Toksik Nodüler ve Multinodüler Guatrlı Hastalarda Tiroid Kanser Sıklığı

Öz

Amaç: Toksik nodüler (TNG) ve toksik multinodüler guatr (TMNG), bir veya birden fazla otonom

fonksiyone tiroid nodülünün varlığı ile karakterize hipertiroidiye yol açan hastalıklardır. Hipertiroidinin

tiroid kanserine karşı koruyucu olduğu inancına karşın son yıllarda bu hastalarda da tiroid kanser

riskinin azımsanmayacak kadar olduğu ve nodüllerin diğer hastalarda olduğu gibi değerlendirilmesi

gerektiği yönünde yayınlar çoğalmaktadır. Bu çalışmanın amacı TNG/TMNG nedeniyle cerrahi

uygulanan hastalarda tiroid kanser sıklığını belirlemek ve kanser ile ilişkili olabilecek preoperatif

özellikleri değerlendirmektir.

Materyal ve Metot: Çalışmaya Ocak 2017 ile Aralık 2014 arasında TNG veya TMNG nedeniyle

tiroidektomi yapılan hastalar alınmıştır. Retrospektif olarak taranan hastaların klinik özellikleri,

laboratuar ve ultrasonografi (US) sonuçları, sitolojik ve histopatolojik bulguları kayıt edilmiştir.

Histopatolojik sonucu benign ve malign saptanan hastaların klinik özellikleri, nodüllerin preoperatif US

özellikleri ve sitolojik sonuçları karşılaştırılmıştır.

Bulgular: Çalışmaya alınan 482 hastanın 335’i (%69,50) kadın, 147’si (%30,50) erkekti ve ortanca yaş 56

(18‐79) idi. 74 (%15,35) hastada TNG, 408 (%84,65) hastada TMNG vardı. Histopatolojik olarak 380

(%78,84) hastada benign, 102 (%21,16) hastada malign patoloji saptandı. Benign ve malign hastalarda yaş,

cinsiyet dağılımı, antitiroid kullanımı, antikor pozitifliği, nodül sayısı açısından fark yoktu. Malign

hastalarda ultrasonografik olarak parankimde tiroidit varlığı anlamlı şekilde yüksekti (%75,26 ve %87,24;

p<0,001). Malign hastalarda sitoloji sonuçları nedeniyle tiroidektomi uygulanan hasta oranı benign

hastalara oranla yüksekti. Benign hastalarda ise dev nodül nedeniyle tiroidektomi yapılan hasta oranı

malign hastalara oranla yüksekti. Preoperatif US verileri incelenen 1263 tiroid nodülünün 1222’si

(%96,75) histopatolojik olarak benign, 41’i (%3,25) malign idi. Malign nodüllerde hipoekojenite oranı

benign nodüllere göre anlamlı şekilde yüksekti. Benign ve malign nodüller arasında diğer US özellikleri

açısından fark saptanmadı. Sintigrafik değerlendirmesi olan nodüllerden benign olanların 406’sı

(%71,99), malign olanların 19’u (%67,86) sintigrafik olarak aktifti (p=0,853).

Sonuç: Bu çalışmada TNG/TMNG nedeniyle cerrahi uygun görülen hastalarda tiroid kanser sıklığı ihmal

edilemeyecek oranda saptanmıştır. Bu hastalarda malign ve benign nodüllerin US özellikleri benzer

bulunmuştur. TNG/TMNG’lı hastalardaki nodüllerde, nodül aktif dahi olsa, ince iğne aspirasyon biyopsi

endikasyonunun diğer hastalarda olduğu gibi konulması, cerrahi planlandığında özellikle TMNG

varlığında total veya totale yakın tiroidektomi tercih edilmesi önerilir.

Anahtar Kelimeler

• Toksik nodüler guatr,toksik multinodüler guatr,tiroid kanseri

Thyroid Cancer Incidence in Patients with Toxic Nodular and Multinodular Goiter

Öz

Objectives: Toxic nodular goiter (TNG) and toxic multinodular goiter (TMNG) are characterized by the presence of one or more autonomously functinoning thyroid nodules that causes hyperthyroidism. In contrary to the previous thought that hyperthyroidism is protective against thyroid cancer, there is increasing evidence that the risk of thyroid cancer should not be underestimated in these patients and nodules should be assessed as being in other patients. We aimed to determine the prevalence of thyroid cancer in TNG/TMNG patients that underwent thyroidectomy and evaluate preoperative features that might be associated with cancer.

Materials and Methods: Patients diagnosed with TNG or TMNG and operated between January 2017 and December 2014 were included. The patients were scanned retropectively and clinical features, laboratuary findings, ultrasonography (US) reports, cytological and histopathological results were recorded. Clinical features of patients with benign and malignant histopathology, and preoperative US features and cytological results of benign and malignant nodules were compared.

Results: There were 482 patients of which 335 (69.50%) were female and 147 (30.50%) were male and the median age was 56 (18-79). Preoperative diagnosis was TNG in 74 (15.35%) and TMNG in 408 (84.65%) patients. Histopathologically, 380 (78.84%) had benign and 102 (21.16%) had malignant disease. There was no significant difference in age, sex distribution, antithyroid usage, antibody positivity and median nodule number in benign and malignant patients. Ultrasonographically presence of thyroiditis in parenchyma was higher in malignant compared to benign patients (87.24% vs 75.26%. p<0.001). Ratio of patients operated for cytological diagnosis was higher in malignant, while patients operated for giant nodule was higher in benign patients. Among 1263 nodules with preoperative US data, 1222 (96.75%) were benign, 41 (3.25%) were malignant histopathologically. Rate of hypoechogenity was significantly higher in malignant than benign nodules. Other US features were similar in two groups. Among nodules with preoperative scintigraphy results, 406 (71,99%) of benign and 19 (67.86%) of malignant nodules were hot (p=0.853).

Conclusion: In this study, the incidence of thyroid cancer in TNG/TMNG patients who underwent surgery was too high to be ignored. Preoperative US features of benign and malignant nodules were similar in these patients. We recommend that nodules in patients with TNG/TMNG should be evaluated by fine needle aspiration biopsy according to the same indications as for other nodules and when surgery is planned; total or near total thyroidectomy can be preferred particularly in the presence of TMNG.

Anahtar Kelimeler

• Toxic nodular guatr,toxic multinodular goiter,thyroid cancer

Kaynakça

1. 1. National Cancer Institute. SEER stat fact sheets: thyroid cancer. http://seer.cancer.gov/statfacts/html/thyro.html. (Erişim tarihi: 20.07.2018).
2. 2. Knox MA. Thyroid nodules. Am Fam Physician 2013;88:193-6.
3. 3. Laurberg P, Pedersen KM, Vestergaard H, Sigurdsson G. High incidence of multinodular toxic goitre in the elderly population in a low iodine intake area vs. high incidence of Graves' disease in the young in a high iodine intake area: comparative surveys of thyrotoxicosis epidemiology in East-Jutland Denmark and Iceland. J Intern Med 1991;229(5):415-20.
4. 4. Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016;26(10):1343-421.
5. 5. Türkiye Endokrinoloji ve Metabolizma Derneği, Tiroid Hastalıkları Tanı ve Tedavi Kılavuzu 2017. Ankara: Ortadoğu Yayıncılık; 2017:61-2.
6. 6. Gitooes NJ, Frankyln JA. Hyperthyroidism. Current treatment guidelines. Drugs 1998;55:543-53.
7. 7. Vaiana R, Cappelli C, Perini P, et al. Hyperthyroidism and concurrent thyroid cancer. Tumori 1999;85:247-52.
8. 8. Gelmini R, Franzoni C, Pavesi E, Cabry F, Saviano M. Incidental thyroid carcinoma (ITC): a retrospective study in a series of 737 patients treated for benign disease. Ann Ital Chir 2010;81:421-7.

9. 9. Kang AS, Grant CS, Thompson GB, van Heerden JA. Current treatment of nodular goiter with hyperthyroidism (Plummer’s disease): surgery versus radioiodine. Surgery 2002;132:916-23.
10. 10. Negro R, Valcavi R, Toulis KA. Incidental thyroid cancer in toxic and nontoxic goiter: is TSH associated with malignancy rate? Results of a meta-analysis. Endocr Pract 2013;19:212-8.
11. 11. Preece J, Grodski S, Yeung M, Bailey M, Serpell J. Thyrotoxicosis does not protect against incidental papillary thyroid cancer. Surgery 2014;156:1153-6.
12. 12. Gul K, Di Ri Koc A, Ki Yak G, et al. Thyroid carcinoma risk in patients with hyperthyroidism and role of preoperative cytology in diagnosis. Minerva Endocrinol 2009;34:281-8.
13. 13. Hung W, Anderson KD, Chandra RS, et al. Solitary thyroid nodules in 71 children and adolescents. J Pediatr Surg 1992;27(11):1407-9.
14. 14. Boelaert K, Horacek J, Holder RL, Watkinson JC, Sheppard MC, Franklyn JA. Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration. J Clin Endocrinol Metab 2006;91(11):4295-301.
15. 15. Cappelli C, Castellano M, Pirola I, et al. The predictive value of ultrasound findings in the management of thyroid nodules. QJM 2007;100:29-35.
16. 16. Moon WJ, Jung SL, Lee JH, et al; and Thyroid Study Group, Korean Society of Neuro- and Head and Neck Radiology. Benign and malignant thyroid nodules: US differentiation–multicenter retrospective study. Radiology 2008;247(3):762-70.
17. 17. Cibas ES, Ali SZ. The Bethesda system for reporting thyroid cytopathology. Thyroid 2008;19:1159-65.
18. 18. Negro R, Valcavi R, Toulis KA. Incidental thyroid cancer in toxic and nontoxic goiter: Is TSH associated with malignancy rate? Results of a meta-analysis. Endocr Pract 2013;19(2):212-8.
19. 19. Karagulle E, Yildirim S, Karakayali F, Turk E, Moray G. Malignancy rates in operated patients with hyperthyroidism in an area of endemic goiter. Int Surg 2009;94(4):325-9.
20. 20. Choong KC, McHenry CR. Thyroid cancer in patients with toxic nodular goiter--is the incidence increasing? Am J Surg 2015;209:974-6.
21. 21. Smith JJ, Chen X, Schneider DF, et al. Toxic nodular goiter and cancer: a compelling case for thyroidectomy. Ann Surg Oncol 2013;20(4):1336-40.
22. 22. Zimmermann MB, Galetti V. Iodine intake as a risk factor for thyroid cancer: a comprehensive review of animal and human studies. Thyroid Res 2015;8:8.
23. 23. Senyurek Giles Y, Tunca F, Boztepe H, Kapran Y, Terzioglu T, Tezelman S. The risk factors for malignancy in surgically treated patients for Graves' disease, toxic multinodular goiter, and toxic adenoma. Surgery 2008;144(6):1028-36.
24. 24. Hegedüs L. The thyroid nodule. N Engl J Med 2004;351:1764-71.
25. 25. Campanella P, Ianni F, Rota CA, Corsello SM, Pontecorvi A. Quantification of cancer risk of each clinical and ultrasonographic suspicious feature of thyroid nodules: a systematic review and meta-analysis. Eur J Endocrinol 2014;170(5):R203-11.
26. 26. Berker D, Isik S, Ozuguz U, et al. Prevalence of incidental thyroid cancer and its ultrasonographic features in subcentimeter thyroid nodules of patients with hyperthyroidism. Endocrine 2011;39(1):13-20.
27. 27. Tfayli HM, Teot LA, Indyk JA, Witchel SF. Papillary thyroid carcinoma in an autonomous hyperfunctioning thyroid nodule: case report and review of the literature. Thyroid 2010;20(9):1029-32.
28. 28. Kim TS, Asato R, Akamizu T, et al. A rare case of hyperfunctioning papillary carcinoma of the thyroid gland. Acta Otolaryngol 2007;Suppl 557:55-57.
29. 29. Nishida AT, Hirano S, Asato R, et al. Multifocal hyperfunctioning thyroid carcinoma without metastases. Auris Nasus Larynx 2008;35:432-6.
30. 30. Bitterman A, Uri O, Levanon A, Baron E, Lefel O, Cohen O. Thyroid carcinoma presenting as a hot nodule. Otolaryngol Head Neck Surg 2006;134:888-9.
31. 31. Majima T, Doi K, Komatsu Y, et al. Papillary thyroid carcinoma without metastases manifestingas an autonomously functioning thyroid nodule. Endocr J 2005;52:309-16.
32. 32. Pazaitou-Panayiotou K, Perros P, Boudina M, et al. Mortality from thyroid cancer in patients with hyperthyroidism: the Theagenion Cancer Hospital experience. Eur J Endocrinol 2008;159:799-803.