these tumors are frequently found as a histological surprise following excision of benign thyroid tumors . even though these tumors are small , a small proportion can behave aggressively and they can present with lymph node / distant metastasis . in low risk cases , the extent of surgery and the adjuvant therapy to be used is still being debated . in this study
this was a retrospective study of patients with ptmc diagnosed between january 2005 and june 2012 .
all details pertaining to their clinical presentation , surgery , adjuvant therapy and follow - up were obtained .
the data was analyzed using the statistical package for social sciences ( spss ) 17.0 software ( spss , inc . , chicago , illinois ) . during this period ,
94 cases of ptmc were detected among 1300 thyroidectomy specimens . among these , there were 77 cases of isolated ptmc and only these were included in the final analysis .
anti - thyroid antibodies were measured in select patients in whom autoimmune thyroiditis was suspected .
the size of each lobe of the thyroid was measured and the presence of nodules was noted .
the features of malignancy included the presence of hypo echoic nodules with irregular margins , loss of peripheral halo , micro calcification , increased central vascularity , the nodule appearing taller than wide and the presence of cervical lymph node enlargement .
for larger nodules direct fnac was performed using the multiple aspiration technique . based on cellularity ,
colloid consistency and nuclear features the fnac reports were classified as follows : inadequate / benign / follicular lesion / indeterminate / malignant .
total thyroidectomy was performed when there was multifocal disease involving both lobes of thyroid or when the pre - operative ultrasound showed a nodule in the opposite lobe and the surgeon found nodules in the opposite lobe .
if the histopathology showed multifocal disease or the tumor was > 6 mm in size , these patients then underwent completion thyroidectomy . following surgery all patients with high risk disease underwent whole body i-131 uptake scans .
when there was no clinical recurrence and thyroglobulin levels were undetectable ( done after stopping thyroxine for at least 30 days ) these patients were declared cured .
patients with aggressive tumors were declared cured based on 3 negative i-131 whole body scans done during their annual follow - up visit .
the size of each lobe of the thyroid was measured and the presence of nodules was noted .
the features of malignancy included the presence of hypo echoic nodules with irregular margins , loss of peripheral halo , micro calcification , increased central vascularity , the nodule appearing taller than wide and the presence of cervical lymph node enlargement .
for larger nodules direct fnac was performed using the multiple aspiration technique . based on cellularity ,
colloid consistency and nuclear features the fnac reports were classified as follows : inadequate / benign / follicular lesion / indeterminate / malignant .
total thyroidectomy was performed when there was multifocal disease involving both lobes of thyroid or when the pre - operative ultrasound showed a nodule in the opposite lobe and the surgeon found nodules in the opposite lobe .
if the histopathology showed multifocal disease or the tumor was > 6 mm in size , these patients then underwent completion thyroidectomy . following surgery
when there was no clinical recurrence and thyroglobulin levels were undetectable ( done after stopping thyroxine for at least 30 days ) these patients were declared cured .
patients with aggressive tumors were declared cured based on 3 negative i-131 whole body scans done during their annual follow - up visit .
there were 18 men and 59 women with a male : female ratio of 1:3 .
the mean age at presentation was 44.54  10.5 years ( range : 18 - 72 years ) .
most patients presented with either thyroid enlargement ( 92.1% ) or cervical lymph node enlargement ( 5.3% ) .
the duration of symptoms ranged from < 1 month to as long as 25 years .
nearly 22% of the cases had only isolated thyroid stimulating hormone ( tsh ) suppression and 6.5% had elevated free thyroxin levels and suppressed tsh .
of the 77 patients included in the study 60 ( 77.9% ) underwent neck ultrasonography and among them 36.4% had single nodules and 41.6% had multiple nodules .
fnac was performed in 59 ( 76.6% ) patients , 40.3% of them were reported as benign .
overt malignancy or suspicious lesions on fnac were found only in 26% of the cases [ table 1 ] .
fine - needle aspiration biopsy based on the ultrasound findings and fnac , 31.4% of the cases were suspected to have an underlying malignancy .
the main indication for surgery in the other cases was the presence of large multinodular goiter .
eleven patients ( 14.3% ) with cervical lymph node metastasis underwent modified radical neck dissection . following surgery
the mean tumor size was 4.11 mm ( range : 0.2 - 9 mm ) .
multifocal disease was noted in 34 patients ( 44.1% ) and among them 15 ( 19.5% ) had multifocal disease restricted to one lobe .
three patients had extra thyroid extension of the tumor and two had only evidence of vascular invasion on their biopsy .
in addition to ptmc , the pathologist noted additional disease in 65% of the thyroidectomy cases .
nodular hyperplasia ( 50.6% ) was the most common condition noted [ table 3 ] .
the mean duration of follow - up was 20 months and the maximum duration of follow - up was 57 months .
she underwent completion thyroidectomy , which was followed by 3 doses of i-131 ; she finally succumbed to metastatic disease arising from the pancreas .
on follow - up , 14.5% of patients with aggressive tumors were declared cured of the disease .
the mean duration of follow - up was 20 months and the maximum duration of follow - up was 57 months .
she underwent completion thyroidectomy , which was followed by 3 doses of i-131 ; she finally succumbed to metastatic disease arising from the pancreas .
on follow - up , 14.5% of patients with aggressive tumors were declared cured of the disease .
this study gives an overview of the clinical profile of patients with papillary microcarcinoma treated in our institution over the past 7 years .
the male : female ratio of 1:3 is lower compared with the larger female preponderance seen among the japanese people .
this could be because of a much larger load of thyroid cancers observed among the japanese .
the mean age of our patients was 44  10.52 years ( range : 18 - 72 years ) and this was similar to that described in earlier studies .
papillary carcinomas as well as micro carcinomas are the most common malignancy seen in autopsy specimens with multinodular goiter . in some studies underlying graves disease was found to be a risk factor for thyroid malignancy .
this was not the case in our study as no case of graves disease was noted among our patients .
the deranged thyroid function tests in our patients was due overtreatment with thyroxin as most patients with thyroid nodules are routinely treated with thyroxin by their local physicians . with the advent of ultrasonography , smaller nodules and bilateral disease
the most common indication for surgery in our patients was a multinodular goiter ( 36.8% ) . a composite clinical diagnosis based on radiology and guided fnac
the mean tumor size ( 4.1  2.3 mm ) was comparable with that of other studies .
noguchi et al . reported that > 40% of their patients had tumors > 6 mm in size .
however , the vast majority remain quiescent , causing no symptoms or threat to life .
all patients in this study with metastatic disease had multifocal cancer , indicating that , multifocality would mean a more aggressive tumor .
lymph nodes , extra thyroidal extension and multifocality were considered as risk factors for recurrence . in our study ,
reported that , lymph node metastasis at presentation , multifocality and the male sex is associated with recurrence .
an interesting finding of multifocal disease restricted to a single lobe was observed in our study .
this could mean that multifocality restricted to a single lobe likely formed from a single clone , rather than from intra thyroidal hematological spread of tumor .
comparing our data with other studies , extra thyroidal extension and cervical lymph node metastases were less common in our patients [ table 4 ] .
this study is limited by the short duration of follow - up and small numbers .
we also have not looked into the pathological subtypes of ptmc ( e.g. , tall cell and insular variants ) , which are more aggressive .
this study is limited by the short duration of follow - up and small numbers .
we also have not looked into the pathological subtypes of ptmc ( e.g. , tall cell and insular variants ) , which are more aggressive .
 background : papillary thyroid microcarcinoma ( ptmc ) describes a focus of papillary thyroid cancer that is less than 1 cm in size . 
 these tumors are frequently found on histopathological examination of thyroid specimens , operated upon for an indication other than suspected malignancy.materials and methods : from 2005 to 2012 , 94 of 1300 thyroidectomy specimens in our institution were found to have ptmc . of these , 77 were isolated ptmc while the others were associated with other differentiated cancers . 
 we studied their clinicopathologic features , treatment and long - term outcome.results:there were 18 men and 59 women ( the male : female ratio was 1:3 ) , their mean age was 44  10.5 years ( range : 18 - 72 years ) . 
 multinodular goiter was the most common indication for surgery . 
 malignancy was suspected in only 31.4% cases . 
 the mean tumor size was 4.1  2.3 mm . 
 nearly 17% cases had slightly larger tumors measuring > 6 but < 10 mm . 
 multifocal tumor was found in 44.1% of cases and among these , multifocal disease restricted to a single lobe was found in 19.5% . 
 eleven patients ( 14.2% ) had cervical lymph node metastasis , 3 ( 3.9% ) had extra thyroid tumor extension and 2 ( 2.6% ) had evidence of vascular invasion . 
 one patient ( 1.3% ) presented with bone metastasis . 
 majority of the patients ( 79.2% ) underwent total thyroidectomy with or without lymph node dissection . 
 sixteen patients ( 20.7% ) who had initially undergone hemithyroidectomy went on to have completion thyroidectomy . twenty nine patients ( 36.8% ) also received radioactive iodine . 
 the mean duration of follow - up was 20.2  13.5 months . on follow - up 
 one patient developed cervical lymph node recurrence and one died due to a second malignancy.conclusions:ptmc is often found as an incidental finding on the thyroidectomy specimen . 
 sometimes they present with regional lymph node metastasis and very rarely with distant metastasis . 
 they have a good prognosis similar to papillary thyroid carcinoma . 
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Ultrasonography and fine-needle aspiration biopsy
Details of surgery and adjuvant therapy
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Follow-up
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Limitations
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