Download MBBS Thyroid malignancies Lecture PPT

THYROID
MALIGNANCIES
S3 UNIT

---

INTRODUCTION
? Commonest endocrine malignancy

--- Content provided by FirstRanker.com ---

? 1% of all malignancies
? Annual incidence - 3.7 per 1,00, 000 population
? Sex ratio 3:1 (Female : Male)

---

TOPICS
? Anatomy -Alphy Theres Teji

--- Content provided by​ FirstRanker.com ---

? Physiology and clinical -Ameena Muhammed
evaluation
? Aetiopathogenesis & -Amruthavarshini B.V
classification
? Investigation - Anagha K Karun

--- Content provided by​ FirstRanker.com ---

? Differentiated thyroid -Anakha M
Carcinoma
? Anaplastic carcinoma, -Anamika S
Medullary carcinoma,
Thyroid lymphoma

--- Content provided by​ FirstRanker.com ---

? Surgery & complications -Anandhu J B
? Prognosis & postop follow - Andrews Paul
up

---

THYROID
ANATOMY

--- Content provided by⁠ FirstRanker.com ---

ALPHY THERES

---

EMBRYOLOGY OF THYROID
? Thyroid gland- endodermal cells of floor
of pharynx
? Parafollicular cel s- neural crest

--- Content provided by FirstRanker.com ---

---

---

ANOMALIES OF POSITION
LINGUAL
THYROID

---

WEIGHT & DIMENSIONS
? Normal gland weighs : 20-25gm

--- Content provided by‍ FirstRanker.com ---

? Each lobe : 5cm in length
3cm in breadth
2cm in thickness
? Isthmus : 1 . 2 c m in length & 1 . 2 c m in breadth

---

SITUATION AND EXTENT

--- Content provided by‌ FirstRanker.com ---

---

CAPSULES OF THYROID
? True capsule: Peripheral
condensation of the
connective tissue of gland
? False capsule: Pretracheal

--- Content provided by⁠ FirstRanker.com ---

layer of deep cervical fascia

---

RELATIONS OF THE LOBES
Lobes are conical in shape
having:
? An apex

--- Content provided by FirstRanker.com ---

? A base
? Three surfaces:
lateral, medial and posterolateral
? Two borders: anterior
and posterior

--- Content provided by​ FirstRanker.com ---

---

? Apex
Superior thyroid artery
External laryngeal nerve
? Base
Inferior thyroid artery

--- Content provided by‌ FirstRanker.com ---

Recurrent laryngeal nerve

---

Lateral surface:
? Sternohyoid
? Superior belly of omohyoid
? Sternothyroid

--- Content provided by‌ FirstRanker.com ---

? Anterior border of
leidomastoid
sternocleidomastoid

---

Medial

--- Content provided by​ FirstRanker.com ---

surface
2 tubes- trachea
oesophagus
2 muscles
inferior

--- Content provided by‍ FirstRanker.com ---

constrictor
cricothyroid
2 nerves
ext.laryngeal
recurrent

--- Content provided by​ FirstRanker.com ---

laryngeal

---

Posterolateral
surface: carotid sheath,
ansa cervicalis & cervical
sympathetic chain

--- Content provided by​ FirstRanker.com ---

Anterior border:
anterior branch of superior
thyroid artery

---

Posterior border:
? Inferior thyroid artery

--- Content provided by FirstRanker.com ---

? Anastomosis between superior
and inferior thyroid arteries
? Parathyroid gland
? Thoracic duct on left side

---

RELATIONS OF ISTHUMUS

--- Content provided by‍ FirstRanker.com ---

? Two surfaces:
Anterior and posterior
o
r
? Two borders:

--- Content provided by⁠ FirstRanker.com ---

superior and inferior

---

BLOOD SUPPLY OF THYROID

---

ARTERIAL SUPPLY
? Superior thyroid artery
? Inferior thyroid artery

--- Content provided by​ FirstRanker.com ---

? Thyroidea ima
arteries

---

VENOUS DRAINAGE
? Superior thyroid vein
? Middle thyroid vein

--- Content provided by‌ FirstRanker.com ---

? Inferior thyroid vein
? Kochers vein

---

LYMPHATIC DRAINAGE

---

JUGULAR LYMPH NODES

---

? periglandular ? prelaryngeal (Delphian) ? pretracheal

--- Content provided by⁠ FirstRanker.com ---

? paratracheal (along RLN) ? sup mediastinum ? deep cervical ? thoracic
duct
? Upper part via prelaryngeal LN to upper deep CLN
? Lower part via pretracheal and paratracheal LN to lower deep CLN

---

NERVE SUPPLY

--- Content provided by‍ FirstRanker.com ---

? Mainly from middle cervical
ganglion
? Partly from superior and
inferior cervical ganglion

---

HISTOLOGY

--- Content provided by⁠ FirstRanker.com ---

? Follicles- structural
unit
? Secretory cells-
follicular and
parafollicular

--- Content provided by⁠ FirstRanker.com ---

---

PARATHYROID GLANDS
? Two pairs-superior and
inferior
? Lie on the posterior border
of thyroid

--- Content provided by⁠ FirstRanker.com ---

? Secrete parathormone
? blood supply from inferior
thyroid arteries

---

PHYSIOLOGY AND CLINICAL
EVALUATION

--- Content provided by⁠ FirstRanker.com ---

Ameena
Muhammed

---

PHYSIOLOGY
OF THYROID
GLAND

--- Content provided by​ FirstRanker.com ---

---

THYROID HORMONES
Follicular cells- Thyroxine[T4] 93%,
Triiodothyronine[T3] 7%
Parafollicular cells- Calcitonin

---

IODINE HEMOSTASIS

--- Content provided by​ FirstRanker.com ---

? Iodine- essential for hormone synthesis
? Daily requirement - 150 mcg
? Absorbed by intestine
Excretory routes
Urine - 80%

--- Content provided by‌ FirstRanker.com ---

Stool- 15%
Rest through bile

---

THYROID HORMONE SYNTHESIS
1. Iodide trapping
Transport of iodide ions into colloid

--- Content provided by​ FirstRanker.com ---

Na+- I- symporter

---

2. OXIDATION
Iodide ion is oxidised to iodine by
peroxidase

---

3. BINDING

--- Content provided by FirstRanker.com ---

Iodine+ tyrosine residues of thyroglobulin =
MIT & DIT

---

4. COUPLING REACTION
MIT+DIT = T3
DIT+DIT= T4

--- Content provided by FirstRanker.com ---

---

5. HORMONE RELEASE
? When hormones are needed, Endocytosis and
Proteolysis of iodinated thyroglobulin
? Release of T3 ,T4 into circulation
? In blood, bound to albumin, thyroxine binding

--- Content provided by FirstRanker.com ---

globulin (TBG), thyroxine binding pre
albumin(TBPA)
? Unbound T3 & T4 is functional

---

6. PERIPHERAL CONVERSION
? Major product secreted is T4

--- Content provided by​ FirstRanker.com ---

? About 35% secreted T4 is converted into
T3 by 5'-deiodinase
? T3 is four times potent than T4 & causes
the peripheral actions.

---

---

TSH enhances the hormone production by

--- Content provided by​ FirstRanker.com ---

increasing:
?Iodination of tyrosine
?Proteolysis of thyroglobulin
?Number, size & secretory activity of cells

---

REGULATION OF SYNTHESIS

--- Content provided by​ FirstRanker.com ---

---

ACTIONS OF THYROID HORMONES
1. EFFECT ON BASAL METABOLISM
Increases the basal rate of metabolism
Increases heat production (Calorigenic action)
BMR increased to about 80% in

--- Content provided by​ FirstRanker.com ---

hyperthyroidism

---

2. CARDIOVASCULAR SYSTEM
Increase heart rate
Increases myocardial contraction
Increases systolic blood pressure

--- Content provided by​ FirstRanker.com ---

Decreases diastolic blood pressure
Enhances erythropoesis.

---

3. EFFECT ON GROWTH & DEVELOPMENT
Facilitate the effect of GH on tissues
Promote linear growth of bones

--- Content provided by​ FirstRanker.com ---

Enhance the activity of chondrocyte in Cartilage
Increases the osteoid activity and Bone remodelling
Eruption and development of Teeth

---

4. EFFECT ON NERVOUS TISSUE
Differentiation and maturation of brain cells

--- Content provided by‌ FirstRanker.com ---

Growth of cerebral and cerebellar cortices and
basal ganglia
Development of synaptic connection

---

5. GI TRACT
Enhance motility

--- Content provided by⁠ FirstRanker.com ---

Increases production of digestive juices.
Increases appetite and food intake

---

6. EFFECTS ON REPRODUCTIVE SYSTEM
Follicular maturation and ovulation
Promote spermatogenesis

--- Content provided by​ FirstRanker.com ---

7. EFFECT ON KIDNEY
Increases renal outflow and GFR

---

CLINICAL EVALUATION

---

HISTORY TAKING
EXAMINATION

--- Content provided by‍ FirstRanker.com ---

---

HISTORY TAKING
AGE
Papillary ca: young
Follicular ca: middle aged
Anaplastic ca, Lymphoma : old age

--- Content provided by‍ FirstRanker.com ---

SEX
Females: male= 3:1
SWELLING
Papillary & follicular - slow growth
Anaplastic - fast growth

--- Content provided by‌ FirstRanker.com ---

---

PAIN
Painless to start
PRESSURE EFFECT
Hoarseness, dysphagia, dyspnoea
PAST HISTORY

--- Content provided by‌ FirstRanker.com ---

Radiation exposure
FAMILY HISTORY
MEN 2A, 2B
Cowden syndrome
Gardner syndrome

--- Content provided by‍ FirstRanker.com ---

---

EXAMINATION
SIGNS OF MALIGNANCY
Stony hard swelling
Restriction of lateral mobility
infiltration of surrounding tissues.

--- Content provided by​ FirstRanker.com ---

Lymphadenopathy in neck
Berry's Sign
Horner Syndrome

---

Features of infiltration
Laryngotracheal complex- stridor & hemoptysis

--- Content provided by​ FirstRanker.com ---

Recurrent laryngeal nerve - hoarseness
Esophagus - dysphagia/ odynophagia
Carotid sheath - Berry's sign
Cervical sympathetic chain - Horner's syndrome

---

Evidence of Metastasis -

--- Content provided by‌ FirstRanker.com ---

Pulsatile bony swelling in scalp or any pathological
fracture.
Abdominal distension & jaundice
Hemoptysis, dyspnoea & chest pain

---

ETIOPATHOGENESIS

--- Content provided by‌ FirstRanker.com ---

AND
CLASSIFICATION
AMRUTHAVARSHINI B V

---

AETIOLOGICAL FACTORS
1. IONIZING RADIATION

--- Content provided by‌ FirstRanker.com ---

? Most imp risk factor
radiation - external/radioiodine - under 5 yrs
? Commonest papilary carcinoma thyroid
? To treat benign condition in the first two decade of life
( tonsilitis, adenoiditis...etc)

--- Content provided by‍ FirstRanker.com ---

? Adolescent - radiotherapy for Hodgkins lymphoma
**Chernobyl nuclear disaster in Ukraine,1986

---

2.GENETIC MUTATION

---

3.FAMILIAL
MEN 2A

--- Content provided by FirstRanker.com ---

MEN 2B
FAMILIAL MTC
COWDEN SYNDROME
GARDNER SYNDROME

---

MEN 2A

--- Content provided by‍ FirstRanker.com ---

?Autosomal dominant inheritance
?Mutation of RET protooncogenes
?Characterized by :
Pheochromocytoma
Hyperparathyroidism

--- Content provided by‍ FirstRanker.com ---

Medul ary carcinoma of thyroid

---

MEN 2B
?RET mutation
?Characterized by:
Medullary carcinoma thyroid

--- Content provided by​ FirstRanker.com ---

Pheochromocytoma
Mucosal neuromas of
lip,tongue,inner eyelid
Marfanoid habitus

---

Familial Medulary Thyroid Carcinoma

--- Content provided by FirstRanker.com ---

?RET proto-oncogene mutation
?only Medullary thyroid cancer
?20% of total cases of MCT

---

COWDEN SYNDROME
?AD inheritence - Mutation of PTEN gene on

--- Content provided by​ FirstRanker.com ---

chr 10
?Characterized by;
Differentiated thyroidcarcinoma
Carcinoma breast
Multiple hamartomas of skin

--- Content provided by‌ FirstRanker.com ---

Neuroendocrine tumor
Endometrial cancer

---

GARDNER SYNDROME
Autosomal dominant inheritance
Mutation of APC gene in chromosome 5

--- Content provided by‌ FirstRanker.com ---

Familial adenomatous polyposis
Multiple polyp in colon which predisposes to colon
cancer

---

?Characterized by:
Papillary carcinoma of thyroid

--- Content provided by​ FirstRanker.com ---

Colorectal cancer
Cancer of ampulla of vater
Hepatoblastoma
Osteomas of the jaw
CHRPE

--- Content provided by FirstRanker.com ---

Primary brain tumors

---

4. PRE EXISTING MNG
Follicular thyroid carcinoma
Dominant or rapidly growing

--- Content provided by FirstRanker.com ---

nodules in long standing
goiters

---

5. ENDEMIC AREAS
?Low iodine areas
? Follicular carcinoma - Increased TSH

--- Content provided by⁠ FirstRanker.com ---

secretion

---

6. HASHIMOTO'S THYROIDITIS
?Also caled diffuse non goitrous thyroiditis
? Hyperplasia - fibrosis - infiltration with plasma cels and
lymphocytes

--- Content provided by​ FirstRanker.com ---

?Non Hodgkins Lymphoma
?Half of the primary thyroid LYMPHOMA

---

CLASSIFICATION OF
THYROID NEOPLASMS

---

BENIGN follicular

--- Content provided by⁠ FirstRanker.com ---

adenoma
MALIGNANT primary follicular cells Follicular
differentiated (10%)
Papillary
(80%)

--- Content provided by‌ FirstRanker.com ---

follicular cells Anaplastic
undifferentiated (5%)

---

parafollicular Medullary
cells (2.5%)

--- Content provided by​ FirstRanker.com ---

lymphoid cells Lymphoma
(2.5%)
MALIGNANT secondary metastatic colon,breast
melanoma,
local kidney

--- Content provided by​ FirstRanker.com ---

infiltration

---

INVESTIGATIONS OF
THYROID MALIGNACIES
ANAGHA K KARUN

---

INVESTIGATIONS

--- Content provided by FirstRanker.com ---

THYROID FUNCTION TEST [TFT]
THYROID IMAGING {USG,CT,MRI,PET scan,
X-RAY}
FINE NEEDLE ASPIRATION CYTOLOGY
[FNAC]

--- Content provided by​ FirstRanker.com ---

RADIOISOTOPE SCANNING{Tc 99m,I 123}

---

THYROID FUNCTION TESTS
? Immunochemiluminometric assay.
? Measures TSH, free T3 and free T4.
? Total T3 and T4 depend on TBG.

--- Content provided by‌ FirstRanker.com ---

? Free T3 and T4 are important.

---

ULTRASONOGRAPHY
? Gold standard investigation
? Use high frequency probe in the
range 7.5-16 MHz

--- Content provided by‍ FirstRanker.com ---

? Number, size, shape, margin, vascularity,
microcalcification

---

USES
?To differentiate cystic & solid swellings
?Non palpable , deep nodules

--- Content provided by‍ FirstRanker.com ---

?Features of malignancy
?Lymph node assessment for metastasis
?USG guided FNAC

---

FEATURES OF MALIGNANCY
Hypo echoic

--- Content provided by​ FirstRanker.com ---

Increased vascularity
Micro calcifications
No peripheral halo
Poorly defined borders
Taler than wide

--- Content provided by‌ FirstRanker.com ---

LN involvement

---

FNAC
? To conclude pathological diagonosis
? 95% accuracy,
83% sensitivity, 92% specificity

--- Content provided by‍ FirstRanker.com ---

? USG guided aspiration
? Advantages :
- patient compliant
- simple & quick to perform
- repeated readily

--- Content provided by‍ FirstRanker.com ---

?C/I : Toxic nodule

---

PROCEDURE
1.
10cc syringe & 23G needle inserted

--- Content provided by⁠ FirstRanker.com ---

2. Multiple passes are made( Minimum 6 aspirations )
3. capillary & suction technique
4. Papanicolaou stain
? Adequate smear: 6 aspiration with 6 cluster of cells
each containing 20 cells

--- Content provided by​ FirstRanker.com ---

---

---

Disadvantages
? Not possible to dif erentiate folicular adenoma and carcinoma.
? Sampling error (False neg. rate: 1-6% ) in non guided
FNAC.

---

RADIO ISOTOPE SCANNING

--- Content provided by‍ FirstRanker.com ---

? I 123 or Tc 99m
? INDICATION
? Solitary thyroid nodule - toxic

---

? HOT : 5% malignant
? COLD : 20% malignant

--- Content provided by‌ FirstRanker.com ---

---

X RAY
? Preoperatively, tracheal deviation or compression
? Retrosternal extension

---

COMPUTED
TOMOGRAPHY

--- Content provided by‍ FirstRanker.com ---

INDICATIONS
? Retrosternal goitre
? Malignancy ( T&N Staging)
? Giant goitre with tracheal compression and
displacement

--- Content provided by⁠ FirstRanker.com ---

? Berry sign +ve
Iodine used with iv contrast , so not used in
malignancies.

---

MRI
? MR Angiography : vessel wall

--- Content provided by‌ FirstRanker.com ---

involvement
? Advantage over CT:
-no iodine contrast
-no radiation exposure

---

POSITRON EMISSION

--- Content provided by‍ FirstRanker.com ---

TOMOGRAPHY[PET]
?Recurrence and metastasis

---

LARYNGOSCOPY
?Preoperatively
?Mobility of VC

--- Content provided by‍ FirstRanker.com ---

?Flexible Laryngoscopy
USES
Medico legal use

---

S.THYROGLOBULIN:
v No significance in initial evaluation

--- Content provided by⁠ FirstRanker.com ---

v in follow-up
v pre operative evaluation
Normal value 3?40ng/mL

---

INTRAOPERATIVE FROZEN SECTION
? Confirm nodal

--- Content provided by⁠ FirstRanker.com ---

involvement in PTC.
? Can avoid 2nd
procedure

---

---

DIFFERENTIATED THYROID
CARCINOMAS

--- Content provided by‌ FirstRanker.com ---

ANAKHA M

---

? Differntiated thyroid carcinomas are;
Papillary thyroid carcinoma
Follicular thyroid carcinoma
Hurthle cell carcinoma

--- Content provided by‍ FirstRanker.com ---

---

PAPILLARY THYROID CARCINOMA
? Most common malignancy -80%
? Excellent prognosis
? Important risk factor- radiation exposure in
childhood

--- Content provided by FirstRanker.com ---

? More common in females 2.5:1 ratio
? Peak incidence less than 40 years of age

---

? Micropapillary carcinoma
? Diffuse sclerosing variant
? Encapsulated variant

--- Content provided by FirstRanker.com ---

? Tall cell variant
? Columnar cell variant

---

CLINICAL FEATURES
? Palpable nodule ;incidental imaging finding;
painless lateral mass

--- Content provided by FirstRanker.com ---

? Lymphadenopathy is usually present
? Compression features less common

---

? Slowly progressive and less aggressive
tumour
? Spread via lymphatics

--- Content provided by​ FirstRanker.com ---

? Multicentricity can be anticipated in 70% of
patients

---

? GROSS FEATURES
-It can be hard or of varying consistency
-It can be solitary or multinodular

--- Content provided by FirstRanker.com ---

? MICROSCOPY
- orphan annie eye nucleus
- papillary projections with psammomma
bodies ,cystic spaces

---

PSAMMOM

--- Content provided by FirstRanker.com ---

PAPILLAR
MA
BODIES
Y
PATTERN

--- Content provided by​ FirstRanker.com ---

---

ORPHAN ANNIE NUCLEI

---

FOLLICULAR THYROID CARCINOMA
? 10% of all thyroid malignancies
? More commonly seen in female 3:1
? 40 to 60 yrs of age

--- Content provided by FirstRanker.com ---

? Either de novo or pre existing MNG

---

? Capsular invasion and angio invasion
? More aggressive,mortality twice than
papillary carcinoma
? Lymph node involement is less common

--- Content provided by‍ FirstRanker.com ---

? Less favourable prognosis
? Blood born metastases common

---

CLINICAL FEATURES
? Presents as painless thyroid mass
? May coexist with MNG 5-10% CASES

--- Content provided by​ FirstRanker.com ---

? In advanced disease
-hoarseness of voice
-stridor
-berry's sign
-pathologic fractures

--- Content provided by⁠ FirstRanker.com ---

-pulsatile bony swelling in the scalp

---

---

HURTHLE CELL CARCINOMA
? Subtype of follicular thyroid carcinoma
? Consists of oxyphilic cells
? Increased no of mitochondria ,enlarged

--- Content provided by‌ FirstRanker.com ---

granular eosinophilic cytoplasm
? 60-70 years of age
? More aggressive behaviour

---

? Secrete thyroglobulin
? 30% multicentric

--- Content provided by FirstRanker.com ---

? More chances of lymphatic spread

---

? Cells with abundant granular eosinophilic
cytoplasm

---

INVESTIGATIONS
? TSH levels

--- Content provided by⁠ FirstRanker.com ---

? FNAC of thyroid nodule and lymph node
? Ultrasound scan neck, CT scan neck

---

TNM STAGING

---

TUMOUR
? Tx ?Primary cannot be assessed

--- Content provided by⁠ FirstRanker.com ---

? T0-No evidence of primary
? T1-Tumour - 2cm
T1a ? 1 cm
T1b-> 1 2cm
? T2-limited to thyroid >2cm but 4cm

--- Content provided by‍ FirstRanker.com ---

? T3 ?Limited to thyroid >4 cm or any tumour with minimal
extrathyroid extension
? T4 ? Any size with extensive extra thyroid extension
T4a :moderately advanced
T4b :very advanced

--- Content provided by‍ FirstRanker.com ---

---

NODES
? Nx- Cannot be assessed
? N0- No regional node metastases
? N1-Regional node metastases
N1a-level 6

--- Content provided by​ FirstRanker.com ---

N1b-any/all other levels

---

METASTASES
? Mx-Cannot be assessed
? M0-No metastases
? M1-Metastases present

--- Content provided by‌ FirstRanker.com ---

---

AJCC STAGING OF DTC
? STAGE <45 yrs
Stage 1- any T any N M0
Stage 2 ? any T any N M1
? STAGE >45 yrs

--- Content provided by⁠ FirstRanker.com ---

Stage 1 ?T1a,T1b,T2N0M0
Stage 2 ?T3N0M0
- T1,T2,T3N1M0
Stage 3-T4a any N M0
Stage 4A- T4bAny N M0

--- Content provided by‍ FirstRanker.com ---

Stage 4b-Any T any N M1

---

TREATMENT
? Papillary thyroid carcinoma
? Total thyroidectomy + CCND
? Follicular thyroid carcinoma

--- Content provided by FirstRanker.com ---

- Total thyroidectomy +CCND
If lymph node seen in USG and proven in
FNAC? lateral lymph node dissection

---

MEDULLARY
CARCINOMA

--- Content provided by‌ FirstRanker.com ---

THYROID
ANAMIKA S

---

INTRODUCTION
? 2 .5% of thyroid carcinoma
? Tumours of parafolicular C cells

--- Content provided by​ FirstRanker.com ---

FORMS
1. Sporadic form (80%)
2.Familial form(10 to 20%)

---

Medullary Thyroid carcinoma
(MTC)

--- Content provided by​ FirstRanker.com ---

INHERITED
SPORADIC
10-20%
80%
FAMILIAL Non

--- Content provided by​ FirstRanker.com ---

MEN 2A
MEN MTC
MEN 2B

---

FAMILIAL
SPORADIC

--- Content provided by‌ FirstRanker.com ---

BILATERAL AND
ORIGINATE IN ONE LOBE
MULTICENTRICITY
YOUNGER AGE GROUP
ANY AGE

--- Content provided by⁠ FirstRanker.com ---

ASSOCIATED WITH C CELL
HYPERPLASIA

---

1.More aggressive
2.RET gene point mutation.

--- Content provided by​ FirstRanker.com ---

3.High levels of CEA and serum CALCITONIN.
4.Not TSH dependent
5.Do not take up radioactive IODINE.
6.Diarrhoea is a feature of 30% of cases.

---

MEDULLARY CARCINOMA

--- Content provided by​ FirstRanker.com ---

Cell balls and Amyloid
stroma

---

METASTASES
Liver ,Mediastinal
nodes,

--- Content provided by​ FirstRanker.com ---

bone(osteoblastic)lung,
trachea,
Blood borne metastases common
MOSTLY TO
LIVER

--- Content provided by‍ FirstRanker.com ---

Cervical Lymph
nodes 50-60%

---

CLINICAL FEATURES
1.Thyroid swelling-neck lymph nodes
2.HTN , Pheochromocytoma ,mucosal neuroma-MEN 2

--- Content provided by‍ FirstRanker.com ---

3.Paraneoplastic symptoms like cushings and carcinoids

---

INVESTIGATIONS
1.FNAC
2.SE.RUM CALCITONIN AND CEA
3.GENETIC TESTING FOR GERMLINE RET

--- Content provided by‌ FirstRanker.com ---

MUTATION
4.THYROID AND NECK USG

---

? All patients should be screened for RET gene
point mutation ,pheochromocytoma and
hyperparathyroidism.

--- Content provided by FirstRanker.com ---

? Pheochromocytoma-to prevent hypertensive
crisis

---

1. Serum Ca-to rule out hyperparathyroidism.
2. 24 hr urine VMA and serum metanephrin,USG
abdomen- to rule out pheochromocytoma

--- Content provided by FirstRanker.com ---

3. If it is + ve ? CECT of abdomen
4. CECT or MRI chest and mediastinum ? if N1disease or
calcitonin greater than 400pg/ml
4. PET scan ? recurrence, Metastasis as they do not take
up radioiodine

--- Content provided by‍ FirstRanker.com ---

---

TREATMENT
1.Surgery is the treatment of choice.
2.Tumour size more than 1cm,chance of
spread to regional nodes is 75%
3.Total thyroidectomy with elective central

--- Content provided by‍ FirstRanker.com ---

neck dissection.
4.When central node (level 6) involved ?
Ipsilateral modified radical neck dissection.

---

? Hypercalcemia and PTH at time of
surgery-Only obviously enlarged

--- Content provided by⁠ FirstRanker.com ---

parathyroid removed
? If vascular pedicle of parathyroid is unable to
maintain ?auto transplantation of ? the gland
in sternocleidomastoid or brachioradialis of
non-dominant forearm.

--- Content provided by FirstRanker.com ---

? Somatostatin analogue (octreotide ,
lanreotide)for cushings syndrome , flushing

---

EXTERNAL BEAM RADIOTHERAPY
1.Resected T4 disease.
2.Unresected residual or recurrent tumour

--- Content provided by⁠ FirstRanker.com ---

3.Symptomatic bony metastasis.

---

POST OPERATIVELY
? Stimulated calcitonin assay to assess the
adequacy of resection
? L evothyroxine is indicated in all

--- Content provided by‌ FirstRanker.com ---

patients .
? TSH-normal range

---

GENETIC SCREENING
MEN 2A
MEN 2 B

--- Content provided by‌ FirstRanker.com ---

FAMILIAL MCT
TOTAL
TOTAL
THYROIDECTOMY
THYROIDECTOMY

--- Content provided by⁠ FirstRanker.com ---

-5YEARS
1 YEAR

---

? Prognosis is variable and depends on the stage at
diagnosis
? FMTC (best) > MEN-2A > Sporadic > MEN-2B

--- Content provided by‍ FirstRanker.com ---

(worst)
? Chance of recurrence 50% & also high mortality

---

FOLLOW-UP
? Basal calcitonin-Fall after resection
Rise in recurrence, residual tumour and

--- Content provided by⁠ FirstRanker.com ---

metastasis.
? PET scan
? CEA
? USG (central and lateral neck compartments)

---

ANAPLASTIC

--- Content provided by⁠ FirstRanker.com ---

THYROID CARCINOMA

---

INTRODUCTION
? Undifferentiated carcinoma
? 5% of al thyroid malignancy
? Most aggressive

--- Content provided by‌ FirstRanker.com ---

? Disease specific mortality 100%
? Occurs mainly in elderly women

---

TYPICAL MANIFESTATION
Older patient with
1. Dysphagia

--- Content provided by‍ FirstRanker.com ---

2. Cervical tenderness
3. Painful, rapidly enlarging neck mass
4. Frequently have history of DTC and upto 50%
goitre

---

? May also Include superior venacava syndrome

--- Content provided by​ FirstRanker.com ---

? Deteroirates into tracheal obstruction
? Rapid local invasion of surrounding structures

---

SPREAD
? Rapid local invasion
? Blood as well as lymph spread present.

--- Content provided by FirstRanker.com ---

? Sites of Mets : lung , brain, bone, liver, kidney, skin, pancreas,
adrenal.

---

STAGING

---

MANAGEMENT
? Treatment of ATC is usually palliative

--- Content provided by‌ FirstRanker.com ---

? Treatment of choice -RADIOTHERAPY
? Tracheal obstruction - ISTHMUSECTOMY

---

THYROID
LYMPHOMA

---

INTRODUCTION

--- Content provided by‌ FirstRanker.com ---

Uncommon lymphoma
2 .5 %of al thyroid malignancies
Involve thyroid as a part of systemic
lymphoma or may arise primarily in thyroid.

---

PREDISPOSING FACTORS

--- Content provided by FirstRanker.com ---

Autoimmune diseases (Lymphocytic
thyroiditis)
Advanced age(>70 yr)
More frequent in women (four times)

---

SIGNS AND SYMPTOMS

--- Content provided by‌ FirstRanker.com ---

? Rapid enlarging neck mass
? Hoarseness
? Dysphagia
? Fever
? Diffuse pain

--- Content provided by​ FirstRanker.com ---

PHYSICAL EXAMINATION
? Firm , slightly tender , fixed mass

---

INVESTIGATIONS
? Ultrasound
? MRI

--- Content provided by⁠ FirstRanker.com ---

? Trucut biopsy
? PET imaging

---

TREATMENT OF LYMPHOMA
RADI ?ATION+CHEMO= treatment of choice
Tracheal obstruction : urgent chemotherapy

--- Content provided by‍ FirstRanker.com ---

CHOP/CVDP regimen:
Cyclophosphamide
Doxorubicin Vincristine

---

Role of surgery only in:
Biopsy

--- Content provided by⁠ FirstRanker.com ---

Pressure symptoms
No response to chemo .

---

sURGical manaGEmEnt
and
complications

--- Content provided by​ FirstRanker.com ---

Anandhu JB
Rol No : 16

---

q For a preoperatively proven case of
? Dif erentiated carcinoma
? Medullary Carcinoma

--- Content provided by FirstRanker.com ---

TOTAL THYROIDECTOMY
Central neck dissection
Modified Radical Neck Dissection

---

RATIONALE FOR
TOTAL THYROIDECTOMY

--- Content provided by‌ FirstRanker.com ---

? Facilitates radioiodine ablation later.
? As there is chance for multifocal d/s.
? Facilitates use of thyroglobulin as tumor
marker in fol owup.

---

STEPS OF SURGERY

--- Content provided by FirstRanker.com ---

General anaesthesia with
endotracheal intubation.

---

Supine position - sand bag placed transversely under the
shoulders

--- Content provided by‌ FirstRanker.com ---

A head ring ? to stabilize head
Table tilted up - 15 at the head end.
ROSE'S POSITION

---

? Horizontal curved - Midway between the notch of
the thyroid cartilage and suprasternal notch.

--- Content provided by​ FirstRanker.com ---

? One sternocleidomastoid to other.

---

? Skin, superficial fascia cut upto investing layer of
deep fascia
? Flaps are raised
o Upper upto laryngeal prominence

--- Content provided by​ FirstRanker.com ---

o Lower upto suprasternal notch
? Investing layer of deep fascia is incised vertically.
? Retract strap muscles laterally

---

? Identify the pedicles

--- Content provided by‍ FirstRanker.com ---

1. Superior pedicle
? (sup. thyroid A & V)
2. Middle pedicle
? (middle thyroid V only)
3. Inferior pedicle

--- Content provided by‌ FirstRanker.com ---

? (inferior thyroid A only)
? Ligate middle thyroid vein first.

---

? Ligate superior thyroid A & V separately &
close to capsule (CAPSULAR LIGATION)

--- Content provided by‌ FirstRanker.com ---

? Ligate inferior thyroid A close to the gland
after safe guarding recurrent laryngeal nerve.

---

? ? Identification of parathyroid
? :Yellowish pink

--- Content provided by FirstRanker.com ---

? :Position ? in relation to ITA-RLN junction
? Sup. parathyroid ? above & behind
? Inf. Parathyroid ? below & anterior

---

? Identification of RLN
? 1.RIDDLE'S TRIANGLE

--- Content provided by‍ FirstRanker.com ---

o Inferior thyroid artery- above
o Common Carotid artery- laterally (base)
o Trachea - medialy

---

? 2.Nerve traced upwards to point of its entry into the

--- Content provided by‌ FirstRanker.com ---

larynx at the cricothyroid junction.
? 3.Tubercle of Zuckerkandl

---

RLN damage points.
1.At crossing with inferior
thyroid artery.

--- Content provided by‌ FirstRanker.com ---

2. In the vicinity of ligament of
Berry
3.In Riddle's Triangle
4.Tubercle Of Zuckerkandl

---

? Ligament of Berry is divided.

--- Content provided by⁠ FirstRanker.com ---

? The thyroid gland is separated from the
underlying trachea.
? Complete hemostasis maintained
? Draining and Wound closure:
--Reapproximate strap muscles and

--- Content provided by‌ FirstRanker.com ---

platysma
--Skin closure

---

Central compartment dissection
Thyroid and thymus
removed en bloc with

--- Content provided by‍ FirstRanker.com ---

level VI nodes-
paratracheal,
pretracheal and
prelaryngeal.

---

? Based on lateral node status lateral neck

--- Content provided by FirstRanker.com ---

dissection is done.

---

COMPLICATIONS
OF
THYROIDECTOMY

---

? Intraoperative

--- Content provided by​ FirstRanker.com ---

? Early post operative
? Late post operative

---

INTRAOPERATIVE
COMPLICATIONS
? Haemorrhage

--- Content provided by‍ FirstRanker.com ---

? Nerve injury

---

EARLY POSTOPERATIVE
? Haematoma
? Laryngeal edema
? Respiratory obstruction

--- Content provided by​ FirstRanker.com ---

? Hypoparathyroidism
? RLN injury & problems
? Thyrotoxic crisis

---

LATE POSTOPERATIVE
? Hypothyroidism

--- Content provided by‌ FirstRanker.com ---

? Recurrent nodule
? Recurrent toxicity
? Wound infection
? Granuloma / keloid

---

HEMORRHAGE

--- Content provided by‍ FirstRanker.com ---

Primary
Reactionary
Secondary
Treatment
?

--- Content provided by⁠ FirstRanker.com ---

Release of sutures
?
Evacuation of hematoma
?
Re exploration & control

--- Content provided by‍ FirstRanker.com ---

bleeding

---

RESPIRATORY OBSTRUCTION
? Haematoma Laryngeal edema
?
Bilateral recurrent laryngeal nerve

--- Content provided by‍ FirstRanker.com ---

? paralysis
Hypocalcemic tetany Tracheomalacia
?
?
MANAGEMENT

--- Content provided by​ FirstRanker.com ---

Release the tension haematoma If
not relieved - - - intubate

---

RECURRENT LARYNGEAL NERVE INJURY
? Hoarseness
? Dysphonia

--- Content provided by⁠ FirstRanker.com ---

? Paralytic aphonia
? Periodic aspiration
? Inef ective cough
RLN injury may be unilateral or bilateral.

---

UNILATERAL RLN PALSY

--- Content provided by‌ FirstRanker.com ---

? Ipsilateral paralysis of all intrinsic muscles
except cricothyroid
In Indirect laryngoscopy,
? Vocal cord - median or paramedian
position

--- Content provided by‌ FirstRanker.com ---

---

MANAGEMENT
? STEROIDS ? within 7 days of injury
(Prednisolone 15mg tid for 10 days)
? SPEECH THERAPY
? MEDIALIZATION OF THE CORD -

--- Content provided by‌ FirstRanker.com ---

by Teflon injection
? LARYNGOPLASTY - if compensation does
not take place

---

Bilateral RLN palsy

--- Content provided by FirstRanker.com ---

Inspiratory stridor
Dyspnea or
Minimal dysphonia.
Management
? Emergency endotracheal

--- Content provided by FirstRanker.com ---

intubation
? Tracheostomy
? Cordectomy or endoscopic
laser treatment
? Thyroplasty

--- Content provided by FirstRanker.com ---

---

INJURY TO THE EXTERNAL
BRANCH OF SUPERIOR
LARYNGEAL NERVE
? Approximately in 20%
? Proximity to the superior thyroid artery.

--- Content provided by⁠ FirstRanker.com ---

? Loss of tension in the vocal cord
? VOICE FATIGUE - Diminished power and
range in the voice.

---

COMBINED PARALYSIS
UNILATERAL

--- Content provided by​ FirstRanker.com ---

? Paralysis of al muscles of larynx on one side except
interarytenoid.
? Cadaveric position ( 3.5mm from midline)
Treatment
? Speech therapy

--- Content provided by​ FirstRanker.com ---

? Injection of teflon paste
? Muscle or cartilage implanted to paralysed cord

---

BILATERAL
? Both cords in cadaveric position

--- Content provided by⁠ FirstRanker.com ---

? Total anesthesia of larynx
Aphonia
Aspiration
Features Inability to cough
Bronchopneumonia

--- Content provided by FirstRanker.com ---

Retention of secretion in the chest
Respiratory arrest

---

Treatment
1. Tracheostomy
2. Epiglottopexy ( epiglottis is folded

--- Content provided by‌ FirstRanker.com ---

backwards and fixed to the arytenoid)
3. Plication of vocal cord to prevent aspiration

---

HYPOPARATHYROIDISM
? Transient in 50%
? Permanent in < 2%.

--- Content provided by‍ FirstRanker.com ---

? Usually manifests within 72 hrs after surgery
? The first symptom is circumoral paresthesia.

---

SIGNS
CHVOSTEK SIGN TROUSSEAU'S SIGN

---

Management

--- Content provided by⁠ FirstRanker.com ---

? Emergency : 10 ml of 10% calcium
gluconate I .V over 10-15 mnts
Chronic patients :
? Calcium carbonate or Calcium
citrate

--- Content provided by‌ FirstRanker.com ---

? Vitamin D3

---

THYROTOXIC CRISIS
(THYROID STORM)
1-2 % patients
Causes

--- Content provided by​ FirstRanker.com ---

? Inadequately prepared thyrotoxic patient
? Infection, trauma, diabetic ketoacidosis,
emergency surgery, stress

---

Treatment
Supportive measures

--- Content provided by⁠ FirstRanker.com ---

Anti adrenergic drugs ? D O C : Propranolol i.v
Thionamides ? Propyl thiouracil 200 mg 4th hrly
Iodide compounds ? 10-15 drops Lugol's iodide 8th
hrly
Glucocorticoids ? hydrocortisone 5 mg/kg 6th hrly

--- Content provided by FirstRanker.com ---

Bile acid suppressants ? cholestyramine 4 g 6th hrly

---

HYPOTHYROIDISM
? For papil ary and follicular carcinoma -
suppressive dose of thyroxine (200 ? 300
mcg per day)

--- Content provided by‌ FirstRanker.com ---

? For medullary carcinoma -
supplementary dose of thyroxine (25 ?
100 mcg per day)

---

KELOID

---

STITCH GRANULOMA

--- Content provided by FirstRanker.com ---

---

PROGNOSIS
POSTOPERATIVE CARE
FOLLOW UP
Andrews Paul

---

PROGNOSIS

--- Content provided by‍ FirstRanker.com ---

Many scoring systems are available
? AMES
? AGES
? MACIS
? TNM

--- Content provided by‍ FirstRanker.com ---

---

AGES AND AMES
PARAMETER
LOW RISK
HIGH RISK
AGE (YRS)

--- Content provided by⁠ FirstRanker.com ---

<40
>40
GENDER
FEMALE
MALE

--- Content provided by‌ FirstRanker.com ---

EXTEND
NO LOCAL EXTENTION LOCAL AND EXTRA
THYROID EXTENSION
METASTASIS
NONE

--- Content provided by‌ FirstRanker.com ---

REGIONAL OR DISTANT
SIZE
<4 CM
>4 CM
GRADE

--- Content provided by⁠ FirstRanker.com ---

WELL DIFFERENTIATED POORLY
DIFFERENTIATED

---

MACIS
FACTORS
SCORE

--- Content provided by⁠ FirstRanker.com ---

DISTANT METASTASIS YES
3
NO
0
AGE

--- Content provided by‍ FirstRanker.com ---

<39 years
3.1
>40 years
0.08 * age
INVASION INTO

--- Content provided by​ FirstRanker.com ---

YES
1
SURROUNDING AREAS NO
0
COMPLETENESS OF

--- Content provided by‌ FirstRanker.com ---

Incomplete
1
SURGICAL RESECTION Complete
0
SIZE OF TUMOUR

--- Content provided by FirstRanker.com ---

0.3 * size(cm)

---

Sum Of MACIS Score
20 year survival
<
6.0

--- Content provided by​ FirstRanker.com ---

99%
6.0 ? 6.99
89%
7.0 ? 7.99
56%

--- Content provided by FirstRanker.com ---

> 8.0
24%

---

Postoperative Measures
Differentiated thyroid cancers
-Radioactive iodine scanning and

--- Content provided by⁠ FirstRanker.com ---

ablation
-TSH suppression
-Follow up testing

---

RADIOIODINE
SCAN

--- Content provided by⁠ FirstRanker.com ---

---

Goals
To identify
- any remaining normal thyroid tissue
- residual thyroid cancer cells
- metastatic disease

--- Content provided by‍ FirstRanker.com ---

Pre requisites
TSH level > 30 mU/L
-stop thyroxine for 4-6 weeks
-Patient advised to be on low iodine diet

---

Low doses of radioactive I? or I? is used.

--- Content provided by FirstRanker.com ---

Given orally in liquid or capsule form.
? I? : half life of 13 hrs, emits rays, better for
diagnostic scanning.
? I? : half life of 8 days, emits and rays.

---

? If positive, Radio Remnant Ablation is done

--- Content provided by FirstRanker.com ---

? If negative, follow up with thyroglobulin level.
? If raised Tg level ? WBS + US neck

---

THYROGLOBULIN ESTIMATION
Serum tumor marker for DTC
Circulating anti thyroglobulin antibodies

--- Content provided by⁠ FirstRanker.com ---

interferes
Undetectable levels ? after thyroidectomy
with TSH suppression
Raised levels ? recurrence/metastasis.
Level above 2ng/l ? abnormal

--- Content provided by‌ FirstRanker.com ---

---

RADIO REMNANT ABLATION
(RRA)

---

Radioactive iodine therapy (RAIT)
Purposes
? Remnant thyroid tissue ablation

--- Content provided by FirstRanker.com ---

? Adjuvant therapy with the intention of targeting
occult metastatic disease
? Primary treatment of known persistent disease

---

Indications
? Tumor size > 4 cm

--- Content provided by​ FirstRanker.com ---

? Gross extra thyroidal extension
? Distant metastases
? Tumor size < 4 cm with lymph node metastases
? Rising serum thyroglobulin level

---

? Radioactive I? is used.

--- Content provided by‌ FirstRanker.com ---

? Dose : 100-200 mCi
? Post ablation WBS done after 5-8 days
? In low risk patients ? with negative Tg and negative
cervical US no need for WBS
? In intermediate and high risk patients ? WBS after 6-

--- Content provided by FirstRanker.com ---

12 months of ablation + Cervical US at 6,12 months
and then annually for 3-5 years

---

? Concerns with RAIT
-isolation of patients
-C/I in pregnant, nursing women and

--- Content provided by‍ FirstRanker.com ---

children
-Avoid pregnancy for 6 months.
? Complications : nausea and vomiting,
sialadenitis, vocal cord paralysis, bone marrow
suppression

--- Content provided by FirstRanker.com ---

---

TSH Suppression
- To prevent hypothyroidism
- To prevent recurrence of thyroid
cancer
? T4 or levothyroxine is given orally

--- Content provided by‍ FirstRanker.com ---

? Suppressive dose of thyroxine ? 200-300 ?g/
day

---

? For patients with high risk DTC, TSH < 0.1 mU/L
? For intermediate risk DTC, TSH b/w 0.1 ? 0.5
mU/L

--- Content provided by‌ FirstRanker.com ---

? For low risk DTC, TSH within 0.5 ? 2 mU/L
? Risks associated ? subclinical thyrotoxicosis,
cardiac irregularities, osteoporosis

---

Follow up
Physical examination

--- Content provided by​ FirstRanker.com ---

Lifelong TSH suppression
Thyroglobulin estimation
Anti thyroglobulin antibodies
Periodic neck ultrasound
Radioiodine imaging

--- Content provided by‌ FirstRanker.com ---

---

Medullary Carcinoma
? Annual measurements of calcitonin and CEA
levels
? Ultrasound, CT, MRI, PET scans - localize
recurrent diseases

--- Content provided by⁠ FirstRanker.com ---

? 10 year survival rate is 80%
? Prognosis also depends on disease type - worst
in patients with MEN2B

---

Anaplastic Carcinoma
? Most aggressive form with disease specific

--- Content provided by‍ FirstRanker.com ---

mortality approaching 100%
? External beam irradiation
? Palliative support and end of life planning

---

SUMMARY
? Commonest malignant endocrine tumor

--- Content provided by‍ FirstRanker.com ---

? Risk factors : Radiation exposure , Genetic alterations
? Divided into differentiated , undif erentiated and medullary thyroid carcinomas
? Investigations:
Clinical examination ? history , physical examination Thyroid function tests
Imaging ? USG , X ray ,MRI , PET Pathological ? FNAC

--- Content provided by FirstRanker.com ---

? Treatment:
Papillary carcinoma ? total thyroidectomy + CCND Follicular
carcinoma ? total thyroidectomy+CCND
Medulary carcinoma ? total thyroidectomy + CC ND
Anaplastic carcinoma ? palliative treatment

--- Content provided by​ FirstRanker.com ---

---

THANK YOU

---