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Thyroid malignancy
- 2. • 66/M • c/o swelling in front of neck for 10 years • c/o Diplopia for the past 3 months • No rapid increase in size • No hyperthyroid/hypothyroid symptoms • No voice change
- 3. O/E • There was a 3x2 cm • size, hard swelling in • the right lobe of • thyroid, which • moved up • with deglutition. • No nodes
- 4. Triple assessment • Clinical assessment – Size, fixity, character on palpation • FNAC • Imaging – USG neck
- 5. History • Rapid increase in size • Childhood radiation • Family h/o thyroid cancer • Syndromes (MEN 2, Cowden’s, FAP)
- 6. Examination • Fixed hard mass • Obstructive symptoms • Voice change • Cervical lymphadenopathy
- 7. FNAC A – Macrofollicle B- Macrofollicle broken apart
- 8. Adenoma Microfollicle with little or no colloid in background No clumping or pleomorphism
- 9. Follicular carcinoma Microfollicles, No colloid Clumping, pleomorphism present Cells not arranged in follicles
- 10. Hurthle cell neoplasm Large polygonal cells with abundant oxyphilic cytoplasm
- 11. Papillary carcinoma Nuclei have clefts, grooves and holes Intranuclear inclusions – Orphan annie eye
- 12. Medullary carcinoma Spindle shaped cells – occasional RED cystoplasmic inclusions Amyloid stroma
- 13. Bethesda classification • Benign • FLUS/AUS • Follicular neoplasm • Suspicious for malignancy • Malignancy • Nondiagnostic
- 14. FLUS/AUS • Cells have mild nuclear atypia • Equal number of micro/macrofollicles • Extensive oncocytic change BUT not enough to characterise as HURTHLE cell neoplasm
- 15. USG Neck
- 16. Our patient • A well defined heterogenous solid nodule with calcification in the right lobe . The skull lesion on the left is similar in appeara nce to the thyroid lesion Findings are highly suspicious of malignancy * Three small isohypoechoic nodules in the left lobe - Probably benign * Suspicious left level 4 node measuring
- 18. TIRADS (Thyroid imaging reporting and data system) TIRADS Interpretation 1 Normal thyroid gland 2 Benign lesion 3 Probably benign lesion 4 a,b,c Suspicious of malignancy 5 Probably malignant (>80% risk) 6 Biopsy proven malignancy
- 19. TIRADS 4 a,b,c • Marked hypoechoic nodule • Solid component • Microlobulations/ irregular margins • Microcalcifications • Taller than wider shape
- 20. • TIRADS 4 a – One suspicious feature (5-10%) • TIRADS 4 b – Two suspicious features • TIRADS 4 c – Three to four suspicious features - Tirads 4b,c – 10-80% risk of malignancy
- 22. MALIGNANT PRIMARY Follicular epithelium – Differentiated Follicular ca Papillary ca Follicular epithelium – Undifferentiated Anaplastic carcinoma Parafollicular cells - Medullary ca Lymphoid cells – Lymphoma
- 23. Incidence Tumor Relative incidence Papillary carcinoma 60 Follicular carcinoma 20 Anaplastic carcinoma 10 Medullary carcinoma 5 Malignant lymphoma 5
- 24. Papillary carcinoma Follicular carcinoma Medullary carcinoma Presentation Younger age M:F – 1:2.5 Older age (40 – 60) MIFC/ WIFC M:F - Sporadic/ Familial/ MEN 2A,B Metastases Common at presentation Lymph node – MC site Poor prognosis Hematogenous Common at presentation (50%) Lymph node Gene NTRK, RET, BRAF RAS oncogene RET Tumor marker None None Calcitonin CEA
- 25. Papillary carcinoma Follicular carcinoma Medullary carcinoma Types Follicular Insular Tall cell Insular Diffuse sclerosing Hurthle cell carcinoma MEN IIA MEN IIB FMTC Radioiodine Concentrates radioiodine Concentrates radioiodine Does NOT concentrate radioiodine RESISTANT to RT, chemo
- 27. Patient risk factor • Age : - Males – 45 years - Females – 50 years • H/O neck irradiation • Signs of invasive nature
- 28. Tumor risk factors • Distant metastases • Vascular invasion • Capsular invasion • Tumor size • Early recurrence
- 30. AJCC staging
- 31. Risk stratification • A – Age • G – Grade • E – Extent • S – Size • A – Age • M – Metastases • E – extent • S - Size • MACIS • M – Metastases • A – Age • C – Completeness of resection • I –Invasiveness • S - Size
- 32. ATA
- 33. Treatment
- 34. Differentiated thyroid cancer- GOAL of intial therapy • To remove the primary tumor and involved lymph nodes • To minimize treatment and disease related morbidity • To permit accurate staging of the disease • To facilitate postoperative iodine treatment
- 35. Surgery in Differentiated thyroid cancer - Primary tumor >1 cm - Presence of regional/ distant mets - Prev h/o neck irradiation - First degree relative with thyroid ca - Age >45 yrs.
- 36. Basis of treatment in MTC • Does NOT take up Radioiodine • Does NOT respong to Thyroid suppression • In 90% of hereditary forms MULTICENTRIC In 20% of sporadic forms • Nodal metastases are present in > 70% of palpable disease
- 37. Advantages of Total thyroidectomy • Radioactive iodine scan and Tg levels on follow-up • Most PTC multicentric • Recurrence rates lower • Re-operative Sx higher morbidity
- 38. Indication of hemithyroidectomy • Tumor < 1cm • No nodal/distant metastases • No adverse patient risk factors
- 39. No role for hemithyroidectomy in Hurthle cell Medullary Ca
- 40. Lymph node dissection - Differentiated Ca thyroid Disease Treatment PTC with no nodal spread TT PTC with nodal spread TT + CCND + Unilateral MRND Follicular carcinoma with no nodal spread TT Follicular carcinoma with lymphnodal spread TT + CCND + Unilateral MRND
- 41. Surgery in DTC
- 42. Surgery in MTC
- 43. Follow-up of patients • High risk group : - Whole body scan - Thyroglobulin levels - USG neck • Low risk group : - Thyroxine suppression therapy TSH levels < 0.1 mU/L Thyroxine 2.2 – 2.5 mcg/Kg body weight for 5
- 44. When to do a WBS? • Do a radioiodine scan in - High risk patients - Tumor size > 1cm - LVI/PNI present - Timing : 45 days after stopping T4 2 weeks after stopping T3 - AIM : To achieve TSH > 30 mU/dl
- 45. Radioiodine scan • I123/ I131 • Low iodine diet prior to scan • Done 1 week post radioiodine therapy • Oral I131 administration – 2-5 mCi
- 47. Tg levels • 95% of patients with distant metastases have elevated Tg levels • Best time to evaluate Tg – when patient is hypothyroid in evaluation for WBS • Tg >> WBS in predicting metastatic disease • Level > 2mg/ml significant
- 48. Recurrence in DTC • Radioiodine ablation • Dosage 150 – 200 mCi • Follow up with atleast 2 negative scans
- 49. Recurrence in MTC • EBRT • Chemotherapy – Doxorubicin NOT EFFECTIVE • Interferon a • Surgery – Tissel described “microdissection” Extensive lymph nodal clearance
- 50. Metastatic carcinoma thyroid • Persistent / Recurrent disease in the neck : Surgical debulking • Invasion of upper aerodigestive tract : Sx + RI ablation/ RT
- 52. Bony metastases • Bone mets - Insensitive to I131 therapy
- 53. Brain metastases • Incidence – 0.15 – 0.30% • Treatment of choice – Surgical excision in view of neurologic symptoms • External RT - Pain
- 54. Mediastinal lymph nodal metastases • Surgical excision
- 55. Role of Chemotherapy • Metastatic disease – 10- 15 % respond to Alkylating agents 20 – 33% response to Bleomycin/Adriamycin • Indication: Tumors not amenable to - Radioiodine - RT
- 56. Role of RT • Painful osseous mets • Bone mets not amenable to Sx - Vertebral column - Base of skull
- 57. Our patient • Underwent TT + CCND + Left MRND
- 58. Biopsy report • Total thyroidectomy specimen: Multifocal follicular variant of papillary carcinoma, right and left lobes. Maximum tumour size is 3.3 cm in right lobe and 1 cm in left lobe. Capsular invasion, present in right lobe. There is no lymphovascular or perineural invasion. Tumour is 0.2 cm from the nearest inked
- 59. CT brain
- 60. Plan • To D/W neurosx regarding feasability of resection • WBS booked