Risk factors for malignancy in multinodular goitres

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Abstract

Background. Multinodular goitre (MNG) is quite often associated with thyroid carcinoma, but the risk factors for malignancy are not well known. The aim is to analyse patients with thyroid carcinoma associated with MNG to determine the clinical risk factors for malignancy.

Method. From a series of 672 MNGs we analysed a subgroup of 59 patients presenting with an associated thyroid carcinoma. The variables analysed were age, sex, family history, cervical radiation therapy, residence in areas of endemic goitre, prior thyroid surgery, time of evolution, asymptomatic status, hyperthyroidism, compressive syndromes, intrathoracic prolongation, goitre consistency and cervical adenopathies. These were compared to MNGs not developing malignancy using the Chi-squared test, Student's t test and a logistic regression test.

Results. Of the 59 cases, 37 corresponded to a microcarcinoma (≤1 cm). The most common histological type was papillary (n=48), followed by follicular (n=6). In 20 cases the carcinoma was multifocal, and capsular involvement was noted in 16 patients, lymph node involvement in five and vascular involvement in another five. The multivariate analysis confirmed the following as independent variables associated with the presence of carcinoma: family history of thyroid pathology (RR=1.6), history of cervical radiation therapy (RR=1.8), recurrent goitre (RR=2.1) and presence of adenopathies on physical exploration (RR=1.6).

Conclusion. The risk factors for carcinoma associated with MNG are family history of thyroid pathology, personal history of cervical radiation therapy, prior surgery and presence of cervical adenopathies.

Introduction

Multinodular goitre (MNG) is the most prevalent thyroid pathology and accounts for a large volume of patients in surgery departments.1 The incidence of malignancy with this goitre ranges from 1 to 10%, and ruling it out is a objective in MNG management,1., 2., 3., 4., 5., 6., 7. since thyroid carcinoma must be operated on early and often requires postoperative radio-iodine. However, MNG without proven malignancy can be often managed conservatively. Partial thyroidectomy may lead to suboptimal management of an incidental carcinoma.

Several studies8 show that microcarcinomas may have a torpid evolution with local recurrence and may cause death, and also that aggressive histological variants may manifest themselves in MG, such as anaplastic carcinoma.2., 9.

The indicators of high risk of MNG-associated carcinoma are not well established.10 The aim of this manuscript is to study a series of patients with thyroid carcinoma associated with MG in order to determine the clinical risk factors for malignancy.

Section snippets

Patients and methods

Between 1974 and 1999, 672 patients with MNGs underwent surgery in our department, of which a subgroup of 59 patients with an associated thyroid carcinoma was analysed. The mean age of the patients was 46±14 years; most of them were female. Fifteen lived in areas of endemic goitre, nine had a family history of thyroid pathology, and three had received cervical radiation therapy for cutaneous angiomas. Eighteen were asymptomatic, and compressive symptoms and hyperthyroidism were the most common

Statistics

A descriptive statistical study was done of the characteristics of the carcinoma. This group with MG and associated carcinoma was compared to the rest of the patients in the series without carcinoma, using contingency tables analysed with the χ2 test complemented with an analysis of residues, and the Student's t test. For the multivariate analysis we used a logistic regression test including the variables, which in the bivariate analysis showed a statistically significant association. In all

Results

In the 59 carcinomas associated with goitre the mean tumour size was 1.3±1.3 cm (0.1–7 cm), of which 37 corresponded to a microcarcinoma (≤1 cm) and the other 22 to a macrocarcinoma (2.1±1; 1.1–7 cm). The most common histological type was papillary (n=48), followed by follicular (n=6), medullary (n=2), mixed or coincident (n=2) and anaplastic carcinoma in one case. The carcinoma was multifocal in 20 cases, and capsular involvement was observed in 16 patients, lymph node involvement in five and

Discussion

The incidence of carcinoma associated with MNG in our series is among the highest reported in the bibliography (8.8% vs. 2–3%),1., 2., 3., 4., 5., 6., 7., 8. although authors such as Yamashita et al.10 report rates of above 30%. It is difficult to differentiate, by palpation, ultrasound or gammagraphy, a goitre with a degenerated nodule from a benign goitre, since no symptom or sign is pathognomonic of malignancy.1 Furthermore, left to its natural evolution it is only detected when the

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