Thyroid Neoplasms

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Published on April 27, 2014

Author: surgical1shl

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Thyroid Neoplasms: Thyroid Neoplasms Muhammad Haris Aslam, FCPS II Trainee Surgical unit 1 SIMS/SHL. OUTLINE: OUTLINE Introduction Epidemiology Etiology Pathophysiology Clinical presentation Workup Staging Treatment Followup Prognosis Case Presentation PowerPoint Presentation: Introduction Introduction: Introduction Most common endocrine tumour Responsible for about 6 deaths per million persons annually It accounts roughly for about 0.5% of all cancers in men and 1.5% of all cancers in women 5% of all thyroid nodules are malignant Single nodule more likely to be malignant than multiple nodules :  Woolner classification: Woolner classification Other variants of papillary carcinoma include Tall cell Insular Columnar Diffuse sclerosing Clear cell Trabecular and Poorly differenciated :  * Micropapillary carcinoma is a tumour, clinically not detectable or less than 1cm with no evidence of local invasiveness through the thyroid capsule or angioinvasion..... PowerPoint Presentation: EPIDEMIOLOGY Epidemiology: Epidemiology Annual incidence is 0.5 to 10 per 100,000 persons Highest Incidence  Northren america Female to male ratio is 3:1 Differenciated carcinomas peaks in 3 rd and 4 th Decade of life Medullary thyroid carcinoma peaks in 5 th and 6 th decade Anaplastic carcinomas peaks in 7 th and 8 th decade. Epidemiology : Epidemiology In Pakistan thyroid cancer is responsible for 1.2% cases of all malignant tumors Papillory thyroid carcinoma  iodine sufficient areas Medullary thyroid carcinoma iodine deficient areas Prevalence according to age: Prevalence according to age Carcinoma Age group Papillary Thyroid carcinoma Medullary thyroid carcinoma associated with MEN type 2. Young age Follicular thyroid carcinoma Anaplastic carcinoma Sporadic Medullary thyroid carcinoma Elderly PowerPoint Presentation: ETIOLOGY Etiology: Etiology Thyroid cancer Arises from 2 types of Cells Thyroid lymphomas  I ntrathyroid lymphoid Tissue Sarcomas  connective tissue of thyroid gland Etiology: Etiology Radiation *  Papillary thyroid carcinoma Signal most imp factor in differenciated carcinoma is irradiation of thyroid under 5 years of age Pre-existing Multinodular goiter Follicular Carcinoma. Hashimotos thyroiditis Papillary Thyroid carcinoma Familial *Increased incidence of thyroid carcinoma among children following exposure to ionising radiation after Chernobyl nuclear disastor in Ukraine in 1986 *Radiotherapy received in adolescents for Hodgkins lymphoma may predispose to PTC Familial cancer syndromes involving non medullary thyroid cancer: Familial cancer syndromes involving non medullary thyroid cancer Syndrome Thyroid tumor Cowdens syndrome FTC and rarely PTC and hurthle cell tumors FAP PTC Werners syndrome PTC, FTC , Anaplastic Cancer Carney complex type 1 PTC, FTC McCune Albright syndrome PTC Clear cell Medullary carcinoma  multiple endocrine neoplasia (MEN) 2A or 2B syndrome, as well as familial MTC (FMTC) syndrome.. Genes implicated in thyroid tumorigenesis: Genes implicated in thyroid tumorigenesis Cancer Oncogenes Tumour suppressor genes Papillary thyroid Carcinoma RET, MET, TRK1,RAS, BRAF p53 Medullary thyroid carcinoma RET Follicular carcinoma Ras, PAX8/PPAR P53, PTEN Anaplastic BRAF p53. PowerPoint Presentation: PATHOPHYSIOLOGY Pathophysiology : Pathophysiology Commonest site  junction of isthmus with one of the lateral lobes Types Toxic solitory nodule Non toxic solitory nodule Solitory thyroid nodule Pathophysiology: Pathophysiology GROSS Soft , firm , hard, cystic. Solitory /multinodular Contain brownish black fluid Microscopy Nuclear groves Orphan annie eye nuclei characteristic Psamomma bodies (50%) Spread Slowly progressive and less aggressive Spread through lymphatics Most commonly to lungs followed by bone, liver and brain Blood spread less often Papillary thyroid carcinoma :  Orphan annie is strip cartoon character with empty circled eyes Lymph node involvement in Papillary carcinoma: Lymph node involvement in Papillary carcinoma Pathophysiology: Pathophysiology Follicular thyroid carcinoma Types Invasive Blood spread common Non invasive Blood spread not common Typical features Capsular invasion Angioinvasion Spread More aggressive tumour. Through blood into bones*, lungs, liver. Occasional spread to lymph nodes in neck (10%) *Bone secondaries typically vascular , warm , pulsatile, localised, commonly in skull , long bones, ribs Pathophysiology : Pathophysiology Variant of Follicular carcinoma according to WHO 75-100% of the tumor is composed of Hürthle cells, also known as oxyphilic, oncocytic, Askanazy, or large cells Large , polygonal follicular cells  abundant granular acidophilic cytoplasm Differ from follicular cancer in Multifocal and bilateral(30%) Donot take radio iodine(5%) More likely to metastasize to local nodes (25%) and distant metastasis Associated with higher mortality rate( ~20 % in 10 years) Hurthle cell carcinoma Pathophysiology: Pathophysiology Anaplastic carcinoma GROSS Firm and whitish Microscopy Sheats of cells with marked heterogenicity Spread One of the Most aggressive thyroid malignancy Spread through lymphatics commonly to lungs, brain and bones Arise from de-differenciation of differenciated thyroid carcinoma Pathophysiology : Pathophysiology Medullary thyroid Carcinoma Types Sporadic(75%) Familial (25%) Gross Well circumscribed Unencapsulated Microscopy Amyloid stroma wherein malignant cells are dispersed Calcitonin in amyloid on immnunochemistry Spread Mainly to lymph nodes (60%) MCT associated with MEN type IIB with pheochromocytoma (sipple syndrome) is MOST AGGRESSIVE Features of Medullary Thyroid Cancer Syndromes: Features of Medullary Thyroid Cancer Syndromes Syndrome Manifestations MEN2A MTC, pheochromocytoma, primary hyperparathyroidism, lichen planus amyloidosis MEN2B MTC, pheochromocytoma, Marfanoid habitus, mucocutaneous ganglioneuromatosis Familial MTC MTC MEN2A and Hirschsprung's disease MTC, pheochromocytoma, primary hyperparathyroidism, Hirschsprung's disease Pathophysiology: Pathophysiology Thyroid lymphomas Most common  non hodgkin B cell lymphomas . Commonly arise from chronic lymphocytic thyroiditis Chronic antigenic lymphocyte stimualtion  lymphocyte transformation PowerPoint Presentation: PRESENTATION Presentation: Presentation History Most common Painless , palpable, solitary thyroid nodule. Solitory nodules presenting before 30 years and after 60 years  increased chances of malignancy Nodules in males  higher chances of malignancy PowerPoint Presentation: Rapidly growing nodule is an ominous sign of malignancy....... History: History Hoarseness  involvement of the recurrent laryngeal nerve and vocal fold paralysis . Dysphagia  impingement of the digestive tract Heat intolerance and palpitations suggest autonomously functioning nodules. :  Carcinoma Clinical Features Papillary thyroid carcinoma Slow growing painless mass Discrete neck lymph nodes (40 %) Lateral aberrant thyroid cervical lymph node invaded by metastatic cancer Compression feature uncommon Follicular carcinoma Solitory thyroid nodules with history of rapid size increase and long standing goiter Tracheal compression stridor +ive Berrys sign* advanced malignancy Dyspnoea, hemoptysis and chest pain when there are lung secondaries Pulsatile secondaries in skull and long bones Cervical lymphadenopathy uncommon Signs and symptoms of thyrotoxicosis *Infiltration of carotid sheath and absence of carotid pulsations James berry is a surgeon who named it :  Secondaries in skull from thyroid primary ( well localised, warm pulsatile vascular tumour with underlying bone erosion). :  Anaplastic carcinoma PowerPoint Presentation: Carcinoma Clinical features Anaplastic carcinoma Long standing neck mass >5cm which enlarges rapidly , may be painful Tracheal obstruction  stridor Hoarseness and dysnea  common (50%) Vocal cord paralysis(30%) Hard Mass fixed to surrounding structures , may be ulcerated, cervical mets (40%) +ive berry’s sign Medullary thyroid carcinoma Develops in superolateral part of thyroid lobes Neck mass with palpable cervical lymphadenopathy (15 to 20%) Pain common Local invasion dysphagia, dysnea, dysphonia Sporadic  unilateral(80%) Familial  bilateral (90%) Clinical presentation of thyroid cancer patients in Pakistan--AKUH experience,: Clinical presentation of thyroid cancer patients in Pakistan--AKUH experience , Thyroid cancer is a more aggressive disease in Pakistan, with majority of patients presenting with multinodular goiters, and a significant number have lymph node metastases. A higher degree of vigilance and a lower threshold for fine needle aspiration (FNA) is needed while evaluating patients with thyroid goiter ...... Physical examination: Physical examination Features suggestive of malignancy in a solitory nodule include Any nodule can be malignant ( hard, firm, cystic,small,large,asymtomatic) Rapid onset/rapid recent increase in size Hoarseness of voice/dysphagia/ stridor/dyspnea Fixity of the nodule Palpable neck nodes Head and neck examination with careful attention to the thyroid gland and cervical lymph nodes, as well as indirect laryngoscopy. Thyroid paradox: Thyroid paradox Cellular tumours are soft and cystic tumors are firm and hard Observed in papillary carcinoma of thyroid Differential diagnosis of CA thyroid: Differential diagnosis of CA thyroid Multinodular goiter Reidels thyroiditis Presents as hard fixed swelling.May have local invasion and fibrosis but is BENIGN . Thyroid adenoma Follicular- colloid , embroyal, fetal Hurthle cell Thyroid cyst Only one nodule palpable in MNG PowerPoint Presentation: WORKUP Workup: Workup Fine needle aspiration biopsy Laboratory investigation Imaging studies Fine Needle Aspiration Biopsy: Fine Needle Aspiration Biopsy Most important diagnostic tool. Safe and minimally invasive Ultrasonographic guidance  increases the accuracy of FNAB  Gharib and Goellner (1993) found that 69% of FNAB results were benign , 4 % were malignant , 10% were indeterminate , and 17 % were nondiagnostic . Sensitivity 83% Specificity 92 % False-positive rate was 2.9%, and their false-negative rate was 5.2%. Fine Needle Aspiration Biopsy: Fine Needle Aspiration Biopsy Fine needle aspiration biopsy: Fine needle aspiration biopsy Complications Minor hematoma and ecchymosis  most common Puncture of the trachea, carotid artery, or jugular vein may occur Can be managed by applying local pressure FNAB: FNAB Limitation Difficult to differenciate between follicular adenoma and carcinoma on cytology as it depends upon capsular and angioinavision Options in Follicular carcinoma Frozen section biopsy Hemithyroidectomy Trucut biopsy Danger of hemmorhage and injury to trachea, recurrent laryngeal nerve and vessels :  * Except in patients with history of external radiation or family history of thyroid cancer Workup : Workup Laboratoty investigation Serum TSH levels Low level suggests autonomously functioning nodule (usually benign) Dosnt rule out malignancy Serum calcitonin levels Highly suggestive of MTC if increased More senstive marker than CEA PCR assays for germline mutations in the  RET   proto-oncogene Diagnostic in Familial medullary thyroid carcinoma Laboratoty investigation: Laboratoty investigation Pentagastrin-stimulated calcitonin used as tumor markers to monitor patients who have been treated for MTC Serum thyroglobulin levels Cannot differenciate between benign and malignant disease Used in patients who underwent total thyroidectomy * for thyroid cancer Patients undergoing non operative managment of thyroid nodule *increased levels indicate recurrence Laboratoty investigation: Laboratoty investigation Urinary VMA, metanephrine and catecholamine To rule out coexisting Pheochromocytoma in MTC S erum levels of CEA Increased in MTC but nonspecific Better indicator of prognosis than Calcitonin New patients with MTC should be screened for RET point mutations, pheochromocytoma and HPT. Imaging studies: Imaging studies Ultrasonography Highly sensitive for thyroid nodules Can depict nodules only a few millimeters in size Can detect non palpable thyroid nodules Differenciate solid from cystic nodules Can detect adjacent lymphadenopathy Ultrasonography : Ultrasonography Features suggestive of malignancy on USG include Fine stippled calcification Enlarged regional lymph nodes Used to follow the size of suspected benign nodules Ultrasonograpy : Ultrasonograpy Thyroid nodule with few, easily countable microcalcifications S olid , hypoechoic, and coarse central calcifications Later proved to be medullary carcinoma Workup: Workup Radio iodine studies Recommended in patients having Follicular CA on FNAB and suppressed TSH. Determine functional status of a nodule Based on radioisotope studies nodule can be Hot Autonomous toxic nodule Warm Normally functioning Cold Non functioning nodule (likely to be malignant but not always) PowerPoint Presentation:  :  Thyroid Scan showing cold nodule Thyroid scan showing hot nodule Workup: Workup 111 indium octreotide scanning MTC (70 %sensitive) Xrays CXR and Xray skull to rule out metastatic deposits Skull mets more likely in Follicular carcinoma CT scanning and MRI used to evaluate soft-tissue extension of large or suspicious thyroid masses into the neck, trachea, or esophagus. To assess metastases to the cervical lymph nodes PowerPoint Presentation: X-ray of skull showing a couple of painless, progressively increasing swellings in the occipitoparietal region of the scalp . World J Radiol. 2012 June 28; 4(6): 286-290. PowerPoint Presentation: STAGING Staging : Staging TNM Classification of Thyroid Tumors Papillary or Follicular Tumors Stage TNM <45 y I Any T, any N, M0 (cancer in thyroid only ) II Any T, any N, M1 ( Distant metastasis ) ≥ 45 y I T1 , N0, M0 II T2 , N0, M0 III T3 , N0, M0; T1–3, N1a, M0 IVA T4a , N0–1a, M0; T1–4a, N1b, M0 IVB T4b , any N, M0 IVC Any T, any N, M1 :  Medullary Thyroid Cancer Stage TNM I T1 , N0, M0 II T2–3 , N0, M0 III T1–3 , N1a, M0 IVA T4a , N0–1a, M0; T1–4a, N1b, M0 IVB T4b , any N, M0 IVC Any T, any N, M1 Anaplastic Cancer Stage TNM IVA T4a , Any N, M0 IVB T4b , Any N, M0 IVC Any T, Any M, M1 Definitions: Definitions Primary tumor (T) TX = Primary tumor cannot be assessed T0 = No evidence of primary tumor T1 = Tumor ≤2 cm in diameter, limited to thyroid T2 = Tumor >2 cm but <4 cm in diameter, limited to thyroid T3 = Tumor >4 cm in diameter, limited to thyroid, or any tumor with minimal extrathyroidal invasion T4a = Any size tumor extending beyond capsule to invade subcutaneous soft tissue, larynx, trachea, esophagus, or recurrent laryngeal nerve, or intrathyroidal anaplastic cancer T4b = Tumor invading prevertebral fascia, or encasing carotid artery or mediastinal vessels; or extrathyroidal anaplastic cancer Regional lymph nodes (N)—include central, lateral cervical, and upper mediastinal nodes NX = Regional lymph nodes cannot be assessed N0 = No regional lymph node metastasis N1 = Regional lymph node metastasis N1a = Metastases to level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes) N1b = Metastases to unilateral, bilateral, or contralateral cervical or superior mediastinal lymph nodes Distant metastasis (M) MX = Distant metastases cannot be assessed M0 = No distant metastasis M1 = distant mets present Staging: Staging Degroot’s* staging of thyroid carcinoma Stage 1 Malignancy is intrathyroidal Stage 2 Cervical nodal metastasis Stage 3 Extrathyroidal invasion Stage 4 Distant metastasis *Applicable in all thyroid malignancies but mainly used in follicular carcinoma Prognostic indicators in PTC : Prognostic indicators in PTC Classify patients into LOW RISK and HIGH RISK groups AGES scoring system A ge, G rade, E xtrathyroidal invasion and S ize. LOW RISK patients are Young <40 years Well differenciated tumor No mets Small primary lesions (<4cm) HIGH RISH include Older >40 years Poorly differenciated tumor Distant metastasis Large primary lesion >4cm MACIS scoring system: MACIS scoring system Post operative system modified from AGES Include M etastasis, A ge , C ompleteness of excision, extrathyroidal I nvasion and S ize. The final prognostic score was defined as MACIS = 3.1 (if aged less than or equal to 39 years) or 0.08 x age (if aged greater than or equal to 40 years), + 0.3 x tumor size (in centimeters), +1 (if incompletely resected), +1 (if locally invasive), +3 (if distant metastases present).  AMES Scoring system: AMES Scoring system Proposed by Cady Include A ge, M etastasis, E xtent of primary tumour, S ize LOW RISK include Age <40 in men and <50 in women No mets No extrathyroidal invasion Size <5 cm HIGH RISK include Age > 40 in men and >50 in women Distant mets +ive Extrathyroidal invasion Size >5cm Tid Bits: Tid Bits Lymph node involvement does not alter the prognosis of papillary carcinoma of thyroid. All scoring systems catagorise the patient as High risk of death i.e 40 % in 20 years Low risk of death i.e 1 % in 20 years Low risk is acheived by complete clearance of macroscopic tumor during first surgery PowerPoint Presentation: TREATMENT Lymph node levels in neck Unilateral thyroid lobectomy is recommended : Unilateral thyroid lobectomy is recommended Cyst persist after 3 attempts for aspiration Cyst >4cm Complex cyst with solid and cystic components  higher chances of malignancy (15 %) Papillary thyroid carcinoma: Papillary thyroid carcinoma HIGH RISK or BILATERAL Total or near total thyroidectomy Minimal papillary carcinoma in thyroid specimen Unilateral thyroid lobectomy and isthmectomy Large , Locally aggressive/ metastatic tumours Total thyroidectomy with excision of adjacent involved structures if necessary and appropriate nodal surgery followed by radioablation with long term TSH suppression Modified Radical neck dissection type III is done in case of lymph node involvement Low risk groups: Low risk groups Points in favour of total thyroidectomy Point in favour of lobectomy Enables the use of RAI to detect and treat residual thyroid tissue/mets Lobectomy has less complication rate Makes serum Tg level more sensitive for recurrent or persistent disease Recurrence in remaining tissue is unsual (5%) and mostly curable by surgery Removes contralateral occult cancer as sites of recurrence ( 85% bilateral) Tumour multicetricity has little prognostic significance Reduces recurrence risk and improved survival Prognosis is comparable to total thyroidectomy Decreases the 1 % risk of progression to anaplastic cancer Reduces rate of re-operation and complication Generally total or near total thyroidectomy is recomended in low risk groups provided complication rates are low <2 % Indication of total thyroidectomy NCCN guidelines: Indication of total thyroidectomy NCCN guidelines If any present If all present (thyroidectomy /lobectomy) Age <15y or >45y Age 15 – 45 y Radiation history No radiation history Known distant mets No distant mets Bilateral nodularity No nodularity Extrathyroidal invasion No extrathyroidal invasion Tumour > 4cm Tumour <4 cm Cervical lymph node mets No cervical lymph nodes mets Aggressive variant No aggressive variant PowerPoint Presentation: Prophylactic lateral neck node dissection is NOT recommended in PTC Cancer dosnt metastatise systemically from lymph nodes Micrometastasis can be ablated by RAI therapy Residual disease Post operatively: Residual disease Post operatively TSH + Tg and antithyroglobulin antibodies 2 to 12 weeks post operatively Total body RAI imaging Suspected or proven RAI EBRT Adequate RAI uptake  Radioiodine treatment and post treatment I 131 imaging If no imaging performed  EBRT In all these cases suppress TSH with Levothyroxine. :  Using the Surveillance, Epidemiology, and End Results (SEER) database, one study compared the overall survival (OS) and cause-specific survival (CSS) of 23,605 subjects with papillary or follicular thyroid cancer treated with local excision, lobectomy, near-total thyroidectomy, or total thyroidectomy. The 10-year OS and CSS results concluded that total thyroidectomy resulted in improved survival over other techniques Poorer outcomes were associated with age, stage T3/T4 disease, positive nodes, and tumor size Metastatic disease NCCN guidelines: Metastatic disease NCCN guidelines CNS  Neurosurgical resection and/or image guided EBRT BONE Surgical paliation ( weight bearing extremities and/or RAI treatment and/or EBRT bisphosphonate or denosumab therapy Embolization of mets Other than CNS  surgical resection and/or EBRT of selected mets and/or radioiodine Best supportive care Follicular carcinoma: Follicular carcinoma Follicular lesion on FNAB  thyroid lobectomy (80 % are adenomas) Total thyroidectomy is recommended in Older patients Lesion >4cm ( cancer risk is 50 %) Intraoperative frozen section examination if Evidence of vascular or capsular invasion Adjacent lymphadenopathy is present If non diagnostic then hemithyroidectomy is done and sent for histopathology Thyroid specimen  follicular carcinoma total thyroidectomy Nodal mets  therapeutic neck dissection Hurthle cell carcinoma: Hurthle cell carcinoma Unilateral lobectomy and isthmectomy Invasive  total thyroidectomy + central neck node removal Modified radical neck dissection if lateral nodes are involved TSH suppression Rediffereciating therapies such as retinoic acid and PPAR gamma have shown some benefit in these tumors but require futher research Post operative management of DTC: Post operative management of DTC Radioiodine scanning and ablation RAI ablation is recommended in All patients with stage 3 and 4 disease All Patients with stage 2 disease <45 years Usually in patients >45 years and stage 2 disease Stage 1 disease with Aggresive histology Nodal mets Multifocal disease Extrathyroidal or vascular invasion :  More senstive than xray/ CT in detecting metastatic disease Less senstive than Tg level except in Hurthle cell Tumours 4-6 weeks after thyroidectomy, hypothyroid can be induced by discontinuing replacement (T4 for 4 weeks or T3 for 2 weeks) to obtain high serum TSH levels . A diagnostic dose of 131  I or 123  I is given initially . Whole-body scanning is performed to detect any tissue taking up radioiodine. If any normal thyroid remnant or metastatic disease is detected, a therapeutic dose of 131  I is administered to ablate the tissue. Posttreatment scanning should also be performed because it may reveal metastatic disease not otherwise noted. PowerPoint Presentation: If a treatment dose of 131  I is required, diagnostic thyroid scanning is repeated after 6 months after initial treatment, If the diagnostic scan Positive  additional therapeutic dose is given. Process is repeated until the diagnostic scan is negative R ole of recombinant human TSH  Thyrogen stimulation avoids the discomfort of patients having to discontinue thyroid replacement t4 stopped 1 day before TSH stimulation Recent advances: Recent advances Sorafenib* (Nexavar) was approved in November 2013 for differentiated thyroid cancer (DTC) that is refractory to radioactive iodine treatment. * Sorafenib is a small molecular  inhibitor of several tyrosine protein kinases Thyroid suppression: Thyroid suppression Used after thyroidectomy and radioablation Reduces tumoural growth and recurrence rates Suppressive dose is 0.3 mg OD lifelong TSH levels should be < 0.1 mU/L External beam radiotherapy: External beam radiotherapy Used in unresectable, locally invasive or recurrent disease In bone mets to decrease Risk of fractures Bone pain Chemotherapy : Chemotherapy Generally has no role Doxorubicin is used as radiation sensitizer in patients undergoing external beam radiation Medullary thyroid carcinoma: Medullary thyroid carcinoma If pheochromocytoma present  operated first Total thyroidectomy is the treatment of choice with bilateral central neck node dissection Palpable cervical lymph nodes modified radical neck dissection Tumour >1 cm  ipsilateral Prophylactic modified radical neck dissection If +ive than contralateral node dissection is done Medullary thyroid carcinoma: Medullary thyroid carcinoma If unresectable Tumour debulking to reduce symptoms External beam radiation Recent advances Tyrosine kinase inhibitors Imitanib Zactima (reduces calcitonin and CEA levels Anti CEA monoclonal antibody Labetuzumab Laproscopic Radiofrequency ablation For Liver mets >1.5 cm (palliative) :  If patient is hypercalcemic at thyroidectomy Only enlarged parathyroid gland is removed RET mutation carrier  total thyoroidectomy MEN2A  before 6 years MEN2B  before 1 year Central neck node dissection Avoided in calcitonin negative and normal USG exam Done prophylactically in calcitonin positive and if USG suggests cancer Maintenance dose of L-thyrosine PowerPoint Presentation: All family members of patients with MTC should be evaluated with serum calcitonin ( genetic evaluation can also be done ) and if it is high they should undergo prophylatic thyroidectomy ...... Anaplastic carcinoma: Anaplastic carcinoma If resectable Adjuant chemoradiotherapy Adriamycin is used for chemo. Tracheostomy and isthemectomy to relieve airway obstruction in unresectable cases Lymphomas: Lymphomas Mainstay  Chemotherapy CHOP ( Cyclophosphamide, Doxorubicin, vincristine, and prednisolone) Radiotherapy may also be given Thyroidectomy and nodal resection to alleviate airway obstruction :  Follow Up Differenciated thyroid carcinoma : Differenciated thyroid carcinoma Throglobulin levels Thyroglobulin is a useful marker of tumor recurrence because well-differentiated thyroid cancers synthesize thyroglobulin After total thyroidectomy levels should be <2 ng/ml if taking t4 <5ng/ml if hypothyroid Levels >2ng/ml suggest metastatic or persistant normal tissue. (>95%) Tg and Tg antibodies measuresd initially  6 months interval then annualy if disease free. Follow up imaging: Follow up imaging In low risk and –ive TSH stimulated Tg and normal cervical USG routine whole bodyscan is not recommended after first post operative scan After remnant ablation routine whole body scan after 6 to 12 months is recommended Cervical USG T o evaluate thyroid bed and lymph node  6 to 12 months post thyroidectomy then annually for 4 to 5 years FDG PET SCAN If RAI and USG normal but Tg remain elevated Medullary thyroid carcinoma: Medullary thyroid carcinoma Annual measurements of calcitonin and CEA levels. Regular USG , CT , MRI if required FGD PET scans Superior to other radionuclide based studies Management of recurrence: Management of recurrence Localised Surgical excision Non localised 131   I radioablation External beam radiotherapy :  Prognosis PowerPoint Presentation: Stage Age < 45 Age > 45 Local Recurrence Distant Recurrence 10 year Survival I Any T Any N M0 T1 N0 M0 5.5% 2.8% 98% II Any T Any N M1 T2 N0 M0 7% 7% 89% III - T3 N0 M0 T1-3 N1a M0 27% 13.5% ~82% IVa - T4a N0 M0 T1-4 N1b M0       IVb - T4b N0-1b M0       IVc - Any T Any N M1 60.9% 100% 50% This table is extrapolated from a number of sources including the American Cancer Society, The National Cancer Institute, and the National Comprehensive Cancer Network, among others According to stage According to cancer type: According to cancer type 5-Year Survival for Papillary Thyroid Cancer Stage 5-Year Survival I Nearly 100% II Nearly 100% III 93% IV 51% 5-Year Survival for Follicular Thyroid Cancer Stage 5-Year Survival I Nearly 100% II Nearly 100% III 71% IV 50% 5-Year Survival for Medullary Thyroid Cancer Stage 5-Year Survival I Nearly 100% II 98% III 81% IV 28% Papillary carcinoma: Papillary carcinoma Good prognosis Age is most important factor AGES system AGES Prognostic score = 0.05 × age (if age ≥40) + 1 (if grade 2) + 3 (if grade 3 or 4) + 1 (if extrathyroid) + 3 (if distant spread) + 0.2 × tumor size (cm maximum diameter ) AGES score Survival (20-yr) ≤3.99 99% 4-4.99 80% 5-5.99 67% ≥6 13% Survival by AMES risk-groups (20-yr): Survival by AMES risk-groups (20-yr ) Low risk 99% High risk 61% Survival by MACIS score (20-yr) MACIS score Survival <6 99% 6-6.99 89% 7-7.99 56% ≥8 24% Follicular carcinoma: Follicular carcinoma Cumulative mortality is 15% at 10years 30 % at 20 years Poor prognosis is associated with Age >50 Tumour size > 4cm High tumor grade Marked vascular and extrathyroidal invasion Distant metastasis Medullary thyroid carcinoma: Medullary thyroid carcinoma 10 yr survival rate is 80 % Decreases to 45 % with lymph node involvement From best to worst prognosis Non MEN familial  MEN 2A  sporadic  MEN2B MEN2B has survival rate of 35 % at 10 years Anaplastic carcinoma: Anaplastic carcinoma Few patients survive 6 months beyond diagnosis Lymphomas Depends upon Histologic grade Tumour within thyroid or disseminated Overall 5 yr survival rate is 50 % Extrathyroidal disease  lower survival rates Patient education: Patient education Patients who discover a neck deformity or thyroid lumps or have a history of prior exposure to ionizing radiation must consult their physician PowerPoint Presentation: Case Presentation Case Presentation: Case Presentation A 40 year old male, resident of Chichawatni, electrician by profession presented with complain of swelling on the right side of neck for 3 months. Swelling was gradual in onset, progresively increasing in size and number. Noticed by the patient by self palpation. Associated with Hoarseness of voice Anorexia and weightloss for last 1 month No h/o pain, fever, palpitation, sweating, heat/cold intolerence, dysphagia, dysnea, radiation exposure , sleep disturbance or neck trauma. Past medical and surgical history unremarkable except HCV infection (7 years) PowerPoint Presentation: Drug history : Took interferon injections for 6 months for HCV. Personel history : Non smoker, non addict Socio economic History: Lower class with 7000/ month income. Family history : Mother is diabetic . Allergic history: Not significant . General physical examination: General physical examination A middle aged male of lean physique sitting comfortably on bed well oriented in time place and person B.P = 130/90 mmHg Pulse = 90/ min regular rhythm, volume and character Resp rate = 14/min Temp = 98.6 F Weight =50 kg BMI=16.03 Bilateral cervical lymphadenopathy Right Post triangle nodes Bilateral along anterior border of sternocleidomastoid Bilateral supraclavicular nodes Right axillary medial group of lymph nodes are also palpable No Pallor, cyanosis, jaundice, clubbing or edema Local examination: Local examination A 3*2 cm soft, globular, nontender, nonfluctuant, non pulsatile, normothermic swelling on the right side of anterior triangle that moves upward with deglutition. Not fixed to overlying skin but fixed to underlying tissues ,with smooth surface and irregular borders but no prominent veins, pulsations or stridor. Carotid pulse palpable i.e berry’s sign –ive Systemic examination: Systemic examination No eye signs CNS : GCS= 15/15 intact CVS : S 1 + S 2 + 0 Chest : NVB + 0 Abdomen: Soft nontender, no viceromegaly, Liver span = 12 cm in midclavicular line, bowel sounds present Investigation: Investigation Laboratory investigation: CBC, LFTS, RFTS, and COAGULATION is NORMAL Thyroid function test are normal FNAC Thyroid nodule Nuclear overlapping, nuclear groves with papillary cores suggestive of Papillary carcinoma of thyroid No inclusion or psamomma bodies Cervical lymph node Sheets of pleomorphic cells with nuclear grooves against hemorrhagic background Imaging studies: Imaging studies CT scan of neck with I/V contrast Large heterogenous enhancing mass involving right side of isthmus and right lobe of thyroid with extrinsic compression of trachea. Calcification also noted in mass Multiple enlarged lymph nodes in right axilla, supraclavicular and cervical region Oro/hypopharynx and larynx appear normal. E sophagus is normal. Great vessels in the neck are un remarkable PowerPoint Presentation: 99m Tc MDP bone scan: Normal ( homogenious and bilateral symmetrical tracer distribution) CHEST X RAY: Normal Indirect laryngoscopy: Bilateral normal mobile vocal cords Plan Total thyroidectomy with neck block dissection followed by lifelong thyroid hormone replacement therapy Intraoperative findings: Intraoperative findings Level IIb , III , IV and V lymph node chains with pericapsular fibrosis invading carotid sheath. Right lobe hard fixed infiltrating right wall of trachea Hard fixed mass extending retrosternally and fixed with trachea.... Procedure done: Procedure done Modified radical neck dissection Accessory nerve saved . Internal jugular vein and sternocleidomastoid removed Left lobectomy and isthmectomy + right nodulectomy

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Tumors Metastatic to Thyroid Neoplasms: A Case Report and ...

Metastasis into a thyroid neoplasm—tumor-to-tumor metastasis—is exceedingly rare. We describe the 28th documented case of a tumor metastatic to a ...
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Thyroid Neoplasms Magazin eBook | Fachzeitungen.de

This is a unique book on thyroid neoplasms in that it covers many current topics in the area including tumor development, tumor markers and preclinical ...
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Thyroid Neoplasms - PharmGKB

Read more about the pharmacogenomics of Thyroid Neoplasms on PharmGKB.
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Thyroid neoplasms (including the solitary nodule)

The focus of this contribution is thyroid neoplasms. Solitary nodules should be investigated to exclude malignancy. Tumours should be staged according to ...
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