2. • 66/M
• c/o swelling in front of neck for 10 years
• c/o Diplopia for the past 3 months
• No rapid increase in size
• No hyperthyroid/hypothyroid symptoms
• No voice change
3. O/E
• There was a 3x2 cm
• size, hard swelling in
• the right lobe of
• thyroid, which
• moved up
• with deglutition.
• No nodes
14. FLUS/AUS
• Cells have mild nuclear atypia
• Equal number of micro/macrofollicles
• Extensive oncocytic change BUT not enough
to characterise as HURTHLE cell neoplasm
16. Our patient
• A well defined
heterogenous solid nodule with calcification in
the right lobe .
The skull lesion on the left is similar in appeara
nce to the thyroid lesion
Findings are highly suspicious of malignancy
* Three
small isohypoechoic nodules in the left lobe -
Probably benign
* Suspicious left level 4 node measuring
17.
18. TIRADS (Thyroid imaging reporting and
data system)
TIRADS Interpretation
1 Normal thyroid gland
2 Benign lesion
3 Probably benign lesion
4 a,b,c Suspicious of malignancy
5 Probably malignant (>80% risk)
6 Biopsy proven malignancy
20. • TIRADS 4 a – One suspicious feature (5-10%)
• TIRADS 4 b – Two suspicious features
• TIRADS 4 c – Three to four suspicious features
- Tirads 4b,c – 10-80% risk of malignancy
31. Risk stratification
• A – Age
• G – Grade
• E – Extent
• S – Size
• A – Age
• M – Metastases
• E – extent
• S - Size
• MACIS
• M – Metastases
• A – Age
• C – Completeness of resection
• I –Invasiveness
• S - Size
34. Differentiated thyroid cancer-
GOAL of intial therapy
• To remove the primary tumor and involved
lymph nodes
• To minimize treatment and disease related
morbidity
• To permit accurate staging of the disease
• To facilitate postoperative iodine treatment
35. Surgery in Differentiated thyroid
cancer
- Primary tumor >1 cm
- Presence of regional/ distant mets
- Prev h/o neck irradiation
- First degree relative with thyroid ca
- Age >45 yrs.
36. Basis of treatment in MTC
• Does NOT take up Radioiodine
• Does NOT respong to Thyroid suppression
• In 90% of hereditary forms MULTICENTRIC
In 20% of sporadic forms
• Nodal metastases are present in > 70% of
palpable disease
37. Advantages of Total thyroidectomy
• Radioactive iodine scan and Tg levels on
follow-up
• Most PTC multicentric
• Recurrence rates lower
• Re-operative Sx higher morbidity
43. Follow-up of patients
• High risk group :
- Whole body scan
- Thyroglobulin levels
- USG neck
• Low risk group :
- Thyroxine suppression therapy
TSH levels < 0.1 mU/L
Thyroxine 2.2 – 2.5 mcg/Kg body weight for 5
44. When to do a WBS?
• Do a radioiodine scan in
- High risk patients
- Tumor size > 1cm
- LVI/PNI present
- Timing : 45 days after stopping T4
2 weeks after stopping T3
- AIM : To achieve TSH > 30 mU/dl
47. Tg levels
• 95% of patients with distant metastases have
elevated Tg levels
• Best time to evaluate Tg – when patient is
hypothyroid in evaluation for WBS
• Tg >> WBS in predicting metastatic disease
• Level > 2mg/ml significant
48. Recurrence in DTC
• Radioiodine ablation
• Dosage 150 – 200 mCi
• Follow up with atleast 2 negative scans
49. Recurrence in MTC
• EBRT
• Chemotherapy – Doxorubicin NOT EFFECTIVE
• Interferon a
• Surgery – Tissel described “microdissection”
Extensive lymph nodal clearance
50. Metastatic carcinoma thyroid
• Persistent / Recurrent disease in the neck :
Surgical debulking
• Invasion of upper aerodigestive tract :
Sx + RI ablation/ RT
58. Biopsy report
• Total thyroidectomy specimen:
Multifocal follicular variant of papillary
carcinoma, right and left lobes.
Maximum tumour size is 3.3
cm in right lobe and 1 cm in
left lobe. Capsular
invasion, present in right lobe.
There is no lymphovascular or perineural
invasion.
Tumour is 0.2 cm from the nearest inked
