THYROID THYROID CANCERCANCER

dr sumer yadavdr sumer yadav

THYROID CANCERTHYROID CANCER

Less than 1% of all cancer Less than 1% of all cancer Dunhill classified them into differentiated Dunhill classified them into differentiated

&undifferentiated &undifferentiated Differentiated cancers-Differentiated cancers-1.1. Papillary cancer Papillary cancer 2.2. Follicular cancerFollicular cancer3.3. Hurthle cell tumorsHurthle cell tumors Undifferentiated cancer-Undifferentiated cancer-1.1. Ana plastic carcinomaAna plastic carcinoma2.2. Medullary carcinoma Medullary carcinoma 3.3. LymphomaLymphoma Secondary growths are rare.Secondary growths are rare. Blood borne metastases are more usually from Blood borne metastases are more usually from

primaryprimarycancers of breast, colon & kidney cancers of breast, colon & kidney

PREDISPOSING FACTORSPREDISPOSING FACTORS Ionizing radiation exposure is a potent Ionizing radiation exposure is a potent

initiator of papillary cancerinitiator of papillary cancerParticularly below 10 year of age with Particularly below 10 year of age with

maximum effect around 4year & no maximum effect around 4year & no effect after 20, with latency period >8 effect after 20, with latency period >8 year.year.

Radioiodine treatment has no significant Radioiodine treatment has no significant effect.effect.

Follicular cancers are prevalent in Follicular cancers are prevalent in endemic goitrous areas probably due to endemic goitrous areas probably due to TSH stimulation.TSH stimulation.

Hashimoto`s thyroiditis increase 70-fold Hashimoto`s thyroiditis increase 70-fold risk of lymphoma.risk of lymphoma.

PREDISPOSING FACTORS (CONT.)PREDISPOSING FACTORS (CONT.)GENETIC FACTOR-GENETIC FACTOR-Mutation of RET- proto oncogene Mutation of RET- proto oncogene

present in about 50% of thyroid cancer.present in about 50% of thyroid cancer.All medullary cancer are due to various All medullary cancer are due to various

mutation in RET-protogene mutation in RET-protogene (chromosome).(chromosome).

FAP is associated with increase risk of FAP is associated with increase risk of papillary cancer which is due to papillary cancer which is due to mutation in APC gene.mutation in APC gene.

Cowden syndrome is due to mutation in Cowden syndrome is due to mutation in PTEN gene.PTEN gene.

PRESENTING CLINICAL PRESENTING CLINICAL FEATURESFEATURES

Painless, hard thyroid swelling with or Painless, hard thyroid swelling with or without lymph node enlargement in without lymph node enlargement in neck.neck.Isolated lymph node enlargement.Isolated lymph node enlargement.Hoarseness of voice.Hoarseness of voice.Dysphasia.Dysphasia.Dyspnoea.Dyspnoea.

DIAGNOSISDIAGNOSIS

Clinical examinationClinical examinationFNACFNACNeedle Core BiopsyNeedle Core Biopsy Incisional BiopsyIncisional BiopsyExcisional BiopsyExcisional BiopsyRadio-iodine thyroid scanRadio-iodine thyroid scanCT and MRI CT and MRI

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISMultinodular goiter.Multinodular goiter.Thyroid adenoma.Thyroid adenoma.Thyroiditis.Thyroiditis.Thyroid cysts.Thyroid cysts.Neck cysts.Neck cysts.Ectopic thyroid tissuesEctopic thyroid tissues

WELL DIFFERENCIATED CANCERWELL DIFFERENCIATED CANCER *PAPILLARY CARCINOMA**PAPILLARY CARCINOMA*

Most common thyroid malignancy(80%)Most common thyroid malignancy(80%) Female to male ratio 3:1Female to male ratio 3:1 Grossly they are solid, whitish, remain flat on Grossly they are solid, whitish, remain flat on

sectioning, invasive & only 10% are encapsulatedsectioning, invasive & only 10% are encapsulated Present as thyroid mass with or without enlarged LN Present as thyroid mass with or without enlarged LN

or isolated LN.or isolated LN. Microscopic features include-Microscopic features include-1.1. Presence of true papillaePresence of true papillae2.2. Orphan annie-eyed nucleiOrphan annie-eyed nuclei3.3. Nuclear pseudo-inclusion.Nuclear pseudo-inclusion.4.4. Psammoma bodiesPsammoma bodies Multiple foci are common.Multiple foci are common. Nodal metastases are common & early,& include Nodal metastases are common & early,& include

deep cervical, pre & paratracheal, prelaryngeal.deep cervical, pre & paratracheal, prelaryngeal. Blood borne metastases are less common.Blood borne metastases are less common. Extrathyroidal involvement may occur up to 25%.Extrathyroidal involvement may occur up to 25%.

PAPILLARY CARCINOMA OF THE THYROID,

SHOWING MULTIFOCAL TUMOUR.

HISTOLOGY OF PAPILLARY THYROID CARCINOMA SHOWING TYPICAL PAPILLARY PROJECTIONS AND EMPTY

(ORPHAN ANNIE-EYED) NUCLEI

VARIANTS OF PAPILLARY VARIANTS OF PAPILLARY CANCERCANCER OCCULT CARCINOMA-OCCULT CARCINOMA-

Present as enlarge cervical LN with no palpable Present as enlarge cervical LN with no palpable thyroid abnormalitythyroid abnormality

Primary tumor is few mm in size.Primary tumor is few mm in size. Excellent prognosis.Excellent prognosis.ENCAPSULATED VARIENTENCAPSULATED VARIENT Presence of a tumor capsule but invasion Presence of a tumor capsule but invasion

presentpresent Nodal metastases may present but distant Nodal metastases may present but distant

metastases & death are rare.metastases & death are rare. Prognosis is excellentPrognosis is excellentFOLLICULAR VARIANTFOLLICULAR VARIANT Mixed lesion with predominance of follicles Mixed lesion with predominance of follicles

over papillaeover papillae But behave like papillary carcinomaBut behave like papillary carcinoma

LINDSAY`S TUMORLINDSAY`S TUMORCombination of encapsulated & follicular Combination of encapsulated & follicular variant.variant.Behave in a very indolent fashion & excellent Behave in a very indolent fashion & excellent prognosis.prognosis.DIFFUSE SCLEROSING VARIANTDIFFUSE SCLEROSING VARIANT Primarily in children & highly aggressive.Primarily in children & highly aggressive.Thyroid gland is freely permeated with tumor Thyroid gland is freely permeated with tumor & a typical lymphocytic infiltrate& a typical lymphocytic infiltrateNodal metastases may up to 100% & distant Nodal metastases may up to 100% & distant metastases is high.metastases is high.Prognosis is poor.Prognosis is poor.TALL CELL PAPILLARY CANCERTALL CELL PAPILLARY CANCERRapidly growing, aggressive tumor of elderly.Rapidly growing, aggressive tumor of elderly.On presentation usually >5cm in size & 30% On presentation usually >5cm in size & 30% cases have vascular & extra capsular invasion.cases have vascular & extra capsular invasion.5-years survival rate is <30%.5-years survival rate is <30%.

FOLLICULAR CANCERFOLLICULAR CANCERSolid, encapsulated, usually solitary Solid, encapsulated, usually solitary

lesion.lesion.Female to male ratio 3:1.Female to male ratio 3:1.Follicular cell differentiation without Follicular cell differentiation without

features of papillary cancer.features of papillary cancer.Multiple foci are seldom seen.Multiple foci are seldom seen.Nodal metastases are unusual.Nodal metastases are unusual.Blood borne metastases are common Blood borne metastases are common

to kidney, lung, bones & brain.to kidney, lung, bones & brain.Mortality rate is twice of papillary.Mortality rate is twice of papillary.

METASTASIS FROM A CARCINOMA OF A

THYROID IN A HUMERUS

FOLLICULAR CANCER (CONT.)FOLLICULAR CANCER (CONT.)Based on degree of invasion, they are Based on degree of invasion, they are

two type.two type.

MINIMAL INVASIVE-MINIMAL INVASIVE-Solid, encapsulated, fleshy tumor like Solid, encapsulated, fleshy tumor like

simple adenoma.simple adenoma.Capsule is thick & irregular with minimal Capsule is thick & irregular with minimal

invasion.invasion.Excellent prognosis.Excellent prognosis.

WIDELY INVASIVE-WIDELY INVASIVE-Wide spread infiltration of blood vessels, Wide spread infiltration of blood vessels,

the capsule & adjacent thyroid tissue.the capsule & adjacent thyroid tissue.

Major differences between papillary & follicular Major differences between papillary & follicular carcinomacarcinoma

1.1. MALE INCIDENCEMALE INCIDENCE

2.2. LYMPH NODE METASTASESLYMPH NODE METASTASES

3.3. BLOOD VESSELBLOOD VESSEL

INVASIONINVASION

1.1. RECURRENCE RATERECURRENCE RATE

2.2. OVERALL MORTALITY RATEOVERALL MORTALITY RATE

LOCATION OF RECURRENT LOCATION OF RECURRENT CaCa

1.1. DISTANT METASTASESDISTANT METASTASES

2.2. NODAL METASTASES NODAL METASTASES

3.3. LOCAL RECURRENCELOCAL RECURRENCE

PAPILLARY PAPILLARY FOLLICULARFOLLICULAR

22% 35%22% 35%

35% 13%35% 13%

40% 60% 40% 60%

19% 29%19% 29%

11% 24%11% 24%

45% 75%45% 75%

34% 12%34% 12%

20% 12%20% 12%

HURTHLE CELL CARCINOMAHURTHLE CELL CARCINOMA Variant of follicular cell neoplasmsVariant of follicular cell neoplasms Derived from the oxypilic cell & account for about Derived from the oxypilic cell & account for about

3% of all thyroid cancers.3% of all thyroid cancers. Female dominant, mean age of 60 years.Female dominant, mean age of 60 years. Lesion are solid, well vascularised & well Lesion are solid, well vascularised & well

encapsulated.encapsulated. unlike follicular cancers, they are more often unlike follicular cancers, they are more often

multifocal & bilateral, are more likely to multifocal & bilateral, are more likely to metastases to local nodes(25%), and usually do metastases to local nodes(25%), and usually do not take radioiodine.not take radioiodine.

Microscopically, >75% follicular cells having Microscopically, >75% follicular cells having oncocystic features & characteristic distinct oncocystic features & characteristic distinct granular acidophilic cytoplasm & pleomorphic granular acidophilic cytoplasm & pleomorphic nuclei .nuclei .

Frequently associated with extra thyroidal Frequently associated with extra thyroidal extension, nodal & distant metastases.extension, nodal & distant metastases.

5-year mortality ranging from 20% to 40% (high 5-year mortality ranging from 20% to 40% (high risk)risk)

PROGNOSTIC INDICATORS OF PROGNOSTIC INDICATORS OF WELL DIFFERENTED CANCERSWELL DIFFERENTED CANCERS

Various staging system have been Various staging system have been develop for prognosis of thyroid cancers develop for prognosis of thyroid cancers like AJCC, AGES system (age, pathological like AJCC, AGES system (age, pathological grade, extent of disease size of tumour), grade, extent of disease size of tumour), AMES system (age, metastases, extent, AMES system (age, metastases, extent, size) TNM (Tumor size, nodal involvement size) TNM (Tumor size, nodal involvement & metastases) & MACIS SCALE [Distant & metastases) & MACIS SCALE [Distant metastases, age at presentation (<40 or metastases, age at presentation (<40 or >40 years), completeness of original >40 years), completeness of original surgical resection, extra thyroidal surgical resection, extra thyroidal involvement & size (cm)]involvement & size (cm)]

But these help in prognosis after surgery But these help in prognosis after surgery with little valve as an intra operative guide with little valve as an intra operative guide

PROGNOSTIC INDICATORS PROGNOSTIC INDICATORS (cont(cont..)) All these system summarized as followAll these system summarized as follow

Low risk group Low risk group Men <&= 40 years &women of <&= 50 years of age Men <&= 40 years &women of <&= 50 years of age

without distant metastaseswithout distant metastases All older patients withAll older patients with1.1. Intra thyroid papillary cancerIntra thyroid papillary cancer2.2. Minimal invasive follicular cancerMinimal invasive follicular cancer3.3. Tumour <5 cm in diameterTumour <5 cm in diameter4.4. No distant metastasisNo distant metastasis High risk groupHigh risk group1.1. All patients with distant metastasisAll patients with distant metastasis2.2. All older patients withAll older patients with Extra thyroidal papillary carcinomaExtra thyroidal papillary carcinoma Widely invasive follicularWidely invasive follicular 25 years mortality rate is 2% in low risk & 46% in high 25 years mortality rate is 2% in low risk & 46% in high

groupgroup

Treatment of well differentiated Treatment of well differentiated thyroid cancerthyroid cancer

TREATMENT OBJECTIVES-TREATMENT OBJECTIVES-

1.1. Eradicate primary diseaseEradicate primary disease

2.2. Reduce the incidence of local or Reduce the incidence of local or distant recurrencedistant recurrence

3.3. Facilitate the treatment of metastasesFacilitate the treatment of metastases

4.4. Cure the maximum number of patients Cure the maximum number of patients

5.5. Achieve all of the above with minimal Achieve all of the above with minimal morbiditymorbidity

Surgical resection of thyroid Surgical resection of thyroid in well differentiated tumourin well differentiated tumourTotal thyroidectomy is required for Total thyroidectomy is required for

all well differentiate carcinomaall well differentiate carcinoma In follicular minimal invasive type In follicular minimal invasive type

lobectomy can cure the conditionlobectomy can cure the condition

SURGICAL RESECTION OF LYMPH SURGICAL RESECTION OF LYMPH NODESNODES

Removal of lymph node individually (berry picking) Removal of lymph node individually (berry picking) is associated with a high recurrence rate is associated with a high recurrence rate compared with a thorough skeletonisation of vital compared with a thorough skeletonisation of vital structurestructure

When lymph nodes are involved in central When lymph nodes are involved in central compartment, a clearance should be performed compartment, a clearance should be performed &this should include the thymus & thyroid enblock&this should include the thymus & thyroid enblock

When lymph node involved in the lateral When lymph node involved in the lateral compartment then modified neck dissection and compartment then modified neck dissection and enblock dissection of fibrofatty tissue & lymphatic enblock dissection of fibrofatty tissue & lymphatic tissue should be done and if invasion occur in tissue should be done and if invasion occur in aggressive tumour then a more radical approach aggressive tumour then a more radical approach is necessaryis necessary

SURGICAL RESECTION OF LYMPH SURGICAL RESECTION OF LYMPH NODES (cont.)NODES (cont.)

A prophylactic central dissection on A prophylactic central dissection on clinical negative node should be clinical negative node should be considered in papillary & hurthle cell considered in papillary & hurthle cell cancers because of in more than 50%in cancers because of in more than 50%in these case micro metastases present & these case micro metastases present & difficultly of re-exploration in case of difficultly of re-exploration in case of recurrence .recurrence .Prophylactic node dissection is not Prophylactic node dissection is not justified in follicular cancers due to justified in follicular cancers due to infrequent nodal involvement.infrequent nodal involvement.

PRESERVATION OF THE PRESERVATION OF THE PARATHYROIDSPARATHYROIDS

In experienced hands the incidence of In experienced hands the incidence of permanent hypo-parathyroidism is less permanent hypo-parathyroidism is less then1%but may be up to 20%in occasional then1%but may be up to 20%in occasional thyrodectomistthyrodectomistUsually lower parathyroids are at risk Usually lower parathyroids are at risk because of devascularisationbecause of devascularisationMain interior thyroid artery should not be Main interior thyroid artery should not be ligated but small division of the artery should ligated but small division of the artery should be ligated close to capsulebe ligated close to capsuleIf doubt about viability, then parathyroid If doubt about viability, then parathyroid should be auto transplanted as 1mm fragment should be auto transplanted as 1mm fragment in a muscular pocket in the neck or forearmin a muscular pocket in the neck or forearm

RE-OPERATIONRE-OPERATION Should take place on 2 or 3 days after Should take place on 2 or 3 days after

initial operation or after 12 week initial operation or after 12 week INDICATIONSINDICATIONS

1.1. After lobectomy for a presumed After lobectomy for a presumed benign disease. Minimal invasive benign disease. Minimal invasive follicular cancer does not need re-follicular cancer does not need re-operationoperation

2.2. If enlarged node in papillary cancer If enlarged node in papillary cancer were not detected perioperativelywere not detected perioperatively

3.3. After previous total thyroidectomy After previous total thyroidectomy when USG or other modality when USG or other modality demonstrates bulky residual thyroiddemonstrates bulky residual thyroid

RADIOACTIVE IODINE (RADIOACTIVE IODINE (131131 I) I) THERAPYTHERAPY

131131I ablation is standard management in high I ablation is standard management in high risk grouprisk groupIn very low risk group radio iodine is In very low risk group radio iodine is unnecessary as surgery will cureunnecessary as surgery will cureTotal thyroidectomy & LN node clearance is Total thyroidectomy & LN node clearance is required to maximize the effect of required to maximize the effect of 131131I ablationI ablationPre operative imaging studies should be Pre operative imaging studies should be performed without iodine contrastperformed without iodine contrastDiagnostic doses should not given to assess Diagnostic doses should not given to assess the presence of any thyroid residual tissue or the presence of any thyroid residual tissue or presence of metastasis because they may presence of metastasis because they may cause blocking of take up by tumour, & cause cause blocking of take up by tumour, & cause ablation less effective & secondly, they will not ablation less effective & secondly, they will not always demonstrate the persistent tumour as always demonstrate the persistent tumour as obvious from post thyroid scanobvious from post thyroid scan

RADIOACTIVE IODINE THERAPYRADIOACTIVE IODINE THERAPY (cont.)(cont.)

After 4 week of thyroidectomy,a ablation dose of 3GBq After 4 week of thyroidectomy,a ablation dose of 3GBq 131131I given (mean radiation dose 410 Gy)I given (mean radiation dose 410 Gy)On 3On 3rdrd day post treatment scan are obtain day post treatment scan are obtain If successful ablation occur--- no further treatment If successful ablation occur--- no further treatment requred.requred.If small remnant persist them low dose 150mc should If small remnant persist them low dose 150mc should be givenbe givenDischarge on T3 as thyroid replacement 20 Discharge on T3 as thyroid replacement 20 µµg three g three times a day (for low risk TSH level 0.1-1 micro U/ml. & In times a day (for low risk TSH level 0.1-1 micro U/ml. & In High Risk < .1 microU/ml.)High Risk < .1 microU/ml.)After 4 month ,thyroglobulin estimation & repeat total After 4 month ,thyroglobulin estimation & repeat total body scan with T3 stopped before 10 daysbody scan with T3 stopped before 10 daysIF successful ablation achieved the T3 converted to T4 IF successful ablation achieved the T3 converted to T4 & only regular thyroglobulin estimation is required &no & only regular thyroglobulin estimation is required &no further treatment is needed. Life long follow up is further treatment is needed. Life long follow up is mandatory. If initial ablation was unsuccessful then mandatory. If initial ablation was unsuccessful then remnant ablation will be required at 6 or 12 monthly remnant ablation will be required at 6 or 12 monthly interval till complete ablationinterval till complete ablationSurgical intervention may be required in persistent Surgical intervention may be required in persistent disease with residual tissuedisease with residual tissue

TSH SUPPERTIONTSH SUPPERTIONTSH suppression with thyroxine is TSH suppression with thyroxine is integral part of management (125 mg integral part of management (125 mg per day)per day)TSH level should be between 0.1-TSH level should be between 0.1-1µU/ml in low risk & < 0.1 µU/ml in 1µU/ml in low risk & < 0.1 µU/ml in higher riskhigher riskReduce mortality & recurrenceReduce mortality & recurrenceLittle use in hurthle cell cancers Little use in hurthle cell cancers

THYROID LYMPHOMATHYROID LYMPHOMA Approximately 1% of all thyroid malignancyApproximately 1% of all thyroid malignancy Risk of lymphoma in Hashimoto`s thyroiditis Risk of lymphoma in Hashimoto`s thyroiditis

increase 70 foldincrease 70 fold History of thyroxine replacement & hypothyroidism History of thyroxine replacement & hypothyroidism

often presentoften present Rapidly enlarged painless massRapidly enlarged painless mass Diagnosis usually suggested by FNAC, but needle Diagnosis usually suggested by FNAC, but needle

core or open biopsy may be necessary for definitive core or open biopsy may be necessary for definitive diagnosisdiagnosis

Most of the primary lymphoma are of the non-Most of the primary lymphoma are of the non-Hodgkin’s B-cell typeHodgkin’s B-cell type

Usually diffuse histiocytic type Usually diffuse histiocytic type Less commonly low grade B-cell MALT lymphomas Less commonly low grade B-cell MALT lymphomas

STAGING OF THYROID STAGING OF THYROID LYMPHOMALYMPHOMA

Staging in mandatory & total body Staging in mandatory & total body scanning is performed with bone scanning is performed with bone marrow biopsymarrow biopsy

IE-- localized to thyroidIE-- localized to thyroid

IIE-- thyroid gland involved & more than IIE-- thyroid gland involved & more than one lymph node one lymph node on same side of diaphragmon same side of diaphragm

IIIE-- disease on both side of diaphragmIIIE-- disease on both side of diaphragm

IVE-- disseminated diseaseIVE-- disseminated disease

MANAGEMENT OF THYROID MANAGEMENT OF THYROID LYMPHOMALYMPHOMA

No role of thyroideotomy or radio iodine ablationNo role of thyroideotomy or radio iodine ablationPrimary treatment is external bean radiation with Primary treatment is external bean radiation with chemotherapychemotherapyWhen disease limited to neck, radiotherapy alone When disease limited to neck, radiotherapy alone achieve good result provided that mediasteinum is achieve good result provided that mediasteinum is irradiateirradiateIn IE stage 5 year survival rate is 80% &worse in In IE stage 5 year survival rate is 80% &worse in other other Chemotherapy regimes vary using Chemotherapy regimes vary using cyclophosphamide, doxorubicin, vincrinstine & cyclophosphamide, doxorubicin, vincrinstine & prednisoloneprednisoloneB-cell MALToma are treated by radiotherapy alone B-cell MALToma are treated by radiotherapy alone with a 90%survival rate at 5 yearwith a 90%survival rate at 5 yearTracheal obstruction almost always responds rapidly Tracheal obstruction almost always responds rapidly to chemotherapy & treacheostomy should be avoidedto chemotherapy & treacheostomy should be avoided

MRI SCANS OF EXTENSIVE MALIGNANT

LYMPHOMA (A) BEFORE AND (B) AFTER 7 DAYS OF EXTERNAL BEAM RADIOTHERAPY.

MEDULLARY THYROID CANCERMEDULLARY THYROID CANCERAccount for 5% of all thyroid cancersAccount for 5% of all thyroid cancersUsually present as solitary thyroid nodule with Usually present as solitary thyroid nodule with involved lymph nodes involved lymph nodes Due to genetic basis, all patients should be screened Due to genetic basis, all patients should be screened for mutation of the RET-proto -oncogene & in positive for mutation of the RET-proto -oncogene & in positive cases all family members should be screenedcases all family members should be screenedPathologyPathologyOriginates in parafollicular or C-cell of the thyroid Originates in parafollicular or C-cell of the thyroid which secret calcitoninwhich secret calcitoninMay be preceded by C-cell hyperplasiaMay be preceded by C-cell hyperplasiaPresence of bilateral thyroid disease with C-cell Presence of bilateral thyroid disease with C-cell hyperplasia is highly suggestive of familial form hyperplasia is highly suggestive of familial form Classically, the tumour cells are round, polygonal or Classically, the tumour cells are round, polygonal or spindle cells with islands of tumour separated by spindle cells with islands of tumour separated by fibrous band, nuclei are elongated with cytoplasmic fibrous band, nuclei are elongated with cytoplasmic nuclear inclusion & amyloid depositionnuclear inclusion & amyloid deposition

HISTOLOGY OF MEDULLARY CARCINOMA SHOWING CHARACTERISTIC “CELL BALLS” AND AMYLOID.

FAMILIAL FORM OF MEDULLARY FAMILIAL FORM OF MEDULLARY CANCERCANCER

1. Familial Medullary thyroid cancer 1. Familial Medullary thyroid cancer (FMTC)(FMTC)

No feature of MEM & a very good prognosisNo feature of MEM & a very good prognosis

2. Multiple endo crine neoplasia type IIA2. Multiple endo crine neoplasia type IIA Medullary thyroid cancer with Medullary thyroid cancer with

pheochoromocytomas, frequently pheochoromocytomas, frequently bilateral ,may be extra adrenal with bilateral ,may be extra adrenal with hyperparathyroidism (less commonly)hyperparathyroidism (less commonly)

3.3. MEN IIBMEN IIB Medullary cancer + pheochromocytomas+ Medullary cancer + pheochromocytomas+

multiple-mucosal-neuroma, multiple-mucosal-neuroma, ganglioneurometosisganglioneurometosis

Pt may have severe gastro intestinal symptomPt may have severe gastro intestinal symptom

TREATMENT OF MEDULLARY TREATMENT OF MEDULLARY CANCERCANCER

Total thyroidectomy with routine dissection Total thyroidectomy with routine dissection of central lymph node & sampling of jugular of central lymph node & sampling of jugular node & modified neck dissection if metastasis node & modified neck dissection if metastasis present .present .In children, who are carrier of the gene In children, who are carrier of the gene abnormalities total thyroidectomy done at abnormalities total thyroidectomy done at age of 3 years in MEN IIA & at one 1 year in age of 3 years in MEN IIA & at one 1 year in MEN IIB.MEN IIB.External bean radiotherapy is recommended External bean radiotherapy is recommended for patient with unresectable residual or for patient with unresectable residual or recurrent tumor although the result are recurrent tumor although the result are debatabledebatableNo role of chemotherapyNo role of chemotherapy

ANAPLASTIC THYROID ANAPLASTIC THYROID CANCERCANCERVary aggressive malignancy with a very Vary aggressive malignancy with a very

poor prognosis poor prognosis High incidence in iodine –deficientHigh incidence in iodine –deficientHalf of cases goiter arises from Half of cases goiter arises from

differentiated thyroid cancer but can differentiated thyroid cancer but can arise de-novoarise de-novo

Present in the seventh & eighth decade Present in the seventh & eighth decade of life & rare before 50 year &female of life & rare before 50 year &female dominantdominant

Present as rapidly growing, hard, fixed Present as rapidly growing, hard, fixed mass (may become painful & ulceratedmass (may become painful & ulcerated

ANAPLASTIC THYROID CANCER ANAPLASTIC THYROID CANCER (CONT.)(CONT.)

Associated symptoms such as dypnoea, Associated symptoms such as dypnoea, dysphagia, & horseness of voice are dysphagia, & horseness of voice are commoncommon

Usually nodal & distant metastasis Usually nodal & distant metastasis presentpresent

Microscopally, sheets of cells are seen Microscopally, sheets of cells are seen with marked heterogenecity & with marked heterogenecity & characteristically spindle or giant & characteristically spindle or giant & multinuclated cellsmultinuclated cells

ANAPLASTIC THYROID ANAPLASTIC THYROID CANCER (Cont…)CANCER (Cont…)

TreatmentTreatmentResult of all therapies are poorResult of all therapies are poorInitial treatment aim to maintain the integrity Initial treatment aim to maintain the integrity of aero- diagestive track & to maintains of aero- diagestive track & to maintains hydration & nutrition.hydration & nutrition.In impending the airways obstruction, a central In impending the airways obstruction, a central thyroid resection with freeing of trachea & thyroid resection with freeing of trachea & possible tracheostomy should be preformedpossible tracheostomy should be preformedTreatment is initial hyperfractionated Treatment is initial hyperfractionated radiotherapy with doxorubicin, then debulking radiotherapy with doxorubicin, then debulking thyroidectomy followed by completion of thyroidectomy followed by completion of radiotherapy & chemotherapyradiotherapy & chemotherapyMedian survival of less than one year Median survival of less than one year

THYROID CANCER IN THYROID CANCER IN PREGNANCYPREGNANCY

IN LOW RISK GROUP-IN LOW RISK GROUP- When present before 20 weeks assessed When present before 20 weeks assessed with MRI and a total thyroidectomy is a safe with MRI and a total thyroidectomy is a safe plan and if required neck dissection should be plan and if required neck dissection should be done.done. Thyroid replacement can be given Thyroid replacement can be given After delivery After delivery 131131I therapy should be I therapy should be considered considered 131131I therapy is contraindicated during I therapy is contraindicated during pregnancypregnancy If diagnose after 20 weeks should wait for If diagnose after 20 weeks should wait for delivery after which the tumor is treated on its delivery after which the tumor is treated on its merits merits

THYROID CANCER IN THYROID CANCER IN PREGNANCY (CONT…)PREGNANCY (CONT…)

In-high risk groupIn-high risk group When present in first trimester, the When present in first trimester, the

termination of pregnancy must be termination of pregnancy must be considered and then appropriate treatment considered and then appropriate treatment should be performedshould be performed

All Medullary cancer patients should have All Medullary cancer patients should have surgery until 20 weekssurgery until 20 weeks

When patients present late than the should When patients present late than the should be considered for possible induction at 32 be considered for possible induction at 32 week then followed by standard treatmentweek then followed by standard treatment

THANTHANK K

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