Prediction of Malignancy in Solitary Thyroid Nodules in a Country with Endemic Goiter Athens, Greece D. Katsikas, MD, Athens, Greece M. Sechas, MD, Athens, Greece N. Kakaviatos, MD, Athens, Greece G. D. Skalkeas, MD, Athens, Greece

J. G. Gogas, MD,

Evaluation of patients with solitary nodules of the thyroid gland continues to be a clinical problem. Benign and malignant pathologic conditions of the thyroid gland appear as single nodules. The incidence of cancer in solitary thyroid nodules varies widely from 3 to 35 per cent in reported series [l-8). The large variation in the published figures results from a combination of factors such as the geographic location, preselection of patients, and the follow-up period. The present study was undertaken in an attempt to assess the diagnostic accuracy and current incidence of carcinoma in the clinically solitary thyroid nodule in a country with endemic goiter. Clinical Material

The records of 455 patients operated on for solitary thyroid nodule at King Paul Hospital from January 1962 through October 1975 were reviewed. Patients with a single thyroid nodule constituted 31.3 per cent of the total number of patients who underwent exploration of the thyroid gland during the same period in the same hospital. Only those patients who had solitary nodules in a thyroid gland otherwise normal upon inspection and palpation were included. Patienta with evidence of multiple nodules, symptoms and signs of hyperthyroidism, or findings such as enlarged lymph nodes of the neck, vocal cord paralysis, or pulmonary or bone metastasis, suggesting the presence of malignancy, were excluded from the series. Radioiodine tests were obtained in 380 of the 455 patients. T@se tests included measurement of iodine 131 (lslI) uptake by the thyroid, of the protein bound 1311(PB 1311)at 48 hours, and performance of a scintiscan.

Results The incidence of detection of thyroid cancer in patients with solitary nodules according to age is shown in Table I. Solitary nodules were more frequent in patients aged twenty to sixty years, whereas in very young and very old patients the incidence was smaller; however, a higher percentage of cancer was observed in the very young and very old patients. The incidence of malignant neoplasms in children younger than ten years was particularly high (40 per cent), followed by the incidence of cancer in patients aged eleven to twenty years (20 per cent) and patients older than sixty-one years (17.4 per cent). Of the 455 patients with solitary nodules in this series, 398 were females and 57 were males-a female:male ratio of 7:l. However, the incidence of cancer of the thyroid in the presence of solitary nodules in females was 8.3 per cent (33/398) and in males 17.5 per cent (10/57). The pathologic conditions found in the 455 patients with a solitary nodule included 212 patients (46.6 per cent) with adenoma, 194 patients (42.4 per cent) with colloid adenomatous goiter, 43 patients (9.5 per cent) with malignant neoplasm, 4 patients (0.9 per cent) with Hashimoto’s thyroiditis, and 2 patients (0.4 per cent) with abscess. TABLE I Incidence of Cancer of the Thyroid Gland in 455 Patients with Solitary Nodules according to Age

Age (yr)


From the 2nd Department of Propedeutic Surgery. Athens University, King Paul Hospital, Athens. Greece. Repint requ&s should be addressed to John G. Gogas. MD, 2nd Department of Propdautic Swgery. King Paul Hospital. Athens, Greece.


132, mondu


11-20 21-40 41-60 61-85 Total

No. of Benign Cases

6(60.0%) 24(80.0%) 175(93.1%) 188(92.2%) 19(82.60/b) 412(90.5%)

No. of Malignant Cases 4(40.0%) 6(20.0%) 13(6.9%) 16(7.8%) 4(17.4%) 43(9.50/o)

Total 10

30 188 204 23 455


Gogas et al

Histologic classification of the 43 malignant neoplasms included 18 papillary carcinomas (41.8 per cent), 10 follicular carcinomas (23.2 per cent), 8 mixed follicular-papillary carcinomas (18.6 per cent), 5 anaplastic carcinomas (11.6 per cent), 1 medullary carcinoma (2.3 per cent), and 1 fibrosarcoma (2.3 per cent). Scanning (using 1311)revealed that most of the nodules were cold.


The results of this study differ in some particulars with similar material in the literature but generally agree with previous reports. The 9.5 per cent incidence of cancer is not as high as in other series [6,9] but agrees absolutely with series from Greece in which goiter is endemic [3,5,lO]. The higher incidence of cancer was observed in patients aged five to twenty years and also has been observed by others [6,10] in patients older than sixty years. Unfortunately, by clinical examination and 1311 scanning, it is not possible to establish a differential diagnosis between benign and malignant nodules [4,6,7]. Of course, 1311scanning of the thyroid provides useful information and establishes the suspicion of the presence of cancer (especially in cold and warm nodules) but is not diagnostic because a similar picture is given by adenomas, cysts, subacute and chronic thyroiditis, hematomas, and necrotic changes. It is possible that in the future improved technic and greater experience with scanning after the administration of selenomethionine 75 or cesium 131 in combination with scanning using radioactive iodine [II] and with ultrasound [12], selective angiography [23], and finally thermography (141 will aid in a more exact differential diagnosis of benign nodules from cancer of the thyroid gland. Thus, the number of patients with benign nodules of the thyroid subjected to unnecessary operation, now comprising approximately 85 per cent of cases, will be limited. The approach to the treatment of solitary thyroid nodules has varied among the various investigators. Most authors agree that, due to the relatively high incidence of cancer in solitary nodules of the thyroid gland, surgical exploration of the thyroid gland should be carried out [3,9,10]. Our policy has been surgical removal of all solitary thyroid nodules inasmuch as neither the clinical features nor the laboratory findings clearly aid in the distinction of benign from malignant nodules.


The operation consists of a subtotal lobectomy on the side of the nodule with the isthmus and with a good margin of normal tissue on the other side [3]. Lifelong treatment with replacement doses of a thyroid medication is indicated in nearly all patients after thyroidectomy [15]. Summary

From January 1962 through October 1975, 455 patients with single thyroid nodules were operated on at King Paul Hospital. Malignancy was proved in forty-three patients. The overall incidence of carcinoma was 9.5 per cent. A higher incidence of cancer was found in patients less than ten years of age (40 per cent), between eleven and twenty years of age (20 per cent), and more than sixty-one years of age (17.4 per cent). Malignant nodules were more frequent in males (17.5 per cent) than in females (8.3 per cent). Radioactive iodine scanning does not distinguish benign from malignant nodule. Solitary thyroid nodules require operative excision supplemented with replacement therapy. References 1.

BowmsOM.vandef JB:ThyroidIkYdules andthyToMmalignancy; the risk involved in delayed surgery. Ann lntem Med 57: 245,

1962. 2. Brooks JR: The solitary thyroid nodule. Am J Surg 125: 477, 1973. 3. Gogas JG, Skalkeas G: The thyroid nodules and thyroid cancer. Int Surg 60: 534, 1975. 4. Hoffman a, Thomson NW. %ffrOn C: The SolitarythyrOd nodule. Arch Surg 105: 379, 1972. 5. Koutras D. Livadas D. Sfondouris J. Messaris G. Statherou PK: A study of 409 cold thyroid nodules in a country with endemic goiter. NuclMed7: 165. 1965. 6. Liechty RD, Graham M, Freemyer P: Benign solitary thyroid nodules, Surg Gynecol Obstet 121: 571, 1965. 7. Taylor S: Carcinoma of the thyroid gland. JR Co// Surg fdinb 14: 267, 1969. 8. Williams AC, Davis JM, Kiely AA: Thyroid cancer in 1,330 cases of surgical goiter. Am J Surg 104: 672, 1962. 9. Kendall LW, Condon RE: Prediction of malignancy in solitary thyroid nodules. Lancet 1: 1071. 1969. 10. Psarras A. Papadopoulos S, Livadas D, F’harmakiotisA, Koutras D: The single thyroid nodule. 6r J Surg 59: 545. 1972. 11. Thomas CG Jr, Pepper FD, Owen J: Differentiation of malignant from benign lesions of tfn3thyroid gland using complementary scanning with ‘%elenomethionine and radioiodine. Ann Surg 170: 396, 1969. 12. Miller JM, Zafar SU: The cystic thyrokt nodule: recognition and management. Program of the 48th meeting of the American Thyroid Association. Chicago, 1972, p 70. 13. Takahashi M, lshibashi T, Kawanami H: Angioqaphic diamis of benign and malignant tumors of the thyroid. Radiology 92: 520. 1969. 14. Samuels Bl: Thermography: a valuable tool in the detection of thyroid disease. Radiology 102: 59, 1972. 15. Skalkeas G. Gogas JG. Pavlatos F, Se&as M: Recurrent goiter after surgery. Hippocrates 1: 228. 1972.


Amsrkbn Journal 04 Surgery

Prediction of malignancy in solitary thyroid nodules in a country with endemic goiter.

Prediction of Malignancy in Solitary Thyroid Nodules in a Country with Endemic Goiter Athens, Greece D. Katsikas, MD, Athens, Greece M. Sechas, MD, At...
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