Thyroid Neoplasms

THYROID
MALIGNANCIES
PRESENTER : Dr.R.RAGUL PRADEEP

MODERATOR : Dr.SATHYASEELAN
PES Institute of Medical Sciences & Research

THYROID NEOPLASMS
• BENIGN
• MALIGNANT

THYROID NEOPLASMS
• BENIGN
• Follicular adenoma can be –
1. Colloid (commonest type);
2. Fetal (microfollicular – has potential for
microinvasion);
3. Embryonal (atypical – has potential for
microinvasion);
4. Hurthle cell/oxyphil or oncocytic (has
potential for microinvasion);
5. hyalinising trabecular adenoma.
THYROID NEOPLASMS
MALIGNANT (PRIMARY AND SECONDARY)

• Of thyroid carcinomas, 90% to 95% are
categorized as DTCs that arise from follicular
cells.
• UDTC Anaplastic thyroid carcinoma (ATC) is
an aggressive malignancy that is responsible
for less than 1% of thyroid carcinomas in the
United States.
• MTC accounts for approximately 6% of thyroid
cancers (MEN2A and MEN2B).
• SECONDARY - RCC
THYROID NEOPLASMS
• MALIGNANT
• Primary thyroid malignancies can also be
classified according to aggressiveness:
• 1. Well-differentiated (e.g. papillary carcinoma,
follicular carcinoma)
• 2. Intermediate (e.g. medullary carcinoma,
Hürthle cell carcinoma)
• 3. undifferentiated (e.g. anaplastic carcinoma)

THYROID NEOPLASMS
• DTC
• . Papillary carcinoma (80%).
• Follicular carcinoma (10%).
• Hurthle cell carcinoma behaves like follicular
carcinoma.

THYROID NEOPLASMS
• In the different subtypes of thyroid carcinoma,

prognosis mirrors incidence in that PTC, which
is the most common thyroid malignancy, also
carries an excellent prognosis in most patients,
whereas ATC is far less common and carries a
dismal prognosis.

THYROID NEOPLASMS

THYROID NEOPLASMS
• PTC- 80%
• FTC – 10%
• MTC- 6%
• ATC – 1%
• LYMPHOMA
• HURTHLE CELL CANCER

THYROID NEOPLASMS
MOST COMMON’S
• M.C OVERALL-PAPILLARY CA >
FOLLICULAR CA
• M.C IN ENDEMIC AREAS- FOLLICULAR CA
• M.C IN CYSTIC LESION- PAPLILLARY CA

THYROID NEOPLASMS
ETIOLOGY
• Radiation either external or radioiodine can cause papillary
carcinoma thyroid.
• Earlier irradiation was practised to head and neck region to
treat benign conditions like tonsillitis, adenoids, thymus
enlargement, acne vulgaris, haemangiomas during first two
decades of life
• Pre-existing multinodular goitre. It turns into follicular
carcinoma of thyroid.
• Medullary carcinoma thyroid is often familial.
• Hashimoto’s thyroiditis may predispose to NHL/papillary
carcinoma of thyroid.

THYROID NEOPLASMS
FAMILIAL
• COWDEN SYNDROME
• CARNEY’S COMPLEX ( NOT CARNEY’S
TRIAD)
• FAP
• HERIDITAY PAPILLARY THYROID AND
RENAL NEOPLAS SYNDROME

THYROID NEOPLASMS
• GENETICS
PTC
BRAF V600E – INITIATING MUTATION
FOUND IN 50% CASES
RET/PTC REARRANGEMENT
RET/PTC-1 – MORE COMMON
LESS AGGRESSIVE
RET/PTC-3 – LESS COMMON
AGGRESSIVE
THYROID NEOPLASMS
FTC
N- RAS MUTATION
HURTHLE CELL CANCER
MITOCHONDRIAL DNA ALTERATIONS
ANAPLASTIC CANCER
P 53 GENE MUTATION
MEDULLARY CANCER
RET PROTO-ONCOGENE

THYROID NEOPLASMS
• GENETICS
FOLLICULAR ADENOMAS
• RAS MUTATION IS SEEN IN 40% CASES.
PAX-8/ PPAR-G FUSION REARRANGEMENT

CAN DIFFERENTIATE BETWEEN
ADENOMA AND CARCINOMA

THYROID NEOPLASMS
FOLLICULAR ADENOMAS
• Most common benign thyroid neoplasm.
• This neoplasm is derived from follicular
epithelium The TSH receptor signalling
pathway plays an important role in the
pathogenesis of adenoma.
• A typical thyroid adenoma is a solitary,
spherical lesion that compresses adjacent
normal tissue

THYROID NEOPLASMS
FOLLICULAR ADENOMAS

THYROID NEOPLASMS
FOLLICULAR ADENOMAS

THYROID NEOPLASMS
SPREAD
PTC – L.N
FTC – BLOOD( PULSATILE SECONDRIES )
MEDULLARY- L.N
ANAPLASTIC- LOCAL INVASION
L.N SPREAD TO LEVEL CENTRAL

COMPARTMENT NODES( PRELARYNGEAL-
DELPHIAN NODES)

THYROID NEOPLASMS
RISK OF CANCER IN THYROID NODULE

• AGE < 14 OR > 70 YRS
• CHILDHOOD H/0 RT EXPOSURE
• FAMILY H/O
• ON H/O – HORSENESS OF VOICE
-RECENT INCREASE IN SIZE
• EXAMINATION – HARD ,FIXED, L.N
PALPABLE
• IDL SCOPY- VOCAL CORD PALSY

THYROID NEOPLASMS

THYROID NEOPLASMS

THYROID NEOPLASMS
CT- SHOWS RETRO STERNAL INVASION

AIRWAY INVASION.
MRI – PREVERTEBRAL FASCIA INVASION
PET-CT – NON IODINE AVID CANCER

RECURRENT CANCER.

THYROID NEOPLASMS

THYROID NEOPLASMS

THYROID NEOPLASMS

THYROID NEOPLASMS

THYROID NEOPLASMS

THYROID NEOPLASMS -PTC
PTC
• Most common type of thyroid cancer 70–90%
of well-differentiated thyroid malignancies.
• Predominant thyroid cancer in individuals
exposed to external radiation in neck during
childhood.
• More common in females (2:1), mean age at
presentation is 30–40 years.
• Slow growing malignant tumor, tends to be
multifocal.

• Propensity to spread by lymphatics, leads to

involvement of regional lymph nodes.
• Most of the patients are euthyroid.
• Hematogenous spread is not so common,
Lungs> Bone> Liver> Brain.








THYROID NEOPLASMS -FTC
FTC
• Account for about 10% of thyroid cancers and
more commonly in iodine-deficient areas.
• Most of the follicular pattern thyroid
malignancies represent the follicular variant of
papillary carcinoma and share the natural
history and many features of papillary
carcinoma.
• Older population (50 years or more) are
commonly affected.
• More common in females (3 : 1)



FOLLOW UP
• Proper clinical examination in the neck for
residual/nodal disease and for distant spread
• Whole body radioisotope scan after one week of
surgery to see residual tumour in the neck or
metastases .
• Estimation of thyroglobulin at regular intervals is very
important—once in 6 months
• Follow up whole body radioisotope scan at 3–6 months
intervals. Thyroxine should be stopped for 6 weeks.
But it is commonly done if thyroglobulin level in the
blood is significantly high.

Prognosis
• Prognosis is good and it is one of the curable
malignancies.
• 99% SURVIVAL RATE.

THYROID NEOPLASMS -HTC
HTC
• A subtype of follicular carcinoma closely resembles
follicular thyroid carcinoma on gross and
microscopic appearance.
• The tumor contains abundance of oxyphilic cells or
oncocytes and characterized by vascular or
capsular invasion.
• More often multifocal, bilateral and more likely
metastasize to regional nodes and distant sites.
• Work up and management are similar to follicular
carcinoma
THYROID NEOPLASMS -HTC
• Hurthle cell carcinoma does not take up I131.

• It secretes thyroglobulin .
• It has got poorer prognosis than follicular cell
carcinoma .
• 99mTc sestamibi scan is very useful for Hurthle
cell carcinoma .
• Regional nodes are more commonly involved than
follicular carcinoma .

THYROID NEOPLASMS - ANAPLASTIC
• Poorly differentiated, aggressive cancer. [It is one

of the most aggressive and difficult human
malignancies to treat.]
• Predominantly found in 7th–8th decades.
• It is commonly related to a prior or concurrent
diagnosis of well-differentiated thyroid cancer or
benign nodular thyroid disease.
• ALWAYS STAGE - 4
• Very poor prognosis – 6 month survival.

• It is a very aggressive tumour of short duration,

presents with a swelling in thyroid region which is
rapidly progressive causing:
i. Stridor and hoarseness of voice due to tracheal
obstruction.
ii. Dysphagia.
iii. Fixity to the skin.
iv. Hard mass





THYROID NEOPLASMS - MTC
MTC
• It arises from the parafollicular ‘C’ cells which is
derived from the ultimobranchial body (neural
crest).
• C cells are more in upper pole of the thyroid
gland or at junction of upper 1/3rd and lower
2/3rd.
• It contains characteristic ‘amyloid stroma’
wherein malignant cells are dispersed.
Immunohistochemistry reveals calcitonin in
amyloid.
• In these patients blood levels of calcitonin both

basal as well as that following calcium or
pentagastrin stimulation is high, a very useful
tumour marker.
• Tumour also secretes 5-HT (serotonin),
prostaglandin, ACTH and vasoactive intestinal
polypeptide (VIP).
• It spreads mainly to lymph nodes (60%).

• In these patients blood levels of calcitonin both

basal as well as that following calcium or
pentagastrin stimulation is high, a very useful
tumour marker.
• Tumour also secretes 5-HT (serotonin),
prostaglandin, ACTH and vasoactive intestinal
polypeptide (VIP).
• It spreads mainly to lymph nodes (60%).
• MCT is not TSH dependent and does not take
up radioactive iodi







THYROID NEOPLASMS
• MALIGNANT LYMPHOMA
• It is NHL type. Occurs in a pre-existing
Hashimoto’s thyroiditis.
• FNAC is useful to diagnose the condition
(Often trucut biopsy).
• Chemotherapy and radiotherapy is the main
treatment.
• Rarely total thyroidectomy is done to enhance
the results.

THANK YOU

Thyroid Neoplasms

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THYROID

PRESENTER : Dr.R.RAGUL PRADEEP

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

MALIGNANT (PRIMARY AND SECONDARY)

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

• In the different subtypes of thyroid carcinoma,

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PAX-8/ PPAR-G FUSION REARRANGEMENT

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

L.N SPREAD TO LEVEL CENTRAL

PES Institute of Medical Sciences & Research

RISK OF CANCER IN THYROID NODULE

PES Institute of Medical Sciences & Research

RISK OF CANCER IN THYROID NODULE

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

RISK OF CANCER IN THYROID NODULE

CT- SHOWS RETRO STERNAL INVASION

MRI – PREVERTEBRAL FASCIA INVASION

PET-CT – NON IODINE AVID CANCER

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

• Propensity to spread by lymphatics, leads to

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

• Hurthle cell carcinoma does not take up I131.

PES Institute of Medical Sciences & Research

• Poorly differentiated, aggressive cancer. [It is one

PES Institute of Medical Sciences & Research

• It is a very aggressive tumour of short duration,

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

PES Institute of Medical Sciences & Research

• In these patients blood levels of calcitonin both