Clinical, subclinical characteristics of thyroid cancer patients were treated by endoscopic surgery

Nội dung text: Clinical, subclinical characteristics of thyroid cancer patients were treated by endoscopic surgery

1. Journal of Diabetes & Endocrinology No. 48 - 2021 CLINICAL, SUBCLINICAL CHARACTERISTICS OF THYROID CANCER PATIENTS WERE TREATED BY ENDOSCOPIC SURGERY Phan Hoang Hiep, Tran Ngoc Luong Vietnam national hospital of endocrinology DOI: 10.47122/vjde.2021.48.7 ABSTRACT 1. INTRODUCTION Background: Thyroid cancer accounts for Thyroid cancer accounts for 1% of all 1% of all cancers. This is the most common type cancers. This is the most common type of of malignant tumor affecting the endocrine malignant tumor affecting the endocrine system system. The disease usually progresses slowly, [4], [7]. In histopathology, this tumor is divided mainly develops locally and metastases of neck into two subtypes: differentiated and lymph nodes. If detected early, it is possible to undifferentiated. Clinical progress, treatment select appropriate treatment methods which will and prognosis of the two types are different. result in high efficiency. Objectives: To describe Differentiated cancer accounts for the majority the clinical and subclinical characteristics of of case (about 80%), including papillary, selected differentiated thyroid cancer patients in follicular and papillary-follicular. laparoscopic surgery. Methods: 115 thyroid The disease usually progresses slowly, cancer patients were performed endoscopic mainly develops locally and metastases of neck thyroidectomy at National Hospital of lymph nodes. If detected early, it is possible to Endocrinology from March 2012 to April 2018. select appropriate treatment methods which will Results: 115 thyroid cancer patients were result in high efficiency [6], [7]. undergone endoscopic thyroidectomy at Research objectives are: Analyzing the National Hospital of Endocrinology included clinical and subclinical characteristics of 109 females (94.8%) and 6 males (5.2%). The selected differentiated thyroid cancer patients in proportion of female/male was 18/1. Age of laparoscopic surgery. patient were 15 to 45. Mean age of male was 30.4 6.4 and 33.2 4.5 of female. The most of 2. SUBJECTS AND METHODOLOGY nodules were not clear boundary (92.2%). 2.1. Subjects 21.7% surface roughness, 80% nodules with 115 thyroid cancer patients were performed solid density. 60/115 (52.18%) with metastatic endoscopic thyroidectomy at National Hospital neck lymph nodes, of which 61.7% central of Endocrinology from March 2012 to April cavity lymph nodes; 38.3% bilateral metastatic 2018. neck lymph nodes. Papillary cancer accounted 2.2. Selection criteria for 76.5%; 10.4% follicular, 13.1% papillary- Patients were diagnosis differentiated thyroid follicular. Compared the results of FNA with cancer with size of nodule <2cm, nodules were pathology: 78.9% positive and false-negative not invasive thyroid capsules,with/without rate was 7.8%. Conclusion: endoscopic metastatic lymph nodes were located by thyroidectomy for thyroid cancer treatment is ultrasound, CT scanner, FNA under ultrasound feasible, safe and cosmetic with selective cases. guilded. Keywords: thyroid, cancer, endoscopy 2.3.Exclusion criteria Main correspondence: Phan Hoang Hiep Patients were diagnosis differentiated thyroid Submission date: 20th April 2021 cancer with size of nodule >2cm, nodules cancer Revised date: 26th April 2021 invaded thyroid capsules, strap muscles, Acceptance date: 26th May 2021 trachea, easophagus, recurrent nerve. Email: hoanghiepbvnt@gmail.com Lymph nodes were Patients were history of Tel: 0904211839 head & neck surgery, history of head, neck, 42
2. Journal of Diabetes & Endocrinology No. 48 - 2021 or upper mediastinal irradiation, inability to A prospective study was conducted tolerate general anesthesia. 2.5. Data analysis 2.4. Study design SPSS software 16.0 for medicine was used. 3. RESULTS AND DISCUSSION 3.1. Age and sex According to a report by the American Endocrine Association (ATA 2015), differentiated thyroid cancer accounts for the majority, encountered at all ages, both men and women. Age and sex are associated with prognosis, people with age 45 years of age are negative prognostic factors. The rate of women getting the disease is 2-3 times higher than that of men [1]. Table 1. Sex Sex Ratio Women 109 94.8% Men 6 5.2% Total 115 100% Table 2. Mean of age Min Mean±SD Max 15 32.7±6.8 45 In Vietnam, the studies of these authors showed that the percentage of female patients accounted for 2-3 times higher than that of men. Nguyen Tien Lang's research has a significantly higher rate of women, 7.85 times compared to that of men. The common age group in the studies of Nguyen Quoc Bao and Tran Minh Duc is over 40 years old, in studies of other authors, the ages are from 31-45 years old. Table 3. Sex ratio and average age of patients were treated by endoscopy Author Female/Male ratio Common age Average age Miccoli Paola (n=127) 6,87/1 40 - 45 Ta-Sen Yeh (n=116) 14,00/1 51,6 Kazuo Shimizu (n=143) 8,37/1 > 40 56,7 Kitano H (n=122) 12,26/1 31 - 40 39,2 Park Yong Lai (n=120) 8,85/1 18 - 50 39,1 Jeong Nam Cho (n=126) 15,85/1 18 - 45 40,1 This study (n=115) 18,23/1 15 - 45 32,7 Patients selected in endoscopic surgery have a thyroid cancer is quite widely distributed in terms higher proportion of women, ranging from 6-18 of age, people of all ages can suffer from thyroid times compared with men, depending on the cancer, especially it is commonly seen in young author. This study has 115 patients with people in working age. In all these studies, the differentiated thyroid cancer, including 109 female average age of of thyroid cancer patients tend to be patients (accounting for 94.8%) and 6 male about 40, the working age, so the treatment to patients (accounting for 5.2%). The lowest age is prolong the survival time for patients is very 15, the highest is 45, the average age of the patient significant. Therefore, when a patient has a thyroid is 32.7 ± 6.8, in which the average age of men is tumor, especially in the 40s, it is necessary to do 30.4 ± 6.4 and that of women is 33.2 ± 4. , 5. The tests to confirm thyroid cancer and apply early and results of our research as well as domestic and thorough treatment for the patient to bring foreign authors differ in the prevalence of common postivive result. age groups and men/women ratio due to the 3.2. Funtional symptoms difference in study subjects and scope ... However, Differentiated tumors are slow, quiet, and long- all of the studies show that the rate of differentiated lasting. Initial symptoms are often scarce, difficult 43
3. Journal of Diabetes & Endocrinology No. 48 - 2021 to detect, and have little diagnostic value. accidently discover a tumor or lymph node in the Symptoms such as choking, hoarseness, and a neck area, which partly helps diagnose the disease, feeling of congestion in the neck are usually not but this is usually only in patients at a late stage, the main symptoms for patients to check and treat. with tumor causing pressure or infection of In the early stages of the disease, there are few surrounding organs such as: muscles, trachea, specific symptoms that are valuable for early nerves. When thyroid cancer is detected and diagnosis, such as when patients who come to treated in a late stage, it is difficult for the surgeon medical examination happen to find a thyroid to completely remove the thyroid gland and tumor or cervical lymphoma, or there is a case of remove the cervical lymph nodes, due to the large an enlarged tumor compressing neighboring size of the tumor and invaded nearby tissues, organs. The appearance of unpleasant symptoms metastasis of many neck lymph nodes. Treatment makes it easy to diagnose, but late illness affects results are limited, recurrence and metastasis rates treatment outcomes and disease prognosis [6], [8]. are high. In our study: the first clinical symptom is also 3.3. Clinical signs the reason for examination: patients with thyroid In the study we found that adenomas of the tumor: 21.8%, sore throat: 24.4%, discovered thyroid gland and neck lymph nodes are the 2 most swallowing problems: 10.4% , choking 13.0% common and the first clinical signs of thyroid and hoarseness (1.7%). Patients who have cancer. Symptoms of hypothyroidism alone hoarse throat were found to have vocal fibers accounted for 35.7%, lymph nodes in the neck and there ultrasound showed thyroid tumors. accounted for 13.9%, with both tumors and lymph Research by Tran Minh Duc: 53.4% of patients nodes accounted for 38.3%. When having this with liver cancer have a feeling of pressure, symptom, the patient went to a specialist and entanglement, in the neck area; 38.9% choke discovered the disease. In clinical examination, we when eating; 15.3% have hoarseness; 22.1% of both found thyroid tumor in 100% of patients. local pain spread to the parotid [8]. According to However, while the rate of clinically detecting Vu Trung Chinh: symptoms are quite scarce, tumors in 2 lobes only 62.9%, the rate of case most patients have average physiology; 4.8% of when thyroid ultrasound found tumors in both patients have weight-loss, these patients have lobes increased to 85.2%. This proves that patients had distant metastases or large tumors affecting have many small tumors or tumors located deep in normal activities. There is a low rate of l the parenchyma, in the posterior wall of the symptoms, poor body-wide symptoms; 98.8% thyroid gland which could not be detected on of patients have no body-wide symptoms. examination. The rate of detection by ultrasound is Patients who come to see a doctor can 22.3% higher compared with clinical examination. Table 4. Characteristics of the nucleus of the thyroid gland in the study group Characteristic of nucleus Patients Rate % Soft 23 20,0 Density Hard, firm 92 80,0 Total (n) 115 100% Clear 106 92,2 Outline Unclear 9 7,8 Total (n) 115 100% Smooth 90 78,3 Surface Rough 25 21,7 Total (n) 115 100% In this study, 80% of tumors have firm 78.3% of tumors have a smooth surface, 21.7% density and 20% of tumors have soft density. have a rough nucleus surface. According to 44
4. Journal of Diabetes & Endocrinology No. 48 - 2021 Nguyen Tien Lang (2008), the thyroid nucleus the tumor size is less than 1.5 cm, and when the appears individually or in association with the tumor is localized in the thyroid, it has almost cervical lymph node in most patients, the not spread to the surrounding organization, it symptom of pure thyroid gland is 54.8%; has hardly spread far. After 30 years, the nucleus and nodule are 45.2. Research by Tran recurrence rate was only 1/3 of that of the larger Trong Kiem (2008): 98.4% of patients have tumor, the mortality rate was 0.4% compared thyroid nucleus; 1.6% of patients do not have a with 7% when the tumor size was ≥ 1.5 cm (p thyroid nucleus but have a cervical lymph node. <0.01 ) [70]. Aspirating these lymph node results in cervical Thus, when the tumor is small, the prognosis lymph node metastasis, when the patient has is better, after treatment, the rate of relapse and thyroidectomy and cervical lymph node death is lower. Early examination when removal, it is observed that the nucleus has detecting neck tumors and subclinical diameter <1 cm [13]. This shows that coordination (ultrasound, radiology, CT ...) to differentiated thyroid cancer progresses slowly detect small thyroid tumors that are still deep in and silently. Therefore, it is necessary to raise the thyroid parenchyma to increase efficiency awareness about liver tumors so that people can better treatment and prognosis for the patient. understand and self-detect. When there is a Number of tumors: According to the thyroid tumor, it is necessary to examine and American Thyroid Association (ATA 2015), 50- treat early to bring best results. 70% of thyroid cancer patients have 2 or more 3.4. Ultrasound assessment of thyroid tumors. Clinical examination is difficult to tumors: Many studies have published the ability detect small tumors or tumors located deep in to predict whether thyroid tumors are benign or the thyroid parenchyma, must be combined malignant on the basis of ultrasonic markers. Jin with ultrasound assessment and surgery [2]. Joung Kwak et al (2011) gave a TIRADS According to Lee.J (2014), thyroid cancer is classification based on 6 ultrasonic often abundant drive, after surgery 52% of characteristics, including: Solid structure or patients have cancerous foci in both lobes, 30% predominant solid composition, hypoechoic, have many small foci in one lobe, autopsy irregular margins or small zones, curvilinear shows 25-36% of patients have microcarcinoma calcifications, the height is greater than the width. but conventional methods do not develop The authors rated TIRADS from 1 to 6. In our currently available. Our research: Thyroid study, the higher the TIRADS level, the greater ultrasound detects tumors that are not clinically the rate of cancer and similar to the numbers other visible, so the rate of thyroid tumors in the two authors reported: TIRADS 5: 63, 5%. TIRADS 4: lobes during ultrasound increases to 85.2% 27.8 (TIRADS 4a: 4.4%; TIRADS 4b: 13.0%; compared with clinical examination is 62.6 %. TIRADS 4c: 10.4%). TIRADS 2 and 3 are only The number of 3 or more tumors accounts for 1.7% and 7%. 73%, patients with 2 tumors 25.2% and 1 tumor Tumor size on ultrasound: has 1.8%. Therefore, in diagnostic examination, Our research results of endoscopic surgery: it is necessary to be cautious, combine many 84.3% of patients have tumors with size from subclinical methods to avoid missing small 2–4cm, 15.7% of patients with tumors of 1 <u nuclei deep in the thyroid parenchyma that ≤ 2 cm and tumors ≤ 1 cm in size 3 account for cannot be detected clinically. 5%. Hay et al. studied 1500 patients with Tumor margins: The margins of the tumor papillary thyroid cancer. Patiens were is an important factor in guiding the diagnosis monitored for 20 years, when the tumor was (2 and treatment. Thyroid tumors if the margins is - 3.9 cm), (4 - 6.9 cm) and the tumor was ≥ 7 not clear, the tumor surface is rough, and the cm. The corresponding mortality rates are 6%, density is firm towards thyroid cancer. In our 16% and 50%. Research of Kim BS et al (2014) research results, the boundary of the thyroid papillary and follicular thyroid cancers, when nucleus is determined on ultrasound. 92.2% of 45
5. Journal of Diabetes & Endocrinology No. 48 - 2021 patients had ill-defined margins tumor with the 3.5. Characteristics of cytology and remaining parenchyma, 7.8% had clear histopathology margins. In all patients the tumors have not yet Cells aspiration with a fine-needle: invaded the surrounding organization. M. J and Thyroid tumor cell aspiration for cytology Cs (2015) studied 262 patients with papillary diagnosis is the gold standard with many thyroid cancer, total thyroidectomy showed that advantages: simple tool, fast, convenient the rate of invasion to the surrounding as: 53% results, high diagnostic value, less muscle, trachea 37%, laryngeal nerve 47%, complications, can be done in many muscles esophagus 21%, larynx 12% and invasions to Health service Dept. Cell aspiration need to be other sites 30%. Ultrasound and CT scan of the combined with ultrasound is very meaningful neck are two tests that can determine the in diagnosis, especially when the thyroid boundary of the tumor to the remaining tumor is small and deep, the test will give glandular tissue and with the surrounding better results. Research of the American organization most quickly and conveniently [2]. Thyroid Association (2015): fine-needle cells * Ultrasound to evaluate neck lymph node aspiration reachs a sensitivity of 79.54%; metastases specificity is 96.7%; the accuracy is 88.7% and Neck metastasis is a common symptom of the positive forecast value is 95.5%. thyroid cancer. Some patients came to the Comparing the results of the diagnosis of hospital because they found a cervical lymph cytology and histopathology: the rate of node before the discovery of a thyroid nucleus. positive results suitable for histopathology After clinical examination, ultrasound is the diagnosis is 65.9%, the rate of suspected first test to detect whether there are lymph diagnosis is 13.6%; the false negative rate is nodes or not, with the characteristics such as 20.5%. For papillary cancer the sensitivity is location, size, boundary, density ... based on the 81.2%; follicular is 61.6% [1].In this study, the criteria for suspecting cancerous lymph nodes rate of positive accounts for 87.9%, false from ultrasound image of ATA 2015 to evaluate negative accounts for 7.8%, and unspecified each patient. 4.3%. The results of our study have a higher rate In our study, ultrasound has found nodes that of positive than other authors, but the accuracy cannot be detected by clinical examination of this method also depends on the tumor, the (additional findings have lymph nodes location of the puncture, the technique of taking increased by 25%). As a result, there were 60 samples and especially whether small tumors patients with metastatic cervical lymph node, that are aspirated under the guidance of 42 patients were consider suspicious by ultrasound or not. During surgery, if it is ultrasound (accounting for 70%), 30% was not suspected that the lesion is cancer, then put the suspected. When compared with the results of tumor organization cells on glass slides to get CT scans with infused light-reflective drug, it an accurate diagnosis and appropriate surgical showed that the suspected lymph nodes on CT methods. (drug-infused lymph nodes) accounted for Immediate biopsy: Peng Y.W. and Cs 73.3%, 3% higher than the suspected lymph (2009) confirmed higher sensitivity and nodes of ultrasound. Both of these methods had specificity of immediate biopsy than aspiration. lower results towards detecting cancerous The sensitivity of cell aspiration was 71%. The nodules than with fine-needle aspiration results of an immediate biopsy in surgery are (78.3%). Thus, metastatic cervical lymph nodes more accurate than the aspiration test because of thyroid cancer can be detected by subclinical the blood vessels and the penetration in the tests, each method has different sensitivity and thyroid organization are visible. Immediate specificity. It is necessary to coordinate the biopsy achieves sensitivity and specificity methods to guide the indication. and choose a above 80%, and has important implications for suitable cervical ganglion dredging method. surgical indications [3]. 46
6. Journal of Diabetes & Endocrinology No. 48 - 2021 In this study, we put cell to glass slide in all suspicious cases accounts for 3.4%. This study cases, the positive rate accounts for 93.9%, result has a positive rate similar to that of other false negative accounts for 2.7%, and authors. Table 5. Classification of histopathology of authors Author Papillary Follicular Papillary- follicular Trinh Thi Minh Chau (n=335) 85,5% 14,5% Le Van Quang (n=308) 79,5% 15,6% Trần Văn Thiệp (n=334) 81,2% 13,8% 5,0% Vu Trung Chinh 88,9% 11,1% Nguyen Tien Lang (n=195) 72,1% 16,4% 11,5% Tran Trong Kiem (n=152) 68,7% 12,5% 19,8% This study 76,5% 10,4% 13,1% Histopathological classification: Currently, central cavity is the most common. This show the histopathological classification of that in the surgical procedure for thyroid cancer, differentiated thyroid cancer including papillary, the dredging of central cavity lymph nodes follicular and papillary- follicular tumors is used should be given priority. Lymph node metastasis by the World Cancer Society and the American on the same side with the tumor is 30%, the Cancer Society in clinical practice and research. lymph node opposite to the tumor is 0%. When Through studies, we found that: in taking lymph nodes in each patient, we differentiated thyroid cancer, the rate of classified them into groups to do postoperative papillary cancer accounts for mainly from 68% pathology. The results showed that the - 88%. Follicular cancer accounts for 10% - metastasis rate of the group VI lymph nodes was 16%. Papillary-follicular thyroid cancer varies the highest, accounting for 35.8%. Group III, from author to author for the following reasons: group IV and group V are similar, accounting for authors can classify it as a separate category or 18.4% respectively; 17.4% and 20.4%. The by histopathological characteristics, it will be lowest metastasis in group I was 1.5%. Our classified as either papillary or follicular. research results are similar to those of domestic - Nodules metastasis in the neck: is a and foreign authors. common symptom of thyroid cancer. Some Relationship between lymph node metastases patients came to the hospital because they found and histopathology: According to Shah D.H, that there were cervical lymph nodes even Samuel A.M lymphoma metastasis in papillary before the discovery of thyroid nucleus. At the cancer accounts for 42%, in follicular cancer it time of diagnosis of thyroid cancer by accounts for 17.2%. According to Fraker, neck puncturing at the nucleus or at the cervical lymph node metastasis in papillary cancer at the lymph node, there were 5% of patients with time of diagnosis accounts for 33 - 36%. Tran papillary thyroid cancer, 10% of patients with Van Thiep's research shows that the rate of follicular thyroid cancer or invasive Hurthle lymph node metastasis in papillary cancer is cells in the neck or distant metastases. 78.3%. Vu Trung Chinh's study showed that In our research group, there are 60 patients lymph node metastasis in papillary cancer with cervical lymph node metastasis, accounting accounted for 62.9%. In our study, papilloma for 52.2% (table 3.21). The metastatic site is metastatic lymphoma accounted for 59.1%, the mainly found in the central cavity lymph nodes, rate of follicular lymph node metastasis is 25%, accounting for 61.7%. Our study results are papillary-follicular lymph node metastasis is lower than that of Allanic H Slemen C (87%) but 33.3%. There is a difference in the lymph node similar to other authors, showing that the metastasis between the histopathology with p metastatic lymph node encountered in the <0.05. Compared with the study of foreign 47
7. Journal of Diabetes & Endocrinology No. 48 - 2021 authors, the rate of lymph node metastasis in our mainly from 68% - 88%. Follicular cancer study is lower, which can be because our chosen accounts for 10% - 16%. subject is in an early stage. Cervical lymph node differentiated metastatic tumor is relatively high, all groups of REFERENCES cervical lymph nodes can metastasize. Tumor 1. Tran Minh Duc (2002). “Research, can combine with metastatic cervical lymph diagnostic and surgical treatment for nodes or solitary metastatic cervical lymph thyroid cancer”, Doctor of Medicine thesis, nodes. Based on the frequency and location of Military Medical Academy. metastatic cervical lymph nodes to guide the 2. Tran Trong Kiem (2008). “A surgical indication and choice of surgical removal of research to remove the thyroid gland with systemic or selective cervical lymph nodes. radioactive iode 131I treatment of differentiated thyroid cancer”, Doctor of 4. CONCLUSION Medicine thesis, Military Medical Thyroid cancer is a common disease in many Academy. age groups, the most common age is 25-35 years 3. Nguyen Tien Lang (2008). “Evaluate a old, accounting for 74.8%. Women are more combined total thyroidectomy 131I vulnerable than men. A large proportion of Treatment for differentiated thyroid patients have nucleus in both lobes. The cancer”, Graduate thesis of Specialist characteristics of solid nucleus and unclear Doctor II, Hanoi Medical University. margin account for high percentages, which are 4. Tran Van Thiep, Phan Trieu Cung, Bui 80%, 92.2% respectively. Aspiration is the best Xuan Truong and CS (2000). “Cervical standard for diagnosis, while ultrasound helps to lymph node metastasis of papillary thyroid detect small nuclei that cannot be detected by carcinoma”, Ho Chi Minh City Medical clinical examination. Metastasis of cervical Journal, 4, p. 148 – 203 lymph node accounted for 52.18% rate, mainly 5. Karl Y.B, David J.B, Clifford Y.K, Andren group VI and lymph nodes on the same side with K.S et al (2012), “Extent of surgery affects thyroid tumor. With differentiated thyroid survival for papillary thyroid cancer”, cancer, the rate of papillary cancer accounts for Annals of Surgery, 246 (3), pp. 375 – 380. 48