Thyroid Cancer

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Thyroid Cancer

  1. 1. The Thyroid
  2. 2. Goals and Objectives <ul><li>Review thyroid anatomy and function </li></ul><ul><li>Present sweet case </li></ul><ul><li>Discuss pathology related to sweet case </li></ul>
  3. 3. Anatomy 101
  4. 4. Closer…
  5. 5. Closer still… <ul><li>Too close </li></ul>
  6. 6. Not quite as close…
  7. 7. Thyroid Function in Review
  8. 8. Key Players <ul><li>TRH </li></ul><ul><ul><li>From parvocellular neurons of hypothalamus </li></ul></ul><ul><li>TSH </li></ul><ul><ul><li>From basophilic cells of anterior pituitary </li></ul></ul><ul><li>Thyroglobulin </li></ul><ul><ul><li>Stores T1-T4 in colloid </li></ul></ul><ul><li>T4 </li></ul><ul><ul><li>More common </li></ul></ul><ul><ul><li>More potent </li></ul></ul><ul><li>T3 </li></ul><ul><ul><li>More common </li></ul></ul><ul><ul><li>More potent </li></ul></ul><ul><li>Calcitonin </li></ul>
  9. 9. Normal Thyroid
  10. 10. When good thyroids go bad <ul><li>Hypofunctioning </li></ul><ul><li>Hyperfunctioning </li></ul><ul><li>Neoplasia </li></ul>
  11. 11. The Case
  12. 12. 1950s
  13. 13. What can’t be radiated? <ul><li>Therapeutic irradiation </li></ul><ul><ul><li>Acne </li></ul></ul><ul><ul><li>Excessive facial hair </li></ul></ul><ul><ul><li>Tuberculosis of the neck </li></ul></ul><ul><ul><li>Fungal diseases of the scalp </li></ul></ul><ul><ul><li>Sore throat </li></ul></ul><ul><ul><li>Chronic cough </li></ul></ul><ul><ul><li>Enlargement of thymus, tonsils, adenoids </li></ul></ul>
  14. 14. 2002 <ul><li>CC: neck mass, fatigue </li></ul><ul><li>TSH 0.42, free T4 1.1 </li></ul><ul><li>138 102 15 8.5 </li></ul><ul><li>94 </li></ul><ul><li>3.7 28 1.0 </li></ul><ul><li>FNA </li></ul><ul><ul><li>benign colloid goiter </li></ul></ul>
  15. 15. 2003 <ul><li>Breast cancer (left) </li></ul><ul><ul><li>Surgical resection </li></ul></ul><ul><ul><ul><li>Adenocarcinoma </li></ul></ul></ul><ul><ul><ul><li>ER/PR positive </li></ul></ul></ul><ul><ul><li>Chemotherapy </li></ul></ul><ul><ul><ul><li>Faslodex </li></ul></ul></ul><ul><ul><ul><li>Zometa </li></ul></ul></ul><ul><li>CT-chest… </li></ul>
  16. 18. 2005 <ul><li>CT-chest </li></ul><ul><ul><li>Large heterogeneous mass at thoracic inlet with tracheal deviation to the left </li></ul></ul><ul><ul><li>Innumerable lung nodules (2mm-1.5cm) </li></ul></ul><ul><ul><li>Rib lesion… </li></ul></ul><ul><ul><ul><li>Metastatic adenocarcinoma (ER/PR+) </li></ul></ul></ul>
  17. 19. 2005 <ul><li>Thyroid U/S </li></ul><ul><ul><li>Right lobe, 5.8x3.6x8.6cm </li></ul></ul><ul><ul><ul><li>Superior nodule, 5.2x2.9x3.8cm </li></ul></ul></ul><ul><ul><ul><li>Inferior nodule, 4.9x3.8x5.3cm </li></ul></ul></ul><ul><ul><li>Isthmus </li></ul></ul><ul><ul><ul><li>Nodule, 4.6x2.2x6.9cm </li></ul></ul></ul><ul><ul><li>Left lobe, 2.2x1.9x5.3cm </li></ul></ul><ul><ul><ul><li>Lower, 1.6x1.6x1.6cm </li></ul></ul></ul><ul><ul><ul><li>Mid, 0.9x1.0x0.9cm </li></ul></ul></ul>
  18. 20. 2005 <ul><li>FNA </li></ul><ul><ul><li>Right lobe </li></ul></ul><ul><ul><ul><li>Upper: benign colloid goiter </li></ul></ul></ul><ul><ul><ul><li>Lower: benign colloid goiter </li></ul></ul></ul><ul><ul><li>Isthmus </li></ul></ul><ul><ul><ul><li>Benign colloid goiter </li></ul></ul></ul><ul><ul><li>Left lobe </li></ul></ul><ul><ul><ul><li>Lower: benign colloid goiter </li></ul></ul></ul><ul><ul><ul><li>Mid: papillary carcinoma </li></ul></ul></ul>
  19. 21. 2006 <ul><li>CC: fatigue, dry skin </li></ul><ul><li>Neck mass enlarging </li></ul><ul><li>TSH 0.11 , free T4 4.4, free T3 5.9 </li></ul><ul><li>Thyroglobulin 292.8 [3-40] </li></ul><ul><li>CT-chest/abd/pelvis </li></ul><ul><ul><li>Thoracic inlet mass has neck extension </li></ul></ul><ul><li>CT-neck… </li></ul>
  20. 24. 2006 <ul><li>CT-neck </li></ul><ul><ul><li>9.0x6.4x7.9cm, poorly defined mass </li></ul></ul><ul><ul><li>Tracheal compression and invasion </li></ul></ul><ul><li>Subtotal thyroidectomy… </li></ul>
  21. 26. 2006 <ul><li>Subtotal thyroidectomy </li></ul><ul><ul><li>Papillary carcinoma, T4aNxMx </li></ul></ul><ul><li>Thyroid body scan </li></ul><ul><ul><li>Thyroid uptake 14% </li></ul></ul><ul><ul><li>No visible mets, but sensitivity decreased </li></ul></ul><ul><ul><ul><li>Remaining thyroid tissue </li></ul></ul></ul><ul><ul><ul><li>Normal TSH </li></ul></ul></ul><ul><li>29 mCi I 131 delivered </li></ul><ul><li>Levothyroxine started </li></ul>
  22. 27. 2007 <ul><li>Thyroid body scan </li></ul><ul><ul><li>Thyroid uptake 4% </li></ul></ul><ul><ul><li>Diffuse lung mets </li></ul></ul><ul><li>143 mCi I 131 delivered </li></ul><ul><li>Thyroid body scan </li></ul><ul><ul><li>Thyroid uptake 1.6% </li></ul></ul><ul><ul><li>Lung uptake 15% </li></ul></ul><ul><ul><li>Left femur/hip lesion? </li></ul></ul><ul><li>75 mCi I 131 delivered </li></ul><ul><li>TSH 4.92 (0.69), Thyroglobulin 175.0 ( 108.4 ) </li></ul>
  23. 28. 2008 and Beyond <ul><li>??? </li></ul>
  24. 29. Thyroid Cancer
  25. 30. The Types Negative Negative Anaplastic Positive Negative Medullary Negative Positive Follicular Negative Positive Papillary Calcitonin Thyroglobulin
  26. 31. Papillary
  27. 32. Follicular
  28. 33. Medullary
  29. 34. Anaplastic
  30. 35. Risk Factors <ul><li>Radiation </li></ul><ul><ul><li>Low- or high-dose </li></ul></ul><ul><ul><li>40-50 Gy </li></ul></ul><ul><ul><li>Ionizing radiation </li></ul></ul><ul><ul><li>X-ray </li></ul></ul><ul><ul><li>Radiotherapy </li></ul></ul><ul><li>Iodine deficiency </li></ul><ul><li>Family history? </li></ul>
  31. 36. What’s a Gy? <ul><li>Gray </li></ul><ul><li>1975: Louis Harold Gray (1905-1965) </li></ul><ul><li>Absorption of one joule of radiation energy by one kilogram of matter </li></ul><ul><li>100 rad </li></ul>
  32. 37. How much is 40-50 Gy? <ul><li>10-20 Gy at once = fatal </li></ul><ul><li>Abdominal x-ray = 1.4 mGy </li></ul><ul><li>CT-abd/pelvis = 30 mGy </li></ul><ul><li>1000m from Nagasaki = 9-10 Gy </li></ul>
  33. 38. Epidemiology <ul><li>1.5% of all cancers worldwide </li></ul><ul><li>Mean survival 90% at 10 years </li></ul><ul><li>70% papillary </li></ul><ul><li>10-15% present with lymph node or lung mets </li></ul><ul><li>Female predominance </li></ul><ul><ul><li>Age > 45 = 2.8:1 </li></ul></ul>
  34. 39. Presentation <ul><li>Common </li></ul><ul><ul><li>Asymptomatic mass </li></ul></ul><ul><ul><li>Cough </li></ul></ul><ul><ul><li>Dypsnea </li></ul></ul><ul><ul><li>Dysphagia </li></ul></ul><ul><li>Rare </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Stridor </li></ul></ul><ul><ul><li>Vocal cord paralysis </li></ul></ul><ul><ul><li>Rapid enlargement </li></ul></ul>
  35. 40. Pathophysiology <ul><li>trk proto-oncogene </li></ul><ul><ul><li>Tyrosine kinase </li></ul></ul><ul><li>ret proto-oncogene </li></ul><ul><ul><li>“ Rearranged during transfection” </li></ul></ul>
  36. 41. Lab work <ul><li>T4 </li></ul><ul><li>T3 </li></ul><ul><li>TSH </li></ul><ul><li>Thyroglobulin </li></ul><ul><li>Calcium </li></ul><ul><li>Calcitonin </li></ul><ul><li>CEA </li></ul><ul><li>TSH suppression test </li></ul>
  37. 42. Other Investigations <ul><li>Plain films, CT, MRI </li></ul><ul><li>Echography </li></ul><ul><li>Scintography </li></ul><ul><li>FNAB </li></ul>
  38. 43. Histology <ul><li>Orphan Annie eyes </li></ul><ul><li>Psammoma bodies </li></ul>
  39. 44. Staging <ul><li>Less than 45 </li></ul><ul><ul><li>Stage I </li></ul></ul><ul><ul><ul><li>Any T, any N, M0 </li></ul></ul></ul><ul><ul><li>Stage II </li></ul></ul><ul><ul><ul><li>Any T, any N, M1 </li></ul></ul></ul><ul><li>Over 45 </li></ul><ul><ul><li>Stage I </li></ul></ul><ul><ul><ul><li>T1, N0, M0 </li></ul></ul></ul><ul><ul><li>Stage II </li></ul></ul><ul><ul><ul><li>T2, N0, M0 </li></ul></ul></ul><ul><ul><ul><li>T3, N0, M0 </li></ul></ul></ul><ul><ul><li>Stage III </li></ul></ul><ul><ul><ul><li>T4, N0, M0 </li></ul></ul></ul><ul><ul><ul><li>Any T, N1, M0 </li></ul></ul></ul><ul><ul><li>Stage IV </li></ul></ul><ul><ul><ul><li>Any T, any N, M1 </li></ul></ul></ul>
  40. 45. Treatment <ul><li>Surgical resection </li></ul><ul><ul><li>Lobectomy </li></ul></ul><ul><ul><li>Subtotal thyroidectomy </li></ul></ul><ul><ul><li>Total thyroidectomy </li></ul></ul><ul><li>Radioablation </li></ul><ul><ul><li>Non-metastatic: 30-100 mCi q3wk </li></ul></ul><ul><ul><li>Metastatic: 150-200 mCi q3wk </li></ul></ul><ul><li>External beam radiation </li></ul><ul><li>Thyroid replacement </li></ul><ul><li>Chemotherapy </li></ul><ul><ul><li>Cisplatin </li></ul></ul><ul><ul><li>Doxorubicin </li></ul></ul>
  41. 46. Summary <ul><li>Number of iodine molecules in the most metabolically active thyroid hormone? </li></ul><ul><ul><li>Three </li></ul></ul><ul><li>Most common thyroid cancer? </li></ul><ul><ul><li>Papillary </li></ul></ul><ul><li>Greatest risk for thyroid cancer? </li></ul><ul><ul><li>Radiation exposure </li></ul></ul><ul><li>Treatment for thyroid cancer? </li></ul><ul><ul><li>Resection and radioablation </li></ul></ul>
  42. 47. The End

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