Transcript Slide 1

Schwartz,s principles of surgery
2005
presented by:.kamran adhami M.D.
Present in 4% of individuals in u.s.a
thyroid cancer has much lower
incidence of 40new case per 1 million
majority of thyroid nodules are benign
and don’t require removal.
Time of onset-change in size-associated symptoms
such as pain,dysphagia,dyspnea,choking
*pain is an unusual symptom=hemorrhage in a
benign nodule,thyroiditis,malignancy
*medullary cancer complain of a dull aching
sensation
*hoarseness is worrisome because it may be
secondary to malignant involvement of the
recurrent laryngeal nerves
• Most importantly,patients should be
questioned regarding risk factors for
malignancy,such as exposure to ionizing
radiation and family history of thyroid and
other malignancies associated with thyroid
cancer
• Low dose therapeutic radiation has been used to
treat conditions such as tinea capitis,thymic
enlargement,enlarged tonsils & adenoids,acne
volgaris and other conditions such as
hemangioma and scrofula..and integral part of
the management of hodgkin,s disease.
It is now known that a history of exposure to low
dose ionizing radiation to the thyroid gland place
the patient at increase risk for thyroid cancer
• Increases linearly from 6.5 to 2000
cGy,beyond which the incidence declines
as the radiation causes destruction of
tissue.
after 20-30 y the risk is max.
• Most thyroid carcinomas following
radiation exposure are papillary-solid type
RET/PTC translocation.
More aggressive,local
invasion,multifocality,lymph node
metastases,higher stage at presentation
• Family history is a risk factor for development of
both medullary and nonmedullary thyroid cancer.
Familial medullary cancers occur in isolation or
in association with other tumors as part of
multiple endocrine neoplasia type2(MEN2)
syndromes.
Nonmedullary thyroid cancer can occur in
association with other familial cancer syndroms
such as:werner,FAP,COWDEN,S.
• COWDEN=intestinal hamartomas,benign
and malignant breast tumors,follicular
thyroid cancer,papillary thyroid cancer,
hurthle cell tumors
FAP=colon polyps and cancer,duodenal
neoplasms,desmoids,papillary thyroid
cancer
WERNER=adult progeroid
syndrome,papillary thyroid cancer,follicular
thyroid cancer,anaplastic cancer
• Move with swallowing .
Gland is best palpated from behind the patient
and with the neck in mild extension.
cricoid cartilage is an important
landmark,isthmus is situated just below it.
Nodules that are hard,gritty,or fixed to
surrounding structures,such as to the trachea or
strap muscles are more likely to be malignant.
Cervical chain of lymph nodes-posterior triangle.
Delphian node and pyramidal lobe situated just
above the isthmus.
• Solitary thyroid nodule=FNAB
1-nondiagnostic=repeat FNAB
2benign:A;cyst=aspirate=reaccumulates#3=thyroi
dectomy
B:colloid nodule=observe
considerT4therapy=continued growth
compressive symptoms=(FNAB+-)thyroidectomy
3-suspicious,folicular lesion=RAI scan:AHOT=thyroidectomy or RAI,BCOLD=thyroidectomy
4-malignant=thyroidectomy
• Most important test+-ultrasound
ultrasound is recommended for nodules that are
difficult to palpate and for complex solid cystic
nodules that recur after the initial aspiration.
23gauge needle.immediately placed on dry
glass slides.70%alcohol solution, others are air
dried.papanicolaou or wright
if a
bloody aspirate is obtained,patient should be
repositioned in a more upright position and
repeated with a finer25 to 30 needle.
• Afer biopsy,categorized into following groups:
benign(65%),suspicious(20%),malignant(5%),nondiagno
stic(10%)
false-positive is 1%,false-negative 3%
nondiagnostic=usually be repeated
bloody FNA may also be reported as nondiagnostic and
often indicates a follicular neoplasm.
Benign lesions=cysts,,colloid nodules.(<3%)
risk of malignancy in suspicious=10-20%(follicular or
hurthle cell neoplasm)diagnosis of malignancy relies on
demonstrating capsular or vascular invasion that cannot
be determined via FNA.
• FNA biopsy is also less reliable in who
have a history of head and neck
irradiation or a family history of thyroid
cancer,because of a higher likelihood of
multifocal lesions.
• Most patients are euthyroid.
TSH is helpful.
hyperthyroid=risk of malignancy is1%
level of Tg cannot differentiate benign from
malignant nodules unless the levels are
extremely high-metastatic thyroid cancer
should be suspected.
• thyroglobulin levels are usful in following
patients who undergone total
thyroidectomy for cancer,or for who follow
for serial evaluation for non operative
management of thyroid nodules.
• Serum calcitonin levels should be obtained
in patients with medullary cancer of a
family history of MTC or MEN2
RET oncogene mutations and have a 24 h
urine collection with measurment of levels
of vanillylamandelic acid
,metanephrine,and catecholamine to rule
out a pheochromocytoma.
• Ultrasound is helpful for nonpalpable
thyroid nodules.(solid from cystic)
and for identifying adjacent
lymphadenopathy.
Size of suspected benign nodules
diagnosed by FNAB.
CT.MRI,are unnecessary in routine
evaluation.exept for large,fixed,or
substernal lesions.
• Scanning the thyroid with I123 or I 99 Tc is
rarely necessary,unless for hot or
automonous thyroid nodules.thyroid
scanning is recommended in thyroid
nodules in who have follicular thyroid
nodules on FNA and a suppressed TSH.
• Simple thyroid cysts resolve with
aspiration in 75% of cases.
some require a second or third aspiration.if
it persists after three attempts at
aspiration,unilateral thyroid lobectomy is
recommended.
lobectomy is also recommended for cysts
greater than 4 cm in diameter and for
complex cysts with solid and cystic
components.
• When FNA is used in complex
nodules,the solid portion should be
sampled. A colloid nodule in biopsy,patient
should be observed with serial ultrasound
and Tg measurements.if it enlarges,repeat
FNA is often indicated.and L-thyroxine in
doses sufficient to maintain a serum TSH
level between 0.1 and 1 u/ml may also be
administered.
• 50%of these nodules decrease in size in response to
TSH supression of this regimen,and others may not
continue to grow,but is effective for smaller than 3cm.
Suppression of TSH increase the risk of osteoporosis
and cardiac arrhythmias.
If a nodule enlarges
on TSH suppression,causes compressive symptoms,or
for cosmetic reason=thyroidectomy
but in patient
who had previous irradiation of the thyroid or who has a
family history of cancer,total or near total thyroidectomy
is recommended
• In usa thyroid cancer is less than 1% of
malignancies(2%f-0.5%m)
6 deaths per 1 million persons annually.
• 80% of all thyroid malignancies in iodinesufficient areas and is the predominant
cancer in children and individuals exposed
to external radiation.
Occurs more often in women with a 2:1
f:m ratio;mean age is 30 to 40 y.
Most are euthyroid and present with a
slow-growing painless mass in the neck.
• Dysphagia,dyspnea,and dysphonia are
usually associated with locally advanced
invasive disease.lymph node metastases
are common,especially in children and
young adults,and may be the presenting
complaint.
• On gross examination ,PTCs are generally
hard and remain flat on sectioning with a
blade,in contrast to normal tissue or
benign nodular lesions that tend to bulge.
Histologically,papillary carcinomas may
exhibit papillary projections.
A mixed pattern of papillary and follicular
structures,or a pure follicular
pattern.(follicular variant).
• The diagnosis is established by characteristic
celluar features. Cells are cuboidal with
pale,abundant cytoplasm,grooving,crowded
nuclei,and intranuclear cytoplasm
inclusions,leading to the designation of orphan
annie nuclei, which allows diagnosis by
FNAB.psammoma bodies,which are
microscopic,calcified deposits representing
clumps of sloughed cells,may be present.
• Mixed papillary-follicular tumors and
follicular variant of papillary carcinoma are
classified as papillary carcinomas
because they act biologically as papillary
carcinomas.multifocality is common in
papillary carcinoma and may be present in
up to 85% of cases on microscopic
examination.
• Multifocality is associated with an
increased risk of cervical nodal
metastases and these tumors may rarely
invade adjacent structures such as the
trachea,esophagus,and recurrent
laryngeal nerves.
• Macroscopically, there are three recognized
forms of PTC,each based on the size and extent
of the primary disease.
Minimal or
occult/microcarcinoma tumors originally included
papillary cancers up to 1.5 cm in diameter.they
now are defined as tumors of 1 cm or less in
size with no evidence of local invasiveness
throug the thyroid capsule or angioinvasion,and
are not associated with lymph node metastases.
• They are nonpalpable and usually are
incidental findings at
operative,histologic,or autopsy
examination.occult papillary thyroid cancer
is present in 2 to 36%of throid glands
removed at autopsy.the recurrence rate in
patients with tumors 1.5cm or smaller after
removal is 5%and the mortality rate 0.5%.
Long term prognosis is better for patients
with intrathyroidal lesions.
• In general ,patients with PTC have an excellent
prognosis with a greater than95% 10-year survival rate.
In1987 hay and associates,proposed the AGES scoring
system which incorporates age,histologic
grade,extrathyroidal invasion,and metastases and tumor
size to predict the risk of dying from papillary cancer.low
risk patient are young,with well differentiated tumors,no
metastases,and small primary lesions,whereas high risk
are older,poorly differentiated tumors local
invasions,distant metastases and large primary lesion
The MACIS scale is a more sophisticated
postoperative system modified from the
AGES scale.this scale incorporates distant
metastases,age at
presentation,completeness of original
surgical resection,extrathyroidal
invasion,and size of original lesion and
classifies patients into four risk-groups
based on their scores.
• Another classification system is the TNM
system.(tumor,nodal
status,metastases)used by most medical
centers in north america.
degroot and associates uses four
groups:class1(intrathyroidal)class2(cervica
l nodal metastases)class3(extrathyroidal
invasion)and class4(distant metastases)
• Papillary or follicular tumors:
younger than age 45 years
1=any t,any n,m0
2=any t,any m,m1
age 45 and older
1=T1N0M0
2=T2N0M0
3=T3N0M0,T1-3,N1aM0
4A=T4aN0-1aM0,T1-4aN1bM0
4B=T4b,anyN,M1
4C=anyT,anyN,M1
• MEDULLARY THYROID CANCER:
1=T1N0M0
2=T2-3N0M0
3=T1-3N1aM0
4A=T4aN0-1a,M0,T1-4a,N1b,M0
4B=T4b,anyN,M0
4C=any T,anyn,M1
• ANAPLASTIC CANCER:
4A=T4a,anyN,M0
4B=T4b,anyNM0
4C=anyT,anyN,M1
• Patients with highrisk tumors(judged by any of
the classification systems discussed before)or
bilateral tumors should undergo total or near
total thyroidectomy.
when patients have a minimal papillary thyroid
carcinoma in a thyroid specimen removed for
other reason,unilateral thyroid lobectomy and
isthmusectomy is considered to be adequate
treatment,unless the tumor has evidence of
angioinvasion,multifocallity,or positive margins
• The optimal surgical strategy in the
majority of patients with lowrisk cancers
remains contraversial-the focus of the
debate centers around outcome data and
risks associated with either lobectomy or
total thyroidectomy in this group.
• Proponents of total thyroidectomy argue
that the procedure
1-enables one to use RAI to effectively
detect and treat residual thyroid tissue or
metastatic disease
2-makes the serum Tg level a more
sensitive marker of recurrent or persistent
3-eliminates the contralateral occult
cancers as site of
recurrence(85%multifocal)
• 4-reduces the risk of recurrence and
improves survival
5-decreases the 1% risk of progression to
undifferentiated or anaplastic thyroid
cancer
6-reduce the need for reoperative surgery
with its attendant risk of increased
complication rates
• Investigators that favor lobectomy argue that:
1-total thyroidectomy is associated with a higher
complication rate than lobectomy
2-recurrence in the remaining thyroid tissue is
unusual(5%)and most are curable by surgery
3- tumor multicentricity seems to have little
prognostic significance
4-patients who have undergone lesser
procedures such as lobectomy still have an
excellent prognosis
• A significant proportion (33to50%) of
patients who develop a recurrence die
from their disease,and even though the
data are retrospective, long term followup
studies suggest that recurrence rates are
lowered, and some but not
all,investigations suggest that survival is
improved in patients undergoing near total
or total thyroidectomy
• Diminished survival is noted in patients
with so called lowrisk disease(mortality
rate of 5% at10to20 years)and its not
possible to accurately risk stratify patients
preoperatively.
Given the above,it is recommended that
even patients with low-risk tumors undergo
total or neartotal thyroidectomy,provided
complication rates are low(<2%)
• Consequently,most patients with thyroid nodules
should have FNA biopsy performed.
When PTC is diagnosed,the definitive operation
can be done without confirming the diagnosis by
frozen section during the operation.
patients with a nodule that may be papillary
cancer should be treated by thyroid
lobectomy,isthmusectomy,and removal of any
pyramidal lobe or adjacent lymph nodes.
• If intraoperative frozen-section
examination of a lymph node or of the
primary tumor confirms
carcinoma,completion of total or near total
thyroidectomy should be performed.if a de
dfinitive diagnosis cannot be made,or if the
surgeon is concerned about the viability of
the parathyroid glands or the status of the
RNL,the operation should be terminated.
• During thyroidectomy,enlarged ipsilateral
central neck nodes should be
removed.lymph node metastases in the
lateral neck in patients with papillary
carcinoma usually should be managed
with modified radical or functional neck
dissection as described later under”neck
dissection for nodal metastases.”
• Dissection of the posterior triangle and
suprahyoid dissection are usually not
necessary unless there is extensive
metastatic disease in level 2,3,and4 but
should be performed when appropriate.
• Prophylactic neck node dissection is not
necessary in patients with PTC because
these cancers donot appear to
metastasize systemically from lymph
nodes and micrometastases appear to be
ablated with RAI therapy.
• Follicular carcinomas account for 10% of
thyroid cancers and occur more
commonly in iodine-deficient areas.
The overall incidence of this tumor is decli
ning in the u.a. probably as a result of
iodine supplementation and improved
histologic classification.
Women have a higher incidence of that
with a f:m ratio 3:1 and a mean age of 50
y.
• It usually present as solitary thyroid
nodules,occasionally with a history of
rapid size increase.and long-standing
goiter.pain is uncommon,unless
hemorrhage into the nodules has
occurred.
• Cervical lymphadenopathy is uncommon
at initial presentation(5%),although distant
metastases may be present.
In less than 1% of cases,follicular cancers
may be hyperfunctioning,leading patients
to present with signs and symptoms of
thyrotoxicosis.
• FNA biopsy is unable to distinguish benign
follicular lesions from follicular
carcinomas.therefore,preoperative
diagnosis of cancer is difficult unless
distant metastases are present .large
follicular tumors (>4cm)in older men are
more likely to be malignant.
• Follicular carcinomas are usually solitary
lesions,the majority of which are
surrounded by a capsule.histologically
,folliclesare present,but the lumenmay be
devoid of colloid.architectural patterns
depend on the degree of differentiation
demonstrated by the tumor. Malignancy is
defined by the presence of capsular and
vascular invasion.
• Minimally –invasive tumors appear grossly
encapsulated but have evidence of
microscopic invasion through the tumor
capsule and/or invasion into small-to
medium-size vessels (venous caliber)in or
immediately outside the capsule,but not
within the tumor.on the other hand,widely
invasive tumors demonstrate evidence of
large-vessel invasion and/or broad areas
of tumor invasion through the capsule.
• They may,in fact,be unencapsulated .it is
important to note that there is a wide
variation of opinion among clinicians and
pathologists with respect to the above
definitions. Tumor infiltration and invasion
,as well as tumor thrombus within the
middle thyroid or jugular veins,may be
apparent at operation.
• Patients diagnosed by FNA B
as having a follicular lesion should
undergo thyroid lobectomy because
at least 80%of these patients will have
benign adenomas.some surgeons
recommened total thyroidectomy in older
patients with follicular lesions larger than 4
cm because of the higher risk of cancer in
this setting(50%).
• Intraoperative frozen-section examination
usually is not helpful, but should be performed
when there is evidence of capsular or vascular
invasion,or when adjacent lymphadenopathy is
present.
Total thyroidectomy should
be performed when thyroid cancer is
diagnosed. There is debate among experts
about whether patients with minimally –invasive
follicular cancers should undergo completion
thyroidectomy because the prognosis is so good
in these patients.
• A diagnosis of frankly invasive carcinoma
necessitates completion of total thyroidectomy
primarily so that I can used to detect and ablate
metastatic disease.
Total
thyroidectomy in patients with angioinvasion is
also recommended.prophylactic nodal dissection
is unwarranted because nodal involvement is
infrequent,but in the unusual patient with nodal
metastases,therapeutic neck dissection is
recommended.
• The cumulative mortality from follicular
thyroid cancer is 15% at 10years and 30%
at 20 years.
poor long-term prognosis is predicted by
age older than 50 years at presentation
,tumor size larger than 4 cm ,higher tumor
grade,marked vascular
invasion,extrathyroiad invasion,and
distant metastases at the time of
diagnosis.
• Account for 3% of all thyroid malignancies.
Under the world health organization
classification ,hurthle cell carcinomas are
considered to be a subtype of follicular thyroid
cancer.like follicular cancers,hurthle cell cancers
are characterized by vascular or capsular
invasion,and therefore cannot be diagnosed by
FNA B.tumors contain sheets of eosinophilic
cells packed with mitochondria ,which are
derived from the oxyphilic cells of the thyroid
.gland.
• Hurthle cell tumors also differ from
follicular carcinomas in that they are more
often multifocal and bilateral(30%) usually
do not take up RAI (5%),are more likely to
metastasize to local nodes (25%)and
distant sites,and are associated with a
higher mortality rate(20% at 10 years).
Hence,they are considered to be a
separate class of tumors by some
surgeons.
• Management is similar to that of follicular
neoplasms,with lobectomy and
isthmusectomy being sufficient surgical
treatment for unilateral hurthle cell
adenomas.
• When hurthle cell neoplasms are found to be
invasive on intraoperative,frozen-section,or
definitive paraffin-section histology,then total
thyroidectomy should be performed.
• These patients should also undergo routine
central neck node removal,similar or patients
with MTC,and modified radical neck dissection
when lateral neck nodes are palpable.
• Although RAI scanning and ablation
usually are ineffective ,they probably
should be considered for ablation of any
residual normal thyroid tissue
and,occasionally ,for ablation of
tumors,because there is no other good
therapy.
• Thyroxine is necessary not only as
replacement therapy in patients after total
or near total thyroidectomy but has the
additional effect of suppressing TSH and
reducing the growth stimulus for any
possible residual thyroid cancer cells.
• TSH suppression reduce tumor recurrence
rates,particularly in young patients with
papillary and follicular thyroid cancer.
• Thyroxine should be administered to ensure that
the patient remains euthyroid,with circulating
TSH levels at about 0.1uU/L in low risk
patients,or less than 0.1uU/mL in high-risk
patients.
• The risk of tumor recurrence must be balanced
with the side effects associated with prolonged
TSH suppression,including osteopenia and
cardiac problems,particularly in older patients.
• Thyroglobulin levels in patients who have
undergone total thyroidectomy should be below
2ng/ml when the patient is taking T4,and
below5ng/ml when the patient is hypothyroid.
a Tg level above 2 ng/ml is highly suggestive of
metastatic disease or persistent normal thyroid
tissue,especially if it increases when TSH levels
increase when the patient is hypothyroid during
preparation for RAI scanning.
• 95% of patients with persistent or
recurrent thyroid cancer of follicular cell
origin will have Tg levels higher than
2ng/ml.
thyroglobulin and anti-Tg antibody levels
should be measured initially at 6month
intervals and then annually if the patient is
clinically disease free.
• The issue of whether RAI therapy offers
any benefit to patients with differentiated
thyroid cancer remains controversial in the
absence of prospective,randomized
controlled trials.some experts advise
routine RAI scan and therapy for all
patients except those with occult or
minimally –invasive tumors,whereas
others only high-risk patients.
• If RAI scan are negative ,but Tg levels
remain elevated,other imaging studies
such as neck ultrasound,MRI,and FDGPET scan may be considered.
• MTCs acoount for about5% of thyroid
malignancies and arise from the parafollicular
C cells of the thyroid,which,in turn,and derived
from the ultimobranchial bodies.
These cells are concentrated superolaterally i
the thyroid lobes,which is where MTC usually
develops.
• C cell secrete calcitonin,a 32-amino-acid
polypeptide that functions to lower serum
calcium levels. In some animals,especially
those that lay eggs with shells,calcitonin is
a significant regulator of calcium
metabolism,but in humans,it has only
minimal physiologic effects.
• Most of MTC occur
sporadically,however,25% occur within the
spectrum of several inherited syndromes
such as familial medullary thyroid
cancer,MEN2A,and MEN2B.all these
variants are known to result secondary to
germline mutations in the RET protooncogene.
• The syndromes are also characterized by
genotype-phenotype correlations,with
specific mutations leading to particular
clinical manifestations.
• Patients with MTC often present with a
neck mass that may be associated with
palpable cervical lymphadenopathy (15 to
20%).
local pain or aching is more common in
patients with these tumors,and local
invasion may produce symptoms of
dysphagia,dyspnea,or dysphonia.
• Distant blood-borne metastases to the
liver ,bone(osteoblastic),and lung occur
later in the disease.the f:m ratio 1.5:1.
most patients present between 50 and 60
y.o. of age.although patients with familial
disease present at a younger age.
• Medullary thyroid tumors secrete not only
calcitonin and carcinoembryonic
antigen(CEA),but also other peptides such
as calcitonin gene-related
peptide(CGRP),histaminadases,prostagla
ndins E2 &F2,and serotonin. Patients with
extensive metastatic disease frequently
develop diarrhea ,which may result from
increased intestinal motility and impaired
intestinal water and electrolyte flux.
• MTCs are typically
unilateral(80%)in
patients with sporadic
disease,and
multicentric in familial
cases,with bilateral
tumors occuring in up
to 90% of familial
patients.
• Microscopically
,tumors are
composed of sheets
of infiltrating
neoplastic cells
separated by collagen
and amyloid.marked
heterogeneity is
present;cells may be
polygonal or spindleshaped.
• The diagnosis of MTC is established by
history, physical examination,raised serum
calcitonin or CEA levels,and FNA cytology
of the thyroid mass. Attention of family
history is important because approximately
25% of patients with MTC have familial
disease.
• Because it is not possible to distinguish
sporadic from familial disease at initial
presentation,all new patients with MTC
should be screened for RET point
mutations,pheochromocytoma(24-hour
urinary levels of VMA,catecholamine,and
metanephrine),and hyperparathyroidism
(serum calcium).
• It is important to rule out a coexisting
pheochromocytoma to avoid precipitating
a hypertensive crisis and death.
• If patients are found to have a
pheochromocytoma,this must be operated
on first.
these tumors are generally bilateral(50%).
Total thyroidectomy is the treatment of
choice for patients with MTC because of
the high incidence of muticentricity,the
more aggressive course,and I therapy is
not usually effective.
• The central compartment nodes are
frequently involved early in the disease
process ,so that a bilateral central neck
node dissection should be routinely
performed.
in patients with palpable cervical nodes or
involved central neck nodes,ipsilateral or
bilateral ,modified radical neck dissection
is recommended.
• Similarly, patients with tumors larger than
1.5 cm should undergo ipsilateral
prophylactic modified radical neck
dissection,because greater than 60% of
these patients have nodal
metastases.30% of these patients will also
have contralateral nodal metastases.
• In the case of locally recurrent or
metastatic disease,tumor debulking is
advised,not only to ameliorate symptoms
of flushing and diarrhea,but also to
decrease risk of death from recurrent
central neck or mediastinal disease.
• Total thyroidectomy is indicated in RET
mutation carries once the mutation is
confirmed.the procedure should be
performed before age6 years in MEN2
patients and prior to age 1 year in MEN2B
patients.
• Prognosis is related to disease
stage.the10-year survival rate is 80% but
decrease to 45% in patients with lymph
node involvement.survival also is
significantly influenced by disease type. It
is best in patients with non-MEN familial
MTC,followed by patients with MEN2A,and
then by patients with sporadic disease.and
is worst in whom with MEN2B(35%in 10 y)
• It accounts for 1%of all thyroid
malignancies in the u.s. and is declining in
incidence.women are more commonly
affected.and the majority of tumors
present in the seven and eighth decades
of life.the typical patient has a longstanding neck mass,which rapidly
enlarges and may be painful.
• Associated symptoms,such as dysphonia
,dysphagia,and dyspnea,are common.the
tumor is large and may be fixed to
surrounding structures or may be
ulcerated. Lymph nodes usually are
palpable at presentation.
• On gross inspection,anaplastic tumors are
firm and whitish in
appearance.microscopically,sheets of cells
with marked heterogeneity are seen.cells
may be spindle-shaped,polygonal or
large,multinucleated cells.
• This tumor is one of the most aggressive
thyroid malignancies,with few patient
surviving 6 months beyond diagnosis.
All forms of treatment have been
disappointing .if anaplastic carcinoma
presents as a resectable
mass,thyroidectomy may lead to a small
improvement in survival,espicially in
younger individuals.
• Combined radiation and chemotherapy in
an adjuvant setting in patients with
resectable disease has been associated
with prolonged survival.tracheostomy may
be needed to alleviate airway obstruction.
• Lymphomas account for less than 1% of
thyroid malignancies and most are of the
non-Hodgkin,s B-cell type.although the
disease can arise as part of a generallized
lymphomatous condition,most thyroid
lymphomas develop in patients with
chronic lymphocytic thyroiditis.
• Patients usually present with symptoms
similar to those of patients with anaplastic
carcinoma,although the rapidly enlarging
neck mass often is painless.patients may
present with acute respiratory distress.
The diagnosis usually is suggested by
FNA biopsy.although needle-core or open
biopsy may be necessary for definitive
diagnosis.
• they respond rapidly to chemotherapy
which is also associated with improved
survival .combined treatment with
radiotherapy and chemotherapy is often
recommended.thyroidectomy and nodal
resection are used to alleviate symptoms
of airway obstruction in patients who do
not respond quickly to the above
regimens,or in patients who have
completed the regimen prior to diagnosis.
• The overall5-y survival rate is about 50%;
• Thyroid is a rare place for
metastases from other
cancers
include:kidney,breast
,lung and melanoma
physical exam.and history
often identified the source
of metastases. And FNAB
gives the defenitive
diagnosis.in most of
patients according to
primary tumor,lobectomy
may be helpful.