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THYROID MALIGNANCY WITH BY,

FUNCTIONAL NECK NODE RASHMA . J


2015 BATCH
DISSECTION
CLASSIFICATION
BENIGN MALIGNANT
SECONDAR
Follicular PRIMARY
Y
adenoma
 Metastati
c
 local
Infiltratio
n
ETIOLOGY
 Papillary CA – Most Common
Females : Males = 3:1
Malignancy Etiology Age Group

Papillary Carcinoma Radiation exposure under 5 years 30 to 40 years

Follicular Carcinoma Preexisting Multinodular Goitre >50 years

Medullary Carcinoma MEN type2 Syndrome Familial – Children and Young


Adults
Sporadic – Any age
Anaplastic Carcinoma De novo or Dedifferentiation from 70 – 80 years
Well differentiated tumors
Malignant Lymphoma Autoimmune thyroiditis
PATHOGENESIS
CLINICAL FEATURES
MOST COMMON PRESENTING SYMPTOM – THYROID
SWELLING
Papillary Carcinoma Slow growing tumor
Lymph nodes palpable
Follicular Carcinoma Solitary Thyroid nodule
Rapidly increasing in size
H/o Long standing Goitre
Hurthle cell Carcinoma Variant of follicular CA
Regional lymph node palpable
Anaplastic Carcinoma Aggressive tumor
Presents with symptoms of invasion of adjacent
structures
Medullary Carcinoma DIARRHOEA, Flushing (VIP, serotonin, Prostaglandin)
MEN 2A – Pheochromocytoma, Hyperparathyroidism
MEN 2B – Mucosal Neuroma, Marfanoid habitus
Malignant Lymphoma Rapidly growing tumor
Associated
symptoms
 Dyspnea / Stridor
 Dysphagia
 Hoarseness of
voice /
Dysphonia
 Berry’s sign
 Horner’s
Syndrome
METASTASIS

Papillary CA Lymphatic spread

gs

Liv
n
Follicular CA Hematogenous Distant

er
Lu
Metastas
Medullary Both lymphatic and is
CA hematogenous SITES

Anaplastic Direct Invasion Bones


CA
SKULL : Pulsatile soft fluctuant non-mobile swelling
SEEN IN FOLLICULAR CARCINOMA
HISTOPATHOLOGY
Papillary carcinoma Psammoma Bodies
cannot
Follicular carcinoma
HISTOPATHOLOGY be diagnosed by
FNAC
Follicular carcinoma

HURTHLE
CELL
CARCINOMA
Abundant
Oxyphill cells
HISTOPATHOLOGY
Medullary carcinoma

Characteris
tic
“AMYLOID
” stroma
HISTOPATHOLOGY
Anaplastic carcinoma

Pleomorphic
spindle-shape
and
epitheloid
tumor cells
AJCC STAGING – WELL
DIFFERENTIATED
STAGING
STAGING

All Anaplastic
carcinoma are
always STAGE 4
METASTASIS TO THYROID
Renal cell carcinoma
Breast cancer
Lung caner
Colon Cancer
Melanoma
DIAGNOSIS
 Thyroid Function tests – free T3(3.5 to 7.5 micromol/L), free T4(10
to 30 nmol/L), TSH(0.3-3.3 mU/L)
Ultrasound Neck
Fine Needle Aspiration Cytology
Trucut Biopsy
Radioactive iodine uptake scan – Only in selected cases
X ray / CT scan – Assess airway
Follicular Lesions – Hemithyroidectomy for intraoperative frozen
section examination
Tumour markers
Thyroglobulin – Differentiated cancer
Calcitonin and Carcinoembryogenic Antigen – Medullary cancer
TREATMENT
Surgery – Total
thyroidectomy
Papillary carcinoma  Total thyroidectomy + Functional neck dissection +
TSH suppression and follow up by thyroglobulin

Follicular carcinoma  Total thyroidectomy and follow up by thyroglobulin


 Radioiodine therapy for remnant tissue
Medullary carcinoma  Total thyroidectomy + central neck node
dissection /Functional neck dissection
 Prophylactic thyroidectomy (MEN SYNDROME)
Anaplastic  Total thyroidectomy + Radiotherapy +/-
carcinoma Chemotherapy
(or) Palliative surgery
Malignant  Radiotherapy and Chemotherapy
lymphoma
FUNCTIONAL NECK
DISSECTION
POSTOPERATIVE
MANAGEMENT
TSH suppression therapy:
High risk: Suppress TSH (Thyroxine - 300 micrograms)
Low risk: Physiological level (Thyroxine -100- 150 micrograms)

Radio Iodine Therapy:


I131 delivered in tumoricidal doses
Dose: 30 – 100 millicuries
Stop thyroxine suppression therapy before 3 – 4 weeks
Given in unresectable disease, distant metastases, rising
thyroglobulin in absence of structural disease
PROGNOSIS
PROGNOSTIC RISK CLASSIFICATION IN WELL DIFFERENTIATED CARCINOMA

FEATURES LOW RISK HIGH RISK


Age <40 years >40 years
Metastasis None Regional or Distant
Grade Well differentiated Poorly differentiated
Extent No local extension, Intrathyroidal, Capsular invasion, Extrathyroidal
No Capsular invasion extension
Size <4 cm >4cm

 Medullary carcinoma POOR


 Anaplastic carcinomaPROGNOSI
 Hurthle cell carcinoma
S