Malignant Thyroid and Parathyroid Disorders

MALIGNANT THYROID AND
PARATHYROID DISORDERS
KHRISTINE S. OLITA, MD
OUTLINE
THYROID CANCER
MANAGEMENT AND SURGICAL TREATMENT
MANAGEMENT OF REGIONAL LYMPH NODES
TYPES OF THYROID CARCINOMA
POSTOPERATIVE MANAGEMENT AND
SURVEILLANCE
PAPILLARY THYROID CARCINOMA
FOLLICULAR THYROID CARCINOMA
HURTHLE CELL CARCINOMA
MEDULLARY THRYOID CARCINOMA
ANAPLASTIC THYROID CARCINOMA
METASTATIC THYROID CARCINOMA
PARATHYROID CANCER
OUTLINE
THYROID CANCER
SURVEILLANCE
PARATHYROID CANCER
• <1% of all malignancies in the US
• More common in women
THYROID CANCER
• History
Ø Hoarseness, difficulty in swallowing
and breathing
Ø Exposure to radiation
Ø Family history
• Physical Examination
q Head and neck
q Inspection and palpation of the thyroid
gland
ü Size
ü Consistency
ü Mobility
q Palpation of cervical lymph nodes
q Vocal cord mobility (Laryngoscope)*
Schwartz’s Principles of Surgery, 11th edition
THYROID CARCINOMA
• Diagnostics
Ø TSH, FT4, FT3
Ø Neck ultrasound
Ø CT/MRI
Ø FNAB
ü Thyroid nodule
ü Thyroid mass associated with palpable lateral neck nodes

OUTLINE
THYROID CANCER
SURVEILLANCE
PARATHYROID CANCER
SURGICAL TREATMENT
• Lobectomy
• Hemithyroidectomy
• Total thyroidectomy
• Near-total thyroidectomy
• Removal of all grossly visible thyroid tissue, leaving only <1g
• Subtotal thyroidectomy
• Leaving 4-7g remnant of thyroid tissue with the posterior capsule on the uninvolved side
• Bilateral subtotal thyroidectomy
• Remnant tissues are left on each side
• Hartley-Dunhill Procedure
• Total lobectomy on one side, subtotal thyroidectomy on the other side
Haugen, B., et. al. (2016). 2015 American thyroid association management guidelines for adult patients
with thyroid nodules and differentiated thyroid cancer. Thyroid. Mary Ann Libert, Inc.. 26(1). 1-133.
TREATMENT
• Indications for lobectomy: • Indications for total thyroidectomy:

ü Tumor 1-4cm in diameter* ü Tumor >4cm
ü Papillary microcarcinoma ü Cervical lymph node metastasis
(Tumor size ≤1cm) ü Consider bilateral nodularity
ü No prior radiation exposure ü Poorly differentiated
ü No distant metastasis ü Extrathyroidal extension
ü No cervical lymph node ü Known distant metastasis
metastasis ü Exposure to radiation
ü No extrathyroidal extension
Haugen, B., et. al. (2016). 2015 American thyroid association management guidelines for adult patients
with thyroid nodules and differentiated thyroid cancer. Thyroid. Mary Ann Libert, Inc.. 26(1). 1-133.
OUTLINE
THYROID CANCER
SURVEILLANCE
PARATHYROID CANCER
MANAGEMENT OF
REGIONAL LYMPH NODES
• PROPHYLACTIC NECK • THERAPEUTIC NECK DISSECTION
DISSECTION ü Removal of lymph nodes likely
ü Removal of lymph nodes containing metastatic focus based of
considered as “normal” by the history and physical exam,
physical examination or imaging imaging, or biopsy-proven
MANAGEMENT OF
• PROPHYLACTIC NECK • THERAPEUTIC NECK DISSECTION
DISSECTION ü Removal of lymph nodes likely
ü Removal of lymph nodes containing metastatic focus based of
considered as “normal” by the history and physical exam,
physical examination or imaging imaging, or biopsy-proven
ü Not recommended in most

thyroid cancer surgeries
MANAGEMENT OF
• CENTRAL NECK DISSECTION • MODIFIED RADICAL NECK
ü For positive central neck nodes DISSECTION
ü For positive lateral
compartment neck nodes
14

OUTLINE
THYROID CANCER
SURVEILLANCE
PARATHYROID CANCER
POSTOPERATIVE
MANGEMENT
• 131I (RAI) • 131I (Whole Body Scan)
ü Ablation or destruction or ü Surveillance
normal residual or metastatic ü Detect residual tumor or
thyroid tissues metastasis
• Thyroid hormones (LT4 and LT3) • Surveillance

ü Decrease tumor recurrence ü To check for recurrence of
ü Suppression for high risk disease
ü Supplement for low risk ü Periodic history and PE
ü Serum Thyroglobulin levels
ü 131I Whole Body Scan

OUTLINE
THYROID CANCER
SURVEILLANCE
PARATHYROID CANCER
THYROID CANCER
Anaplastic, 1% Metastatic, <1%
Medullary, 5% Hürtle, 3%
Follicular, 10%
Papillary, 80%

• Diagnostics:
PAPILLARY THYROID Ø FNAB
CARCINOMA Ø Neck ultrasound
• Pathology:
• 80% of all thyroid carcinomas • Orphan-Annie Nuclei
• F > M (2:1) • Psammoma bodies
• 30-40 y/o
• Tx: Total thyroidectomy
• Painless neck mass, euthyroid
• Minimal occult/Microcarcinoma
• “Lateral aberrant thyroid”
Ø Non-palpable, incidental
• Multifocality (85%)
Ø Tumor ≤1cm
Ø No angioinvasion
• Excellent prognosis Ø No extrathyroidal extension
Ø 95% 10-year survival rate Ø No lymph node metastasis

Multifocality
• Two or more foci within the same
quadrant
Multicentricity
• Two or more foci in different
quadrants of the same lobe
Oh, J.L. (2008). Multifocal or Multicentric Breast Cancer: Understanding Its Impact on Management and Treatment Outcomes. In: Hayat, M.A. (eds) Methods of Cancer
Diagnosis, Therapy and Prognosis. Methods of Cancer Diagnosis, Therapy and Prognosis, vol 1. Springer, Dordrecht. https://doi.org/10.1007/978-1-4020-8369-3_40
PAPILLARY THYROID
CARCINOMA

FOLLICULAR THYROID
CARCINOMA
• 10% of all thyroid cancers • Lobectomy
• Common in iodine-deficient areas ü 70-80% Benign follicular adenoma
• F > M (3:1)
• 5th decade of life • Total thyroidectomy
ü Follicular lesions >4cm
• Pain is uncommon ü Atypia on FNAB
ü History of radiation exposure
• Cervical lymphadenopathy
ü Family history of cancer
uncommon (5%)
• FNAB
• Unable to distinguish benign from
malignant follicular neoplasms

HÜRTHLE CELL CARCINOMA
• 3% of all thyroid cancers • Lobectomy

ü Hürthle cell adenoma
• Vascular and capsular invasion
• Total thyroidectomy
• Cannot be diagnosed with FNAB ü Invasive cancer
• Multifocal and bilateral (30%) • Total thyroidectomy + MRND

ü If with clinically palpable lymph nodes
(cN1) or identified by ultrasound
• Decrease RAI uptake

MEDULLARY THYROID
CARCINOMA
• 5% of all thyroid cancers • Multicentric
• Arises from parafollicular or C cells of • Aggressive
the thyroid
• F > M (1.5:1) • Signs and symptoms:
• 5th to 6th decade of life • Pain (common)
• Signs of local invasion:
• Sporadic (majority) • Dysphonia
• Dyspnea
• Familial (25%) – younger age • Dysphagia
• Familial MTC, MEN2A and MEN2B

MEDULLARY THYROID
CARCINOMA
• DIAGNOSTICS: • TREATMENT:
• Calcitonin (sensitive tumor • Management of pheochromocytoma
marker) (should be done first)
• Primary hyperparathyroidism
• CEA (predictor of prognosis) 131I Therapy not effective
•
• Neck ultrasound (routine)
• CT/MRI • Total thyroidectomy + central neck
• FNAB dissection (treatment of choice)
• RET-proto-oncogene mutation
testing • Lateral neck dissection (if cN1)

ANAPLASTIC THYROID
CARCINOMA
• 1% of all thyroid cancers
• Most aggressive thyroid cancer
• Women are commonly affected
• 7th to 8th decade of life
• Longstanding neck mass, fixed to

surrounding structures
• Rapid enlargement
• Pain
• Dysphonia, dysphagia, dyspnea
• Palpable cervical lymph nodes
• Metastasis
ANAPLASTIC THYROID
CARCINOMA
• DIAGNOSTICS • TREATMENT
• Total thyroidectomy + therapeutic neck
• FNAB dissection
• Adjuvant radiotherapy
• Giant and multinucleated cells
• Adjuvant chemotherapy
• Ultrasound, CT/MRI, PET-CT

• Assess resectability
• Laryngoscopy
• Vocal cord evaluation

METASTATIC THYROID
CARCINOMA
• Rare site of metastasis • Treatment:
• Resection of the thyroid, depending of
• Primary cancer from: the primary tumor
Ø Kidney
Ø Breast
Ø Lung
Ø Melanoma
• History and PE
• FNAB – definitive diagnosis

OUTLINE
THYROID CANCER
SURVEILLANCE
PARATHYROID CANCER
PARATHYROID CARCINOMA
• 1% PHPT cases q Treatment:

Ø En bloc resection of tumor
• Severe symptoms of Ø Thyroid lobectomy (ipsilateral)
hyperparathyroidism Ø Removal of lymph nodes
• Palpable parathyroid gland • Tracheoesophageal
• Serum calcium (>14mg/dL) • Paratracheal
• PTH (5x elevated from baseline) • Upper mediastinal
• Local invasion • RLN is preserved, unless directly

• Regional metastasis (15%) involved by the tumor
• Distant metastasis (30%) • Radiotherapy – if unresectable
u Suspicious for papillary carcinoma (SUSP)
u Similarsurgical management to malignant
cytology
u Clinical risk factors
u Sonographic features
u Patient preference
u Mutational testing results (if performed)
Haugen, B., et. al. (2016). 2015 American thyroid association management guidelines for adult patients with
thyroid nodules and differentiated thyroid cancer. Thyroid. Mary Ann Libert, Inc.. 26(1). 1-133.
• In an analysis of 52,173 PTC patients diagnosed between 1985 and
1998 from the National Cancer Data Base (Bilimoria et al., 2007)
• Total thyroidectomy (43,227) vs Lobectomy (8946)
• Slightly higher 10-year relative overall survival for total

thyroidectomy as opposed to thyroid lobectomy
• (98.4% vs. 97.1%, p < 0.05)
• Slightly lower 10-year recurrence rate
• (7.7% vs. 9.8%,respectively, p < 0.05).
• Risk stratifications
• Consistently provide the highest proportion of variance explained
when applied to a broad range of patient cohorts
• AJCC/UICC TNM system (Recommended)
• Utility in predicting disease mortality, and its requirement or cancer registries
• MACIS system
• Distant METASTASIS, patient AGE, COMPLETENESS of resection, local INVASION,
and tumor SIZE
Dean, D., & Hay, I. (2016). Prognostic indicators of differentiated thyroid carcinoma. Journal of the Moffit
Cancer Center
Dean, D., & Hay, I. (2016). Prognostic indicators of differentiated thyroid carcinoma. Journal of the Moffit
Cancer Center
• A goal TSH of >30 mIU/L has been generally adopted in
preparation for RAI therapy or diagnostic testing
• Direct LT4 withdrawal or LT4 withdrawal with substitution of LT3

in initial weeks
• Similar short-term quality of life and hypothyroidism symptom scores
• Comparable remnant ablation success rate
• rhTSH (Thyrogen) (alternative)

• A low iodine diet (LID) for approximately 1–2 weeks should
be considered for patients undergoing RAI remnant ablation
or treatment
• What is the appropriate degree of initial TSH suppression?
TSH SUPPRESSION LEVEL

LOW RISK 0.5 – 2mU/L
INTERMEDIATE RISK 0.1 – 0.5 mU/L
HIGH RISK <0.1 mU/L
THANK YOU

Malignant Thyroid and Parathyroid Disorders

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Malignant Thyroid and Parathyroid Disorders

Uploaded by

Copyright:

Available Formats

MALIGNANT THYROID AND

Schwartz’s Principles of Surgery, 11th edition

• Indications for lobectomy: • Indications for total thyroidectomy:

ü Not recommended in most

Schwartz’s Principles of Surgery, 11th edition

• Thyroid hormones (LT4 and LT3) • Surveillance

Schwartz’s Principles of Surgery, 11th edition

Schwartz’s Principles of Surgery, 11th edition

Schwartz’s Principles of Surgery, 11th edition

Schwartz’s Principles of Surgery, 11th edition

Schwartz’s Principles of Surgery, 11th edition

• 3% of all thyroid cancers • Lobectomy

• Multifocal and bilateral (30%) • Total thyroidectomy + MRND

Schwartz’s Principles of Surgery, 11th edition

Schwartz’s Principles of Surgery, 11th edition

Schwartz’s Principles of Surgery, 11th edition

• Longstanding neck mass, fixed to

• Ultrasound, CT/MRI, PET-CT

Schwartz’s Principles of Surgery, 11th edition

Schwartz’s Principles of Surgery, 11th edition

• 1% PHPT cases q Treatment:

• Local invasion • RLN is preserved, unless directly

• Slightly higher 10-year relative overall survival for total

• Direct LT4 withdrawal or LT4 withdrawal with substitution of LT3

• rhTSH (Thyrogen) (alternative)

TSH SUPPRESSION LEVEL

You might also like