|Year : 2014 | Volume
| Issue : 3 | Page : 112-116
Spectrum of goitrous lesions in patients at a tertiary care center of Sikkim
Subhabrata Sengupta1, Isha Preet Tuli1, Binayak Baruah1, Santosh Prasad Kesari1, Bhargav Ilapakurty1, Amlan Gupta2
1 Department of ENT, Sikkim Manipal Institute of Medical Sciences, 5th Mile Tadong, Gangtok, 737 102, Sikkim, India
2 Department of Pathology, Sikkim Manipal Institute of Medical Sciences, 5th Mile Tadong, Gangtok, 737 102, Sikkim, India
|Date of Web Publication||6-Sep-2014|
Associate Professor, Department of ENT, Sikkim Manipal Institute of Medical Sciences (SMIMS), 5th Mile Tadong, Gangtok 737 102, Sikkim
Background: Sikkim is declared as a goitre endemic state with an estimated prevalence of 54%. The spectrums of diseases include simple goitre, thyroiditis, adenoma, carcinoma, multinodular goitre and Graves' disease. The present study aims to determine the pattern of thyroid swelling in a hospital setup at Sikkim. Materials and Methods: This study is a retrospective analysis of records of all patients presenting with thyroid swelling in a tertiary care hospital at Gangtok, Sikkim during the period of 4 years between 1 st January 2008 and 31 st December 2011. Patients were diagnosed by clinical examination, FNAC, USG, CT scan and hormone estimation. Histopatholgical confirmation was done in surgical cases. Clinic opathological and demographic data of 166 such patients were obtained and analyzed for the present study. Results: The most common goitrous disease was simple goitre (69.27%) followed by thyroiditis (10.24%), toxic goitre (7.83%) and malignancy (12.65%). Papillary variant was the commonest carcinoma. Overall female:male ratio was 4.9:1. The prevalence goitrous lesion was highest in the middle age group between 30-39 years, while the extremes of age (below 10 years and above 70 years) were rarely involved. Conclusions: The prevalence of goitre in Sikkim is still very high despite iodisation programs by the Government. There is urgent need for more data on autoimmunity and goitrogens status to explain the high prevalence of goitre in this population.
Keywords: Age sex distribution, cancer, Goitre, Sikkim, thyroiditis
|How to cite this article:|
Sengupta S, Tuli IP, Baruah B, Kesari SP, Ilapakurty B, Gupta A. Spectrum of goitrous lesions in patients at a tertiary care center of Sikkim. Sahel Med J 2014;17:112-6
|How to cite this URL:|
Sengupta S, Tuli IP, Baruah B, Kesari SP, Ilapakurty B, Gupta A. Spectrum of goitrous lesions in patients at a tertiary care center of Sikkim. Sahel Med J [serial online] 2014 [cited 2020 Jan 27];17:112-6. Available from: http://www.smjonline.org/text.asp?2014/17/3/112/140295
| Introduction|| |
Diseases of the thyroid gland are one of the commonest endocrine disorders in India as well as in the world. It is estimated that nearly 42 million people in India suffer from thyroid diseases.  They may be diffuse or nodular, benign or malignant, euthyroid or hyperthyroid in status. The spectrum of thyroid diseases includes simple goitre, thyroiditis, adenoma, carcinoma, multinodular goitre and Graves' disease. It is postulated that the incidence of thyroid nodule increases with age, in women, in people with iodine deficiency, and after radiation exposure. A report suggests a prevalence of 2-6% with palpation, 19-35% with ultrasound, and 8-65% in autopsy data [ 2 ] while a prevalence of 4-7% has been estimated in another [3 ] The prevalence of goitre is different according to the geographical region, age and sex.  The present study aims to find out the pattern of thyroid swelling and their distribution in different age and sex groups in a hospital setup in the hill town of Gangtok, Sikkim
| Materials and methods|| |
This is a retrospective analysis of all patients presenting with thyroid swelling in the Department of ENT at Central Referral Hospital, Sikkim Manipal Institute of Medical Sciences, Tadong, Gangtok, Sikkim during a period of 4 years between 1 st January 2008 and 31 st December 2011. Diagnosis was made following detailed history, clinical examination and some of the following investigations: FNAC, USG of the neck and biochemical profile of the thyroid hormones. CT scan was done in few cases where malignancy was suspected. Final histopathological diagnosis was confirmed in all the cases which underwent surgical removal. Clinicopathological and demographic data of all such patients were obtained and analyzed for the present study.
| Results|| |
One hundred and sixty-six patients with thyroid swelling were included in the study. [Table 1] shows the various types of goitrous lesions observed in the study population. The most common cause of thyroid enlargement included simple goitre which accounted for 69.27% of the cases, followed by thyroiditis (10.24%). Toxic goitre and malignant goitre were observed in 7.83% and 12.65% of cases, respectively. Of the simple euthyroid goitrous lesions, the most common was solitary adenoma, followed by diffuse hyperplastic goitre and multinodular goitre. Of the toxic goitrous lesions toxic multinodular goitre was most common followed by toxic adenoma and Grave's disease. We recorded a few cases of thyroiditis causing clinically swollen thyroid gland. Among this group De-quervain's thyroiditis was the most common followed by Hashimoto's thyroiditis and chronic lymphocytic thyroiditis. We had only one case of acute thyroiditis causing swelling of the gland. Solitary thyroid nodule was found in 27.7% cases. Of these a large majority were euthyroid while only five cases were toxic adenomas. Most frequent malignancy encountered was papillary carcinoma followed by follicular carcinoma. Only one case each of squamous cell carcinoma, medullary carcinoma and malignant lymphoma was found, along with two cases of anaplastic carcinoma [Table 1].
In the current study, 83.13% of patients were female. The prevalence of simple goitre and thyroiditis were almost five times in female than male whereas the prevalence of carcinoma was just about twice that in male. Most strikingly, toxic nodular goitre was 12 times in female than male. The overall prevalence of thyroid disease was five times in female than in male [Table 2].
Around 61.4% of the patients belonged in the age group of 20-49 years. Goitre was most frequent (31.32%) in patients in their 4 th decade of life (30-39 years) the extremes of age below 10 years and above 70 years were rarely involved [Table 3] and [Table 4].
| Discussion|| |
India has the world's largest goitre belt in the sub-Himalayan region  It has been estimated that 12% of adult population in India have a palpable goitre.  Our report suggests that despite the promotion of iodization, the prevalence of goitre still continues to be a public health problem.  Sikkim has been declared a goitre endemic state on the basis of survey conducted by Indian Council of Medical Research in 1976. Studies estimate that the prevalence of goitre in Sikkim is around 54%.  In the present study conducted at a tertiary care hospital at Sikkim located in the Himalayas, simple goitre still stands out as the largest cause of thyroid swelling (69.27%). The other causes of thyroid swelling in our study were thyroiditis, adenomas, toxic goitres and carcinomas in decreasing order of frequency.
The patterns of thyroid diseases observed in the current report are comparable with the available world literature. In the study conducted by Handa et al., the incidence of goitres among thyroid nodules was 57.6%, followed by thyroiditis (27.4%), adenomatous goitre (2.3%), follicular/hurthle cell neoplasm (1.4%) and malignant tumors (3.9%), of which papillary carcinoma was the commonest.  Another Indian study conducted by Andaleeb et al., in 2002 showed 54.7% of multinodular goitre and 27.6% of follicular lesions.  Various studies from Pakistan also reveals that the largest number of patients had benign goitre followed by follicular lesions, thyroiditis and malignancy. ,, In a study from Mexico, the findings were colloid goitre (47.2%), follicular adenomas (23.5%), Hashimoto's thyroiditis (20.5%), papillary carcinomas (5.9%) and oxyphilic cell adenoma (2.9%).  Similar patterns in a western population was reported by Antonello et al., and Klemi et al. 
Little information is available regarding the prevalence of thyroiditis in the population. In a study on school girls in India, 7.5% of subjects with goitre undergoing FNAC had evidence of juvenile autoimmune thyroiditis (including both Hashimoto's thyroiditis and focal lymphocytic thyroiditis).  In our study the prevalence of thyroiditis was 10% in which the above group of autoimmune thyroiditis is the commonest.
In most of the studies on thyroid swelling majority of cases are of benign origin. Our figures reveal 87% and 12% prevalence rates of benign disease and thyroid cancers, respectively. A study from Italy shows the incidence of benign thyroid swelling to be 68.75% and malignancy in 31.25% of patients. Most common malignancy detected was papillary carcinoma.  Study by Rahaman et al., shows the occurrence of malignancy to be only 8.2% out of all cases of thyroid swelling. In their study follicular carcinoma was commonest.  Refeidi et al., demonstrated that the commonest thyroid cancer to be papillary carcinoma, followed by follicular carcinoma while lymphoma ranked third with only 1.1% incidence.  Similar finding has been reported by Ht we et al. Papillary carcinoma was commonest in their series, while anaplastic carcinoma had the lowest incidence. 
In Africa, the documented prevalence rates of papillary carcinoma ranges from 6.7-72.1%, follicular: 4.9-68%, anaplastic: 5-21.4%, and medullary: 2.6-13.8%. There is a changing trend toward more frequent occurrence of papillary CA compared to follicular CA and this may be attributable to widespread iodization programs.  Data from The Indian Council of medical Research also established that the commonest cancer type was papillary, followed by follicular cancer.  It is well established that Papillary carcinoma is the most common malignant neoplasm of the thyroid gland, representing about 80% of all thyroid cancers.  We observed rare cases of squamous cell carcinoma and non-Hodgkin's lymphoma. However, the incidence of papillary carcinoma was the highest followed by follicular variant.
The overall female: male ratio in the current report was 5:1. This was hugely increased to 12:1 in the patients of toxic goitre. In the study conducted by Handa et al., the female:male ratio was 6.35:1. The same sex ratio is increased to 29:1 for thyroiditis group.  Various studies worldwide reveal this sex ratio in the range of 5-9:1. ,,,,, In the scenario of malignant thyroid swelling the age-adjusted incidence rates of thyroid cancer per 100 000 are about 1 for males and 1.8 for females as per the Mumbai Cancer Registry, which covered a population of 9.81 million subjects.  In our study, the occurrence of malignancy was 2.5 times more in female than in male.
The highest incidence of thyroid swelling is noted in the 4 th decade of life, followed by that in the elderly. Least incidence was observed in the young age groups. In the study conducted by Handa et al., the overall age of the patients ranged from 5 to 80 years with a mean age of 37.69 ± 14.93 years.  The commonest age group involved in the study by Musani et al., was 16-45 years accounting for 77.7% of cases followed by elderly group of 46-60 years of age accounting for 23.1% of cases.  In the Refeidi study mean age for males was 41.35±15.52 years compared to 36.59±13.28 years for females.  Ht we et al., observed that the highest prevalence in the age group 41-60 years (45.2%) while the lowest prevalence in the age group under 21 years (3.8%).  In other studies the mean age of patients ranged from 39 to 45 years.  In our study, maximum number of patients were in the age group of 30-39 years (31.32%), followed by another peak in the age group of 50-59 years (20.48%). Very few patients were found below the age of 20 and above the age of 70 years.
| Conclusion|| |
Sikkim is still very high despite iodisation programmes by the Government. Majority of thyroid lesions in the study population were benign presenting as simple euthyroid goitre. Autoimmune thyroiditis was the commonest form of inflammation of the thyroid gland while papillary carcinoma was the commonest malignancy encountered. There was, as expected marked female predominance in all types of thyroid diseases and this was mostly marked in toxic goitres. The commonest age group affected is 30-39 years, while the extremes of age below 10 years and above 70 years were rarely involved.
There is urgent need for new data on autoimmune and goitrogens status of the study population.
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[Table 1], [Table 2], [Table 3], [Table 4]