Journal of Postgraduate Medicine
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ORIGINAL ARTICLE
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Year : 2011  |  Volume : 57  |  Issue : 2  |  Page : 120-122  

Surgery in Hashimoto's thyroiditis: Indications, complications, and associated cancers

PV Pradeep1, M Ragavan1, BA Ramakrishna2, B Jayasree1, SH Skandha1,  
1 Department of Endocrine Surgery, Narayana Medical College & Superspeciality Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
2 Department of Pathology, Narayana Medical College & Superspeciality Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India

Correspondence Address:
P V Pradeep
Department of Endocrine Surgery, Narayana Medical College & Superspeciality Hospital, Chinthareddypalem, Nellore, Andhra Pradesh
India

Abstract

Background : Indications for surgery in Hashimoto«SQ»s thyroiditis (HT) patients are compressive symptoms and suspicion of malignancy. A high incidence of thyroid malignancy has been reported in patients with HT. The effect of surgery on discomfort in swallowing and tightness in the neck has not been properly evaluated. Aims: The aim of our study is to compare the indications, complications, and associated cancers in patients operated for HT with those surgically treated for other benign goitres. The effect of surgery on minor symptoms like tightness in the neck and discomfort in swallowing is included. Setting and Design : This was a retrospective case-control study at a tertiary care centre. Patients and Methods : A total of 271 patients who had undergone surgery for benign thyroid diseases were included. Group A consisted of 35 patients who had HT and Group B consisted of patients operated for other benign thyroid diseases (236 patients). Statistical Analysis : Data were analyzed using SPSS 12 software. Independent group«SQ»s t-test was used to compare the means and Fisher«SQ»s exact test was used for categorical data. Results : In Group A, the common indications for surgery were discomfort associated with swelling (45.7%), cosmesis (34.3%), and pain with swelling (11.4%) whereas in Group B, the indication was predominantly cosmetic (80%). A total of 22.9% patients of Group A and 6% of Group B were hyperthyroid. The sensitivity of FNAC for diagnosing thyroiditis was 62.8% (n = 22). Postoperative complication rates were similar in both the groups. The mean operating time was higher in Group A even though the gland was smaller. Incidental malignancy was 3.4% in Group B whereas there was none in Group A. Discomfort in swallowing and tightness in the neck were relieved at 3 months after surgery. Conclusions : Large, euthyroid and apparently asymptomatic HT occasionally need surgical intervention. Discomfort in swallowing and tightness in the neck are relieved after surgery. Thyroidectomy is safe to perform and has a low incidence of permanent complications. There was no associated malignancy in our series of HT.



How to cite this article:
Pradeep P V, Ragavan M, Ramakrishna B A, Jayasree B, Skandha S H. Surgery in Hashimoto's thyroiditis: Indications, complications, and associated cancers.J Postgrad Med 2011;57:120-122


How to cite this URL:
Pradeep P V, Ragavan M, Ramakrishna B A, Jayasree B, Skandha S H. Surgery in Hashimoto's thyroiditis: Indications, complications, and associated cancers. J Postgrad Med [serial online] 2011 [cited 2022 May 21 ];57:120-122
Available from: https://www.jpgmonline.com/text.asp?2011/57/2/120/81867


Full Text

 Introduction



Medical treatment is usually opted for majority of patients with Hashimoto's thyroiditis (HT). This includes both hypothyroid and hyperthyroid patients. The currently accepted indications for surgery are suspicion of malignancy, tracheal/esophageal compression and pain. However, few patients having large, apparently asymptomatic and euthyroid goiters also undergo surgery for cosmetic reasons, discomfort in swallowing without obvious dysphagia, and sensation of tightness in the neck. Even though these symptoms are not absolute indications for surgery, they need evaluation. The prevalence of malignancy in HT in various surgical series ranges from 0.4% [1] to 28%. [2] The aim of the study was to determine the indications, complications, and associated cancers in patients with HT treated surgically and to compare them with those who underwent surgery for other benign goiters. A special focus on the effect of surgery in relieving minor symptoms like tightness in the neck and discomfort in swallowing is also included.

 Patients and Methods



Ours was a retrospective study done among 271 patients who underwent thyroidectomy for benign goiters in our hospital between February 2008 and August 2009. This study was conducted after the formal clearance from the institutional ethical committee of the Narayana General Hospital. All patients were operated after obtaining formal informed consent for the surgery. Among the 271 cases, 35 patients confirmed to have HT on histopathological examination (Group A). We compared this group with the remaining 236 patients who underwent thyroidectomy for other benign thyroid disorders (Group B). Parameters assessed were demographics, symptomatology, preoperative investigations, indications for surgery, incidence of malignancy, and postoperative complications. All patients with goiters had their symptomatology recorded as per a predesigned, department-specific history and physical examination chart. Minor symptoms like discomfort in swallowing and tightness in the neck were noted in this chart. Diagnosis of HT was based on the presence of lymphocytic infiltration of the stroma, Hurthle cell change of the follicular epithelium, distribution of lymphoid tissue within and around lobules with prominent germinal centers, and the presence of histiocytes, plasma cells, and scattered intra-follicular multinucleated giant cells. We analyzed the data using SPSS 12 software. We compared the two groups by using independent group's t-test to compare the means and Fisher's exact test for categorical data. A P-value of < 0.05 was considered significant.

 Results



The mean age of the patients and duration of goiter are shown in [Table 1]. In both the groups, females were commonly affected. There was no statistically significant difference between the two groups concerning the age and duration of the goiter. Significantly, more patients in Group A were hyperthyroid but the prevalence of hypothyroidism was not different between the groups [Table 1]. Thyroperoxidase (TPO) antibodies and antithyroglobulin antibodies (anti-TG Ab) were measured in Group A. The titers were positive in 88.57% of cases (n = 31). Mean TPO Ab levels were 33.52 ± 93.34 AU/mL (ref.: <20 AU/mL) and anti-TG Ab were 2.66 ± 2.38 (ref.: <0.04 AU/mL). The mean TPO Ab and anti-Tg Ab level in Group B (n = 71) was 12.5 ± 14.3 and 1.1 ± 1.3 AU/mL, respectively. [Table 2] shows the indications for surgery in both the groups. Discomfort with associated swelling (45.7%), cosmetic reasons (34.3%), and pain with swelling (11.4%) were the common indications for surgery in Group A whereas cosmesis (80%) was the major indication in Group B. Hyperthyroidism was the indication for surgery in eight (22.9%) cases of Group A. However, some of these hyperthyroid patients also had other multiple indications for surgery like pain or discomfort in swallowing. [Table 2] depicts the clinical examination findings and procedures performed. The involvement of both the lobes was high in Group A (77.1% vs. 57.4%) while single-lobe involvement was more frequent in Group B (42.6% vs. 22.9%). All patients had a normal hormonal profile at surgery, (TSH 2.07 ± 1.38 mIU/L). In Group A, preoperative FNAC accurately diagnosed thyroiditis in 62.8% (n = 22) cases whereas the FNAC was follicular neoplasm in 25.7% (n = 9) of cases. Even though follicular neoplasm is an indication for surgery, these nine patients also had other indications for surgery like pain/discomfort in swallowing/hyperthyroidism. Total thyroidectomy was performed more commonly in Group A whereas hemithyroidectomy was proportionately higher in Group B. The mean gland weight was significantly higher in Group B (P=0.01). Due to the firm and rubbery consistency, we have encountered difficulty in mobilizing the gland medially especially to dissect the parathyroid and recurrent laryngeal nerves (RLNs) in Group A. Hence, the average operating time was more in Group A. All patients routinely underwent postoperative indirect laryngoscopy for the assessment of the vocal cord function at 4 weeks. Patients who underwent total thyroidectomy in Group A (n = 24) and Group B (n = 117) were compared for the postoperative complications. There was no case of permanent hypocalcemia/RLN palsy but temporary hypocalcemia was seen in 11.4% in Group A versus 8.5% in Group B (P=0.52). The average postoperative hospital stay was not significantly different between the two groups [Table 3]. The final histopathology report did not reveal malignancy in Group A; however, 25% had associated follicular adenoma. In Group B, the incidental malignancy rate was 3.4%. Patients having discomfort in swallowing and having tightness in the anterior neck were relieved of their symptoms 3 months after surgery.{Table 1}{Table 2}{Table 3}

 Discussion



Hashimoto, in 1912, described four patients with a chronic disorder of the thyroid gland characterized by diffuse lymphocytic infiltration, fibrosis, parenchymal atrophy, and eosinophilic changes in some of the acinar cells, which he described as strauma lymphomatosa. [3] As in our experience and in other surgical series, the incidence of HT has been up to 13% but surgery is seldom needed in making diagnosis in view of the characteristic clinical and laboratory findings. [4] Anti-TG Ab and TPO antibodies have been reported to have a diagnostic sensitivity of 96.4% and 73.5%, [5] respectively, which in our patients was 88.5% and 82.8%, respectively. We consider South India as an iodine sufficient area with a high incidence of thyroiditis. [6] Many of these patients undergo surgery due to various indications like pain, tracheoesophageal compression, and suspicion for malignancy. The indications for surgery have been different in different series. Nenkov et al.[7] in their series of 132 cases reported that compressive symptoms, lack of response to thyroxine suppression, nodular variant of HT and cosmetic reasons as the indications for surgery. Majority of the patients in our series had undergone surgery due to discomfort and pain with or without swelling (57.1%). It was also noticed that in Group B, 80% of the cases had surgery due to cosmetic concerns which amounted to only 30% of the cases in Group A. The condition of patients in Group A who were operated due to discomfort in swallowing and pain during swallowing improved significantly after thyroidectomy. These are considered as minor symptoms, and are neither documented during initial evaluation nor assessed in the follow-up. If these patients are methodically followed up, it can be appreciated that patients experience relief after surgery. Apart from these indications in Group A, the presence of hyperthyroidism (n = 8) and follicular neoplasm on FNAC (n = 9) became an indication for surgery. Even though the preoperative FNAC report was follicular neoplasm in nine cases, the final histopathology report revealed that only three had follicular adenoma whereas one had Hurthle cell adenoma, three patients had hyperplastic follicular lesions, and two had nodular goiter. MacDonald et al.[8] reported in their series that 31% of their cases who had histopathological diagnosis of HT did not correlate with the preoperative cytology. The sources of error in 60% of the cases were Hurthle cell neoplasm and follicular neoplasm. The presence of hyperplastic follicular cells and pleomorphic Hurthle cells in the FNAC specimen was often misinterpreted as part of HT. [8] In spite of these limitations, FNAC had a sensitivity of 92% in diagnosing HT. [9] Since both lobes were involved in majority of patients in Group A, total thyroidectomy was the choice in many. The incidence of temporary hypocalcemia and RLN paralysis was not statistically different between the two groups. Permanent hypoparathyroidism and RLN palsy rates were similar between the groups. We feel that the technique of intentional identification of all four parathyroid glands and the RLN on either side through meticulous dissection ensuring a bloodless field yields good results comparable with the usual routine thyroidectomy. However, this resulted in significantly more operating time in Group A in spite of the fact that the gland was smaller. The postoperative stay was not significantly different between the groups (P=0.59), since the complications were low due to the meticulous dissection. Shih et al.[2] reported a 32.1% incidence of transient hypocalcemia and 0.4% transient RLN palsy. Gyory et al.[10] reported a 6.7% incidence of temporary RLN palsy and 5.1% permanent RLN palsy. In their series, the temporary hypocalcemia rate was 5.1%. One of the indications mentioned for surgery in HT has been the association of papillary carcinoma and lymphoma. [1],[11] The surgical specimen of patients with histopathology of HT (Group A), on reevaluation for finer sections, showed no incidental malignancies. There were few histological surprises of malignancy (3.4%) in Group B. The incidental malignancy identified in Group B was not statistically significant (P=0.60).

To conclude, patients with euthyroid, large but apparently asymptomatic Hashimoto's goiters, occasionally need surgical intervention. Symptoms like discomfort in swallowing and tightness in the neck are relieved after surgery and can be considered as indications for surgery. We did not come across any associated malignancy in HT unlike other series. Thyroidectomy is technically more demanding in HT even though the gland is small but can be performed safely with a low incidence of permanent complications.

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