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Thyroid neoplasms

This presentation gives general overview of different types of thyroid neoplasm especially surgical management and recent advances

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Thyroid neoplasms

  1. 1. Thyroid Neoplasms Muhammad Haris Aslam Janjua Resident, Surgical Unit I SIMS/Services Hospital, Lahore
  2. 2. OUTLINE  Introduction  Epidemiology Etiology Pathophysiology  Clinical presentation Workup  Staging Treatment Followup Prognosis Case Presentation
  3. 3. Introduction  Most common endocrine tumour  Responsible for about 6 deaths per million persons annually  It accounts roughly for about 0.5% of all cancers in men and 1.5% of all cancers in women  5% of all thyroid nodules are malignant  Single nodule more likely to be malignant than multiple nodules
  4. 4. Classification of Thyroid Neoplasms Benign i)Follicular adenoma. ii)Hurthle cell adenoma iii)Colloid adenoma(commenest) Malignant (dunhill classification) Differenciated i) Papillary Carcinoma (80%) ii) Follicular Carcinoma (10%) iii) Hurthle cell carcinoma (3%) iv) Papillofollicular carcinoma Undifferenciated i)Anaplastic carcinoma (1-2%) Medullary Carcinoma (5-10%) Malignant lymphoma (~1%) Secondaries from colon, kidney, Melanoma
  5. 5. Woolner classification Papillary carcinoma Occult primary<1.5cm intrathyroidal extrathyroidal • Other variants of papillary carcinoma include • Tall cell • Insular • Columnar • Diffuse sclerosing • Clear cell • Trabecular and • Poorly differenciated
  6. 6. *Micropapillary carcinoma is a tumour, clinically not detectable or less than 1cm with no evidence of local invasiveness through the thyroid capsule or angioinvasion.....
  7. 7. Epidemiology  Annual incidence is 0.5 to 10 per 100,000 persons  Highest Incidence  Northren america  Female to male ratio is 3:1  Differenciated carcinomas peaks in 3rd and 4th Decade of life  Medullary thyroid carcinoma peaks in 5th and 6th decade  Anaplastic carcinomas peaks in 7th and 8th decade.
  8. 8. Epidemiology In Pakistan thyroid cancer is responsible for 1.2% cases of all malignant tumors Papillory thyroid carcinoma iodine sufficient areas Medullary thyroid carcinoma iodine deficient areas
  9. 9. Prevalence according to age Carcinoma Age group a) Papillary Thyroid carcinoma b) Medullary thyroid carcinoma associated with MEN type 2. Children a) Follicular thyroid carcinoma b) Anaplastic carcinoma c) Sporadic Medullary thyroid carcinoma Elderly
  10. 10. Etiology  Thyroid cancer Arises from 2 types of Cells Endodermally derived Follicular cells • Papillary • Follicular • anaplastic Neuroendocrine derived calcitonin producing C cells • Medullary thyroid carcinomas  Thyroid lymphomas  Intrathyroid lymphoid Tissue  Sarcomas  connective tissue of thyroid gland
  11. 11. Etiology  Radiation*  Papillary thyroid carcinoma  Signal most imp factor in differenciated carcinoma is irradiation of thyroid under 5 years of age  Pre-existing Multinodular goiterFollicular Carcinoma.  Hashimotos thyroiditisPapillary Thyroid carcinoma  Familial *Increased incidence of thyroid carcinoma among children following exposure to ionising radiation after Chernobyl nuclear disastor in Ukraine in 1986 *Radiotherapy received in adolescents for Hodgkins lymphoma may predispose to PTC
  12. 12. Familial cancer syndromes involving non medullary thyroid cancer Syndrome Thyroid tumor Cowdens syndrome FTC and rarely PTC and hurthle cell tumors FAP PTC Werners syndrome PTC, FTC , Anaplastic Cancer Carney complex type 1 PTC, FTC McCune Albright syndrome PTC Clear cell  Medullary carcinoma multiple endocrine neoplasia (MEN) 2A or 2B syndrome, as well as familial MTC (FMTC) syndrome..
  13. 13. Genes implicated in thyroid tumorigenesis Cancer Oncogenes Tumour suppressor genes  Papillary thyroid Carcinoma RET, MET, TRK1,RAS, BRAF p53  Medullary thyroid carcinoma RET  Follicular carcinoma Ras, PAX8/PPAR P53, PTEN  Anaplastic BRAF p53.
  14. 14. Pathophysiology  Commonest site  junction of isthmus with one of the lateral lobes Types Toxic solitory nodule Non toxic solitory nodule
  15. 15. Pathophysiology GROSS  Soft , firm, hard, cystic.  Solitory /multinodular  Contain brownish black fluid  Microscopy  Nuclear groves  Orphan annie eye nuclei characteristic  Psamomma bodies (50%) Spread  Slowly progressive and less aggressive  Spread through lymphatics  Most commonly to lungs followed by bone, liver and brain  Blood spread less often
  16. 16. Orphan annie is strip cartoon character with empty circled eyes
  17. 17. Lymph node involvement in Papillary carcinoma Central compartment(Level 6) medial to the carotid sheaths on both sides, from the hyoid bone superiorly to the sternal notch inferiorly Jugular lymph node chains (levels 2-4) posterior triangle of the neck (level 5)
  18. 18. Pathophysiology Types  Invasive Blood spread common  Non invasive Blood spread not common  Typical features  Capsular invasion  Angioinvasion Spread  More aggressive tumour.  Through blood into bones*, lungs, liver.  Occasional spread to lymph nodes in neck (10%) *Bone secondaries typically vascular , warm , pulsatile, localised, commonly in skull, long bones, ribs
  19. 19. Pathophysiology  Variant of Follicular carcinoma according to WHO  75-100% of the tumor is composed of Hürthle cells, also known as oxyphilic, oncocytic, Askanazy, or large cells  Large, polygonal follicular cells  abundant granular acidophilic cytoplasm  Differ from follicular cancer in  Multifocal and bilateral(30%)  Donot take radio iodine(5%)  More likely to metastasize to local nodes (25%) and distant metastasis  Associated with higher mortality rate( ~20 % in 10 years)
  20. 20. Pathophysiology  Arise from de-differenciation of differenciated thyroid carcinoma GROSS  Firm and whitish  Microscopy  Sheats of cells with marked heterogenicity Spread  One of the Most aggressive thyroid malignancy  Spread through lymphatics commonly to lungs, brain and bones
  21. 21. Pathophysiology Types  Sporadic(75%)  Familial (25%) Gross  Well circumscribed  Unencapsulated  Microscopy  Amyloid stroma wherein malignant cells are dispersed  Calcitonin in amyloid on immnunochemistry Spread  Mainly to lymph nodes (60%)  MCT associated with MEN type IIB with pheochromocytoma (sipple syndrome) is MOST AGGRESSIVE
  22. 22. Features of Medullary Thyroid Cancer Syndromes Syndrome Manifestations MEN2A MTC, pheochromocytoma, primary hyperparathyroidism, lichen planus amyloidosis MEN2B MTC, pheochromocytoma, Marfanoid habitus, mucocutaneous ganglioneuromatosis Familial MTC MTC MEN2A and Hirschsprung's disease MTC, pheochromocytoma, primary hyperparathyroidism, Hirschsprung's disease
  23. 23. Pathophysiology Most common  non hodgkin B cell lymphomas. Commonly arise from chronic lymphocytic thyroiditis Chronic antigenic lymphocyte stimualtion  lymphocyte transformation
  24. 24. Presentation History Most commonPainless, palpable, solitary thyroid nodule.  Solitory nodules presenting before 30 years and after 60 years  increased chances of malignancy Nodules in males higher chances of malignancy
  25. 25. Rapidly growing nodule is an ominous sign of malignancy.......
  26. 26. History • Hoarseness  involvement of the recurrent laryngeal nerve and vocal fold paralysis. • Dysphagia impingement of the digestive tract • Heat intolerance and palpitations suggest autonomously functioning nodules.
  27. 27. Carcinoma Clinical Features  Papillary thyroid carcinoma  Slow growing painless mass  Discrete neck lymph nodes (40 %)  Lateral aberrant thyroidcervical lymph node invaded by metastatic cancer  Compression featureuncommon  Follicular carcinoma  Solitory thyroid nodules with history of rapid size increase and long standing goiter  Tracheal compressionstridor  +ive Berrys sign* advanced malignancy  Dyspnoea, hemoptysis and chest pain when there are lung secondaries  Pulsatile secondaries in skull and long bones  Cervical lymphadenopathyuncommon  Signs and symptoms of thyrotoxicosis  *Infiltration of carotid sheath and absence of carotid pulsations  James berry is a surgeon who named it
  28. 28. Secondaries in skull from thyroid primary ( well localised, warm pulsatile vascular tumour with underlying bone erosion).
  29. 29. • Anaplastic carcinoma
  30. 30. Carcinoma Clinical features  Anaplastic carcinoma  Long standing neck mass >5cm which enlarges rapidly , may be painful  Tracheal obstruction stridor  Hoarseness and dysnea common (50%)  Vocal cord paralysis(30%)  Hard Mass fixed to surrounding structures , may be ulcerated,cervical mets (40%)  +ive berry’s sign  Medullary thyroid carcinoma  Develops in superolateral part of thyroid lobes  Neck mass with palpable cervical lymphadenopathy (15 to 20%)  Pain common  Local invasion dysphagia, dysnea, dysphonia  Sporadic  unilateral(80%)  Familial  bilateral (90%)
  31. 31. Clinical presentation of thyroid cancer patients in Pakistan--AKUH experience, • Thyroid cancer is a more aggressive disease in Pakistan, with majority of patients presenting with multinodular goiters, and a significant number have lymph node metastases. A higher degree of vigilance and a lower threshold for fine needle aspiration (FNA) is needed while evaluating patients with thyroid goiter......
  32. 32. Physical examination  Head and neck examination with careful attention to the thyroid gland and cervical lymph nodes, as well as indirect laryngoscopy. Features suggestive of malignancy in a solitory nodule include  Any nodule can be malignant ( hard, firm, cystic,small,large,asymtomatic)  Rapid onset/rapid recent increase in size  Hoarseness of voice/dysphagia/ stridor/dyspnea  Fixity of the nodule  Palpable neck nodes
  33. 33. Thyroid paradox Cellular tumours are soft and cystic tumors are firm and hard Observed in papillary carcinoma of thyroid
  34. 34. Differential diagnosis of CA thyroid • Multinodular goiter • Reidels thyroiditis – Presents as hard fixed swelling.May have local invasion and fibrosis but is BENIGN. • Thyroid adenoma – Follicular- colloid , embroyal, fetal – Hurthle cell • Thyroid cyst • Only one nodule palpable in MNG
  35. 35. Workup Fine needle aspiration biopsy Laboratory investigation Imaging studies
  36. 36. Fine Needle Aspiration Biopsy Most important diagnostic tool. Safe and minimally invasive Ultrasonographic guidance  increases the accuracy of FNAB  Gharib and Goellner (1993) found that  69% of FNAB results were benign,  4% were malignant,  10% were indeterminate, and  17% were nondiagnostic.  Sensitivity 83%  Specificity 92% False-positive rate was 2.9%, and their false-negative rate was 5.2%.
  37. 37. Fine Needle Aspiration Biopsy
  38. 38. Fine needle aspiration biopsy • Complications • Minor hematoma and ecchymosis  most common • Puncture of the trachea, carotid artery, or jugular vein may occur – Can be managed by applying local pressure
  39. 39. FNAB • Limitation • Difficult to differenciate between follicular adenoma and carcinoma on cytology as it depends upon capsular and angioinavision Options in Follicular carcinoma  Frozen section biopsy  Hemithyroidectomy  Trucut biopsy  Danger of hemmorhage and injury to trachea, recurrent laryngeal nerve and vessels
  40. 40. *Except in patients with history of external radiation or family history of thyroid cancer
  41. 41. Workup • Laboratoty investigation • Serum TSH levels – Low level suggests autonomously functioning nodule (usually benign) – Dosnt rule out malignancy • Serum calcitonin levels – Highly suggestive of MTC if increased – More senstive marker than CEA • PCR assays for germline mutations in the RET proto-oncogene – Diagnostic in Familial medullary thyroid carcinoma
  42. 42. Laboratoty investigation • Pentagastrin-stimulated calcitonin used as tumor markers to monitor patients who have been treated for MTC • Serum thyroglobulin levels – Cannot differenciate between benign and malignant disease – Used in patients who underwent total thyroidectomy * for thyroid cancer – Patients undergoing non operative managment of thyroid nodule *increased levels indicate recurrence
  43. 43. Laboratoty investigation • Urinary VMA, metanephrine and catecholamine – To rule out coexisting Pheochromocytoma in MTC • Serum levels of CEA – Increased in MTC but nonspecific – Better indicator of prognosis than Calcitonin • New patients with MTC should be screened for RET point mutations, pheochromocytoma and HPT.
  44. 44. Imaging studies Ultrasonography Highly sensitive for thyroid nodules Can depict nodules only a few millimeters in size Can detect non palpable thyroid nodules Differenciate solid from cystic nodules Can detect adjacent lymphadenopathy
  45. 45. Ultrasonography • Features suggestive of malignancy on USG include – Fine stippled calcification – Enlarged regional lymph nodes • Used to follow the size of suspected benign nodules
  46. 46. Ultrasonograpy Thyroid nodule with few, easily countable microcalcifications Solid, hypoechoic, and coarse central calcifications Later proved to be medullary carcinoma
  47. 47. Workup Radio iodine studies  Recommended in patients having Follicular CA on FNAB and suppressed TSH.  Determine functional status of a nodule • Based on radioisotope studies nodule can be  Hot  Autonomous toxic nodule  Warm  Normally functioning  Cold  Non functioning nodule (likely to be malignant but not always)
  48. 48. Thyroid Scan showing cold nodule Thyroid scan showing hot nodule
  49. 49. Workup • 111 indium octreotide scanning MTC (70 %sensitive) Xrays • CXR and Xray skull to rule out metastatic deposits – Skull mets more likely in Follicular carcinoma CT scanning and MRI – used to evaluate soft-tissue extension of large or suspicious thyroid masses into the neck, trachea, or esophagus. – To assess metastases to the cervical lymph nodes
  50. 50. X-ray of skull showing a couple of painless, progressively increasing swellings in the occipitoparietal region of the scalp. World J Radiol. 2012 June 28; 4(6): 286-290.
  51. 51. Staging TNM Classification of Thyroid Tumors Papillary or Follicular Tumors • Stage TNM • <45 y • I Any T, any N, M0 (cancer in thyroid only) • II Any T, any N, M1 (Distant metastasis) • ≥45 y • I T1, N0, M0 • II T2, N0, M0 • III T3, N0, M0; T1–3, N1a, M0 • IVA T4a, N0–1a, M0; T1–4a, N1b, M0 • IVB T4b, any N, M0 • IVC Any T, any N, M1
  52. 52. Medullary Thyroid Cancer • Stage TNM • I T1, N0, M0 • II T2–3, N0, M0 • III T1–3, N1a, M0 • IVA T4a, N0–1a, M0; T1–4a, N1b, M0 • IVB T4b, any N, M0 • IVC Any T, any N, M1 Anaplastic Cancer • Stage TNM • IVA T4a, Any N, M0 • IVB T4b, Any N, M0 • IVC Any T, Any M, M1
  53. 53. Definitions Primary tumor (T) • TX = Primary tumor cannot be assessed • T0 = No evidence of primary tumor • T1 = Tumor ≤2 cm in diameter, limited to thyroid • T2 = Tumor >2 cm but <4 cm in diameter, limited to thyroid • T3 = Tumor >4 cm in diameter, limited to thyroid, or any tumor with minimal extrathyroidal invasion • T4a = Any size tumor extending beyond capsule to invade subcutaneous soft tissue, larynx, trachea, esophagus, or recurrent • laryngeal nerve, or intrathyroidal anaplastic cancer • T4b = Tumor invading prevertebral fascia, or encasing carotid artery or mediastinal vessels; or extrathyroidal anaplastic cancer Regional lymph nodes (N)—include central, lateral cervical, and upper mediastinal nodes • NX = Regional lymph nodes cannot be assessed • N0 = No regional lymph node metastasis • N1 = Regional lymph node metastasis • N1a = Metastases to level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes) • N1b = Metastases to unilateral, bilateral, or contralateral cervical or superior mediastinal lymph nodes • Distant metastasis (M) • MX = Distant metastases cannot be assessed • M0 = No distant metastasis • M1 = distant mets present
  54. 54. Staging Stage 1 Malignancy is intrathyroidal Stage 2 Cervical nodal metastasis Stage 3 Extrathyroidal invasion Stage 4 Distant metastasis *Applicable in all thyroid malignancies but mainly used in follicular carcinoma
  55. 55. Prognostic indicators in PTC  Classify patients into LOW RISK and HIGH RISK groups AGES scoring system • Age, Grade, Extrathyroidal invasion and Size. – LOW RISK patients are • Young <40 years • Well differenciated tumor • No mets • Small primary lesions (<4cm) – HIGH RISH include • Older >40 years • Poorly differenciated tumor • Distant metastasis • Large primary lesion >4cm
  56. 56. MACIS scoring system Post operative system modified from AGES • Include Metastasis, Age , Completeness of excision, extrathyroidal Invasion and Size. • The final prognostic score was defined as – MACIS = 3.1 (if aged less than or equal to 39 years) or 0.08 x age (if aged greater than or equal to 40 years), + 0.3 x tumor size (in centimeters), +1 (if incompletely resected), +1 (if locally invasive), +3 (if distant metastases present).
  57. 57. AMES Scoring system • Proposed by Cady • Include Age, Metastasis, Extent of primary tumour, Size • LOW RISK include – Age <40 in men and <50 in women – No mets – No extrathyroidal invasion – Size <5 cm • HIGH RISK include – Age > 40 in men and >50 in women – Distant mets +ive – Extrathyroidal invasion – Size >5cm
  58. 58. Tid Bits Lymph node involvement does not alter the prognosis of papillary carcinoma of thyroid. All scoring systems catagorise the patient as High risk of death i.e 40 % in 20 years Low risk of death i.e 1 % in 20 years  Low risk is acheived by complete clearance of macroscopic tumor during first surgery
  59. 59. Lymph node levels in neck
  60. 60. Unilateral thyroid lobectomy is recommended Cyst persist after 3 attempts for aspiration Cyst >4cm Complex cyst with solid and cystic components higher chances of malignancy (15 %)
  61. 61. Papillary thyroid carcinoma HIGH RISK or BILATERAL  Total or near total thyroidectomy Minimal papillary carcinoma in thyroid specimen  Unilateral thyroid lobectomy and isthmectomy Large , Locally aggressive/ metastatic tumours  Total thyroidectomy with excision of adjacent involved structures if necessary and appropriate nodal surgery followed by radioablation with long term TSH suppression  Modified Radical neck dissection type III is done in case of lymph node involvement
  62. 62. Low risk groups Points in favour of total thyroidectomy Point in favour of lobectomy  Enables the use of RAI to detect and treat residual thyroid tissue/mets  Lobectomy has less complication rate  Makes serum Tg level more sensitive for recurrent or persistent disease  Recurrence in remaining tissue is unsual (5%) and mostly curable by surgery  Removes contralateral occult cancer as sites of recurrence ( 85% bilateral)  Tumour multicetricity has little prognostic significance  Reduces recurrence risk and improved survival  Prognosis is comparable to total thyroidectomy  Decreases the 1 % risk of progression to anaplastic cancer  Reduces rate of re-operation and complication Generally total or near total thyroidectomy is recomended in low risk groups provided complication rates are low <2 %
  63. 63. Indication of total thyroidectomy NCCN guidelines If any present If all present (thyroidectomy/lobectomy)  Age <15y or >45y  Age 15 – 45 y  Radiation history  No radiation history  Known distant mets  No distant mets  Bilateral nodularity  No nodularity  Extrathyroidal invasion  No extrathyroidal invasion  Tumour > 4cm  Tumour <4 cm  Cervical lymph node mets  No cervical lymph nodes mets  Aggressive variant  No aggressive variant
  64. 64. • Prophylactic lateral neck node dissection is NOT recommended in PTC – Cancer dosnt metastatise systemically from lymph nodes – Micrometastasis can be ablated by RAI therapy
  65. 65. Residual disease Post operatively • TSH + Tg and antithyroglobulin antibodies – 2 to 12 weeks post operatively • Total body RAI imaging – Suspected or proven RAIEBRT – Adequate RAI uptake  Radioiodine treatment and post treatment I131 imaging • If no imaging performed  EBRT • In all these cases suppress TSH with Levothyroxine.
  66. 66. • Using the Surveillance, Epidemiology, and End Results (SEER) database, one study compared the overall survival (OS) and cause-specific survival (CSS) of 23,605 subjects with papillary or follicular thyroid cancer treated with local excision, lobectomy, near-total thyroidectomy, or total thyroidectomy. • The 10-year OS and CSS results concluded that total thyroidectomy resulted in improved survival over other techniques – Poorer outcomes were associated with age, stage T3/T4 disease, positive nodes, and tumor size
  67. 67. Metastatic disease • CNS  Neurosurgical resection and/or image guided EBRT • BONE Surgical paliation ( weight bearing extremities and/or RAI treatment and/or EBRT – bisphosphonate or denosumab therapy – Embolization of mets • Other than CNS  surgical resection and/or EBRT of selected mets and/or radioiodine – Best supportive care
  68. 68. Follicular carcinoma • Follicular lesion on FNAB  thyroid lobectomy (80 % are adenomas) • Total thyroidectomy is recommended in – Older patients – Lesion >4cm ( cancer risk is 50 %) • Intraoperative frozen section examination if – Evidence of vascular or capsular invasion – Adjacent lymphadenopathy is present • If non diagnostic then hemithyroidectomy is done and sent for histopathology • Thyroid specimen  follicular carcinoma total thyroidectomy • Nodal mets  therapeutic neck dissection
  69. 69. Hurthle cell carcinoma • Unilateral lobectomy and isthmectomy • Invasive  total thyroidectomy + central neck node removal • Modified radical neck dissection if lateral nodes are involved • TSH suppression Rediffereciating therapies such as retinoic acid and PPAR gamma have shown some benefit in these tumors but require futher research
  70. 70. Post operative management of DTC Radioiodine scanning and ablation • RAI ablation is recommended in – All patients with stage 3 and 4 disease – All Patients with stage 2 disease <45 years – Usually in patients >45 years and stage 2 disease – Stage 1 disease with • Aggresive histology • Nodal mets • Multifocal disease • Extrathyroidal or vascular invasion
  71. 71. • More senstive than xray/ CT in detecting metastatic disease • Less senstive than Tg level except in Hurthle cell Tumours • 4-6 weeks after thyroidectomy, hypothyroid can be induced by discontinuing replacement (T4 for 4 weeks or T3 for 2 weeks) to obtain high serum TSH levels. • A diagnostic dose of131 I or123 I is given initially. • Whole-body scanning is performed to detect any tissue taking up radioiodine. • If any normal thyroid remnant or metastatic disease is detected, a therapeutic dose of131 I is administered to ablate the tissue.
  72. 72. • If a treatment dose of131 I is required, diagnostic thyroid scanning is repeated after 6 months after initial treatment, • If the diagnostic scan Positive  additional therapeutic dose is given. Process is repeated until the diagnostic scan is negative Role of recombinant human TSH • Thyrogen stimulation avoids the discomfort of patients having to discontinue thyroid replacement – t4 stopped 1 day before TSH stimulation
  73. 73. Recent advances • Sorafenib* (Nexavar) was approved in November 2013 for differentiated thyroid cancer (DTC) that is refractory to radioactive iodine treatment. • *Sorafenib is a small molecular inhibitor of several tyrosine protein kinases
  74. 74. Thyroid suppression • Used after thyroidectomy and radioablation • Reduces tumoural growth and recurrence rates • Suppressive dose is 0.3 mg OD lifelong • TSH levels should be < 0.1 mU/L
  75. 75. External beam radiotherapy • Used in unresectable, locally invasive or recurrent disease • In bone mets to decrease – Risk of fractures – Bone pain
  76. 76. Chemotherapy • Generally has no role • Doxorubicin is used as radiation sensitizer in patients undergoing external beam radiation
  77. 77. Medullary thyroid carcinoma • If pheochromocytoma present  operated first • Total thyroidectomy is the treatment of choice with bilateral central neck node dissection • Palpable cervical lymph nodes modified radical neck dissection • Tumour >1 cm  ipsilateral Prophylactic modified radical neck dissection – If +ive than contralateral node dissection is done
  78. 78. Medullary thyroid carcinoma • If unresectable – Tumour debulking to reduce symptoms – External beam radiation Recent advances  Tyrosine kinase inhibitors  Imitanib  Zactima (reduces calcitonin and CEA levels  Anti CEA monoclonal antibody  Labetuzumab  Laproscopic Radiofrequency ablation  For Liver mets >1.5 cm (palliative)
  79. 79. • If patient is hypercalcemic at thyroidectomy – Only enlarged parathyroid gland is removed • RET mutation carrier  total thyoroidectomy – MEN2A  before 6 years – MEN2B  before 1 year • Central neck node dissection – Avoided in calcitonin negative and normal USG exam – Done prophylactically in calcitonin positive and if USG suggests cancer • Maintenance dose of L-thyrosine
  80. 80. • All family members of patients with MTC should be evaluated with serum calcitonin ( genetic evaluation can also be done ) and if it is high they should undergo prophylatic thyroidectomy ......
  81. 81. Anaplastic carcinoma • If resectable – Adjuant chemoradiotherapy • Adriamycin is used for chemo. • Tracheostomy and isthemectomy to relieve airway obstruction in unresectable cases
  82. 82. Lymphomas • Mainstay  Chemotherapy – CHOP ( Cyclophosphamide, Doxorubicin, vincristine, and prednisolone) • Radiotherapy may also be given • Thyroidectomy and nodal resection to alleviate airway obstruction
  83. 83. Differenciated thyroid carcinoma Throglobulin levels  Thyroglobulin is a useful marker of tumor recurrence because well-differentiated thyroid cancers synthesize thyroglobulin • After total thyroidectomy levels should be – <2 ng/ml if taking t4 – <5ng/ml if hypothyroid – Levels >2ng/ml suggest metastatic or persistant normal tissue. (>95%) • Tg and Tg antibodies measuresd initially 6 months interval then annualy if disease free.
  84. 84. Follow up imaging • In low risk and –ive TSH stimulated Tg and cervical USG routine whole bodyscan is not recommended after first post operative scan • After remnant ablation routine whole body scan after 6 to 12 months is recommended Cervical USG • To evaluate thyroid bed and lymph node  6 to 12 months post thyroidectomy then annually for 4 to 5 years FDG PET SCAN • If RAI and USG normal but Tg remain elevated
  85. 85. Medullary thyroid carcinoma • Annual measurements of calcitonin and CEA levels. • Regular USG , CT , MRI if required • FGD PET scans – Superior to other radionuclide based studies
  86. 86. Management of recurrence • Localised – Surgical excision • Non localised – 131 I radioablation – External beam radiotherapy
  87. 87. According to stage Stage Age < 45 Age > 45 Local Recurrence Distant Recurrence 10 year Survival I Any T Any N M0 T1 N0 M0 5.5% 2.8% 98% II Any T Any N M1 T2 N0 M0 7% 7% 89% III - T3 N0 M0 T1-3 N1a M0 27% 13.5% ~82% IVa - T4a N0 M0 T1-4 N1b M0 IVb - T4b N0-1b M0 IVc - Any T Any N M1 60.9% 100% 50% • This table is extrapolated from a number of sources including the American Cancer Society, The National Cancer Institute, and the National Comprehensive Cancer Network, among others
  88. 88. According to cancer type 5-Year Survival for Papillary Thyroid Cancer Stage 5-Year Survival I Nearly 100% II Nearly 100% III 93% IV 51% 5-Year Survival for Follicular Thyroid Cancer Stage 5-Year Survival I Nearly 100% II Nearly 100% III 71% IV 50% 5-Year Survival for Medullary Thyroid Cancer Stage 5-Year Survival I Nearly 100% II 98% III 81% IV 28%
  89. 89. Papillary carcinoma • Good prognosis • Age is most important factor AGES system AGES Prognostic score = 0.05 × age (if age ≥40) + 1 (if grade 2) + 3 (if grade 3 or 4) + 1 (if extrathyroid) + 3 (if distant spread) + 0.2 × tumor size (cm maximum diameter) AGES score Survival (20-yr) ≤3.99 99% 4-4.99 80% 5-5.99 67% ≥6 13%
  90. 90. • Survival by AMES risk-groups (20-yr) Low risk 99% High risk 61% • Survival by MACIS score (20-yr) MACIS score Survival <6 99% 6-6.99 89% 7-7.99 56% ≥8 24%
  91. 91. Follicular carcinoma • Cumulative mortality is – 15% at 10years – 30 % at 20 years • Poor prognosis is associated with – Age >50 – Tumour size > 4cm – High tumor grade – Marked vascular and extrathyroidal invasion – Distant metastasis
  92. 92. Medullary thyroid carcinoma • 10 yr survival rate is 80 % • Decreases to 45 % with lymph node involvement • From best to worst prognosis – Non MEN familial  MEN 2A  sporadic  MEN2B • MEN2B has survival rate of 35 % at 10 years
  93. 93. Anaplastic carcinoma • Few patients survive 6 months beyond diagnosis Lymphomas • Depends upon • Histologic grade • Tumour within thyroid or disseminated • Overall 5 yr survival rate is 50 % • Extrathyroidal disease  lower survival rates
  94. 94. Patient education • Patients who discover a neck deformity or thyroid lumps or have a history of prior exposure to ionizing radiation must consult their physician
  95. 95. Case Presentation • A 40 year old male, resident of Chichawatni, electrician by profession presented with complain of swelling on the right side of neck for 3 months. • Swelling was gradual in onset, progresively increasing in size and number. Noticed by the patient by self palpation. • Associated with – Hoarseness of voice – Anorexia and weightloss for last 1 month • No h/o pain, fever, palpitation, sweating, heat/cold intolerence, dysphagia, dysnea, radiation exposure , sleep disturbance or neck trauma. • Past medical and surgical history unremarkable except HCV infection (7 years)
  96. 96. • Drug history : Took interferon injections for 6 months for HCV. • Personel history : Non smoker, non addict • Socio economic History: Lower class with 7000/ month income. • Family history : Mother is diabetic . • Allergic history: Not significant .
  97. 97. General physical examination • A middle aged male of lean physique sitting comfortably on bed well oriented in time place and person – B.P= 130/90 mmHg – Pulse= 90/ min regular rhythm, volume and character – Resp rate = 14/min – Temp= 98.6 F – Weight =50 kg BMI=16.03 • Bilateral cervical lymphadenopathy – Right Post triangle nodes – Bilateral along anterior border of sternocleidomastoid – Bilateral supraclavicular nodes • Right axillary medial group of lymph nodes are also palpable • No Pallor, cyanosis, jaundice, clubbing or edema
  98. 98. Local examination • A 3*2 cm soft, globular, nontender, nonfluctuant, non pulsatile, normothermic swelling on the right side of anterior triangle that moves upward with deglutition. • Not fixed to overlying skin but fixed to underlying tissues ,with smooth surface and irregular borders but no prominent veins, pulsations or stridor. • Carotid pulse palpable i.e berry’s sign –ive
  99. 99. Systemic examination • No eye signs • CNS : GCS= 15/15 intact • CVS : S1 + S2 + 0 • Chest : NVB + 0 • Abdomen: Soft nontender, no viceromegaly, Liver span = 12 cm in midclavicular line, bowel sounds present
  100. 100. Investigation • Laboratory investigation: – CBC, LFTS, RFTS, and COAGULATION is NORMAL – Thyroid function test are normal • FNAC – Thyroid nodule • Nuclear overlapping, nuclear groves with papillary cores suggestive of Papillary carcinoma of thyroid • No inclusion or psamomma bodies – Cervical lymph node • Sheets of pleomorphic cells with nuclear grooves against hemorrhagic background
  101. 101. Imaging studies • CT scan of neck with I/V contrast – Large heterogenous enhancing mass involving right side of isthmus and right lobe of thyroid with extrinsic compression of trachea. – Calcification also noted in mass – Multiple enlarged lymph nodes in right axilla, supraclavicular and cervical region – Oro/hypopharynx and larynx appear normal. Esophagus is normal. Great vessels in the neck are un remarkable
  102. 102. • 99m Tc MDP bone scan: – Normal ( homogenious and bilateral symmetrical tracer distribution) • CHEST X RAY: – Normal • Indirect laryngoscopy: – Bilateral normal mobile vocal cords Plan • Total thyroidectomy with neck block dissection followed by lifelong thyroid hormone replacement therapy
  103. 103. Intraoperative findings Level IIb , III , IV and V lymph node chains with pericapsular fibrosis invading carotid sheath. Right lobe hard fixed infiltrating right wall of trachea Hard fixed mass extending retrosternally and fixed with trachea....
  104. 104. Procedure done • Modified radical neck dissection – Accessory nerve saved . Internal jugular vein and sternocleidomastoid removed • Left lobectomy and isthmectomy + right nodulectomy