MOHD HELMY B ABU BAKAR

FARRAH HANNA BT MOHD NASIR

KHAIRUNISA BT JUHARI
Thyroid Malignancies
 Majority are primary tumors.
 Female > male (3:1).
 Typical Presentation of
Thyroid Cancer
Painless lump
Normal thyroid function tests
Found on routine examination or by the patient
Slow growth or no growth over several months
Signs & Symptoms of Malignant goitres:
Patients are usually euthyroid.
Thyroid nodule/ mass.
Cervical nodes enlargement- local discomfort in
neck.
Bone pain
Cough- lung metastasis
Stridor
Dysphagia
Hoarseness
Risk factors for Malignancy
Solitary thyroid nodules in patients >60 or <30 years
of age
Irradiation of the neck or face during infancy or
teenage years
Symptoms of pain or pressure (especially a change in
voice)
Male sex
Large Nodules (>3 or 4 cm)
Growth of nodule
Types of Thyroid Gland Malignancies
1) Papillary : 60%
Well-Differentiated
2) Follicular : 20%

3) Anaplastic : 5-8 % Poorly differentiated

4) Medullary : 5% Moderately differentiated

Papillary Carcinoma

Most common form, esp in young adults.

Assc. with previous exposure to ionizing
radiation.
Slow growing, painless nodule & often multifocal
within the gland.
TSH dependent.
Non functional tumor.
Spread:
i) Lymphatic (early) - int jugular, para aortic,
jugulodigastric nodes.
ii) Distant metastasis (rare) via blood –lungs, bone,
liver,etc.

Managements:
- Total thyroidectomy + removal of involved LN
- Thyroxine: lifelong hormone replacement, to
suppress TSH secretion.

Prognosis: Excellent (10 yrs survival rate 85%)

Follicular Carcinoma
Older age gp, peak at 40-50 years old.
Predisposition: Iodine-deficiency goitre.
Slow growing, painless, solitary, cold nodule.
Spread: Hematogenous to lungs, bones, liver.
More aggressive than papillary ca.
Managements:
- Total thyroidectomy + preservation of parathyroid gland.
- Thyroxine replacement.
- Radioactive iodine: for mets
- Thyroglobulin estimation every 6 months-marker of
recurrence.

Prognosis in 10 yrs survival rate:

- No mets: 90%
- Mets: 30%
Medullary Carcinoma
Neuroendocrine neoplasm of parafollicular cell (C
cell)- secrete calcitonin,VIP, serotonin, etc.

Aetiology:
1)Sporadic (80%): 40-50 yrs old.
2)Assoc. with MEN IIa/IIb : 20-30 yrs old.

Others: Familial MTC, Von Hippel Lindau Syndrome,

Neurofibromatosis
Presentation:
- Thyroid mass (hard enlargement).
- Compression symptoms: dysphagia, hoarsness
- Diarrhea : secretion of VIP

Spread:
-Lymphatic: regional LN
-Hematogenous: lungs, liver, bones
Anaplastic Carcinoma
Rapidly growing,large and bulky, highly malignant &
metastasize widely.
> elderly.
Predisposition: endemic goitre.

Spread:
1) Local invasion:
- Recurrent laryngeal nerve: hoarseness
- Trachea: dyspnoea,stridor
- Esophagus: dysphagia
- Cervical symphathetic nerves: Horner’s syndrome.
2) Lymphatic
3) Hematogenous: lungs (common), etc.

Managements:
- Resection rarely possible.
- Mainly palliative to relieve pressure symptoms: surgery
debulking.
- Chemo/radiotherapy: not effective.

Prognosis: Fatal within 1 yr of diagnosis.

Managements:
-Total thyroidectomy + removal of affected lymph nodes.
-Calcitonin level: monitor progress (any residual or
recurrence) and screen relatives (if inherited).
- Inoperable tumor: Irradiation.
- Prophylactic thyroidectomy for MEN IIa/IIb.

Prognosis: 30-50% for 10 yrs survival.

TNM Staging
 Tumor (T) Stage
 TX: Tumor cannot be evaluated.
 T0: There is no evidence of tumor.
 T1: Thyroid tumor is 2 centimeters (cm) or less.
 T2: Thyroid tumor is 2 cm to 4 cm, and within the thyroid.
 T3: The thyroid tumor is larger than 4 cm and within the thyroid, or any tumor that has minimal extension
outside of the thyroid.
 T4: The thyroid tumor has spread beyond the thyroid and involves other neighboring tissues within the neck.
All anaplastic thyroid cancers are considered T4 tumors. Tumors may be divided to T4a and T4b.

 T4a: This refers to a thyroid tumor regardless of size, which extends beyond the capsule surrounding the thyroid gland invading
the esophagus, trachea, and larynx .
 T4b: The thyroid tumor invades blood vessels (the carotid artery or blood vessels in chest) and the covering around the vertebrae.
 Note: All anaplastic thyroid cancers are considered T4 tumors, with T4a being surgically resectable and T4b being surgically
unresectable.

 Lymph Nodes (N) Stage

 NX: Nodes cannot be evaluated.
 N0: There are no cancer cells in the regional lymph nodes.
 N1: There are cancer cells in lymph nodes of the neck (cervical lymph nodes) or upper chest (upper mediastinal
lymph nodes). N1 nodes may be divided to N1a and N1b, depending on the distance from the thyroid.

 Distant Metastasis (M) Stages

 MX: Presence of metastasis cannot be evaluated.
 M0: There is no distant metastasis.
 M1: There is distant metastasis, such as to distant lymph nodes, liver, lungs, and/or brain.
 Overall Stage
 Staging of follicular and papillary thyroid cancers also takes into account on the age, since the
disease has a higher mortality rate in people over the age of 45.

 Staging for Follicular or Papillary Thyroid Cancer

 Stage I: T1, N0, M0
 Stage II: T2, N0, M0
 Stage III:
 T3, N0, M0
 T1-3, N1a, M0
 Stage IV:
 T4a, N0-N1a, M0
 T1-4a, N1, M0
 T4b, any N, M0
 T1-4, any N, M1

 Staging for Medullary Thyroid Cancer

 Stage I: T1, N0, M0
 Stage II: T2, N0, M0
 Stage III: T1-3, N1a, M0
 Stage IV: Any T, any N, M1

 Staging for Anaplastic Thyroid Cancer

- All anaplastic thyroid cancers are considered to be Stage IV because of the aggressive,
fast-growing nature of the disease. Stage IV is made up of any T, any N, and any M.
Investigations
Blood test:
- Thyroid function test: TSH, T4, T3.
- Calcitonin and serum calcium levels: if medullary ca is
suspected.

Ultrasound of thyroid gland.

FNAC – for histological diagnosis.
Thyroid scan (scintigraphy)- evaluate how the cells in
the nodule are functioning.
Chest Xray- lung mets.
Bone scan & radiographs – secondary deposits.
CT scan, MRI- staging.
THANK YOU