THYROID NEOPLASMS

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THYROID NEOPLASMS

  1. 1. Thyroid Neoplasms <ul><li>Benign </li></ul>1. Adenoma <ul><li>Follicular – colloid, embryonal,foetal </li></ul><ul><li>Hurthle cell </li></ul>2. Teratoma
  2. 2. Thyroid Neoplasms <ul><li>Malignant Tumours: </li></ul><ul><li>1. Well differentiated </li></ul><ul><li>Papillary </li></ul><ul><li>Follicular </li></ul><ul><li>Hurthle cell </li></ul><ul><li>2. Undifferentiated </li></ul><ul><li>Anaplastic </li></ul><ul><li>3. Medullary carcinoma </li></ul>
  3. 3. Thyroid neoplasms <ul><li>Lymphomas </li></ul><ul><li>Hodgkin`s lymphoma </li></ul><ul><li>NonHodgkin`s lymphoma </li></ul><ul><li>Others </li></ul><ul><li>Squamous or Mucinous </li></ul><ul><li>carcinoma </li></ul><ul><li>Secondaries </li></ul>
  4. 4. Aetiology of Thyroid carcinoma <ul><li>Molecular Biology </li></ul><ul><li>RET – oncogene Papillary ca. </li></ul><ul><li>& medullary carcinoma </li></ul><ul><li>ras mutations in follicular ca. </li></ul><ul><li>P53 mutations in anaplastic ca. </li></ul>
  5. 5. Aetiology of thyroid ca <ul><li>Radiation </li></ul><ul><li>Iodine excess/ deficiency </li></ul>
  6. 6. <ul><li>Pap Ca 60% </li></ul><ul><li>Foll Ca 17% </li></ul><ul><li>Anaplastic 13% </li></ul><ul><li>Medullary 6% </li></ul><ul><li>Lymphoma 4% </li></ul>
  7. 7. <ul><li>Incidence 3.7/100000 </li></ul><ul><li>Females more affected </li></ul><ul><li>3:1 </li></ul><ul><li>Mortality 2-3% </li></ul>
  8. 8. Papillary carcinoma <ul><li>Most common – 60 to 70%. </li></ul><ul><li>Least aggressive cancer. </li></ul><ul><li>Prolonged course. </li></ul><ul><li>3 rd and 4 th decades of life. </li></ul><ul><li>More common in women. </li></ul><ul><li>Predominant thyroid cancer </li></ul><ul><li>in children. </li></ul>
  9. 9. Pathology <ul><li>Grey white poorly defined nodule varying in size from a few mm. To several cms. </li></ul><ul><li>In large lesions, haemorrhage, necrosis and cyst formation with visible papillae may be seen. </li></ul>
  10. 10. Pathology - Microscopy <ul><li>Typical papillary structures </li></ul><ul><li>Optically clear nuclei called Orphan Annie nuclei </li></ul><ul><li>Round laminated calcified bodies – psammoma bodies. </li></ul><ul><li>Nuclear grooves,lobulations and atypia </li></ul>
  11. 11. pathology <ul><li>Multiple foci in same lobe </li></ul><ul><li>Sometimes opposite lobe </li></ul><ul><li>Intrathyroidal lymphatic spread/ </li></ul><ul><li>Multicentric growth </li></ul>
  12. 12. Pathology <ul><li>They grow slowly and tend to metastasize to lymph nodes </li></ul><ul><li>Better prognosis than other forms of thyroid cancer </li></ul><ul><li>Tendency to more malignant growth with advancing age </li></ul><ul><li>Local spread to trachea,recurrent laryngeal nerve and oesophagus </li></ul>
  13. 13. Occult carcinoma <ul><li>Papillary CA less than 1.5 cm </li></ul><ul><li>Palpable LN </li></ul><ul><li>Jugular chain </li></ul><ul><li>Primary may be only few mms size </li></ul>
  14. 14. Clinical Features <ul><li>Solitary Nodule (STN) </li></ul><ul><li>Dysphagia,dyspnoea,hoarseness indicate locally invasive disease </li></ul><ul><li>Lymph node enlargement </li></ul><ul><li>Occasionally lymph node enlargement alone </li></ul>
  15. 15. Investigations <ul><li>Thyroid function tests </li></ul><ul><li>Ultrasound scan </li></ul><ul><li>Isotope thyroid scan </li></ul><ul><li>Fine needle aspiration cytology </li></ul>
  16. 16. Treatment <ul><li>Near total/total thyroidectomy </li></ul><ul><li>Lobectomy/Hemithyroidectomy </li></ul><ul><li>Modified neck dissection </li></ul><ul><li>TSH suppression </li></ul>
  17. 17. <ul><li>Total thyroidectomy </li></ul><ul><li>hemithyroidectomy </li></ul>
  18. 18. Thyroid suppression <ul><li>0.1-0.2 mg daily </li></ul><ul><li>Suppress endogenous TSH </li></ul><ul><li>Not very much useful in follicular Ca </li></ul>
  19. 19. Thyroglobulin <ul><li>Tumour marker </li></ul><ul><li>Obviate the need of serial isotope scanning </li></ul><ul><li>Only adjunct to clinical examination </li></ul>
  20. 20. Follicular carcinoma <ul><li>Occurs in the fifth decade </li></ul><ul><li>More common in females </li></ul><ul><li>15% of thyroid malignancies </li></ul><ul><li>Occurs more frequently in iodine deficiency areas </li></ul><ul><li>More aggressive and dangerous </li></ul><ul><li>Blood stream spread </li></ul>
  21. 21. Pathology <ul><li>Tumour is well encapsulated </li></ul><ul><li>. </li></ul><ul><li>Haematologic spread </li></ul>
  22. 22. Microscopy <ul><li>Follices are crowded with cells with hardly any colloid. </li></ul><ul><li>Capsular and vascular invasion are prominent features. </li></ul><ul><li>Tumour with large cells with abundant eosinophilic cytoplasm are called Hurthle cell carcinoma </li></ul>
  23. 23. Clinical features <ul><li>Solitary nodule or multiple painless nodules </li></ul><ul><li>May arise in a long standing goiter </li></ul><ul><li>Lymph node involvement rare </li></ul><ul><li>Haematogenous spread to bones lungs or liver </li></ul><ul><li>Bony metastasis may be pulsatile </li></ul>
  24. 24. Investigations <ul><li>FNAC not helpful </li></ul><ul><li>Radiology - X –ray chest , neck, bones, CT scan </li></ul><ul><li>Raio isotope scan </li></ul>
  25. 25. Treatment <ul><li>Total thyroidectomy/Near total thyroidectomy </li></ul><ul><li>Radioiodine </li></ul><ul><li>External beam radiation </li></ul><ul><li>Chemotherapy </li></ul><ul><li>TSH suppression </li></ul>
  26. 26. Prognosis of DTC <ul><li>Age </li></ul><ul><li>Histological variant </li></ul><ul><li>Extra thyroidal spread </li></ul><ul><li>size </li></ul>
  27. 27. Low risk <ul><li>Men<40, women<50 </li></ul><ul><li>Older patients </li></ul><ul><li>- intrathyroid papillary Ca </li></ul><ul><li>-foll with minor caps. Invasion </li></ul><ul><li>-<5cm </li></ul><ul><li>-no distant mets </li></ul>
  28. 28. High risk <ul><li>Distant mets </li></ul><ul><li>Older patients </li></ul><ul><li>- extra thyroidal Pap </li></ul><ul><li>- major caps.invasion </li></ul><ul><li>- >5 cm </li></ul>
  29. 29. <ul><li>2% mortality in 25 yr survival in low risk group </li></ul><ul><li>46% in high risk group </li></ul>
  30. 30. Medullary carcinoma(MTC) <ul><li>Arises from the C – cells </li></ul><ul><li>,derived from the neural crest – APUD system </li></ul><ul><li>Sporadic or familial form </li></ul>
  31. 31. Familial MTC <ul><li>Familial with MTC only </li></ul><ul><li>with MEN IIA – </li></ul><ul><li>MTC </li></ul><ul><li>hyperparathyroidism & </li></ul><ul><li>phaeochromocytoma </li></ul>
  32. 32. <ul><li>MTC secretes calcitonin </li></ul><ul><li>CEA, </li></ul><ul><li>histamine,and </li></ul><ul><li>serotonin </li></ul>
  33. 33. Pathology <ul><li>Sporadic form – usually unilateral, familial form – multinodular </li></ul><ul><li>Sheets of infiltrating malignant cells with areas amyloid </li></ul><ul><li>Special staining can be performed for calcitonin in the cells </li></ul><ul><li>Lymphatic & haematogenous spread </li></ul>
  34. 34. Clinical features <ul><li>Age – sporadic form (80%) 40 – 60 yrs. Familial (20%) – younger age group </li></ul><ul><li>Single nodule (sporadic) , multinodular (familial) </li></ul><ul><li>Lymph node enlargement +(- ) </li></ul><ul><li>Dysphagia ,dyspnoea hoarseness </li></ul><ul><li>MEN IIA - symptoms of hyperthyroidism or phaeochromocytoma </li></ul>
  35. 35. Investigations <ul><li>FNAC OF Thyroid mass </li></ul><ul><li>Urinary metabolites – VMA,metanephrine,catecholamine </li></ul><ul><li>Serum Calcium </li></ul><ul><li>USG Abdomen </li></ul><ul><li>Serum calcitonin </li></ul>
  36. 36. Treatment <ul><li>Total thyroidectomy with central neck dissection </li></ul><ul><li>External – beam radiotherapy in unresctable disease </li></ul>
  37. 37. Anaplastic thyroid carcinoma <ul><li>Rapidly growing tumours with invasion of surrounding structures </li></ul><ul><li>Lymph node involvement is frequent & early </li></ul><ul><li>Foci of both undifferentiated and differentiated cells are seen in follicular or papillary pattern </li></ul>
  38. 38. Clinical features <ul><li>Presents with rapidly progressive lump of short duration </li></ul><ul><li>May be painful or ulcerated </li></ul><ul><li>Compressive symptoms+ </li></ul><ul><li>Mass hard and fixed to the surrounding structures </li></ul><ul><li>Stridor+ </li></ul><ul><li>Metastasis lymph nodes, liver ,lungs. bones </li></ul>
  39. 39. Treatment <ul><li>FNAC – diagnostic </li></ul><ul><li>Treatment – disappointing </li></ul><ul><li>Debulking , tracheostomy radiotherapy </li></ul>
  40. 40. Secondaries <ul><li>Breast </li></ul><ul><li>Colon </li></ul><ul><li>Kidney </li></ul><ul><li>Melanoma </li></ul>
  41. 41. hypothyroidism <ul><li>Commonest endocrine problem </li></ul><ul><li>5% of female population affected </li></ul>
  42. 42. Types <ul><li>Primary </li></ul><ul><li>Secondary </li></ul><ul><li>tertiary </li></ul>
  43. 43. Primary <ul><li>Auto immune </li></ul><ul><li>Surgery </li></ul><ul><li>Radioactive iodine </li></ul><ul><li>Ext.beam RT to neck </li></ul><ul><li>drugs </li></ul>
  44. 44. Hashimoto’s thyroiditis <ul><li>Auto immune </li></ul><ul><li>Familial </li></ul><ul><li>Females 9:1 </li></ul><ul><li>40-50 yrs </li></ul>
  45. 45. features <ul><li>Compensated hypothyroidism </li></ul><ul><li>Hyperthyroidism </li></ul><ul><li>hypothyroidism </li></ul>
  46. 46. <ul><li>TSH </li></ul><ul><li>ANTIBODIES </li></ul><ul><li>antimicrosomal </li></ul><ul><li>antiTG </li></ul>
  47. 47. Treatment <ul><li>Normalise the TSH </li></ul>
  48. 48. Complications <ul><li>Other autoimmune disorders </li></ul><ul><li>lymphoma </li></ul>

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