Thyroid Tumor


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Thyroid Tumor

  1. 1. THYROID TUMORS Salma Saud Al-Sharhan King Faisal University – Khobar Saudi Arabia
  4. 4. TYPES OF THYROID CANCER:  Primary:  Follicular epithelium – well differentiated papillary follicular  Follicular epithelium – undifferentiated Anaplastic  Parafollicular cells Medullary  Lymphoid cells lymphoma  Secondary : metastatic
  5. 5. THE CAUSES:  Radiationexposure to thyroid gland in child hood Schneider AB etal,Radation-induced endocrine tumor Cancer treat res 1997;89:141  Family hx. : a 4 to 10 fold increased risk of well differentiated thyroid cancer in 1st degree relatives with this neoplasia Galanti MR et al, risk of papillary and follicular thyroid carcinoma , Br J Cancer 1997;75:451
  6. 6. THE CAUSES:  Iodine:Iodine-deficient diets may lead to increase the TSH level and considered goitrogenic  Thyroiditis: (Hashimoto's Disease) may develop into a form of cancer called lymphoma.
  8. 8. EVALUATION OF THYROID TUMOR:  History: Age and Gender Rapid increase in size, dyspnea, dysphagia and hoarseness of voice Family Hx. Of thyroid cancer Hx. Of irradiation  On Examination: Firmness, Mobility, Size and adherence to surrounding structures Presence of lymphadenopathy
  9. 9. INVESTIGATIONS:  FNAC: The accuracy cytological diagnosis from FNA ranges from 70% to 97% and highly dependent on the skill of the physician and the cytopathologist interpreting it. Burch HB. Endocrinol Metab Clin North Am 1995;24:663
  10. 10. INVESTIGATIONS:  US: For the presence of malignant assosciations Microcalcification Irregular margins Hypervascularity Extra glandular extension Frates MC et al, Doppler sonography aid in the predfcation of malignancy of predication of thyroid of nodules J US Med 2003;22:127
  11. 11. INVESTIGATIONS:  US guided FNA : Decrease the nondiagnostic specimen Increase the sensitivity and specificity Avoiding vascular structures Carmeci C et al, US guided FNA of thyroid masses 1998;8:283
  12. 12. INVESTIGATIONS:  Radionuclide Scan: To determine the functional status of the nodule Hypofunctional “cold nodule”ule”  Serum Calcitonin level: Routine measurement of calcitonin level advocated by some authors to Dx. Medullary cancer is unknown
  13. 13. Ten most common types of Cancer among Adult Saudis by Sex, 2001
  14. 14. EASTERN REGION,2001
  15. 15. PAPILLARY THYROID CANCER:  Cysticor Solid  Most common (80-85%)  Spread through lymphatic  Female: Male is 3:1
  16. 16. PAPILLARY CANCER Typical papillary projections and empty (orphan annie-eyed) nuclei
  17. 17. CLINICAL PRESENTATION:  Incidental as a small occult tumor <1cm (papillary microcarcinoma)  Mass in the Neck the commonest way papillary cancer presents  Glands in the Side of the Neck The spread to local glands (sometimes called erroneously quot;lateral aberrant thyroidquot;).  Distant Spread Spread to lungs or bone is very rare but when it occurs unlike most other cancers, cure is possible.
  18. 18. THE FOLLICULAR CANCER:  It is unifocal, thickly encapsulated and shows invasion of both capsule and blood vessels  Spread by the blood stream and rarely through lymphatic  It is unusual tumor (5 -10%)
  19. 19. CLINICAL PRESENTATION: As a single lump in the thyroid: This is the common mode of presentation. As pain in a bone or a spontaneous fracture: in case of metastases to bone through the blood stream
  20. 20. THE PROGNOSIS IN DIFFERENTIATED THYROID CARCINOMA:  Thetwo dominant factors are the age at the diagnosis and the presence of distant metastases. Mazzafferi El etal, Long term impact of initial surgical and medical therapy on thyroid cancer .Am J Med 1994;97:418  Recentseveral scoring systems based on multifactorial analysis of risk factors have been advise
  21. 21. Low risk High risk Patient age < 45 y > 45 y Tumor size < 4.0 cm > 4.0 cm Extrathyoidal absent present extension Distant absent present metastases High tumor absent present grade
  22. 22. THE TREATMENT OF WELL DIFFERENTIATED THYROID CANCER: It Consists of a three- pronged attack :  Thyroid Surgery  Radioactive iodine therapy  Drug - Thyroxine therapy
  23. 23. SURGERY:  Acceptable surgical procedure to remove thyroid tumor include Ipsilateral lobectomy Near total thyroidectomy Total thyroidectomy  The recent American Thyroid Association Guide lines recommended for more aggressive (total thyroidectomy ) for well differentiated thyroid carcinonoma Cooper DS et al. Management guidelines for thyroid nodules ,Thyroid2006;19:109
  24. 24. SURGERY :  With a 20-year follow up the incidence of local recurrence with unilateral resection was (14%),whereas, for bilateral resection it was (2%) Brauckhoff M, et al surgery 2006;140:953  Forgross involvement of trachea or esophagus resection of these structures with reconstruction Cooper DS et al. Management guidelines for thyroid nodules , Thyroid2006;19:109
  25. 25. RADIOIODINE THERAPY:  The Indications: 1.After Surgery to destroy any residual thyroid cancer cells or residual normal thyroid tissue. 2.To treat thyroid cancer that has spread to the lymph nodes, lungs or bones. 3.To treat thyroid cancer recurrence after initial treatment by surgery or previous radioactive iodine or both.
  26. 26. RADIOIODINE THERAPY: Recent American thyroid association guide lines recommended radioiodine ablation for:  Pt. with stage III or IV disease  All Pt. with stage II disease <45 yrs or > 45 yrs  Selected Pt. with stage I disease those with:  large tumor ( >1.5 cm )  multifocality  residual disease  nodal metastasis Cooper DS et al . Management guide line for patient with thyroid nodules and cancer . Thyroid 2006;16:109
  27. 27. THYROXIN THERAPY :  Recent meta-analysis supported the efficacy of TSH suppression in preventing adverse clinical effect  High risk pt. are maintained at TSH level below 0.1 mU/ L  Low risk pt. TSH level at or below the normal range (0.1- 0.5 mU/ L) McGriff NJ, et al. effect of thyroid hormone suppression therapy on thyroid cancer. Ann Med 2002;34:557
  28. 28. THYROXIN THERAPY :  Thedegree of thyroid suppression is dictated by balancing the risk of recurrent thyroid cancer and subclinical thyrotoxicosis particularly the cardiovascular risks
  30. 30. CLINICAL IMPACT OF MOLECULAR ANALYSIS ON THYROID MANAGEMENT: PAILLARY FOLLICULAR CARCINOMA CARCINOMA CPTC PDPTC MIFTC WIFTC PDFTC Recurrence 10% 50% 10% 40% 60% Death 5% 40% 10% 40% 60% of disease RET/PTC 30% 10% 0% 0% 0% BRAF 40% 70% 0% 0% 0% P53 <5% <5% <5% <5% 40% RAS <5% 40% 40% 50% 60%
  31. 31.  Looking at BRAF mutation detection of thyroid cancer in FNAB samples demonstrate a 100% specificity and sensitivity in cases of PTC carrying BRAF mutation. Chung KW,etal. Detection of BRAF in FNA specimen of tyroid nodule.Clin Endocri 2006;65:660-6
  32. 32. MEDULLARY THYROID CANCER:  These are tumors of parafollicular (C cells), which produce a hormone called calcitonin  Types of MTC :  Sporadic MTC  Familial MTC MEN 2A MEN 2B Familial Non- MEN
  33. 33. CLINCAL PRESENTATION:  SporadicMTC: asymptomatic thyroid mass  FamilialMTC : screening stimulation test for calcitonin or with molecular analysis ( detection of RET gene mutation)
  34. 34. TREATMENT OF SPORADIC MTC: Ccells do not concentrate iodine so radioactive iodine is of no value in the management
  35. 35. Surgery is the only definitive therapy of MTC: Total thyroidectomy Central node dissection Ipsilateral modified radical neck dissection
  37. 37. TREATMENT OF FAMILIAL MTC:  Based on the genetic test for the mutation of RET gene  Since different mutations in the RET gene are associated with variable disease aggressiveness this leading to individualized treatment of pt. with inherited MTC
  38. 38. MEN2A AND FMTC RX. : Prophylactic thyroidectomy at age 5 to 6 years Moley JF. Medullary thyroid carcinoma. Curr Treat Options Onco 2003;4:339
  39. 39. MEN2B RX.: Thyroidectomy during infancy Moley JF. Medullary thyroid carcinoma. Curr Treat Options Onco 2003;4:339
  40. 40. ANAPLASTIC CANCER OF THE THYROID:  It is a very aggressive tumor with a poor prognosis  A female to male ratio 1.5:1 and a mean age is 67 years  It is commonest in areas of endemic goiter where there is chronic iodine deficiency.  ATC commonly related to prior diagnosis of well differentiated thyroid cancer Mclver B et al, Anaplastic Thyroid Carcinoma surgery 2001;130;1028
  41. 41. CLINICAL PRESENTATION: a long-standing goiter that suddenly increases in size.  Local invasion lead to obstructive symptoms, hemoptysis, dysphagia and hoarseness  At the time of Dx. 25 to 50 % of Pt. have synchronous pulmonary metastases Mclver B et al, Anaplastic Thyroid Carcinoma .Surgery 2001;130;1028
  42. 42. A woman with anaplastic A CT scan showing anaplastic cancer of the thyroid cancer of the thyroid
  43. 43. SURGICAL TREATMENT OF ATC:  Inthe majority of cases surgery is limited to an open biopsy to exclude lymphoma Mclver B et al, Anaplastic Thyroid Carcinoma .Surgery 2001;130;1028
  44. 44. RADIOTHERAPY AND CHEMOTHERAP:  External beam radiotherapy (EBRR) as been used with limited success to treat locally recurrent ATC  Doxorubicin is the single most effective chemotherapeutic for ATC Ain KB etal, treatment of anaplastic carcinoma of thyroid. (CATCHIT) Group. Tyroid 2000;10;587
  45. 45. THYROID LYMPHOMA:  Thyroid lymphoma is relatively rare disease constituting <1% of all lymphoma and accounting for 2% of extranodal non- Hodgkin’s lymphoma Green LD et al, anaplastic thyroid cancer and 1ry thyroid lymphoma. J Surg Oncol 2006;94:725  Female: Male ratio from 3:1 up to 8:1  Median age is seventh decade of life
  46. 46. CLINICAL PRESENTATION:  Local invasion : hoarseness, dyspnea with stridor, or dysphagia  Hypothyroidism in case of Autoimmune thyroiditis or Hashimoto’s thyroiditis
  47. 47. A 70 Y. old lady with diffuse large B cell lymphoma
  48. 48. TREATMENT :  Primarytreatment should be EBRT combined with Chemotherapy regimen based on histopathological subtype of lymphoma Green LD et al, anaplastic thyroid cancer and 1ry thyroid lymphoma. J Surg Oncol 2006;94:725
  49. 49. TREATMENT :  Primarytreatment should be EBRT combined with Chemotherapy regimen based on histopathological subtype of lymphoma Green LD et al, anaplastic thyroid cancer and 1ry thyroid lymphoma. J Surg Oncol 2006;94:725