THYROID CARCINOMA

Dr ganesh

Introduction
Most common endocrine malignancy 3% of total human malignancies 75% occur in woman Pts with well differentiated carcinomas excellent prognosis

Risk factors
Family history
Thyroid exposure to irradiation
low or high dose external irradiation (40-50 Gy [40005000 rad]) especially in childhood for: large thymus, acne, enlarged tonsils, cervical adenitis, sinusitis, and malignancies 30%-50% chance of a thyroid nodule to be malignant mostly papillary

 Age and Sex

Benign nodules occur most frequently in women 20-40 years 5%-10% of these are malignant Men have a higher risk of a nodule being malignant

Geneti factors
In PTC 50% association with activation of BRAF Kinase, (ras/MAPK). Ras mutations in follicular neoplasms RET proto oncogen , chr 10 95% inherited MTC Mutations of p 53 tumor supressor gene found in ATC

Types of Thyroid Cancer

Papillary (80%-85%): develops from thyroid follicle cells in 1 or both lobes; grows slowly but can spread Follicular (5%-10%): common in countries with insufficient iodine consumption; lymph node metastases are uncommon

Medullary: develops from C-cells, can spread quickly; sporadic and familial types
Anaplastic: develops from existing papillary or follicular cancers; aggressive, usually fatal Lymphoma: develops from lymphocytes; uncommon

Staging
Different staging systems include AGES AMES TNM

AJCC/UICC Staging
Stage I II III Age < 45 yrs Any T, any N, M0 Any T, Any N, M1 Age > 45 yrs <2 cm, intrathyroidal, N0, M0 2- 4cm, intrathyroidal, N0, M0 Minimal ETE, or > 4cm, N0, M0 or T1-3, N1a, M0

IVA
IVB

Any T, Any N1b/ T4a , any N,M0

T4b,any N,M0

IVC

Any T,N,M1

Papillary Thyroid Cancer

Most common type Makes up about 80% of all thyroid carcinomas Females outnumber males 2:1
Highest incidence in women in midlife

PTC pathology Variants

Conventional-65-85% Follicular-15-20% Tall cell -5-10% Solid -1-3% Diffuse sclerosing-1-2% Columnar-<1%

Papillary Thyroid Cancer Characteristics

Unencapsulated tumor nodule with ill-defined margins Tumor typically firm and solid May present as nodal enlargement Commonly metastasizes to neck and mediastinal lymph nodes 40% to 60% in adults and 90% in children <5% of patients have distant metastases at time of diagnosis Lung is most common site

Follicular Thyroid Cancer

Second most common type of thyroid cancer Solid invasive tumors, usually solitary and encapsulated Usually stays in the thyroid gland, but can spread to the bones, lungs, and central nervous system Usually less spread to the lymph nodes

Follicular Thyroid Cancer

Follicular Thyroid Cancer Diagnosis and Prognosis

Most FTCs present as an asymptomatic neck mass If caught early, this type of thyroid cancer is often curable
Tumors >3 cm have a much higher mortality rate

Hrthle Cell Cancer

A variant of follicular cancer that tends to be aggressive Represents about 3% to 5% of all types of thyroid cancer

Hrthle Cell Tumor

High power magnification

Hrthle Cell Cancer Prognosis

May be benign or malignant, based on demonstration of vascular or capsular invasion Malignancies tend to have a worse prognosis than other follicular tumors and rarely respond to 131I therapy Tend to be locally invasive

Anaplastic Thyroid Cancer

Extremely aggressive and exceptionally virulent Composed wholly or in part of undifferentiated cells

Anaplastic Thyroid Cancer (Continued)

Tumor is typically hard, poorly circumscribed, and fixed to surrounding structures Often occurs in the elderly population (mean age: 65 years) 3-fold greater risk in iodine-deficient areas

Medullary Thyroid Cancer

Tumor arising from the calcitonin-secreting C-cells of the thyroid gland Mortality rate of 10% to 20% at 10 years
Medullary (C-cell) Carcinoma

MTC Family traits

Sipplessyndrome (MEN II a) MTC
Pheochromocytoma hyperparathyroidism

Wermerssyndrome (MEN II b) MTC pheochromocytoma mucosal neuromas marfanoidhabitus.

Medullary Thyroid Cancer Types

70% to 80% of cases are sporadic disease (median age=51 years) 20% to 30% are part of 3 familial autosomal dominant syndromes (MEN-2A, MEN2B, or familial non-MEN medullary thyroid cancer [median age=21 years])

Medullary Thyroid Cancer Metastases

Cervical lymph node metastases occur early Tumors >1.5 cm are likely to metastasize, often to bone, lungs, liver, and the central nervous system Metastases usually contain calcitonin and stain for amyloid

Primary Thyroid Lymphoma

A rare type of thyroid cancer Affects fewer than 1 in 2 million people Constitutes 5% of thyroid malignancies
Large Cell Lymphoma of the Thyroid

Primary Thyroid Lymphoma Characteristics and Diagnosis

Develops in the setting of pre-existing lymphocytic thyroiditis Often diagnosed because of airway obstruction symptoms Tumors are firm, fleshy, and usually pale

Diagnosis
Serum TSH Fine Needle Aspiration Cytology (FNA)

High Resolution Thyroid US- helpful in detecting non palpable nodule and solid versus cystic lesion Thyroid Isotope Scanning- to assess functional activity of a nodule

Management WDTC
Surgical options Total thyroidectomy Thyroid lobectomy benign or inconclusive frozen section Near total thyroidectomy
Preserve minimal thyroid tissue, RLN, parathyroid glands.

Neck dissection

Management WDTC
Adjuvant therapy: Post-op radioactive iodine
Total body scan to evaluate for residual and mets If positive, I-131 ablation performed Pts should be hypothyroid (TSH > 30 mU/l) prior to scan Patients are followed with yearly scanning X 5 years

External beam radiation therapy

Advanced locoregionalWDTC with gross residual Tumors that do not pick up I-131 Unresectablebone mets

More sensitive in follicular & papillary vs. Hurthlecell

Management MTC
Surgery: Thyroidectomyand SLND (level II, III, IV), anterior compartment ND (include level VI, and/or VII). 10-year survival rate is 90% Recurrent MTC: resistant to chemo and RT