Papillar and follicula

y
thyroi cancerr
d
K. A. Ikram Hussain
Final year M.B.B.S.
Papillary thyroid
cancer
It is a relatively common well thyroi

differentiated d
cancer

 Accounts for 85% of all thyroid cancers
In more than 50% cases in spreads to the
 It is more common in females than
lymphnodes
males of
neck
 Aetiology
Most thyroid cancers are sporadic

It can be a complication of Hashimoto’s

thyroiditis
Familial and genetic are associated with

syndromes
thyroid malignancies

 Cowden’s syndrome
 Gardner’s syndrome
Associated chromosomal
 Carney’s syndrome
mutations:
involving RET proto- translocations
oncogene
Pathology

It is made of colloid filled follicles with papillary


projections. bodies

In some cases calcific lesions are found called nuclei
 psammoma
Characteristic pale empty nuclei called Orphan Annie
 eye are seen in some cases
 Can present as cystic lesions
 Can be multifocal involving both lobes
Lymph nodes and Lungs are the usual sites of
metastases
Psammoma bodies
Orphan Annie eye appearance
Clinical
presentation
Young females of age 20-40 years are

group commonly
Principal
affected sign is a firm non tender nodule in thyroid

area
with a hard consistency and ill defined borders

Signs of hoarseness, tracheal and
 esophagal compression is present
Very often lymph nodes in lower deep cervical
region are involved and thyroid may or may not be
palpable.
Prognostic
criteria
Prognostic Risk Classification for Patients with
Well-Differentiated Thyroid Cancer (AMES or
AGES)
Low Risk Hi2h Risk

• Age <40 years >40 years

• Sex Female Male
• Extent No local extension,
Capsular invasion, extra-
intrathyroid, no caps thyroidal extension
mvasion

• Metastasis None Regional/distant

• Size <2cm >4cm

• Grade Well diff Poorly diff

Investigation
s
Thyroid profile

Ultrasound of and central neck

thyroid
Fine needle aspiration cytology of the

nodule

Serum thyroglobulin

TSH suppression test
Immunohistochemisty
findings
Carcinoembryonic antigen (CEA) negative

Calcitonin negative

Thyroglobulin positive

Keratin positive

 Treatmen
t
Total thyroidectomy

After thyroidectomy, patients are given thyroid replacement therapy for

approximately 4-6 weeks. Thyroid replacement is then discontinued, to
induce a hypothyroid state and promote high serum thyroid-stimulating
hormone (TSH) levels.
Approximately 4-6 weeks after surgical thyroid removal, patients may have

radioiodine therapy to detect and destroy any metastasis and residual
tissue in the thyroid
A diagnostic dose of (131I I) is then given, and a whole-

radioiodineis performed to detectorany
scintiscan 123 tissue
body taking up radioiodine. If any
thyroid remnant or metastatic disease is detected, a therapeutic
normal of 13 I
dose
administered to ablate the tissue. The patient is then placed back on1 is
thyroid
hormone replacement (levothyroxine) therapy.

Therapy is administered until radioiodine uptake is completely absent

Long term surveillance: Thyroglobulin

Prognosis:95% adults survive over 10 years
Complications due to surger and radio
y
iodine therapy
Hypothyroidism

Dysphagia

 Vocal cord paralysis
 Hypoparathyroidism
radioiodine is taken up by the salivary
 Sialoadenitis
glands with large lung metastases
Pulmonary
because fibrosis in patients

Brain edema in patients with brain metastases (may be

prevented by glucocorticoid therapy)
Permanent sterility and transient oligospermia or

menstrual irregularities
A small increase in the risk for leukemias or breast and

bladder carcinomas
Factors poor outcome
affecting
Large primary tumor

Age > 45 years

Male sex

Lymph nodal

metastases

Distant metastases

Multifocal disease

Extra-thyroidal
extension
Follicular carcinoma of
thyroid
It is a well differentiated tumor 2n most common

and d

after papillary thyroid cancer


Follicular adenomas are 20% malignant and 80%
 Incidence is 17% of cases
benign
Aetiology

Follicular carcinoma usually arises in a


multinodular
goitre especially in a cases of endemic goitre.

It should be suspected when multinodular goitre
starts growing rapidly
Pathology

Depending on invasion it is classified


Noninvasive as

Invasive refers to angio-invasion and capsular

invasion
Angioinvasio
n
 Clinical presentation
It can present as multinodular or solitary nodular goitre.

 The diagnosis is confirmed after an ultrasound scan reveals
features of malignancy like microcalcifications
Metastasis in flat bones: when a patient with a thyroid swelling

presents with metastasis in the bone in the form of bony
swelling or pathological fractures, a diagnosis of follicular
carcinoma can be considered.
Common secondaries are flat bones like skull,ribs,sternum and

vertebral column because fat bones retain red marrow for a
longer time.
Clinical features of a secondary are: they are

rapidly growing,warm, vascular and pulsatile.
Metastasis to
bone
 Treatment
Treatment of primary:

Total thyroidectomy is always

preferred

Treatment of the metastasis:


After total thyroidectomy a whole body scan is done to look for

metastasis in the bone. A single secondary can be treated with oral
radioiodine therapy followed by radiotherapy depending on the response
to treatment

Multiple secondaries are also treated with oral radio iodine.

Postoperative thyroxine:

Postoperative period patient should receive thyroxine 0.3mg/day to

suppress
TSH and to supplement thyroxine.

Prognosis: 15% mortality in 10 years.
 Summar
y
Characteristics Papillary carcinoma Follicular
carcinoma
Aetiology Sporadic/irradiation Endemic goitre
Incidence 60% 17%
Age (years) 20-40 30-50
Diagnosis Thyroid swelling with Thyroid swelling
with bony lymphnode metastasis metastasis
Microscopy Orphan Annie eye nuclei,
Angioinvasion, Psammoma bodies
Spread Capsular invasion
Lymphatic Blood
Investigation FNAC Frozen section
Treatment of primary Subtotal/total
Subtotal/total thyroidectomy
Treatment of metastasis thyroidectomy
Functional neck dissection Radioiodine 131 iodine
Hurthle cell
carcinoma
It is a variant of follicular cell carcinoma and more aggressive than

follicular
cell carcinoma

These tumors are defined by presence of more than 75% of follicular
cells with oncocytic features.

Tumor contains sheets of eosinophilic cells packed with mitochondria

They secrete thyroglobulin

Even if hurthle cell adenoma is well encapsulated it is potentially

malignant.

It does not take up iodine 131. hence less likely to respond to
radioablation.
Mortality is high 20% in 10 years
Criteria to
diagnose
Capsular or vascular invasion and distant

metastasis
to follicular

Higher chance of spread to lymph nodes thyroid
compared carcinoma

Higher chances of spread to distant sites too
TREATMENT:
Total thyroidectomy is the treatment of choice.
TSH suppression and follow-up is required
regularly.
Follow
up
Serum thyroglobulin- thyroid is the only organ which produces

thyroglobulin.
Levels greater than 1-2mg/ml in patients receiving replacement
thyroxine therapy indicates presence of metastasis.

So serum thyroglobulin response to injected recombinant TSH is
assessed every year.

Ultrasound or MRI scans of neck for localisation of residual or
recurrent tumor