solitary nodule. Whether nodule size itself is a risk factor for malignancy is controversial. Fine needle aspiration biopsy plays a vital role in the assessment of thyroid swelling8. High resolution (7.5MHZ) ultrasound is helpful for differentiating solid from cystic nodules, and for identifying lymphadenopathy9. The optimal management of a solitary thyroid nodule continues to be a source of controversy, because mot surgeons recommend operative intervention and surgery is not always considered by some physicians. The basis of the conflict of divergent opinions may stem from the fact that the thyroid nodule undoubtedly has different connotations, when considered by a clinician, a surgeon or a pathologist. All are concerned whether the thyroid swelling in question is benign or malignant. Most patients with a solitary nodule will have a benign lesion; however; thyroid cancer must be considered in all patients. Deciding between conservative management and surgical therapy relies on careful analysis of the clinical findings, risk assessment, imaging, and diagnostic testing.10,11 Physical exam findings that increase the concern for malignancy include nodules larger than 4 cm in size (19.3% risk of malignancy) 12, firmness to palpation, fixation of the nodule to adjacent tissues, cervical lymphadenopathy and vocal fold immobility. Even now, there is no general agreement regarding the treatment of thyroid cancer. Long history together with evolving mode of treatment has made it extremely difficult to judge the effectiveness of any single or combined therapeutic approach where in widely different viewpoints have been expressed with great amount of convictions on either side. The aim of this study is to evaluate the distribution of solitary nodule, occurrence of malignancies presenting as solitary thyroid nodule and to assess the risk factors for malignancies presenting in patients with solitary thyroid nodule.

 

METHODS

The study was a hospital-based study conducted for a period of 2 years from September 2014 to August 2016, among patients diagnosed with solitary thyroid nodule in all the surgical units in a tertiary care hospital, Tamil Nadu. A total of 50 patients of both sex were randomly selected and included in the study. The data was collected from patients admitted with a diagnosis of solitary nodule using a pretested semi structured questionnaire, which includes sociodemographic profile, details regarding solitary nodule, malignancy and clinical examination. All patients were investigated with routine and specific investigations. Necessary treatment was planned once arrived to a definitive diagnosis of solitary thyroid nodule. An informed and written consent has been obtained from the study participants. Confidentiality of the respondents was maintained. Data were entered in excel sheet and analysed using SPSS software version 21.

 

RESULTS

The study participants comprised of 10 males (20%) and 40 females (80%), females outnumbered the males giving ratio of 1:4. The maximum number of participants belonged to age group was between 21 - 40 years (60%) with a peak incidence in 31 – 40 years (34%). Youngest patient being 19 years and the oldest being 58 years. It is observed in the study, 20 (40%) of solitary nodules were in the right lobe, 15 (30%) were in the left lobe and 15 (30%) presented in the isthmus. The duration of symptoms ranged from 3 month to more than one year. 18 patients complained of a swelling for more than one-year duration (Table – 1).

Table 1: Distribution and presentation of solitary nodule

Age wise distribution of study participants

Age(year)

Male

Female

Total

11-20

1

4

5

21-30

3

10

13

31-40

4

13

17

41-50

2

8

10

51-60

0

5

5

Total

10

40

50

Site of solitary nodule

Site

Number

%

 

Right Lobe

20

40

 

Left Lobe

15

30

 

Isthmus

15

30

 

Total

50

100

 

Duration of symptoms

Duration of symptoms(months)

Benign

Malignant

Total

1 - 3

4

0

4

4- 6

7

0

7

7-9

11

0

11

10- 12

9

1

10

More than 12

14

4

18

Total

45

5

50

Modes of presentation

Modes of Presentation

Benign

Malignant

Total

Swelling

45

5

50

Sudden increase in size

0

0

0

Pain

0

0

0

Dysphagia

4

0

4

Dyspnoea

3

0

3

Change in voice

1

3

4

Euthyroid (clinically)

44

4

48

Hyperthyroid

1

1

2

Hypothyroid

0

0

0

 


Out of 50 participants, 5 turned out to be malignant and 45 were benign. Among the malignancy positive participants, symptoms persisted for almost for more than one-year duration. Swelling in the region of the thyroid was the predominant feature and complaint in all the cases reported. The participants in the younger age group i.e., those below 30 years of age had no other symptoms, apart from the swelling and disfigurement was the purpose they sought treatment. Out of 50 cases only 11 cases presented with pressure symptoms. All the patients with dysphagia and dyspnoea had benign solitary nodules. Of the 4 patients with change in voice, one patient had a benign nodule and the other three had malignant nodules. Size (smallest 2*2 cm and largest 8*7 cm) and consistency (soft - 35 cases, firm -10 cases and hard - 5 cases) were varying from case to case Various risk factors for malignancy were studied which includes age, gender, immunodeficiency state, family history of thyroid cancer and family history of benign thyroid nodules. Among these ages was the only factors showing (p value of 0.0034) statistically significant (p<0.05) association with thyroid malignancy in the present study. Of the 35 patients with soft nodules and 10 patients with firm nodules, none had malignant nodules. All patients presenting with hard nodules had malignancy. Deviation of the trachea was observation in 15 cases. Deviation to the right: 4 cases (30%) Deviation to the left :11 cases (70%) Toxicity was observed in only 2 cases of the total solitary nodules constituting about 1.6% Indirect laryngoscopy was done in all cases. Vocal cord palsy was present in 2 cases. All these 2 patients had malignant nodules. In the present study, malignancy was statistically significant (p<0.05) for hard and immobility of nodules (p value of 0.001) and cervical lymphadenopathy (p value of 0.048). Ultrasonogram of the thyroid was done in all cases, among 50 patients who underwent ultrasonography, 3 types of solitary nodules were ruled out - Solid: 24, Cystic: 18, and Mixed: 8 in number. Univariate and multivariate analysis of ultrasound variable were studied for hypoechogenic and micro calcification, which both had statistically significant association with malignancy, whereas contours showed significant association (p value of 0.004) only with univariate analysis (Table – 2).


 

Table 2: Univariate analysis of associated factors

Variables

 

Cancer rate (%)

OR

95% CI

P Value

Related risk factors potentially associated with thyroid cancer

Gender

Male

16.95

1.46

[0.58 -2. 57]

0.06

Female

12.30

Immunodeficiency

No

13.10

1.68

[0.25 -7. 65]

0.32

Yes

21.10

Family H/O thyroid cancer

No

12.44

2.58

[0.75 -7. 92]

0.09

Yes

27.30

Family H/O thyroid nodules

No

12.90

1.08

[0.45 -1. 16]

0.42

Yes

13.85

Analysis of physical findings potentially associated with thyroid cancer

Number of nodules

Solitary nodule

15.34

1.58

[0.78 – 2 .98]

0.08

Goitre with two or more nodules

11.45

Hard and / or immobile nodule

Yes

28.13

5.86

[3.41 – 9 .45]

0.001

 

No

8.45

Suspicious cervical lymphadenopathy

Yes

56.28

9.75

[1.86 -45 .35]

0.048

 

No

12.48

Associations between high resolution ultrasonography findings and cancer

Hypoecho genicity

Yes

4.8

 

 

 

 

No

1.58

[1.69– 8.98]

0.005

 

Microcalcification

Yes

6.94

 

 

 

 

No

1.78

[3.41 – 9.45]

0.001

 

Uneven contours

Yes

3.94

 

 

 

 

No

1.38

[1.86-6.35]

0.004

 

 

 

 

 

 

 

* OR – Odds Ratio, CI- Confidence Interval

 


Nodular colloid goiter emerged as the single largest group with 42 cases. FNAC findings correlated with malignancy in all the participants, of which Papillary carcinoma constituted 3 cases, 1 case of Follicular neoplasm/ suspicious follicular lesion and 1 case of anaplastic carcinoma. Hashimoto’s thyroiditis was reported on histopathology in one case. As a total 45 cases were benign and 5 cases were malignant. In the study, the benign nodules constitute about 90% and malignant nodules 10% of all clinically solitary nodules.

 DISCUSSION

In present study in all cases the presenting complaint was, swelling in the region of the thyroid. But they sought advice for different reasons which included pressure symptoms like dysphagia, dyspnoea and change in voice. The female -male ratio is 4:1 with peak age incidence is in 21 – 30 years group. Study done by SM Nazmul Huque et al with 118 patients of STN, majority of the patients were within 21-40 years age group with female predominance. In thyroid malignancy male and female ratio was 1:114. In the present study females outnumbered the males. There were totally 10 males and 40 females, giving male to female ratio of 1:4. Most of the patients are (i.e., 30 out 50 between 21 and 40 years with a peak incidence in 21 – 30 years group. Youngest patient being 19 years and the oldest being 58 years. Most of the patients in the younger age group i.e., those below 30 years of age had no other symptoms apart from the swelling and sought advice because of the disfigurement. A thyroid nodule is more likely to be a thyroid carcinoma in patients under 20 years of age and those over 65 years of age than in those between. Benign thyroid nodules are four to five times more common in women than men, but thyroid carcinomas are only two to three times more common in women thus a nodule is more likely to be malignant in men7. In a study thyroid swelling was the common presentation in all cases (100%). Some patients also presented with other symptoms like cervical lymphadenopathy in 6 (5.08%) cases, dysphagia 2 (1.69%) cases and hoarseness of voice 1(0.85%) cases14,15, the present study also has similar findings with most common presentation is a swelling in the region of thyroid. Majority of the patients with change in voice have malignant nodules as clinical solitary nodules and 11 participants was observed with pressure symptoms was noted. After swelling, pain over swelling was second most common presentation (5.8%) which is similar to the present study where swelling was the commonest manifestation15. All hard-solitary nodules are malignant nodules. Most of the solitary nodules are benign constituting of 90% the incidence of malignancy being 10 % Papillary carcinoma is the most common malignant variant encountered. The incidence of Hashimoto ‘s thyroiditis in clinical solitary nodules is 2%. Most common benign pathology is follicular adenoma (24%) and malignancy is papillary carcinoma (11.42%) and follicular carcinoma (11.42%). Commonest surgery performed was hemithyroidectomy in 19(54.28%) cases. Majority of patients are euthyroid on presentation. FNAC is first investigation of choice. USG was a useful diagnostic aid. Modified neck dissection is advised for patients with enlarged nodes in papillary carcinoma and for those postop patients who are diagnosed to have malignancy with lymph node metastasis16.Most patients with thyroid carcinoma present with an asymptomatic thyroid nodule, as do most patients with benign thyroid nodules, and the most common method of detection appears to have shifted from physical examination to incidental imaging by radiology studies. Recently published evidence-based guidelines by professional societies provide similar recommendations for the evaluation and management of patients with thyroid nodules beginning with history and physical examination and then progressing to diagnostic testing and therapeutic recommendations10,13. The following are the various studies comparing the effectiveness of FNAC in the diagnosis of malignancy in solitary thyroid nodule. Study by Safa Mezher Al-Obaidi et al on the utility and efficacy of FNAC in the diagnosis of solitary nodule thyroid nodule showed a sensitivity of 83.3% and specificity of 100% correlation of FNAC with HPE which is similar in diagnosing malignancy 100% by FNAC in the present study. Papillary carcinoma (60% of malignant carcinoma) was more common in the present study. A study showed statistical significance (p <0.01) between papillary and follicular carcinoma, highly statistical significance (p<0.001) between papillary and anaplastic carcinoma. Papillary carcinoma was more common among all thyroid malignancies in patients with solitary thyroid nodule. Significant proportion of solitary thyroid nodule (18.65%) was malignant, therefore careful assessment of thyroid nodule is important for early diagnosis15. And Study done by Nirav Priyadarshi et al consists of study of 35 cases of solitary thyroid nodule. Majority of the patients is between 30-49 years of age. The present study of 50 clinically solitary nodules of thyroid is compared with the series published by H.S. Sachdeva et al, Richard D.Liechty, A.S. Fenn et al, M.M. Kapur et al, and S.K. Ansali. Most of the features of the present series are not at a marked variance with those of fore mentioned. 7% in 67 cases reported by Richard D.Liechty et al and 43.2% in a series constituting 342 cases reported by A.S. Fenn et al S.K Bhansali 7.5%, in his large series of 600 cases in which thyroid scan is also made up of in the preoperative diagnosis. The incidence of malignancy in the present series is 10%. H.S. Sachdeva reported 6.8% incidence of malignancy and Richard D.Liechty 17.9%, A.S. Fenn, 12.6% M.M.Kapur 11% and S.K. Bhansali 10%. Benign nodules constituted majority of the solitary nodules in all the series, as is so in the present study. The incidence of Hashimoto ‘s thyroiditis alone is one case (2%) in the present study which is compared to other series. 1.9% H.S. Sachdeva, 8.9% Richard D.Liechty 5.2%, A.S.fenn 7.0%, M.M.Kapur 0.30%, S.K.Bhansali. In these studies, all varieties of thyroiditis are put together and the incidence of Hashimoto ‘s thyroiditis is not separately mentioned. In the present study, one case of cystic nodule having ragged margins was diagnosed as malignant nodule USG. This was later proved by biopsy report. In the present study of 50 cases only hypo echogenicity and microcalcifications were shown to be significantly associated with malignancy. The female to male ratio in the present series is 4:1 as against 6:1 (H.S. Sachdeva). 7.5:1 (Richard D.Liechty) 4.9:1 (A.S Fenn), 2:1 (M.M.Kapur) and 7:2 (S.K.Bhansali). In the present study, most of the patients are between 21 - 40 years age group with peak incidence in 21-30 years age group. This is not at variance with those reported in other series. In the rest of patients ultrasonogram could not differentiate whether the nodule was benign or malignant. The ultrasonogram is not much useful to know whether the nodule is benign or malignant. In addition to know whether the clinically palpable nodule is cystic or solid, ultrasonogram is useful to know the nature of the rest of thyroid gland showing the clinical solitary nodule is true solitary nodule or simply dominant nodule of a multinodular goitre. This is found in the present series where some patients with clinically solitary nodules showed nodularity in the rest of the gland.

 

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