TUMOURS OF THYROID GLAND

PRESENTED BY PALAK GUPTA

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CLASSIFICATION OF TUMOURS OF THYROID GLAND

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BENIGN ADENOMAS Follicular adenoma Papillary adenoma Hurthle cell adenoma Colloid adenoma MALIGNANT TUMOURS (Dunhill classification ) PRIMARY WELL DIFFERENTIATED CARCINOMA
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Papillary carcinoma (60 % ) Follicular carcinoma ( 17 % ) Papillofollicular carcinoma behaves like papillary carcinoma of thyroid Hurthle cell carcinoma behaves like follicular carcinoma
POORLY DIFFERENTIATED CARCINOMA

Anaplastic carcinoma ( 13 % )
ARISING FROM PARAFOLLICULAR CELLS

Medullary carcinoma (6 % )
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ARISING FROM LYMPHATIC TISSUE Malignant lymphoma (4 % ) SECONDARY ( METASTASIS ) Malignant melanoma ( rare ) Renal cell carcinoma Breast carcinoma produce secondaries in the thyroid due to blood spread

ETIOLOGY OF THYROID MALIGNANCY

Radiation either external or radioiodine can cause papillary carcinoma thyroid. Pre existing multinodular goiter. It turns into follicular carcinoma of thyroid. Medullary carcinoma thyroid is often familial.

PAPILLARY CARCINOMA

It is 60 % common. Common in females and young age group. TSH levels in the blood of these patients are high, so it is called HORMONE DEPENDENT TUMOUR. Slowly progressive and less aggressive tumour. Commonly multicentric. Spreads within the gland through intra thyroidal lymphatics. No blood spread.
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ADENOMAS

The benign tumours of thyroid gland are not uncommon. They are present as a solitary nodule. Diagnosis is established by histological examination. Treatment by hemithyroidectomy/lobectomy. FNAC cannot distinguish follicular adenoma from follicular carcinoma. Hence a frozen section is arranged.
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ETIOLOGY Irradiation to the neck during childhood. Complication of Hashimotos thyrioditis. TYPES Occult ( < 1.5 cm ) Intrathyroidal Extrathyroidal GROSS FEATURES It can be soft, firm, hard, cystic. It can be multinodular or solitary. It contains brownish black fluid.

MICROSCOPY Made up of colloid filled follicles with papillary projections. In some cases calcified lesions are found which are called as PSAMMOMA bodies. These are diagnostic of papillary carcinoma of thyroid. Characteristic pale, empty nuclei are present which are called as ORPHAN ANNIE EYED NUCLEI. (intranuclear cytoplasmic inclusions ) CLINICAL PRESENTATION Young females are commonly affected. ( age of 20 40 years ).
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It can be present as soft or hard or firm, solid or cystic, solitary or multinodular swelling. Compression features are uncommon. Often discrete lymph nodes in the neck are palpable. Thyroid may or may not be palpable. When not palpable it is called as occult ( hidden ) Few patients present late to the hospital with fixed nodes in the neck, and fixed thyroid to the trachea with or without recurrent laryngeal nerve paralysis.

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DIAGNOSIS Routine investigations such as blood examination, chest x ray, laryngoscopy, are to be done. Radioisotopes scan shows cold nodule. TSH level in the blood is higher. FNAC ( fine needle aspiration cytology ) can demonstrate colloid filled follicles with papillary projections, hence preoperative diagnosis is possible with FNAC.
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TREATMENT Near total thyroidectomy Suppressive dose of L THYROXINE 0.3 mg OD life long. Block dissection ( functional block ) is required if lymphnodes are involved. If small lymph nodes are present Berry picking may be done ( not accepted now ). PROGNOSIS Prognosis is good One of the curable malignancies.
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AMES scoring. A: age, < 40 years has better prognosis. M: distant metastasis E: extent of the primary tumor. S: size of the tumor. AGES scoring A: age, < 40 years has better prognosis. G: pathologic grade of the tumor. E: extent of the primary tumor. S: size of the primary tumor. Size < 4 cm has better prognosis.

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Incidence: constitutes 17 % of cases. Common in females. Can occur either de novo or in a pre existing multinodular goitre. More aggressive tumor. Spreads mainly through blood into the lungs, bones and liver. Spreads to lymph nodes of neck occassionaly. Bone secondaries are vascular, warm, pulsatile and localised.

FOLLICULAR CARCINOMA

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ETIOLOGY Usually arises in a multinodular goitre, especially endemic goitre. Occurs in de novo. CLASSIFICATION NON INVASIVE, which means minimal invasion. INVASIVE refers to angio invasion and capsular invasion. The tumor cells lines the blood vessels and get dislodged into the systemic circulation producing secondaries in the bone.

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CLINICAL PRESENTATION Swelling in the neck, firm or hard and nodular. Peak age group is around 40 years. Tracheal compression and stridor. Dyspnea, hemoptysis, chest pain during lung secondaries. Recurrent laryngeal nerve involvement causes hoarsness of voice, +ve Berrys sign. Pulsatile secondaries in the skul and long bones. ( metastasis in the flat bones ).
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INVESTIGATIONS Routine investigations Thyroid scan can demonstrate cold nodule. FNAC of the cold nodule is inconclusive because capsular and angio invasion is not detected by FNAC. Frozen section biopsy is useful. Ultrasound abdomen, chest x ray, bone x ray are done to reveal osteolytic lesions. Alkaline phosphatase if increased, bone scan should be done.
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TREATMENT Near - total thyroidectomy is done, along with block dissection if lymph nodes are enlarged. Maintenance dose of L thyroxine 0.1 mg OD is given lifelong. After near total thyroidectomy, a whole body, bone scan is done to see for metastasis in the bone. A single secondary can be treated by radiotherapy followed by oral radioiodine therapy. Multiple secondaries are treated by oral radioiodine therapy.
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HURTHLE CELL CARCINOMA

It is a variant of follicular carcinoma. It is more aggressive than follicular carcinoma. These tumors have more than 75 % of follicular cells having oncocytic features. Do not take up 131I. Secretes thyroglobulin. Hurthle cell adenoma even if well capsulated is highly malignant. It contains abundant oxyphill cells. It spreads to regional lymph nodes more than follicular carcinoma of thyroid.
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TREATMENT Total thyroidectomy. In many cases lymph nodes are enlarged, hence modified radical neck dissection ( MRND ) is done. TSH suppression, follow up regularly done.

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ANAPLASTIC CARCINOMA
Incidence: 10 % 12 % of cases. The most rapidly growing thyroid malignancy. Advanced age group at presentation. Advanced nature of presentation. CLINICAL FEATURES Common in elderly woman around 60 70 years of age. Rapidly growing thyroid swelling of short duration. The surface is irregular and consistency is hard.
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Very aggressive tumor causing Stridor and hoarseness of voice. Dysphagia Fixity to the skin. Involvement of isthmus and bilateral lateral nodes. Early infiltration of trachea ( stridor ) Infiltration of carotid sheath ( carotid artery pulsation not palpable ). +ve Berrys sign. Differential diagnosis intrinsic carcinoma of larynx.

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DIAGNOSIS FNAC is diagnostic. TREATMENT Tracheostomy and isthmectomy are done to relieve respiratory obstruction temporarily. External radiotherapy. Prognosis is poor. Death occurs within 6 8 months.

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MEDULLARY CARCINOMA OF THYROID ( MCT )

Uncommon ( 5 % ) type of thyroid malignancy. Arises from parafollicular C cells, which is derived from ultimobronchial body. Contains characteristic amyloid stroma wherein malignant cells are dispersed. There maybe mucosal neuromas in lips, oral cavity. ( Sipple syndrome, MEN IIb ) TYPES Sporadic ( 80 - 90 % ).

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Familial MCT MCT with MEN II syndrome. CLINICL FEATURES Thyroid swelling often with enlargment of neck lymph nodes. Diarrhea, flushing. Hypertension, pheochromocytomas and mucosal neuromas. Sporadic and familial types occur in adulthood whereas MEN syndrome II occurs in younger age groups.
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HORMONES PRODUCED BY MCT Calcitonin Prostaglandins Serotonin ( 5 HT ) ACTH SPREAD Both by lymphatics and blood INVESTIGATIONS FNAC shows amyloid deposition with dispersed malignant cells and C cells hyperplasia.
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Tumor marker calcitonin levels will be high. Ultrasound neck thyroid region. TREATMENT Total thyroidectomy + central node dissection + maintenance dose of L thyroxine. Neck lymph node block dissection if lymph nodes are involved. Adriamycin is drug used for chemotherapy. PROGNOSIS Sporadic MCT and MCT with MEN II are aggressive. Familial MCT with no MEN II has better prognosis.
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MALIGNANT LYMPHOMA
It is rare. Hashimoto thyroiditis can pre dispose to malignant lymphoma. Older patients are commonly affected. Tumor is rapidly growing, large thyroid swelling. ( Primary lymphoma ). FNAC used to diagnose the condition. Chemotherapy is the main treatment. Often total thyroidectomy is done to enhance the results.
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