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The dead indeed tell tales

2017; Medknow; Volume: 14; Issue: 3 Linguagem: Inglês

10.4103/trp.trp_40_17

2250-1452

KrishnaG Seshadri,

Empathy and Medical Education

The word autopsy has Greek origins – autos (self) + optos (see). The original usage dates back to the 1600s, suggesting "to see with one's own eyes" its use in this meaning is extinct. The use of autopsy in the context of postmortem examination dates back to 1805. Autopsies continue to remain an important but underutilized tool outside of the medicolegal setting. There is considerable recognition of the value of autopsies in clinical, educational, and research settings; however, the number of clinical autopsies (other than medico legal) is low and continues to decline.[1] This persists, despite the existence of clear evidence that discrepancies between antemortem and postmortem diagnosis remain high in clinical practice.[23] Very little historical published material is available on the thyroid at autopsy. The oldest thyroid gland examined by autopsy appears to be the mummified remains of a 30-year-old female belonging to the Nazca Culture from the Hacienda Ocucaje Valley in Southern Peru carbon dated to 94 B.C. The enlarged thyroid gland revealed two large calcified areas and several smaller foci with the histological sections showing occasional scattered follicles filled with thick colloid material.[4] From early publications in the modern era, it is apparent that a normal thyroid gland at autopsy is an uncommon finding.[5] Approximately 25% of 840 thyroids examined in a serial autopsy series were normal. The weight of the thyroid increases steadily with age with an incidence of goiter reaching 64% by the 10th decade. Hyperplastic nodules are the most common pathology seen in up to 40% of patients.[6] Patients who die of chronic nonthyroidal illness appear to have smaller glands with reduction in follicular diameter and depletion of colloid.[7] Depending on the series, occult thyroid cancer can be present in up to 36%. One concern that has been expressed is the increased detection of differentiated thyroid cancer (DTC). Whether this is a true increase in DTC or merely reflective of increased detection has been debated. In a fixed meta-analysis looking at 35 studies between 1949 and 2007 with 42 datasets and 12,834 autopsies, the prevalence of incidental DTC was 11.2% among glands that were fully examined. When the intensiveness of thyroid examination was accounted for in the regression model, the prevalence odds ratio stabilized from 1970 onward, and no time effect was observed suggesting that the observed increasing incidence is not mirrored by prevalence within autopsy studies and therefore is unlikely to reflect a true population-level increase in tumorigenesis.[8] The issue highlighted exemplifies the importance of autopsy as a continuing valuable resource in our quest for understanding the thyroid and its pathology. In this issue of the journal, Mohan Das et al. provide insights to autopsy findings in Indians.[9] In a series of 240 patients over 18 months, the authors provide valuable information hitherto unavailable from the northeastern part of India, in particular, and India, as a whole. The median weight of the thyroid gland was around 35 g which is somewhat larger than other series. Solitary nodules were found in 20% of the patients with multiple nodules in 4.2%. The presence of nodularity is significantly lower than more widely cited figures from the west.[10] In contrast to other series, >50% (54.6%) of the thyroids were normal on histology. Again, hyperplastic nodules were the most common pathology seen. Surprisingly, autoimmune thyroiditis was evident in <10% of the patients and appeared to be a feature predominantly of patients in the fourth decade. The population prevalence of AITD is higher at 21.8%.[11] Latent DTC was seen in approximately 2.1% of patients, all of them being <60 years of age as opposed to an estimated nationwide prevalence of 0.1%–0.2%.[12] As noted above, the literature is variable on the incidence of DTC in autopsy and these differences are mostly attributable to methodology used in various series than actual population differences. Dr. Mohan Das et al. provide a valuable addition to the existing literature. Work such as theirs while not flamboyant is crucial to add to our understanding the thyroid its disease and its history. Moreover, this editorial is written with the hope that it spurs more investigators from India to find more thyroid tales from the crypt!