Medicinski Glasnik, Volume 10, Number 1, February 2013
NOTES Clinical management and outcomes of papillary, follicular and medullary thyroid cancer surgery
Nasrin Rahmani1, Seyyed Abbas Hashemi2, Mehran Fazli2, Mohammad Raisian2 Department of General Surgery, 2Student Research Committee; School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
1
Corresponding author: Seyyed Abbas Hashemi; Student Re-
search Committee, Mazandaran University of Medical Sciences Moallem Square, Sari, Mazandaran, Iran; Phone: +98 91 125 81 083; Fax: +98 15 135 432 48;
Email:
[email protected]
Original submission: 29 September 2012; Accepted: 15 October 2012.
Med Glas Ljek komore Zenicko-doboj kantona 2013; 10(1):164-167
ABSTRACT The clinical characteristics, pathological subtypes and patients’ survival in 40 patients with thyroid carcinoma between March 2007 and March 2012 were evaluated. This study included 33 (82.5 %) females and seven (17.5%) males (female to male ratio of 4.7:1). The median age of patients was 47.5 (range; 24-64). Papillary carcinoma was the commonest pathological subtype (23 patients, 57.5%), followed by follicular carcinoma (14 patients, 35%) and medullary carcinoma (3 cases, 7.5%). Total thryoidectomy was performed in 30 (75%), lobectomy in six (15%), subtotal and multifocal thryoidectomy in two (5%) patients. The median time of follow up was 3 years with range of 1-5 years. After ive years 34 (85%) patients were alive and six (15%) were dead. The overall 5-year actuarial survival was 85%, for papillary carcinoma 91.3%, for follicular carcinoma 85.7% and for medullary carcinoma it was 33.3%. The results suggest that total thryoidectomy had better outcome in comparison with other surgeries. Key words: thyroid, malignancy, survival, treatment INTRODUCTION During the past 30 years there was an increase in the incidence of thyroid cancer and a research indicated the prevalence of this malignancy in fe-
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males and males 67%, 48%, respectively between 1973 and 2002 in the world (1). The incidence of thyroid cancer is higher in females than in males with a ratio of 3:1, apart from adolescent and young adult patients where the incidence in women is 5-fold higher (2). In this relation, different ethnic backgrounds and population have been showen in various reports (1,3,4). Moreover, some studies revealed an increase in small-size tumors (5-7) and some other reports revealed an increase in all sizes (1, 3, 8). Some investigators reported an increase in thyroid malignancy incidence caused by a widespread increase in a still esoteric environmental or lifestyle factor(s) (3, 8-11). Primary thyroid cancers are unusual tumors while diagnosis and treatment of these tumors are a challenging issue, because there are no identiied morphological, immunohistochemical or molecular features correlated with these neoplasms (12). Therefore, in this paper, we tried to describe clinical characteristics of thyroid malignancies and reveal their association with inal histopthological report and to clarify the outcomes of surgery in treatment and survival of these patients. PATIENTS AND METHODS The clinical data including details of the diagnosis, age, histology, thyroglobulin levels, treatment details, response to treatment between March 2007 to March 2012 of patients who had undergone thyroid surgery for malignancy at Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran, were retrospectively analyzed. Study endpoints included date of last follow-up of all cases in the same day (20 March 2012). The Ethics Committee of Mazandaran University of Medical Sciences (Sari, IRAN) approved this study. All the cases were referred by endocrinologists, oncologists or other clinics as having thyroid nodules, and all the cases had undergone ultra sonography and ine needle aspiration (FNA) to determine the nodule. Clinical and follow-up information was obtained from the patients’ iles or from referral information where available and survivals were examined by checking the current state of the
Notes
patients. Inclusion criteria included the patients with a new diagnosis of thyroid cancer (histologically proved to have malignancy). Exclusion criteria involved the patients with thyroid cancer who were returned due to recurrence of the disease. Data were collected, reviewed, coded and entered into the computer program. Data were presented in the form of frequencies and percentages. Cumulative survival plots were constructed using the Kaplan-Meier method. Log rank test was preformed to evaluate the difference in overall survival time between the groups. Chi-squared test was used for comparing qualitative data. RESULTS The study population included 40 patients with thyroid carcinoma including 33 females (82.5%) and seven males (17.5 %) with female to male ratio of 4.7:1. Sixteen (40%) patients were under the age of 45, 20 (50%) between 45 to 60 years of age and four (10%) patients were older than 60 years. The median age of patients was 47.5 and the minimum age was 24, whereas the maximum age was 64 years. The mean age of cases was 46.92±9.60 (CI 95%: 43.85-49.99). Papillary carcinoma was presented at the lowest age group with Mean ± SD age of 46.14±9.75 years and meddulary carcinoma was presented at highest age group with Mean ± SD age of 52.33±1.52 years (Table 1). The median time of follow up was 3 years with the range of 1-5 years. After ive years 34 (85%) patients were alive and six (15 %) were dead. Hyperthyroidism was presented in 34 (85%) patients and six patients (15%) were presented with hypothyroidism. Papillary carcinoma was the commonest pathological subtype (23 cases, 57.5 %) followed by follicular carcinoma (14 patients, 35 %) and medullary carcinoma (3 cases, 7.5 %) (Table 1). Table 1. Mean ± SD of age according to a tumor type CI 95% 42.24-50.97 40.51-51.77 48.53-56.12
Median
Mean ± SD
47.00 45.00 52.00
46.14±9.75 46.60±10.08 52.33±1.52
No (%) of patients 23 (57.5) 14 (35) 3 (7.5)
Type of tumor Papillary Follicular Medullary
Total thryoidectomy was the most common type of surgery which was applied in 30 (75%), followed by lobectomy in six (15%) patients (Table 2).
Table 2. Surgery methods used according to pathological subtypes of tumors No of patients
Tumor type
4 2
Papillary Follicular
15 12 3
Papillary Follicular Medullary
2 2
Papillary Overall
2 2
Papillary Overall
type Surgery Lobectomy Total thryoidectomy
Subtotal thryoidectomy Multifocal thryoidectomy
Levothyroxin (levoxine) was prescribed for 25 patients after the surgery, eight patients were without drug therapy and seven patients received metimazol (tapazol) (Table 3). Table 3. Drug therapy after surgery Papillary Without drug therapy 5 (62.5) Levothyroxin 18 (72.0) Metimazol 0 Total 23 (57.5)
No (%) of patients Follicular Meddulary 3 (37.5) 0 7 (28.0) 0 4 (57.1) 3 (42.9) 14 (35.0) 3 (7.5)
Total 8 (20) 25 (62.5) 7 (17.5) 40 (100)
The overall 5-year survival was 85% (95% CI, 79%–92%). The 5-year survival of patients with papillary carcinoma was 91.3%, it was 85.7% for follicular carcinoma and 33.3% for medullary carcinoma. The overall mean survival time was 57.34 ±1.60 month (median 60 month). The mean survival time in follicular carcinoma was 54.55±3.51 month (median 60 month), in papillary carcinoma it was 60 month (median 60 month) and in medullary carcinoma it was 54.00±6.00 month (median 48 month) (p = 0.040) . DISCUSSION There have been very few investigations looking primarily at the clinical management and outcomes of surgery and simultaneously discussing the clinical indings associated with thyroid cancers. So this study was conducted to achieve reliable outcomes in this regard. Sampson et al (13) examined the clinical and outcomes of treatment of 49 cases with thyroid malignancy with median time of follow- up 3.5 years and revealed 51% patients were alive and
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Medicinski Glasnik, Volume 10, Number 1, February 2013
49% died. Likewise, in the current study, the median time of follow up was 3 years with the range of 1-5 years, and after ive years 85% of patients were alive and 15% were dead. However, in contrast to the present work where the overall 5-year actuarial survival was 85%, in the Sampson study 5-year actuarial survival was 50% (13). In the current research the patients with papillary carcinoma had the best survival rate. Although the mean age of the patients with papillary carcinoma was lower than in the patients with other carcinoma they had better prognoses. The patients’ age tended to be a strong prognostic factor in both papillary and follicular carcinomas and has its own effect on the presence of metastatic disease (14-22). The mean age of the cases from this study was 46.92±9.60, which was lower than the mean age of 51 reported in other investigations (14,21). Al-Zaher N et al (23) indicated 58% of patients were under the age of 45 years with a peak incidence in the fourth and ifth decades of life, with the female to male ratio of 2.4:1. Eightyfour percent of their series had papillary thyroid carcinoma, while follicular thyroid carcinoma, anaplastic thyroid carcinoma and medullary carcinoma were seen in 14%, 1.4% and 0.6%, respectively. However, in the present study 40 % of patients were below 45 years of age and 60% were older than 45, with the female to male ratio of 3.4:1 suggesting the predomination of females like in Al-Zaher study (23). Bukhari U et al (24) found papillary carcinoma as the commonest carcinoma (90.2%), with the female to male ratio of 4.7:1. The majority of the study populations was in the fourth decade of life followed by the third and second decades. Likewise the previous studies, the majority of our cases had papillary carcinoma, which has been seen in most countries around the Persian Gulf (23, 24). In conclusion, the majority of this study population had papillary and follicular carcinoma of thyroid, and had undergone total thyroidectomy resulting in more than 85% ive-year survival. Additional studies on more cases are needed to conirm the results.
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FUNDING This work was supported by a grant from Mazandaran University of Medical Sciences, Sari, Iran TRANSPARENCY DECLARATIONS Competing interests: none to declare. REFERENCES 1. Kilfoy BA, Zheng T, Holford TR, Han X, Ward MH, Sjodin A, Zhang Y, Bai Y, Zhu C, Guo GL, Rothman N, Zhang Y. International patterns and trends in thyroid cancer incidence, 1973-2002. Cancer Cause Cont 2009; 20:525-31. 2. Bleyer, A, O’Leary M, Barr R, Ries LAG (Eds.). Cancer epidemiology in older adolescents and young adults 15 to 29 years of age, including SEER incidence and survival: 1975-2000. NIH (Pub. No. 06-5767). Bethesda: National Cancer Institute, (2006). http:// seer.cancer.gov (March 13 2009) 3. Yu GP, Li JC, Branovan D, McCormick S, Schantz SP. Thyroid cancer incidence and survival in the National Cancer Institute Surveillance, Epidemiology, and End Results Race/Ethnicity Groups. Thyroid 2010; 20:465-73. 4. Mitchell I, Livingston EH, Chang AY, Holt S, Snyder WH 3rd, Lingvay I, Nwariaku FE. Trends in thyroid cancer demographics and surgical therapy in the United States. Surgery 2007; 142: 823-8. 5. Colonna M, Guizard AV, Schvartz C, Velten M, Raverdy N, Molinie F, Delafosse P, Franc B, Grosclaude P. A time trend analysis of papillary and follicular cancers as a function of tumour size: a study of data from six cancer registries in France (1983-2000). Euro J Cancer 2007; 43:891-900. 6. Davies L, Welch HG. Increasing incidence of thyroid cancer in the United States, 1973-2002. JAMA 2006; 295:2164-7. 7. Kent WDT, Hall SF, Isotalo PA Houlden RL, George RL, Groome PA. Increased incidence of differentiated thyroid carcinoma and detection of subclinical disease. Can Med Assoc J 2007; 177:1357-61. 8. Enewold L, Zhu K, Ron E, Marrogi AJ, Stojadinovic A, Peoples GE, Devesa SS. Rising thyroid cancer incidence in the United States by demographic and tumor characteristics, 1980-2005. Cancer Epidemio Biomark Prevent 2009; 18:784-91. 9. Chen AY, Jemal A , Ward EM. Increasing incidence of differentiated thyroid cancer in the United States, 1988-2005. Cancer 2009; 115: 3801-3807. 10. Burgess JR, Dwyer T, McArdle K, Tucker P , Shugg D. The changing incidence and spectrum of thyroid carcinoma in Tasmania (1978-1998) during a transition from iodine suficiency to iodine deiciency. J Clin Endocr Metab 2000; 85:1513-7. 11. Mulla ZD , Margo CE. Primary malignancies of the thyroid: epidemiologic analysis of the Florida Cancer Data System registry. Ann Epidemiol 2000; 10:2430.
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12. Weissferdt A, Moran CA. Anaplastic thymic carcinoma: a clinicopathologic and immunohistochemical study of 6 cases. Hum Path 2012; 43:874-7. 13. Elliot Sampson, James D. Brierley, Lisa WL, Lorne R, Richard W.Tsang. Clinical management and outcome of papillary and follicular (differentiated) thyroid cancer presenting with distant metastasis at diagnosis. Cancer 2007; 110:1451-6. 14. Shaha AR, Shah JP, Loree TR. Differentiated thyroid cancer presenting initially with distant metastasis. Am J Surg 1997; 174:474-6. 15. Ruegemer JJ, Hay ID, Bergstralh EJ, Ryan JJ, Offord KP, Gorman CA. Distant metastases in differentiated thyroid carcinoma: a multivariate analysis of prognostic variables. J Clin Endocr Metab1988; 67:501-8. 16. Schlumberger M, Tubiana M, De Vathaire F, Hill C, Gardet P, Travagli JP, Fragu P, Lumbroso J, Caillou B, Parmentier C. Longterm results of treatment of 283 patients with lung and bone metastases from differentiated thyroid carcinoma. J Clin Endocr Metab 1986; 63:960-7. 17. Samaan NA, Schultz PN, Haynie TP, Ordonez NG. Pulmonary metastasis of differentiated thyroid carcinoma: treatment results in 101 patients. J Clin Endocr Metab 1985; 60:376- 80. 18. Brierley J, Tsang R, Panzarella T, Bana N. Prognostic factors and the effect of treatment with radioactive iodine and external beam radiation on patients with differentiated thyroid cancer seen at a single institution over 40 years. Clin Endocrinol (Oxf) 2005; 63:41827. 19. Hay ID, Bergstralh EJ, Goellner JR, Ebersold JR, Grant CS. Predicting outcome in papillary thyroid carcinoma: development of a reliable prognostic scoring system in a cohort of 1779 patients surgically treated at one institution during 1940 through 1989. Surgery 1993; 114:1050-7. 20. Mazzaferri EL , Jhiang SM. Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Am J Med1994; 97:418-28. 21. Haq M, Harmer C. Differentiated thyroid carcinoma with distant metastases at presentation: prognostic factors and outcome. Clin Endocrinol (Oxf) 2005; 63:87-93. 22. Dinneen SF, Valimaki MJ, Bergstralh EJ, Goellner JR, Gorman CA , Hay ID. Distant metastases in papillary thyroid carcinoma: 100 cases observed at one institution during 5 decades. J Clin Endocr Metab 1995; 80:2041-5. 23. Al-Zaher N, Al-Salam S , El Teraii H. Thyroid carcinoma in the United Arab Emirates: perspectives and experience of a tertiary care hospital. Hematol Oncol Stem Cell Ther 2008; 1:14-21. 24. Bukhari U, Sadiq S, Memon J , Baig F. Thyroid carcinoma in Pakistan: a retrospective review of 998 cases from an academic referral center. Hematol Oncol Stem Cell Ther 2009; 2:345-8.
NOTES Preoperative evaluation in the era of laparoscopic surgery
Ljiljana Gvozdenović1, Vladimir Pilija2, Saša Milić3, Dejan Ivanov1, Radovan Cvijanović1, Vesna Pajtić4
Clinical Center of Vojvodina; Novi Sad, Serbia; 2Department for Forensic Medicine, Clinical Center of Vojvodina; Novi Sad, 3 Emergency Medical Service, Health Center; Inđija, 4Emergency Medical Center, Clinical Center of Vojvodina; Novi Sad, Serbia 1
Corresponding author: Ljiljana Gvozdenović; Clinical Center of Vojvodina; Hajduk Veljkova 1, 21000 Novi Sad, Serbia; Phone: +381 21 633 200; fax: +381 21 423 902;
E-mail:
[email protected]
Original submission: 30 April 2012; Revised submission: 18 July 2012; Accepted: 19 September 2012.
Med Glas Ljek komore Zenicko-doboj kantona 2013; 10(1):167-170
ABSRACT To conirm the importance of preoperative evaluation of a patient’s health state, to reduce perioperative morbidity and mortality after laparoscopic surgery. A total number of 1,070 patients were selected into groups based on a type of intervention, gender, ASA and NYHA classiication. The most common laparoscopic procedure that was performed was cholecystectomy in 920 (86%) patients. Cardiovascular disease had been presented in 952 (89%) patients, 1006 (94 %) of patients were ASA class I- III, while 1049 (98%) patients were NYHA class I and II. Frequency of lethal outcome was 0.1% due to postoperative thromboembolic complications. A lower mortality rate is a result of prescribed protocol and adequate preoperative examination. Key words: laparoscopic surgery, risk group, complication INTRODUCTION The age of patients has increased thus increasing risks and importance of anesthesiology (1-5). Important things for different pathophysiologic changes compared to classic cholecystectomy are the position of a patient on the operatng table and forming of intraabdominal pressure (also called pneumoperitoneum) (1-5). Great attention is paid to the psychological evaluation of patients (5-7).
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