Thyroid malignancy is the most common endocrine cancer worldwide and represents a significant public health concern because of its steadily increasing incidence over the past three decades. Although most thyroid cancers exhibit an indolent clinical course with excellent long-term survival, a subset demonstrates aggressive biological behaviour associated with local invasion, distant metastasis, and disease-specific mortality.¹ The thyroid gland is a highly vascular endocrine organ located in the anterior neck and is responsible for the synthesis and secretion of thyroxine (T4) and triiodothyronine (T3), hormones essential for normal growth, metabolism, and cellular differentiation. Malignant transformation of thyroid follicular or parafollicular cells results in a spectrum of thyroid cancers with distinct histopathological characteristics and prognostic outcomes. ²

Globally, thyroid cancer accounts for approximately 4–5% of all newly diagnosed cancers in women and is one of the fastest-growing malignancies in terms of incidence. According to GLOBOCAN 2022 estimates, thyroid cancer remains among the leading endocrine malignancies, with increasing detection across both developed and developing countries. ³  The rising incidence has been attributed partly to advances in high-resolution ultrasonography, widespread use of fine-needle aspiration cytology (FNAC), improved pathological classification, and increased surveillance, leading to the detection of small papillary thyroid carcinomas. Nevertheless, a true increase in disease burden has also been suggested, indicating the contribution of environmental, genetic, and lifestyle factors.⁴

India has witnessed a gradual increase in the incidence of thyroid malignancy over recent years, particularly among women. Population-based cancer registries have identified thyroid cancer as one of the common endocrine malignancies in urban regions, with improving diagnostic facilities contributing to earlier detection and treatment. Despite this trend, delayed presentation remains common in many parts of the country because of limited awareness and disparities in healthcare access.  Papillary thyroid carcinoma constitutes approximately 80–85% of all thyroid malignancies and generally carries an excellent prognosis following appropriate surgical treatment. Follicular carcinoma accounts for nearly 10–15%, whereas medullary thyroid carcinoma, poorly differentiated carcinoma, and anaplastic carcinoma are comparatively uncommon but exhibit more aggressive clinical behaviour.

Several etiological factors have been implicated in thyroid carcinogenesis, including exposure to ionizing radiation during childhood, family history, inherited genetic syndromes, iodine imbalance, female sex, increasing age, obesity, autoimmune thyroid disease, and specific molecular alterations such as BRAF, RAS, and RET mutations. These factors influence tumour development, progression, and prognosis. The clinical presentation of thyroid malignancy is highly variable. Most patients present with a painless thyroid swelling or solitary thyroid nodule detected during clinical examination or incidentally on imaging. Advanced disease may manifest with rapidly enlarging neck swelling, cervical lymphadenopathy, hoarseness of voice due to recurrent laryngeal nerve involvement, dysphagia, dyspnoea, or symptoms related to distant metastasis. The evaluation of suspected thyroid malignancy requires a comprehensive approach incorporating detailed history, clinical examination, thyroid function tests, ultrasonography, FNAC based on the Bethesda System, and cross-sectional imaging when indicated. These investigations facilitate accurate diagnosis, risk stratification, and surgical planning.

Surgery remains the cornerstone of treatment for the majority of thyroid malignancies. Depending on tumour size, histological subtype, extent of disease, and patient-related factors, procedures may include hemithyroidectomy, total thyroidectomy, central compartment neck dissection, or modified radical neck dissection. Appropriate surgical intervention provides excellent disease control while minimizing postoperative morbidity. Postoperative outcomes are influenced by tumour stage, histopathological subtype, adequacy of surgical resection, lymph node involvement, and surgeon experience. Common complications include recurrent laryngeal nerve injury, hypocalcaemia due to parathyroid dysfunction, postoperative haemorrhage, wound infection, and the need for lifelong thyroid hormone replacement following total thyroidectomy.

Recent advances in risk stratification, molecular diagnostics, intraoperative nerve monitoring, and standardized surgical techniques have significantly improved surgical safety and long-term oncological outcomes. The overall five-year survival for differentiated thyroid carcinoma exceeds 95%, whereas poorly differentiated and anaplastic thyroid cancers continue to have a less favourable prognosis. ⁵ Despite the generally excellent prognosis, considerable variation exists in the pattern of clinical presentation, stage at diagnosis, histopathological characteristics, extent of surgery, postoperative complications, recurrence rates, and survival across different populations and healthcare settings. Such variations highlight the need for institution-specific data to optimize management protocols and improve patient outcomes. In India, studies evaluating the relationship between the clinical presentation of thyroid malignancy and surgical outcomes are relatively limited.   these patterns is essential for improving early diagnosis, selecting appropriate surgical procedures, minimizing complications, and enhancing postoperative quality of life.

Therefore, the present study, "Patterns of Clinical Presentation and Surgical Outcomes in Patients with Thyroid Malignancy: A Prospective Observational Study at a Tertiary Care Centre," has been undertaken to evaluate the demographic profile, clinical presentation, histopathological spectrum, surgical management, postoperative complications, and early surgical outcomes in patients with thyroid malignancy treated at a tertiary care hospital. The findings of this study are expected to contribute to evidence-based surgical decision-making and improve the overall management of patients with thyroid cancer.

Aim

To evaluate the patterns of clinical presentation and surgical outcomes in patients with thyroid malignancy undergoing surgical management at a tertiary care centre.

Objectives

1. To study the demographic characteristics, clinical presentation, radiological findings, cytological diagnosis, and histopathological spectrum of patients with thyroid malignancy.
2. To evaluate the surgical procedures performed, postoperative complications, and early surgical outcomes in patients with thyroid malignancy and to determine their association with clinicopathological factors.

Study Design A prospective observational hospital-based study was conducted. Study Setting The study was conducted in the Department of General Surgery in collaboration with the Department of Pathology and the Department of Radiodiagnosis at a tertiary care teaching hospital. Study Population All consecutive patients diagnosed with thyroid malignancy and undergoing surgical treatment during the study period were included. Sample Size A total of 50 patients with histopathologically confirmed thyroid malignancy who fulfilled the inclusion criteria were included in the study. Sampling Technique Consecutive sampling was adopted until the required sample size of 50 patients was achieved. Inclusion Criteria • Patients aged 18 years and above. • Patients with thyroid malignancy diagnosed by clinical evaluation, ultrasonography, FNAC, and confirmed by postoperative histopathological examination. • Patients undergoing surgical management for thyroid malignancy. • Patients willing to participate and providing written informed consent. Exclusion Criteria • Patients with benign thyroid disorders. • Patients with recurrent thyroid malignancy previously operated elsewhere. • Patients managed conservatively without surgery. • Patients with incomplete clinical records or lost to immediate postoperative follow-up. • Patients unwilling to provide informed consent. Methodology After obtaining approval from the Institutional Ethics Committee and written informed consent from all participants, eligible patients presenting with suspected thyroid malignancy were enrolled in the study. A detailed clinical history was obtained, including age, sex, duration of symptoms, family history, history of neck irradiation, associated thyroid disorders, and presenting complaints such as thyroid swelling, pain, dysphagia, hoarseness of voice, dyspnoea, and cervical lymphadenopathy. A comprehensive clinical examination, including general physical examination and local neck examination, was performed. Routine laboratory investigations, thyroid function tests, ultrasonography of the neck, and fine-needle aspiration cytology (FNAC) were carried out in all patients. Contrast-enhanced computed tomography (CT) of the neck and thorax was performed whenever clinically indicated to assess extrathyroidal extension or nodal disease. Patients underwent appropriate surgical treatment based on the American Thyroid Association recommendations, tumour characteristics, and surgeon discretion. Surgical procedures included hemithyroidectomy, total thyroidectomy, total thyroidectomy with central compartment neck dissection, and modified radical neck dissection whenever indicated. The excised specimens were subjected to histopathological examination to determine the tumour subtype, tumour size, multifocality, lymphovascular invasion, extrathyroidal extension, lymph node involvement, margin status, and TNM staging. Patients were monitored during the postoperative period for complications such as recurrent laryngeal nerve palsy, hypocalcaemia, postoperative haemorrhage, seroma formation, wound infection, chyle leak, and length of hospital stay. Vocal cord mobility was assessed by indirect or fibre-optic laryngoscopy whenever vocal cord dysfunction was suspected. Patients were followed up until discharge and during the first postoperative outpatient visit to assess early surgical outcomes and postoperative recovery. Statistical Analysis Data were entered into Microsoft Excel and analysed using IBM SPSS Statistics version 26.0. Continuous variables were expressed as mean ± standard deviation (SD) or median (interquartile range), whereas categorical variables were expressed as frequencies and percentages. The Chi-square test or Fisher's exact test was used to compare categorical variables. Continuous variables were compared using the Independent Student's t-test or the Mann–Whitney U test, depending on data distribution. Associations between clinicopathological variables and postoperative complications were assessed using binary logistic regression where appropriate. A p-value <0.05 was considered statistically significant.

A total of 50 patients with histopathologically confirmed thyroid malignancy who underwent surgical management were included in the study. The clinical presentation, diagnostic findings, histopathological patterns, surgical procedures and early postoperative outcomes were analysed.

Table 1. Demographic and Clinical Characteristics of the Study Participants (n = 50)

*Multiple clinical symptoms were present in some patients; therefore, the percentages do not total 100%.

p < 0.001.

Interpretation: The mean age of the study participants was 43.6 ± 12.4 years, with the largest proportion belonging to the 41–50-year age group. Females constituted 76% of the study population and were significantly more commonly affected than males. A painless thyroid swelling was the most frequent clinical presentation, observed in 88% of patients, followed by cervical lymphadenopathy in 28%.

Table 2. Ultrasonography and FNAC Findings Among the Study Participants (n = 50)

Association Between TI-RADS Category and Malignant/Suspicious FNAC

p = 0.006.

Interpretation: TI-RADS 5 lesions constituted 56% of the thyroid lesions, while 78% of patients had Bethesda V or VI cytology. Malignant or suspicious FNAC findings were significantly more frequent among patients with TI-RADS 5 lesions than among those with TI-RADS 3 or 4 lesions. This finding demonstrates a significant association between highly suspicious ultrasonographic features and malignant cytological findings.

Table 3. Histopathological Spectrum of Thyroid Malignancy (n = 50)

Additional Histopathological Characteristics

p < 0.001.

Interpretation: Papillary thyroid carcinoma was the predominant histopathological subtype, accounting for 68% of all thyroid malignancies. Follicular carcinoma was the second most common subtype. Aggressive histopathological features included cervical lymph node metastasis in 28%, tumour size greater than 4 cm in 26%, multifocality in 24% and extrathyroidal extension in 22% of patients. The distribution of histological subtypes was statistically significant, with papillary carcinoma being substantially more frequent than the other subtypes.

Table 4. Surgical Procedures and Early Postoperative Outcomes (n = 50)

Comparison of Complications According to Extent of Surgery

p = 0.009.

Interpretation: Total thyroidectomy was the most commonly performed surgical procedure, accounting for 48% of operations. At least one early postoperative complication was documented in 34% of patients. Transient hypocalcaemia was the most frequent complication, occurring in 18%, followed by transient recurrent laryngeal nerve palsy in 8%. Postoperative complications were significantly more common among patients who underwent thyroidectomy with neck dissection than among those who underwent thyroidectomy without neck dissection.

Table 5. Association of Clinicopathological Factors with Postoperative Complications (n = 50)

Interpretation: Postoperative complications were significantly associated with age above 50 years, tumour size greater than 4 cm, extrathyroidal extension, cervical lymph node metastasis and the performance of neck dissection. The highest complication rate was observed among patients with extrathyroidal extension. These findings indicate that advanced tumour characteristics and more extensive surgical procedures were associated with increased early postoperative morbidity.

Overall Results Summary

Papillary thyroid carcinoma was the most common thyroid malignancy, and a painless thyroid swelling was the predominant presenting complaint. A significant association was observed between TI-RADS 5 lesions and Bethesda V–VI cytology. Total thyroidectomy was the most frequently performed operation. Most patients had an uncomplicated postoperative recovery; however, transient hypocalcaemia was the most common early complication. Older age, larger tumour size, extrathyroidal extension, cervical lymph node metastasis and neck dissection were significantly associated with postoperative complications.

The present prospective observational study evaluated the patterns of clinical presentation and surgical outcomes among 50 patients with thyroid malignancy treated at a tertiary care centre. Thyroid malignancy was predominantly observed among middle-aged females, with a painless thyroid swelling being the most common presenting complaint. Papillary thyroid carcinoma was the most frequent histopathological subtype, followed by follicular thyroid carcinoma. A significant association was observed between TI-RADS 5 lesions and Bethesda V–VI cytological findings, highlighting the importance of combined ultrasonography and FNAC in preoperative diagnosis and surgical planning.

Total thyroidectomy was the most commonly performed surgical procedure. The majority of patients had an uneventful postoperative recovery, while transient hypocalcaemia was the most frequent complication. Advanced clinicopathological characteristics, including age greater than 50 years, tumour size greater than 4 cm, extrathyroidal extension, cervical lymph node metastasis and the requirement for neck dissection, were significantly associated with increased postoperative complications. Despite these risk factors, the incidence of permanent complications remained low, reflecting the effectiveness of meticulous surgical technique and comprehensive perioperative care.

The findings of this study emphasize that early diagnosis, accurate preoperative risk stratification, appropriate selection of the surgical procedure and careful postoperative monitoring are essential for achieving favourable surgical outcomes in patients with thyroid malignancy. Larger multicentric studies with long-term follow-up are recommended to further evaluate recurrence, disease-free survival and overall survival following surgical treatment of thyroid cancer.

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