The epidemiology, pathology, and management of goitre in Yemen.

BACKGROUND: The total goitre rate in Yemen declined by half after the country adopted universal salt iodisation in 1995. We investigated the recent epidemiology, pathology, and management of goitre so as to evaluate changes since the initiation of the salt iodisation programme. We also sought to determine the effect of new diagnostic tools in the preoperative work-up of surgically treated patients. METHODS: Data were collected from the records of 667 patients with goitre seen in Kuwait University Hospital between 1997 and 2001. RESULTS: Females constituted 92.5 % (n=617) of the series. The mean age of all patients was 35.2+/-11.58 years (range, 13 to 90 years). Most patients (93%) came from highland areas with an average altitude of 2000 to 2600 meters above sea level. The average duration since patients noticed swelling until the diagnosis was made was about 4 years. Multinodular bilateral swelling was the most common clinical finding (44.9%), while solitary nodules constituted the least common (17.4%). The most common associated symptom was dyspnoea (20.5%). The most common histopathological finding was nodular and colloid goitre (62.8%), while malignancy accounted for 17.7%. Subtotal thyroidectomy was the most frequent procedure, and the most common postoperative complication was hypocalcaemia. CONCLUSIONS: Goitre is a national problem in Yemen. The late presentation, which may be important in malignant transformation of the thyroid gland, makes surgery imperative. The salt iodisation programme has been associated with a decrease in the malignancy rate. Yemen is in great need of experienced cytologists and radiologists to increase the efficacy of fine needle aspiration cytology and ultrasonography in the diagnosis of thyroid lesions. Patients need to be educated about the importance of post-operative follow up.

Thyroid cancer in Yemen.

OBJECTIVE: To evaluate the characteristics of thyroid cancer (TC) patients in regard to demographic distribution, histological variants, mode of presentation and modalities of diagnosis and treatment. METHODS: We retrospectively audited the records of 97 consecutive cases with histologically proved thyroid cancer between 1997 and 2001 presenting to the Kuwait University Hospital, Sana'a, Yemen. RESULTS: Patients with TC in this study comprise 17.7% of goiter patients who were admitted at the same period. Females constituted 89.7% (n=87), and males 10.3% (n=10). The average age of diagnosis was 38.4 years. More than two thirds were at the age of <40. Among patients with goiter, the percentage of carcinoma was higher in the following groups, males (37.9% versus 16.6%, p=0.028), patients aged >47 (25.8% versus 12.6%, p=0.001), patients with enlarged lymph nodes (9.3% versus 3.8%, p=0.020), and patients with recurrent disease after being operated for a presumably benign disease (8.2% versus 2.9%, p=0.012). The average period since patients noticed the swelling until seeking medical help was 4 years. Most patients (90%) came from highland areas. Multinodular swelling was the most common clinical finding (43.3%), and hoarseness was the most common symptom (17.5%). In histopathological examination, papillary carcinoma accounted for 93.8% of the cases and papillary microcarcinoma was found in 10 cases (10.3%). The papillary/follicular carcinoma ratio was 22:1. Hormone assay and ultrasonic imaging were the most commonly used investigations. Sub total thyroidectomy was the most common procedure used in treatment (39%). CONCLUSION: Not all histological variants of TC are represented in this study. Papillary carcinoma formed the bulk of TC cases. Salt iodization program might have an effect on the incidence of thyroid malignancy, and on the papillary/follicular carcinoma ratio. Better level of expertise is needed in the field of fine needle aspiration and ultrasonography. A consensus has to be reached, which is based on our environment and capabilities, where TC has to be managed aggressively by experienced surgeons. Yemen is in real need of a national cancer registry to assess the problem on a national level.

The diagnostic value of fine needle aspiration cytology in thyroid swellings in a university hospital, Yemen.

OBJECTIVE: To evaluate the correlation between the fine needle aspiration (FNA) cytology and the histopathological findings in cases of the thyroid swellings and to assess the accuracy of cytological examination of thyroid nodules. METHODS: This study was carried out at Kuwait University Hospital, Sana'a, Yemen. There were 243 thyroid FNAs of which 199 had subsequent excisional histopathological examination in the period 1997 to 2001. All the records of cytology and histology were reviewed. Cases were classified into 6 subsets: benign follicular lesion, thyroiditis, follicular neoplasm, suspicious for papillary carcinoma, malignant, and non-diagnostic aspirate. For statistical analysis, we excluded cases, which had not had subsequent histopathological examination (n=44), and cases with non-diagnostic aspirate (n=3), so only the histology and medical records of 196 cases were reviewed and correlated with the cytology results. RESULTS: There were 156 (78.4%) cases of benign aspirate, 31 (15.6%) cases of follicular neoplasm, 4 (2%) cases that were suspicious for papillary carcinoma, 4 (2%) cases of papillary carcinoma, and 3 (1.5%) cases of non-diagnostic aspirates. The 196 cases, which underwent cytological and histopathological examinations, were classified as non-neoplastic and neoplastic (including follicular neoplasm and malignancy) according to postoperative histopathology and correlation which, was carried out with preoperative cytology. There were 115 true negatives, 26 true positives, 42 false negatives, and 13 false positives. This gives a sensitivity of 38%, specificity of 89.9%, positive predictive value of 66.7%, negative predictive value of 73.2%, and accuracy of 72%. CONCLUSION: The sensitivity of FNA cytology in this study is very low compared to published studies, which had adversely affected the surgical decision making as well as the outcome. We should realise that negative FNA cytology does not exclude malignancy and we have to seriously evaluate the situation and to rethink on how to raise the scale of sensitivity in FNA cytology in the diagnosis of thyroid nodules, and to improve the level of expertise in cytology.