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Thyroid cancers
•Infrequent cancers-3% of all cancers
•Benign diseases common
•Requires multidisciplinary action
•Women are affected 3 times more than
men
•Peak incidence 30-40yrs
Types-
• Papillary-80%
• Folllicular-10%
• Medullary-5-10%
• Anaplastic-1-2%
• Lymphoma
• Sarcoma
Etiology & Risk factors
• Arise from 2 types of cells
• Follicular cells makes papillary,follicular &
  anaplastic
• Parafollicular C cells makes medullary

• Radiation exposure & Hashimotos
  thyroiditis are risk factors for papillary ca.
• Low dietary iodine is riskfactor for follicular
  & anaplastic
History
• Present as Painless palpable thyroid
  nodule
• Nodules are present in 4-7% of population
  but most are benign,5% are mlignant
• Peak incidence occurs between age of 30-
  50yrs
• More common in females
• Malignant nodules are usually painless
• Hoarseness suggests malignancy-nerve
  involvement
• Dysphagia
• Family history present in case of
  medullary cancer
Examination
• Thyroid gland
• Soft tissues of neck
• Tenderness?
• Consistency(Hard/firm/soft) mobility(fixed
  or not)
• Laryngoscopy if hoarseness presents
GOAL is
• To differentiate malignant from benign
  nodules
• Determine which patient require
  intervention / who can be monitered
• Avoid unnecessary surgery
FNAC
•First intervention in evaluation of nodule
•Inexpensive,easy,few complications
•Needs a good cytopathologist
•Four types of results-benign-69%
                        mallignant-4%
                        indeterminate-10%
                        nondiagnostic-17%
Sensitivity-83%,specificity-91%
•   If nondiagnostic-repeat
•   If benign-followup
•   If malignant-surgery
•   If indeterminate-surgery
Lab
• TSH-to know the hyper/hypo thyroidism,
  not helpful in malignancy
• Sr.Thyroglobulin as a tumour marker in
  post op to assess
• Calcitonin for medullary ca.
Imaging
• U/S-to differenciate solid & cystic
  lesions,for FNA accuracy & for monitoring
  of benign lesions
• Scans-determine function of nodule
• Carcinoma can not be ruled out based on
  scans as 4%of hot nodules also malignant
• CT/MRI not used routinely
Papillary cancer
• Most common(80%)
• Women-3 tims more common
• 30-40yrs of age
• Risk factors-radiation exposure in
  childhood, Hashimotos thyroiditis
• Slow growing,TSH sensitive,take up
  iodine,TSH stimulation produces Tg
  response
Pathology
• Unencapsulated,arborizing papillae,well
  differentiated,rare mitoses50% have
  Psammaoma bodies-calcific
  concretions,circular laminations
• Multicentric
• Histology-Orphan anney eye with nuclear
  grooving
• Loacl invasion through capsule, invading
  trachea, nerve causing dyspnea,
  hoarseness
• Propensity to spread to the cervical
  lymphnodes,clinically evident in 1/3 of
  patients-mostly central compartment
• Distal spread to lung & bones
Follicular carcinoma
• Second most common(10%)
• Iodine deficient areas
• 3 times more in Women
• Presents more in advanced stage than
  papillary
• Late 40’s
• Also TSH sensitive, takes up iodine,
  produces Tg
pathology
• Round, encapsulated, cystic
  changes,fibrosis, haemorrhages
• Microscopically neoplastic follicular cells

• Differentiated by follicular adenoma by
  capsular invasion & angioinvasion
• Cannot reliably diagnose based on FNA
• Local invasion is similar to papillary cancer
  with same presentation
• Cervical metastases are uncommon
• Distant metastases is significantly
  higher(20%),with lung & bone as most
  common sites
Treatment & Prognosis
• Total thyroidectomy with lymphnode
  dissection if positive nodes present is
  mainstay of treatment for differentiated
  thyroid cancers
• Post surgery radioiodine scan for
  detection & ablation of remnant thyroid
  tissue in neck or in metastatic sites
Post operative radioiodine &
             Ablation
• I-131 targets residual thyroid tissue &
  tumour after thyroidectomy
• First given in diagnostic dose to detect &
  then in therepeutic dose to ablate it
• Hypothyroid state (TSH>30mIU/l) is
  required for better iodine uptake for that
  routine eltroxin supplimentation after
  surgery is to be avoided
Thyroid supression therapy
• Low TSH levels reduce the tumour growth
  rates & recurrence rates,so after surgery &
  radioablation patients should be
  maintained on thyroxin
• Most recommended TSH level is
  <0.1mIU/l
• Followup 6monthly with thyroglobulin level
  & scans are recommended
Prognosis
• Age at diagnosis-Cancer related deaths
  are more common if patient is older than
  40yrs
• Recurrences are common in patients
  diagnosed at <20yrs / >60yrs of age
• Men are at double risk to die
• Tumors of >4cm have high recurrence
  rate & deaths
• 30yr cancer related death rate is 6% for
  papillary & 15% for follicular cancer
• Local invasion portends poorer prognosis
• LN metastases is not important for
  prognosis
• Distant metastases associated with 68fold
  increase in disease specific death rate
Hurthle cell carcinoma
• A Variant of follicular cancer,also known as
  oncocytic carcinoma
• 5yr survival-50%
• More common in females and in 5th decade of life
• Same clinical presentation as follicular ca.
• Can not be diagnosed on FNA
• Does not take up Iodine, so treat aggressively
• Radio iodine, Thyroid suppression does not work
Medullary carcinoma
• 5% female preponderance
• 75% sporadically,25% familial.
• In familial cases, the lesions are usually all
  over the gland whereas in sporadic they
  are not
• Associated with MEN 2a,2b & FMTC
  syndromes
• MEN 2a - also known as Sipple syndrome

              MTC, pheochromacytoma,
              pitutory,parathyroid adenomas
•   MEN 2b – MTC, pheochromacytoma,
              ganglionomas/neuromas,
              morphanoid habitus
•   FMTC – only MTC
•   MTC in familial cases are more
    aggressive, presents in younger age, with
    rapid growth & metastases
•   Whereas in sporadic cases presents as
    painless nodule/symptoms of invasion
Biochemical test in MTC
• Calcitonin levels are used as tumour marker for
  MTC in post op to detect recurrence
• Stimulating Calcitonin release with IV
  pentagastrin increases sensitivity of test- first
  measures baseline calcitonin, then gives
  pentagastrin, then measure calcitonin serially at
  1.5 & 5min intervals
• Genetic test to detect RET gene for screening
• Histologically test for Calcitonin,CEA
Treatment for MTC
• Total thyroidectomy
• Lymphnode dissection of level 6
• Parathyroid reimplantation if necessary
• Prophylactic thyroidectomy in children with
  MEN 2a,b (>90% penetrance)
• Survielance with Calcitonin, CEA
• Does not take up iodine, so no radioiodine
• Prognosis-10yr survival rate is 65%
Anaplastic cancer
•   Bad
•   Aggressive, much invasive
•   Surgery is not indicated
•   Radio/chemotherapy
Indications for total thyroidectomy
•   Well differentiated thyroid cancer
•   Medullary thyroid cancer
•   Sarcoma of thyroid
•   Lymphoma of thyroid
•   Obstructive goitre
Thank you

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Thyroid cancers

  • 1. Thyroid cancers •Infrequent cancers-3% of all cancers •Benign diseases common •Requires multidisciplinary action •Women are affected 3 times more than men •Peak incidence 30-40yrs
  • 2. Types- • Papillary-80% • Folllicular-10% • Medullary-5-10% • Anaplastic-1-2% • Lymphoma • Sarcoma
  • 3. Etiology & Risk factors • Arise from 2 types of cells • Follicular cells makes papillary,follicular & anaplastic • Parafollicular C cells makes medullary • Radiation exposure & Hashimotos thyroiditis are risk factors for papillary ca. • Low dietary iodine is riskfactor for follicular & anaplastic
  • 4. History • Present as Painless palpable thyroid nodule • Nodules are present in 4-7% of population but most are benign,5% are mlignant • Peak incidence occurs between age of 30- 50yrs • More common in females • Malignant nodules are usually painless • Hoarseness suggests malignancy-nerve involvement
  • 5. • Dysphagia • Family history present in case of medullary cancer
  • 6. Examination • Thyroid gland • Soft tissues of neck • Tenderness? • Consistency(Hard/firm/soft) mobility(fixed or not) • Laryngoscopy if hoarseness presents
  • 7. GOAL is • To differentiate malignant from benign nodules • Determine which patient require intervention / who can be monitered • Avoid unnecessary surgery
  • 8. FNAC •First intervention in evaluation of nodule •Inexpensive,easy,few complications •Needs a good cytopathologist •Four types of results-benign-69% mallignant-4% indeterminate-10% nondiagnostic-17% Sensitivity-83%,specificity-91%
  • 9. If nondiagnostic-repeat • If benign-followup • If malignant-surgery • If indeterminate-surgery
  • 10. Lab • TSH-to know the hyper/hypo thyroidism, not helpful in malignancy • Sr.Thyroglobulin as a tumour marker in post op to assess • Calcitonin for medullary ca.
  • 11. Imaging • U/S-to differenciate solid & cystic lesions,for FNA accuracy & for monitoring of benign lesions • Scans-determine function of nodule • Carcinoma can not be ruled out based on scans as 4%of hot nodules also malignant • CT/MRI not used routinely
  • 12. Papillary cancer • Most common(80%) • Women-3 tims more common • 30-40yrs of age • Risk factors-radiation exposure in childhood, Hashimotos thyroiditis • Slow growing,TSH sensitive,take up iodine,TSH stimulation produces Tg response
  • 13. Pathology • Unencapsulated,arborizing papillae,well differentiated,rare mitoses50% have Psammaoma bodies-calcific concretions,circular laminations • Multicentric • Histology-Orphan anney eye with nuclear grooving
  • 14. • Loacl invasion through capsule, invading trachea, nerve causing dyspnea, hoarseness • Propensity to spread to the cervical lymphnodes,clinically evident in 1/3 of patients-mostly central compartment • Distal spread to lung & bones
  • 15. Follicular carcinoma • Second most common(10%) • Iodine deficient areas • 3 times more in Women • Presents more in advanced stage than papillary • Late 40’s • Also TSH sensitive, takes up iodine, produces Tg
  • 16. pathology • Round, encapsulated, cystic changes,fibrosis, haemorrhages • Microscopically neoplastic follicular cells • Differentiated by follicular adenoma by capsular invasion & angioinvasion • Cannot reliably diagnose based on FNA
  • 17. • Local invasion is similar to papillary cancer with same presentation • Cervical metastases are uncommon • Distant metastases is significantly higher(20%),with lung & bone as most common sites
  • 18. Treatment & Prognosis • Total thyroidectomy with lymphnode dissection if positive nodes present is mainstay of treatment for differentiated thyroid cancers • Post surgery radioiodine scan for detection & ablation of remnant thyroid tissue in neck or in metastatic sites
  • 19. Post operative radioiodine & Ablation • I-131 targets residual thyroid tissue & tumour after thyroidectomy • First given in diagnostic dose to detect & then in therepeutic dose to ablate it • Hypothyroid state (TSH>30mIU/l) is required for better iodine uptake for that routine eltroxin supplimentation after surgery is to be avoided
  • 20. Thyroid supression therapy • Low TSH levels reduce the tumour growth rates & recurrence rates,so after surgery & radioablation patients should be maintained on thyroxin • Most recommended TSH level is <0.1mIU/l • Followup 6monthly with thyroglobulin level & scans are recommended
  • 21. Prognosis • Age at diagnosis-Cancer related deaths are more common if patient is older than 40yrs • Recurrences are common in patients diagnosed at <20yrs / >60yrs of age • Men are at double risk to die • Tumors of >4cm have high recurrence rate & deaths
  • 22. • 30yr cancer related death rate is 6% for papillary & 15% for follicular cancer • Local invasion portends poorer prognosis • LN metastases is not important for prognosis • Distant metastases associated with 68fold increase in disease specific death rate
  • 23. Hurthle cell carcinoma • A Variant of follicular cancer,also known as oncocytic carcinoma • 5yr survival-50% • More common in females and in 5th decade of life • Same clinical presentation as follicular ca. • Can not be diagnosed on FNA • Does not take up Iodine, so treat aggressively • Radio iodine, Thyroid suppression does not work
  • 24. Medullary carcinoma • 5% female preponderance • 75% sporadically,25% familial. • In familial cases, the lesions are usually all over the gland whereas in sporadic they are not • Associated with MEN 2a,2b & FMTC syndromes
  • 25. • MEN 2a - also known as Sipple syndrome MTC, pheochromacytoma, pitutory,parathyroid adenomas • MEN 2b – MTC, pheochromacytoma, ganglionomas/neuromas, morphanoid habitus • FMTC – only MTC • MTC in familial cases are more aggressive, presents in younger age, with rapid growth & metastases • Whereas in sporadic cases presents as painless nodule/symptoms of invasion
  • 26. Biochemical test in MTC • Calcitonin levels are used as tumour marker for MTC in post op to detect recurrence • Stimulating Calcitonin release with IV pentagastrin increases sensitivity of test- first measures baseline calcitonin, then gives pentagastrin, then measure calcitonin serially at 1.5 & 5min intervals • Genetic test to detect RET gene for screening • Histologically test for Calcitonin,CEA
  • 27. Treatment for MTC • Total thyroidectomy • Lymphnode dissection of level 6 • Parathyroid reimplantation if necessary • Prophylactic thyroidectomy in children with MEN 2a,b (>90% penetrance) • Survielance with Calcitonin, CEA • Does not take up iodine, so no radioiodine • Prognosis-10yr survival rate is 65%
  • 28. Anaplastic cancer • Bad • Aggressive, much invasive • Surgery is not indicated • Radio/chemotherapy
  • 29. Indications for total thyroidectomy • Well differentiated thyroid cancer • Medullary thyroid cancer • Sarcoma of thyroid • Lymphoma of thyroid • Obstructive goitre