European Journal of Cardiovascular Medicine

Thyroid malignancies are the most common endocrine neoplasms, representing a growing concern in both developed and developing countries. The global burden of thyroid cancer has significantly increased over the past few decades, owing not only to genuine changes in incidence but also to advancements in diagnostic techniques such as high-resolution ultrasonography and fine-needle aspiration cytology (FNAC), which have improved the detection of subclinical and early-stage disease [1]. In particular, differentiated thyroid carcinomas (DTCs), which include papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC), account for more than 90% of all thyroid cancers and generally carry a favorable prognosis when identified early and managed appropriately [2].

PTC is the commonest subtype, known for its indolent course, high propensity for lymphatic spread, and excellent long-term survival rates with appropriate treatment. It commonly affects younger individuals and shows a clear female preponderance [3]. In contrast, follicular thyroid carcinoma, though less prevalent, tends to follow a more aggressive course due to its potential for vascular invasion and distant metastasis, most frequently to the lungs and bones [4]. A third variant within the differentiated group, Hurthle cell carcinoma, is relatively rare but is increasingly recognized for its distinct histopathological and clinical behavior, often requiring more aggressive management [5].

India, like many other low- and middle-income countries, lacks comprehensive population-based cancer registries for thyroid malignancies, making hospital-based studies vital to understanding local disease patterns. Environmental influences, such as iodine intake, exposure to radiation, and genetic predisposition, are known to impact both the incidence and aggressiveness of thyroid cancers . However, the regional variability in disease presentation and management outcomes remains under-reported, especially in resource-limited settings. This is particularly important as recent guidelines emphasize the need for individualized treatment strategies based on risk stratification, histopathological subtype, and surgical findings [6].

From a surgical perspective, thyroid cancer poses unique challenges. The decision between hemithyroidectomy and total thyroidectomy, with or without neck dissection, is often guided by tumor size, multifocality, lymph node involvement, and surgeon expertise. Although surgery remains the cornerstone of treatment, the importance of accurate histopathological classification, intraoperative decision-making, and the prevention of complications such as hypoparathyroidism and recurrent laryngeal nerve injury cannot be overstated. Moreover, appropriate follow-up with imaging and biochemical markers like thyroglobulin plays a critical role in long-term surveillance and early detection of recurrence [7].

Despite these evolving paradigms, there is a paucity of updated data on the current trends in thyroid malignancy presentation, histological types, and surgical outcomes in Indian tertiary care hospitals. Local datasets are crucial to inform practice patterns and adapt international guidelines to regional needs.

This study aims to evaluate the clinico-pathological profile, surgical approaches, and early postoperative outcomes in patients diagnosed with DTC.

This prospective cross-sectional study was conducted in the Department of Surgery, Andhra Medical College, over a period of one year, from January 2018 to December 2018. The objective was to analyze the clinico-pathological features and surgical outcomes of patients with differentiated thyroid carcinoma (DTC) treated at this tertiary care center. Ethical approval was obtained from the Institutional Ethics Committee prior to the commencement of the study.

57 adult individuals diagnosed with differentiated thyroid carcinoma, confirmed on postoperative histopathological examination, were included in this study. Patients under 18 years of age, those previously treated for thyroid malignancy elsewhere, and those diagnosed with medullary or anaplastic thyroid carcinoma were excluded from the study. Additionally, cases with incomplete clinical records or those unwilling to provide informed consent were excluded.

Data collection began with a detailed clinical history focusing on the duration and progression of symptoms, presence of compressive features like dysphagia and dyspnea, and any associated neck swellings or voice changes. A thorough physical examination was carried out, documenting the size and consistency of thyroid swellings, mobility with deglutition, and the presence of palpable cervical lymphadenopathy.

Each patient underwent a standard diagnostic work-up that included serum thyroid function tests, neck ultrasonography, and ultrasound-guided fine-needle aspiration cytology (FNAC) for cytological evaluation of thyroid nodules and suspicious lymph nodes. Where indicated, contrast-enhanced computed tomography (CT) of the neck and chest was performed to assess retrosternal extension, tracheal involvement, or distant spread. Indirect laryngoscopy was routinely done in all patients preoperatively to evaluate vocal cord mobility and assess potential recurrent laryngeal nerve involvement.

Surgical management was individualized based on cytological findings, tumor size, and nodal status. The procedures performed included hemithyroidectomy, total thyroidectomy, and total thyroidectomy with central or lateral neck dissection. For patients who were initially managed with hemithyroidectomy and later diagnosed with carcinoma on histopathology, completion thyroidectomy was carried out in a staged manner. All surgical interventions were carried out under general anesthesia by experienced surgical teams.

Postoperative monitoring included clinical assessment for complications like hypocalcemia, RLN palsy, wound infection, and hematoma. Serum calcium levels were monitored routinely, and symptoms suggestive of hypocalcemia were managed with calcium and vitamin D supplementation. Voice changes were evaluated clinically and by repeat laryngoscopy when indicated. Patients were discharged after clinical stabilization and were followed up at regular intervals in the outpatient clinic.

Follow-up assessments included physical examination, serum thyroglobulin levels as a tumor marker, neck ultrasonography, and, where relevant, radioactive iodine scans. Data was analyzed using the SPSS software (25.0). Quantitative parameters such as age were expressed as mean ± SD, while percentage was used to describe qualitative parameters.

A total of 57 patients with histopathologically confirmed differentiated thyroid carcinoma were included in the study. The cohort comprised 44 females (77.2%) and 13 males (22.8%), with a female-to-male ratio of approximately 3.4:1. The mean age at diagnosis was 43.6 ± 13.2 years, ranging from 21 to 76 years. The majority of patients (59.6%) were in the age group of 31–50 years, with the highest concentration observed in the 31–40 year range.

Table 1: Age and Gender Distribution of Patients

PTC was the commonest histological subtype, seen in 47 out of 57 cases (82.5%), followed by follicular carcinoma in 8 cases (14.0%) and Hurthle cell carcinoma in 2 cases (3.5%).

Table 2: Histological Subtypes of Differentiated Thyroid Carcinomas

The most common presenting symptom was anterior neck swelling, which was present in all 57 patients (100%). Additional clinical symptoms included palpable cervical lymphadenopathy in 20 patients (35.1%), pain in 12 patients (21.1%), hoarseness of voice in 4 patients (7.0%), and dysphagia in 5 patients (8.8%).

Table 3: Clinical Presentations at Time of Diagnosis

Radiological imaging revealed tracheal deviation in 15 patients (26.3%), coarse calcifications in 9 cases (15.8%), and retrosternal extension in 2 patients (3.5%).Regarding surgical management, total thyroidectomy was the most common procedure, performed in 36 patients (63.2%). Hemithyroidectomy followed by completion thyroidectomy was carried out in 13 cases (22.8%), while total thyroidectomy with central neck dissection and modified radical neck dissection was performed in 5 (8.8%) and 3 (5.3%) patients, respectively.

Table 4: Types of Surgical Procedures Performed

Postoperative complications were encountered in 18 patients. Transient hypocalcemia was the most frequent, seen in 15 patients (26.3%), followed by transient recurrent laryngeal nerve palsy in 4 cases (7.0%). One patient developed a superficial wound infection that responded to conservative management.

Table 5: Postoperative Complications

On follow-up, recurrence was documented in one case (1.8%), which was a follicular carcinoma with distant metastasis to the frontal bone. No mortality was reported during the follow-up period of the study.

This study highlights the clinico-pathological trends of differentiated thyroid carcinoma (DTC) in a tertiary surgical center over a one-year period, reflecting both global patterns and region-specific variations. The predominance of papillary thyroid carcinoma (82.5%) over other subtypes aligns well with existing literature, which consistently reports papillary carcinoma as the most common thyroid malignancy, constituting around 80–85% of all cases [8, 9].

The observed mean age of presentation (43.6 ± 13.2 years) is similar to findings from other Indian and international studies. Martin et al. [10] observed the mean age of DTC patients as 41 years, while international cohorts place the average between 40 and 50 years depending on regional iodine intake and access to screening. Our study also confirmed the well-known female preponderance in thyroid cancers, with a female-to-male ratio of 3.4:1. This is in line with population-based data from the Surveillance, Epidemiology, and End Results (SEER) Program in the United States, which shows a female-to-male ratio of 3:1 to 4:1 in DTCs [11].

Neck swelling remained the most consistent presenting complaint, seen in 100% of cases. This mirrors findings by Mehrotra et al., where anterior neck swelling was the presenting feature in 98% of patients with DTC [12]. Cervical lymphadenopathy was present in 35.1% of our patients—again consistent with global trends. According to Ito et al., up to 40% of PTC cases present with lymph node involvement at diagnosis, although the clinical significance varies with age and tumor size [13]. Interestingly, while lymph node metastasis is common in papillary carcinoma, its impact on survival is minimal in younger patients and more significant in older individuals, particularly those over 55 years of age [14].

Our study reported a relatively low incidence of compressive symptoms such as dysphagia (8.8%) and hoarseness (7%). This is likely reflective of the trend toward earlier diagnosis. However, in resource-limited settings, delayed presentation remains a challenge, contributing to the occasional identification of retrosternal extension (3.5%) and tracheal deviation (26.3%), both seen in our patients. These findings are consistent with study by Ito et al. [13].

Surgical management remains the mainstay of treatment for DTC. In our study, total thyroidectomy was done in 63.2% of study participants. This approach is supported by guidelines from the American Thyroid Association (ATA), which recommend total thyroidectomy in tumors measuring>1 cm, multifocality, or nodal metastasis [15]. Completion thyroidectomy was necessary in 22.8% of cases, underscoring the importance of accurate preoperative FNAC and imaging to guide initial surgical decisions.

Postoperative complications in our study were well within acceptable limits. Transient hypocalcemia occurred in 26.3% of patients, which is consistent with reported rates of 20–30% in literature following total thyroidectomy [16]. Transient recurrent laryngeal nerve (RLN) palsy was seen in 7%, which is slightly below the reported global average of 8–10% [17]. These complications, while generally reversible, underscore the need for meticulous surgical technique and postoperative monitoring, especially in high-volume centers where case load may affect individual attention.

Recurrence occurred in only one patient (1.8%), which again supports the excellent prognosis of differentiated thyroid cancers when appropriately treated. Long-term disease-specific survival for papillary carcinoma exceeds 95% in most series [18]. Hurthle cell carcinoma, although rare in our cohort (3.5%), is known for its higher recurrence rate and poorer prognosis compared to classical PTC, and therefore warrants more aggressive follow-up [19].

Finally, the lack of exposure to well-known risk factors such as prior radiation or strong family history in our study population is notable. This reflects findings from Indian studies where sporadic cases are the norm, and familial or radiation-associated thyroid cancers remain rare [20]. However, the rising detection of incidental thyroid nodules and cancers poses questions regarding over-diagnosis and overtreatment, an issue increasingly discussed in global literature [21].

This study reaffirms that differentiated thyroid carcinoma, particularly papillary carcinoma, is the predominant thyroid malignancy in the Indian population, with a marked female preponderance and a peak incidence in the third and fourth decades of life. Anterior neck swelling remains the most common presenting feature, and while lymph node involvement is frequent, distant metastasis is rare at presentation.

Total thyroidectomy continues to be the optimal surgical technique, particularly in multifocal disease, nodal involvement, or indeterminate preoperative cytology. Despite the inherent risks associated with thyroid surgery, such as hypocalcemia and recurrent laryngeal nerve injury, outcomes remain favorable with meticulous surgical technique and appropriate postoperative care.

The low recurrence rate in our cohort reflects the generally excellent prognosis of DTC when diagnosed early and treated adequately. These findings underscore the importance of prompt clinical evaluation, reliable cytological and radiological workup, and personalized surgical planning.

Acknowledgement:

The authors would like to extend their gratitude towards the faculty whoever has supported while conducting this study.

Conflicts of interest: None declared

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