This document discusses lymphomas and Hodgkin lymphoma. It covers their incidence rates, risk factors, clinical presentation, investigations and staging, classification systems, prognostic factors, and treatments. For non-Hodgkin lymphomas, the most common subtype is diffuse large B-cell lymphoma. Hodgkin lymphoma is bimodal with peaks in young adults and older adults and has associations with Epstein-Barr virus. Staging uses the Ann Arbor system while prognosis relies on indexes like the International Prognostic Index. Treatment often involves chemotherapy regimens like CHOP.

1. Limphomas. Thyroid cancer.
The clinic, diagnosis, screening methods.
Classification. Treatment. Risk Factors.
Prevention

3. • The haematological malignancies make up a
group of diverse diseases ranging from the
very indolent, which may co-exist with the
patient for many years, to the highly
aggressive and rapidly fatal.
• They can occur anywhere in the body.
Introduction

4. Lymphomas: general aspects
• Non-Hodgkin lymphoma (NHL) is the seventh
most common cancer in the UK, with a yearly
incidence of about 9000 new cases, and
occurs mostly in patients over age 65. This
rate appears to be rising by 3 to 5% each year,
for reasons that are not clear.
• Hodgkin lymphoma (HL) is the 22nd most
common cancer in adults, with a relatively
stable yearly incidence of 1500.

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6. Lymphomas: general aspects
• In children under 14 years of age, lymphoma
is the third most common cancer, after
leukaemia and CNS tumours,
• but in adolescents and young adults aged
between 14 and 24 years, lymphoma is the
most common cancer, accounted for mainly by
HL.

7. Lymphomas: general aspects
• There are more than 60 types of lymphoid
neoplasms with a spectrum ranging from
some of the most indolent malignancies, such
as mucosa-associated lymphoid tissue (MALT)
lymphoma, to some of the most aggressive,
such as Burkitt lymphoma.
• Historically, the use of multiple systems of
classification has confounded the results of
therapeutic trials.

8. Aetiology of lymphoma
• The aetiology of lymphoma is not clearly
understood and appears to be multifactorial.
Risk factors include
• Immunodeficiency (HIV infection, post-
transplant).
• Autoimmune disorders.

9. Aetiology of lymphoma
• Viruses – EBV, HIV, HTLV-1, hepatitis C, HHV-8.
• Other infectious agents –Helicobacter pylori,
Chlamydia, Borrelia, TB (usually MALT
lymphomas).
• Environmental carcinogens.
• Family history.

10. Clinical presentation
• A patient presenting with lymphoma usually
has painless lymphadenopathy. The patient
may also have systemic ‘B’ symptoms in the 6
months before diagnosis:
• fever higher than 38◦C, drenching night
sweats and weight loss of more than 10% of
the original body weight.
• Symptoms of organ involvement or
compression may also be present.

11. Investigations and staging
• It is important to emphasise to newly
diagnosed patients that an accurate diagnosis
and staging are very important in deciding
their treatment.

12. Investigations and staging
• A clinical history should be taken and an
examination performed to assess systemic
symptoms, performance status and the
presence of palpable disease.
• A full blood count and film; ESR; renal, liver
and bone profile; urate; lactate
dehydrogenase (LDH); and β2-microglobulin
should be taken.

13. Investigations and staging
• A CT scan of the neck (or ultrasound), CT scan
of the thorax, abdomen and pelvis should be
done.
• An MRI of the head and neck should be
performed if relevant.
• The use of PET as a staging investigation is not
yet standard practice.

14. Investigations and staging
• A biopsy is preferably excisional, or cutting
needle, and requires expert pathological
review.

15. Investigations and staging
• Bone marrow examination should be carried
out for all patients with NHL and for patients
with HL who have advanced disease or
abnormal blood counts.
• Immunophenotyping of blood, bone marrow
or tissue should be performed as appropriate.

16. Investigations and staging
• A CSF examination should be done in cases of
suspected CNS involvement, or in cases of
parameningeal or testicular disease

17. Staging classification
• The Ann Arbor staging system was initially
developed for HL but is also the basis for
anatomic staging in NHL.
• However, the system has limitations for NHL
because the pattern of disease differs from
that of HL, with more frequent extranodal and
bone marrow involvement.

18. Staging classification
• The lymph node regions defined at the Rye
Symposium in 1965 are as follow:
• Right and left cervical (including cervical,
supraclavicular, occipital and preauricular).
• Right and left axillary.
• Right and left infraclavicular.

19. Staging classification
• Mediastinal.
• Right and left hilar.
• Para-aortic.
• Mesenteric.
• Right and left pelvic.
• Right and left femoral-inguinal.

20. Cotswolds modification of the Ann
Arbor staging system
• Stage Description
• I - Involvement of a single lymph node region,
lymphoid structure or extra-nodal site
• II - Involvement of two or more lymph node
regions on the same side of the diaphragm, or
localised involvement of an extranodal site
and one or more lymph node regions on the
same side of the diaphragm.

21. Cotswolds modification of the Ann
Arbor staging system
• III - Involvement of lymph node regions on
both sides of the diaphragm with or without
localised involvement of an extranodal site, or
spleen, or both
• IV - Diffuse organ involvement, any liver/bone
marrow disease

22. Cotswolds modification of the Ann
Arbor staging system
• X - Bulk disease>10 cm
• E - Extranodal extension or single isolated site
of extranodal disease
• A/B - B symptoms: weight loss>10%, fever,
drenching night sweats

23. Prognostic index: NHL
• The Ann Arbor staging system does not give
adequate prognostic information for many
subtypes of NHL, nor does it always help to
decide management.
• The International Prognostic Index (IPI), based
on a study of more than 2000 patients with
high-grade NHL treated with anthracycline-
containing regimens, showed that five factors
independently predict outcome.

24. Prognostic index: NHL
• The IPI scoring factors (score 1 point for each)
include age>60 years, performance status of 2
to 4, stage III or IV disease, LDH elevated
above normal, and the patient having more
than one extranodal disease site.
• The prognoses, based on IPI category (score)
and 5-year survival (5YS), are low (score 0 to 1,
5YS =73%), low intermediate (2; 5YS=51%),
intermediate high (3; 5YS=43%) and high (4 to
5; 5YS=26%).

25. Prognostic index: NH
• The age-adjusted IPI for patients age 60 years
or more (score 1 point for each) includes a
performance status of 2 to 4, stage III or IV
disease, and elevated LDH. The prognoses,
based on age-adjusted IPI category (score)
• and 5-year survival (5YS), are low (0;
5YS=83%), low intermediate (1; 5YS =69%),
intermediate high (2; 5YS =46%) and high (3;
5YS=32%).

26. Pretreatment assessment
• Semen cryopreservation should be discussed
with all postpubertal males.
• An echocardiogram or MUGA scan should be
performed to assess cardiac function in
patients with risk factors for ischaemic heart
disease,
• or in all patients over 70 years in whom
anthracyclines are being considered.

27. Pretreatment assessment
• Assess the disease bulk and the risk of tumour
lysis before chemotherapy, and start
allopurinol 300 mg p.o. o.d. as prophylaxis.
• When there is evidence of tumour lysis
occurring with an elevated serum uric acid
despite allopurinol prophylaxis, rasburicase
should be given.

28. Pretreatment assessment
• Rasburicase may be indicated as prophylaxis in
patients allergic to allopurinol
• or in patients experiencing renal failure prior
to starting chemotherapy (serumcreatinine
>150μM/l).

29. PET scanning in lymphoma
• Functional imaging with positron emission
tomography using a radiolabelled glucose
analogue, 2-18 F-fluoro-2-deoxy-D-glucose
(FDG-PET), identifies increased glycolytic
activity associated with malignant tumours
and complements conventional imaging.

30. PET scanning in lymphoma
• FDG-PET imaging is used most commonly in
the assessment of a residual mass at the end
of treatment, and it is better than CT scanning
in distinguishing between residual tumour and
fibrosis.

31. Diffuse large B-cell lymphoma
(DLBCL)
• The annual incidence of DLBCL is 5 in 100 000
people and the median age of diagnosis is 64
years. The male-to-female ratio of disease
occurrence is 1:1.
• Phenotypes CD19, CD20, CD22, CD79a are
involved, and it has been determined more
recently that BCL6, CD10 and MUM1 can
differentiate germinal centre (GC) types from
non-GC types.

32. Hodgkin lymphoma
• The incidence of HL is bimodal.
• Indeveloping countries, the first peak occurs in
childhood, whereas in developed countries, it is seen
in young adults.
• The second peak occurs in older adults, usually men.
• Epidemiological studies suggest an infectious
aetiology, particularly involving EBV.
• The male-to-female ratio of disease incidence is
1.5:1.

33. Hodgkin lymphoma

34. Changes at LGM

35. Cells
Berezovsky
Reed-
Sternberg-
Normal
lymphocytes

36. Depending on which cellular elements dominate
the polymorphic granuloma distinguish
with lymphoid advantage
nodular sclerosis,
mixed-cell variant
lymphoid depletion.
According to the WHO International
Classification of morphologic release four
pathomorphological variants LGM

37. Stage 1 - destruction of one group l. nodes or other
organs of the lymphatic system (thymus, spleen, ring
Valdeyyera);
Clinical classification
LGM

38. - The defeat of several neighboring
groups l. nodes on the same side of the
diaphragm, or a local one extranodal
organ lesions on the same side of the
diaphragm.
Second stage of
LGM

39. - L damage. organs or lymph nodes on
both sides of the diaphragm, which can
be combined with extranodal organ
damage
Stage III LGM

40. disseminated lesions of one or more extranodal organs with
lesions nerehionarnyh l. nodes. In particular, liver and bone marrow
are always evaluated as 1U stage LGM.
AndV stage LGM

41. Clinical presentation
• Patients usually present with widespread
nodal or extranodal disease and B symptoms;
10% have bone marrow involvement.

42. Magnification retroperitoneal LV. at
the LGM
(Data spiral of computer tomography)

43. Macropreparations
affected
lymphogranulomatosis
liver
Lesion
locus

44. Treatment overview
• A SWOG/ECOG trial found that chemotherapy
with cyclophosphamide, doxorubicin,
vincristine and prednisolone (CHOP) was as
effective as, but less toxic than, multiple-drug
dose-intense regimens (MACOP-B, mBACOD,
ProMACE-CytaBOM).
• The 5-year survival was about 45% (Fisheret
al., 1993), and a recent update showed 15-
year survival to be about 40% (Fisheret
al.,2004).

45. Treatment overview
• The biggest therapeutic impact has been the
introduction of rituximab, an anti-CD20
monoclonal antibody. The GELA study of
patients ages 60 to 80 years compared eight
cycles of rituximab with CHOP (RCHOP) with
CHOP alone and showed 2-year survival rates
of 76% compared to 63% in favour of R-
CHOP,with similar benefits seen at 5 years
(Coiffieret al., 2002).

46. Treatment overview
• The MInT study, which used rituximab added
to anthracycline-based chemotherapy in
patients below the age of 60 with low-risk IPI
scores, showed that the addition of rituximab
improved 3-year progression free survival
from 68 to 85%, and 3-year overall survival
from 84 to 93% (Pfreundschuhet al., 2006).

47. Treatment overview
• In this trial, RT (30 to 40 Gy) was given to sites
of initial bulky disease larger than 5 cm.
• Bulky disease larger than 7.5 cm was found to
be an independent poor prognostic factor

48. Hodgkin lymphoma
• Of HL patients, 95% have classical HL, in which
the tumour cells express CD30 and CD15, and
lack B-cell antigens.
• In nodular lymphocyte predominant HL (5%),
B-cell markers such as CD20 are expressed,
and CD30 and CD15 are absent.

49. Management of early stage (I to
IIA) disease
• Patients with early stage HL may be divided
into two prognostic groups to decide
treatment: favourable and unfavourable.
• The prognostic factors are age, number of
involved sites (three or more), B symptoms,
ESR greater than 50 and bulky disease larger
than 10 cm (usually mediastinal).
• Patients with one or more risk factors may be
treated as patients with advanced disease

50. Management of early stage (I to
IIA) disease
• Doxorubicin, bleomycin, vinblastine and
dacarbazine (ABVD) chemotherapy has been
shown to be more effective and less toxic.
• The current standard treatment is three to
four cycles of ABVD followed by IFRT 30 Gy in
15 fractions (RCR, 2006).

51. Management of advanced disease
(stage IIB and higher)
• ABVD has replaced MOPP as the standard
chemotherapy regimen; ABVD gives
comparable overall survival rates with less
toxicity.
• However, some patients still relapse, whereas
others may be overtreated.
• A prognostic index has been defined, based
on more than 5000 patients treated with
ABVD or an equivalent regimen.

52. International Prognostic Factor
Score (IPFS)
• On the IPFS for Hodgkin lymphoma, score 1
point for each of the following patient
characteristics:
• Age>45 years.
• Male.
• Serum albumin<40 g/l.
• Hb<10.5 g/dl.

53. Most frequently used regimens in
LGM
ABVD
Doxorubicin 25, in / to First 15th
Bleomycin 10 in / to 1i15
Vynblastyn 6 in / to 1i15
Dacarbazine 375 in /in 1and15th
MOPP-ABV
Mustarhen 6 in / to 1
Vynkrystyn 1.4 (maximum
2.0)
in / to 1
Natulanum 100 p.os 1-7
Prednisone 40 p.os 1-14
Doxorubicin 35 in / to 8
Bleomycin 10 in / to 8
Vynblastyn 6 in / to 8

54. International Prognostic Factor
Score (IPFS)
• Stage IV disease.
• Leucocytosis>15×10 /9/l.
• Lymphopenia<0.6×10/9/l or<8% WBC count.

55. Prognosis based on the IPFS score
• 5-year disease-free survival (5YDFS) and 5-
year overall survival (5YOS) are as follows:
• Score =0 to 3 – 81% of patients; 5YDFS =70%;
5YOS=83%.
• Score=4 or more – 19% of
patients;5YDFS=47%; 5YOS=60%.

56. Prognosis based on the IPFS score
• This prognostic score can identify patients
who are at a higher risk of relapse.
• Patients with a score of 0 to 3 are treated
with six to eight cycles of ABVD.
• Whereas patients with a score of 4 or more
may be considered for more intensive
treatment.

57. Role of radiotherapy in advanced
HL
• In the current standard practice, RT is not
given to patients who have a complete
response to full-course chemotherapy.
• Patients with a partial response at the end of
treatment, confirmed on PET scanning or with
a biopsy, are usually referred for second-line
chemotherapy followed by high-dose
chemotherapy and an ASCT.

58. Role of radiotherapy in advanced
HL
• Another option, if residual disease at the end
of first-line therapy is encompassable within a
reasonable radiation field, is to give
consolidation RT, with a dose of 30 to 34 Gy
in15 to 20 fractions of 1.8 to 2 Gy over 3 to 4
weeks.
• If a patient is not a candidate for high-dose
chemotherapy, then consolidation RT can
improve complete response rates, though
probably not overall survival.

59. Acute side effects of mantle
radiotherapy
• Acute side effects include mild
• oropharyngitis
• dysphagia
• fatigue
• skin erythema
• localised hair loss.

60. Acute side effects of mantle
radiotherapy
• L’Hermitte’s sign may occur in about 15% of
patients approximately 6 to 12 weeks
following RT.
• It is characterised by an electric shock
sensation radiating down the backs of both
legs when the neck is flexed, and is due to
transient demyelination.
• It usually resolves spontaneously without any
permanent sequelae.

61. Late complications of treatment for
lymphoma
• Subclinical hypothyroidism develops in about
a third of patients who undergo mantle RT.
• Loss of fertility is usually compounded by the
use of chemotherapy, particularly high-dose
chemotherapy.
• Sperm cryopreservation should be offered to
all postpubertal males.

62. Late complications of treatment for
lymphoma
• Women who do not need urgent treatment
may undergo a cycle of in vitro fertilisation
before cancer treatment with
cryopreservation of embryos, but this process
delays the start of treatment (Wallaceet al.,
2006).
• Cryopreservation of mature, unfertilised
oocytes is not yet an established technique,
nor is cryopreservation of ovarian tissue.

63. Late complications of treatment for
lymphoma
• The major causes of late mortality, apart from
HL, are second malignancies and
cardiovascular disease.
• Mediastinal irradiation increases the risk of
coronary artery disease, and patients should
be warned about additional risk factors such
as smoking, hyperlipidaemia, and
hypertension.

64. Late complications of treatment for
lymphoma
• Second malignancies may include
myelodysplasia and leukaemia, NHL and solid
tumours, particularly of the breast and lung.
• It is clear that the increasing risk of breast
cancer is inversely related to age, but directly
related to increasing dose.
• The risk is particularly high for patients under
the age of 25 years who are treated with
radiotherapy (Swerdlow et al., 2000).

65. Late complications of treatment for
lymphoma
• The current strategy of using smaller field
sizes and lower radiation doses should reduce
this risk without compromising survival.
• Current guidelines recommend screening
women from eight years after treatment,
using either mammography or MRI,
depending on the patient’s age and breast
density.

66. THYROID

67. Introduction
• Thyroid cancer consists of a diverse group of
tumours with different clinical features and
prognoses.
• Thyroid cancer can occur at any age, but it is
rare in patients under the age of 25.
• Radiation exposure is the best-documented
risk factor.

68. Introduction
• Most thyroid cancers are carcinomas: these
are papillary, follicular, medullary, and
anaplastic, in order of frequency. Thyroid
lymphomas and sarcomas are rarer.
• The overall prognosis is related to histological
type; well-differentiated thyroid cancer
(papillary and follicular) has the best
prognosis. In contrast, anaplastic carcinoma
progresses rapidly and has a very poor
prognosis.

69. Epidemiology of thyroid cancer
Thyroid cancer is 1-3% of malignant tumors
Most sick persons aged 30-60 years, mostly women.

70. Types of thyroid tumour
• Thyroid tumours can be divided into benign,
malignant primary and malignant secondary.
• The relative proportions of patients with
differentiated thyroid cancer in a geographic
area depend on dietary iodine intake.
• The proportion of follicular cancers increases
where there is dietary iodine deficiency.

71. Benign tumors of thyroid
Follicular adenoma – single or multiple;
variant=H¨ urthle cell adenoma

72. Malignant
primary
• Differentiated thyroid cancer
• Papillary (PTC: 80%)
• Follicular (FTC: 5–20%)
• Other carcinomas
• Medullary (8–12%, of which 75–80% are
sporadic)
• Anaplastic (1–3%)
• Other malignant tumours
• Lymphoma (5%)

73. Malignant
secondary
• Melanoma
• Renal
• Breast
• Lung

74. Anatomy
• The thyroid develops from an endodermal
outgrowth from the midline of the pharyngeal
floor, which then becomes the thyroglossal
duct and elongates before developing into two
lobes.
• The solid cord joining the gland to the tongue
then disappears.

75. Anatomy

76. Anatomy
• The thyroid consists of two lobes connected
by the isthmus, and it weighs 15 to 20 g.
• It is very vascular and is surrounded by a
sheath derived from the pretracheal fascia.
• The apex of each lobe can reach up to the
oblique line on the thyroid cartilage and the
base lies at the level of the fourth or fifth
tracheal ring.

77. Anatomy
• The isthmus overlies the second, third and
fourth tracheal rings.
• The pyramidal lobe is often present and
extends up from the isthmus.
• The posterior aspect of each lobe is related to
the four parathyroid glands, which lie within
the fascial capsule of the thyroid gland behind
the middle and inferior parts of the gland.

78. Anatomy
• The recurrent laryngeal nerve passes deep to
the thyroid gland and is closely related to it,
lying in the groove between the trachea and
the oesophagus.
• With respect to lymphatic drainage, the first-
station nodes are paralaryngeal, paratracheal
and prelaryngeal (central compartment/level
VI).

79. Pathology
• Microscopically, the majority of the thyroid
gland is made up of follicles filled with colloid.
• The parafollicular or C cells originate from the
neural crest, produce calcitonin, and are
located outside the follicles.
• They account for 0.1% of thyroid cells and
they lie at the junction of the upper and lower
two-thirds of the lobes.

80. Pathology
• Tumours can arise from the
• follicular epithelium (papillary, follicular and
anaplastic),
• parafollicular or C cells (medullary), or non-
epithelial stromal elements.

81. Papillary cancers
• Papillary cancers are multifocal in up to 75% of
cases (frequency of multifocality depends on
method of pathological assessment).
• Orphan Annie nuclei and psammoma bodies
are typical.
• The tall cell, columnar, and diffuse sclerosing
variants are more aggressive.

82. Follicular cancers
• Cytology cannot distinguish adenomas from
malignant tumours and, therefore, follicular
cancers cannot be diagnosed with FNA.
• Histologically, capsular or blood vessel
invasion is often the only feature of
malignancy.

83. Anaplastic carcinoma
• Anaplastic carcinoma arises from follicular
cells.
• There is disagreement regarding whether it
originates de novo or from differentiated
thyroid cancer.

84. Medullary thyroid cancer
• MTC arises from parafollicular cells or C cells
(neural crest/neuroendocrine origin), which
can secrete calcitonin and carcinoembryonic
antigen (CEA).
• Amyloid may be present.

85. Hereditary types
• Tumours arising with MEN 2A and MEN 2B are
often bilateral and multicentric.
• They are inherited in an autosomal dominant
fashion and are associated with a germline
mutation in the RET proto-oncogene on
chromosome 10q, which codes for a receptor-
like tyrosine kinase.
• C cell hyperplasia may be present.

86. Non-Hodgkin lymphoma
• Many tumours are derived from mucosa-
associated lymphoid tissue (MALT) and are
therefore of low grade with a tendency for
distant relapse.
• High-grade lymphomas can also occur.

87. H¨ urthle cell/oxyphil tumours
• The majority of H¨ urthle cell/oxyphil tumours
are benign;
• If malignant, they are usually well
differentiated.
• They produce thyroglobulin but rarely take up
iodine.

88. Screening
• There is currently no screening programme for
the general population.
• For individuals with a strong family history of
thyroid cancer or association with other
cancers, genetic advice should be sought.

89. Screening
• For MTC, all newly diagnosed patients,
regardless of their family history, should be
referred for RET mutation testing, which tests
for exons 10, 11 and 13 to 15.
• Adult gene carriers are at high risk and are
therefore recommended to have total
thyroidectomy with central lymph node
dissection (after excluding
phaeochromocytoma).

90. Screening
• As a general guide, child gene carriers of MEN
2B should undergo surgery at an early age;
• In practice, thyroidectomy is often performed
soon after the first year.

91. Screening
• Children carrying MEN 2A mutations typically
have surgery by the age of 3 so that they are
well established on thyroxine therapy by
school age.
• The precise timing and extent of surgery is
now dictated by the specific type of codon
mutation.

92. Stage classification
Classification prevalence of thyroid cancer by TNM system
Primary tumor (T):
Tx - Insufficient data to assess
T0 - No evidence of primary cell
T1 - Up to 2.0 cm tumor within the gland tissue,
T2 - Tumor to 4.0 cm within the gland tissue,
T3 - Tumor size of 4.0 cm within the gland tissue,
T4 - Tumor of any size, extends beyond the capsule gland.
Regional lymph nodes (N):
Nx - Insufficient data to assess regional lymph nodes,
N0 - No signs of regional lymph nodes,
N1 - There are lymph nodes on the side of the tumor,
N2 - Existing bilateral lesions regional lymph nodes.
Distant metastases (M):
M0 - No distant metastasis,
M1 - There are distant metastases.

93. Differentiated thyroid cancer
Incidence and epidemiology
• Differentiated thyroid cancer makes up fewer
than 1% of all malignancies but is the most
common endocrine malignancy.
• The UK annual incidence is 2.3 per 100 000
females, 0.9 per 100 000 males.
• The female-to-male ratio ranges from 1.5:1 to
4:1.

94. Differentiated thyroid cancer
Incidence and epidemiology
• In England and Wales, 900 new cases are
diagnosed per year, and approximately 250
deaths occur per year in the UK (British
Thyroid Association, 2002).
• Recently, there has been an increase in
incidence and decrease in mortality (9% die of
their disease).
• High disease incidence occurs in Hawaii,
Iceland, Finland, Israel and Colombia

95. Risk factors and aetiology
• Risk factors for disease include the following:
• Increasing age and female gender.
• History of neck irradiation in childhood
(particularly for papillary carcinomas).
• Nuclear fallout (age at exposure is important).
• Endemic goitre.
• Family history or personal history of adenoma.

96. Risk factors and aetiology
• Gardner’s syndrome.
• Cowden’s syndrome.
• Familial adenomatous polyposis (FAP).
• Familial differentiated thyroid cancer.
• Turcot’s syndrome.
• Carney complex.

97. Clinical presentation
• Possible clinical scenarios at presentation
include the following:
• Asymptomatic thyroid nodule or cervical
node.
• Sense of fullness/pressure in neck.

98. Clinical presentation
• Stridor, dysphonia, dysphagia, odynophagia,
cough (more likely with lymphoma and
anaplastic tumours).
• Unexpected finding after thyroidectomy for
presumed benign disease.
• Distant metastases – dyspnoea, haemoptysis,
bone pain and so fort.

99. General investigation
• Fine needle aspiration cytology (FNAC) is
categorised as Thy 1 to 5 (1=inadequate, 2
=benign, 3=follicular, 4=suspicious,
5=malignant). The malignant potential of
follicular and H¨ urthle cell tumours cannot be
determined on FNA or frozen section because
these investigations cannot demonstrate
capsular and vascular invasion. Lymphoma
often cannot be reliably diagnosed without
incisional biopsy.

100. General investigation
• US of the neck usually shows a hypoechogenic
solid lesion.
• CT/MRI of neck and chest should be carried
out to assess local disease extent and to plan
treatment.
• CT/MRI is indicated if there is bulky or fixed
neck disease in order to assess retrosternal
extension, nodal status, and whether there
are pulmonary metastases

101. Thyroid ultrasonography

102. Thyroid Scan
radioisotope method for diagnosing

103. Enlargement of the thyroid gland: a - II degree, second - third
degree, c, d - fourth degree, d, f - V Class.
A B
D D
In
E
Enlargement of the thyroid gland:

104. General investigation
• Serum calcitonin should be checked if MTC is
suspected. Vocal cords should also be
examined.
• Radionuclide imaging is of limited use in the
diagnosis of thyroid cancer. Malignant nodules
are classically stated to be ‘cold’ but they may
also appear as ‘warm’ and ‘hot’ areas.
• Serumthyroglobulin measurement is of no
diagnostic value unless the thyroid has been
removed

105. General investigation
• 18FDG-PETis not routinely indicated in the
diagnostic stages (Intercollegiate Standing
Committee on Nuclear Medicine, 2003).
• Consider imaging after TSH stimulation.
• 18FDG-PET-positive metastatic disease is
often radioiodine negative

106. Treatment overview
• Early cases of differentiated thyroid cancer
may potentially be cured with surgery alone,
although the majority of cases are usually
managed with a combination of surgery,
radioiodine and TSH-suppressive doses of
thyroxine.
• External beam radiotherapy may play a role in
locally advanced and metastatic disease

107. Surgery
• Surgery is the mainstay of treatment.
• There is controversy about the extent of
surgery required for low-risk cases

108. Treatment of Thyroid Cancer
The main method of treatment thyroid cancer is surgery

109. Lobectomy
• It can be argued that lobectomy is suitable for
papillary cancers smaller than 1 cm in females
younger than 45 years of age who have node-
negative necks, and for follicular cancers
smaller than 1 cm with minimally invasive
features.
• The disadvantage of this approach is the
difficulty of follow-up, because Tg
measurements are inaccurate and imaging
shows residual thyroid tissue.

110. Lobectomy
• There are two reasons proposed to support
the lobectomy approach:
• 1. Total thyroidectomy is associated with
increased risks of hypoparathyroidism and
recurrent laryngeal nerve damage.
• 2. This is a good prognosis group of patients
and survival is not significantly increased with
more ‘radical’ surgery.

111. Total thyroidectomy
• Total thyroidectomy is indicated if the tumour
is larger than 1 cm
• Multifocal, with extrathyroidal spread
• If there is familial disease
• Positive lymph nodes
• Previous neck irradiation
• H¨ urthle cell subtype.

112. Total thyroidectomy
• The rate of recurrent laryngeal nerve injury is
1 to 6% (higher if performed as a re-
operation);
• 30% of patients require postoperative calcium
supplementation.
• After 3 months, the rate of hypocalcaemia is
only 2%.

113. Radioisotope therapy
• Postoperative ablation should be performed
for
• papillary tumours > 1 cm.
• papillary tumours with lymph node
involvement or thyroid capsule invasion.
• follicular tumours > 1 cm that are minimally
invasive.

114. Radioisotope therapy
• Follicular tumours < 1 cm that are widely
invasive.
• Follicular tumours with thyroid capsule
invasion or involved lymph nodes.
• Treatment should also be used if the primary
tumour is inoperable or if there is
postoperative residual neck disease, distant
metastases or recurrent disease.

115. External beam radiotherapy
• External beam radiotherapy is infrequently
used. The main indications for its use are
• Unresectable disease
• Non-iodine-avid disease
• Gross local invasion with macro- or
microscopic residual,
• Recurrent neck disease
• Not amenable to surgery, and palliation of
inoperable metastatic disease

116. Radiotherapy

117. Chemotherapy
• Chemotherapy is not routinely used in the
treatment of thyroid carcinoma. Its use is
restricted to symptomatic progressive disease
when surgery, radiotherapy and radioactive
iodine have failed.
• Doxorubicin is the most frequently used drug,
with a reported partial response rate of
approximately 20 to 30%.
• There is no clear evidence that its use
increases survival.

118. Prognosis
• Of patients with well-differentiated thyroid
cancer, 5 to 20% develop distant metastases
(lung > bone > liver and brain).
• Older age is associated with worse outcomes.
• The most important predictors are the
patient’s age; the tumour’s size, grade and
extrathyroidal spread; and distant metastases.

119. Prognosis
• Approximately 75% of all patients with DTC
would be classified as low risk.
• For anaplastik tumors the median survival is 6
months from development of symptoms; 75%
of patients still die from local progression.
• In practice the patient often spends much of
their remaining life receiving treatment and
recovering from acute radiation toxicity.

120. The survival rate of thyroid cancer
Type of
thyroid
cancer
5-year survival
10-year
survival
STAGE I
STAGE II
STAGE III
STAGE IV
Survival Survival
Papillary 100% 100% 93% 51%]
96%[ or
97%
93%
Follicular 100% 100% 71% 50% 91% 85%
Medullary100% 98% 81% 28,%
80% 83%
Or 86%
75%
Anaplastic(always stage IV) 7%
7% Or
14,%
There is
not Data

121. Thank you