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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 80-85

Prevalence of thyroid lesions in thyroidectomy specimens - A histomorphological study in urban industrial area


Department of Pathology, Dr. D. Y. Patil Medical College, Pune, Maharashtra, India

Date of Submission12-Nov-2021
Date of Decision25-Dec-2021
Date of Acceptance01-Jan-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
Shirish Sahebrao Chandanwale
75/1 + 2/1, Krishna Appt, New Sangvi, Pune - 411 027, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_71_21

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  Abstract 


Introduction: The prevalence of thyroid diseases is enormous in general population of India and more common in women than men. Although the World Health Organization assessment status has classified India as having optimal iodine nutrition in 2004, hypothyroidism still contributes significantly to burden of thyroid disorders in India. The prevalence of thyroid diseases varies according to different geographical areas, age, and sex. The aim of this study is to determine the pattern of thyroid lesions in surgically resected specimens in urban industrial area and to study their histomorphological features. Materials and Methods: The 430 patients in whom partial or complete surgical resection of thyroid was done were included in the study. The histomorphological features were studied in detail and correlated with clinical findings. Results: The majority of thyroid specimens (90.71%) were total thyroidectomies. More than half, i.e., 54.65% (n = 235) of the thyroidectomies were done in 3rd and 4th decade. The 85.11% (n = 366) were female patients. The multinodular goiter was the commonest etiology (n = 341) for thyroidectomy. The follicular adenoma (n = 25) and the papillary thyroid carcinoma (n = 20) were common neoplastic lesion. Conclusion: The thyroid lesions in females more often require surgical intervention as compared to males. The 31–50 years is the most common age group who require surgical intervention. The substantial number of younger females in the age group of 16–30 years requires surgical intervention. The multinodular goiter due to iodine deficiency appears to be most common cause of thyroidectomy. The early diagnosis and proper therapy is the key for reducing the thyroidectomies in younger females.

Keywords: Goiter, neoplasm, papillary thyroid carcinoma, thyroidectomy


How to cite this article:
Chandanwale SS, Sutreja D, Patel P, Verma A, Kulkarni S. Prevalence of thyroid lesions in thyroidectomy specimens - A histomorphological study in urban industrial area. J Head Neck Physicians Surg 2022;10:80-5

How to cite this URL:
Chandanwale SS, Sutreja D, Patel P, Verma A, Kulkarni S. Prevalence of thyroid lesions in thyroidectomy specimens - A histomorphological study in urban industrial area. J Head Neck Physicians Surg [serial online] 2022 [cited 2022 Jun 28];10:80-5. Available from: https://www.jhnps.org/text.asp?2022/10/1/80/347994




  Introduction Top


Incidence of thyroid diseases in general population is enormous. They are most frequently encountered endocrine diseases in India and more common in women than men. The prevalence and pattern of thyroid disorders depend on sex, age, ethnic and geographical factors, especially on Iodine intake. They are endemic in mountainous regions where the soil, water, and food contain little iodine.[1],[2],[3]The World Health Organization (WHO) assessment status classified India as having optimal iodine nutrition in 2004. Still hypothyroidism contributes significantly to burden of thyroid disorders in India.[4]

Diagnosis of thyroid diseases relies on thorough clinical signs and symptoms, ultrasonographic examination, fine needle aspiration cytology (FNAC) of enlarged thyroid gland, thyroid hormonal evaluation, and thyroid scan.[5] Main indications of surgical treatment of thyroid swelling are neoplastic lesions, indeterminate cytology features in FNAC, and pressure symptoms in the neck.[5] Total thyroidectomy provides the advantage of eliminating the risk of recurrent lesions; hence, increasing number of total thyroidectomies are currently being performed.[6] The aim of this study is to determine the pattern of thyroid lesions in surgically resected specimens in urban industrial area and to study their histomorphological features.


  Materials and Methods Top


This retrospective study was done at urban teaching medical hospital in western part of India from January 2014 to January 2021. The 430 surgically resected specimens of thyroid in the form of total or partial thyroidectomy or lobectomy were included in the study. Core biopsies were not included in the study. Medical records of these patients were retrieved and reviewed. Detailed clinical history, radiological findings, FNAC diagnosis, status of thyroid function (T3, T4, and thyroid-stimulating hormone [TSH]) and thyroid antibodies were noted from case sheets.

Surgical specimens received for histopathological examination were fixed in 10% formalin, adequate sections were routine paraffin processed. Three to five thin micron sections were cut and stained with hematoxylin and eosin (H and E). Detailed histomorphological findings were studied and final diagnosis was made.


  Results Top


Over the period of 6 years, a total of 430 thyroidectomy specimens were received for histopathological diagnosis in department of pathology. The 90.71% (391) thyroidectomy specimens were total thyroidectomies while 9.28% (n = 40) were partial thyroidectomies. More than half, i.e., 54.65% (n = 235) of the thyroidectomies were done in the 3rd and 4th decade. The 85.11% (n = 366) were female patients [Table 1].
Table 1: Age and sex distribution of nonneoplastic and neoplastic thyroid lesions

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The nonneoplastic pathology (n = 370) was the most common cause for thyroidectomies. The 31–40 years of age group was the most common age group in which thyroidectomies were done for nonneoplastic as well as neoplastic lesions [Table 1].

In the nonneoplastic lesions (n = 370), hyperplastic etiology (n = 341) was the most common, followed by congenital lesions (n = 15) and inflammatory etiology (n = 14). [Table 2] shows detailed age and sex distribution in various nonneoplastic lesions. In the neoplastic lesions, out of 60 neoplastic lesions, the 31 were malignant and 29 were benign. The follicular adenoma (n = 25) was the most common followed by papillary thyroid carcinoma (PTC) (n = 20). [Table 3] shows detailed age and sex distribution in various neoplastic lesions.
Table 2: Age and sex distribution of nonneoplastic thyroid lesions

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  Discussion Top


Neoplastic and nonneoplastic thyroid diseases are common all over the world with varying frequencies, depending upon iodine deficiency status.[7],[8] These diseases can be controlled by medical or surgical management if diagnosed early. Thyroidectomy has become a routine procedure as a result of safe anesthesia, antiseptics, fine surgical instruments, and development of new techniques.[9]

In our study, thyroidectomy for neoplastic and nonneoplastic lesions was done most commonly in 3rd and 4th decade. Out of 430 patients, it was done most commonly in females (n = 366) than males [Table 1]. Similar observations were made in many studies.[10],[11],[12] Female preponderance of thyroid diseases has been attributed to the presence of estragon receptors in thyroid tissues.[13] The final diagnosis of thyroid lesions was based on histomorphological features.

The nonneoplastic lesions in our study were categorized into 3 gropes: (1) congenital (n = 15); (2) inflammatory (n = 14); (3) hyperplastic lesions (n = 341). In the congenital lesions, the thyroglossal duct cyst (TDC) (n = 15) was the only lesion we came across. Although it is frequently encountered in children, the prevalence in adult population is 7%. In our study, we came across with one case even in the 6th decade [Table 2]. Although it is a congenital lesion, it comes to the notice when patient clinically manifests. Histopathological examination of TDC showed a cyst wall lined by pseudostratified columnar or cuboidal epithelium and cyst wall showed few lymphocytes and few thyroid follicles [Figure 1]a. The one case was diagnosed as PTC arising in TDC.[14],[15]
Figure 1: (a) Thyroglossal duct cyst (Hematoxylin and Eosin × 100), (b) Hashimotos thyroiditis (Hematoxylin and Eosin × 100), (c) Hashimotos thyroiditis (Hematoxylin and Eosin × 400), (d) Nodular goiter (Hematoxylin and Eosin × 100)

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In our study, the thyroidectomy was done in 14 (3.3.25%) patients for Hashimoto's thyroiditis. The compressive symptoms and suspicion of malignancy are the indications for thyroidectomies in Hashimoto's thyroiditis. The most common age group was 31–40 years (n = 5) and females (n = 10) outnumbered males [Table 2]. Histopathology examination showed destruction and infiltration of thyroid parenchyma with lymphocytes with oncoytic change [Figure 1]b and [Figure 1]c.

Hyperplastic lesions of thyroid are traditionally classified into 3 major forms based on their pathogenesis, clinical and morphological features. (1) Dyshormonogenic goiter in which there is a defect in synthesis of thyroid hormones. (2) Graves' disease which is one of the two major forms of autoimmune thyroid disease in which thyroid-stimulating immunoglobulins activate TSH receptor, causing overproduction of thyroid hormones and hyperthyroidism. (3) Nodular hyperplasia or multinodular goiter is the most common thyroid disease and its development is influenced by environmental factors mainly iodine deficiency and by genetic factors.

Of the 430 thyroidectomy lesions, 341 were multinodular goiter. Majority were female patients (n = 301). Similar observations were made in other studies.[11],[12],[16],[17] Histopathology examination of these lesions showed nodules of thyroid follicles of varying sizes separated by fibrous septae [Figure 1]d. Follicles were of different sizes and filled with colloid admixed with areas of hyperplastic thyroid follicles, oncocytic cells, few papillae and degenerative changes in the form of hemorrhage, calcification and cystic changes. In some cases, stroma showed infiltration by lymphocytes suggesting associated chronic thyroiditis. In our study, in all the cases, thyroidectomy was done to relieve pressure symptoms.

Neoplastic etiology was the cause of thyroidectomy in 60 cases in our study. Thyroid neoplasms are divided into 3 major categories depending on the cell types involved: (1) tumors exhibiting follicular cell differentiation which accounts for more than 95% of cases, (2) tumors exhibiting C-cell differentiation, (3) tumors exhibiting follicular and C-cell differentiation.

In our study, out of 60 lesions, the malignant lesions (n = 31) were slightly more than benign (n = 29). High prevalence of malignant lesions in our study can be possibly because of geographical variation and our medical facility is being the tertiary care center, more cases were referred. Similar observations were made in other studies.[11],[18]

Histopathology examination of follicular adenoma (n = 25) showed a complete thin fibrous capsule encircling tumor tissue which was different from the surrounding normal thyroid tissue. Follicular adenomas showed different architectural patterns such as normofollicular, macrofollicles, microfollicles, and solid/trabecular patterns [Figure 2]a and [Figure 2]b. Occasional mitotic activity was seen, and degenerative changes such as hemorrhage, edema, fibrosis were less commonly seen.
Figure 2: (a) Follicular adenoma (Hematoxylin and Eosin x100), (b) Follicular adenoma (Hematoxylin and Eosin × 400), (c) Hurthle cell adenoma (Hematoxylin and Eosin × 100), (d) Hurthle cell adenoma (Hematoxylin and Eosin × 400)

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The four lesions were diagnosed as hurthle cell adenoma [Table 3]. Conventionally, they have been described as a variant of follicular adenoma. However, their biological characteristics, morphological features, and natural history are distinctive enough for them to be regarded as a special group. They commonly arise in adult females. All patients in our study were adult females. Histopathological examination showed follicular and trabecular pattern. Tumor cells showed eosinophilic granular cytoplasm and vesicular nuclease. There was thin fibrous capsule at the periphery. There were no features of anaplasia [Figure 2]c and [Figure 2]d.
Table 3: Age and sex distribution of neoplastic thyroid lesions

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The PTC which shows follicular differentiation is the most common thyroid carcinoma worldwide. It commonly occurs in the age group of 20–50 years. In our study, out 31 malignant lesions, PTC (n = 20) was the most common. Majority (n = 9) of the patients were in the age group of 16–30 years with female (n = 7) preponderance [Table 3]. Histopathology examination of these tumors showed complex branching papillae with true fibrovascular core. The papillae were lined by single to stratified cuboidal epithelium. Areas of irregular follicles were seen [Figure 3]a. Nuclei of the tumor cells showed ground-glass appearance [Figure 3]b. Nuclear psedoinclusions, nuclear grooves were seen. The psammoma bodies were seen in 13 cases [[Figure 3]b, insite].
Figure 3: (a) Papillary thyroid carcinoma (Hematoxylin and Eosin × 100), (b) Optically clear nuclei of papillary thyroid carcinoma and psammoma body in insight (Hematoxylin and Eosin × 400), (c and d) Vascular and capsular invasion in follicular carcinoma (Hematoxylin and Eosin × 100)

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Stroma showed variable lymphocytic inflammatory cells. Many morphologic variants of PTC have been described in the standard surgical pathology textbook. All cases in our study were classical PTC while only one case each of encapsulated and follicular variants.

Second most common carcinoma in our study was follicular carcinoma (n = 6). The majority patients were female (n = 5). As compared to PTC, they were more common (n = 5) in older age group, i.e., >40 years [Table 3]. Histopathological examination showed well to poorly formed follicles or solid, trabecular, or cribriform growth. Increased mitotic activity was seen in 2 cases. The histopathological diagnosis of follicular carcinoma depends entirely on demonstration of blood vessels and or capsular invasion. The blood vessels should be typically vein and should be located in or immediately outside capsule and contain 1 or more clusters of tumor cells, attached to wall and protruding into lumen. Intravascular tumor nests must be covered by endothelium or surrounded by fibrin. In capsular invasion, interruption of the capsule must be full thickness [Figure 3]c and [Figure 3]d.

Based on degree of invasiveness, they are divided into 3 forms: (1) minimally invasive which are encapsulated with vascular invasion only but no capsular invasion; (2) encapsulated angioinvasive variant in which there is limited vascular invasion (1–3 vessels with or without capsular invasion); (3) widely invasive in which there is extensive invasion (macroscopic and microscopic evidence) and multinodular growth with no obvious tumor capsule.[17] Out of the six follicular carcinoma cases, two cases were minimally invasive and four cases were encapsulated angioinvasive.

The recent classification of thyroid tumors by the WHO (4th edition)[18] introduced the new term, borderline thyroid follicular tumors in which they included tumors of uncertain malignant potential, noninvasive follicular thyroid neoplasms with papillary-like nuclear features and hyalinizing trabecular adenoma. In our study, we did not come across any borderline tumors. The variation in frequency of types can be attributed to the geographical variation and the stage at the time of diagnosis.

The medullary carcinoma (n = 2) is composed of C (parafollicular) cells. Histopathological examination showed solid proliferation of round to polygonal cells with granular amphophilic cytoplasm and medium-sized nucleus. These solid sheets are separated by vascular fibro collagenous stroma with amyloid deposits at places [Figure 4]a and [Figure 4]b.
Figure 4: (a) Medullary carcinoma (Hematoxylin and Eosin × 100), (b) Medullary carcinoma (Hematoxylin and Eosin × 400), (c) Poorly differentiated carcinoma (Hematoxylin and Eosin × 100), (d) Anaplastic thyroid carcinoma (Hematoxylin and Eosin × 100)

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We came across with two cases of poorly differentiated thyroid carcinoma in our study. Histopathology examination showed small uniform tumor cells with nesting pattern of growth. Tumor cells had hyperchromatic nuclei with inconspicuous nucleoli with little pleomorphism. The tumor nests were separated by fibrovascular septa [Figure 4]c.

The only case of anaplastic thyroid carcinoma was in a 55 male who presented with hard midline neck mass. Histopathological examination showed fascicles of spindle cells with nuclear and cellular pleomorphic and hyperchromatic nuclei. Occasional giant cells were seen [Figure 4]d.


  Conclusion Top


The thyroid lesions in females often require surgical intervention as compared to males. The most common age in both females and males is 31–50 years when they require surgical intervention for both nonneoplastic and neoplastic thyroid lesions. The substantial number of females in the age group of 16–30 years also requires surgical intervention. Even though the WHO assessment status has classified India as having optimal iodine nutrition in 2004, multinodular goiter due to iodine deficiency appears to be most common cause of thyroidectomy. Hence, there is a need for the evaluation of additional dietary and environmental factors for their role in etiology of multinodular goiter. PTC is most common in females and 16–30 is the most common age group. Early diagnosis and proper therapeutic remedy is the key for reducing the thyroidectomies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer-reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee before starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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