Thyroid tutorial by our dedicated Dr. Lohith [BMJH]

1. THYROID TUMORS
Dr Lohith S
DNB Resident
Department of General Surgery
Bhagwan Mahaveer Jain Hospital, Bangalore

2. NORMAL ANATOMY OF THE THYROID GLAND:

3. MICROSCOPIC PICTURE OF THE THYROID
GLAND:

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. THE CAUSES:
Radiation exposure to thyroid gland in
child hood
Family history : a 4 to 10 fold increased
risk of well differentiated thyroid
cancer in 1st degree relatives with this
neoplasia

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.

7. TNM STAGING OF THYROID CANCER:

8. EVALUATION OF THYROID TUMOR:
 History:
Age and Gender
Rapid increase in size, dyspnea,
dysphagia and hoarseness of voice
Family History Of thyroid cancer
History Of irradiation
 On Examination:
Firmness, Mobility, Size and adherence
to surrounding structures
Presence of lymphadenopathy

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.

10. INVESTIGATIONS:
Ultrasound:
For the presence of malignant assosciations
Microcalcification
Irregular margins
Hypervascularity
Extra glandular extension

11. INVESTIGATIONS:
Ultrasound guided FNAC :
Decrease the nondiagnostic specimen
Increase the sensitivity and specificity
Avoiding vascular structures

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 Diagnose
Medullary cancer is unknown

13. PAPILLARY THYROID CANCER:
 Cystic or Solid
 Slow growing
 Young females
 Female: Male is 3:1
 Most common (80-85%)
 Local recurrence rate of papillary carcinoma is
more while distant metastasis is less
 Spread through lymphatic
 Multicentric-local recurrence rate of pappilary
carcinoma is more while distant metastasis is rare.
 Hugely non encapsulated

14. Most common risk factors :
 Radiation
 Family history
 FAP
 Iodine excess
Presentations:
 Nodule in thyroid
 Dysphagia
 Dysphonia
 Lymphnode enlargement

15. PAPILLARY CANCER
Typical papillary projections and
empty (orphan annie-eyed) nuclei

16. Orphan annie nuclei: large amount of chromatin
present in nucleus makes it transparent

17. PSAMMOMA BODIES
 Psammoma bodies (PBs) are concentric
lamellated calcified structures, observed most
commonly in papillary thyroid carcinoma (PTC),
meningioma, and papillaryserous
cystadenocarcinoma of ovary but have rarely
been reported in other neoplasms and
nonneoplastic lesions.

19. 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 "lateral aberrant thyroid").
Distant Spread
Spread to lungs or bone is seen but when it occurs
unlike most other cancers, cure is possible.

20. Common mode of
spread: lymphatics
Most common organ of
distant metastasis: lung

21. THE FOLLICULAR CANCER:
It is unifocal(local recurrence is less)
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%)

22. RISK FACTORS:
 iodine deficiency
 Family history
 radiation
PRESENTATION:
 Already existing swelling growing in size
 Nodules
 Dysphagia
 Dysphonia
MOST COMMON HEMATOGENEOUS SPREAD
IS TO SKULL (USUALLY TO
OCCIPUT)CAUSING PULSATILE
SECONDARIES.

23. 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

25. COMPARISON:
 Non capsulated
 Multicentric
 Slow-growing
 Iodine excess
 Usually lymphatic route
of spread
 Distant metastasis to
lung
 Encapsulated
 Unifocal
 Present as rapid
increase in size
 Iodine deficiency
 Usually hematogenous
route of spread
 Distant metastasis to
occiput
Papillary Follicular

27. THE PROGNOSIS IN DIFFERENTIATED
THYROID CARCINOMA:
 The two dominant factors are the age at the
diagnosis and the presence of distant
metastases.
 Recent several scoring systems based on
multifactorial analysis of risk factors have been
advise

29. Most important to determine the
prognosis is
STAGE OF CARCINOMA.

30. Low risk High risk
Patient age < 45 y > 45 y
Tumor size < 4.0 cm > 4.0 cm
Extrathyoidal
extension
absent present
Distant
metastases
absent present
High tumor
grade
absent present

31. DEPENDING OF INVASION
 <1cm
 Noncapsular invasion
 No blood vessel
 No lymphnode invasion
 >1cm
 Capsular invasion
 Blood vessel invasion
 Lymphatic invasion
MICROINVASIVE INVASION

32. THE TREATMENT OF WELL
DIFFERENTIATED THYROID CANCER:
It Consists of a three- pronged attack :
Thyroid Surgery
Radioactive iodine therapy
Drug - Thyroxine therapy

33. 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

34. USUALLY WE FOLLOW
 For Papillary Thyroid Carcinoma
microinvasive –Total thyroidectomy >near total
invasive - Total thyroidectomy
o For Follicular Thyroid Carcinoma
microinvasive –hemithyroidectomy
invasive - Total thyroidectomy
If lymphnodes are involved
ipsilateral modified radical neck
dissection is done.

36. SURGERY :
 With a 20-year follow up the incidence of
local recurrence with unilateral resection was
(14%),whereas, for bilateral resection it was
(2%)
 For gross involvement of trachea or
esophagus resection of these structures with
reconstruction

37. ONE OF THE FEATURE OF PAPILLARY THYROID
CARCINOMA IS CYST
 In case of cyst-aspiration is done
simple /benign
3 times re-aspired
If it still recurs then excision is done

38. 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.

39. 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

40. 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)

41. THYROXIN THERAPY :
The degree of thyroid suppression is
dictated by balancing the risk of
recurrent thyroid cancer and
subclinical thyrotoxicosis
particularly the cardiovascular risks
Supression therapy is monitored by
serum thyroglobulin(ideally should
be <2ng/ml)

42. MEDULLARY THYROID CANCER:
 These are tumors of parafollicular (C
cells), which produce a hormone called
calcitonin
 Types of MTC :
 Sporadic MTC(common type)
 Familial MTC
MEN 2A
MEN 2B
Familial Non- MEN

44. So a patient with Medullary Thyroid
Carcinoma, rule out MEN Syndrome
by ruling out
PHEOCHROMOCYTOMA.
In MEN- pheochromocytoma is
treated first even if it is benign

45. CLINCAL PRESENTATION:
Sporadic MTC:
asymptomatic thyroid mass that is
patient usually presents with a nodule.
Familial MTC :
patient may usually present with
diarrohea.
screening stimulation test for calcitonin
or with molecular analysis ( detection
of RET gene mutation)

46. ENZYMES SECRETED IN MEDULLARY THYROID
CARCINOMA
Calcitonin
CEA
ACTH
PROSTAGLANDINS
SEROTONIN(release is the
reason for diarrohhea)

47. TREATMENT OF SPORADIC MTC:
C cells do not concentrate
iodine so radioactive iodine is of
no value in the management

48. Surgery is the only definitive
therapy of MTC:
-Total thyroidectomy
-Central node dissection
- Ipsilateral modified radical neck
dissection
1. if size of medullary thyroid
carcinoma is more than 2 cm.
2. if LN are enlarged.

49. A TUMOR ERODING INTO THE CHEST WALL

50. 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

51. MEN2A AND FMTC RX. :
Prophylactic thyroidectomy at age 5 to
6 years

52. MEN2B RX.:
Thyroidectomy during infancy that is around 6
months.
Surveillance is usually by
yearly calcitonin assessment.

53. ANAPLASTIC CANCER OF THE THYROID:
It is a very aggressive tumor with a worst
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

54. 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 Diagnosis 25 to 50 % of
Patient have synchronous pulmonary
metastases

55. ANAPLASTIC CARCINOMA
Most common mode of spread
is- local infiltration.
Consistency- woody hard
Life expectancy is 6 months.

56. A CT scan showing anaplastic
cancer of the thyroid
A woman with anaplastic
cancer of the thyroid

57. SURGICAL TREATMENT OF ATC:
In the majority of cases surgery is
limited to an open biopsy to exclude
lymphoma
Otherwise treatment usually involves
total thyroidectomy with chemotherapy
agents
Or we can go for palliative treatment
like istemectomy or tracheostomy

58. 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

59. THYROID LYMPHOMA:
Thyroid lymphoma is relatively rare
disease constituting <1% of all
lymphoma and accounting for 2% of
extranodal non- Hodgkin’s lymphoma
 Female: Male ratio from 3:1 up to 8:1
Median age is seventh decade of life

60. CLINICAL PRESENTATION:
 Local invasion : hoarseness, dyspnea
with stridor, or dysphagia
Hypothyroidism in case of Autoimmune
thyroiditis or Hashimoto’s thyroiditis

61. A 70 Y. old lady with diffuse
large B cell lymphoma

62. TREATMENT :
Primary treatment should be EBRT
combined with Chemotherapy
regimen based on histopathological
subtype of lymphoma

63. TREATMENT :
Primary treatment 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