|Year : 2012 | Volume
| Issue : 1 | Page : 51-55
Clinico-pathological correlates of incidentally revealed thyroid swelling in Bihar, India
Arup Sengupta1, Ranabir Pal2, Sumit Kar2, Forhad Akhtar Zaman2, Mausumi Basu3, Shrayan Pal2
1 Department of Otorhinolaryngology, M.G.M. Medical College, Kisanganj, Bihar, India
2 Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences and Central Referral Hospital, Gangtok, Sikkim, India
3 Department of Community Medicine, SSKM Hospital, Kolkata, India
|Date of Submission||20-Apr-2011|
|Date of Decision||06-Sep-2011|
|Date of Acceptance||03-Nov-2011|
|Date of Web Publication||9-Feb-2012|
Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences and Central Referral Hospital, Gangtok, Sikkim
| Abstract|| |
Background: Global prevalence of thyroid cancer has been on the rise in recent decades. Objectives: To study the clinical presentations to reach an agreement for diagnosis and optimal management of incidentally revealed thyroid swellings for early diagnosis. Materials and Methods: A prospective study was carried out on 178 cases of incidentally detected thyroid swelling attending a tertiary care teaching institute of Kishanganj Bihar. All the cases were subjected to a thorough clinical examination followed by evidence-based interventions. Fine needle aspiration cytology was done in all the cases preoperatively as out-patients basis and histopathologically confirmed postoperatively. Results: The highest incidence of thyroid swelling (75.84%) was found in the age group of 20-40 years; a female preponderance was noted in the ratio 4:1. The duration of swelling ranged from six months to three years. Difficulty in swallowing and breathing was complained by 23 (12.9%) and 18 (10.1%) of the patients respectively. Typically the swellings were located in the right lobe. Commonly the subjects in our study were in euthyroid state (90%) and were with firm swellings (66.7%). Follicular and anaplastic carcinoma was important postoperative cytological findings. Majority of surgical intervention was hemithyroidectomy (55.06%). Conclusion: Incidentally revealed thyroid swelling was quite high in eastern India for which we need a consensus line of intervention.
Keywords: Bihar, thyroid swelling, fine needle aspiration cytology
|How to cite this article:|
Sengupta A, Pal R, Kar S, Zaman FA, Basu M, Pal S. Clinico-pathological correlates of incidentally revealed thyroid swelling in Bihar, India. J Pharm Bioall Sci 2012;4:51-5
|How to cite this URL:|
Sengupta A, Pal R, Kar S, Zaman FA, Basu M, Pal S. Clinico-pathological correlates of incidentally revealed thyroid swelling in Bihar, India. J Pharm Bioall Sci [serial online] 2012 [cited 2013 May 18];4:51-5. Available from: http://www.jpbsonline.org/text.asp?2012/4/1/51/92730
Globally the most common indication for thyroid operation is a solitary nodule with the possibility of malignancy. Thyroid nodules are common in clinical practice. The patient may seek medical advice due to cosmetic deformity or the thyroid swelling may also present as obstructive symptoms of trachea and esophagus or change of voice. They may be solitary within a "normal" thyroid gland or dominant within a multinodular goiter. The incidence of thyroid nodules has been on the rise in recent decades, mainly due to the wider use of neck imaging. Therefore, the incidental finding of a thyroid nodule in an asymptomatic patient is not rare. The differential diagnosis of a thyroid nodule is crucial, as malignancy necessitates surgery, while strict patient follow-up is necessary in the case of benignity. 
Clinically thyroid nodules are noted as an incidental finding during routine physical examination or during any non-invasive procedure. Several disorders may be the cause of a thyroid nodule. The majority of thyroid nodules are asymptomatic. Their clinical importance is primarily necessitates to exclude a thyroid malignancy. ,,
Stimulating thyroid stimulating hormone (TSH)-receptor antibodies does not seem to induce nodule/carcinoma formation or a change in the biologic behavior of thyroid malignancies in patients with Graves' disease.  It has been reported that the patients' visit to an endocrinologist before undergoing clinical evaluation contributes to decreasing the diagnostic cost and increasing diagnostic usefulness.  The formation of malignancies in a nodular goiter is debatable. The most workers are in the opinion that solitary nodules are prone to develop malignant changes than that of multinodular goiter. Researchers reported that the frequency of carcinoma in multinodular goiters is about half of that found in solitary nodules. 
Other studies, however, indicated that goitrous multinodularity should no longer be considered as an indicator of benign disease and that the nodules within a multinodular goiter should be valued as the solitary nodules in an otherwise normal gland. ,, European Thyroid Cancer Taskforce opined that the risk of malignancy is similar among hypofunctioning single nodules and multinodular goiter. 
The age long controversy in the management of thyroid swelling centered around the satisfactory treatment on one hand and the definitive morbidity associated with extensive surgery even in expert hands on the other. The strategy of management is formed after a detailed history taking, a thorough clinical examination, biochemical assessment, ultrasonography and fine needle aspiration cytology (FNAC), scintigraphy, and estimation of tumor markers. The battery of investigations suggested by the researchers was aimed at providing a standard protocol for identification and management of cases of thyroid swelling for surgical removal and also for those patients who refuses surgery on the ground that these are asymptomatic.
An attempt was made to find out the clinico-pathological correlates of the incidentally revealed thyroid swellings and to reach an agreement for diagnosis workup for the accuracy of preoperative diagnostic methods for optimal intervention of thyroid malignancy.
| Materials and Methods|| |
The study conformed to the Helsinki declaration. This was a prospective study on 178 cases with either incidentally detected or evident thyroid swelling out of a total of 1264 cases attending the otorhinolaryngology (ENT) outpatient department of MGM Medical College and LSK Hospital, Kishanganj, Bihar during January 2007 to December 2009. The study population was from the hinterland of Kishanganj and its adjoining districts of West Bengal.
The participants were selected with the following criteria
the patients with either incidentally detected or evident thyroid swelling.
ill with other morbidities and non-consenting patients.
A good number of cases were referred from other departments and peripheral health centers. The main outcome measures were the clinico-pathological correlates and diagnosis of thyroid swellings that were incidentally observed. Institutional ethical committee approved the study. All the subjects were explained about the purpose of the study and were ensured that the information collected from them would be kept confidential and would be used only for academic purpose. Then written informed consent was taken from each subject. The participants were also given the options to withdraw themselves from the study whenever they wish. The principal investigator thoroughly examined all cases at the ENT department by taking a detailed history, general examination along with a system-based otorhinolaryngological assessment. Special emphasis was given on the onset, duration, rate of growth, sudden increase in size, family history, residence, food habits, history of drug intake and particularly of any irradiation in the head and neck area in the recent or distant past. In female patients, an enquiry was made about reproductive health.
After clinical assessment, each of the patients was investigated to confirm our clinical impression as well as to access his or her fitness for general anesthesia for surgery. Complete blood count, bleeding time, clotting time, fasting and post-prandial blood glucose, renal function by serum urea and serum creatinine were assessed. Electrocardiography was done routinely as a preoperative measure. Routinely thyroid status was determined by estimation of T3, T4, and TSH by Enzyme-linked immunosorbent assay (ELISA) method in all patients to know the exact thyroid function status. Fine needle aspiration cytology (FNAC) was done in all cases as an OPD procedure. Other non-invasive procedures were done as required to arrive at the diagnosis. X-ray chest PA view and soft tissue X-ray neck lateral view was taken to see any calcification, or deviation of trachea and retrosternal extension. Following admission, the patients were prepared to euthyroid state wherever necessary; counseling was done regarding possibility of iatrogenic hoarseness of voice particularly to those who by their profession had to depend on their voice. Preoperative indirect laryngoscopy was done in all cases. Blood grouping was done and blood was kept ready in blood bank in case of any eventuality.
During operation all operative findings were recorded meticulously and carefully including macroscopic finding, visualization and isolation of parathyroid glands and recurrent laryngeal nerve, status of draining lymph nodes. All specimens are sent to the Department of Pathology collected in a 10% buffered normal saline with proper labeling and histopathological study was done in all the cases for a confirmed diagnosis. In the postoperative period all the patients were examined for any postoperative complication of immediate or delayed in nature and routinely before discharge, indirect laryngoscopy was done to see the vocal cord movement and their position. All the histopathologically confirmed cases were sincerely followed by evidence-based interventions according to the international clinical protocol. The patients were followed up as OPD basis after six weeks, 12 weeks and 24 weeks with noting down the condition of the scar, any discharge or persistence of swelling. Besides looking for any postoperative complications as mentioned above, vocal cord position and movement were checked in all cases by indirect laryngoscopy in immediate postoperative period routinely to exclude any injury to recurrent laryngeal nerve. We also followed up all the subjects for further intervention as an ethical responsibility. All cases presented for follow-up till six weeks regularly. Incidentally, during follow-up at 12 weeks and 24 weeks, the attendance dropped to 80% and 60%, respectively.
Those cases came up for follow-up are enjoying good health. Information on thyroid swellings was disseminated in health education sessions to complement the findings of study. The data were thoroughly cleaned and entered into MS-Excel spread sheets, and analysis was carried out. The procedures involved were transcription, preliminary data inspection, content analysis, and interpretation. Percentages were used in this study to analyze epidemiological variables.
| Results|| |
In our present study, the duration of the swelling of the study population extended from 7 days to 18 years. In most of the cases, it ranges from 6 months to 3 years. The average size of the goiter was 2.8 cm and most of the patients presents as solitary thyroid nodule. The highest incidence of thyroid swelling (75.84%) in our study was found among the study population in the age group of 20-40 years. The youngest patient in out study group was of nine years and the oldest patient was a male of 59 years. In the present series female outnumbered male by a ratio of 4:1 [Table 1].
It was noted that 166 (93.2%) patients sought medical advice because of the swelling in front of the neck. 35 (19.7%) patients also had pain in the swelling. Difficulty in swallowing and breathing was complained by 23 (12.9) and 18(10.1%) of the patients respectively. Pain with fever was the complaint for 12 (6.7) patients and change of voice was the complaint of 6 (3.3%) patients [Table 2].
|Table 2: Distribution of study subjects according to the presenting features|
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In our present study, it was observed that 43.3% of the patients had swelling in the right lobe followed by 19.7% in the left lobe of the thyroid gland. It was observed that majority of the swelling (66.8%) was of firm consistency followed by hard (16.9%), soft (13.3%), and cystic (3.3%) [Table 3].
|Table 3: Distribution of study subjects according to the nature of the swelling|
Click here to view
The present study shows that 90% of the cases had euthyroid status. Hypothyroidism and hyperthyroidism were observed in 6.7% and 3.3% of the cases respectively [Table 4].
Only cases diagnosed with colloid goiter had various forms of surgery. Otherwise, majority were subjected to hemithyroidectomy (51.5%) [Table 5].
| Discussion|| |
In our study, the majority of patients had been reported to be in the age group of 21-40 years (76.7%) followed by 41-50 years (10%). Among the study participants, the youngest patient was nine years old; the oldest was 59 years old. These finding correlated well with the observations of several authors. ,,,
There was a ratio between female and male to be 4:1. This was in conformity with the observation of several workers. ,,,
In our present study 93.2% cases sought medical advice because of neck swelling and 19.7% swellings were with associated pain, difficulty in swallowing in 12.9%, difficulty in breathing in 10.10%, change of voice 3.3% and pain associated with fever 6.7%. Bhansali, in his series of 600 cases, also noted that pain and dysphagia were reported by 13 and 12% patients respectively; but majority of the cases were without any symptom. 
Our study confirmed with the study of Ananthakrishnan et al that 94% of patients presented with history of swelling in the neck and only 10% with pain. 
None of out patients gave history of radiation exposure though low doses of radiation of accidental exposure reportedly can lead to nodular hyperplasia, lymphocytic thyroiditis and papillary carcinoma. ,
In out study the swelling was located in the right lobe in 43.3% of the cases followed by left lobe (19.7%). The site affected in the thyroid gland varied in reports of different study groups; most have found right lobe to be affected more. ,,
In our series, consistency of the thyroid swelling varied with highest as firm (66.8%). Bhansali also reported that the majority of the nodules in thyroid cancer were firm in consistency. 
Routine thyroid profiles were done to find out the functional status of the thyroid. In our series 90% cases were euthyroid, 6.7% were hyperthyroid and 3.3% with hypothyroid status, which was also reported by the researchers in this field. ,
National Cancer Registry Program, noted that, between 1984 and 1993, Thiruvananthapuram had the highest relative frequency of cases of thyroid cancer among all cancer cases enrolled in the hospital registry, 1.99 percent among males and 5.71 percent among females in comparison to national level of 0.1-0.2 percent; the age-adjusted incidence rates per 100,000 were about 1 for males and 1.8 for females as per the Mumbai Cancer Registry. 
Researcher from Kidwai Memorial Institute of Oncology (KIMIO), Bangalore noted that thyroid metastases were in bones in 72 percent, in lungs 41 percent, in liver 5 percent, and in brain 3 percent of cases. 
Due to the wide use of ultrasound imaging diagnostic techniques, the prevalence of thyroid nodules was greater than before up to 67% in randomly selected populations, with a higher frequency in women and the elderly. This means that a thyroid nodule found incidentally in an asymptomatic patient (thyroid incidentaloma) is not rare. ,,,
A prospective study of 245 patients indicated that 35% of them had thyroid nodules and at least 3.3% had thyroid malignancy, most of which were micropapillary carcinomas (one of eight carcinomas was palpable). In other words, 9.2% of thyroid nodules were malignant with the risk of malignancy was higher in patients over 45, regardless of the duration or severity of hyperthyroidism or goiter size. 
In our study hemithyroidectomy was done in 98 (55.06 %) cases followed by lobectomy. In treating solitary thyroid nodule, Crile and Dempsey in 1949 that a high index of suspicion should be directed and stressed that 90% cases can be diagnosed preoperatively with proper investigations.  The incidence of thyroid cancer with a palpable nodule, managed surgically, ranges from 11% to 20%. 
Removing the lesion for definitive histological assessment provide the only method of obtaining a firm tissue diagnosis. Researchers had noted that 50% of clinically solitary nodules were truly solitary and during exploration many cases were found to be of multinodular variety and recommended hemithyroidectomy for solitary nodular goiter. ,,,
Strength of our study lies in conducting all relevant investigations at the out patients department to increase patient compliance. With the advent and improvement of FNAC, we were able to have an improved understanding of the pathology of thyroid disease preoperatively. This also helped in subsequent management in a better approach. Moreover, as all the patients were from poor socio-economic background, they were given a therapy of maximum surgical ablation keeping in mind the fact that they may not routinely come up for follow up. None of the cases in our present series developed any postoperative complications including recurrent laryngeal nerve palsy, hypoparathyroidism, hypothyroidism or thyroid crisis (storm). Lastly, an attempt has been made to strike a balance between adequacy of therapy on one hand and morbidity and cost of lifelong substitution therapy associated with total thyroidectomy on the other.
We had several limitations. Firstly, ultrasonography was not done regularly except in one case where a thyroid swelling was associated with vascular malformation. Secondly, we had not done isotope scan scintigraphy as the facility was not available at our centre. Thirdly, we did not have facilities for frozen section analyses and the radio iodine ablation postoperatively. With all these constraints our surgical management was guided entirely by FNAC report and clinical acumen.
In the future directions of study, we have to plan tailor-made protocol for diverse situations. The controversy in managing benign or malignant thyroid swellings lies in the extent of operation as a vast majority of operation for solitary thyroid nodules are performed on benign cases. There is continuing disagreement on the most appropriate operation for differentiated carcinoma between lobectomy with isthmusectomy and total thyroidectomy as a routine beacuse many unilateral thyroid carcinomas have intraglandular dissemination. Minimally invasive techniques have to be developed. Laser-induced reduction of thyroid tissue has been performed on an animal model, but further work needs to be done before this can be used to treat hyperthyroid humans. 
| Conclusion|| |
To sum up, a vast majority of operations for solitary nodules are performed in benign nodules. The identification of malignant thyroid swelling amidst numerous benign or apparently benign goitres has always been a problematic part for the clinicians as well as for the cytologists. Fortunately most carcinomas of the thyroid swelling can be readily diagnosed by battery of investigations available.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]