Thyroid Disease 3

Thyroid Neoplasia
Thomas Ashley
Thyroid neoplasia - types
• Benign
• Follicular – colloid (commonest), embryonal, fetal
• Hurtle cell
• Malignant
• Differentiated – Papillary, follicular, Hurtle cell
• Undifferentiated – Anaplastic
• Medullary cell ca
• Lymphoma
• Metastatic secondaries
Thyroid neoplasia – risk factors
• Radiation
• Female sex
• Multinodular goitre
• Thyroiditis
• Familial
Papillary Carcinoma
• Commonest thyroid malignancy – 60-80%
• Female:Male = 2:1
• Age 30-40yrs
• It is called the hormone dependent tumour – Due to high level of TSH
• Spread is slowly progressive, multicentric, via lymphatics
• Woolner classification
• Ocult primary (<1.5cm )
• Intrathyroidal
• extrathyroidal
 Papillary Carcinoma
• Pathology
• Gross -
• can be soft, firm or hard
• Solitary of multinodular
• Contains brownish black fluid
• Microscopy
• Cystic spaces
• Papillary projections with
psammoma bodies
• Malignant cell with ‘Orphan Annie
eye’
Psammoma bodies - black arrow. Orphan Annie nuclei with
cleared center and chromatin marginated periphery
Papillary Carcinoma
• Clinical features
• Soft or firm or hard. Multinodular or solitary
• Thyroid paradox – cystic tumours are firm or hard, solid tumours are soft
• Lymph node palpable in 40% of cases
• Investigations
• TSH high
• Radio-isotope scan shows cold nodule
• FNAC – characteristic features seen
• Neck X-ray – fine calcification
• USS
Papillary Carcinoma
• Treatment
• Total or near total thyroidectomy ± modified radical neck dissection
• Hemithyroidectomy can be done if slow growing, solitary, well differentiated
but needs monitoring
• Followed by suppressive dose of L-thyroxine
• Calcium and Vit D to prevent osteoporosis when taking suppressive dose of T4
Papillary Carcinoma - Prognosis
• Several scoring systems available.
• All categorise as high (40% mortality in 20 yrs) or low risk (1% in 20
yrs)
• AGES, AMES, MACIS, ATA systems
• A – Age <40yrs better prognosis
• G – grade of tumour(M – Metastasis)
• E – Extent of spread
• S – Size <4cm better prognosis
Papillary Carcinoma - Prognosis
• MACIS - Favourable prognostic factors
• M – no metastasis
• A – Age <55yrs
• C – Complete resection
• I – no extra-nodal thyroidal invasion
• Female sex
Papillary Carcinoma - Prognosis
• 2015 American Thyroid Association (ATA)
• Low risk - intrathyroidal differentiated thyroid cancer; ≤5 lymph node micro-
metastases (<0.2 cm)
• Intermediate-risk: aggressive histology, minor microscopic extrathyroidal
extension, vascular invasion, or >5 involved lymph nodes (0.2 to 3.0 cm)
• High-risk: gross extrathyroidal extension, incomplete tumour resection,
distant metastases, or lymph nodes >3.0 cm).
Role of ultrasound (U/S) in thyroid diseases

• To detect number,size,natureofthenodules(cystic /solid/complex)

(complex means cystic and solid together- more suspicious of
carcinoma). Size upto 2 mm can be detected
• U/S guided FNAC is very useful
• U/S at regular intervals is advisable to observe a
• small nodule in thyroid
• To detect recurrent nodule
• Tofindouttheinvasion/spread/vascularity/status
• of carotid artery and internal jugular vein
• To find out enlarged lymph nodes in neck
Role of FNAC in thyroid swelling
• Highly sensitive in papillary carcinoma of thyroid and also its nodal spread
• Useful to differentiate between benign and malignant
• Should be done in all thyroid diseases especially when there is a nodule
or multiple nodules
• Useful in lymphoma/anaplastic carcinoma/ medullary carcinoma
thyroid/Hashimotos thyroi- ditis
• It is not very useful in follicular carcinoma as it is difficult to differentiate
it from follicular adenoma as main feature in follicular carcinoma is
capsular invasion/vascular invasion which are not made out in FNAC
Follicular Thyroid Carcinoma
• 2nd most common thyroid malignancy – 17%
• Female:Male = 2-3:1
• Present in all ages. Peak age 45-54yrs
• Slow growing , but more aggressive than papillary ca
• Derived from follicular cells
• Spread is via haematogeneous route – to bone , lungs, liver
• Bony metastases are typically warm, pulsatile, and localised
Follicular Thyroid Carcinoma - Pathology
• On gross examination, FTC
appears encapsulated and
solitary and is often found in
necrotic and/or haemorrhagic
areas
Follicular Thyroid Carcinoma - Histology
• Surgical specimen
demonstrating
thyroid epithelium
with follicular
differentiation
extending through
the capsule of the
tumour and
invading a blood
vessel
• Three types
1. Minimally
invasive
2. Encapsulated
angioinvasive
3. Widely invasive
Follicular Thyroid Carcinoma – Clinical
features
• Firm or hard nodular anterior neck swelling

• Obstructive features – stridor, dyspnoea, dysphagia

• Infiltrative features - hoarse voice, +Berry’s sign, Horner’s syndrome

• Metastatic features – sudden increase in size, haemoptysis, chest pain,

hepatomegaly, jaundice, bone pain, pulsatile secondaries in the skull and long bones
Follicular Thyroid Carcinoma - Investigation
• FNAC –
• Usually inconclusive due to inter observer differences and the fact that they
are usually well encapsulated makes it hard to differentiate between
adenoma.
• Cannot be detected on FNAC
• Frozen section is useful but it’s inconclusive in 15% of cases
• USS – Neck, Abdomen
• X-rays – Chest, bones
• Trucut - Useful, but danger of haemorrhage and injury to vital
structures
Follicular Thyroid Carcinoma - Treatment
• Total thyroidectomy + block block dissection if LNs enlarged
• Maintenance dose of L-Thyroxine
• On table frozen section
• Radioiodine therapy for secondaries in the neck
• External beam radiation for bone metastasis

• There is no role for chemotherapy in follicular thyroid ca

Follicular Thyroid Carcinoma – Follow-up
• Clinical evaluation
• 6 monthly radioisotope scan
• Thyroglobiuln estimation 3 monthly
• USS/MRI neck for early detection of relapse
Hurthle cell Carcinoma
• A variant of FTC with abundant oxyphil cells and commoner lymph
node involvements and poorer prognosis
• It secretes thyroglobulin
• 99mTc sestamibi scan is very useful for Hurthle cell carcinoma
• Treatment
• Total thyroidectomy, MRND and TSH suppression
Anaplastic Thyroid Carcinoma
• Poor prognosis
• Rapidly growing
• Cause obstructive and infiltrative clinical features
• Hard swelling fixed to skin
• FNAC is diagnostic
Anaplastic Thyroid Carcinoma
• Treatment
• Usually palliative
• Surgery is usually not possible
• External beam radiation
• Tracheostomy and isthmusectomy may help
• Chemotherapy - adriamycin
Medullary Thyroid Carcinoma
• Derived from parafollicular C cells
• Amyloid stroma (containing colloids) with dispersed malignant cells
• Lymph node mets are common
• Produces large amount of calcitonin. Also, serotonin, prostaglandin,
ACTH and vasoactive peptide
• Does not take up radioiodine
• 3 types
• Sporadic 70%
• Familial 20%. - autosomal dominant
• Syndromic – MEN II
Medullary Thyroid Carcinoma – Clinical
features
• Thyroid swelling with associated LNs
• Diarrhoea, flushing 30%
• If MEN II - Hypertention, mucosal neuromas
• Obstructive and infiltrative symptoms
Medullary Thyroid Carcinoma -
Investigations
• USS neck and abdomen
• CT scsn of neck and abdomen
• Urine – VMA, catecholamine, metanephrine
• Serum - calcium, calcitonin, PTH
• Indium 111 octreotide scanning – 70% sensitivity
• Screen family members
Medullary Thyroid Carcinoma - Treatment
• Total thyroidectomy + central cervical lymph node dissection
• Parathyroidectomy if parathyroid hyperplasia present
• Prophylactic surgery
• MENs IIA – at age 5yrs
• MENs IIB – at age 1yr
• Maintenance dose of L-thyroxine is given
• No role for radioiodine therapy
• Chemotherapy has limited results
• Give somatostatin for diarrhoea
Medullary Thyroid Carcinoma - prognosis
• Sporadic type is aggressive and has the worse prognosis
Thyroid Lymphoma
• Non-Hodgkin’s lymphoma
• FNAC is diagnostic
• Treatment is chemotherapy
• Differential diagnoses
• MNG
• SN
• Riedel’s thyroiditis