Thyroid papillary cancers: microcarcinoma and carcinoma, incidental cancers and non‐incidental cancers – are they different diseases?

Summary Objective  Tumour size represents a much-debated prognostic factor in papillary cancer, and the necessity to perform a fine-needle aspiration (FNA) on small nodules is a frequent matter of discussion. We compared some prognostic histological features for various sizes of papillary cancers (PCs) and, with regard to these prognostic features, we compared non-incidental with incidental PCs. We also considered the possibility that ultrasonography could detect nodules harbouring the most aggressive cancers. Design and patients  We have studied patients with a histological diagnosis of PC from 1999 to 2003. FNA was performed on all nodules > 1·0 cm and on hypoechoic nodules with irregular margins or microcalcification when the size was < 1·0 cm (3321 FNAs in total). We were able to consider several different types of patients: those with PC diagnosed by FNA before surgery; those with large goitre and PC of small size diagnosed after histological examination and in whom a careful examination of the presurgical ultrasonography could show a distinct highly suspicious nodule that was not subjected to FNA, and patients with real incidental PC (that is, those with nodular goitre who correctly underwent FNA on suspicious nodules but in whom thyroid cancer was discovered only at histological examination). We considered two groups of patients with PC. Group 1 PCs were diagnosed before surgery with FNA (128 cases); in this group we also considered the two cases that were not correctly diagnosed before surgery. Group 2 real incidental PCs (12 cases) were found in goitres at histological examination after thyroidectomy for goitre (282 thyroidectomies). Group 1 was divided into three subgroups according to the maximum size of the PC at histological examination: (a) 44 PCs with maximum size < 10 mm, (b) 47 PCs with maximum size between 10 mm and 20 mm, and (c) 39 PCs with maximum size  20 mm. In all subgroups 1 as well as in group 2, the following four histological features were considered separately: multifocality, extracapsular extension, lymph-node involvement and its extent, and special aggressive features (dedifferentiation and/or insular aspects, tall and columnar variants). Results  In subgroups 1a, 1b and 1c the results were, respectively: multifocality 56·8, 57·4 and 51·2%; extracapsular extension 27·2, 23·4 and 46·3% (P = 0·01, subgroups 1a and 1b vs. subgroup 1c); lymph-node metastasis 13·5, 23·3 and 46·1% (P = 0·003 subgroup 1a vs. 1c; P = 0·04, subgroup 1b vs. 1c); special aggressive features 11·3, 25·5 and 28·2% (P = ns). Group 2 showed one case of multifocality (8·3%) in a patient with prior exposure to radiotherapy in childhood, while no case was found of extracapsular invasion or lymph-node involvement, and only one patient had a PC with features of dedifferentiation. Conclusions  Non-incidental cancer, apart from multifocality, showed a classical progression for all prognostic factors from microcarcinoma to larger cancers. However, real incidental PC seemed to be different from non-incidental PC microcarcinoma regarding the main prognostic features. We conclude that ultrasonography is useful not only in terms of revealing the presence of cancer but also in identifying the most aggressive cancers.