thyroid malignancy

2. SOEPEL
Abdul Waris Khan
Dept: Internal medicine

3. SOEPEL
• Subjective: A 32 years old male previously
known case of goitre presents with history of
dysphagia, hoarseness of voice, painful front
part of the neck, trouble breathing for the
past few weeks, but this time symptoms have
worsened even more.

4. • Objective: History taking & Physical exam
• Evaluation: dysphagia, , Goitre, Thyroid CA
• Plan: ultrasound, FNAC
• Treatment: Thyroidectomy
• Learning goals: Thyroid malignancy

5. Epidemiology
These tumours are responsible for 400 deaths annually
in the UK and an annual incidence of 30 000 cases in
the USA.
Over 75% occur in women.
In 90% of cases they present as thyroid nodules, but
occasionally with cervical lymphadenopathy (about
5%), or with lung, cerebral, hepatic or bone metastases.

7. • Carcinomas derived from thyroid epithelium may be
papillary or follicular (differentiated).
• Anaplastic (undifferentiated).
• medullary carcinomas (about 5% of all thyroid
cancers) arise from the calcitonin-producing C cells.

8. • Papillary thyroid cancer (75% to 85% of cases) –
often in young females – excellent prognosis.
• Follicular thyroid cancer (10% to 20% of cases)
• Anaplastic thyroid cancer (less than 5% of cases) is
not responsive to treatment and can cause pressure
symptoms.
• Medullary thyroid cancer (5% to 8% of cases).

9. • 90% of these tumors secrete thyroglobulin,
which can therefore act as a tumour marker.

10. Signs & Symptoms
 A lump in the neck, sometimes growing quickly
 Swelling in the neck
 Pain in the front of the neck, sometimes going up to the ears
 Hoarseness or other voice changes that do not go away
 Trouble swallowing
 Trouble breathing
 A constant cough that is not due to a cold

11. Diagnosis
• After a thyroid nodule is found during a physical examination, refer to
endocrinologist.
• Most commonly an ultrasound is performed to confirm the presence of a
nodule, and assess the status of the whole gland.
• Measurement of TSH and anti-thyroid antibodies will help decide if there
is a functional thyroid disease such as Hashimoto's thyroiditis present, a
known cause of a benign nodular goiter.
• Measurement of calcitonin is necessary to exclude the presence of
medullary thyroid cancer.
• Finally, to achieve a definitive diagnosis before deciding on treatment, a
FNAC test is usually performed.

13. Treatment
• Papillary and follicular carcinomas:
– Primary treatment is surgical. Total or near total
thyroidectomy for local disease.
– radioactive iodine (RAI) ablation of residual thyroid
tissue post-operatively for most patients with
differentiated thyroid cancer.
– When recurrence does occur, local invasion and lymph
node involvement is most common, and lungs and
bone are the most common sites of distant
metastases.

14. • Patients are treated with suppressive doses of levothyroxine (sufficient to
suppress TSH levels below the normal range) in order to minimize risk of
recurrence.
• Patient progress is monitored using serum thyroglobulin levels as a
tumour marker.
• The measurement of thyroglobulin is most sensitive when TSH is high but
this requires the withdrawal of levothyroxine therapy.
• Recombinant TSH (thyrotropin alfa, rhTSH) 900 μg (2 doses over 48 hours)
is used to stimulate thyroglobulin without stopping thyroxine therapy.
• Detectable thyroglobulin suggests recurrence, in which case whole body
131I scanning is required.

15. • The prognosis is extremely good when these types of tumour
are excised while confined to the thyroid gland.
• Accepted markers of high risk include greater age (> 40 years),
larger primary tumour size (> 4 cm) and macroscopic invasion
of capsule and surrounding tissues.

16. • Anaplastic carcinomas and lymphoma
– These do not respond to radioactive iodine, and
external radiotherapy produces only a brief
respite.

17. • Medullary carcinoma
– Total thyroidectomy and wide lymph node
clearance is usually indicated in MTC.
– Local invasion or metastasis is frequent, and the
tumour responds poorly to treatment, although
progression is often slow.

18. References
• Kumar & Clark internal medicine 7th edition
• Wikipedia
• Cancer.org