Cancer of thyroid gland

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  • Radiation exposure (papillary). Populations with low dietary iodine have a higher proportion of follicular and anaplastic cancers.
  • On April 26, 1986 at 1.23 a.m. the world's 1.23 a.m. the world's worst nuclear disaster worst nuclear disaster took place at the took place at the Chernobyl nuclear Chernobyl nuclear power station in power station in northern Ukraine
  • „ In differentiated thyroid carcinoma, several classification and In differentiated thyroid carcinoma, several classification and staging systems have been introduced. However, no clear staging systems have been introduced. However, no clear consensus has emerged favoring any one method over another consensus has emerged favoring any one method over another
  • T4a – includes invasion of subc tissue, trachea, esophagus and RLN T4b – invades prevertebral fascia or encases carotid or mediastinal vessels Level VI (pretracheal, paratracheal, prelaryngeal)

Transcript

  • 1.  
  • 2.
    • Dr. Zahoor Ahmad
    • PGR, SU-I
    • SZMC/H. RYK, Pakisatan
  • 3.  
  • 4.  
  • 5.
    • Lymph vessels :
    • drain to
    • Prelaryngeal (Delphian),
    • pretracheal
    • paratracheal nodes.
  • 6.
    • Parasympathetic
    • vagus
    • Sympathetic
    • superior,
    • middle,
    • inferior sympathetic ganglia
  • 7.  
  • 8.
    • Superior thyroid v (to IJV)
    • middle thyroid v. (to IJV)
    • Inferior thyroid v. (to brachiocephalic trunk)
  • 9.
    • Sim’s triangle
    • lateral common Carotid artery
    • medially Trachea
    • superiorly Inferior pole of thyroid
  • 10.
    • Lobule: 20-30 follicles
    • Follicle :
    • functional unit
    • Follicular cells
    • Contains colloid
    • Parafollicular cell or C-cell
  • 11.  
  • 12.  
  • 13.  
  • 14.
    • 1% of total
    • 3/million cases
    • Women 3 times more than men.
    • Peak incidence 40s.
    • Papillary 60%, follicular 20%, anaplastic 10%, medullary 5%, malignant lymphoma 5%.
  • 15.
    • RADIATION (most important)
    • Family history of Goiter (MEN-II. ret oncogene)
    • Personal history of Autoimmune thyroiditis
    • Inheritance of oncogenes (ret/PTC1, ret/PTC3)
    • Male sex
    • Age > 45 years
  • 16.  
  • 17.  
  • 18.  
  • 19.  
  • 20.
    • Chief complaints
    • Rapidly growing, Painless, palpable, irregular, solitary nodule.
    • Cervical lymph node enlargement
    • Associated symptoms
    • Neck pain, hoarseness, dysphagia, dyspnea, stridor, hemoptysis
  • 21.
    • Thyroid gland
    • Soft tissues of neck
    • Solid, soft, mobile, or fixed?
    • Tenderness?
    • Laryngoscopy if hoarse preop!
  • 22.  
  • 23.
    • Baseline labs
    • Tumor markers (S. thyroglobulin, S. calcitonin, CEA, )
    • CXR
    • TSH, TFTs
    • IDL
  • 24.
    • FNAC
    • Trucut biopsy
    • Incisional biopsy
    • USG neck
    • CT scan neck & thorax
    • MRI
    • Thyroid scan
  • 25.  
  • 26.  
  • 27.
    • Tumors of Follicular Cell Origin
    • Differentiated
    • „ „ Papillary 60%
    • „ „ Follicular 20%
    • Undifferentiated
    • „ „ Anaplastic 10%
    • Tumors of Parafollicular
    • „ „ Medullary 5%
    • „ Other
    • „ „ Lymphoma 5%
  • 28.
    • Primary
    • Follicular cells (papillary, follicular, and anaplastic)
    • Para-follicular cells (medullary)
    • Lymphocytes (lymphoma)
    • Secondary
    • Metastases
    • Local infiltration
  • 29.
    • „ TNM system
  • 30.
    • T1  2cm
    • T2 2-4cm
    • T3 >4cm, limited to thyroid
    • T4a Any size, invasion of SQ, trachea, esophagus, RLN, paravertebral fascia, carotid artery
    • N0 no nodes
    • N1a Level VI
    • N1b All other levels
    • M0 no metastases
    • M1 distant mets
  • 31.
    • Stage I T1, N0, M0
    • Stage II T2, N0, M0
    • T3, N0, M0
    • Stage III T4, N0, M0
    • any T, N1, M0
    • Stage IV any T, any N,M1
  • 32.
    • AMES system
    • AGES System
    • GAMES system
    • MACIS system
    • University of Chicago system
  • 33.
    • Age
    • Metastasis
    • Extent/ extrathyroid
    • Size
  • 34.
    • Age
    • Grade
    • Extent
    • Size
  • 35.
    • Metastasis
    • Age
    • Completeness of excision
    • Invasion
    • Size
  • 36.
    • staging system for papillary carcinoma
    • Class I— disease limited to the thyroid gland
    • Class II— lymph node involvement
    • Class III— extrathyroidal invasion
    • Class IV — distant metastases
  • 37.
    • Most common (60%)
    • Women 3 times more common
    • 30-40 years of age
    • Radiation exposure as a child
    • Multifocality
    • Slow growing
    • microscopically BRANCHING PAPILLAE are characteristic
    • Orphan-Annie nuclei
  • 38.
    • Local invasion invading trachea, RLN.
    • Propensity to spread to the cervical lymph nodes .
    • Distant spread to bone, lungs.
  • 39.
    • Second most common (20%)
    • Iodine deficient areas
    • 3 times more in women
    • Presents more advanced in stage than papillary
    • Late 40’s
  • 40.
    • Pathology: round, encapsulated, cystic changes, fibrosis, hemorrhages.
    • Microscopically, neoplastic follicular cells.
    • Differentiated from follicular adenomas by the presence of capsule invasion , vascular invasion .
    • Cannot reliably diagnose based on FNA .
  • 41.
    • Local invasion is similar to papillary cancer with the same presentation.
    • Cervical metastases are uncommon.
    • Distant metastases is significantly higher (75%), with lung and bone most common sites.
  • 42.
    • A variant of follicular,
    • also known as oncocytic carcinoma.
    • More common in women than men,
    • presents in 5 th decade of life.
    • Cannot diagnose on FNA
    • Does not take up iodine, so treat aggressively.
    • Thyroid suppression and radioiodine don’t work.
  • 43.
    • 5%, female preponderance
    • 75% sporadically, 25% familial. Familial cases are usually all over the gland, sporadic usually not multifocal.
    • MEN 2A, MEN2B and FMTC syndromes.
    • Arises from parafollicular cells
  • 44.
    • Highly lethal form of thyroid cancer
    • Median survival <8 months
    • 10% of all thyroid cancers
    • Affects the elderly
    • 30% of thyroid cancers in patients >70 years
    • 53% have previous benign thyroid disease
  • 45.
    • Pathology
        • Classified as large cell or small cell
        • Large cell is more common and has a worse prognosis
        • Histology - sheets of very poorly differentiated cells
        • little cytoplasm
        • numerous mitoses
        • necrosis
        • extrathyroidal invasion
  • 46.
    • MEN 2a is Sipple syndrome MTC, pheochromocytoma, hyperparathyroidism.
    • MEN 2b is MTC, pheo, ganglionomas.
    • FMTC is just MTC
    • Medullary cancer in these are most aggressive, younger age, rapid growth and metastases.
    • Sporadic painless nodule, symptoms of invasion.
  • 47.
    • Controversy regarding extent of therapy continues.
    • Surgical excision whenever possible.
    • Total thyroidectomy has been mainstay (all apparent thyroid tissue removed).
    • After surgery, perform radioiodine scan, ablation if residual disease or recurrence.
  • 48.
    • Radioiodine targets residual thyroid tissue and tumor after thyroidectomy.
    • Given in diagnostic doses and therapeutic doses to ablate tissue.
  • 49.
    • Maintained on thyroxine after surgery and ablation. Low TSH levels reduce tumor growth rates and reduce recurrence rates.
    • Most recommend TSH levels of 0.1 mU/l.
    • Follow-up q 6 months with thyroglobulin levels and repeat scans.
    • Thyroglobulin is good because well differentiated tumors produce it.
  • 50.
    • Suspicion for malignancy
    • Compressive symptoms
    • Cosmetic issues
    • Patient wishes
    • Well-differentiated thyroid carcinoma in low risk patient (controversial)
  • 51. Thank You !