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Clinical Characteristics and Treatment Outcomes of Thyroid Cancer at a Tertiary Care Hospital in Najran Region, Saudi Arabia: A Single-Centre Retrospective Study

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Abstract

Background The global incidence of thyroid cancer has increased significantly over the past decades. This study aims to review the clinical characteristics and treatment outcomes of thyroid cancer at the Tertiary Care Hospital in the Najran region of Saudi Arabia. Material and methods We conducted a retrospective study of 279 patients diagnosed with thyroid cancer at our hospital from March 2014 to December 2021. Clinicopathologic parameters were obtained from the patient's medical records and examined using univariate and multivariate Cox regression to identify independent predictive markers. Result The mean age was 42.8 ±14.5 years, and most cases were female (n= 203, 72.8%). Most cases (n=170, 60.9%) underwent total thyroidectomy. Additionally, lymph node dissection was performed in 28 (10.0%) cases. Localized disease, distant, and regional metastasis were observed in 214 (76.7%), 34 (12.2%), and 31 (11.1%), respectively. The neck lymph nodes and lungs were the most common metastasis regions in 19 (6.8%) and 11 (3.9%) cases, respectively. Papillary thyroid cancer and follicular thyroid cancers accounted for the majority of cases in 236 (84.6%) and 33 (11.8%), respectively. Adjuvant therapy, including radioactive iodine ablation, was reported in 51 (18.3%) and external beam radiotherapy in four (1.4%). Independent prognostic factors of overall mortality of thyroid carcinoma were older age (Hazard ratio (HR):1.05, 95% confidence interval (CI): 1.01-1.09, p=0.008), Diabetic mellitus (HR: 4.30, 95% CI: 1.11-16.62, p=0.035), pathologic subtype of follicular carcinoma (HR: 4.48, 95% CI: 1.07-18.73, p=0.040) or non-papillary thyroid carcinoma subtypes (HR: 12.56, 95% CI: 2.44-64.74, p=0.002), metastasis presentation (HR: 11.70, 95% CI: 3.30-41.46, p<0.001), pulmonary metastasis (HR: 27.92, 95% CI: 6.96-111.98, p<0.001), bone and liver metastasis (HR: 15.20, 95% CI: 1.70-135.98, p=0.015), tumor size >4 cm (HR:121.21, 95% CI: 15.33- 958.34, p<0.001), and extrathyroidal extension (HR: 6.15, 95% CI: 1.59-23.77, p=0.009). Conclusion This study demonstrates that advanced age, the presence of diabetes, non-papillary thyroid carcinoma subtypes, metastatic disease, tumor size greater than 4 cm, and extrathyroidal extension are independently associated with a poorer prognosis in patients with thyroid carcinoma. To offer the finest modern care, a multidisciplinary approach should be employed when developing a tailored treatment strategy, considering relevant recommendations and stratification systems.
Review began 10/05/2024
Review ended 10/19/2024
Published 10/25/2024
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DOI: 10.7759/cureus.72380
Clinical Characteristics and Treatment Outcomes
of Thyroid Cancer at a Tertiary Care Hospital in
Najran Region, Saudi Arabia: A Single-Centre
Retrospective Study
Ahmed M. Badheeb , Samer Alkarak , Mana A. Alhajlan , Rakan Alwadai , Ali M. Al-Qannass ,
Abbas H. Almakrami , Abdelaziz A. Aman , Hossam A. Hussein , Nadeem M. Nagi ,
Mohammed A. Fagihi , Islam A. Seada , Ahmed Harwn , Saleh M. Alqahtani , Ibrahim Mokhtar ,
Abdullah Abu Bakar , Faisal Ahmed , Mohamed Badheeb
1. Oncology, King Khalid Hospital, Oncology Center, Najran, SAU 2. Medicine, Hadhramaut University, Mukalla, YEM
3. General Surgery, King Khalid Hospital, Najran, SAU 4. Otolaryngology - Head and Neck Surgery, Armed Forces
Hospital Southern Region, Khamis Mushait, SAU 5. Endocrinology, King Khalid Hospital, Najran, SAU 6. Internal
Medicine/Endocrine and Diabetes, King Khalid Hospital, Najran, SAU 7. Otolaryngology - Head and Neck Surgery,
Menoufiya University, Shebien Elkoom, EGY 8. Otorhinolaryngology, King Khalid Hospital, Najran, SAU 9. Oncology,
King Khalid Hospital, Najran, SAU 10. Surgical Oncology, King Khalid Hospital, Najran, SAU 11. Cardiothoracic
Surgery, King Khalid Hospital, Najran, SAU 12. Nuclear Medicine/Radiology, King Khalid Hospital, Najran, SAU 13.
Internal Medicine, King Khalid Hospital, Najran, SAU 14. Ophthalmology, King Khalid Hospital, Najran, SAU 15.
Urology, Ibb University, Ibb, YEM 16. Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, USA
Corresponding author: Ahmed M. Badheeb, badheebdr@gmail.com
Abstract
Background
The global incidence of thyroid cancer has increased significantly over the past decades. This study aims to
review the clinical characteristics and treatment outcomes of thyroid cancer at the Tertiary Care Hospital in
the Najran region of Saudi Arabia.
Material and methods
We conducted a retrospective study of 279 patients diagnosed with thyroid cancer at our hospital from March
2014 to December 2021. Clinicopathologic parameters were obtained from the patient's medical records and
examined using univariate and multivariate Cox regression to identify independent predictive markers.
Result
The mean age was 42.8 ±14.5 years, and most cases were female (n= 203, 72.8%). Most cases (n=170, 60.9%)
underwent total thyroidectomy. Additionally, lymph node dissection was performed in 28 (10.0%)
cases. Localized disease, distant, and regional metastasis were observed in 214 (76.7%), 34 (12.2%), and 31
(11.1%), respectively. The neck lymph nodes and lungs were the most common metastasis regions in 19
(6.8%) and 11 (3.9%) cases, respectively. Papillary thyroid cancer and follicular thyroid cancers accounted
for the majority of cases in 236 (84.6%) and 33 (11.8%), respectively. Adjuvant therapy, including radioactive
iodine ablation, was reported in 51 (18.3%) and external beam radiotherapy in four (1.4%). Independent
prognostic factors of overall mortality of thyroid carcinoma were older age (Hazard ratio (HR):1.05, 95%
confidence interval (CI): 1.01-1.09, p=0.008), Diabetic mellitus (HR: 4.30, 95% CI: 1.11-16.62, p=0.035),
pathologic subtype of follicular carcinoma (HR: 4.48, 95% CI: 1.07-18.73, p=0.040) or non-papillary thyroid
carcinoma subtypes (HR: 12.56, 95% CI: 2.44-64.74, p=0.002), metastasis presentation (HR: 11.70, 95% CI:
3.30-41.46, p<0.001), pulmonary metastasis (HR: 27.92, 95% CI: 6.96-111.98, p<0.001), bone and liver
metastasis (HR: 15.20, 95% CI: 1.70-135.98, p=0.015), tumor size >4 cm (HR:121.21, 95% CI: 15.33-
958.34, p<0.001), and extrathyroidal extension (HR: 6.15, 95% CI: 1.59-23.77, p=0.009).
Conclusion
This study demonstrates that advanced age, the presence of diabetes, non-papillary thyroid carcinoma
subtypes, metastatic disease, tumor size greater than 4 cm, and extrathyroidal extension are independently
associated with a poorer prognosis in patients with thyroid carcinoma. To offer the finest modern care, a
multidisciplinary approach should be employed when developing a tailored treatment strategy, considering
relevant recommendations and stratification systems.
Categories: Endocrinology/Diabetes/Metabolism, Internal Medicine, Oncology
Keywords: cancer, mortality, najran region, saudi arabia, survival, thyroid, treatment outcome
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Open Access Original Article
How to cite this article
Badheeb A M, Alkarak S, Alhajlan M A, et al. (October 25, 2024) Clinical Characteristics and Treatment Outcomes of Thyroid Cancer at a Tertiary
Care Hospital in Najran Region, Saudi Arabia: A Single-Centre Retrospective Study. Cureus 16(10): e72380. DOI 10.7759/cureus.72380
Introduction
The increased use of imaging modalities, followed by subsequent invasive testing, has led to a rise in the
incidence and prevalence of thyroid cancer globally [1,2]. Epidemiological studies report a higher incidence
of thyroid cancer in high-income regions, including North America and Europe. However, high rates have
also been reported in Asian regions, such as China [3]. In the United States, thyroid carcinoma is the 13th
most prevalent cancer overall and the sixth most common among women [4]. These figures differ from those
in the Kingdom of Saudi Arabia (KSA), where recent reports show thyroid cancer as the second leading
malignancy among females, with a 26-fold increase from 1990 to 2016 [5]. More recent data from the Saudi
Cancer Registry indicate that thyroid cancer is the third most common malignancy among Saudi adults and
the leading malignancy among younger females aged 15-29 years [6].
While the increased incidence may be partly attributed to the frequent use of imaging, improved
accessibility to healthcare services and increased social awareness are likely contributing factors [7].
Notably, there is a significant variation in cancer distribution across different regions of KSA. In the Najran
region, thyroid cancer accounts for the majority of cancer cases (15.8%), contrasting with other regions
where breast, colorectal, and hematological malignancies predominate [6]. There is a notable scarcity of
literature regarding the patterns of thyroid malignancies, patient profiles, and predictors of outcomes. This
study aims to examine the clinical and histological characteristics of differentiated and poorly differentiated
thyroid cancer, as well as the factors associated with survival over nine years in an oncology referral hospital
in Najran, Saudi Arabia.
Materials And Methods
Study design
A retrospective chart review study covered the period between March 1, 2014, to December 31, 2021,
involving 279 adult patients with thyroid nodules who were presented to King Khaled Hospital, Najran, Saudi
Arabia. This study was approved by the Ethics Research Committees of Najran Health Directorate (Code:
KACST, KSA: H-I1-N-089) in compliance with the ethical standards outlined in the Declaration of Helsinki.
Owing to the study's retrospective nature, written informed consent from the included patients was waived.
Patients less than 18 years old and patients without confirmed thyroid cancer diagnosis were excluded.
Collected data
The patients' electronic medical records were reviewed, and the extracted data included patients’
demographics, comorbidities, family history of thyroid cancer, initial presentation, and ultrasonographic
findings with corresponding Thyroid Imaging Reporting and Data System (TI-RADS™) scores. Additionally,
pathological findings from fine-needle aspiration cytology (FNAC), based on the Bethesda System for
Reporting Thyroid Cytopathology (TBSRTC), were obtained, along with operative approaches, findings, and
surgical staging. Post-operative data included complications, thyroglobulin levels, radioiodine scan (RAI)
findings, and overall patient outcomes. Data were collected through independent chart reviews. The
collected data were thoroughly assessed for accuracy, completeness, and consistency. In cases where
contradictory or missing information was identified, the charts were reviewed and reevaluated to ensure
data quality.
Ultrasonography (USG) findings
Thyroid ultrasounds were conducted by qualified radiologists using the TI-RADS and American College of
Radiology (ACR) 2017 criteria [8]. The nodule composition, echogenicity, form, margin, and echogenic foci
were evaluated. Each feature was evaluated using ACR TI-RADS, with scores ranging from 0 to 2 for
composition, 3 for echogenicity, form, and margin, and 3 for echogenic foci [9].
FNAC findings
The FNAC was performed under USG guidance only. FNA was done on the thyroid nodules, and the
cytological diagnosis was determined using Bethesda's international cytological classification.
Cytopathology reports were categorized into six types: Bethesda I, II, III, IV, V, and VI represent
unsatisfactory material, benign, atypical/follicular lesion, suspected follicular neoplasia, suspected
malignancy, and malignancy, respectively [10]. Overall survival (OS) was calculated from diagnosis to death.
Clinical assessment and follow-up
Lobectomy and isthmectomy were executed for T1 and T2 tumors localized to unilateral lobes. At the same
time, total thyroidectomy was indicated for T3 and T4 tumors or in patients exhibiting high-risk factors such
as multifocality, lymphatic or distant metastasis, familial predisposition, and prior ionizing radiation
exposure. In certain instances where postoperative radionuclide therapy was anticipated, total
thyroidectomy was deemed appropriate. Central neck dissection was carried out for cN1 and the majority of
cN0 patients, with modified lateral lymph node dissection, applied to those with clinically suspicious lateral
metastases. Pathological confirmation was obtained for all samples, and thyrotrophic (Thyroid Stimulating
Hormone) suppressive therapy was the primary postoperative treatment, complemented by radioactive
2024 Badheeb et al. Cureus 16(10): e72380. DOI 10.7759/cureus.72380 2 of 13
iodine for advanced PTC cases. Follow-up protocols included routine assessments via neck palpation,
ultrasound, and thyroid function tests, with imaging modalities like computed tomography (CT)/magnetic
resonance imaging (MRI) and needle biopsy reserved for suspected recurrences or metastases. At the same
time, elevated thyroglobulin levels without identified lesions post-surgery did not constitute adverse events
for disease-free survival analysis. Local recurrence, distant metastasis, or death were unfavorable outcomes
in the disease-free survival (DFS) study. The diagnosis of local recurrence should be validated by pathology.
The 1-year and 5-year survival periods were defined as being alive for 365 and 1825 days after diagnosis,
respectively. It should be noted that the 1-year relative survival estimates are more current than the 5-year
survival statistics due to the survival technique used. We used the eighth edition of the American Joint
Committee on Cancer/tumor node metastasis (AJCC/TNM) staging system to predict disease-specific
mortality and the American Thyroid Association (ATA) risk stratification system to predict the risk of
recurrent or persistent disease.
Primary outcome
The primary outcome was to report the clinical, radiological, and histological characteristics of thyroid
cancer, treatment, and overall survival. The secondary outcome was documenting the factors associated with
survival in thyroid cancer patients.
Statistical analysis
We utilized the mean ± standard deviation (SD) to represent the quantitative variables, and the frequency
(percentage) was employed to describe the qualitative variables. Chi-squared tests were used to compare the
characteristics of patients and tumors. Kaplan-Meier survival curves and Cox-proportional hazard methods
were applied for survival analyses. The relationship between pre-therapeutic variables and overall survival
was reported as a hazard ratio (HR) with a 95% confidence interval (CI). A P-value less than 0.05 was deemed
statistically significant. All the data were processed using the SPSS version 20 software (IBM Corp., Armonk,
USA).
Results
Participants' demographic and baseline characteristics
The mean age was 42.8 ±14.5 years (Range 19- 89 years), most cases were aged between 30-39 (n= 85, 31%)
followed by between 40-49 (n= 73, 26%), and most cases were female (n= 203, 72.8%). Comorbidities include
hypertension, diabetic mellites, history of thyroid cancer, and cerebrovascular accidents in 33 (11.8%), 26
(9.3%), 11 (3.9%), and four (1.4%), respectively. The most commonly reported symptom was dysphagia
(n=266, 95.3%), and most cases were diagnosed at least three months after the presenting symptom (n=176,
63.5%). The TIRADS showed a malignant feature in most cases and were presented as TIRADS 5 in 117
(41.9%) of cases, while TIRADS 1 and TIRADS 2 were mentioned in 7 (2.5%) and 19 (6.8%), respectively. Most
cases were reported initially as malignant according to FNA results based on the Bethesda System and
categorized as Category 6, Category 5, and Category 4 in 133 (47.7%), 105 (37.6%), and 24 (8.6%),
respectively. However, 14 (5.0%) were reported as benign nodules (Category 2), one (0.4%) was reported as
nondiagnostic or unsatisfactory (Category 1), and two (0.7%) were reported as atypia or follicular lesions of
undetermined significance (Category 3) (Table 1).
Variables N (%)
Age (year), Mean ±SD 42.8 ±14.5
Age group
Less than 19 years 5 (1.8%)
Between 20–29 years 40 (14%)
Between 30–39 years 85 (31%)
Between 40–49 years 73 (26%)
Between 50–59 years 38 (14%)
Between 60–69 years 20 (7.2%)
Between 70–79 years 9 (3.2%)
More than 80 years 8 (2.9%)
Gender
Male 76 (27.2%)
2024 Badheeb et al. Cureus 16(10): e72380. DOI 10.7759/cureus.72380 3 of 13
Female 203 (72.8%)
Comorbidity
Hypertension 33 (11.8%)
Diabetic mellites 26 (9.3%)
History of thyroid cancer 11 (3.9%)
Cerebrovascular accidents 4 (1.4%)
Main symptoms
Dysphagia 266 (95.3%)
Goiter 248 (88.9%)
Pain 164 (58.8%)
Dyspnea 79 (28.3%)
Hoarseness 23 (8.2%)
Cervical lymphadenopathy 19 (6.8%)
The time between the first symptom and diagnosis
< 3 months 176 (63.5%)
Between 3-6 months 28 (10.1%)
Between 6-12 months 5 (1.8%)
Between 12-24 months 9 (3.2%)
> 24 months 15 (5.3%)
Not mentioned 46 (16.6%)
TRIAD
TIRADS 1: normal thyroid gland 7 (2.5%)
TIRADS 2: benign nodules 19 (6.8%)
TIRADS 3: mildly suspicious of malignancy 68 (24.4%)
TIRADS 4: moderately suspicious of malignancy 68 (24.4%)
TIRADS 5: highly suspicious of malignancy 117 (41.9%)
FNA result based on Bethesda System
Category 1: nondiagnostic or unsatisfactory 1 (0.4%)
Category 2: benign 14 (5.0%)
Category 3: atypia, follicular lesion of undetermined significance 2 (0.7%)
Category 4: Follicular neoplasm or suspicious for follicular neoplasm 24 (8.6%)
Category 5: suspicious for malignancy 105 (37.6%)
Category 6: Malignant 133 (47.7%)
TABLE 1: Clinicopathological profile of thyroid disease cases (N= 279)
Abbreviation: TIRADS, Thyroid Imaging R eporting and Data System; FNA, fine-needle aspiration; SD, standard deviations.
Operative and postoperative characteristics
Most cases (n=170, 60.9%) underwent total thyroidectomy, followed by near-total thyroidectomy and
lobectomy in 96 (34.4%) and 9 (3.2%), respectively. Additionally, lymph node dissection was performed in 28
(10.0%) cases. In most cases, the disease was localized (n=214, 76.7%). Meanwhile, distant and regional
2024 Badheeb et al. Cureus 16(10): e72380. DOI 10.7759/cureus.72380 4 of 13
metastasis were reported in 34 (12.2%) and 31 (11.1%), respectively. The commonly reported metastasis
locations were neck lymph nodes and lungs in 19 (6.8%) and 11 (3.9%) cases, respectively. The tumor was
more significant than 40 mm in 22 (7.9%), multifocal in 2 (0.7%), and extra thyroid invasion in 19 (6.8%)
(Table 2).
Variables N (%)
Surgical procedure
Total thyroidectomy 170 (60.9%)
Near-total thyroidectomy 96 (34.4%)
Total thyroidectomy with lymph node dissection 28 (10.0%)
Lobectomy 9 (3.2%)
Biopsy or no surgery 4 (1.4%)
Stage
Localized 214 (76.7%)
Regional 31 (11.1%)
Distant metastasis 34 (12.2%)
Metastasis location
Neck lymph nodes  19 (6.8%)
Lung 11 (3.9%)
Bone 2 (0.7%)
Liver 2 (0.7%)
Tumor pathologic features
Primary tumor size > 40 mm 22 (7.9%)
Multifocality 2 (0.7%)
locally advanced 4 (1.4%)
TABLE 2: Types of operative treatment and pathologic features
Pathologic and follow-up characteristics
The most commonly final histopathology report was Papillary thyroid carcinoma in 236 (84.6%), followed by
follicular thyroid carcinoma in 33 (11.8%). Other reports were anaplastic carcinoma of the thyroid,
medullary thyroid carcinoma, Well-differentiated thyroid tumor of uncertain malignant potential, Hurthle
cell cancer, and non-Hodgkin's lymphoma in four (1.4%), one (0.4%), two (0.7%), and two (0.7%),
respectively. Following surgery, adjuvant therapy, including radioactive iodine (RAI) ablation, was reported
in 51 (18.3%) and external beam radiotherapy in four (1.4%) (Table 3).
2024 Badheeb et al. Cureus 16(10): e72380. DOI 10.7759/cureus.72380 5 of 13
Variables N (%)
Final histopathology report
Papillary thyroid carcinoma 236 (84.6%)
Follicular thyroid carcinoma 33 (11.8%)
Well-differentiated thyroid tumor of uncertain malignant potential 1 (0.4%)
Medullary thyroid carcinoma 1 (0.4%)
Anaplastic carcinoma of the thyroid 4 (1.4%)
Hurthle cell cancer 2 (0.7%)
Non-Hodgkin's lymphoma 2 (0.7%)
Postoperative evolution
Relapse or recurrence 15 (5.4%)
Residual mass in thyroid scan 40 (14.3%)
Adjuvant therapy
Radioactive iodine ablation 51 (18.3%)
External beam radiotherapy 4 (1.4%)
Follow-up time (months), Mean ±SD 113.1 ±24.2
Status
Alive 269 (96.4%)
Dead 10 (3.6%)
TABLE 3: Final histopathology and follow-up report.
Abbreviations: SD, standard deviations.
Survival analysis
Within the follow-up period, residual mass in the thyroid scan was detected in 40 (14.3%), and relapse or
recurrence occurred in 15 (5.4%). Ten (3.6%) died during the follow-up period. The median overall survival
was 120 months. The one- and five-year survival was 96.77% (95% CI: 94.72%-98.87%) and 96.42% (95% CI:
94.26%-98.62%), respectively (Figure 1).
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FIGURE 1: Kaplan-Meier survival curves for overall survival among
thyroid cancer patients.
Factors associated with mortality in thyroid carcinoma
Based on univariate Cox regression analysis, independent prognostic factors of overall mortality of thyroid
carcinoma were older age (HR:1.05; 95% CI: 1.01-1.09, p=0.008) (Figure 2A), diabetic mellitus (HR: 4.30; 95%
CI: 1.11-16.62, p=0.035) (Figure 2B), extrathyroidal extension (HR: 6.15; 95% CI: 1.59-23.77, p=0.009)
(Figure 2C), tumor size > 4 cm (HR:121.21; 95% CI: 15.33-958.34, p<0.001) (Figure 2D), metastasis
presentation (HR: 11.70; 95% CI: 3.30-41.46, p<0.001) (Figure 3A), pulmonary metastasis (HR: 27.92; 95% CI:
6.96-111.98, p<0.001), bone and liver metastasis (HR: 15.20; 95% CI: 1.70-135.98, p=0.015) (Figure 3B),
pathologic subtype of follicular carcinoma (HR: 4.48; 95% CI: 1.07-18.73, p=0.040) or non-papillary thyroid
carcinoma subtypes (HR: 12.56; 95% CI: 2.44-64.74, p=0.002) (Figure 3C) (Table 4).
FIGURE 2: Among thyroid cancer patients, cox-proportional hazard
methods found a statistically significant association between mortality
and (A) older age (p=0.008), (B) diabetic mellitus (p=0.035), (C)
extrathyroidal extension (p=0.009), and (D) tumor size larger than 4 cm
(p<0.001).
2024 Badheeb et al. Cureus 16(10): e72380. DOI 10.7759/cureus.72380 7 of 13
FIGURE 3: Among thyroid cancer patients, cox-proportional hazard
methods found a statistically significant association between mortality
and (A) distant metastasis (p<0.001), (B) metastasis locations
(pulmonary metastasis; p<0.001 and bone and liver metastasis;
p=0.015), (C) pathologic subtypes (follicular carcinoma (p=0.004) and
other nonpapillary subtypes (p=0.002)).
Cervical LN: Cervical lymph nodes
2024 Badheeb et al. Cureus 16(10): e72380. DOI 10.7759/cureus.72380 8 of 13
Variable Subgroups N (%) HR (95% CI) p-value
Age (year) Mean (SD) 43.5 (14.3) 1.05 (1.01-1.09) 0.008
Gender
Male 76 (27.2) Reference group
0.607
Female 203 (72.8) 1.50 (0.32-7.07)
Hypertension
No 246 (88.2) Reference group
0.431
Yes 33 (11.8) 1.86 (0.40-8.78)
Diabetic mellitus
No 253 (90.7) Reference group
0.035
Yes 26 (9.3) 4.30 (1.11-16.62)
Pathology subtype
Papillary carcinoma 236 (85.2) Reference group
Follicular carcinoma 33 (11.9) 4.48 (1.07-18.73) 0.040
Other carcinomas* 8 (2.9) 12.56 (2.44-64.74) 0.002
Thyroglobulin
Normal 242 (86.7) Reference group
0.533
High 37 (13.3) 1.64 (0.35-7.71)
Metastasis
No 245 (87.8) Reference group
<0.001
Yes 34 (12.2) 11.70 (3.30-41.46)
Metastasis locations
No 245 (87.8) Reference group
Cervical lymphadenopathy 19 (6.8) 3.30 (0.37-29.52) 0.286
Pulmonary 11 (3.9) 27.92 (6.96-111.98) <0.001
Bone or liver 4 (1.4) 15.20 (1.70-135.98) 0.015
Type of surgery
Total thyroidectomy 170 (60.9) Reference group
0.476
Other procedures 109 (39.1) 1.57 (0.45-5.42)
Radioactive iodine ablation
No 228 (81.7) Reference group
0.881
Yes 51 (18.3) 1.13 (0.24-5.30)
Tumor size
≤ 4 cm 253 (91.7) Reference group
<0.001
> 4 cm 23 (8.3) 121.21 (15.33-958.34)
Extrathyroidal extension
No 260 (93.2) Reference group
0.009
Yes 19 (6.8) 6.15 (1.59-23.77)
Relapse or recurrence
No 264 (94.6) Reference group
0.709
Yes 15 (5.4) 1.10 (0.66-1.86)
TABLE 4: Univariate Cox regression analyses of thyroid carcinoma overall survival.
Abbreviations: SD, standard deviations; HR, Hazard Ratio; CI, confidence interval.
Notes:
* Other pathologies include anaplastic carc inoma of the thyroid, medullary thyroid carcinoma, well-differentiated thyroid tumor of uncertain malignant
potential, Hurthle cell cancer, and non-Hodgkin's lymphoma.
A p-value less than 0.05 was considered statistically significant.
Discussion
This study reviewed a single-center database of the pattern of thyroid cancer and the patients’ profile in a
single cancer center. In addition, our study investigates the link between survival and prognostic factors
2024 Badheeb et al. Cureus 16(10): e72380. DOI 10.7759/cureus.72380 9 of 13
such as comorbidities, thyroglobulin levels, treatment activity, tumor multifocality, metastasis presentation
and location, residual size, and thyroidectomies subtypes in differentiated thyroid carcinoma patients.
The mean age of the patients in our study was 42.8 years, with the majority falling within the age range of 30
to 39 years (n = 85, 31%), followed by those aged 40 to 49 years (n = 73, 26%). Our findings are consistent
with previous reports from Saudi Arabia, including those by Samargandy et al., Jammah et al., and Hussein et
al. Furthermore, our study demonstrated a disproportionate prevalence among females, which aligns with
both national and international studies [11-13]. Notably, advanced age was associated with increased
mortality. Although female gender was also linked to higher mortality rates, this association did not reach
statistical significance. In a study by Shah et al., age was found to be a significant predictor of treatment
response, recurrence, and mortality, with younger patients exhibiting a higher percentage of favorable
responses compared to older patients [14]. Jonklaas et al. further observed that prognosis varied within
different age groups and between genders. Specifically, younger females (aged < 55 years) showed better
outcomes, whereas females aged 55 years and older had prognoses comparable to their male counterparts
[15].
Consistent with prior reports, papillary thyroid cancer accounted for the majority of the cases (84.6%) [5,11-
13,16]. Follicular thyroid cancer was reported in (11.8%) of our patients. Overall, these tumors represent
well-differentiated carcinomas, that carry an overall favorable prognosis [17]. Our study reveals that the
pathologic subtypes of follicular thyroid carcinoma (HR: 4.48) and non-papillary thyroid carcinoma subtypes
(HR: 12.56) were associated with increased mortality. These findings might be related to the tendency of
follicular carcinoma to metastasize to distant organs, compared to papillary thyroid cancer which tends to
metastasize to regional lymph nodes [18].
The potential association between systemic illness and thyroid cancer has been suggested, though results
from various studies remain inconclusive. Elevated thyroid hormone levels, insulin resistance, obesity, and
vitamin D insufficiency may all have a modest association with thyroid cancer [19]. In the present study,
diabetes mellitus was observed in 9.3% of thyroid cancer patients and was significantly associated with
increased mortality. However, a pooled analysis by Kitahara et al. found no significant association between
diabetes mellitus or physical inactivity and thyroid malignancies [20]. Conversely, a more recent meta-
analysis by Yeo et al. indicated that women with pre-existing diabetes are more likely to develop thyroid
cancer compared to their non-diabetic counterparts [21]. Moreover, findings by Dong et al. demonstrated a
significant link between diabetes and an increased risk of thyroid cancer in both men and women,
suggesting a positive association between diabetes and thyroid cancer [19]. While these findings imply a
modest correlation, further research is necessary to assess this relationship.
Total thyroidectomy was the most commonly performed surgical intervention among our patients,
accounting for 60.9% of cases. Following surgery, adjuvant therapies such as radioactive iodine ablation and
external beam radiotherapy were administered in 18.3% and 1.4% of patients, respectively. Notably, our
approach differs from reported data by another cancer center, where radioactive iodine was utilized in the
majority of cases [22]. The use of radioactive iodine is primarily dependent on the risk of recurrence and is
routinely recommended by the American Thyroid Association for patients with high-risk diseases [23].
Nevertheless, risk stratification data were not reported for the patients in their study.
Long-term survival in thyroid cancer patients is influenced by surgery type and tumor size, but the
prognosis is independent of prophylactic lymph node dissection in clinically node-negative disease.
Previous studies have demonstrated that tumor size and lymph node involvement independently affect
overall survival, regardless of the type of surgery performed [24-26]. In this study, the surgery type and
lymph node dissection were unrelated to mortality. This may be due to the majority of cases (60%)
undergoing total thyroidectomy and a few numbers (10.0%) undergoing total thyroidectomy with lymph
node dissection. Additionally, our study discovered that pre-treatment thyroglobulin levels were connected
with mortality (HR: 1.64). However, the association was not statistically significant despite earlier studies
indicating a relationship between high thyroglobulin levels and disease metastasis [25,27].
In thyroid cancer, variables such as tumor size, extra-thyroidal extension, axillary lymph node status,
pulmonary metastasis, histological grade, multiple organ involvement, and distant metastasis all have a
substantial impact on survival, as documented in several reports [28-30]. Identifying indicators to predict
and prevent organ-specific colonization in thyroid cancer patients might aid in developing follow-up
measures and individualized therapy. In concordance with these findings, our study reveals that metastasis
presentation, pulmonary metastasis, bone and liver metastasis, tumor size > 4 cm, and extrathyroidal
extensions were associated with mortality in thyroid carcinoma patients.
In our study, the interval between the manifestation of a sign or symptom and the diagnosis of thyroid
cancer varied, although, in the majority of instances, it was under three months. However, no specific details
regarding this longer time to diagnosis due to the retrospective design of this study. In another report,
Gianlorenzo Dionigi et al. reported that the time interval between the occurrence of a sign/symptom and
thyroidectomy averaged 3 months. They found that the patient's time interval ranged from 25-85 days,
diagnostic time interval from 12-40 days, and therapeutic time interval from 7-30 days. Furthermore, the
2024 Badheeb et al. Cureus 16(10): e72380. DOI 10.7759/cureus.72380 10 of 13
patient's time interval was higher than the diagnostic time interval and therapeutic time interval and was
statistically significant [31].
Study limitations
This study has several limitations. The methodological design, limited to a retrospective chart review, is
subject to risks of selection and misclassification biases. Additionally, data accuracy may be compromised
due to incomplete or inaccurate documentation. Moreover, the study reflects the experience of a single
cancer center. Although conducted in a tertiary referral hospital, the findings may not be representative of
the entire nation. Further research, involving prospective studies using a registry of consecutive cases with
longer follow-up periods, is necessary to validate our results.
Conclusions
Our study analyzed thyroid cancers in Najran between 2014 and 2021, revealing that women and individuals
aged 30-39 were the most affected, and the most frequent type of thyroid cancer was papillary carcinoma.
Additionally, advanced chronological age, the existence of diabetes mellitus, non-papillary thyroid
carcinoma variants, metastatic progression, tumor dimensions exceeding 4 cm, and extrathyroidal extension
are independently correlated with an unfavorable prognosis in individuals diagnosed with thyroid
carcinoma. To provide the highest standard of contemporary medical care, a multidisciplinary framework
should be utilized when formulating a customized therapeutic regimen, considering pertinent guidelines and
stratification methodologies.
Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.
Concept and design: Ahmed M. Badheeb, Faisal Ahmed, Mohamed Badheeb, Samer Alkarak, Ali M. Al-
Qannass, Mana A. Alhajlan, Rakan Alwadai, Abbas H. Almakrami, Ibrahim Mokhtar, Mohammed A. Fagihi,
Islam A. Seada, Nadeem M. Nagi, Abdullah Abu Bakar, Saleh M. Alqahtani, Abdelaziz A. Aman, Hossam A.
Hussein, Ahmed Harwn
Acquisition, analysis, or interpretation of data: Ahmed M. Badheeb, Faisal Ahmed, Mohamed Badheeb,
Samer Alkarak, Ali M. Al-Qannass, Mana A. Alhajlan, Rakan Alwadai, Abbas H. Almakrami, Ibrahim Mokhtar,
Mohammed A. Fagihi, Islam A. Seada, Nadeem M. Nagi, Abdullah Abu Bakar, Saleh M. Alqahtani, Abdelaziz
A. Aman, Hossam A. Hussein, Ahmed Harwn
Drafting of the manuscript: Ahmed M. Badheeb, Faisal Ahmed, Mohamed Badheeb, Samer Alkarak, Ali M.
Al-Qannass, Mana A. Alhajlan, Rakan Alwadai, Ibrahim Mokhtar, Mohammed A. Fagihi, Islam A. Seada,
Nadeem M. Nagi, Abdullah Abu Bakar, Saleh M. Alqahtani, Abdelaziz A. Aman, Hossam A. Hussein, Ahmed
Harwn
Critical review of the manuscript for important intellectual content: Ahmed M. Badheeb, Faisal
Ahmed, Mohamed Badheeb, Samer Alkarak, Ali M. Al-Qannass, Mana A. Alhajlan, Rakan Alwadai, Abbas H.
Almakrami, Ibrahim Mokhtar, Mohammed A. Fagihi, Islam A. Seada, Nadeem M. Nagi, Abdullah Abu Bakar,
Saleh M. Alqahtani, Abdelaziz A. Aman, Hossam A. Hussein, Ahmed Harwn
Supervision: Ahmed M. Badheeb, Faisal Ahmed, Mohamed Badheeb, Samer Alkarak, Ali M. Al-Qannass,
Mana A. Alhajlan, Rakan Alwadai, Abbas H. Almakrami, Ibrahim Mokhtar, Mohammed A. Fagihi, Islam A.
Seada, Nadeem M. Nagi, Abdullah Abu Bakar, Saleh M. Alqahtani, Abdelaziz A. Aman, Hossam A. Hussein,
Ahmed Harwn
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Research Committees of
Najran Health Directorate issued approval KACST, KSA: H-I1-N-089. This study was approved by the Ethics
Research Committees of Najran Health Directorate (Code: KACST, KSA: H-I1-N-089) in compliance with the
ethical standards outlined in the Declaration of Helsinki. Owing to the study's retrospective nature, written
informed consent from the included patients was not required. . Animal subjects: All authors have
confirmed that this study did not involve animal subjects or tissue. Conf licts of interest: In compliance
with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All
authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present or
within the previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or activities that could
appear to have influenced the submitted work.
2024 Badheeb et al. Cureus 16(10): e72380. DOI 10.7759/cureus.72380 11 of 13
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Background and Aims Thyroid cancer (TC) is the second most common neoplasm occurring in adult Saudi women. Therefore, this study aimed to discuss the demography, classification, and management of TC among adults in Najran, Saudi Arabia. Materials and Methods This retrospective study reviewed 88 patients with histopathologically identified TC at Najran King Khalid Hospital between January 2018 and September 2022. Descriptive data analysis was performed, focusing on the clinical and pathological information, treatment strategies, comorbidities, and demographics. Results This study included 88 patients with TC. Female sex (81.8%), age 30–44 years (46.6%), and Saudi nationality (77.3%) were not significantly associated with the histopathological diagnosis ( P = 0.064, P = 0.313, and P = 0.603, respectively). Comorbidities were identified in 52 patients (59.1%), with thyroid diseases being the most common (21.6%), followed by hypertension (16.1%). Total thyroidectomy showed statistically significant results in 63/71 papillary carcinoma patients (88.7%), and hemithyroidectomy was significant in 9/14 follicular carcinoma patients (64.3%) ( P < 0.001). Statistically significant results were reported with no neck dissection in the papillary, follicular, and coexisting papillary and follicular TC cases ( P = 0.046), while bilateral dissection showed significant results in the medullary carcinoma case ( P = 0.001). Conclusion Our study examined the demographic and clinicopathological data of TC between 2018 and 2022 in Najran. We found that Saudi nationals, women, and individuals aged 30–44 years comprised the majority of those affected. The most frequent type of TC was papillary carcinoma.