Michele Zini Servizio di Endocrinologia Arcispedale S. Maria Nuova - IRCCS Reggio Emilia michele.zini@asmn.re.it

1. THYROID CARCINOMA
Selected clinical cases for discussion
Michele Zini
Servizio di Endocrinologia - Arcispedale S. Maria Nuova, Reggio Emilia
michele.zini@asmn.re.it
Michele Zini 2010

2. Patient #1 - Anna, age 48, ♀
• She is a nurse
• 2 sons
• Summer 2009: in Poland for holidays she
complaints for abdominal pain
• Evidence for gallbladder stones
• Back in Italy:
– CT scan: two large liver masses 7 x 6.4 cm and 3 x
3.5 cm
Michele Zini 2010

3. Patient #1 - Anna, age 48, ♀
• Liver biopsy:
– Poorly differentiated carcinoma.
Primary neoplasia not identifiable on the basis of
morphology
• FDG-PET:
– Intense glucose uptake in the liver left lobe, from
neoplastic mass
– Focal uptake in the neck, left side, supposedly in the
thyroid left lobe
Michele Zini 2010

6. Patient #1 - Anna, age 48, ♀
• Phone call form the oncologist: “Here is a patient with
liver metastasis, may be from thyroid carcinoma.
Could you please see her this morning ?”
• Colonoscopy: negative
• Gastroscopy: hiatal hernia
• Thyroid US:
– In the upper part of the left lobe: hypoechoic nodule,
irregular
burdens,
disomogeneous
content,
no
microcalcifications. No pathological cervical nodes.
Michele Zini 2010

7. Patient #1 - Anna, age 48, ♀
Michele Zini 2010

8. Patient #1 - Anna, age 48, ♀
Michele Zini 2010

9. Patient #1 - Anna, age 48, ♀
• General Practinioner’s mail:
“I have a patient with liver metastases from
thyroid cancer: could you please perform
FNA A.S.A.P. ?”
Michele Zini 2010

10. Patient #1 - Anna, age 48, ♀
• FNA report:
“Papillary sheets of epithelial thyroid cells with
nuclear grooves and pseudoinclusions. Dense
hyperchromatic colloid.
Diagnostic for papillary thyroid carcinoma. Thy 5.”
Michele Zini 2010

11. Patient #1 - Anna, age 48, ♀
• Liver malignancy (Primary ? Metastatic ?)
• Papillary thyroid carcinoma
• Not likely liver metastases from thyroid
PTC (oncologist and GP agree)
• Excluded MTC
Michele Zini 2010

12. Patient #1 - Anna, age 48, ♀
• Plasma calcitonin: < 4 pg/ml
• The pathologist is requested to perform
staining for thyroglobulin and calcitonin on
the liver biopsy:
– Negative
for
thyroglobulin,
chromogranin A, synaptophysin
calcitonin,
Michele Zini 2010

13. Patient #1 - Anna, age 48, ♀
• June 2010: Operated on for partial left liver
resection
• Histology:
– Poorly differentiated cholangiocarcinoma
• Currently waiting for thyroidectomy
Michele Zini 2010

14. Patient #1 - Anna, age 48, ♀
Issues for discussion:
 PTC of incidental diagnosis
 Epidemiology & Clinical relevance
 How to manage
 PET thyroid incidentalomas
 Epidemiology & Clinical relevance
 Role of FDG-PET in thyroid carcinoma diagnosis & follow-up
 Thyroid cancer diagnosed in metastatic patients (nodes,
lungs, liver, brain) without a known primary neoplasia
Michele Zini 2010

15. Patient #2 – Giovanna, age 50,
♀
• December 2006 - Due to family history of goiter
the GP orders a thyroid US:
– Right lobe:
3 cm. node, growing outward the capsule
2 more nodules, 4 and 7 mm.
– Left lobe:
mixed nodule, 3 cm.
2 more nidules, 6 mm.
– 15 mm lymphnode, left laterocervical
Michele Zini 2010

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19. Patient #2 – Giovanna, age 50,
♀
• TSH = 0.9 µU/ml
• FNA:
– thyroid - right side:
– thyroid - left side:
– right lymphnode:
Thy5
Thy2
• Cytology: bloody specimen
• Intranodular Tg: 1.5 ng/ml
Michele Zini 2010

20. Patient #2 – Giovanna, age 50,
♀
• April 2007: Total thyroidectomy with central
compartment dissection
• Histology: tall cell papillary carcinoma of the right
lobe. Extension to perithyroidal soft tissues
including the muscle. Surgical margins are
multifocally involved by the tumor. No vascular
invasion. 3 metastatic paratracheal nodes.
Parathyroid adenoma.
MACIS
pTNM
Stage
5,9
pT3N1AM0
III
Michele Zini 2010

21. Patient #2 – Giovanna, age 50,
♀
• September 2007:
– 150 mCi radioactive iodine
– Thyroglobulin: 5.1 ng/ml
• TSH = 78 µU/ml
• Tg antibodies: negative
– Whole body scan: thyroid remnant
Michele Zini 2010

22. Patient #2 – Giovanna, age 50,
♀
• December 2008:
– Tg levels:
• Basal:
0.6 ng/ml
• rhTSH stimulated: 4.3 ng/ml
– Neck US:
• right side, level 5: 1 cm. lymphnode
• right side, level 2: round-shaped lymphnode located
in front of jugular vein and carotid artery, with hylus T
15 mm x AP 6 mm + further similar lymphnode L 32
mm x AP 10 mm
Michele Zini 2010

23. Patient #2 – Giovanna, age 50,
♀
• FNA – neck right side:
– level 5:
• cytology: papillary clusters of follicular cells with
grooves
• intranodular Tg: 88 ng/ml
– level 2:
• cytology: bloody, stromal cells
• intranodular Tg: 0.5 ng/ml
Michele Zini 2010

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27. Patient #2 – Giovanna, age 50,
♀
• April 2009:
– lateral neck dissection (levels 2-3-4-5)
• Histology:
– level 3: PTC metastases (2/9 nodes)
– level 4: PTC metastases (2/22 nodes)
– level 5a: PTC metastases (3/13 nodes)
– level 5b: adipose tissue, no lymphnodes
Initial staging:
MACIS
pTNM
Stage
Restaging:
5,9
pT3N1AM0
III
MACIS
pTNM
Stage
5,9
pT3N1BM0
IVA
Michele Zini 2010

28. Patient #2 – Giovanna, age 50,
♀
• Follow-up:
– further RAI only if detectable thyroglobulin
node surgery
December 2008:
August 2009:
Tg levels (ng/ml):
Tg levels (ng/ml):
Basal:
rhTSH stimulated:
0.6
4.3
Basal:
rhTSH stimulated:
1.2
5.0
Michele Zini 2010

29. Patient #2 – Giovanna, age 50,
• October 2009:
♀
RAI 200 mCi
– Tg = 13 ng/ml
TgAb = 38 U/ml (30-100)
– Whole body scan: no RAI uptake
node surgery
RAI 200 mCi
December 2008:
August 2009:
April 2010:
Tg levels (ng/ml):
Tg levels (ng/ml):
Tg levels (ng/ml):
Basal:
0.6
rhTSH stimulated: 4.3
Basal:
1.2
rhTSH stimulated: 5.0
Basal:
1.5
rhTSH stimulated: 7.7
Michele Zini 2010

30. Patient #2 – Giovanna, age 50,
• March 2010:
whole-body
PET
Neoplastic uptake in thyroid
bed, right sided
Michele Zini 2010
♀

31. Patient #2 – Giovanna, age 50,
♀
• Neck US:
– level 6, right side: little paratracheal
hypoechoic area, 6 mm.
• FNA:
– cytology: localization of PTC
– FNA-Tg = 7500 ng/ml
Michele Zini 2010

32. Patient #2 – Giovanna, age 50,
♀
• June 2010:
– reoperated on for central neck dissection (3° surgical
procedure)
– calcemia = 6.6 mg/dl (8.5-10.5)
• Histology:
– one cystic lymphatic metastasis form PTC
– one soft tissue metastasis form PTC
Michele Zini 2010

33. Patient #2 – Giovanna, age 50,
♀
“LAST EPISODE”
node surgery
RAI 200 mCi
further surgery
December 2008:
August 2009:
April 2010:
August 2010:
Tg levels (ng/ml):
Tg levels (ng/ml):
Tg levels (ng/ml):
Tg levels (ng/ml):
Basal:
0.6
rhTSH stimulated: 4.3
Basal:
1.2
rhTSH stimulated: 5.0
Basal:
1.5
rhTSH stimulated: 7.7
Basal:
1.5
rhTSH stimulated: 5.8
Michele Zini 2010

34. Patient #2 – Giovanna, age 50,
♀
Issues for discussion:
 Histologic variants
 prognosis
 modalities of treatment
 timing of follow-up
 Recurrent thyroid carcinoma
 role of repeated surgery
 role of repeated RAI
 role of external beam radiotherapy
Michele Zini 2010