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ORIGINAL ARTICLE
Year : 2018  |  Volume : 14  |  Issue : 2  |  Page : 357-360

A study of clinicopathological characteristics of thyroid carcinoma at a Tertiary Care Center


1 Department of Surgical Oncology, Mahavir Cancer Sansthan, Patna, Bihar, India
2 Department of Pathology, Mahavir Cancer Sansthan, Patna, Bihar, India

Date of Web Publication8-Mar-2018

Correspondence Address:
Dr. Ankit A Shah
C/O Meena Pandey, Ashok Mani Bhavan, Mitra Mandal Colony, Nala Road, Anisabad, Patna - 800 002, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.180611

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 > Abstract 


Context: To share clinicopathological data of thyroid carcinoma from a high volume Tertiary Care Centre in East India.
Aim: To share the epidemiology and clinicopathological presentation of thyroid cancer at a high volume Tertiary Care Center in East India.
Settings and Design: Retrospective observational study.
Subjects and Methods: Forty-two consecutive patients of thyroid neoplasm diagnosed by fine needle aspiration cytology (FNAC) and primarily underwent surgical treatment from July 2005 to June 2012 were included. Retrospective data analyses of patient's records were done.
Statistical Analysis Used: The statistical analysis was performed using Epi Info version 3.5.3.
Results: Forty-two patients underwent surgery for thyroid neoplasm. Median age of diagnosis was 39 years. It was 6 times more common in females (female:male - 6:1). Papillary carcinoma consists of 63.15%, follicular carcinoma consists of 23.68%, and medullary carcinoma and anaplastic carcinoma each consist of 5.26% of malignant cases. Out of them, lymph node metastases were seen in 17 patients (44.73%). FNAC shows positive predictive value of 89.74%.
Conclusions: In our study, differentiated thyroid cancers were found to be more common in younger age group. Cervical lymph node metastases occur in a large number of patients. Central compartment lymph node dissection with exploration of lateral neck and modified neck dissection whenever needed is helpful in all cases of thyroid carcinoma for proper pathological staging. FNAC is rapid and efficient procedure with high positive predictive value in diagnosing thyroid neoplastic lesions.

Keywords: Carcinoma thyroid, epidemiology, fine needle aspiration cytology, lymph node, metastasis


How to cite this article:
Shah AA, Jain PP, Dubey AS, Panjwani GN, Shah HA. A study of clinicopathological characteristics of thyroid carcinoma at a Tertiary Care Center. J Can Res Ther 2018;14:357-60

How to cite this URL:
Shah AA, Jain PP, Dubey AS, Panjwani GN, Shah HA. A study of clinicopathological characteristics of thyroid carcinoma at a Tertiary Care Center. J Can Res Ther [serial online] 2018 [cited 2019 Nov 22];14:357-60. Available from: http://www.cancerjournal.net/text.asp?2018/14/2/357/180611




 > Introduction Top


Carcinoma of thyroid is relatively uncommon but is the most common endocrine cancer (approximately 1.0–1.5% of all new cancers diagnosed each year in the USA), and its incidence has continuously increased in the last three decades all over the world.[1] There is considerable controversy about the prognostic implications of lymph node metastases in thyroid cancer patients. Differentiated thyroid cancer shows about 98–100% 5-year survival rate after proper treatment.[2],[3] The aim of this study is to share epidemiology and clinicopathological characteristics of thyroid cancer from Tertiary Care Center in Eastern India.


 > Subjects and Methods Top


Study design

Retrospective observational study.

Methodology

Forty-two consecutive patients of thyroid neoplasm diagnosed by fine needle aspiration cytology (FNAC) and primarily treated by surgery from July 2005 to June 2012 were included in the study. FNAC results were categorized as (1) carcinoma (including papillary, medullary, anaplastic, or suspicious for carcinoma); (2) follicular neoplasm; (3) benign (nodular goiter, colloid goiter, hyperplastic goiter); (4) atypia of undetermined significance; (5) nondiagnostic. FNAC was repeated in the patients showing report either atypia of undetermined significance or nondiagnostic. If repeat FNAC report was also same, it was considered as benign or malignant as per clinical parameters such as history, examination, and radiological findings and treated accordingly. Ultrasound of neck was performed in all patients for any suspicious nodes. Contrast enhanced computed tomography scan was done in bulky tumor or clinical suspicion of surrounding structure infiltration. Apart from all routine investigation, direct laryngoscopy was performed in all cases for vocal cord mobility. All patients were subjected to total thyroidectomy and prophylactic central compartment clearance. Ipsilateral and/or contralateral modified neck dissection was done if any suspicious nodes were found on ultrasound or clinically. The main histologic types of thyroid carcinoma include the following: (1) differentiated (including papillary, follicular, hurthle); (2) medullary; and (3) anaplastic (aggressive undifferentiated tumor). Retrospective data analyses of patient's records were done for various clinical factors and pathological factors such as age, sex, histology, tumor size, pattern of lymph node metastases, lymphatic invasion, capsular invasion, and vascular invasion. Identification of tumor cells invading through a vessel wall and identifying thrombus adherent to intravascular tumor was considered as criteria for angioinvasion described by Mete and Asa.[4] Patients were categorized as per the American Joint Committee on Cancer tumor, node, metastasis (TNM) staging for thyroid cancer (7th edition, 2010). Patients of having differentiated histology with any one of the factors such as tumor size more than 4 cm, nodal involvement, vascular invasion, and gross extrathyroid extension were sent for radioiodine treatment after discussion in multidisciplinary tumor board. Radiotherapy was given to all patients with gross extrathyroid extension disease.

Statistical analysis

The statistical analysis was performed using Epi Info Version 3.5.3. (Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, USA).


 > Results Top


Forty-two patients underwent surgery. Median age of diagnosis was 39 years with youngest of 18 years and oldest of 70 years [Table 1]. It was six times more common in females (female:male - 6:1). Four patients had benign pathology on final histopathology report (two were multi-nodular goiter, one was follicular adenoma, and one was Hashimoto's thyroiditis) and 38 patients were having malignancy. Papillary carcinoma consists of 63.15%, follicular carcinoma consists of 23.68% and medullary carcinoma and anaplastic carcinoma each consist of 5.26% of all malignant cases [Table 2]. Out of 24 cases of papillary carcinoma, 8 (33.33%) were follicular variant of papillary carcinoma, 14 (58.33%) were classical papillary histology and two were insular variant (poorly differentiated). Out of follicular carcinoma, 3 (33.33%) were Hurthle cell variant and rest 6 (66.66%) were classical follicular histology. Mean size of the tumor in largest dimension in thyroid gland was 4.3 cm. Both patients of anaplastic carcinoma were having foci of papillary histology.
Table 1: Age-wise distribution of patients of thyroid carcinoma

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Table 2: Histological pattern of different thyroid neoplasm

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Cervical lymph node metastases were seen in 17 (44.73%) patients in which 13 (82.35%) had papillary histology and 2 (11.76%) had follicular histology [Figure 1]. Mean size of largest lymph node involvement was 1.3 cm. Extranodal extension was seen in only 3 (17.64%). Usual nodal involvement pattern were seen as central and/or ipsilateral or central plus ipsilateral compartment involvement. Only papillary histology had bilateral nodal involvement [Figure 1]. Capsular invasion was seen in 13 patients (34.21%) in which four patients were having focal invasion and nine were having gross invasion with extrathyroid extension. Lymphatic invasion was present in 8 (21.05%) patients. Vascular invasion were seen in four patients (10.52%).
Figure 1: Pattern of lymph node metastasis and different histology

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Histology wise TNM classification and stage were mentioned in [Table 3] and [Table 4]. Out of 14 patients of classical papillary histology, 13 were in stage I (one). Three out of 8 (37.5%) patients with follicular variant of papillary carcinoma presented with lymph node metastasis. Both patients having insular variant of papillary carcinoma presented in stage IVA disease. One patient was having metastasis (squamous cell carcinoma) to the thyroid gland which was not included in TNM classification and staging. Primary site was not identified as the patient was lost to follow-up.
Table 3: Histology wise tumor, node, metastasis classification and number of patients

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Table 4: Histology of tumor and final tumor, node, metastasis staging

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FNAC had diagnosed 39 cases as malignant and three as benign, whereas final histopathology was suggestive of malignancy in 38 cases and benign in four cases. Four cases were diagnosed as follicular neoplasm on FNAC which finally comes out to be follicular variant of papillary carcinoma on final histopathological review. Concordance of FNAC and biopsy report comes in 35 cases (83.33%). Positive predictive value of FNAC for malignancy came out to be 89.74%.


 > Discussion Top


In our study, median age of diagnosis was 39 years; however, no family history was found positive. SEER database shows median age at 50 years and United Kingdom (UK) database shows median age at 40–44 years.[5],[6] Our study results suggest that younger population was affected in our region. This happens due to higher incidence of cases in 20–29 years of age. This indicates the need of further study to find out the cause of thyroid carcinoma in young age group. In our study, females are 6 times more affected than male. SEER database shows thyroid carcinoma was 3 times, and UK database shows 5 times more common in females.[5],[6] Unnikrishnan and Menonhad reported 53.24% papillary, 20.16% follicular, 4.38% medullary carcinoma in the series of 1185 patients.[7] Parikh et al. also reported that it was 5 times more common in females and in India, incidence of papillary to follicular ratio was 60:40.[8] Our data was also comparable to other Indian data but was showing lower incidence of papillary and higher incidence of follicular than reported by Hundahl et al. who had reported 77–80% of papillary and 11–14% of follicular carcinoma.[9] This difference might be due to lower sample size in our study.

Thirteen out of fourteen patients of classic papillary histology were classified as stage I (one) disease suggesting that in spite of higher percentage of presence of lymph node metastasis in papillary histology, almost all were early stage and hence having good prognosis. Patients having follicular variant of papillary histology presented with less lymph node involvement than classic papillary (53.33% vs. 37.5%) but with higher stage (one patient each in stage II, III, IV). Yu et al. reported that follicular variant of papillary carcinoma is a common variant of papillary thyroid cancer with its unique clinical behavior and represents an intermediate entity with clinical features that are between classical papillary thyroid cancer and follicular thyroid cancer.[10] Our data is too small to compare it but follicular variant does show unique behavior.

Cervical lymph node metastases were seen in 17 patients (44.73%). Out of papillary histology, lymph node metastasis was seen in 54.16% of patients which is less than reported by Wada et al. who had reported 69.5%.[11] Prophylactic central compartment lymph node dissection in clinically node-negative (cN0) patient is still a debatable issue and needs further prospective randomized trials.[12],[13] Giugliano et al. reported that the decision to perform a prophylactic central compartment node dissection in patients with cN0 disease should be taken into account not only for T3 and T4 tumors, but also for all lesions above 1 cm in diameter, because complete pathological examination of central neck nodes can change both the tumor stage and therapeutic approach, especially for small tumors as pT1 tumors with central node metastasis (pT1pN1) are usually submitted to radioiodine treatment, while larger tumors such as pT2 without nodal involvement can avoid it.[14],[15] Large-scale studies on micropapillary (<1 cm) thyroid carcinoma reported against the need and usefulness of prophylactic central compartment node dissection.[16],[17] More recent large-scale population-based studies, mainly from Sweden, have shown that regional lymph node metastases among patients with thyroid cancer impact both local recurrence and cause-specific mortality.[18],[19] The association between lymph node metastasis and mortality seems to be preferentially identified in older patients, whereas such an association is less certain in their younger counterparts.[20],[21] In our patients, none of the patient was having tumor size less than one cm so prophylactic central compartment lymph node clearance was done in all cases. Clark reported that the presence of macroscopic metastases of papillary thyroid cancer in cervical lymph nodes results in a higher recurrence rate and increased death rate, especially in patients with 45 years of age or older, whereas microscopic nodal metastases do not appear to adversely influence survival and recommended preoperative ultrasonography and a selective ipsilateral neck dissection for patients with papillary thyroid cancer.[22] We also prefer to do prophylactic central compartment lymph node dissection with exploration of lateral neck with lymph node dissection in the presence of any suspicious nodes either clinically or radiologically. Positive predictive value of FNAC for malignancy came out to be 89.74%. Various series had reported positive predictive value of FNAC for carcinoma ranging from 83.78% to 94.9%.[23],[24]


 > Conclusions Top


In our study, differentiated thyroid cancers were found to be more common in younger age group. Cervical lymph node metastases occur in a large number of patients. Central compartment lymph node dissection with the exploration of lateral neck and modified neck dissection whenever needed is helpful in all cases of thyroid carcinoma for proper pathological staging. FNAC is rapid and efficient procedure with high positive predictive value in diagnosing thyroid neoplastic lesions.

Limitation of study

Having lack of resources and nonavailability of radioiodine treatment facility with poorly compliant and largely uneducated people, we had to send them outstate for further treatment. Hence, follow-up data is very limited.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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