? Six deaths per 1 million people occur annually.
? Occurs in about 40 per 1 million people per year
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? The most common endocrine malignancy
? Accounts for 95% of all endocrine cancers
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? Female to Male Ratio 2.5:1Thyroid Neoplasms
Primary Tumours
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? Epithelial? Malignant Lymphomas
? Mesenchymal tumours
Metastatic Tumours
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Epithelial Thyroid Neoplasms
? Tumours of follicular cells
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? Benign (adenomas)? Follicular adenoma
? Malignant (carcinomas)
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? Follicular carcinoma (10-20%)
? Papillary carcinoma (75-85%)
? Undifferentiated (anaplastic) carcinoma (<5%)
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? Tumours of C-cells? Medullary thyroid carcinoma (MTC - 5%)
Risk Factors for Thyroid Cancer
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The only wel -established risk factor for differentiated thyroidcancer is head and neck Radiation,especial y during infancy
Papil ary thyroid carcinoma may occur in several rare inherited
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syndromes, including familial adenomatous polyposis,
Gardner's syndrome, and Cowden's disease
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Patient's Age and Gender? Malignancy more common in children and adults >60
? Men
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Follicular Carcinoma
? Second most common form, 10-20%
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? Females > Males, average age = 45 - 55 yr? Rare in children
? Solitary nodule, painless, cold on isotopic scan
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? 50% 10 yr survival Vs 90%10 yr survival
? Haematogenous route is preferred mode of spread
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Follicular Carcinoma
? Solitary round or oval
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nodule? Thick capsule
? Composed of follicles
? Capsular invasion or
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vascular invasion
within or outside
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capsular wallPapillary Carcinoma
? Commonest thyroid malignancy, 75-85%
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? Female:Male = 2.5:1
? Mean age at onset = 20 - 40 yr
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? May affect children? Prior head & neck radiation exposure
? Indolent, slow-growing painless mass cold on isotopic scan
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? Cervical lymphadenopathy may be presenting feature
Papillary Carcinoma
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? Variable size
(microscopic to
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several cm)? Solid or cystic
? Infiltrative or
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encapsulated? Solitary or multicentric
(20%)
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Papillary Carcinoma
Nuclear Features
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? Optically clear (groundglass, Orphan Annie)
nuclei
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? Nuclear
pseudoinclusions or
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nuclear groovesPapil ary Carcinoma Prognosis
Excellent but following factors play important role:
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? Age and sex? Size
? Multicentricity
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? Extra-thyroid extension
? Distant metastasis
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? Total encapsulation, pushing margin of growth & cysticchange
Anaplastic Carcinoma
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? Rare; < 5% of thyroid carcinomas
? Highly malignant and general y fatal < 1yr.
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? Elderly 65 yrs; females slightly > males? Rapidly enlarging bulky neck mass
? Dysphagia, dyspnoea, hoarseness
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Anaplastic Carcinoma
? Large, firm, necrotic mass
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? Frequently replaces entire thyroid gland
? Extends into adjacent soft tissue, trachea and oesophagus
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? Highly anaplastic cell on histology with:? Giant, spindle,small or mix cell population
? Foci of papillary or follicular differentiation
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Anaplastic Carcinoma
? Cellular pleomorphism
? +/- multinucleated
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giant cells
? High mitotic activity
? Necrosis
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Medullary Thyroid Carcinoma (MTC)? Malignant tumour of thyroid C cel s producing Calcitonin
? 5 % of al thyroid malignancies
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? Sporadic (80%)
? Rest in the setting of MEN I A or B or as familial without
associated MEN syndrome
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Medullary Thyroid Carcinoma (MTC)
Sporadic MTC
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? Middle-aged adults? Female:male = 1.3:1
? Unilateral involvement of gland
? +/- cervical lymph node metastases
? Indolent course with 60-70% 5-yr survival after
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thyroidectomy
Multiple Endocrine Neoplasia Types IIA & IIB
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? Germ-line mutation in Ret protooncogene on
chromosome 10q11.2
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? MEN IIA: MTC, phaeochromocytoma, parathyroidadenoma or hyperplasia
? MEN IIB: MTC, phaeochromocytoma, mucosal
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ganglioneuromas, Marfanoid habitus, other skeletal
abnormalities
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Medullary Thyroid Carcinoma (MTC)? Histology same for
sporadic & familial
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? Solid, lobular or
insular growth
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patterns? Tumour cells round,
polygonal or spindle-
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shaped
? Amyloid deposits in
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many casesMedullary Thyroid Carcinoma (MTC)
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? Amyloid deposits stainorange-red with
Congo Red stain
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Clinical Manifestation
? Most patients are euthyroid and present with a
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thyroid nodule? Symptoms such as dysphagia, dyspnea and
hoarseness usually indicate advanced disease
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? Ipsilateral Cervical lymph glands may also be present.
Diagnosis
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? Serum TSH
? Fine Needle Aspiration Cytology (FNA)
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? High Resolution Thyroid US- helpful in detectingnon palpable nodule and solid versus cystic lesion
? Thyroid Isotope Scanning- to assess functional activity
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of a noduleFine Needle Aspiration
? Procedure of Choice ? Fast, minimal y invasive and few
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risk
? Incidence of False positive: 1%
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? Incidence of False negative: 5%? FNA is not a tissue diagnosis
? Limitation of FNA: cannot distinguish a benign fol icular
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from a malignant lesion.
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FNA Results of Thyroid Nodule
Staging For Differentiated Thyroid Cancer
In differentiated thyroid carcinoma, several classification
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and staging systems have been introduced. However, no
clear consensus has emerged favoring any one method
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over another? AMES system/AGES System/GAMES system
? TNM system
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? MACIS system
? National Thyroid Cancer Treatment Cooperative Study
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(NTCTCS)Prognosis
? GAMES scoring (Papil ary & Fol icular Cancer)
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? G Grade
? A Age of patient when tumor discovered
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? M Metastases of the tumor (other than Neck LN)? E Extent of primary tumor
? S Size of tumor (>5 cm)
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The patient is then placed into a high or low risk
Category
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Age for poor prognosis has been raised from 45 to 55 years (AJCC 8thEdition)
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(GAMES)Prognosis of Thyroid Carcinomas
Papillary
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Best prognosis
Follicular
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MedullaryAnaplastic
Worst prognosis
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H?rthle Cell Neoplasms? More aggressive than other differentiated thyroid carcinomas
(higher mets/lower survival rates)
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? Decreased affinity for I131
? Need to differentiate from benign/malignant
? 65% of tumors > 4cm are malignant
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? If malignant, needs total thyroidectomy and I131 with thyroglobulin
assays
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? Mets may be more sensitive to I131 than primarySecondary Tumours
Direct extensions from: larynx, pharynx, oesophagus
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Metastasis from: renal cell carcinoma, large bowel carcinoma,
malignant melanoma, lung carcinoma, breast carcinoma
Treatment
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The main treatment of papillary carcinoma of the thyroid is
surgical resection.
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For lesions <1 cm, there is general agreement in the literaturethat lobectomy plus isthmectomy is the appropriate treatment.
For adults with lesions larger than 2 cm, a total thyroidectomy is
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favored by most surgeons.
Patients with history of exposure to ionizing radiation of the
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head and neck should have total thyroidectomyControversies in Treatment
Total Vs Lobectomy
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? Controversy exists about the use of total thyroidectomy
versus lobectomy and isthmectomy in adults with a 1-
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to 2-cm lesions? Role of Lymph node dissection also debated
Central Lymph Node Dissection
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Central compartment =the region bounded by thejugular veins, the hyoid bone, and the sternal notch
All central nodes removed at time or procedure
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Removal of Central Nodes important in medullary andHurthle Cell Ca
? Microscopic spread is high
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? Do not take up I131 and cannot be ablatedLateral Lymph Node Dissection
Diseased nodes lateral to the jugular vein =modified
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radical neck dissectionRemoval of LN's anterior and posterolateral to the IJV from
the mastoid to the subclavian vessels inferiorly and lateral y
to spinal accessory nerve (Level 2-5)
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Sparing the internal jugular vein, spinal accessory nerve,
and sternocleidomastoid muscle
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TreatmentComplications of Surgery
Hypocalcemia -devascularization of parathyroid
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about 5%, which resolves in 80% of these cases in about 12
months
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Recurrent Laryngeal Nerve Injury-either tractioninduced or division.
less than 3%
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Bleedingwound hematomas
Postoperative management for
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thyroid cancerTwo principles:
? Radioiodine remnant ablation
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? Adminstration of Thyroid Hormone
? To suppress TSH and growth of any residual thyroid
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? To maintain patient euthyroid? Maintain TSH level 0.1uU/ml in low risk pts
? Maintain TSH Level < 0.1uU/ml in high risk pts
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Postoperative RAI
Recommendations:
? Postoperative remnant ablation for al patients with
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differentiated thyroid carcinoma 45 years of age or older
? Those with primary tumor 1.5 cm in diameter or more
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? Extrathyroidal disease, whether manifested by directinvasion through the capsule of the gland or local or
regional metastases.
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Radioiodine therapy
The nonsurgical treatment for papillary thyroid
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carcinoma is radioiodine (131-I).Radioiodine has three uses in the postoperative
treatment of patients with thyroid cancer:
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? ablation of residual thyroid tissue
? imaging for possible recurrent disease
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? treatment of residual or recurrent thyroid cancerExternal Beam Radiotherapy and
Chemotherapy
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External Radiation required to control unresectable cancer.Chemotherapy may occasionally be beneficial in patients with
progressive symptomatic thyroid carcinoma that is unresponsive
or not amenable to surgery, radioiodine therapy, or external
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radiotherapy