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RUPTURE OF FOLLICULAR
CARCINOMA OF THYROID


Satish Ranka*, Chetan Kantharia**, R D Bapat***,Ashish Rajput+, Arati Sherlakar++, Samir Shirodkar+++
*Medical Officer; **Associate Professor of Surgery; ***HOD of Surgery; +Resident in Pathology; ++Research Officer; +++Resident in Surgery, Department of Surgery, Seth GS Medical College, KEM Hospital, Parel, Mumbai 400 012.

Spontaneous rupture with haemorrhage is a rare complication of thyroid malignancy. We present a case report of a 70 year old female who had spontaneous rupture with haemorrhage and was operated on emergency basis.

CASE REPORT

A 70 year old female, resident of Uttar Pradesh presented with a large protruding goitre. On enquiry she had a swelling which was small since last ten years but grew rapidly in size since last six months. She had no pressure symptoms. She was clinically suspected to have malignancy and as admitted for expediting her work up (Fig. 1). Her fine needle aspiration cytology revealed follicular carcinoma and thyroid scan too substantiated the diagnosis. She was planned for elective surgery when the goitre suddenly ruptured in the ward with severe haemorrhage. She was taken up for emergency surgery where a near total thyroidectomy was done. Her prospective recovery was uneventful. Histopathology confirmed our diagnosis (Fig. 2).

DISCUSSION

Follicular carcinoma of thyroid account for 17% of all thyroid malignancies. Spontaneous rupture rarely occurs. Its prevalence in Iodine deficiency areas is well known (incidence about 2.4%).[1] In our case too the patient hailed from foot hills of Himalaya. It is also sometimes found in ectopic thyroid glands.[2] It usually presents as an nodule as in our case, but may some times present in one of its severe forms as a tracheal stenosis.[3] FNAC has a limited accuracy and its usefulness in diagnosing a follicular carcinoma remains controversial,[4] it however was diagnostic in this lady. However Ultrasound complemented by a cytological score has been proposed for better patient selection for surgery.[5] Depending upon its vascular invasion and capsular involvement, it is classified into minimal invasive and highly invasive carcinoma. Minimally invasive carcinoma behave in a benign manner and SAMES criteria can differentiate between high risk and low risk groups.[6] Hemithyroidectomy or Total thyroidectomy is advocated for the surgical management. Radical neck dissection is not needed unless there are metastasis. Pre and paratracheal fat removal is an essential step in dissection. Periodic follow up with whole body scanning and serum thyroglobulin measurement, performed either during thyroid hormone withdrawal or by recombinant human thyrotropin stimulated scanning and thyroglobulin measurement.[7] There also is no need for a speciality unit to perform these surgeries as results are equally good with non speciality surgeons.[8]

Fig. 1
Fig. 1 : Large goitre with ulcerated area, the site of haemorrhage.


Fig. 2
Fig. 2 : Histological image of follicular carcinoma showing back arrangement of thyroid cells. Follicular cells are large with increased nuclear : cytoplasmic ratio, abnormal mitosis, pleomorphism and coarsely granular chromatin with areas of haemorrhage and necrosis. HE original magnification x 40.


ACKNOWLEDGEMENT

We would like to thank Dean, Seth GS Medical College and KEM Hosp. for granting us permission to publish this case report.


REFERENCES
  1. Floretti F, Tavani A, Gallus S, et al. Case control study of thyroid cancer in Northern Italy : attributable risk. International Journal of Epidemiology 1999; 28 (4) : 626-30.
  2. Floretti F, Tavani A, Gallus S, et al. Case control study of thyroid cancer in Northern Italy : attributable risk. International Journal of Epidemiology 1999; 28 (4) : 626-30.
  3. Churei H, Takeshita J, Hiraki Y, et al. A case of follicular thyroid cancer with tracheal stenosis responded to external radiation therapy. Radiation medicine 1999; 17 (1) : 77-80.
  4. St. Louis JD, Leight GS, Tyler DS. Follicular neoplasms : the role of observation, fine needle aspiration biopsy, thyroid suppression, and surgery. Seminars in Surgical Oncology 1999; 16 (1) : 5-11.
  5. Tomimori EK, Camargo RY, Bisis, et al. Combined ultrasound and cytological studies in the diagnosis of thyroid nodules. Biochimie 1999; 81 (5) : 447-52.
  6. Sanders LE, Silverman M. Follicular and Hurlble cell carcinoma : Predicting outcome and directing therapy. Surgery 1998; 124 (6) : 967-74.
  7. Mazzaferi EL. An overview of management of papillary and follicular thyroid carcinoma. Thyroid 1999; 9 (5) : 421-7.
  8. Martins RG, Caplan RH, Lambert PJ. Management of Thyroid cancer of follicular cell origin : Gundersen/Lutheran Medical Centre, 1965-1995. Journal of American College of Surgeons 1997; 185 (4) : 388-97.

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