Thyroid Carcinoma
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Transcript Thyroid Carcinoma
Thyroid Carcinoma
Vic V. Vernenkar, D.O.
St. Barnabas Hospital
Department of Surgery
Introduction
Infrequent cancer -1% of all cancers
Benign diseases common
1200 pts die annually
Requires multidisciplinary approach
Anatomy
Frequency
17,000 cases diagnosed annually.
Women 3 times more than men.
Peak incidence 30-40s.
Papillary, follicular, medullary, anaplastic,
lymphoma, and sarcoma.
Papillary 80%, follicular 10%, medullary 510%, anaplastic 1-2%.
Etiology/Risk Factors
Arise from the two cell types in the gland.
Follicular cells make papillary, follicular,
and anaplastic.
C-cells produce medullary.
Radiation exposure (papillary).
Populations with low dietary iodine have a
higher proportion of follicular and
anaplastic cancers.
History
Painless, palpable solitary nodule.
Nodules are present in 4-7% of population.
Most are benign
5% are malignant
Age at presentation (>60 and <30)
Sex (males)
Rapid growth
History
Malignant nodules usually painless
Sudden onset pain usually benign.
Hoarseness suggests malignancy, nerve
involvement.
Dysphagia
Heat intolerance, palpitations suggest
autonomously functioning nodules.
Family history (medullary).
Physical Exam
Thorough HEENT exam includes:
Thyroid gland
Soft tissues of neck
Solid, soft, mobile, or fixed?
Tenderness?
Laryngoscopy if hoarse preop!
The Goal…..
Differentiate malignant from benign.
Determine which patients require
intervention.
Who can be monitored?
Avoid unnecessary surgery.
Fine Needle Aspiration
First intervention in evaluation of a nodule.
Inexpensive, easy, few complications.
Need a good cytopathologist.
Four types of results; Benign,
malignant,indeterminate, non-diagnostic.
69% benign, 4% malignant, 10% indeterminate,
17% non-diagnostic.
Sensitivity 83%, specificity 92%
False positive 2.9%, negative 5.2%
FNA
If non-diagnostic, repeat
If malignant go to OR
If benign, stop and follow
If indeterminate or suspicious OR
OK, the path says it’s a “Follicular neoplasm.”
FNA can diagnose papillary and medullary
cancers
Complications of FNA
Laboratory
TSH sensitive for hypo and
hyperthyroidism, but does not rule out
malignancy.
TFTs not indicated in work up initially.
Serum thyroglobulin used as tumor marker
post op.
Calcitonin, for post op monitoring in
Medullary cancers.
Imaging
Ultrasound: solid vs. Cystic, for FNA accuracy,
for monitoring of benign lesions.
Scans: determines function of the nodule. Cold
nodules are those that don’t take up iodine123, hot
ones are the opposite.
Carcinoma cannot be ruled out based on scans,
with 4% of hot nodules being malignant. May be
useful with indeterminate however.
CT and MRI not used routinely.
Papillary Carcinoma
Most common (80%)
Women 3 times more common
30-40 years of age
Familial also (FAP)
Radiation exposure as a child
Patients with Hashimoto’s thyroiditis
Slow growing, TSH sensitive, take up iodine, TSH
stimulation produces thryroglobulin response.
Papillary Carcinoma
Pathology:Unencapsulated, arborizing
papillae. Well differentiated, rare mitoses.
50% have psammoma bodies (calcific
concretions, circular laminations.
Multicentric with tumor present in
contralateral lobe as well.
Papillary Carcinoma
Local invasion through capsule, invading
trachea, nerve, causing dyspnea, hoarseness.
Propensity to spread to the cervical lymph
nodes. Clinically evident in 1/3 patients.
Most commonly central compartment,
located medial to carotids, from hyoid to
sternal notch.
Distant spread to bone, lungs.
Follicular Carcinoma
Second most common (10%)
Iodine deficient areas
3 times more in women
Present more advanced in stage than
papillary
Late 40’s
Also TSH sensitive, takes up iodine,
produces thryroglobulin.
Follicular Carcinoma
Pathology: round, encapsulated, cystic
changes, fibrosis, hemorrhages.
Microscopically, neoplastic follicular cells.
Differentiated from follicular adenomas by
the presence of capsule invasion,vascular
invasion.
Cannot reliably diagnose based on FNA.
Follicular Carcinoma
Local invasion is similar to papillary cancer
with the same presentation.
Cervical metastases are uncommon.
Distant metastases is significantly higher
(20%), with lung and bone most common
sites.
Treatment and Prognosis
Controversy regarding extent of therapy
continues.
Surgical excision whenever possible.
Total thyroidectomy has been mainstay (all
apparent thyroid tissue removed).
Complications include nerve damage
bilaterally, parathyroid injury bilaterally.
After, get radioiodine scan, ablation if
residual disease or recurrence.
Treatment and Prognosis
Over the years, modification to procedure to
reduce the above complications.
Subtotal thyroidectomy( small portion of
thyroid tissue opposite the side of
malignancy is left in place) and postop
ablation.
Thyroid lobectomy and isthmectomy also
a viable option with small tumors
Neck
Examine the neck prior to surgery to detect
lymph node spread.
Gross cervical mets should be removed en
bloc with a dissection in the compartment in
which they reside.
Excision of single nodes is not adequate.
Elective lymph node dissection is not done,
as radioactive iodine takes care of this.
Postoperative Radioiodine and
Ablation
Radioiodine targets residual thyroid tissue
and tumor after thyroidectomy.
Given in diagnostic doses and therapeutic
doses to ablate tissue.
Thyroid Suppression Therapy
Maintained on thyroxine after surgery and
ablation. Low TSH levels reduce tumor
growth rates and reduce recurrence rates.
Most recommend TSH levels of 0.1 mU/l.
Follow-up q 6 months with thyroglobulin
levels and repeat scans.
Thyroglobulin is good because well
differentiated tumors produce it.
Prognosis
Age: at diagnosis. Cancer relate death more
common if patient is older than 40 years.
Recurrences common in patients diagnosed
when they were less than 20 years or older
than 60 years.
Men are twice more likely as women to die.
Tumors greater than 4 cm have higher
recurrence, death.
Prognosis
Histology:papillary has 30 year cancer related
death rate of 6%. Follicular has a 30 year cancer
related death rate of 15%.
Local invasion portends poorer prognosis.
After surgery, thyroxine is given. Do I scanning
after stopping it for 6 weeks, TSH high now. Do
scan, if some tissue remains on diagnostic dose,
ablate it. Do it again if needed.
LN metastases not important for prognosis.
Distant metastases associated with a 68.1-fold
increase in the rate of disease specific death.
Hurthle Cell
A variant of follicular, also known as oncocytic
carcinoma. 5 year survival 50%.
More common in women than men, presents in 5th
decade of life.
Same clinical presentation.
Cannot diagnose on FNA
Does not take up iodine, so treat aggressively.
Thyroid suppression and radioiodine don’t work.
Medullary Carcinoma
5%, female preponderance
75% sporadically, 25% familial. Familial
cases are usually all over the gland,
sporadic usually not multifocal.
MEN 2A, MEN2B and FMTC syndromes.
Men 2a, 2b, FMTC
MEN 2a is Sipple syndrome,MTC,
pheochromocytoma, hyperparathyroidism.
MEN 2b is MTC, pheo, ganglionomas, marfan
habitus.
FMTC is just MTC
Medullary cancer in these are most aggressive,
younger age, rapid growth and metastases.
In sporadic you get painless nodule, symptoms of
invasion.
Biochemical Testing
Stimulating calcitonin release with IV
pentagastrin increases sensitivity of test.
First measure baseline calcitonin, then give
pentagastrin. Measure calcitonin serially 1.5
and 5 min later.
Used as tumor marker postop rather than
screening now.
Use genetic testing for screening.
Histologically test for calcitonin and CEA.
Treatment
Total thyroidectomy
Lymph node dissection of level VI.
Parathyroid reimplantation if necessary.
Lymph node mets are very common.
Prophylactic thyroidectomy in children with MEN
2a,b.
Surveillance with CEA, calcitonin.
Does not take up iodine, so no radioiodine.
Prognosis 10 y is 65%.
Anaplastic Thyroid Carcinoma
Bad.
Indications for Thyroid
Lobectomy
Suspicion for malignancy
Compressive symptoms
Cosmetic issues
Well-differentiated thyroid carcinoma in
low risk patient (controversial)
Indications for Total
Thyroidectomy
Well-differentiated thyroid cancer
Medullary thyroid cancer
Sarcoma of thyroid
Lymphoma of thyroid
Obstructive goiter