Thyroid CA

1. Thyroid Cancer & its
Management
Dr. Ankit Choudhary
2nd Year PGT
Department of ENT
IPGMER

2. ANATOMY OF THYROID GLAND
Lobus
dexter
(right lobe)
Lobus
sinister
(left lobe)
Each lobe is 5cm long,
3cm wide 2 cm thick
Lalouette’s /
pyramidal
lobe

3. Superior & recurrent
laryngeal nerve
Superior thyroid artery,
Inferior thyroid artery,
Thyroid ima artery
Lateral deep cervical lymph nodes,
pre & para tracheal lymph nodes
Superior thyroid veins,
Inferior thyroid veins,
Left brachiocephalic
vein

4. PHYSIOLOGY OF THYROID GLAND

5. Classification of Thyroid
Tumours
 Follicular epithelial cell
-Differentiated thyroid cancer
 papillary and mixed cell variant
 Classic
 Papillary microcarcinoma
 Encapsulated variant
 Follicular variant
 Aggressive variants
a. Diffuse sclerosing
b. Tall cell variant
c. Columnar cell variant
 Follicular cancer
a. Classic morphology- Follicular carcinoma
b. Hurthle cell variant

6. - Poorly differentiated thyroid cancer
- Insular carcinoma
-Undifferentiated thyroid cancer( anaplastic carcinoma)
 Parafollicular cell ( C cell)
Medullary carcinoma
 Non epithelial tumors
- Lymphoma
- sarcoma
- hemangioendothelioma

8. Etiology
 Predisposing factors for Thyroid Ca includes :
◦ Prolonged Stimulation by Elevated TSH
◦ Solitary Thyroid Nodule
◦ Ionising Radiation
◦ Genetic factors
◦ Chronic Lymphocytic Thyroiditis

9. Papillary Adenocarcinoma
 Papillary adenocarcinoma presents as a solitary nodule in the
thyroid
 Macroscopically :
◦ Firm and unencapsulated tumour sharply circumscribed by the
surrounding normal thyroid tissue.
◦ It is multicentric in 80 percent of cases and frequently involves both lobes.
Papillary thyroid cancer is referred to as minimal (or micro carcinoma) when
it is less than 1 cm in diameter.
The occult sclerosing carcinoma appears as an irregular white scar within a
normal or goitrous gland. Such lesions are often incidental findings at
sonography, following surgery for benign disease and at autopsy.
 Histologically
◦ The mixed pattern is most common,
◦ Pure papillary the most rare.
◦ The papillary component is characterized by a fibrous stalk with a
periphery of follicular epithelium. Laminated calcifications called
'psammoma bodies' are often found in the stalk region.

11.  Histological variants
 Papillary microcarcinoma - occult sclerosing, occult papillary: < 1 cm
4-30 percent incidence at autopsy;
 Encapsulated papillary carcinoma: -10 percent of all papillary
tumours;
25 percent associated with nodal
metastases.
 Follicular variant of papillary carcinoma – typical papillary cytology;
 Tall cell and columnar - Older patients, bigger more aggressive
tumours:
vascular and extrathyroid invasion common;
associated with a worse prognosis.
One in five patients have pulmonary metastases
Bone metastases are much less common.

12. Follicular Adenocarcinoma
 Well defined capsule
 Histologically –
Composed of Follicles with no Papillary structure
Capsular and Vascular invasion confirms diagnosis
FNAC do no confirm the diagnosis
 Blood borne metastasis seen more to bone and
lungs
 Lymph node less commonly involved

13. Medullary Thyroid Carcinoma
 5% of all Thyroid Malignancy
 Arises from Parafollicular C cell which secrete
Calcitonin
 Cervical node metastasis in 50% of cases
 Types :
Sporadic
MEN 2A
MEN 2B
Familial Non MEN

14.  HURTHLE CELL CARCINOMA
- Also called as oncocytic carcinoma
- Characterised by large cells with abundant
granular eosinophilic cytoplasm
- At least 75% of the tumour must be comprised of
Hurthle cells to designate it Hurthle cell carcinoma
 ANAPLASTIC THYROID CARCINOMA
- Comprise <5% of all malignant thyroid neoplasms
- Most aggressive form of thyroid carcinoma
- Most patients are diagnosed at the age of 65 years
or older
- Usually accompanied by bulky mediastinal
lymphadenopathy and distant metastatic spread
- Mean overall survival from the time of diagnosis is
3-6 month

15. How to approach a Patient of Thyroid
Carcinoma
 History
 Clinical Examination
 Radiology
 Laboratory Investigations
 Cytology

16. Calcitonin
 Basal calcitonin levels are high in most patients
with sporadic MTC but are normal in those with
familial MTC or MEN type 2
 So in these patients a calcium infusion provocative
test or pentagastrin infusion test is used to detect
the abnormality

17. TNM Staging
Tx Primary tumour cannot be assessed
T0 No evidence of primary tumour
T1 Tumour 2 cm or less in greatest dimension and limited to the thyroid
gland
T1a
Tumour 1 cm or less in greatest dimension and limited to the thyroid
gland
T1b
Tumour > 1cm but not > 2 cm in greatest dimension and limited to
thyroid gland
T2 Tumour > 2 cm but not > 4 cm in greatest dimension and limited to the
thyroid gland
T3 Tunour > 4cm in greatest dimension limited to the thyroid or any
tumour with minimal extrathyroidal extension to the sternothyroid
muscle or perithyroid soft tissue
T4 Advanced disease defined as more than minimal extrathyroid
extension
T4a
Tumor of any size extending beyond the thyroid capsule to invade
subcutaneous soft tissue, larynx, trachea, esophagus, or recurrent
laryngeal nerve

18.  All anaplastic carcinomas are considered T4 tumors
T4a Intrathyroidal anaplastic carcinoma
T4b Anaplastic carcinoma with gross extrathyroidal extension
Regional lymph node(N)
Nx Regional LN cannot be assessed
N0 No evidence of regional LN metastasis
N1 Regional LN metastasis
N1a
Metastasis to level VI
N1b
Metastasis to unilateral, bilateral, contralateral cervical or
retropharyngeal or superior mediastinal LN
Distant metastasis
M0 No distant metastasis
M1 Distant metastasis

20. Prognostic Indicators

21. MACIS

23. Management
 Surgery
-Lobectomy or total thyroidectomy
-Extent of neck dissection
 Hormonal therapy
 Radioactive iodine therapy
 EBRT
 Chemotherapy

24. Surgery
 Surgery is the primary treatment of thyroid cancer
 Total thyroidectomy is the preferred oncologic procedure
- The gland is surgically accessible
- Primary endocrine function can be replaced by
exogenous hormones
 Conservative Procedure if
◦ Age between the age of 15 and 45 years with PTC tumor <1
cm
◦ No prior radiotherapy
◦ No distant metastasis
◦ No cervical LN metastasis
◦ No extrathyroidal extension
◦ Absence of aggressive histologic variant

25. Neck dissection
 Central compartmenta ( level VI) is recommended
for all patients with clinically involved nodes
 Prophylactic central neck dissection in clinically N0
patients with T3 or T4 tumors
 Lateral level II to level IV should only be reserved
for biopsy proven metastatic lateral cervical LAP
 Level I, V, VII should only be dissected when
clinically suspicious
 Central and lateral neck dissection are part of
standard primary therapy for all patients with
sporadic and hereditary forms of medullary thyroid
cancer

26. Hormonal Therapy
 TSH suppression to just below 0.1 Mu/L for high
risk patients
 Maintainance of TSH at or slightly below the lower
limit of normal( 0.1-0.3 Mu/l) in low risk patients
 Administartion of T4 in an effort to drive the TSH
below detectable limits( < 0.1 Miu/L), thereby
decreasing stimulation of residual benign and
malignant follicular derived thyroid cells

27. Radioactive Iodine Therapy
 All patients with distant metastasis
 Gross extrathyroidal extension of the tumour regardless of
tumour size
 Primary tumor size> 4 cm, even in the absence of other
higher risk features
 Patients with 1-4 cm thyroid tumor with high risk features
 LN metastasis
 Age> 45 years
 Intra thyroid vascular invasion
 Aggressive histologic variants ( tall cell, columnar cell, or insular carcinoma
 All patients with follicular and Hurthle cell variants except
those with smallest unifocal FCs manifesting as only capsular
invasion and without vascular invasion
 Patients with persistent disease

29. Patient Preparation
 Low iodine diet
 Intravenous iodine exposure
 Urinary iodine measurement
 rhTSH
 Low risk: 30-50 mCi
 Inermediate risk: 100-150 mCi
 High risk: 200 mCi

30. EBRT
 EBRT is the standard of care for palliation of local
symptoms from unresectable disease or as
adjuvant therapy in rare case a completely
resected tumor
 In MTC - Treatment of unresectable gross disease
Positive margin
T4 primary tumors
Nodal metastasis with extensive extracapsular
extension

31. Chemotherapy
 Systemic chemotherapy has no significant role in
the management of DTC
 Advanced Medullary Thyroid Carcinoma-CVD
Protocol CYCLOPHOSPHAMIDE – 750mg/m.sq.
– D1
VINCRISTINE – 1.4mg/m.sq. – D1
DACARBAZINE – 600mg/m.sq. – D1,D2
CYCLE- to be repeated every 3-4 weeks
 Most commonly used agent is Doxorubicin, either
alone or in combination with cisplatin.

32. Special Therapy for MTC
SORAFENIB-400 mg- PO –BD- Daily
Indication – metastatic , iodine refractory carcinoma
MOTESANIB-125mg- PO - Daily
Indication – Progressive advanced (metastatic , radio
iodine resistant differentiated carcinoma
Octreotide is recommended to manage symptoms
due to elevated calcitonin level in medullary thyroid
cancer like diarrhoea
Dose is 100-250 mcg tid sc

33. Follow Up
 DTC – Radioiodine 131 Scan
Serum Thyroglobulin (Unsupresses
TSH)
rhTSH stimulated serum Thyroglobulin
MTC - Serum Calcitonin
I MIBG scan