Frequency of Thyroid Cancer at King Fahad Hospital, Madinah

Frequency of Thyroid Cancer at  King Fahad Hospital, Madinah

1. Muhammad Jawed2. AftabAhmed Shaikh3. Muhammad Iqbal Khan

1. Asstt. Prof. of Surgery & Bariatric Surgeon, Surgical Unit-1, Dow University Hospital OJHA Campus Karachi 2. Consultant Radiologist, King Fahad Hospital Madina Munawara 3. Senior Registrar, Jinnah Postgraduate Medical Centre, Karachi

ABSTRACT

Objective: To assess the frequency of common thyroid cancer at king Fahad  Hospital, Madinah.       

Study Design: Retrospective study.

Place and Duration of Study: This study was carried out on all the patients treated for Cancer of Thyroid Gland, at King Fahad Hospital (KFH)-Madinah between Jan 2009 to February 2012.

Patients and Methods: Ninety-one patients diagnosed with Cancer of Thyroid of various Age, Sex & Races were registered with King Fahad Hospital Madinah.

Results: 75% patients were Saudi nationals, 10 % patients were from other Arab countries and the remaining 15 % were non-Arabs. There were 72%  females and 28%  Males . The Ages ranged from 14 years to 94 years.  34%  of these patients were less then 30 years of Age at the time of the diagnosis. Over 90 % of the cases presented with Swelling Anterior Neck while in other 10%  of the cases Dysphagia or Dyspnoea  with Rt. or Lt. supraclavicular masss/swelling was the major complaint. 71% patients under went various surgical procedures for the Neck swelling. The Total Thyroidectomy was  done in 48% patients .  The Histology revealed 52 % of pure Papillary Carcinoma and 23 %  were of Follicular origin. Majority of the diagnosed patients of Ca. Thyroid were referred to King Faisal Specialist Hospital Riyadh for Radioactive Iodine Ablation Therapy. The follow-up was poor as patients were from highly mobile population and belonged to Nine different countries.

Conclusion: The study reveals that the presentation of Ca. Thyroid in our series is essentially similar to what has been reported from other parts of the world. 

Key Words:Radioactive Iodine (RAI) Ablation Therapy, Thyroidectomy, Thyroglobulin, Goiter, Malignancy, Thyroid.

 

INTRODUCTION

Thyroid cancer is a relatively rare and comprises a heterogeneous group of malignant neoplasms that show differences in biological behavior, but in prognosis as well 1-2. Follicular cancer tends to metastasize to the lungs and bones, while the papillary carcinoma commonly spreads to the lymph nodes. Metastases to the cervical lymph nodes are located in the 15% -50% of papillary carcinoma when time of diagnosis3. Thyroid cancer is the most common of all cancers of the endocrine glands, which represents 87% of all cancers of the endocrine glands. Thyroid cancer, although relatively rare, is the second most common cancer among women in Saudi Arabia4-7.

Over the past two decades, there has been significant improvement in the survival of the cancer patients in general and those suffering from Cancer of thyroid.  This is largely attributed to the multicentre prospective studies conducted by various Centers in the United States, Europe and other internationally recognized institutes8,9 . However this may not be the case in the developing countries where social as well as the regional factors contributes to the outcome of the disease. The study of epidemiology and pattern of cancer is of the utmost importance for the establishment of  the both preventive and therapeutic measures. This calls for  the setting up of a Multicentre National  Cancer Registry in the Kingdom of the Saudi Arabia for Ca. Thyroid patients.

PATIENTS AND METHODS

The King Fahad Hospital (KFH)-Madinah is a tertiary care referral hospital in the Kingdom of Saudi Arabia.  A retrospective study was done of all the patients treated for Cancer of Thyroid Gland at the hospital between Jan 2009 to February 2012.  Between this period 91 patients were treated at the hospital for the various types of thyroid malignancies. The Medical Records of these patients of Ca. Thyroid were reviewed for the Age at diagnosis, Sex & Mode of presentation. An attempt is also made to analyze the Ethnic distribution, Initial diagnosis before registration with KFH, Clinical Extent of the disease at Initial Presentation, the Commonest type of   Malignancy and the type of treatment given  in these patients.

RESULTS

Ninety-one (91) patients  diagnosed with Cancer of  Thyroid of  different Age , Sex and races were registered at  KFH  between the study period. Of  these, 68 patients were Saudi nationals , 09 patients were from other Arab countries and remaining 14 patients  were non-Arabs Chart No-1. There were 66 Females and  25 Males. The Female to male  ratio was 5:2.  The Ages ranged from 14 years to 94 years. 31 of these patients were less then 30 years of Age at the time of the diagnosis.  Over 90 percent of the cases presented with Swelling Anterior Neck while in other 8 to 10 percent cases Dysphagia & Dyspnoea with Rt. or Lt. supraclavicular mass/swelling was the major complaint. Their mode of presentation is given in Table-1.  Of these 91 patients , one patient was diagnosed having Sub-Sternal mass, one patient came with the complaints of Scrotal swelling  who was diagnosed coincidentally as a case of Ca. Thyroid and the one patient came with the diagnosis of  Lipoma  Thyroid.

Majority of the patients 63 (69%) were referred from various local or territory hospitals around Madinah with the provisional diagnosis of Goiter while 07(8 %) patients were referred with the diagnosis of Ca. Thyroid.

Clinical Extent: Well Differentiated  Papillary Ca. tends to metastasize to local neck nodes while Follicular lesions tends to hematogenously metastasize mostly to Lungs and Skeleton3,9,10,11.  In our series the disease was diagnosed at early stage  as in 73 ( 80 %) patients the disease was localized while wide spread Metastasis ( Lungs Bone etc.) was noted in 13 ( 14 % )  patients. Five (5.5 %) patients came with the Recurrence of the disease.

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Chart No.1: Nationality

Predominant Histology & Treatment: Primary treatment offered at KFH was Surgery  which was followed by the Radioactive Iodine 131 Ablation Therapy at King Faisal Specialist Hospital (KFSH)-Riyadh. The surgical procedures were chosen according to the Clinical Status and the Extent (staging) of the disease. 65 ( 71% )  patients under went various surgical procedures for the Neck Swelling. The Total Thyroidectomy was done in 31 ( 48 % ) patients,  Near Total Thyroidecomy in 8 (12 %) patients, Sub-Total Thyroidectomy in 12 cases (18%) while the Partial Thyroidectomy was carried out in 14(21 %) patients Table No. 2. Due to poor general condition or other accompanying systemic diseases the surgery was not possible in 10 (11 % ) patients and these patients were given only symptomatic treatment. Due to extensive disease 11 (12 %) patients were Inoperable , these patients were refereed to KFSH Riyadh for further management while in other 5 patients the details of the surgery was not available.

Majority of the diagnosed patients of  Ca. Thyroid from KFH-Medina were referred to King Faisal Specialist Hospital - Riyadh for Radio-active I-131 Ablation Therapy.

Table No.1: Presenting symptoms

Symptoms

No. of Patients

Percentage

Neck mass

91

100%

Dysphagia

17

18.68%

Pain

10

10.98%

Dyspnea

8

8.79%

Hoarseness

6

6.59%

Thyrotoxicosis

3

3.29%

Weight loss

2

2.19%

Table No.2: Surgical Procedures (n=65)

Symptoms

No. of Patients

Percentage

Total Thyroidectomy

31

48%

Near Total Thyroidecomy

8

12%

Sub-Total Thyroidectomy

12

18%

Partial Thyroidectomy

14

21

DISCUSSION

The incidenceof thyroid cancer is increasing much faster than any other cancer in the United States (including liver cancer), almost tripled from 1980 to 2006. Improved diagnosis has been proposed as the main reason for this change by some, while others argue that other factors are responsible for the increase10,11. Cancer of thyroid is more common in women than men 12. In our set up, majority of the female patients attending out patient clinics are Muslims , covering their faces and neck and hesitate to uncover. Without proper physical examination of the neck, small or deeply cited thyroid nodule may remain obscure or undiagnosed . This indicates the importance of the physical examination of the neck even if the presenting complaint is only dysphagia or dyspnoea. The female patients may be explained the importance of the physical exam to overcome this problem.

It is interesting to note that patients with the complaint of Neck swelling attended the hospital after considerable laps of time. 10 %  of these patients came with the history of Neck swelling for a period more than 10 years  while 22 %  patients with Neck swelling for a duration between 5 to 10 years.  Despite of other complications , in  the long-standing  cases there is high probability of cancerous changes in thyroid nodules. Awareness in the general population  regarding Thyroid related diseases and its outcome in long-standing cases  may be an ultimate remedy . 

Although most thyroid nodules are not cancerous, thyroid cancer is diagnosed in about 10,000 people each year in United States 13. The  Fine Needle Aspiration Cytology (FNAC) of palpable nodules in the thyroid gland may also greatly contribute in the early detection of the disease. The thyroid scan may differentiate between Hot and Cold nodules. As reported in many international journals the cold nodules are more prone to be cancerous than Hot nodules 14 . This may increase the sensitivity of FNAC and help in selecting patients for the procedure. The thyroid scintigraphy and FNAC is  routinely carried out in our hospital and majority of our patients had thyroid scanning and FNAC in this series.

Total or near Total thyroidectomy is preferable to a more limited excision, specially in persons with primary lesions that are larger than 2.5 cm, multiple or locally invasive 15,16 . In our series 39 patients (60 %) out of selected 65 patients  for thyroid surgery had Total or near Total Thyroidectomy.

The use of Radioactive Iodine 131 in the treatment of cancer of thyroid has a sound theoretical basis 17. Iodine organification is a thyroid specific function and  I 131 is an effective agent for delivering radiation to the thyroid tissue with low radiation dose to other portions of the body . Despite the theoretical suitability it is not clear whether such therapy prolongs life . Various  series report either no effect or an effect only in a subset of patients. However this modality is commonly employed because of paucity of long-term complications and acute adverse effects at least in the adult . Due to some limitations , this treatment was not possible at KFH Medina . With the provision of a consultant Endocrinologist and active Nuclear Medicine department, this treatment will soon be started at this hospital.

The Human Thyroglobulin (Tg) is secreted only by thyroid gland  and can be elevated in benign thyroid conditions ( goiter , benign nodules) . It is also secreted by most differentiated thyroid cancer 18. Post thyroidectomy and ablation therapy , the thyroglobulin measurement does appears to be highly sensitive and specific in the follow up. Sensitivity range 83-100 % and specificity 83-97%. We noticed that very few patients were screened for this important  diagnostic modality in our series. This may be due to the reason as the patients were treated in “Split Manner” between KFH-Medina and King Faisal Specialist Hospital Riyadh and the  follow up record of majority of the patients was maintained by KFSH Riyadh.

It was difficult to define the long-term survival rate of these patient  as the patients were from a highly mobile population  and patients over 9 countries were included in this study. The follow up of the patients was also very  poor as most the patients were attending KFSH-Riyadh for their follow-up visits after Radioactive Iodine 131 Therapy.

CONCLUSION

We have attempted to document those aspects of the management of Thyroid cancer which we believe to be important. We are concerned that patients managed outside the King Fahad Hospital-Medina following surgery, face considerable inconvenience of traveling for their  treatment  & also for the follow up visits post Radioactive Iodine 131 therapy. Moreover the documentation at re-referral is usually inadequate, which make logical decision making with regard to further therapy at our hospital difficult. Often, it is necessary to make empirical decision based on little data provided. This situation is clearly not ideal for the patients. We hope that the provision of Radioactive Iodine 131 therapy at this hospital will bring an improvement in patients care and management. We also purpose to undertake a quantitative analysis of the problems we have pointed out in this paper.

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Address for Corresponding Author:

Muhammad Jawed

Asstt. Prof. of Surgery & Bariatric Surgeon,
Surgical Unit-1, Dow University Hospital,
OJHA Campus, Karachi

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Cell No.: 03322514095