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Original Research |
1 Department of Diagnostic Radiology, Yonsei University, College of Medicine,
146-92 Dogok-dong, Kangnam-gu, Seoul 135-720, Korea.
2 Department of Surgery, Yonsei University, College of Medicine, Kangnam-gu,
Seoul 135-720, Korea.
3 Department of Pathology, Yonsei University, College of Medicine, Kangnam-gu,
Seoul 135-720, Korea.
Received October 25, 2004;
accepted after revision February 28, 2005.
Address correspondence to K. K. Oh
(kbrrdoh{at}yumc.yonsei.ac.kr).
Abstract
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SUBJECTS AND METHODS. Between January 2003 and March 2004, we examined thyroid glands during routine diagnostic or follow-up breast sonography. A total of 5,549 females underwent breast and thyroid screening sonography (n = 4,864) or sonography for diagnosis or follow-up of breast cancer (n = 685). When a thyroid lesion was suspicious for malignancy, sonographically guided fine-needle aspiration was performed. We compared the cases of pathologically proven thyroid cancer in two groups: a cancer group, including patients with breast cancer, and a noncancer group, including patients with negative or benign breast disease.
RESULTS. Among the 5,549 cases, 42 (0.76%) were diagnosed as thyroid cancer; all were papillary carcinomas. Pathologically proven thyroid cancers were identified in 13 (1.9%) of the 685 breast cancer patients and in 29 (0.6%) of the 4,864 non-breast-cancer patients. The diameters of the 13 thyroid masses were 0.1-3.0 cm; the mean diameters in the cancer and noncancer groups were 9.9 and 8.6 mm, respectively.
CONCLUSION. The incidence of thyroid cancer was significantly higher in the group with breast cancer than in the group who did not have breast cancer. The results of routine concurrent sonographic breast and thyroid examinations were helpful in detecting small thyroid tumors in both patient groups.
Keywords: breast cancer • oncologic imaging • sonography • thyroid cancer • thyroid gland
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Although the precise relationship between thyroid cancer and breast cancer is unknown, many researchers have reported an increased incidence of thyroid cancer in patients with breast cancer and they have suggested possible roles of genetic, hormonal, or radiation effects [8-11]. However, to our knowledge, there is no report to date about prospective sonographic screening of thyroid cancers with a large number of patients. Therefore, we evaluated the incidence of incidentally diagnosed thyroid cancer that was detected on screening sonography in a population who underwent breast sonography, and we compared the incidences of thyroid cancer in those with and those without breast cancer.
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Between January 2003 and March 2004, we prospectively examined thyroid glands in women in the standard manner, while screening or during diagnostic or follow-up breast sonography, using 10- to 12-MHz probes of HDI 5000 or 3000 scanners (Philips Medical Systems). Two radiologists, with at least 6 years' experience with breast and thyroid sonography performed the examinations.
We excluded male breast cancers and patients who had a diagnosis of thyroid cancer before the initial breast sonography examination. A total of 5,549 females (age range, 13-83 years; mean age, 48.4 years) enrolled in this study consecutively: 4,864 for screening and 685 for diagnosis or follow-up of breast cancer. All patients with breast cancer underwent follow-up breast sonography after mastectomy, every 6 months for the first 2-3 years after mastectomy, and annually thereafter.
When the thyroid nodules had one or more suspicious sonographic findings of malignancy, such as hypoechogenicity, ill-defined margin, irregular shape, taller-than-wider orientation, or microcalcifications, we performed sonographically guided fine-needle aspiration with 21- to 23-gauge needles. Pathologically proven thyroid cancers were allocated to one of two groups: the cancer group, including pathologically proven breast cancers; and the noncancer group, including negative or benign breast disease. We compared the characteristics of the thyroid nodules in the two patient groups—that is, the size and presence of extracapsular invasion of thyroid cancer and lymph node metastasis.
Statistical comparisons of the differences between the two groups were determined using Student's t and Mann-Whitney tests with SPSS software (version 11.5, Statistical Package for the Social Sciences) for Windows (Microsoft).
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The diameters of the thyroid tumor were 0.1-3.0 cm (mean, 8.9 mm), and microcarcinomas with diameters less than 1 cm were noted in 26 cases (61.9%). Pathologically proven thyroid cancers occurred in 13 (1.9%) of the 685 breast cancer patients (Figs. 1A and 1B) and in 29 (0.6%) of the 4,864 patients without breast cancer (Figs. 2A and 2B).
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The mean diameters of the thyroid tumors in the cancer and noncancer groups were 9.9 and 8.6 mm, respectively. Extracapsular invasion of the thyroid cancer was noted in three (23.1%) and 10 (34.5%) cases in the cancer and noncancer groups, respectively. There was no significant difference between the two patient groups in the size of the tumors or the presence of extracapsular invasion (p > 0.05). A significant correlation was found between tumor size and extracapsular invasion (p < 0.05).
In the cancer and noncancer groups, respectively, two (15.4%) and 13 (44.8%) patients with thyroid cancer had central node metastasis; of these, one each had lateral neck node metastasis. The rate of lymph node metastasis was significantly higher in the noncancer group (p < 0.05), but no significant relationship was found between tumor size and lymph node metastasis in either group (p > 0.05).
None of the patients with thyroid cancer showed distant metastasis.
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Careful palpation has been widely used as a screening method for thyroid cancer. However, previous reports have revealed that physical examination can detect only thyroid nodules with a diameter exceeding 1.5 cm. Sonographic screening is now possible because of the advent of advanced high-resolution-high-frequency probes, and this technique can detect small thyroid cancers [4-6]. Miki et al. [5] reported that tumors in a screening group were significantly smaller and the incidence of regional lymph node metastasis in the screening group was significantly lower than in the outpatient group.
The thyroid sonography examinations were performed without difficulty, using the same probe as that for the breast sonography. The overall incidence of thyroid cancer was 0.76%, which is higher than that in other mass screening studies (0.2%) [4, 5]; the previously reported low-incidence data may be due to the lack of lower screening sensitivity.
The cancer group had a higher incidence of thyroid cancer (1.9%) than the noncancer group (0.6%) (p < 0.05), and 46% of the thyroid cancers in the cancer group were diagnosed as concurrent thyroid and breast cancers. Previous studies have reported the increased occurrence of thyroid cancer in patients with breast cancer, and vice versa, and although the precise relationship between the two remains unknown, many possibilities have been investigated [8, 11, 13, 14]. Genetic and hormonal factors may play roles in this concurrence. Exposure to ionized radiation is a known risk factor of thyroid and breast cancers, but the adverse effect of radiation therapy used for the primary cancer remains controversial [8]. Weiss and Rossing [15] suggested the increased incidence of secondary malignancy might be due to increased medical surveillance after diagnosis of the primary cancer.
Thyroid cancers are a variable group of malignant disorders, ranging from indolent papillary to fatal anaplastic carcinomas. Papillary and follicular carcinomas account for 90% of all cases of thyroid cancer [3]; however, in our cases, all thyroid cancers were papillary carcinomas. Most thyroid cancers are differentiated carcinomas and are associated with a good long-term prognosis, especially in the low-risk group—that is, young patients with small, well-differentiated intrathyroidal tumors and no evidence of nodal or distant spread, which have a cancer-specific mortality of less than 1-2% [3, 16, 17]. In terms of prognosis, there is some debate about the optimal treatment of small thyroid cancer [18, 19], although it should be considered that even an occult carcinoma is sometimes associated with distant metastasis [17, 19].
In our study, the mean size of the thyroid cancer was 8.9 mm, with microcarcinomas accounting for 61.9% of the thyroid cancers, and the incidental thyroid cancers were detected by sonography rather than with the use of another traditional screening method.
In conclusion, the incidence of thyroid cancer was higher in the cancer than in the noncancer group. The results of routine concurrent sonographic breast and thyroid examinations were helpful for the detection of small thyroid tumors in both groups. However, additional studies are needed to determine the cost effectiveness and survival benefit of thyroid cancer screening in the breast cancer population.
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