J. Lukáš 1,6; J. Paska 1; B. Hintnausová 2; D. Lukáš 3; M. Syrůček 4; P. Sýkorová 5
Authors place of work:
Oddělení ORL a chirurgie hlavy a krku, Nemocnice Na Homolce, Praha , 2Interna-endokrinologická ambulance, Nemocnice Na Homolce, Praha, 3Chirurgické oddělení, Nemocnice Na Františku, Praha, 4Patologie, Nemocnice Na Homolce, Praha, 5Univerzita Karlova v Pra
Published in the journal:
Čas. Lék. čes. 2010; 149: 378-380
Background. Microcarcinomas, minimum carcinomas, are tumors, which are in clinical practice defined as tumors ≤1cm in size. WHO defines thyroid microcarcinomas as tumors ≤ 2cm in size, which have different biological behavior. The aim of the study was to analyze the occurrence of MC in post-operative patients.
Methodology. Using retrospective analysis we evaluated the occurrence of thyroid microcarcinoma in post-operative patients. Except for basic demographic data, carcinoma size and histological variance, we evaluated the occurrence of bilateral impairment, presence of multi-focuses and occurrence of regional throat metastases.
Results. From 2004 to 2008 we performed thyroid surgeries in 400 patients. Microcarcinoma was diagnosed in 34 patients (8.5%); 5 men and 29 women. The average age of patients with microcarcinoma was 52 years, and unlike other patients undergoing surgery. Histologically, 32 cases (94%) were papillary carcinoma, from which 4 cases were papillary follicular and 2 were follicular carcinomas. There were multifocal findings of microcarcinomas in 5 patients (15%), and 4 patients (12%) had bilateral involvement. The average size of the tumors was 5mm, sd 2.6. Two patients (6%) had metastases in the lymph nodes of the neck. We carried out total thyroidectomies in 32 patients (94%) and hemithyroidectomies in 2 patients (6%). Five patients (15%), i. e. both patients with metastases in the lymph nodes of the neck and three patients with bilateral multifocal carcinomas underwent postoperative adjuvant radioiodine 131I ablation therapy.
Conclusion. We do not consider microcarcinomas to be harmless, almost insignificant findings, due to the possibility of their future growth, metastasizing and reoccurrence. The increased risk of the MC occurrence was found in chronic lymphoplasmocellular thyroiditis (17%).
the last decades we have experienced a growing occurrence of little
advanced forms of thyroid carcinomas, microcarcinomas (MC) (1,2,3).
According to the WHO definition from 1974, these are tumors with a
maximum diameter of < 2cm, which are surrounded by normal thyroid
tissue with no capsular invasion or extrathyroidal spreading having
manifestations and the biological behavior of thyroid microcarcinomas
can vary from occult to aggressive, with locoregional metastases and
MCs are often accidental histopathological findings in glands
operated on due to some benign disease. The first clinical
manifestations of MC can also be an occurrence of metastases in the
lymph nodes of the neck in so far occult gland tumor. Furthermore,
there are microcarcinomas that could be revealed by an accidental
sectional finding in glands of patients in which thyroid disease was
not diagnosed during their life. According to some published data, MC
found in sectional findings occurs in approximately 1-35% of total
cases (2). The prognosis of patients with MC is generally good; the
ten-year survival rate is around 93 % (2,3,4). We demonstrate the
occurrence of microcarcinomas in post-operative patients and the most
frequent histopathological changes in thyroid using the retrospective
analysis for the period of 4 years.
of thyroid microcarcinomas in patients having
surgery at the Otolaryngology-Head
and Neck Surgery Department of the “Nemocnice Na Homolce”
endocrinologists there indicated surgeries and their scope, i.e.
hemi- or total thyroidectomy, in patients with thyroid impairment.
Patients approved their consent to the surgery and its scope by
signing the “Informed Consent” form.
for the basic demographic data of patients (age and sex), we
evaluated histopathological findings, multifocal and bilateral
occurrence and presence of metastases in the neck lymph nodes.
data are presented as absolute and relative. Hypothesis regarding the
compliance in percentage presentation were tested using the Fisher’s
exact test. The data were analyzed using the Stata package software,
release 9.2 (Stata Corp.LP, College Station, USA). All procedures and
protocols were in conformance with the Declaration of Helsinki. The
Ethical Committee of the “Nemocnice na Homolce” Hospital agrees
with the presentation of the data herein.
In the period from 2004 to 2008, 400 patients (66
men and 334 women) underwent thyroid surgeries. Benign lesions were
diagnosed in 336 patients (84%) who had undergone surgery, malignant
tumors in 30 patients (7.5%) and microcarcinoma was verified in 34
patients (8.5%), out of which 29 were women and 5 men. The risk of
the MC occurrence was almost identical (p=0.497) in both sexes in
case of the thyroid impairment. The average age of patients was 52
11.6 (range 30-78 years) and unlike in other patients that had
undergone surgery. During preoperative fine needle aspiration biopsy
examinations under US control, MC was verified in 10 patients
(29.4%). There were accidental MC findings during postoperative
histopathological thyroid examinations in 23 patients (67.6%). In one
case (2.9%), the MC was diagnosed based on the examination of
metastasis resected from a lymph node of the neck, see Table 1.
anatomical changes in thyroid, due to which patients were indicated
for surgery; in 76 cases there were single nodule and in 172 cases
multinodular goiters, in 76 cases thyreotoxicosis and in 12 cases
chronic lymphoplasmocytic thyroiditis, see table 2.
Papillary carcinoma was found in 32
patients (94%), out of which 4 cases were papillary follicular
carcinoma subtypes; follicular carcinoma was found in 2 patients
(5.8%). The average MC size was 5 mm, sd
2.6 mm; in two-thirds of patients, the carcinoma size was 2 to 7 mm
and a third ranged between 8 and 10 mm. Multifocal occurrence of MC
(2 - 4 focuses) was detected in 5 patients (15%), out of which one
was unilateral and four bilateral. Two patients (6%) had metastases
in the neck lymph nodes, and two patients (6%) had both MC and lung
carcinoma. A total thyroidectomy was carried out in 32 patients
(94%), out of which 6 underwent two-stage surgeries and 2 had (6%)
hemithyroidectomies. Five patients (15%), i.e. both patients with
locoregional metastases and 3 patients with bilateral multifocal
microcarcinomas received postoperative adjuvant radioiodine 131I
therapy. The average monitoring period was 28.1 months (range 2 - 69
months), sd 22.8 and median 20.7, and included a controlled
ultrasonography of the neck and a laboratory examination of
thyreoglobulin (TGL). During the monitored period, no local relapse
or distant metastases occurred.
ultrasound-guided fine needle biopsy of the nodal goiter is essential
for the determination of its biological character. When a sufficient
cell tissue sample is obtained and assessed by an experienced
cytopathologist, the sensitivity and specificity of the method
exceeds 85% (5). Despite this, most MCs are only diagnosed during
histopathological examinations. MCs exhibit a varied biological
behavior. Most authors regard microcarcinomas as significant lesions
leading to both morbidity and lethality (3). We had only one case of
papillary microcarcinoma with an aggressive behavior in our set, when
a 2 mm tumor metastasized into a jugulo-carotid lymph node, which was
the first clinical manifestation. Roli et al. and other authors
consider the tumor size to be a significant risk factor of metastases
in lymph nodes of the neck (6). No metastases were found in tumors
under 8 mm in size, whereas in larger ones metastases did occur. Our
second patient with locoregional metastases had multifocal, bilateral
MCs with focuses of 5-7mm on one side and 8-10 mm on the other side.
Except for tumor size, other risk factors of locoregional metastases
are follicular variants of papillary carcinoma (7). Roli et al.
report incidental MC findings during histopathological examinations
when treating, until then, benign thyreopathy in 21.4% of the cases;
in our set they constituted almost 68% of the cases (6). Roli and
Sakorafas report the occurrence of minimum carcinomas in the form of
occult tumors during thyroid autopsies in 36% of cases (6,8). In 1985
Harach et al. revealed high incidences (77%) of MC during thyroid
autopsies with findings spread evenly through the individual life
stages (9). There are geographical differences in MC incidences,
which are determined genetically and environmentally. Furthermore,
they are influenced by the use of histopathological examination
methods (10). Lupoli states that prevalence of familiar non-medullary
thyroid carcinomas ranges between 3.5 and 6.2%, and their biological
behavior is more aggressive with a much worse prognosis than in cases
of sporadically occurring carcinomas (11). Most surgeons accept
total thyroidectomy as a consensus treatment. The reasons are the
high incidence of multifocal and bilateral MC findings, decreasing
the risk of local recurrence by removing the central compartment
lymph nodes; easier postoperative and post-radiation monitoring of
plasma thyreoglobulin (TGL);
and easier ultrasonographic detection of neck metastases (12). Dvořák
et al. recommended total
thyroidectomy in patients older
than 65 years and with
a tumour □≤ 1 cm;
together with postoperative adjuvant 131I
therapy in patients younger than 65 years with bilateral or
multifocal occurrence of MC; and TTE
together with selective
modified neck dissection
and postoperative adjuvant 131I
patients with metastases in regional lymph nodes of the neck.
Patients with multifocal occurrence of carcinomas and tumors ≥ 1 cm
must be subjected to the postoperative L-thyroxine suppression
therapy and close follow-ups monitoring TSH, fT4 and TGL, as well as
ultrasonographic examination once in every six months. A sufficient
follow-up of other patients with MC is once a year (3). The most
frequent histological type of thyroid carcinoma is its papillary
form, which occurs in 65% - 99% of cases, and we obtained
corresponding results (94%). Bramley et al. state that 30% of
papillary carcinomas are papillary microcarcinomas (1). Follicular
variant of papillary carcinoma occurred in 6% of cases.
Women and age over 45 are
the thyroid impairment risk group.
We regard microcarcinomas as clinically
serous lesions that must be radically solved and patients must be
subjected to close follow-ups. As for the
pathological anatomical changes in thyroid, the most frequent MC
occurrence was found in patients with chronic lymphoplasmocellular
-Fine-needle aspiration biopsy
- World Health Organization
sd - standard deviation
- total thyroidectomy
-near- total thyroidectomy
- thyroid stimulating hormone
authors would like to thank prof.
MUDr. J. Dvořák , Ph.D., from Oddělení chirurgie Karlovarské
krajské nemocnice for obtain comments.
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