The intent of survey is to measure the frequence of malignance in both sexes, in different age groups and comparing of different types of carcinoma, which occur in cold nodule. We hope to happen out the frequence of malignance in a cold nodule thyroid, which is a common status and tends to show in a younger age group. This survey will assist in foregrounding the significance of such a determination and aid towards set uping a intervention protocol applicable to our scene.It is a descriptive survey including 65 patients with cold nodule thyroid, during a period of three old ages from September, 2004 to August, 2007, conducted in the Department of General Surgery, Ward-2, Jinnah Postgraduate Medical Centre, Karachi.
The patients presented in Surgical outpatient section with lone thyroid nodules were advised thyroid scan. The patients in which thyroid scan shows cold nodule were farther evaluated.Out of 65 patients with cold nodule, 47 ( 72.3 % ) patients had simple colloid goiter, 7 ( 10.76 % ) patients had follicular adenoma, 1 ( 1.5 % ) patient had thyroiditis, 5 ( 7.69 % ) patients had papillose carcinoma, 2 ( 3.07 % ) patients had follicular carcinoma and 1 ( 1.
5 % ) patient had medullary carcinoma. The incidence of malignance in cold nodule thyroid was 12.3 % .All the patients with thyroid carcinoma were finally treated by entire thyroidectomy and postoperative tetraiodothyronine and radioactive I therapy was advised.
No return or metastasis found in the follow-up period. Hence this survey recommended the entire thyroidectomy as a process of pick for thyroid carcinoma.Keywords: Cold nodule, Thyroid carcinoma, Entire thyroidectomy.
Thyroid is an endocrinal secretory organ, situated in the lower portion of the forepart and sides of the cervix. It secretes tri-iodothyronin ( T3 ) , tetraiodothyronine ( T4 ) and calcitonin, T3 and T4 control basal metabolic rate and the bodily and psychoic growing of the person. Calcitonin plays an of import function in Ca metamorphosis.Normally thyroid secretory organ is non tangible. Expansion of thyroid secretory organ is called “ Goitre ” . The term goiter is derived from the Gallic word “ goiter ” which is bend comes from the Latin “ trough ” , intending “ Throat ” . 1Goitre may be classified as a diffuse goitre – diffuse expansion of the thyroid secretory organ ; or nodular goiter – expansion by one ( lone nodule ) or more nodules ( multinodular ) .
The goiter is one of the most often happening upsets of the thyroid all over the universe.Thyroid nodules are a common job. In the United States, the prevalence of tangible thyroid nodules is 4 – 7 % 2, 3, 6. This prevalence has dbeen derived from a non-goitrous countries and may be much higher in countries of Iodine deficiency2.A lone nodule 4.7 %A dominant nodule in a multinodular secretory organ 4.1 %Multinodular goitre 1 %The patients with a lone nodule ( about 15 % malignant ) and a dominant nodule in a multinodular secretory organ ( less than 5 % ) have a higher incidence of malignance as compared to those of multinodular goiter.
Malignancy may be in 5 % 3 to every bit many as 30 % 4 of all tangible lone nodules.On thyroid scanning, clinically lone nodules are farther classified as hot, warm, or cold. About 80 % of lone nodules are cold, but merely 15 % prove to be malignant.5There is besides a really high incidence of thyroid nodules in Pakistan. So many patients admitted in our ward non merely come from mountain countries but besides from other parts of state every bit good. The chief job in our state is that the patient ‘s holding thyroid nodules are coming to the hospital really tardily, sometimes after a hold of even 10 – 20 old ages. This hold can turn out deadly ( opportunities of malignance ) in certain instances.
Because of these facts, we planned and conducted a survey to measure the frequence of malignance in cold nodule thyroid in patients showing with clinically lone thyroid secretory organ in Surgical section Ward II, JPMC Karachi.
MATERIAL AND METHODS:
This is a retrospective survey of 65 patients with cold nodule thyroid admitted in the Surgical Ward-2, Jinnah Postgraduate Medical Centre, Karachi during a period of three old ages from September, 2004 to August, 2007. The present survey is conducted to measure frequence of malignance in cold nodule thyroid on the footing of clinical presentation, laboratory probes, FNAC, thyroid scanning and histopathology ( after lobectomy ) .The patients presented in Surgical outpatient section with lone thyroid nodules were advised thyroid scan. The patient in which thyroid scan shows cold nodule were farther evaluated. After choice from the OPD, the patients were admitted in the ward where initial rating included a elaborate history, physical scrutiny, everyday probes, FNAC, operative findings, histopathology study were done in all patients. The consequences were so analysed and decisions were made. The consequences of this survey were compared with the other surveies of National and International literatures.
The age of patients ranged from 16 – 60 old ages. The peak incidence of disease in this survey was in the 2nd decennary of life. Out of 65 patients, 11 were male and 54 were female. The male to female ratio was 1:4.9. Out of 8 patients of thyroid carcinoma, 7 were female and 1 male.
All the patients presented with swelling infront of cervix. Swelling was present in the right lobe in 35 patients ( 53.8 % ) in the left lobe in 23 patients ( 35.38 % ) and in the isthmus in 7 patients ( 10.76 % ) , 60 patients ( 92.3 % ) had house puffiness, 4 patients ( 6.
15 % ) had difficult puffiness, while in 1 patient ( 1.5 % ) it was fixed with next constructions.Consequences of FNAC were benign cystic lesion in 12 patients ( 18.46 % ) ; out of which 1 was hemorrhagic colloid cyst.
In 41 instances ( 63.07 % ) the study was benign, in 8 instances ( 12.3 % ) the study was leery and in 3 instances ( 4.6 % ) it showed malignant cells.
Merely in 1 instance the study was necrotizing thyroiditis.Depending upon the consequences of all probes, patients were classified into three groups:Group-I: Benign cystic lesions ( 18.46 % )Group-II: Benign solid lesions ( 64.61 % )Group-III: Malignant and leery lesions ( 16.
9 % )
Out of 12 patients in this group, 2 patients ( 3.07 % ) had complete decompression of the cyst after aspiration. In 1 patient ( 1.5 % ) , who had blood-stained aspirate, lobectomy was done. Lobectomy was besides done in the staying patients due to big size of goiter, cosmesis or wants of the patients. Postoperative histopathology study showed benign cystic lesions. All the patients in this group were females.
No postoperative complication occurred in this group.
This group included 42 patients. All the patients were operated due to big size of goiter, anxiousness, or decorative intent, lobectomy + isthmusectomy was the process performed in these patients.The histopathology study was thyroiditis in one patient while all others had simple colloid goiter.Three patients developed gruffness of voice after surgery, which recovered wholly later on.
Two patients developed postoperative lesion infection, which was treated with antiseptic dressings and antibiotics. Recurrence is non observed in any instance up to day of the month.
This group included 11 patients. All the 3 patients who showed malignant cells on FNAC and clinically and per-operatively were besides in favor of malignance ( thyroid nodule was difficult and fixed and in 2 instances cervical lymphadenopathy was present ) , were subjected to entire thyoidectomy. All the 8 patients confirmed malignance and was papillose carcinoma in 2 patients, follicular carcinoma in 2 patients and medullary carcinoma in 1 patient. Then completion entire thyroidectomy was performed in these patients.After entire thyroidectomy, the malignant instances were advised tetraiodothyronine in divided doses of 0.
2 – 0.3mg/day and besides referred to atomic energy Centre, JPMC, Karachi for radio-iodine therapy.Following protocol was made for the followup of the patients.All the 8 patients with malignance were advised radioactive I ( 131 I ) scan after 6 hebdomads of surgery.Ablation of remnant working thyroid tissue with radioactive I.Rescan after six months to one twelvemonth.
Thyroxine was omitted six hebdomads before scanning.Rescan after one twelvemonth, so after two old ages.Two patients with malignance did non come for follow up while the others had no grounds of return and metastasis during the follow-up period of two old ages.Two patients had transeunt marks of hypocalcaemia after entire thyroidectomy and were treated suitably.
One patient developed one-sided palsy of vocal cord postoperatively.Table No. I.FREQUENCY OF VARIOUS CARCINOMAS IN 8 PATIENTS OF COLD NODULE THYROID
Papillary carcinoma562.5 %Follicular carcinoma225 %Medullary carcinoma112.5 %Table No. II.
Sexual activity DISTRIBUTION IN 8 PATIENTS OFTHYROID CARCINOMA
NO. OF Patient
5 %Entire8100 %Table No. III.AGE DISTRIBUTION IN 8 PATIENTS OFTHYROID CARCINOMA
AGE ( YEARS )
NO. OF Patient
10-20337.5 %21-30112.5 %31-40337.
5 %41-50112.5 %51-60
n = 8ten = 27.75 old agesten A± S.D27.75 A± 11.26 old ages
Thyroid nodule is a common surgical job and the prevalence rate is about 5 % of the population.1,2,3,7 Solitary thyroid nodule is really common and largely benign.
1 The incidence of malignance in lone thyroid nodule is 11-20 % 6 while harmonizing to some writers, it is 15-20 % and even up to 50 % .2 About 80 % of the lone thyroid nodules are cold, but merely 15 % prove to be malignant.5 As the thyroid surgery carries important hazard, one should non run on every patient of goiter. Therefore, there should be some selective attack for the direction of the patient with cold thyroid nodules and surgery in benign conditions should be avoided.Thyroid nodules occur 3-4 times more often in adult females than men.
1,8 In this survey the male to female ratio is 1:4.9. Thyroid nodules occur early in the endemic area.5 The prevalence of a cold nodule is 2.5 times greater in countries of I lack than in iodine-sufficient areas.8 Thyroid nodules are most normally found in 20 to 40 old ages of age group.
5 In this survey the peak incidence was between 21-30 old ages of age. Right lobe of the thyroid secretory organ is involved more frequently by the lone thyroid nodule.9 In present survey, 35 patients ( 53.8 % ) had nodule nowadays in the right lobe. The incidence of malignance in cold thyroid nodule is 15 % .1,5 In this survey out of 65 patients with cold thyroid nodules, 8 had carcinoma. The incidence of malignance in cold thyroid nodule is 12.
3 % . The chief intent of FNAC is to distinguish benign from malignant nodules that will necessitate surgical remotion. In this survey, it served this intent. In 11 patients out of 65, it showed the study of malignant or leery cytology. After operation 8 instances proved to be of thyroid carcinoma.
Therefore, FNAC has a really high diagnostic truth rate of more than 90 % . It is the most cost effectual, safe and dependable for the rating of a thyroid nodule.10,11 But it is unable to distinguish follicular adenoma from follicular carcinoma. Papillary carcinoma is the most common signifier of thyroid malignant neoplastic disease, accounting for 50 to 80 % of all thyroid malignances.
The reported incidence of Papillary thyroid carcinoma has more than doubled in many states during the past half century. In Tasmania, an Island State of the commonwealth of Australia, the incidence has increased by 24.7 % per annum during the last two decades.12 While follicular carcinoma histories for 10-20 % , anaplastic for 13 % and medullary carcinoma for 5-10 % .
1,5 A survey done in the surgery section of Mauriziano Hospital of Torino, Italy shows that amongst the thyroid tumor, papillose carcinoma is the commonest 1 ( 54.3 % ) , medullary carcinoma ( 4.6 % ) and others ( 2.4 % ) .
13 The consequences obtained in this survey of 8 patients of thyroid malignant neoplastic disease were, papillose carcinoma in 5 patients ( 62.5 % ) , follicular carcinoma in 2 patients ( 25 % ) and medullary carcinoma in one patient ( 12.5 % ) .
Lone nodules doing airway compaction or those at high hazard for Carcinoma should motivate rating for surgical treatment.14 There is considerable contention sing the most appropriate surgical intervention of patients with differentiated thyroid carcinoma. This contention concerns the extent of thyroid resection. Most sawboness prefer entire thyroidectomy on patients with differentiated thyroid carcinoma. Recurrence rate addition if less than entire thyroidectomy is performed.15 For differentiated thyroid tumors, near-total thyroidectomy with saving of a part of the posterior thyroid capsule on the contralateral side should be done to cut down the hazard of parathyroid insufficiency.
16There is practical consensus that lobectomy is the least that should be done for a thyroid nodule that is leery for malignancy.1,5,8 Many have reported minimum morbidity following entire thyroidectomy and recommended its usage for all thyroid malignant neoplastic diseases, while others recommended lobectomy, which is associated with less complications because merely one recurrent laryngeal nervus is at hazard and it is impossible to take or wound all the parathyroids. Whether the long-run endurance is the same with lobectomy as with entire thyroidectomy is still ill-defined. On the footing of some retrospective surveies, the writers concluded that the complications like recurrent laryngeal nervus hurts and hypoparathyroidism, are more frequent with entire thyroidectomy than with a process less than entire thyroidectomy.
14Brooks et Als proposed that entire thyroidectomy has increased complication rate and did non diminish the incidence of local or nodal returns and disease related deceases. There was besides no difference in endurance. Therefore, these writers concluded that lobectomy is every bit effectual as entire thyroidectomy for differentiated thyroid carcinoma.
Writers, in favor of lobectomy, besides recommend that if a contralateral focal point of malignant neoplastic disease becomes clinically important in instance of papillose carcinoma, completion thyroidectomy can be performed easy at a ulterior date.8Entire thyroidectomy is recommended in high hazard patients, bilateral disease, larger tumors with extra-thyroidal extension, multicentricity and vascular invasion.1,5,8,17,18,19,20 Total thyroidectomy is effectual in extinguishing local disease such as multicentric bilateral tumor focal point and avoids return of malignant neoplastic disease in the contralateral lobe.
It besides prevents the distant possibility of anaplastic transmutation of a staying focal point of malignant neoplastic disease in the opposite lobe. Most significantly entire thyroidectomy facilitates the sensing and extirpation of metastatic disease with postoperative radioactive I therapy, which has been shown to diminish return and prolong survival.8 A important tendency towards entire thyroidectomy for low-risk differentiated thyroid carcinoma is present in the United States after a paradigm displacement from intervention of macroscopic disease to the intervention of macroscopic and microscopic disease progressively sensitive trials. Compeling statements for thyroid Lobectomy and entire throidactomy for low-risk thyroid malignant neoplastic disease remain.21In present survey lobectomy was done in 8 patients, isthmusectomy in 2 patients, lobectomy with isthmusectomy in 42 patients, near entire thyroidectomy in 3 patients and entire thyroidectomy in 8 patients. Correlating clinical image with FNAC and logical usage of thyroid malignance short of surgery and at the same clip forestalling patients from being addressed to a potentially evitable operation.
22The 2nd standard was adopted in this survey for handling the thyroid malignance based upon FNAC diagnosing and operative findings. Three patients with malignant cytology and 8 patients with leery cytology were treated by lobectomy + isthmusectomy ab initio. Histopatholoy study in 5 patients out of 8 confirmed malignance and they were so subjected to completion entire thyroidectomy. Completion thyroidectomy for thyroid malignance should be performed either within 10 yearss of the primary operation or after 3 months to cut down the incidence of complications. In one survey it was concluded that there is non definite impact of the timing of surgery on the rate of complications after completion thyroidectomy.23 In our survey, all the 3 patients who showed malignant cells on FNAC and clinically and peroperatively were besides in favor of malignance were treated by entire thyroidectomy. No international consensus exists about what exactly constitutes a low-risk or high -risk tumour.
Established indicants for less than entire thyriodectomy include little ( & lt ; 1 centimeter ) , unifocal and non-metastatic papillose thyroid carcinoma and minimally invasive follicular thyroid carcinomas.24 Formal cervix dissection was avoided in this survey, because of clinical absence of lymph node metastasis. For node-positive thyroid malignant neoplastic diseases, compartment oriented microdissection is the gilded criterion, whereas the construct of contraceptive lymph node dissection continues to elicit contention.
Most experts agree that everyday lymph node dissection is un necessary for low-risk well-differentiated thyroid cancer.24 Cervical lymoh node metastasis conferred independent hazard in all patients with follicular carcinoma, and in those patients with papillose carcinoma aged & gt ; 45 old ages, but did non impact endurance in patients with papillose carcinoma & lt ; 45 years.25No patient had return in the follow up period of about two old ages. Whether the endurance rate in patients holding lobectomy + isthmusectomy is the same as in entire thyroidectomy is ill-defined due to less figure of patients in this survey and short period of follow up. All the patients were on thyroxine suppression and radioiodine therapy, and showed high success rates as are observed with this type of accessory therapy.
Surgical complications were infrequent. Wound infection is an unusual complication after thyroid surgery.26 It was found in 2 patients ( 3.
17 % ) in this survey. Hypocalcemia necessitating Ca addendums occurs in 2 – 11 % of patients in different studies.27,28 Two patients ( 3.17 % ) developed hypocalcaemia which was transient and recovered by Ca addendums in this survey. Inspiratory stridor due to engagement of intrinsic laryngeal musculuss may predate tetanilla in post-operative patients.29 In this survey 1 patient ( 1.58 % ) developed tetany postoperatively. Sorethroat, hoarsness of voice, laryngeal hydrops and stridor are the complications of extubation.
29 In this survey, 3 patients ( 4.76 % ) developed gruffness of voice postoperatively. The incidence of perennial laryngeal nervus hurt ranges from 1.5 – 5 % .29,30 The rate of recurrent laryngeal nervus paralysis is much lower in lone nodules whether solid or cystic.
31 In this survey 1 patient ( 1.58 % ) developed one-sided palsy of vocal cords after thyroid surgery.
Lone thyroid nodule is a common surgical job. The sequences of probes is directed towards the anticipation of carcinoma of thyroid. Thyroid isotope scanning can non know apart between benign and malignant nodules. FNAC has become the first pick probe for lone thyroid nodule, because it provides a diagnosing with high truth rate.
Entire thyroidectomy is the operation of pick for thyroid carcinoma. Lymph node dissection should be performed merely if they are clinically involved. Surgical deletion for malignance should be followed by tetraiodothyronine and radioactive I therapy, because, some of the differentiated thyroid carcinomas are dependent on TSH.
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