Thyroid Carcinoma

Abhishek Thakur 1610050

Frequency
17,000 cases diagnosed annually.

Incidence in Women 3 times more than

men. Peak incidence 30-40s. Papillary 80%, follicular 10%, medullary 510%, anaplastic 1-2%.

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) Rapid growth

History
Malignant nodules usually painless

Sudden onset pain usually in benign.

Hoarseness suggests malignancy, nerve

involvement. Dysphagia Heat intolerance, palpitations suggest autonomously functioning nodules. Family history (medullary).

The Goal..
Differentiate malignant from benign.

Determine which patients require

intervention. Who can be monitored? Avoid unnecessary surgery.

Fine Needle Aspiration

First intervention in evaluation of a nodule.

Inexpensive, easy, few complications.

Four types of results : 69% benign, 4% malignant,

10% indeterminate, 17% non-diagnostic. Sensitivity 83%, specificity 92% False positive 2.9%, negative 5.2%

Laboratory
TSH sensitive for hypo and

hyperthyroidism, but does not rule out malignancy. TFTs not indicated in work up initially. Serum thyroglobulin used as tumor marker post op.

Imaging
Ultrasound: solid vs. Cystic, for FNA accuracy,

for monitoring of benign lesions. Scans: radioiodine scans determines function of the nodule. Cold nodules are those that dont take up iodine123, hot ones are the opposite. CT and MRI not used routinely.

Papillary Carcinoma
Most common (80%)

Women 3 times more incidence

30-40 years of age Radiation exposure as a child Patients with Hashimotos thyroiditis Slow growing, TSH sensitive, take up iodine, TSH

stimulation produces thryroglobulin response.

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.

Papillary Carcinoma
Local invasion through capsule, invading

trachea, nerve, causing dyspnea, hoarseness. Propensity to spread to the cervical lymph nodes. Clinically evident in 1/3 patients. Distant spread to bone, lungs.

Follicular Carcinoma
Second most common (10%)

Iodine deficient areas

3 times more in women

Present more advanced in stage than

papillary Late 40s Also TSH sensitive, takes up iodine, produces thryroglobulin.

Follicular Carcinoma
Pathology: round, encapsulated, cystic

changes, fibrosis, hemorrhages. Microscopically, neoplastic follicular cells. Differentiated from follicular adenomas by the presence of capsule invasion,vascular invasion. Cannot reliably diagnose based on FNA.

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.

Treatment and Prognosis

Controversy regarding extent of therapy

continues. Surgical excision whenever possible. Total thyroidectomy has been mainstay (all apparent thyroid tissue removed). Complications include nerve damage bilaterally, parathyroid injury bilaterally. Afterwrds, get radioiodine scan, ablation if residual disease or recurrence.

Treatment and Prognosis

Over the years, modification to procedure to

reduce the above complications. Subtotal thyroidectomy( small portion of thyroid tissue opposite the side of malignancy is left in place) and postop ablation. Thyroid lobectomy and isthmectomy also a viable option with small tumors

Postoperative Radioiodine and Ablation

Radioiodine targets residual thyroid tissue

and tumor after thyroidectomy. Given in diagnostic doses and therapeutic doses to ablate tissue.

Thyroid Suppression Therapy

Maintained on thyroxine after surgery and

ablation. Low TSH levels reduce tumor growth rates and reduce recurrence rates. Follow-up 6 months with thyroglobulin levels and repeat scans. Thyroglobulin is good because well differentiated tumors produce it.

Prognosis
Age: at diagnosis. Cancer related 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. Tumors greater than 4 cm have higher recurrence, death.

Hurthle Cell
A variant of follicular, also known as oncocytic

carcinoma. More common in women than men, presents in 5th decade of life. Same clinical presentation. Cannot be diagnosed on FNA Does not take up iodine, so treated aggressively. Thyroid suppression and radioiodine dont work.

Indications for Total Thyroidectomy

Well-differentiated thyroid cancer

Medullary thyroid cancer

Sarcoma of thyroid

Lymphoma of thyroid
Obstructive goiter

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