Care of the patient with thyroid and parathyroid cancer

1. Case scenario
 Neha , 46 years old c/o anterior neck swelling for the
past 12 years
 She noticed the swelling 12 years ago while looking at
herself in the mirror during her last pregnancy .At that
time the swelling was as big as a 20 cents coin located
at the anterior of her neck on the right side. After
delivery the swelling persisted and over 12 years it
gradually increased in size as big as a lemon
 It was not painful, no skin changes on the overlying
skin, no other swellings
 Does not complain of obstructive symptoms such as:
shortness of breath or difficulty in swallowing
 However she had unintentional weight loss where she
had lost 12 kilograms in the past 2 months

2. Care of patient with cancer
Thyroid and parathyroid
Moderator:
Dr.L.Gopichandran
Lecturer
AIIMSCON
Presenter:
Saumya P.Srivastava
Msc.Nsg 2nd year
Oncology Nursing
AIIMSCON

3. Objectives
At the end of the class group will be able to:
• Introduce the topic
• Explain epidemiology of thyroid cancer
• Describe anatomy and physiology of thyroid cancer
• Enumerate etiology and risk factors associated with
thyroid cancer
• Elaborate on types of thyroid cancer
• Explain pathogenesis of thyroid cancer
• Describe classification (TNM, Staging) of thyroid
cancer
• List down clinical manifestation of the patient with Ca
thyroid
• Explain diagnostic workup of the patient with ca thyroid
• Explain management of thyroid cancer

4. Introduction
• Thyroid cancers represent approximately 1% of
new cancer diagnoses in the United States
each year.
• Thyroid malignancies are divided into papillary
carcinomas (80%), follicular carcinomas (10%),
medullary thyroid carcinomas (5-10%),
anaplastic carcinomas (1-2%), primary thyroid
lymphomas (rare), and primary thyroid
sarcomas (rare).

5. Cont..
• Hürthle cell carcinoma is a rare thyroid
malignancy that is often considered a variant of
follicular carcinoma.
• Hürthle cell carcinomas account for 2-3% of all
thyroid malignancies.

6. Epidemiology
• Uncommon cancer but most common malignancy of
the endocrine system.
• The incidence of this malignancy has been
increasing over the last decade
• Women >men .
• Mean age of presentation 40-45 yrs (females), 65-69
yrs (males).
• Women are 3 times more likely to develop thyroid
cancer than men.
• Higher in young age < 40 years
• The vast majority of thyroid cancers is highly
treatable.

7. Epidemiology
• Thyroid cancer is the sixth most common cancer in
women.
• About 2% of cases occur in children and teens.
• Men have a worse prognosis than women when
there is a diagnosis of thyroid cancer.
• Overall, the 5-year survival rate for people with
thyroid cancer is 98%.
• For localized anaplastic thyroid cancer, the 5-year
survival rate is 30%.
• In India relative frequency of thyroid cancer 0.1%–
0.2%.
• Highest incidence is in Thiruvanantpuram district.

8. Thyroid cancer: incidence and deaths in u.s

10. Trends in thyroid cancer incidence in India
janeesh sekkath veedu, kevin wang et al, J Clin Oncol 36, 2018
• Aim: To investigate the trends in thyroid cancer incidence in India by
region, gender and age group.
• Methods: data from the Population Based Cancer Registries
(PBCRs) compiled by the National Cancer Registry Program
(NCRP) of the Government of India. Analyzed data from 14 regions
from 2004/05 to 2013/14.
• Results: Over a decade, the incidence rate of thyroid cancer in
India in women increased from 2.4 to 3.9 and in men from 0.9
to 1.3 per 100,000 persons, a relative increase of 62% and
48% respectively. The relative increase in thyroid cancer
incidence in women over 10 years was 121% in age group <
30 years, 107% in age group of 30-44, 50% in 45-59, 15% in
60-74 and 27% in ≥75. Similarly, the greatest relative increase
in thyroid cancer incidence in men was in age group < 45.
• Conclusions: The incidence of thyroid cancers is rapidly increasing
in India particularly among the younger population (age group < 45).

12. Anatomy

15. Vascular Supply

16. Innervation

17. Lymphatic drainage

18. Functions of thyroid
• It plays a major role in the metabolism, growth and
development of the human body
• The thyroid gland uses iodine from the diet to make
thyroid hormone (thyroxine).
• The release of thyroid hormone is controlled by the
thyroid stimulating hormone that stimulates the thyroid
to make and release more thyroid hormone.
• The thyroid gland also secretes a hormone
called calcitonin that is produced by the parafollicular
cells (also called C cells).

20. Control of Thyroid Hormone Synthesis and
Secretion

21. Etiology and Risk Factors
NON- MODIFIABLE :
• Gender: 3 times more common in women
• Hereditary: Mutations in RET proto-oncogene causing
familial medullary thyroid carcinoma (FMTC) and multiple
endocrine neoplasia type 2 (MEN 2a and MEN 2b)
• Family history: Having a first-degree relative (parent,
brother, sister, or child) with thyroid cancer
• Race : Asian
MODIFIABLE:
• Diet low in iodine, H/O Goitre :Follicular thyroid cancers
• Radiation exposure: Sources include radiotherapy, X rays,
CT scans ,power plant accidents or nuclear weapons. Risk
increases with larger doses and with younger age at
exposure

22. Etiology and Risk Factors
• Radiation therapy for hodgkin lymphoma or other
form of lymphoma in the head and neck.
• Race-White people and Asian people are more likely
to develop thyroid cancer.
Breast cancer survivors may have a
higher risk of thyroid cancer,
particularly in the first 5 years after
diagnosis and for those diagnosed
with breast cancer at a younger age.

23. Anaplastic thyroid cancer is usually
diagnosed after age 60. Older infants
(10 months and older) and adolescents
can develop MTC, especially if they
carry the RET proto-oncogene mutation.

24. Research Input
The Risk Factors in the Lifestyles of Thyroid Cancer
Patients and Healthy Adults of South Korea
Yoo, Yang Gyeong PhD, RN et al
Cancer Nursing: January/February 2018 - Volume 41 - Issue 1 - p
E48–E56
• Objective: The aim of this study were to identify lifestyle and
habit differences in thyroid cancer patients and healthy
adults and to investigate risk factors that influence the
development of thyroid cancer.
• Methods: The study was designed as a retrospective
comparison survey study of thyroid cancer patient group and
healthy adult group.
• Conclusion: Based on the results of this study comparing
thyroid cancer patients and healthy adults, it is
recommended to encourage an increase in physical activity,
minimize both direct and indirect exposure to smoking,
develop healthy eating habits of consuming more
vegetables, and effectively manage stress levels.

25. Types of thyroid cancer
Differentiated Thyroid Carcinoma (DTC): 90%
» Papillary carcinoma (80%)
» Follicular carcinoma (10%): Hurthle cell
carcinoma(2-3%)
Medullary Thyroid Carcinoma (5- 10%)
Anaplastic Carcinoma (1-2%): Undifferentiated

26. Other types: (rare)
Primary tumours:
 Sarcomas
 Lymphomas
 Epidermoid carcinomas
 Teratomas.
Secondary tumors:
 Metastasis from lung, breast, and kidney.

27. Papillary carcinoma
• Papillary carcinoma is the most common thyroid
malignancy, representing approximately 80%.
• Papillary carcinoma is a slow-growing tumor that arises
from the thyroxine (T4)- and thyroglobulin-producing
follicular cells of the thyroid.
• Women develop papillary cancer 3 times more
frequently than men do, and the mean age at
presentation is 34-40 years.
• Tumors typically appear after a latency period of about
10-20 years.
• Increased incidence of papillary cancer is hypothesized
among patients with Hashimoto thyroiditis (chronic
lymphocytic thyroiditis).

28. Papillary carcinoma
Pathology:
• Histologic feature is the presence of psammoma
bodies, which occur in 50% of papillary carcinomas.
• Thyrocytes may have so-called "Orphan Annie
eyes," ie, large round cells with a dense nucleus and
clear cytoplasm
• The tumors are unencapsulated neoplasms that
characteristically grow with papillae

30. Papillary Carcinoma
Local invasion:
• Tumors can grow directly through the thyroid
capsule to invade surrounding structures.
• Growth into the trachea can occur, producing
hemoptysis.
• Extensive involvement can cause airway
obstruction.
• The recurrent laryngeal nerves can become
involved because of their proximity in the
tracheoesophageal groove.
• Patients present with a hoarse, breathy voice and,
occasionally, dysphagia.

31. Papillary Carcinoma
Regional and metastatic disease-
• The most common site of lymph node involvement
is in the central compartment (level 6) ,(levels 2-4)
are the next most common sites of cervical node
involvement.
• Lymph nodes in the posterior triangle of the neck
(level 5) may also develop metastases.
• Approximately 5-10% of patients with papillary
thyroid carcinoma develop distant metastases.
Distant spread of papillary carcinoma typically
affects the lungs and bone.

32. Follicular Carcinoma
• Second most common thyroid malignancy and
represents about 10% of thyroid cancers.
• Usually arises in iodine deficient areas.
• Similar to papillary carcinoma, follicular carcinoma
occurs 3 times more frequently in women than in
men.
• The mean age range at diagnosis is late in the
fourth to sixth decades.
• Arise from the follicular cells of the thyroid.
• Metastasise to lungs and bones via blood vessel
invasion rather via lymphatic system

33. Follicular carcinoma
Histology:
• The tumors appear as round, encapsulated, light
brown.
• Fibrosis, hemorrhage, and cystic changes are
found in the lesions.
• Encapsulated lesion and may demonstrate well-
defined follicles containing colloid.
• The follicular cells in these tumors do not have
characteristic features like papillary carcinoma
cells.
• Immunohistochemical staining for thyroglobulin and
cytokeratins is nearly always positive.

34. Follicular Carcinoma
Local invasion:
• Local invasion can occur as it does with papillary
carcinoma, with the same presenting features:
• Hemoptysis.
• Airway obstruction
• A hoarse, breathy voice and,
occasionally, dysphagia.

35. Follicular Carcinoma
Cervical and distant metastases:
• Unlike papillary carcinoma, cervical metastases
from follicular carcinomas are uncommon.
• Lung and bone are the most common sites.

36. Follicular Carcinoma

37. Hurthle cell carcinoma
• Rare thyroid malignancy.Variant of follicular
carcinoma
• Also known as oncocytic carcinoma
• Encapsulated thyroid lesion comprising at least 75-
100% Hürthle cells.
• Mean age : 50-60 years
• Higher risk to metastasise among follicular cancers
HISTOLOGY:
• Hurthle cells/Oncocytic cells/ Oxyphilic cell :
Enlarged cells with abundant eosinophilic granular
cytoplasm as a result of accumulation of altered
mitochondria.

38. Medullary Thyroid Carcinoma
• MTCs represent approximately 5% of all thyroid
malignancies.
• Tumors arise from the parafollicular C cells of the
thyroid gland.
• About 75% of MTCs occur sporadically, and 25%
occur familially.
• More aggressive than papillary and follicular
cancers.
• Usually inherited and associated with MEN (2A and
2B)

39. MTC
• Mutation of RET proto onco-gene
• Age: 5th or 6th decade of life [MTC]
2nd or 3rd decade of life [MTC with MEN]
•Elevated serum calcitonin levels > 100 pg/ml
•No response to radioactive iodine therapy
Histology:
• MTCs are fairly well circumscribed, though they are
unencapsulated.
• Most tumors arise in the middle and upper third of the
thyroid lobes.
• Calcitonin and carcinoembryonic antigen are microscopically
useful for differentiating MTC from other tumors.

40. Anaplastic carcinoma
• Fastest growing and most aggressive
• Less than 2 % of all thyroid cancers
• 5 year survival rate < 10%
• Presents with a rapidly growing neck
mass. Metastases, particularly in the lung present
at diagnosis >50% of the time
• Peak age of incidence : 6th to 7th decade of life
• At least one half of patients already have distant
metastases at the time of diagnosis.
• The most common sites of involvement are the
lungs, bones, and brain.

41. Anaplastic carcinoma
Pathology:
• Anaplastic thyroid carcinoma is a large and invasive
tumor.
• Areas of focal necrosis and hemorrhage may be
present throughout the tumor.
• Believed to arise from a preexisting, well
differentiated thyroid carcinoma.
• Immunohistochemical stains are often positive for
low-molecular-weight keratins and occasionally
positive for thyroglobulin.

42. Primary Thyroid Lymphoma
• Represent approximately 2-5% of all thyroid
malignancies.
• Most thyroid lymphomas are non-Hodgkin B-cell
tumors.
• The incidence peaks in the sixth decade of life.
• This tumor is highly associated with chronic
lymphocytic thyroiditis (Hashimoto thyroiditis).
• Shows local extension and involvement of the
recurrent laryngeal nerve.

43. Sarcoma of the Thyroid Gland
• They are aggressive tumors that most likely arise
from stromal or vascular tissue in the gland.
• The treatment for thyroid sarcomas is total
thyroidectomy.
• Radiation therapy may be used in an adjunctive
setting.
• Recurrence is common
• patient's overall prognosis is poor.

44. Pathogenesis

46. Staging papillary and follicular carcinoma
Patients aged <45 years
Stage I Any T, Any N, M0
Stage II Any T, Any N, M1

47. Staging papillary and follicular carcinoma
Patients aged > 45 years
Stage I T1N0M0, T2N0M0
Stage II T1N1M0, T2N1M0, T3 Any N M0
Stage III T4a Any N M0
Stage IV A T4b Any N M0
Stage IV B Any T Any N M1

48. T1N0M0, T2N0M0 T1N1M0, T2N1M0,
T3 Any N M0

49. T4a Any N M0 T4b Any N M0

50. Medullary Thyroid Cancer
• Stage I: T1, N0, M0
Stage II: T2, N0, M0 ; T3, N0, M0
Stage III: T1–T3, N1a, M0
Stage IVA: T4a, Any N, M0; T1–T3, N1b, M0
Stage IVB: T4b, Any N, M0
Stage IVC: Any T, Any N, M1
•

51. Anaplastic thyroid cancer
• All patients are considered to have stage IV
disease

52. Clinical manifestations
Early signs:
• Lump or swelling in neck
• Painless (often), palpable, thyroid nodules ( Hard and
fixed nodules) on physical examination
• Pain if present may radiate up to ears
Late signs:
• Hoarseness : Involvement of the recurrent laryngeal
nerve and vocal fold paralysis.
• Firm cervical masses : Regional lymph node
metastases.
• Dyspnea or stridor: Tracheal compression
• Dysphagia : Esophageal compression
• Persistent cough (not due to cold)

53. Diagnostic workup
• History
• Physical Examination: Painless, Hard consistency, Ill-
defined borders, Fixed in respect to surrounding tissues,
Moves with the trachea at swallowing
• Thyroid ultrasound : To examine thyroid nodule and
nearby lymph nodes
• Ultrasonographically guided fine-needle aspiration
biopsy: 80% sensitivity, 100% specificity.Confirmatory
• Thyroid scintigraphy (or radio iodine scanning) with I 131 :
Malignant nodules appear as cold nodules
• Chest Xray : To rule out lung metastases

54. THYROID ULTRASOUND

55. Diagnostic workup
• CECT or MRI : To assess tumour invasion and
lymph node involvement
• (PET) or PET-CT scanning : Recurrent cancers
when tumor markers are positive and negative
anatomic imaging
• Laryngoscopy (direct or indirect) : For vocal
cord examination
• Biopsy: cells are removed from the nodule that
are then examined by a cytopathologist. This test
is often done with the help of ultrasound. Fine
needle aspiration, Surgical biopsy.

56. PET-CT SCAN

57. Diagnostic workup
• Molecular testing of the nodule sample:This is
done to identify specific genes, proteins, and other
factors unique to the tumor.
• Blood tests:
 Thyroid function studies : To assess thyroid function.
 Thyroglobulin(Tg and TgAb): Elevated
 Serum calcium and calcitonin : Elevated in medullary
carcinoma
 Carcinoembryonic antigen (CEA) : Positive in
medullary thyroid cancers (>3 ng/dl)

58. Diagnostic Workup
Radionuclide scanning:
• This test may also be called a whole-body scan.
• The scan will either be done using a very small,
harmless amount of radioactive iodine I-131 or I-
123, called a tracer.
• The patient swallows the tracer, which is absorbed
by thyroid cells. This makes the thyroid cells appear
on the scan image.
• TECHNETIUM 99m, I123, DMSA AND MIBG SCAN

62. Precautions after RAI therapy
• Sleep alone for 3 to 5 nights after treatment, depending
on the strength of your dose.
• Personal contact with children (hugging or kissing, for
example), should be avoided for 3 to 7 days, depending
on the strength of your dose.
• For the first 3 days after treatment, stay a safe distance
away from others (6 feet is enough). Avoid public places
and drink plenty of water (to encourage the removal of
radioactive iodine through your urine).
• For the first three days, do not share items (utensils,
bedding, towels, and personal items) with anyone else.
Do your laundry and dishwashing separately. Wipe the
toilet seat after each use. Wash your hands often, and
shower daily.

63. Differential diagnosis
• Goitre
• Grave’s disease
• Parathyroid carcinoma
• Thyroid nodule
• Thyroiditis

64. Management
• Surgery
- Lobectomy
- Sub-total thyroidectomy
- Near total thyroidectomy
- Total thyroidectomy
- Extent of neck dissection
• Hormonal therapy
• Radioactive iodine therapy
• EBRT
• Chemotherapy

65. SURGERY
• Surgery is the primary treatment of localised thyroid
cancer .
• Major surgical approaches are:
 Lobectomy(Hemithyroidectomy)
 Subtotal Thyroidectomy
 Near-total Thyroidectomy
 Total Thyroidectomy

66. Hemithyroidectomy(Lobectomy)
• Hemithyroidectomy, or unilateral thyroid lobectomy,
refers to removal of half the thyroid gland.
• It is typically performed via a transcervical collar
incision, but endoscopic and transoral routes have
also been described.
• The procedure involves mobilization of the thyroid
lobe, ligation of thyroid vessels, preservation of
parathyroids, protection of the recurrent laryngeal
nerve and dissection away from the trachea.

67. Lobectomy in the management of thyroid
cancer
• Age between the age of 15 and 45 years with PTC
tumor <4 cm
• No prior radiotherapy
• No distant metastasis
• No cervical LN metastasis
• No extrathyroidal extension
• Absence of aggressive histologic variant

68. Subtotal Thyroidectomy
• Subtotal thyroidectomy—Removal of majority of
both lobes leaving behind 4-5 grams (equivalent to
the size of a normal thyroid gland) of thyroid tissue
on one or both sides
• This used to be the most common operation for
multinodular goitre.

69. Near-total Thyroidectomy
Near total thyroidectomy:Both lobes are removed
except for a small amount of thyroid tissue (on one or
both sides) in the vicinity of the recurrent laryngeal
nerve entry point and the superior parathyroid gland.

70. Total Thyroidectomy
• Entire gland is removed.
• Done in cases of papillary or follicular carcinoma of
thyroid, medullary carcinoma of thyroid.
• This is now also the most common operation for
multinodular goitre.
• video-assisted thyroidectomy and robot-assisted
thyroidectomy have recently emerged

71. Indications of complete thyroidectomy
• Tumor > 4 cm in diameter
• Positive margin
• Gross extrathyroid extension
• Macroscopic multifocal disease
• Macroscopic nodal metastasis
• Confirmed contralateral disease
• Vascular invasion

72. Complications related to surgery
• Hypothyroidism in up to 50% of patients after ten
years
• Recurrent laryngeal nerve damage: Unilateral
damage results in a hoarse voice. Bilateral damage
presents as laryngeal obstruction after surgery and
can be a surgical emergency: an
emergency tracheostomy may be needed.
• Hypoparathyroidism temporary (transient) in many
patients, but permanent in about 1-4% of patients
• Hypocalcemia

73. Cont..
• Wound Infection :Incidence is 0.2-0.5%
• Stitch granuloma
• Chyle leak
• Haemorrhage/Hematoma (This may compress the
airway, becoming life-threatening.)
• Removal or devascularization of the parathyroids
Airway obstruction: In the first 24 hours is
most likely from compressive hematoma.
After 24 hours consider laryngeal
dysfunction secondary to hypocalcemia.

74. Neck dissection in thyroid cancer
• Cervical lymphadenectomy,
or neck dissection, is the
treatment of choice when
there is evidence of lymph
node metastasis from
thyroid cancer.
• A neck dissection can also
be performed
"prophylactically" at the
time of thyroidectomy to
avoid a second operation
due to recurrence.

75. Recommendation for Neck Dissection
• Central compartment ( level VI) is recommended
for all patients with clinically involved nodes.
• Prophylactic central neck dissection in clinically N0
patients with T3 or T4 tumors
• 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

76. Complications associated with Neck Dissection
Central neck dissection
1) Hypoparathyroidism – temporary/permanent
2) Recurrent laryngeal nerve injury
3) Superior laryngeal nerve injury
Lateral neck dissection
1) Hypoparathyroidism – temporary/permanent
2) Chyle leak
3) Hemorrhage
4) Seroma
5) Wound infection
6) Nerve injuries – accessory, ramus mandibularis, sympathetic
(Horner’s syndrome), phrenic, brachial plexus, cutaneous cervical

77. RADIOACTIVE IODINE ABLATION
• If residual disease is found, adjuvant therapy with
radioactive iodine (RAI) may be considered.
• RAI ablation is indicated for patients with any of the
following:
• Large (>4 cm) tumors
• Known distant metastasis
• Gross extrathyroid extension
• 4-6 weeks after total thyroidectomy to detect and
destroy any metastasis and residual tissue in the
thyroid using I131.
• For iodine sensitive papillary and follicular cancers

78. RAI Therapy

79. RAI Therapy
RAI ablation is not recommended for the
following:
• Small (<1 cm), solitary tumors
• Multifocal tumors when all foci are < 1 cm
Available forms:
• I131 is available in the form of: Capsule, Liquid
preparation, Intravenous
• Capsule is the most common used because of
safety and easy of administration

80. Patient preparation for I-131
• Low iodine diet: A diet that is low in iodine(
<50mcg/day) for 2 weeks before,and 2 days after I-
131- Salty product to be avoided.
• Stop thyroid hormone replacement:Levothyroxine
and other thyroid replacement should be withheld 6
weeks before I-131.
• Lithium carbonate to increase the potency of I-131

81. Short-term side effects of RAI treatment
• Neck tenderness and swelling
• Nausea and vomiting
• Swelling and tenderness of the salivary glands
• Dry mouth
• Taste changes

82. Tsh suppression for differentiated thyroid
cancer
• Rationale- Administration of subtherapeutic doses 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.
• 2.5-3.5 mcg/kg of L-T4 every day to inhibit TSH to a
value of 0.1-0.5 mU/L
• RECOMMENDATION
• TSH suppression to just below 0.1 Mu/L for high risk
patient.
• Maintainance of TSH at or slightly below the lower
limit of normal(0.1-0.5 Mu/l) in low risk patients

83. Tsh Suppression
Limitations
• Subclinical and even overt thyrotoxicosis
• Tachyarrhythmia
• Conduction abnormalities
• Ventricular hypertrophy
• Systolic and diastolic dysfunction

84. External beam radiation therapy
• Most often used to treat medullary thyroid cancer and
anaplastic thyroid cancer.
• Better treatment for cancers that take up iodine.
• As palliation for unresectable and metastatic tumors
• Dosage:6000-6500 cGy
• External beam radiation therapy is usually given 5
days a week for several weeks.

85. Toxicity Of EBRT
• Acute toxicity
• Mucositis
• Fibrosis
• Pharyngitis
• Dysphagia
• Hoarseness
• Radiation dermatitis
• Weight loss
• Malnutrition
Late Toxicity
• Fibrosis and
atrophy of skin,
lung apices,
musculature
• Taste changes
• Xerostomia

86. Chemotherapy
• Systemic chemotherapy has no significant role in
the management of DTC
• Poor response rate on the order of 25- 40%
• The most commonly used agent is doxorubicin,
either alone or in combination with cisplatin.
Palliative chemotherapy:For metastatic and
recurrent cancers

87. Complications associated with Chemotherapy
• Mucositis
• Hair loss
• Low blood counts
• Peripheral neuropathy
• Loss of apetite
• Ototoxicity

88. Targeted therapy
 Tyrosine kinase inhibitors: Sorafenib , Lenvatinib
For iodine resistant papillary and follicular thyroid
cancers
 Tyrosine kinase inhibitors of RET receptor kinase:
Vandetanib, Cabozantinib for medullary thyroid
cancers

89. Side effect of Targeted Therapy
• Common side effects include fatigue, rash, loss of
appetite, diarrhea, nausea, high blood pressure,
and hand foot syndrome (redness, pain, swelling, or
blisters on the palms of the hands or soles of the
feet.

90. Treatment According to type of thyroid
cancer
Papillary and follicular
• Localized: Surgery: Total thyroidectomy,
Lobectomy,RAI therapy, Thyroid suppression
therapy,EBRT.
• Metastatic: Iodine sensitive: RAI therapy, Thyroid
suppression therapy
• Iodine resistant: Thyroid suppression therapy,Targeted
therapy, Surgery, EBRT
Medullary thyroid cancer
• Localized: Total thyroidectomy , EBRT
• Locally advanced and metastatic disease:Targeted
therapy, Palliative chemotherapy

91. Cont..
Anaplastic thyroid cancer
• Surgery, EBRT, Chemotherapy

92. Research Input
Effect of Comprehensive Nursing Intervention on Thyroid
Stimulating Hormone Suppression for Patients with Differentiated
Thyroid Cancer
Zhou Miaoli et al
American Journal of Nursing Science. Vol. 8, No. 1, 2019, pp. 32-35.
Objective- to investigate the effect of comprehensive nursing
intervention on thyroid stimulating hormone (TSH) suppression for
patients with differentiated thyroid cancer (DTC).
Method: a total of 90 patients with DTC, receiving 131I treatment in the
Department of Nuclear Medicine of the First Affiliated Hospital of Jinan
University are enrolled in this study. All patients have received TSH
suppression treatment for at least 3 months prior to admission, and are
given individual-based comprehensive nursing intervention on TSH
suppression after admission. Through questionnaire and telephone
follow-up, patients’ awareness of TSH suppression and their medication
compliance before and after nursing intervention are analyzed and
compared.

93. Cont..
Result: the awareness of the knowledge of TSH suppression
and medication compliance are significantly improved in 90
patients after comprehensive nursing intervention.
Conclusion: Individual-based comprehensive nursing
intervention can effectively improve awareness of the
knowledge of TSH suppression, medication compliance and
confidence in cure in patients with DTC, which helps promote
the harmonious relationship between nurses and patients and
improve the prognosis of patients.

94. Prognosis
• Differentiated thyroid cancers: 10 year survival rate
> 90%.(Good prognosis)
• Hurthle cell carcinoma: 5 year survival rate: 50 -
60%.
• Medullary : 10 year survival rate 75-85%
• Anaplastic: 5 year survival rate: <10%. (Poor
prognosis)

95. Prognostic factors (poor prognosis)
• Tumour size > 5 cm
• Age : Men >40 yrs, Women > 50 yrs
• Extrathyroidal invasion
• Distant metastases

96. Ca Parathyroid

97. Objectives
At the end of the class group will be able to:
• Introduce the topic
• Explain epidemiology of parathyroid cancer
• Describe anatomy and physiology of parathyroid gland
• Enumerate etiology and risk factors associated with
parathyroid cancer
• Describe classification (TNM, Staging) of parathyroid cancer
• List down clinical manifestation of the patient with Ca
parathyroid
• Explain diagnostic workup of the patient with ca parathyroid
• Explain management of parathyroid cancer
• Describe nursing management of patient with cancer thyroid
and parathyroid

98. Introduction
• Parathyroid carcinoma is an extremely rare but
aggressive and life-threatening form of primary
hyperparathyroidism (pHPT).
• Most hyperparathyroidism is caused by a single benign
adenoma (approximately 85%) or by parathyroid
hyperplasia or multiple adenomas.
• Parathyroid carcinoma accounts for less than 1% of
cases of hyperparathyroidism.
• Patients with HPT-JT also have an increased risk of
developing parathyroid carcinoma, ranging from 15% to
37.5% in different case series.

99. Cont..
• Untreated, parathyroid carcinoma leads to
severe hyperparathyroidism, with signs and
symptoms including hypercalcemia, bone pain,
osteoporosis, fractures, and kidney stones or other
renal damage.
• Rarely diagnosed preoperatively, PC is often
discovered in the treatment of primary
hyperparathyroidism

100. Anatomy
• The parathyroid glands are four or more small
glands, about the size of a grain of rice, located on
the posterior surface of the thyroid gland.
• 4 parathyroid glands, 2 superior and 2 inferior
glands; located on the posterior and lateral surface
of the thyroid gland.
• Arterial supply : Inferior thyroid artery
• Lymphatics :deep cervical and pretracheal lymph
nodes
• Nerve supply: Recurrent laryngeal nerve
• Functional cells : Chief cells, which secrete
parathyroid hormone

101. Function
• Parathyroid gland maintains the body’s calcium
level within a very narrow range.
• PTH works in concert with another hormone,
calcitonin, that is produced by the thyroid to
maintain calcium homoeostasis.
• Parathyroid hormone acts to increase blood
calcium levels, while calcitonin acts to decrease
blood calcium levels

103. Epidemiology
• Parathyroid cancer is a rare disease.
• More recently the annual incidence has stabilized
to a rate of approximately 11 cases per 10 million
persons.
• Parathyroid cancer occurs equally in males and
females.
• Males fare slightly worse in prognosis.
• Median Age : 44 to 54 years

104. Cont..
• Almost all tumors that develop in the parathyroid
gland are benign.
• They may result in hypercalcemia that is difficult to
control or could cause death.
• The current 5-year survival rate for people with
parathyroid cancer ranges broadly, from 20% to
85%.( Cancer.Net Editorial Board)

105. Etiology and risk factors
• Unknown in most cases.
• Genetic disease [CDC73 mutation]:
Hyperparathyroidism–Jaw Tumor (HPT-JT)
• Familial isolated hyperparathyroidism.
• Primary parathyroid hyperplasia.
• History of radiation to the neck

106. TNM Classification
T (tumor)
• (Tx) - No information available
• T1 - Evidence of capsular invasion
• T2 - Invasion of surrounding soft tissues, excluding
the vital organs of the trachea, larynx, and
esophagus
• T3 - Evidence of vascular invasion
• T4 - Invasion of vital organs, such as the
hypopharynx, trachea, esophagus, larynx, recurrent
laryngeal nerve, carotid artery

107. TNM Classification
N (node)
• (Nx) - Lymph node not assessed
• N0 - No regional lymph node metastases
• N1 - Regional lymph node metastases
M (metastasis)
• (Mx) - Distant metastases not assessed
• M0 - No evidence of distant metastases
• M1 - Evidence of distant metastases

108. Classes
• Class I - T1 or T2 N0M0
• Class II - T3 N0 M0
• Class III - Any T, N1 M0, or T4
• Class IV - Any N, M1

109. High/low risk system
Criteria are as follows:
• Low risk - Capsular invasion combined with
invasion of surrounding soft tissue
• High risk - Vascular invasion and/or lymph node
metastases and/or invasion of vital organs and/or
distant metastases

110. Pathology
Gross description
• May be circumscribed
• Gray-white, firm, irregular, may exceed 10 g, may adhere to
adjacent structures, rarely within thyroid gland.
Microscopic (histologic) description
• Uniform cells with minimal atypia in nodular or trabecular
patterns with dense fibrous bands
• Tumor cells are spindled, mitotic figures are frequent,
• Vascular invasion (81% had tumor inside vessel and
attached to vessel wall), perineural invasion (19%) and soft
tissue invasion usually reliable indicators of malignancy
• May produce amyloid
• Diffuse nuclear enlargement with macronucleoli suggests
malignancy

111. The nests of neoplastic cells that are not very
pleomorphic. Note the bands of fibrous tissue
between the nests.

112. Clinical presentation
• Palpable central neck mass in combination with
hyperparathyroidism or hypercalcemia
• Onset: Abrupt
 Bone pain, pathologic fracture (90% of patients)
 Renal stones (50-80%)
 Symptoms of hypercalcemia - Fatigue,
weakness, confusion, depression, constipation

113. Diagnostic workup
Blood tests:
• Simultaneous calcium and parathyroid hormone
(PTH) levels should be determined.
• PTH :3 times the normal limit
• Profound hypercalcemia
X-ray :
• Hand: Subperiosteal bone resorption of the distal
phalanges
• Skull: Ground glass or Salt and pepper
appearance.

114. Subperiosteal bone
resorption of the distal
phalanges
Ground glass or Salt and
pepper appearance.

115. Cont..
• Ultrasonography: Larger, More hypoechoic,
Hypervascular, irregular borders, Greater infiltration into
surrounding tissues compared to benign lesions
• CT and PET scans: To determine metastasis and staging
respectively.
• Genetic Testing: Genetic testing for
germline CDC73 mutation should be considered to rule out
HPT-JT.
• Histologic Findings: The parathyroid glands are usually
large (2-10 g).Tumors are usually encapsulated and often
have fibrous septa extending into the gland. The majority
of tumors are fibrotic. The parenchyma of the tumor
usually has a predominance of chief cells.

116. Sestamibi parathyroid scintigraphy
• Sestamibi scanning is
the preferred way to
localize diseased
parathyroid glands prior
to an operation.
• However, sestamibi
scans are wrong at
least 50% of the time,
even at the best places
in the world.
Tc99m-sestamibi is absorbed faster by a
hyperfunctioning parathyroid gland than by a normal
parathyroid gland

117. Fine-needle aspiration is
contraindicated in the workup for
parathyroid carcinoma.Diagnosis of
parathyroid carcinoma is generally
made at the time of surgery.

118. Differential diagnosis
• Hypercalcemia
• Hyperparathyroididsm
• Paraneoplastic syndromes
• Thyroid nodule

119. Treatment and Management
• Two kinds of treatment are used:
• Surgery and radiation therapy (using high-dose
x-rays to kill cancer cells).
• Chemotherapy is being studied in a few clinical
trials, but there have been no good chemotherapy
drugs identified as effective up to this point.

120. Treatment and Management
• Medical care is limited to the control of
hypercalcemia (if necessary).
• The diagnosis of parathyroid carcinoma is usually
not known prior to surgery.
• Unusually severe hyperparathyroidism or a
palpable mass should trigger suspicion for
parathyroid carcinoma.
• Surgery: Parathyroidectomy or En bloc resection
of the parathyroid tumor and invaded adjacent
tissues, ipsilateral thyroid lobe, and any enlarged
lymph nodes

121. Parathyroidectomy
• Parathyroidectomy is surgery to remove the
parathyroid glands or parathyroid tumors.
• Most parathyroidectomies are performed
for primary hyperparathyroidism.
Minimally invasive surgeries:
• Minimally invasive parathyroidectomy
• Video-assisted parathyroidectomy.
• Endoscopic parathyroidectomy

122. Parathyroidectomy

123. Complications related to Parathyroidectomy
• Bleeding and hematoma: Airway compromise
• Infection
• Injury to recurrent laryngeal nerve: Change in voice
• Hypoparathyroidism: Hypocalcemia
• Thyrotoxic storm: Due to manipulation of the
thyroid gland during surgery
• Hypothyroidism

124. En bloc resection
• Surgery to remove the entire parathyroid gland
and the capsule around it. Sometimes lymph
nodes, half of the thyroid gland on the same side
of the body as the cancer, and muscles, tissues,
and a nerve in the neck are also removed.
• While en bloc resection results in fewer
reoperations for disease, limited data exist on the
implications of prophylactic lymph node
dissections for PC

125. Cont..
• Tumor debulking: A
surgical procedure in
which as much of the
tumor as possible is
removed. Some
tumors cannot be
completely removed.

126. The MIRP Procedure (Minimally Invasive
Radioguided Parathyroid surgery)
• The concept is to make the hyper-active
parathyroid cells radioactive with a mild radioactive
substance that is absorbed by the overactive cells.
• The surgeon operates using a very small (pencil
size) radiation detector.
• Parathyroid disease is typically cured in under 20
minutes using minimally invasive methods.
• All patients can (and should) have minimally-
invasive (radioguided) parathyroid surgery...

127. Advantages of MIRP
• Surgeon has a very good idea
which one of the four parathyroid
glands is hyperactive prior to
beginning the operation.
• Allows the surgeon to operate on
one very small area of the neck.
• Potential risks are expected to be
less than that of a complete neck
exploration.
• The band-aid comes off in one
week. There are no stitches to take
out.
• Does not require an endotracheal
tube and deep anesthesia

128. Resection of recurrence
• Reoperation for local and regional recurrence is
indicated and may provide substantial palliation
from hypercalcemia, in some cases for many
years.
• Resection or ablation of pulmonary or hepatic
metastases also may provide palliation.

129. Adjuvant treatment
• Use of Adjuvant therapy is questionable
• Fair number of Parathyroid tumors are considered
radioresistant.
• Cytotoxic chemotherapy is used even less
frequently than external beam radiation therapy, and
only isolated reports with very small numbers of
patients exist.

130. Radiation therapy
• External beam radiation therapy (EBRT) is
controversial.
• Postoperative EBRT may decrease local recurrence,
but the evidence for this is not strong.
• EBRT may also be used in specific circumstances for
treatment of a metastasis.
• Use of radiotherapy is often restricted to palliative
treatment of advanced disease or in the presence of
distant disease
• In general, however, parathyroid carcinoma is relatively
resistant to radiation therapy.

131. Management of hypercalcemia
• Intravenous hydration with saline and calcium
wasting loop diuretic (Furosemide)
• IV Bisphosphonates , IV Calcitonin
• Cinacalcet : In hypercalcemia refractory to
bisphosphonates
• Denosumab (120 mg/month): In hypercalcemia
resistant to bisphosphonates and cinacalcet.

132. Prevention
First-degree relatives of patients with parathyroid
cancer or HPT-JT should also be genetically screened
for CDC73 mutation (when mutation is known) or
periodically screened for primary hyperparathyroidism.

133. Long-Term Monitoring
After surgical treatment, periodic follow-up with serum
calcium determinations is mandatory. If serum calcium
begins to rise, elevation of parathyroid hormone level can
confirm recurrence.
• Once suspected, the location of the recurrence should be
determined:
• Neck imaging with CT scan, MRI, or ultrasound is
indicated.
• PET scanning may detect distant metastases but its
accuracy in this disease is not clearly defined.
• A chest radiograph is indicated, but a chest CT scan may
reveal pulmonary metastases missed on plain
radiograph.

134. Prognostic Factors
• Prognosis is poor
• 2/3rd of patients develop reccurence and 1/3rd can
die from tumor progression or refractory
hypercalcemia.
• Male gender, younger age,higher calcium level are
associated with poor prognosis.
• Most common site of metastasis are: upper
mediastinum, lung, pleura and bone

135. Preoperative Assessment:
• Explore patient’s feelings and concerns regarding
the diagnosis, treatment, and prognosis.
• Palpate for mass on the anterior part of neck
• Assess for pain on the mass
• Assess for dyspnes, dysphagia, hoarseness of
voice, stridor
• Assess for bruits by auscultation due to increased
thyroid vascularity.
• Assess for fear, anxiety and concerns regarding the
disease condition and treatment

136. Preoperative management
• The patients should be subjected to fasting for 12
hours and fasting water for 6-8 hours before
surgery.
• Preoperative cross-matching blood should be
prepared for the patients with huge thyroid tumor
for use.
• Prophylactic antibiotics should be administered
before surgery.
• Before surgery, the patients with secondary
hyperthyroidism should receive oral treatment of
Lugol’s iodine solution.

137. Psychological Nursing
• Doctors and nurses should adopt the ward
rounds, health education and others together to
communicate with the patients.
• Explain the circumstances of surgery and methods
of cooperation.
• Relieve tension of patients and establish a good
relationship between the patients and nurses.
• The operation site and incisions should be marked
by the doctors and nurses together to improve the
safety of the operation

138. Acute pain related to enlargement of thyroid
nodule and radiation of pain to ear as evidenced
by pain scale =5/10
 Assess verbal and nonverbal reports of pain, noting
location, intensity (0–10 scale), and duration.
 Place in semi-Fowler’s position and support head
and neck with sandbags or small pillows.
 Maintain head and neck in neutral position and
support during position changes.
 Give cool liquids or soft foods, such as ice cream
 Administer analgesics and/or analgesic throat
sprays and lozenges as necessary.
 Encourage patient to use relaxation techniques

139. Imbalanced Nutrition less than body requirement
related to difficulty in swallowing as evidenced by
weight loss
• Monitor daily food intake. Weigh daily and report
losses.
• Provide semi-liquid diet and gradually transferred to
a normal diet.
• Assess choking, aspiration or other symptoms.
• Maintain Calm surrounding while giving meals

140. Post-operative management
Routine postoperative nursing:
• Tracheostomy kit has to be prepared at the bedside
conventionally after surgery.
• The patients should be placed on ECG monitoring
and low-flow oxygen inhalation to observe the change
of vital signs closely.
• 70°semi-reclining position should be kept
• Inform doctors of abnormal drainage timely.
• Additionally, the drainage tube should be removed if
the drainage volume was less than 5ml/24h .
• The patients should be encouraged to move 24h after
surgery.

141. Post-operative management
Diet nursing:
• Postoperative diet should be cool and not too hot
to avoid overheating which could induce neck
blood vessels to dilate and increase bleeding.
• Semi-liquid diet can be given if there was no
discomfort in the patients (gradually transferred to
a normal diet).
• Nurses needed to observe whether choking,
aspiration or other symptoms occurred in the
patients.
• If coughing occurred, the patients can be guided to
drink a small amount of water each time.

142. Post-operative management
Trachea management:
• It is of great significance to prevent respiratory
obstruction and infection.
• The patients should be placed in semi-recumbent
position after surgery and given continuous low-flow
oxygen inhalation and continuous mask oxygen
inhalation if necessary, with their oxygen saturation of
blood maintained around 98- 100%.
• Daily aerosol inhalation should be given routinely in
order to help clearing secretion in the airway.
• For those patients with indwelling endotracheal tube,
continuous intratracheal instillation of 0.45% saline and
medicine should be given to reduce sputum production.

143. Nursing of postoperative complications
Bleeding:
• Bleeding mostly occurs within 24 hours after
surgery.
• Nurses should observe the symptoms including
whether thickened neck, subcutaneous
congestion, bleeding exudation in wound
dressings, sudden increase of drainage liquid in
the negative-pressure drainage tube on the
wound, bright red drainage and dyspnea and
other symptoms of tracheal compression occurred
in patients.

144. Cont…
• Sandbag oppression could be employed for
hemostasis of mild subcutaneous hematoma, or
cold compression using ice packs could be adopted
to alleviate the symptoms of bleeding.
• Drainage tube can be squeezed once within 30-60
minutes depending on the conditions in order to
prevent clogging of the drainage tube.

145. Nursing of postoperative complications
Dyspnea :
• In most cases,dyspnea is induced by bilateral
recurrent laryngeal nerve (RLN) injury, hematoma
compression, laryngeal edema, tracheal collapse.
• Sterile tracheotomy kit and sterile gloves should
be prepared at the bedside after surgery.
• Timely inspections of wards should be carried out
to observe whether dyspnea, cyanosis, irritability
and other kinds of discomfort with thickened neck
circumference, decrease in oxygen saturation,
expectoration and sputum tone occurred.

146. Nursing of postoperative complications
Hoarseness and drinking cough:
• Hoarseness and drinking cough are often induced
by injury of laryngeal nerve and recurrent nerve.
• After surgery, the patients should be encouraged
to speak, and observed to find whether there
were some symptoms including hoarseness,
aphonia, dyspnea, tone lowering, drinking cough.
• The patients should be guided to drink a small
amount of water each time and to speak gradually
when they were awake after anesthesia.

147. Nursing of postoperative complications
Limb twitch and lip numb:
• Limb twitch and lip numb are often caused by
parathyroid damage.
• Patient should be managed on intravenous
injection of 10% calcium gluconate .
• Followed by oral and intravenous treatment of
calcium supplements.

148. Postoperative management
Shivering and fever:
• Belonging to symptoms of thyroid storm, shivering
and fever mostly occurred within 12 h-36 h after
surgery.
• After surgery, the patients should be monitored for
changes in vital signs.
• Patients may show fever, irritability, delirium,
sweating, vomiting and can exhibit coma, shock
and even death if they were not promptly treated.
• Patients should be immediately given treatments
of oxygen, cooling, sedation, oral intake of iodine,
intravenous injection of hydrocortisone.

149. Postoperative management
Acute Pain related to surgical
interruption/manipulation of tissues/muscles
 Assess verbal and nonverbal reports of pain, noting
location, intensity (0–10 scale), and duration.
 Place in semi-Fowler’s position and support head
and neck with sandbags or small pillows.
 Maintain head and neck in neutral position and
support during position changes.
 Give cool liquids or soft foods, such as ice cream
 Administer analgesics and/or analgesic throat
sprays and lozenges as necessary.
 Encourage patient to use relaxation techniques:
guided imagery, soft music, progressive relaxation

150.  Monitor respiratory rate, depth, and work of breathing
 Auscultate breath sounds, noting presence of rhonchi.
 Assess for dyspnea, stridor, “crowing,” and cyanosis.
Note quality of voice.
 Suction mouth and trachea as indicated, noting color
and characteristics of sputum
 Assist with repositioning, deep breathing exercises,
and/or coughing as indicated
 Check dressing frequently, especially posterior
portion.
 Keep tracheostomy tray at bedside.
 Provide steam inhalation; humidify room air.

151. Risk for tetany related to loss of parathyroid
glands
 Monitor vital signs: remaining alert for elevated
temperature, tachycardia, dysrhythmias, respiratory
distress and cyanosis.
 Evaluate reflexes periodically.
 Observe for neuromuscular irritability (twitching,
numbness, paraesthesias, positive Chvostek’s and
Trousseau’s signs, seizure activity).
 Keep side rails raised/padded, the bed in low
position, and an artificial airway at bedside.
 Avoid use of restraints.

152. Impaired Verbal Communication related to vocal
cord injury /laryngeal nerve damage
 Assess speech periodically. Encourage voice rest
 Keep communication simple. Ask yes or no
questions.
 Provide alternative methods of communication as
appropriate: slate board, picture board.
 Anticipate needs as possible. Visit patient
frequently.
 Maintain quiet environment.

153. Research Input
Effect of teaching patients neck stretching exercises on neck pain and
disability following thyroidectomy
sahar a. Et al
Journal of Nursing Education and Practice 2018, Vol. 8, No. 1
• METHODS: Randomized controlled trial
• SAMPLE: 60 adult male and female patients scheduled to undergo
thyroidectomy. Neck stretching exercises :relax your neck and
shoulders ,look down, turn your face to the right side, turn your face
to the left side, incline your head to the right side, incline your head
to the left side, turn your shoulders round and round, and slowly
raise your shoulders fully then lower them again.
• RESULT: 56.7% patients in study group as compared to 10% in
control group had no disablity and pain on the neck 7 days post
thyroidectomy
• CONCLUSIONS: Teaching and applying neck stretching exercises
significantly improved the neck condition of patients in the study
group regarding pain and disability of the neck.

154. Discharge teaching
 Encourage well-balanced, nutritious diet rich in calcium and
vitamin D. and, when appropriate, inclusion of iodized salt.
 Teach postoperative exercises to be instituted after incision
heals: flexion, extension, rotation, and lateral movement of
head and neck.
 Encourage rest and relaxation, avoiding stressful situations
and emotional outbursts.
 Instruct in incisional care: cleansing, dressing application
 Advice to apply moisturising cream after healing to minimise
scarring
 Reinforce to take thyroxine supplements throughout the life
 Notify physician on developing fever, chills, continued or
purulent wound drainage, erythema, nausea and vomiting,
insomnia, constipation, drowsiness, intolerance to
cold, fatigue.
 Stress necessity of continued medical follow-up.

155. Conclusion
• Many thyroid cancers remain stable, microscopic,
and indolent. Total thyroidectomy increases survival
rates and decreases recurrence rates. Treatment
with 131I, Molecular-targeted therapies, such as TKIs,
have kept the mortality rate for thyroid cancer low,
despite the recent increase in its incidence.
• Designing clinical trials for new treatments is very
challenging due to the rarity of parathyroid cancer.
Adequate en-bloc excision of the tumour at initial
surgery offer the best chance of cure and elongated
disease-free survival.
• Observation and nursing during perioperative period
is very crucial for preventing postoperative
complications.

156. References
• Kandil E, Noureldine SI, Abbas A, Tufano RP. The
impact of surgical volume on patient outcomes
following thyroid surgery. Surgery 2013; 154: 1346-
1352; discussion 1352-1343.
1. https://www.thyroid.org/thyroid-cancer
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC44151
74
3. https://emedicine.medscape.com/article/2500021-
overview
4. https://emedicine.medscape.com/article/280908-
overview
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC30592
45
6. https://en.wikipedia.org/wiki/Parathyroid_carcinoma