carcinoma of-thyroid-gland2003-1233910943260832-2
TRANSCRIPT
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CARCINOMA OF THYROID GLAND
Presented by Dr.K.S.DAYANIDHI P.G.
Moderator
Dr.K.RAMURTHY Prof.
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OUTLINES
Epidemiology Causes and Risk Factors Classification Clinical Presentation Diagnosis Management
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EPIDEMIOLOGY
Commonest malignant Endocrine tumor, compromise 1% of all malignancies.
Annual Incidence is 3.7 per 100,000 Sex Ratio is 3:1 (Female:Male) Can occur at any age group
Peak incidence after age of 30. Aggressiveness increases with old age.
5-year relative survival rate for all stages reach 97%. Anaplastic Thyroid Cancer ,,, much lower survival
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CAUSES AND RISK FACTORS
Genetics: Abnormal RET oncogene may cause MTC. MEN 2A, 2B Syndrome.
Family History: Hx of goiters increase risk for Papillary Ca. Gardner’s Syndrome and FAP increase risk for
Papillary Ca. Radiation Exposure:
Radiation therapy to Head or Neck. Exposure to Radioactive Iodine during childhood,
or other radioactive substances (Chernobyl) ↑ risk for particularly Papillary carcinoma.
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CAUSES AND RISK FACTORS
Chronic Iodine deficiency ↑ risk for Follicular carcinoma.
Gender: Female > Males.
Age: More common at young adults. MTC usually diagnosed after 60.
Race: White race > Black race.
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Thyroid Neoplasm
Benign Malignant
Secondary
PrimaryFollicularPapillary
Follicular Cells
Parafollicular Cells
Lymphoid Cells
LymphomaMedullary
Differentiated Undifferentiated
AnaplasticFollicularPapillary
Hurthle Cell
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Thyroid carcinomas:
Papillary carcinoma
Follicular carcinoma
Poorly differentiated carcinoma
Undifferentiated (anaplastic) carcinoma
Squamous cell carcinoma
Mucoepidermoid carcinoma
Sclerosing mucoepidermoid carcinoma with eosinophilia
Mucinous carcinoma
Medullary thyroid carcinoma
Mixed medullary and follicular cell carcinoma
Spindle cell tumor with thymus-like differentiation (SETTLE)
Carcinoma showing thymus-like differentiation (CASTLE)
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CLINICAL PRESENTATION
Solitary thyroid nodule Single most common presentation. Up to 99% of nodules are benign.
Hoarseness of Voice. Enlarged Cervical Lymph nodes. Difficulty swallowing. Dyspnea. Pain in the Neck. Persistent cough.
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DIAGNOSIS
Laboratory: TSH T3, T4 Serum Thyroglobulin Serum Thyroid
Antibodies FNA Tru-cut Biopsy Intra-operative
frozen-section
Imaging U/S C.T MRI Scintigraphy
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LABORATORY
Most patients are Euthyroid. Hyperfunctioning nodule 1% chance of
malignancy. Serum Tg cannot differentiate between
benign and Malignant nodules Tg is used for:
F/U after total thyroidectomy Serial F/U for non-operative treatment
Serum Calcitonin patients with MTC, or with family hx of MTC (MEN2)
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FNA CYTOLOGY
Popularized in the 1960s by Einhorn and Franzen at the Karolinska Institute, Stockholm.
Single most important test. U/S guidance improve the sensitivity. Accuracy ranges from 70 – 97%. Nodules
Benign 70% Malignant 4% Suspicious or Intermediate 10% (Frozen-sction) Insufficient Sampling 17%
FNAC cannot differentiate between Benign and Malignant Follicular Neoplasia
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IMAGING
U/S is the investigation of choice. Solid vs. Cystic, Size, Content etc. Adjacent Lymphadenopathy
C.T Regional and distant metastases MRI Limited role in the diagnosis
Useful in detecting cervical LN metastases Scintigraphy (I-123, Gallium-67)
Characterizing funtioning nodules Staging of follicular and papillary Ca Gallium-67 used in detection of thyroid lymphoma
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PROGNOSTIC INDICATORS
AGES score:Age Hisological GradeExtrathyroidal invasionMetastasis
MACIS score (post-operative): Distant MetastasisAgeCompleteness of original surgical resection Extrathyroidal InvasionSize of original lesion
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PAPILLARY CARCINOMA Most common Thyroid carcinoma (80%) Related to radiation exposure in I-sufficient
areas. Female:male ratio is 2:1 Mean age of presentation is 30 to 40 yrs. Slow growing painless mass. Euthyroid-
status. LN metastases is common, may be the
presenting symptom (Lateral Aberrant Thyroid).
Distant metastases is uncommon at initial presentation.
Develop in 20% of cases. (Lungs, liver, bones,brain)
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PAPILLARY CARCINOMA
FNA biopsy is diagnostic.
Treatment Ipsilateral Lobectomy + Isthmusectomy (No LN
metastasis) Near-total or Total Thyroidectomy + Modified-
radical or Functional neck dissection (+ve LN metastasis).
Prophylactic LN dissection is unnecessary.
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HISTOPATHOLOGY
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FOLLICULAR CARCINOMA
Account for 10% of all thyroid cancers. More common in I-deficient areas. Female:male ratio is 3:1 Mean age at presentation is 50 yrs. Solitary thyroid nodule, rapid increase in size
and long-standing goiter. Cervical LN metastasis is uncommon at
presentation (5%), distant metastasis may be present.
Hyperfunctioning < 1%. (S&S of Thyrotoxicosis)
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FOLLICULAR CARCINOMA
FNA biopsy cannot differentiate between benign and malignant follicular tumors.
Pre-operative diagnosis of malignancy is difficult unless there is distant metastasis.
Large follicular tumor > 4 cm in old individual CA.
Treatment: Thyroid Lobectomy (at least 80% are benign
adenomas) Total-Thyroidectomy in older individual with
tumor > 4cm (50% chance of malignancy). Prophylactic nodal dissection is unnecessary.
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HISTOPATHOLOGY
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MEDULLARY CARCINOMA
5% of all thyroid malignancies. Arise from Parafollicular cells, concentrated in
superolateral aspect of thyroid lobes. Most cases are sporadic, 25% are inherited
(Germline mutation in RET oncogene). Female:Male ratio is 1.5:1 Most patients present between 50 and 60 yrs. Neck mass + palpable cervical LN (15-20%). Local pain or aching is common.
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HISTOPATHOLOGY
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MEDULLARY CARCINOMA
Treatment: > 50% are bilateral, ↑ Multicentricity. Total Thyroidectomy + :
Bilateral central node dissection as routine (No LN involvement)
Bilateral Modified-Radical Neck dissection (palpable LN) Ipsilateral Prophylactic nodal dissection in tumor size >
1.5cm. External Beam radiation for unresectable residual or
recurrent tumor. No effective Chemotherapy.
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ANAPLASTIC CARCINOMA
1% of all thyroid malignancies. Women > Men. Majority present at 7th - 8th decade of life. Long-standing neck mass, rapidly enlarging
in size. May be painful, with dyphonia, dyspnea,
dysphagia. LN are usually involved at presentation. ± Distant metastasis.
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ANAPLASTIC CARCINOMA
FNAC is diagnostic. Treatment:
Most aggressive thyroid tumor. Total Thyroidectomy if resectable. Adjuvant Chemotherapy + Radiotherapy slightly
improve long-term survival.
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HISTOPATHOLOGY
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HISTOPATHOLOGY
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Hurthle-Cell Carcinoma: 3% of all Thyroid Ca. Subtype of Follicular Ca. More multicenteric and bilateral (30%). FNAC is not conclusive. Lobectomy + isthmusectomy (unilateral) Total Thyroidectomy (bilateral)
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HISTOPATHOLOGY
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PROGNOSIS
Tumor Prognosis
Papillary Ca. 74-93% long-term survival rate
Follicular Ca. 43-94% long-term survival rate
Hurthle Cell Ca. 20% mortality rate at 10 years
Medullary Ca. 80% 10-year survival rate45% with LN involvement
Anaplastic TumorMedian survival of 4 to 5
months at time of diagnosis
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THANK YOU