THYROID CANCER

Thyroid Cancer Type and

Incidence

 Papillary ~ 60-75%
 Follicular ~20-30%
 Medullary ~ 5-10%
 Anaplastic ~ 3%
 KEY POINTS
 Thyroid cancer is the most common
malignancy of the endocrine glands.
 The great majority of cancers of the
follicular thyroid epithelium are well-
differentiated (papillary and
follicular) and have a good
prognosis, particularly in young
patients.
 KEY POINTS

 Thyroid Ca is one of the most

curable cancers.
 The incidence of thyroid Ca in

thyroid nodules ranges from

0.5% to 10%.
 ETIOPATHOGENESIS
 ONCOGENES:
– gene rearrangements RET/PTC
(papillary Ca)
– mutations of the ras gene family
(an early event in thyroid
tumorigenesis)
– inactivating mutations of the p53
tumor-suppressor gene
(undiffereniated thyroid Ca)
 ETIOPATHOGENESIS

 External irradiation of the neck

(the latency period is at least 5

years)
 Iodine deficiency (Follicular Ca)
 PAPILLARY CANCER

The Most Common Thyroid

Cancer
 Peak onset ages 30 through 50
 Females more common than males by 3
to 1 ratio
 Prognosis directly related to tumor size
[less than 1.0 cm - good prognosis]
 Accounts for 85% of thyroid cancers
due to radiation exposure
 PAPILLARY CANCER
 Spread to lymph nodes of the neck
present in more than 50% of cases
 Distant spread (to lungs or bones)
is very uncommon
 Overall cure rate very high

(near 100% for small lesions in

young patients)
 MANAGEMENT OF
PAPILLARY THYROID
CANCER
 Papillary carcinomas that are
well circumscribed, isolated, and
less than 1cm in a young patient
(20-40) without a history of
radiation exposure may be
treated with hemithyroidectomy
and isthmusthectomy.
 MANAGEMENT OF
PAPILLARY THYROID
CANCER
All others should be treated
with total thyroidectomy and
removal of any enlarged
lymph nodes in the central or
lateral neck areas.
 MANAGEMENT OF
PAPILLARY THYROID
CANCER AFTER SURGERY
 Since papillary cancer may
respond to TSH, thyroid
hormone is given in doses
large enough to suppress
secretion of TSH and help
prevent a recurrence.
 MANAGEMENT OF
PAPILLARY THYROID
CANCER AFTER SURGERY
 Serum FT3 i FT4 should be in the
normal range to avoid iatrogenic
thyrotoxicosis
 Serum Tg, a marker of cell
function, increases dramatically
during hypothyroidism, while it
returns to low levels during
hormone therapy
 MANAGEMENT OF
PAPILLARY THYROID
CANCER AFTER SURGERY
 Papillary cancer cells absorb
iodine and therefore they
can be targeted for death
by giving the toxic isotope
(I-131).
 MANAGEMENT OF
PAPILLARY THYROID
CANCER AFTER SURGERY
 In patients with larger tumors,
spread to lymph nodes or other
areas, tumors which appear
aggressive microscopically,
radioactive iodine is often given in
expectation that any remaining
thyroid tissue or cancer that has
spread away from the thyroid will
take it up and be destroyed.
 PAPILLARY THYROID
CANCER LONG-TERM
FOLLOW UP
 A yearly chest X-ray
A yearly chest X-ray
 Thyroglobulin levels
a high serum thyroglobulin level that
had previously been low following total
thyroidectomy especially if gradually
increased with TSH stimulation is
virtually indicative of recurrence.
A value of greater than 10 ng/ml is often
associated with recurrence even if an
iodine scan is negative.
 FOLLICULAR CANCER

THE SECOND MOST COMMON THYROID

CANCER
 Peak onset ages 40 through 60
 Females more common than males by 3
to 1 ratio
 Prognosis directly related to tumor size
[less than 1.0 cm - good prognosis]
 Rarely associated with radiation
exposure
 Spread to lymph nodes is uncommon
(~10%)
 FOLLICULAR CANCER
 Invasion into vascular structures
(veins and arteries) within the
thyroid gland is common.
 Distant spread (to lungs or bones) is
uncommon, but more common than
with papillary cancer.
 Overall cure rate high (near 95% for
small lesions in young patients),
decreases with advanced age.
 FOLLICULAR THYROID
CANCER
 Many cases of follicular thyroid cancer
are subclinical.
 Most common presentation of thyroid
cancer is an asymptomatic thyroid mass,
or a nodule, that can be felt in the neck.
 Some patients have persistent cough,
difficulty breathing, or difficulty
swallowing.
 Pain seldom is an early warning sign of
thyroid cancer.
 FOLLICULAR THYROID
CANCER
 Other symptoms (rare):
 pain,
 stridor,
 vocal cord paralysis,
 hemoptysis,
 rapid enlargement.

These symptoms can be caused by

less serious problems.
 FOLLICULAR THYROID
CANCER
 At diagnosis, 10-15% of
patients have distant
metastases to bone and lung
and initially are evaluated for
pulmonary or osteoarticular
symptoms (eg, pathologic
fracture, spontaneous fracture).
 MANAGEMENT OF
FOLLICULAR THYROID
CANCER
 Follicular carcinoma should always
be treated with total
thyreoidectomy.
 A completion thyreoidectomy
should always be performed in
patients who have undergone a
lobectomy for a presumed benign
tumor that proved to be follicular
carcinoma at definitive histology.
MANAGEMENT OF FOLLICULAR
THYROID CANCER AFTER
SURGERY
 Perform postoperative
scintiscan of the neck after 4-6
weeks.

If thyroid tissue is present, a
dose of radioactive iodine is
administrated to destroy
residual tissue.
MANAGEMENT OF FOLLICULAR
THYROID CANCER AFTER
SURGERY

Repeat scintiscan 6-12

months after ablation and,
thereafter, every 2 years.
Radioactive iodine may
ablate the metastatic tissue
in the lungs and bone.
MANAGEMENT OF FOLLICULAR
THYROID CANCER AFTER
SURGERY

Perform thyroid hormone

suppression in all patients
with total thyroidectomies
and in all patients who have
had radioactive ablation of
any remaining thyroid tissue.
MANAGEMENT OF FOLLICULAR
THYROID CANCER AFTER
SURGERY
 A patient who has had a
thyroidectomy without parathyroid
preservation will require vitamin D
and calcium for the rest of their
life.
 Evaluate thyroglobulin serum
levels every 6-12 months for at
least 5 years.
FOLLICULAR ADENOMA
 It is benign neoplasm.
 No differentiation is possible
between adenoma and carcinoma
by cytology or in most cases even
by frozen section.
 Capsular and vascular invasion
are key features that distinguish
between benign and malignant
follicular proliferation.
 HÜRTHLE CELL
CARCINOMA
WHO 1988: oxyphilic variant
of follicular carcinoma.
 It may be also Hürthle cell
variant of papillary thyroid Ca.
 Some authors classify it
separately as Hürthle cell
carcinomas.
 HÜRTHLE CELL
CARCINOMA
 Although preferentially classified
among follicular tumors, Hüthle
cell carcinomas are usually more
aggresive and metastasizing,
and they are less prone to take
up radioiodine and produce
thyroglobulin than well-
differentiated thyroid
carcinomas.
ANAPLASTIC CANCER
 Peak onset age 65 and older.
 Very rare in young patients.
 Males more common than
females by 2 to 1 ratio.
 Can occur many years after
radiation exposure.
 Typically presents as rapidly
growing neck mass.
 ANAPLASTIC CANCER
 Spread to lymph nodes of the neck
present in more than 90% of cases.
 Distant spread (to lungs or bones)
is very common even when first
diagnosed.
 Overall 5-year survival rate is
reportedly less than 10%, and
most patients do not live longer
than a few months after diagnosis.
 ANAPLASTIC CANCER
SYMPTOMS
A rapidly growing neck mass
Dysphagia
Cough
Neck pain
Dyspnea
Patients with metastases also may
note bone pain, weakness, and cough
Neurologic deficits may be observed
with brain metastases.
ANAPLASTIC CANCER
SURGICAL CARE

 Perform surgery in
conjunction with radiation
and chemotherapy.
 Use surgery to obtain a
definitive diagnosis when fine
needle aspiration is
unsuccessful.
 ANAPLASTIC CANCER

Despite the typically large

size of these tumors,

extent of resection is
limited when diagnosis is
made.
 ANAPLASTIC CANCER
 Rather than performing complete
thyroidectomy, resect as much
thyroid tissue as possible without
attempting resection of all
adjacent structures because of
the high incidence of
postoperative morbidity (eg,
vocal cord paralysis, esophageal
fistula).
 ANAPLASTIC CANCER
FURTHER INPATIENT CARE

Radiotherapy:
Despite the fact that ATC is
largely radioresistant, use
external beam radiotherapy
for local control.
 ANAPLASTIC CANCER
Chemotherapy:
 Currently, no available
chemotherapeutic agent or combination
of chemotherapeutic agents shows
sufficient antineoplastic activity to
prevent death;
yet in rare instances, chemotherapy may
prolong life by a few weeks or perhaps
months.
Doxorubicin and cisplatin are the two most
common agents used.
 MEDULLARY THYROID
CANCER
 A distinct thyroid carcinoma
that originates in the
parafollicular C cells of the
thyroid gland.
These C cells produce calcitonin.
 Females more common than
males
(except for inherited cancers).
 MEDULLARY THYROID
CANCER
Regional metastases (spread
to neck lymph nodes) occurs
early in the course of the
disease.
Spread to distant organs
(metastasis) occurs late and
can be to the liver, bone,
brain, and adrenal medulla.
 MEDULLARY THYROID
CANCER

Not associated with radiation

exposure.
Usually originates in the
upper central lobe of the
thyroid.
 MEDULLARY THYROID
CANCER
 Poor prognostic factors
include age >50, male, distant
spread (metastases), and MEN
II-B.
 Residual disease (following
surgery) or recurrence can be
detected by measuring
calcitonin.
 MEDULLARY THYROID
CANCER
FOUR CLINICAL SETTINGS

 SPORADIC
Accounts for 80% of all cases of
medullary thyroid cancer

 MEN II-A (SIPPLE SYNDROME)

 bilateral medullary carcinoma or
C cell hyperplasia,
 pheochromocytoma
 hyperparathyroidism
MEDULLARY THYROID CANCER

FOUR CLINICAL SETTINGS

 MEN II-B
 medullary carcinoma
 pheochromocytoma
 an unusual appearance which is
characterized by mucosal
ganglioneuromas (tumors in the
mouth) and a Marfanoid habitus.
 hyperparathyroidism (uncommon)
 INHERITED MEDULLARY CARCINOMA
WITHOUT ASSOCIATED
ENDOCRINOPATHIES.
 Endocrine diseases occuring
together in different endocrine
glands are due to multiple, mostly
hereditary benign and malignant
neoplasms or hyperplasia with
excessive function (MEN=MEA),
or develop in response to an
autoimmune reaction affecting
different endocrine and perhaps
other glands
(autoimmune polyglandular
syndromes =APS)
 AUTOIMMUNE POLYGLANDULAR
SYNDROMES
TYPE 1 = Blizzard’s TYPE 2 = Schmidt’s
syndrome syndrome
Major components: Major components:
 Chronic  Autoimmune thyroid
mucocutaneous disease
candidiasis  Type 1 diabetes
 Hypoparathyroidis melltus
m  Addison’s disease
 Addison’s disease  Premature ovarian
+ other failure
endocrinopathies + other endocrinopathies
and features and features
 MEDULLARY THYROID
CANCER
SYMPTOMS

a lump at the base of the

neck, especially during
swallowing;
hoarseness, dysphagia, and
respiratory difficulty;
 MEDULLARY THYROID
CANCER
SYMPTOMS
 various paraneoplastic
syndromes, including Cushing or
carcinoid syndrome
(uncommon).
 Diarrhea secondary to high
plasma calcitonin levels.
 Distant metastases.
 MEDULLARY THYROID
CANCER
WORKUP
 Serum calcitonin levels.
 Pentagastrin-stimulated calcitonin
levels.
 DNA testing for RET (it may
replace the diagnostic method
mentioned above).
 24-hour urinalysis for
catecholamine metabolites.
 MEDULLARY THYROID
CANCER
WORKUP
 Screening for the development of
familial MCT in family members of
patients with history of MCT or MEN
2A or 2B.

 Screen all family members for

missense mutation in RET in
leukocytes.
 MEDULLARY THYROID
CANCER
WORKUP
 A cervical ultrasound

(to detect LN metastases).

 CT scan, MRI, and bone scans.

 Fine needle aspiration.

 MEDULLARY THYROID
CANCER
MANAGEMENT
 All patients should receive total
thyroidectomy, a complete central neck
dissection (removal of all lymph nodes
and fatty tissues in the central area of the
neck), and removal of all lymph nodes and
surrounding fatty tissues within the side
of the neck which harbored the tumor.

 Radioactive iodine therapy is not useful.

 MEDULLARY THYROID
CANCER
MANAGEMENT

Long-Term Follow

A yearly chest x-ray as well as

calcitonin levels.