Approach to thyroid cancer

1. Approach to thyroid
cancer
Mohammed AlHinai

2. Thyroid cancer :
Thyroid cancer classify histo-pathological finding into :
• Group A as well differentiation
and good prognosis.
• Group B as poor differentiation
and poor prognosis.

3. Papillary thyroid cancer
Most common thyroid cancer with prevalence :
• 80% overall incidence.
• More common under age of 40 yrs.
• Female to male 2:1.
• Risk factors :
- Previous radiation to head and neck.
- Family history of thyroid cancer.
Pathology
features
• Multifocality lesions with papillary pattern, un-encapsulated with pale homogenous and cystic
degeneration.
• Spread by lymphatic and usually into cervical lymph node.
• Diagnosed by presence of cellular features in FNAC include :
- Psammomma bodies and orphan annie nucleus (specific for papillary cancer).
- Other features of malignancy include ( nuclear groove, nuclear overlapping, nuclear clearance, nuclear
crowding, nuclear inclusion).
• Prognosis is 98% survival at 10 yrs but need to make sure that the patient
receive appropriate management.
• There is risk for recurrence for patient who done hemi-thryoidectomy as
papillary cancer is multifocal lesions which some of them not visible under US
especially small size lesion. So need to be more aggressive in management to
achieve good prognosis.
Prognosis

5. Follicular thyroid cancer
Less common thyroid cancer with prevalence :
• 10% overall incidence.
• More common in elderly with mean age of 50yrs.
• Female to male 3:1.
• Risk factors :
- Previous radiation to head and neck.
- Family history of thyroid cancer.
- Associated with lack of iodine.
Pathology
features
• Follicular adenoma is unifocal lesion, encapsulated and rarely associated with cystic degeneration.
• Follicular carcinoma If the tumor associated with invasive of vessels and/or capsule.
• Spread by blood stream and most common sites are lung, bone and brain.
• There is no cytological features of cell in follicular malignancy, hence FNAC is not diagnostic for it as
not differentiate between follicular adenoma or carcinoma.
• So required histopathology on paraffin section of resected specimen to see the invasion of vessel or
capsule.
• Prognosis is 92% survival at 10 yrs but need to make sure that the patient
receive appropriate management.
Prognosis

7. Anaplastic thyroid cancer
Very less common thyroid cancer with prevalence :
• Less than 1% overall incidence.
• More common in elderly with mean age of 65yrs.
• Risk factors :
- Previous radiation to head and neck.
- Family history of thyroid cancer.
- Coexisting of differentiated thyroid cancer.
• The patient present with rapidly enlarging neck mass with surrounding compression. Features of
constitutional symptoms and metastatic features also present.
Pathology
features
• undifferentiated tumors of the thyroid follicular epithelium.
• Very rapid spread and growth
• Commonly spread to lung, bone and brain.
• Diagnosed by FNAC by presence of morphologic patterns of anaplastic thyroid cancer include
spindle cell, pleomorphic giant cell, and/or squamoid with Numerous mitotic figures and atypical
mitoses.
• Poor prognosis as rapidly spread with 20-35% at 1 yr. the management
depend on stage of malignancy as mixed of surgical with radiation and
chemotherapy in locally advanced but no effective therapy for metastatic
which consider palliative therapy.
Prognosis

9. Medulla thyroid cancer
Very less common thyroid cancer with prevalence :
• Less than 4% overall incidence.
• typical age of presentation is in the fourth and sixth decades of life
• Risk factors :
- 80% occur as sporadic tumor.
- 20% familial as part of multiple endocrine neoplasia type 2 (MEN2) syndrome.
• The patient present with upper solitary thyroid nodule (located in upper portion as C cell
predominantly located there)with surrounding compression. Features of constitutional symptoms
and metastatic features also present.
• Systemic symptoms due to hormonal secretion of calcitonin.
Pathology
features
• neuroendocrine tumor of the parafollicular or C cells of the thyroid gland
• Rapidly growth and metastatic.
• Commonly spread to liver, lung, bone and brain.
• Diagnosed by mix picture of tumor mass with high basal serum calcitonin and FNAC features of C
cell presence.
• Prognosis depend on stage of tumor with overall prognosis 50% at 10yrs and
20% at 10yrs if detected when clinically palpable. Management include total
thyroidectomy and median lymph node dissection with surrounding tissue.
Then follow the patient by check the level of calcitonin.
Prognosis

11. Lymphoma thyroid cancer
Very less common thyroid cancer with prevalence :
• Less than 1% overall incidence.
• typical age of presentation is in the elderly women.
• Female to male 4:1.
• Risk factors :
- Preexisting chronic autoimmune (Hashimoto's) thyroiditis.
• The patient present with rapidly enlarging goiter with surrounding compression. Features of
constitutional symptoms also present.
• Systemic symptoms due to hormonal secretion of calcitonin.
Pathology
features
• FNAC not enough to diagnose the lymphoma, large bore needle biopsy or excisional biopsy required
for obtain sufficient material for definitive diagnosis by immunohistochemical studies.
• Prognosis depend on stage of tumor. No surgical intervention required for the
patient. Combined radiotherapy and chemotherapy (CHOP) are the
treatment.
Prognosis

13. Approach to patient with
neck swelling

14. • 49 yrs old male presented with a thyroid swelling of 9 months duration. It has been
gradually increasing in size and in the last 6 weeks it has been increasing more rapidly.
He has noticed some hoarseness of voice in the past 1 month. There is no family
history of thyroid malignancy. On examination, there is 4X4 cm thyroid nodule in the
right lobe. It is hard in consistency. There are multiple cervical lymph nodes palpable in
the right lateral group (III and IV).
 Full history and clinical examination.
 Laboratory test as initial diagnosis :
• Thyroid function test.
• Thyroid autoimmune antibodies.
 Other test need as baseline for other intervention:
• CBC
• Coagulation profile.
• RFT
• LFT

16.  US of thyroid :
 Indicated in case of :
• All patient with rapid growth of goiter or physical examination reveal
thyroid asymmetry, focal firm consistency or tenderness.
• Present of goiter with normal TSH and TPO.
• Patient with goiter and positive TPO for Hashimoto’s thyroiditis.
The result of thyroid
US that suspicious for
malignancy
• Positive if :
- Micro-calcification
- Lymph node metastasis and local invasion
- Irregular margin
- Vascularity
- Shape (AP more than transverse diameter)
- Hypoechoic lesion

17.  Fine needle aspiration cytology (FNAC) :
 By aspirate the selected nodule and then put them in 6 slides to send them
to pathological studies.
 The result depend on the presence of cells features including :
• Psammoma bodies and orphan anni cells.
• Features of malignancy include nuclear groove, nuclear overlapping, nuclear
clearance, nuclear crowding, nuclear inclusion.
• Atypical cells
• Hurthle cells
If US thyroid positive
for suspicious features
according to Bethesda
classification, it
classify the FNAC
result into:

18. Risk for
malignancy
FNAC featuresStage
Containing histiocytes with little or no follicular cells or no significant
cytological atypia.
Non-diagnostic
or unsatisfactory
(C 1)
95% benign
5% malignancy
Showed the cytomorphological features of colloid
goiter/adenomatoid goiter, Hashimoto's thyroiditis, thyrotoxicosis, de
Quervain's thyroiditis, or granulomatous thyroiditis
Benign (C 2)
15%
malignancy
showed cytological features of high cellularity, tiny follicular cells
arranged in sheets, clusters or singly, with occasional occurrence of
multinucleated giant cells, and focal occurrence of Hurthle cells.
Atypical
follicular lesion
of undetermined
significance (C3)
25%
malignancy
cytomorphologic features of moderate to high cellularity, scant or
absent colloid, with predominantly microfollicular or trabecular
configuration of follicular cells in repetitive pattern and features of
hurthle cell.
suspicious for
follicular
neoplasm
Or hurthle cell
lesion (C4)
75%
malignancy
cytological features of high cellularity, comprised elongated oblong
cells with occasional plasmacytoid appearance.
Present ≥ 2 of malignancy features include nuclear groove, nuclear
overlapping, nuclear clearance, nuclear crowding, nuclear inclusion.
Suspecious for
malignancy (C5)
95%
malignancy
Present as C5 but with ≥ 4 of malignancy features with psammoma
bodies and orphan anni cells
Papillary thyroid
carcinoma (C6)

19.  For staging and metastatic workup :
• CT scan or MRI.
• Chest x-ray.
• Bone survey
• PET scan
• Brain scan

20. TNM staging

22. Assess the prognosis and
mortality rate for the
patient with different
scoring system
Low risk of mortality :
• Young patient (<40yrs),
small lesion (<1cm), lesion
intra-thyroidal with no local
extension or metastasis.
• MACIS score <4.
High risk of mortality :
• Older patient (>40yrs), large
sized lesion (>1cm)with local
invasion or metastasis.
• MACIS score >4.

23. Management group A thyroid cancer
Depend on multiple factors including the type of cancer, stage and prognostic
scoring system as well as patient factors if candidate for surgical or not. Overall the
surgical approach for thyroid cancer include :
Pre-
operative
assessment
Surgical
approach
Post-
operative
assessment
Post-
operative
surveillance

24. Pre-operative assessment :
 Need to order some tests including :
• TFT for thyroid level as the patient need to be euthyroid during the surgery
unless emergency cases.
• Bone profile and VitD to check the Ca level before surgical as baseline and to
prevent hypocalcaemia in post-OP.
• Other assessment related to anesthesia.

25. ManagementStage
No intervention needed but active surveillance might required.(C 1)
As other diagnosis is considered, treatment depend on the diagnosis.Benign (C 2)
Hemi-thyroidectomy then send to histopathology evaluation of that tissue.
If any element of malignancy found on that tissue, remove the other part.
(C3)
Hemi-thyroidectomy then send to histopathology evaluation of that tissue.
If any element of malignancy found on that tissue, remove the other part.
(C4)
• Some doctors preferred to do total thyroidectomy.
• Other depend on the size found during surgery and number of nodules
or foci :
• If > 1cm, do total thyroidectomy followed by Radioiodine therapy
• If < 1cm and multifocal, do total thyroidectomy followed by
Radioiodine therapy
• If < 1cm and unifocal, hemi-thyroidectomy.
Suspecious for
malignancy (C5)
Total thyroidectomy followed by Radioiodine therapyPapillary thyroid
carcinoma (C6)
Surgical approach
depend on the protocol, according to European guidelines:

26. Post-operative assessment :
 Look for any signs of early complication within first 24 hrs which include :
• Hemorrhage with signs of swelling and airway compression as stridor or anemia and
treat with :
• oxygen supplement and evacuation of hematoma by release of suture.
• Recurrent laryngeal nerve damage (1-2%) with signs of stridor in case of bilateral injury
and patient need to be intubated.
• Superior laryngeal nerve paresis.
• Hypoparathyroidism which cause hypocalcaemia and treat with Ca supplement and Vit
D
• Tracheal collapse.
• Thyroid crisis.
• Cervical symptomatic damage.
• Wound infection.
 Delay complication :
• Hypothyroidism.
• Wound complication as keloid.
• Recurrent hyperthyroidism.

27. Radioiodine treatment :
Radioiodine (The uptake of 131-I) is administered after thyroidectomy in patients with
differentiated thyroid cancer to ablate residual normal thyroid tissue (remnant ablation), to
provide adjuvant therapy of subclinical or clincally apparent of micrometastatic disease.
• Done within 4-6 week after the thyroid surgery for those who are indicated include :
• Metastasis thyroid cancer.
• According to the classification of FNAC ( see page 25).
• Pregnancy and breastfeeding are absolute contra-indication.
• Patient preparation :
• Avoid all iodine containing medication and limit dietary intake of iodine include salt,
milk. Eggs and seafood for at least 1 week.
• In breastfeeding, should be stopped at least 6 to 8 weeks.
• Thyroid hormones should be withdrawn three to four weeks prior to radioiodine
therapy.
• The treated patient should remain ≥1.8 m (6 feet) away from family members,
caregivers, and the general public as much as possible for approximately 24 hours after
treatment.

28. Post-operative surveillance :
 Long term follow up to detect any recurrence every 6-12 months with :
• Clinical examination.
• Serum TSH.
• Free thyroxin.
• Measurement of serum thyroglobulin.
• Routine neck US.