Thyroid Carcinoma

Dr Suleman Mumtaz
PG 2 Ward 2
 Introduction
 Infrequent cancer -1% of all cancers
 Requires multidisciplinary approach
 Discussion about clinical assessment of malignant thyroid
 Investigating modalities
 Management carried out in most parts of our country like
JPMC.
 It is practically oriented presentation
The Big Question

Is it cancer?
THYROID GLAND ANATOMY
Frequency
Women 3 times more than men.
 Peak incidence 30-40s.
 Papillary, follicular, medullary, anaplastic,
lymphoma, and sarcoma.
 Papillary 80%, follicular 10%, medullary 5-
10%, anaplastic 1-2%.
Epidemiology
 Increases with age
 Higher in women (1.2:1  4.3:1)
 Estimated 5-15% of nodules are
cancerous
 Although cancer more common in women,
a nodule in a man is more likely to be
cancer
Epidemiology – Children
 10% thyroid cancer age <21
 Thyroid ca 1.5-2.0% all peads
malignancies
 More likely to present with neck mets
 Most common cause thyroid enlargement
is chronic lymphocytic thyroiditis
Epidemiology – Children
 Medullary Thyroid Carcinoma
 MEN 2A, MEN 2B
 RET proto-oncogene (chromosome 10)
Epidemiology – Carcinoma
 Occult carcinoma in 6 – 35 % of glands at
autopsy (usu 4-10 mm)
 12,000 new thyroid cancers / year
 1000 deaths / year
 Surgically removed nodules:
 8-17 % carcinomas
Epidemiology – Cancer
 Histological subtype
 Papillary – 70%
 Follicular – 15%
 Medullary – 5-10%
 Anaplastic – 5%
 Lymphoma – 5%
 Mets
 Etiology/Risk Factors
 Arise from the two cell types in the gland.
 Follicular cells make papillary, follicular, and
anaplastic.
 C-cells produce medullary.
 Radiation exposure (papillary).
 Populations with low dietary iodine have a
higher proportion of follicular and anaplastic
cancers.
History
 Painless, palpable solitary nodule.
 Nodules are present in 4-7% of population.
 Most are benign
 5% are malignant
 Age at presentation (>60 and <30)
 Sex (males)
 Rapid growth
History
 Malignant nodules usually painless
 Sudden onset pain usually benign.
 Hoarseness suggests malignancy, nerve
involvement.
 Dysphagia
 Heat intolerance, palpitations suggest
autonomously functioning nodules.
 Family history (medullary).
History
 Age
 Gender
 Exposure to Radiation
 Signs/symptoms of hyper- / hypo-
thyroidism
 Rapid change in size
 With pain may indicate hemorrhage into nodule
 Without pain may be bad sign
History
 Gardner Syndrome (familial
adenomatous polyposis)
 Association found with thyroid ca
 Mostly in young women (94%)
 Thyroid ca preceded dx of Garners 30% of
time
History
 Familial h/o medullary thyroid carcinoma
 Familial MEN II
 Family hx of other thyroid ca
 H/o Hashimoto’s thyroiditis (lymphoma)
History
 History elements suggestive of malignancy:
 Progressive enlargement
 Hoarseness
 Dysphagia
 Dyspnea
 High-risk (fam hx, radiation)
Physical Exam
 Thorough HEENT exam includes:
 Thyroid gland
 Soft tissues of neck
 Solid, soft, mobile, or fixed?
 Tenderness?
Physical Exam

 Thyroid exam generally best from behind

 Check for movement with swallowing
Physical
 Complete Head & Neck exam
 Vocal cord mobility
 Palpation thyroid
 Cervical lymphadenopathy(Aberant
Thyroid)
 Ophthalmopathy
Physical
 Physical findings suggestive of malignancy:
 Fixation
 Adenopathy
 Fixed cord
 Induration
 Stridor
Physical Examination
Left Sided Goiter with Aberant
Thyroid
Recurrent multinodular goiter
Carcinoma of the thyroid. Superficial veins are coursing
over the anterior chest wall indicating superior vena cava
obstruction
Ophthalmopathy
Neck Bruising

 Suggests hemorrhage into malignant

nodule
Workup
The Goal…..
 Differentiate malignant from benign.
 Determine which patients require
intervention.
 Who can be monitored?
 Avoid unnecessary surgery.
Serum Testing
 TSH – first-line serum test
 Identifies subclinical thyrotoxicosis
 T4, T3
 Calcium
 Thyroglobulin
 Post-treatment good to detect recurrence
 Calcitonin – only in cases of medullary
 Antibodies – Hashimoto’s
Laboratory
 TSH sensitive for hypo and hyperthyroidism, but does
not rule out malignancy.
 Serum thyroglobulin used as tumor marker post op.
 Calcitonin, for post op monitoring in Medullary
cancers.
Test for Calcitonin
 Stimulating calcitonin release with IV
pentagastrin increases sensitivity of test.
 First measure baseline calcitonin, then give
pentagastrin. Measure calcitonin serially 1.5 and
5 min later.
 Used as tumor marker postop rather than
screening now.
Fine Needle Aspiration Cytology
 First intervention in evaluation
 Inexpensive, easy, few complications.
 4% malignant, 10% indeterminate
 Sensitivity 83%, specificity 92%
 False positive 2.9%, negative 5.2%
FNAC
 If non-diagnostic, repeat
 If indeterminate or suspicious

then it’s a “Follicular neoplasm.”

 FNA can diagnose papillary and medullary
cancers
H&P vs FNAB
Imaging
Plain Films
 May show:
 Tracheal deviation
 Pulmonary metastasis
 Calcifications (suggests papillary or
medullary)
Tracheal Deviation

 May be incidentally noted

Anteroposterior thoracic inlet view. Benign calcification is
seen in the right lobe of the thyroid. A retrosternal goiter is
present (white arrows) with deviation of the trachea to the
right (black arrows)
Imaging
 Ultrasound: solid vs. Cystic, for FNA accuracy.
 CT and MRI not used routinely.But Specific.
 Isotope Scans: determines function of the nodule. Cold
nodules are those that don’t take up iodine123, hot ones
are the opposite.
 Carcinoma cannot be ruled out based on scans, with 4%
of hot nodules can be malignant.
Ultrasound
Thyroid lymphoma. This CT scan with intravenous contrast
shows that the trachea (arrow) is deviated to the left by a
huge mass arising in, occupying and expanding the right
lobe of the thyroid gland with encasement of the common
carotid artery (highlighted by contrast).
MRI of Patient
MRI Scan
Nuclear Medicine
 Iodine is taken up by gland and organified
 Technetium trapped but not organified
 Usually only for papillary and follicular
Hot Nodule
Nuclear Medicine

 Tc-99m versus I-123

A solitary cold nodule. This technetium-99m thyroid scan
demonstrates a mass expanding the right lobe of the
thyroid gland.
Hot, Warm, Cold
 patients with nodules
 All
scanned
 Results
 Cold 84%  16% cancer
 Warm 10%  9% cancer
 Hot 5.5%  4% cancer
PATHOLOGY:Papillary Carcinoma
 Most common (80%)
 Women 3 times more common
 30-40 years of age
 Radiation exposure is a cause
 Patients with Hashimoto’s thyroiditis
 Slow growing, take up iodine, TSH stimulation
produces thryroglobulin response.
PATHOLOGY:Papillary Carcinoma

 Pathology:
 Unencapsulated, arborizing papillae. Well
differentiated, rare mitoses.
 50% have psammoma bodies (calcific
concretions, circular laminations.
 Multicentric with tumor present in
contralateral lobe as well.
PATHOLOGY:Papillary Carcinoma
 Local invasion through capsule, invading
trachea, nerve, causing dyspnea, hoarseness.
 Propensity to spread to the cervical lymph
nodes. Most commonly central compartment,
located medial to carotids, from hyoid to
sternal notch.
 Distant spread to bone, lungs.
 HISTOPATHOLOGY:Papillary
Carcinoma
 “Orphan Annie” nuclei
 Psamomma bodies
PATHOLOGY:Follicular Carcinoma
 Second most common (10%)
 Iodine deficient areas
 3 times more in women
 Present more advanced in stage than papillary
 Late 40’s
 Also takes up iodine, produces thryroglobulin.
PATHOLOGY:Follicular Carcinoma

 Pathology:
 round, encapsulated, cystic changes, fibrosis,
hemorrhages. Microscopically, neoplastic
follicular cells.
 Differentiated by the presence of capsule
invasion,vascular invasion.
 Cannot reliably diagnose based on FNAC.
PATHOLOGY:Follicular Carcinoma

 Local invasion is similar to papillary cancer

with the same presentation.
 Cervical metastases are uncommon.
 Distant metastases is significantly higher
(20%), with lung and bone most common
sites.
 HISTOPATHOLOGY:Follicular
Carcinoma
 Capsular
invasion must
be present
 FNAC
inadequate for
diagnosis
PATHOLOGY:Hurthle Cell
 A variant of follicular, also known as oncocytic
carcinoma. 5 year survival 50%.
 More common in women than men, presents in
5th decade of life.
 Same clinical presentation.
 Cannot diagnose on FNAC
 Does not take up iodine, treat aggressively..
PATHOLOGY:Medullary
Carcinoma
 5%, female preponderance
 25% familial. Familial cases are usually all
over the gland.
 MEN 2A, MEN2B syndromes.
Thyroid Mets
 Breast
 Bones
 Lung
 Renal
 GI
Treatment
 Surgical excision whenever possible.
 Total thyroidectomy has been mainstay
(all apparent thyroid tissue removed).
Complications include nerve damage
bilaterally, parathyroid injury bilaterally.
 After, get radioiodine scan, ablation if
residual disease or recurrence.
Treatment
 Subtotal thyroidectomy( small portion of
thyroid tissue opposite the side of
malignancy is left in place) and postop
ablation.
 Thyroid lobectomy and isthmectomy
viable option with small tumors
Neck Dissection
 Examine the neck prior to surgery to detect
lymph node spread (Aberrant thyroid)
 Gross cervical mets should be removed with a
dissection in the compartment in which they
reside.
 Excision of single nodes is not adequate.
Treatment
 Total thyroidectomy
 Lymph node dissection
 Parathyroid reimplantation if necessary.
 Lymph node mets are very common.
 If Medullary Ca,then Surveillance with
CEA, calcitonin.It does not take up iodine,
so no radioiodine.Prognosis 10 y at 65%.
OVERALL OPTIONS OF
THYROIDECTOMY
• Lobectomy – removing half of the thyroid gland
(including isthmus)
• Total thyroidectomy – removing all identifiable thyroid
tissue
• Near-total thyroidectomy – removing nearly all of the
thyroid gland, leaving about one gm/cm of thyroid tissue
on one side
Indications for Thyroid
Lobectomy
 Suspicion for malignancy
 Obstructive symptoms
 Well-differentiated thyroid carcinoma
(controversial)
Indications for Total
Thyroidectomy
 Well-differentiated thyroid cancer
 Medullary thyroid cancer
 Lymphoma of thyroid
 Obstructive Symtoms.
HOW MUCH THYROID TO
REMOVE?
 Papillary/Follicular cancer
 Total / Near-total thyroidectomy

 Large primary tumours (>1.5cm) & medullary

cancer with lymph node involvement
 Total thyroidectomy +/- lymph node
dissection
Postoperative Radioiodine
and Ablation
 Radioiodine targets residual thyroid tissue
and tumor after thyroidectomy.
 Given in therapeutic doses to ablate
tissue.
Multidisciplinary approach to the treatment thyroid
carcinoma.
Investigation and management of a patient with a thyroid
nodule. FNAC, fine-needle aspiration cytology; 99mTc,
technetium-99m
Prognosis
 Age: at diagnosis. Cancer relate death more common
if patient is older than 40 years.
 Recurrences common in patients diagnosed when
they were less than 20 years or older than 60 years.
 Men are twice more likely as women to die.
 Tumors greater than 4 cm have higher recurrence,
death.
Prognosis
 Local invasion portends poorer prognosis.
 After surgery, thyroxine is given. Do Iodine
scanning after 6 weeks.
 LN metastases not important for prognosis.
 Distant metastases associated with an increase
in the rate of disease specific death.
Prognosis :Undifferentiated
Thyroid Carcinoma

Bad.
SUMMARY
 I have talk about

1. prevalence of thyroid ca
2. etiology
3. surgical pathology
4. scanning modalities of thyroid ca
5. Surgical operation to deal with different types of
thyroid ca
Finally multi disiplinary approaching
MCQS
 The term laternal aberrant thyroid really implies

A. congentical aberrant thyroid tissue lateral to the

thyroid
B. a metastasis in a cervical lymph node from thyroid
carcinoma
C. a metastasis from carcinoma of the larynx
D. a type of branchial cyst
E. that a loose piece of thyroid has become implanted in
a thyroid has become implanted in a thyroid has ectomy
scar
MCQS
 Routine test for detecting thyroid ca
include
A. total serum T4
B. FNAC
C. Free serum T3
D. serum calcitonin
E. TSH
MCQS
 Primary malignant tumours of the thyroid
include those that are
A. squamous
B. papillary
C. columnar
D. cuboidal
E. basaloid
MCQS
 Total thyroidectomy

A. is indicated for papillary carcinoma only

B. is indicated for medullary carinoma only
C. is often not for anaplastic carcinoma
D. includes the removal of all the parathyroid glands
in close relationship with the thyroid
E. necessarily means the division of both recurrent
laryngeal nerves
THANKS