Carcinoma Of Thyroid Gland

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Information about Carcinoma Of Thyroid Gland

Published on February 23, 2009

Author: Dr_Shammasi

Source: slideshare.net

CARCINOMA OF THYROID GLAND Dr. Ahmed Mirza Al-Shammasi 2031040009 Surgical Intern – KFU – Saudi Arabia

OUTLINES Anatomy and Blood Supply Epidemiology Causes and Risk Factors Classification Clinical Presentation Diagnosis Management

Anatomy and Blood Supply

Epidemiology

Causes and Risk Factors

Classification

Clinical Presentation

Diagnosis

Management

 

 

 

 

EPIDEMIOLOGY Commonest malignant Endocrine tumor, compromise 1% of all malignancies. Annual Incidence is 3.7 per 100,000 Sex Ratio is 3:1 (Female:Male) Can occur at any age group Peak incidence after age of 30. Aggressiveness increases with old age. 5-year relative survival rate for all stages reach 97%. Anaplastic Thyroid Cancer ,,, much lower survival

Commonest malignant Endocrine tumor, compromise 1% of all malignancies.

Annual Incidence is 3.7 per 100,000

Sex Ratio is 3:1 (Female:Male)

Can occur at any age group

Peak incidence after age of 30.

Aggressiveness increases with old age.

5-year relative survival rate for all stages reach 97%.

Anaplastic Thyroid Cancer ,,, much lower survival

CAUSES AND RISK FACTORS Genetics: Abnormal RET oncogene may cause MTC. MEN 2A, 2B Syndrome. Family History: Hx of goiters increase risk for Papillary Ca. Gardner’s Syndrome and FAP increase risk for Papillary Ca. Radiation Exposure: Radiation therapy to Head or Neck. Exposure to Radioactive Iodine during childhood, or other radioactive substances (Chernobyl) ↑ risk for particularly Papillary carcinoma.

Genetics:

Abnormal RET oncogene may cause MTC.

MEN 2A, 2B Syndrome.

Family History:

Hx of goiters increase risk for Papillary Ca.

Gardner’s Syndrome and FAP increase risk for Papillary Ca.

Radiation Exposure:

Radiation therapy to Head or Neck.

Exposure to Radioactive Iodine during childhood, or other radioactive substances (Chernobyl) ↑ risk for particularly Papillary carcinoma.

CAUSES AND RISK FACTORS Chronic Iodine deficiency ↑ risk for Follicular carcinoma. Gender: Female > Males. Age: More common at young adults. MTC usually diagnosed after 60. Race: White race > Black race.

Chronic Iodine deficiency ↑ risk for Follicular carcinoma.

Gender:

Female > Males.

Age:

More common at young adults.

MTC usually diagnosed after 60.

Race:

White race > Black race.

 

Thyroid Neoplasm Benign Malignant Secondary Primary Follicular Papillary Follicular Cells Parafollicular Cells Lymphoid Cells Lymphoma Medullary Differentiated Undifferentiated Anaplastic Follicular Papillary Hurthle Cell

 

CLINICAL PRESENTATION Solitary thyroid nodule Single most common presentation. Up to 99% of nodules are benign. Hoarseness of Voice. Enlarged Cervical Lymph nodes. Difficulty swallowing. Dyspnea. Pain in the Neck. Persistent cough.

Solitary thyroid nodule

Single most common presentation.

Up to 99% of nodules are benign.

Hoarseness of Voice.

Enlarged Cervical Lymph nodes.

Difficulty swallowing.

Dyspnea.

Pain in the Neck.

Persistent cough.

DIAGNOSIS Laboratory: TSH T3, T4 Serum Thyroglobulin Serum Thyroid Antibodies FNA Tru-cut Biopsy Intra-operative frozen-section Imaging U/S C.T MRI Scintigraphy

Laboratory:

TSH

T3, T4

Serum Thyroglobulin

Serum Thyroid Antibodies

FNA

Tru-cut Biopsy

Intra-operative frozen-section

Imaging

U/S

C.T

MRI

Scintigraphy

LABORATORY Most patients are Euthyroid. Hyperfunctioning nodule  1% chance of malignancy. Serum Tg cannot differentiate between benign and Malignant nodules Tg is used for: F/U after total thyroidectomy Serial F/U for non-operative treatment Serum Calcitonin  patients with MTC, or with family hx of MTC (MEN2)

Most patients are Euthyroid.

Hyperfunctioning nodule  1% chance of malignancy.

Serum Tg cannot differentiate between benign and Malignant nodules

Tg is used for:

F/U after total thyroidectomy

Serial F/U for non-operative treatment

Serum Calcitonin  patients with MTC, or with family hx of MTC (MEN2)

FNA CYTOLOGY Popularized in the 1960s by Einhorn and Franzen at the Karolinska Institute, Stockholm. Single most important test. U/S guidance improve the sensitivity. Accuracy ranges from 70 – 97%. Nodules Benign 70% Malignant 4% Suspicious or Intermediate 10% (Frozen-sction) Insufficient Sampling 17% FNAC cannot differentiate between Benign and Malignant Follicular Neoplasia

Popularized in the 1960s by Einhorn and Franzen at the Karolinska Institute, Stockholm.

Single most important test.

U/S guidance improve the sensitivity.

Accuracy ranges from 70 – 97%.

Nodules

Benign 70%

Malignant 4%

Suspicious or Intermediate 10% (Frozen-sction)

Insufficient Sampling 17%

FNAC cannot differentiate between Benign and Malignant Follicular Neoplasia

 

IMAGING U/S is the investigation of choice. Solid vs. Cystic, Size, Content etc. Adjacent Lymphadenopathy C.T  Regional and distant metastases MRI  Limited role in the diagnosis Useful in detecting cervical LN metastases Scintigraphy (I-123, Gallium-67) Characterizing funtioning nodules Staging of follicular and papillary Ca Gallium-67 used in detection of thyroid lymphoma

U/S is the investigation of choice.

Solid vs. Cystic, Size, Content etc.

Adjacent Lymphadenopathy

C.T  Regional and distant metastases

MRI  Limited role in the diagnosis

Useful in detecting cervical LN metastases

Scintigraphy (I-123, Gallium-67)

Characterizing funtioning nodules

Staging of follicular and papillary Ca

Gallium-67 used in detection of thyroid lymphoma

 

 

PROGNOSTIC INDICATORS AGES score: A ge Hisological G rade E xtrathyroidal invasion M etastasis MACIS score (post-operative): Distant M etastasis A ge C ompleteness of original surgical resection Extrathyroidal I nvasion S ize of original lesion

AGES score:

A ge

Hisological G rade

E xtrathyroidal invasion

M etastasis

MACIS score (post-operative):

Distant M etastasis

A ge

C ompleteness of original surgical resection

Extrathyroidal I nvasion

S ize of original lesion

 

 

MANAGEMENT Medical Radioactive Iodine ablation therapy. Chemotherapy (Adriamycin, Cisplatin). Post-operative Thyroid hormone. Replacement therapy. Suppression of TSH release. (↓ recurrence) Surgical Treatment of choice. Extent of resection is still controversial.

Medical

Radioactive Iodine ablation therapy.

Chemotherapy (Adriamycin, Cisplatin).

Post-operative Thyroid hormone.

Replacement therapy.

Suppression of TSH release. (↓ recurrence)

Surgical

Treatment of choice.

Extent of resection is still controversial.

THYROID SURGERIES Relates to the management of contralateral lobe. Types Ipsilateral lobectomy Subtotal Thyroidectomy Near-total Thyroidectomy Total Thyroidectomy

Relates to the management of contralateral lobe.

Types

Ipsilateral lobectomy

Subtotal Thyroidectomy

Near-total Thyroidectomy

Total Thyroidectomy

 

 

ARGUMENTS FOR LESS RADICAL RESECTION Total thyroidectomy is associated with a higher complication rate than lobectomy. Recurrence in the remaining thyroid tissue is unusual (5%), and most are curable by surgery. Tumor Multicentricity seems to have little prognostic significance Patient with less resection still carry excellent long-term prognosis

Total thyroidectomy is associated with a higher complication rate than lobectomy.

Recurrence in the remaining thyroid tissue is unusual (5%), and most are curable by surgery.

Tumor Multicentricity seems to have little prognostic significance

Patient with less resection still carry excellent long-term prognosis

PAPILLARY CARCINOMA Most common Thyroid carcinoma (80%) Related to radiation exposure in I-sufficient areas. Female:male ratio is 2:1 Mean age of presentation is 30 to 40 yrs. Slow growing painless mass. Euthyroid-status. LN metastases is common, may be the presenting symptom (Lateral Aberrant Thyroid). Distant metastases is uncommon at initial presentation. Develop in 20% of cases. (Lungs, liver, bones,brain)

Most common Thyroid carcinoma (80%)

Related to radiation exposure in I-sufficient areas.

Female:male ratio is 2:1

Mean age of presentation is 30 to 40 yrs.

Slow growing painless mass. Euthyroid-status.

LN metastases is common, may be the presenting symptom (Lateral Aberrant Thyroid).

Distant metastases is uncommon at initial presentation.

Develop in 20% of cases. (Lungs, liver, bones,brain)

PAPILLARY CARCINOMA FNA biopsy is diagnostic. Treatment Ipsilateral Lobectomy + Isthmusectomy (No LN metastasis) Near-total or Total Thyroidectomy + Modified-radical or Functional neck dissection (+ve LN metastasis). Prophylactic LN dissection is unnecessary.

FNA biopsy is diagnostic.

Treatment

Ipsilateral Lobectomy + Isthmusectomy (No LN metastasis)

Near-total or Total Thyroidectomy + Modified-radical or Functional neck dissection (+ve LN metastasis).

Prophylactic LN dissection is unnecessary.

FOLLICULAR CARCINOMA Account for 10% of all thyroid cancers. More common in I-deficient areas. Female:male ratio is 3:1 Mean age at presentation is 50 yrs. Solitary thyroid nodule, rapid increase in size and long-standing goiter. Cervical LN metastasis is uncommon at presentation (5%), distant metastasis may be present. Hyperfunctioning < 1%. (S&S of Thyrotoxicosis)

Account for 10% of all thyroid cancers.

More common in I-deficient areas.

Female:male ratio is 3:1

Mean age at presentation is 50 yrs.

Solitary thyroid nodule, rapid increase in size and long-standing goiter.

Cervical LN metastasis is uncommon at presentation (5%), distant metastasis may be present.

Hyperfunctioning < 1%. (S&S of Thyrotoxicosis)

FOLLICULAR CARCINOMA FNA biopsy cannot differentiate between benign and malignant follicular tumors. Pre-operative diagnosis of malignancy is difficult unless there is distant metastasis. Large follicular tumor > 4 cm in old individual  CA. Treatment: Thyroid Lobectomy (at least 80% are benign adenomas) Total-Thyroidectomy in older individual with tumor > 4cm (50% chance of malignancy). Prophylactic nodal dissection is unnecessary.

FNA biopsy cannot differentiate between benign and malignant follicular tumors.

Pre-operative diagnosis of malignancy is difficult unless there is distant metastasis.

Large follicular tumor > 4 cm in old individual  CA.

Treatment:

Thyroid Lobectomy (at least 80% are benign adenomas)

Total-Thyroidectomy in older individual with tumor > 4cm (50% chance of malignancy).

Prophylactic nodal dissection is unnecessary.

 

POST-OPERATIVE MANAGEMENT Thyroid hormone Replacement therapy Suppression of TSH release At 0.1 μ U/L in Low-risk group < 0.1 μ U/L in High-risk group Thyroglobulin measurement At 6-months interval then annually when disease-free < 2ng/mL in total or near-total + Hormones < 5ng/mL in hypothyroid patients. Level > 2ng/mL = Recurrence/Persistent thyroid tissue

Thyroid hormone

Replacement therapy

Suppression of TSH release

At 0.1 μ U/L in Low-risk group

< 0.1 μ U/L in High-risk group

Thyroglobulin measurement

At 6-months interval then annually when disease-free

< 2ng/mL in total or near-total + Hormones

< 5ng/mL in hypothyroid patients.

Level > 2ng/mL = Recurrence/Persistent thyroid tissue

POST-OPERATIVE MANAGEMENT Radioiodine Therapy: Controversial (No prospective RCTs). Long-term cohort studies by Mazzaferri and Jhiang and DeGroot: Small improvement in survival rate and less recurrence when RAI is used, even with Low-risk group. RAI is less sensitive than Tg in detecting metastatic disease. I-131 detect and treat 75% of metastatic differentiated thyroid tumors.

Radioiodine Therapy:

Controversial (No prospective RCTs).

Long-term cohort studies by Mazzaferri and Jhiang and DeGroot:

Small improvement in survival rate and less recurrence when RAI is used, even with Low-risk group.

RAI is less sensitive than Tg in detecting metastatic disease.

I-131 detect and treat 75% of metastatic differentiated thyroid tumors.

 

 

MEDULLARY CARCINOMA 5% of all thyroid malignancies. Arise from Parafollicular cells, concentrated in superolateral aspect of thyroid lobes. Most cases are sporadic, 25% are inherited (Germline mutation in RET oncogene). Female:Male ratio is 1.5:1 Most patients present between 50 and 60 yrs. Neck mass + palpable cervical LN (15-20%). Local pain or aching is common.

5% of all thyroid malignancies.

Arise from Parafollicular cells, concentrated in superolateral aspect of thyroid lobes.

Most cases are sporadic, 25% are inherited (Germline mutation in RET oncogene).

Female:Male ratio is 1.5:1

Most patients present between 50 and 60 yrs.

Neck mass + palpable cervical LN (15-20%).

Local pain or aching is common.

MEDULLARY CARCINOMA MTC secrets a range of compounds: Calcitonin, CEA, CGRP, PG A 2 and F 2 α , Seritonin. May develop flushing and diarrhoea, Cushing’s syndome (ectopic ACTH). Diagnosis Hx and P/E (Family hx of similar tumors). ↑ Serum Calcitonin, ↑ CEA FNAC Screen patient for: RET point mutation. Coexisting Pheochromocytoma (24-hour urinary level of VMA, catecholamine, metanephrine). Hyperparathyroidism (Serum calcium).

MTC secrets a range of compounds:

Calcitonin, CEA, CGRP, PG A 2 and F 2 α , Seritonin.

May develop flushing and diarrhoea, Cushing’s syndome (ectopic ACTH).

Diagnosis

Hx and P/E (Family hx of similar tumors).

↑ Serum Calcitonin, ↑ CEA

FNAC

Screen patient for:

RET point mutation.

Coexisting Pheochromocytoma (24-hour urinary level of VMA, catecholamine, metanephrine).

Hyperparathyroidism (Serum calcium).

 

MEDULLARY CARCINOMA Treatment: > 50% are bilateral, ↑ Multicentricity. Total Thyroidectomy + : Bilateral central node dissection as routine (No LN involvement) Bilateral Modified-Radical Neck dissection (palpable LN) Ipsilateral Prophylactic nodal dissection in tumor size > 1.5cm. External Beam radiation for unresectable residual or recurrent tumor. No effective Chemotherapy.

Treatment:

> 50% are bilateral, ↑ Multicentricity.

Total Thyroidectomy + :

Bilateral central node dissection as routine (No LN involvement)

Bilateral Modified-Radical Neck dissection (palpable LN)

Ipsilateral Prophylactic nodal dissection in tumor size > 1.5cm.

External Beam radiation for unresectable residual or recurrent tumor.

No effective Chemotherapy.

MEDULLARY CARCINOMA Prophylactic Thyroidectomy in RET mutation detection Before age of 6 yrs for MEN2A Before age of 1 yr for MEN2B

Prophylactic Thyroidectomy in RET mutation detection

Before age of 6 yrs for MEN2A

Before age of 1 yr for MEN2B

ANAPLASTIC CARCINOMA 1% of all thyroid malignancies. Women > Men. Majority present at 7 th - 8 th decade of life. Long-standing neck mass, rapidly enlarging in size. May be painful, with dyphonia, dyspnea, dysphagia. LN are usually involved at presentation. ± Distant metastasis.

1% of all thyroid malignancies.

Women > Men.

Majority present at 7 th - 8 th decade of life.

Long-standing neck mass, rapidly enlarging in size.

May be painful, with dyphonia, dyspnea, dysphagia.

LN are usually involved at presentation.

± Distant metastasis.

ANAPLASTIC CARCINOMA FNAC is diagnostic. Treatment: Most aggressive thyroid tumor. Total Thyroidectomy if resectable. Adjuvant Chemotherapy + Radiotherapy slightly improve long-term survival.

FNAC is diagnostic.

Treatment:

Most aggressive thyroid tumor.

Total Thyroidectomy if resectable.

Adjuvant Chemotherapy + Radiotherapy slightly improve long-term survival.

OTHER TYPES Thyroid Lymphoma: 1% of all Thyroid Ca. Most are Non-Hodgkin B-cell Lymphoma. Underlying chronic lymphocytic thyroiditis. FNAC is diagnostic. Combined Chemotherapy (CHOP) + Radiotherapy. Hurthle-Cell Carcinoma: 3% of all Thyroid Ca. Subtype of Follicular Ca. More multicenteric and bilateral (30%). FNAC is not conclusive. Lobectomy + isthmusectomy (unilateral) Total Thyroidectomy (bilateral)

Thyroid Lymphoma:

1% of all Thyroid Ca.

Most are Non-Hodgkin B-cell Lymphoma.

Underlying chronic lymphocytic thyroiditis.

FNAC is diagnostic.

Combined Chemotherapy (CHOP) + Radiotherapy.

Hurthle-Cell Carcinoma:

3% of all Thyroid Ca.

Subtype of Follicular Ca.

More multicenteric and bilateral (30%).

FNAC is not conclusive.

Lobectomy + isthmusectomy (unilateral)

Total Thyroidectomy (bilateral)

PROGNOSIS Tumor Prognosis Papillary Ca. 74-93% long-term survival rate Follicular Ca. 43-94% long-term survival rate Hurthle Cell Ca. 20% mortality rate at 10 years Medullary Ca. 80% 10-year survival rate 45% with LN involvement Anaplastic Tumor Median survival of 4 to 5 months at time of diagnosis

REFERENCES Bailey & Love’s Short Practice of Surgery, 24 th edition. Schwart’s Principles of Surgery, 8 th edition. DeVita, Hellman & Rosenberg Principles & Practice of Oncology, 7 th edition. Grant’s Atlas of Anatomy, 10 th edition. Internet: emedicine.medscape.com www.mayoclinic.com www.nlm.nih.gov

Bailey & Love’s Short Practice of Surgery, 24 th edition.

Schwart’s Principles of Surgery, 8 th edition.

DeVita, Hellman & Rosenberg Principles & Practice of Oncology, 7 th edition.

Grant’s Atlas of Anatomy, 10 th edition.

Internet:

emedicine.medscape.com

www.mayoclinic.com

www.nlm.nih.gov

THANK YOU

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