Transcript follicular thyroid cancer

 Thyroid Cancer accounts for 1.5% of all cancers
in the US
 Six deaths per 1 million people occur annually.
 The most common endocrine malignancy
accounts for 95% of all endocrine cancers
 Female to Male Ratio 2.5:1
Classification of thyroid tumours
Benign
Malignant
Follicular cell adenoma
Papillary carcinoma(80%)
Hurthle cell adenoma
Follicular carcinoma (10%)
Teratoma
Hurthle cell carcinoma
Medullary carcinoma (5%)
Anaplastic carcinoma (3%)
Lymphoma(1%)
Sarcoma
SCC
Secondary
Kidney, lung, colon, breast
TNM classification system (2002).
 T-Primary Tumour
 Tx
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Primary tumour cannot be assessed
T0No evidence of primary tumour
T1 - Tumour 2 cm or less in greatest dimension, limited to the thyroid
T2- Tumour more than 2 cm but not more than 4 cm in greatest dimension, limited to
the thyroid
T3- Tumour more than 4 cm in greatest dimension, limited to the thyroid or any
tumour with minimal extrathyroid extension (e.g. extension to sternothyroid muscle or
perithyroid soft tissues)
T4a- Tumour extends beyond the thyroid capsule and invades any of the following:
subcutaneous soft tissues, larynx, trachea, oesophagus, recurrent laryngeal nerve
T4b- Tumour invades prevertebral fascia, mediastinal vessels, or encases carotid artey
T4a* T4a* (anaplastic carcinoma only) Tumour (any size), limited to the thyroid** T4b*
(anaplastic carcinoma only) Tumour (any size), extends beyond the thyroid capsule***
Notes: Multifocal tumours of all histological types should be designated (m) (the
largest determines the classification), e.g.,T2 m).
* All anaplastic/undifferentiated thyroid carcinomas are considered T4.
** Intrathyroidal anaplastic carcinoma – considered surgically resectable.
*** Extrathyroidal anaplastic carcinoma – considered surgically unresectable.
 N-Regional Lymph Nodes
 NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1
Regional lymph node metastasis
N1a Metastasis in Level VI (pretracheal and paratracheal, including prelaryngeal and
Delphian lymph nodes)
N1b Metastasis in other unilateral, bilateral or contralateral cervical or upper/superior
mediastinal lymph nodes.
M – Distant Metastasis
 MX
M0
M1
Distant metastasis cannot be assessed
No distant metastasis
Distant metastasis
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Stage Grouping
Separate stage groupings are recommended for papillary and follicular, medullary and
anaplastic/undifferentiated carcinomas:
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Stage I
Stage II
Stage I
Stage II
Stage III
Stage IVA
Stage IVB
Stage IVC
Stage IVA
Stage IVB
Stage IVC
Papillary or Follicular under 45 years
Any T
Any N
Any T
Any N
M0
M1
Papillary or Follicular 45 years and older and Medullary
T1
N0
M0
T2
N0
M0
T3
N0
M0
T1, T2, T3
N1a
M0
T1, T2, T3
N1b
M0
4a
N0, N1
M0
T4b
Any N
M0
Any T
Any N
M1
Anaplastic/Undifferentiated (all cases are stage IV)
T4a
Any N
M0
T4b
Any N
M0
Any T
Any N
M1
Risk Factors for Thyroid Cancer
 2-4 times more frequent in women than men
 Rare in children below 16 yrs
 Median age 40-50 yrs.
 Prolonged stimulation by TSH
 Solitary thyroid nodule
 Genetic factors
 Chronic lymphocytic thyroiditis, grave’s disease, longstanding goitre
Radiation and Thyroid Cancer
 Thyroid exposure to irradiation
low or high dose external irradiation (40-50 Gy [4000-5000
rad])
 especially in childhood for:
 large thymus, acne, enlarged tonsils, cervical adenitis,
sinusitis, and malignancies
 Irradiation for soft tissue malignancy, such as Hodgkin’s lymphoma,
have an increased incidence of thyroid nodules and cancer.
 Latent period is 10-15 yrs with peak incidence20-30 yrs after.
 Multifocal and 25% node positive
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Well-differentiated carcinoma of the thyroid
 5% and 15% asymptomatic, solitary nodule
 history and head and neck examination
 personal or family history
 history of Graves’ disease
 Symptoms of hypothyroidism or hyperthyroidism
 previous radiation therapy
 Rapidly progressive mass
 Hoarseness, dysphagia, odynophagia, shortness of breath, and hemoptysis
 physical examination
 Size
 presence of other nodules
 tenderness or fixation, and their consistency and location
 LAP
 vocal cord mobility
Malignant thyroid nodule
 Hard fixed nodule
 Ipsilateral cord paralysis
 Cervical LAP
 Positive FNAC
 Solitary solid nodules/complex cysts >4cm on USG
 Hypofunctioning cold nodule on I123 scan
WDTC - Papillary Carcinoma
 80-90 % of all thyroid cancers
 Females > Males(3:1)
 Mean age of 20-45 years (avg 40 yrs)
 Multicentric
 60% cases lymphadenopathy
 Unencapsulated in 70% cases
 10 yrs survival
 Intrathyroidal-90%
 Extrathyroidal-60%
 arises from the follicular cells of the normal thyroid gland
 Distinctive, nuclear features, include:
 (1) nuclear membrane irregularities that manifest as indentations,
pseudonuclear inclusion, or nuclear grooves
 (2) overlapping and enlarged nuclei(tiles on a roof or an egg-basket)
 (3) an empty appearance of the nuclei that seem pale, optically clear, and
resemble ‘‘Orphan Annie’s eyes’’.
 Other morphologic features frequently seen include
 round, calcific concretions with concentric lamination known as
psammoma bodies (50% of cases)
 squamous metaplasia (20% to 40% of cases)
 abundant fibrous stroma, frequently in the form of wide, hyaline
bands that surround islands of tumor cells.
 Presents as solitary nodule
 Firm and unencapsulated tumour but sharply circumscribed.
 Histologic subtypes
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Papillary microcarcinoma
Follicular variant
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Typical papillary cytology
Tall cell and Columnar
Encapsulated
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10% of all papillary
25% LAP
WDTC - Papillary Carcinoma
 Major route of metastasis is lymphatic
 46%-90% of patients have lymph node involvement (Goepfert, 1998,
Scheumann, 1984, De Jong, 1993)
 Gross regional metastasis is not uncommon on initial presentation and is
microscopically present in 90% of elective neck dissection specimens
 nodal metastasis is associated with an increased risk of regional recurrence
and reduced disease-free survival
FOLLICULAR THYROID CANCER
 Occurs in old age groups,common b/w 50-59 yrs
 15-20% Of Thyroid Cancers.
 Usually Encapsulated
 More Aggressive & Less Curable Than Papillary
 Hematologic Spread
 Bone and lung involvement-20-30%
 Lymph node involvement-10%
 2 principal histologic features of invasiveness that prove the diagnosis
of carcinoma
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Capsular invasion
 vascular invasion
 60% 10 Year Survival
Hurthle Cell Carcinoma
 oncocytic carcinoma
 Hurthle cells (oncocytes) are large, polygonal cells that contain
abundant cytoplasm with pink granularity.
 Ultrastructurally, these cytoplasmic granules are predominantly
abnormal mitochondria
 Lymphatic spread seen in 30% of patients (Goldman, 1996)
 Distant metastases to bone and lung is seen in 15% at the time of
presentation
 long been considered to be a variant of follicular carcinoma
 now considered by most investigators to be a distinct, clinical entity.
 Like follicular carcinoma, the diagnosis can be difficult
 Hurthle cells in nodular goitres,lym. Thyroiditis, diffuse toxic goitre,
after radiation or chemo.
 Definition (Hurthle cell neoplasm) - an encapsulated group of
follicular cells with at least a 75% Hurthle cell component
 Carcinoma requires evidence of vascular and capsular invasion
 4%-10% of all thyroid malignancies (Sessions, 1993)
Imaging
 Ultrasound
 readily available
 safe, noninvasive, relatively inexpensive
 efficacious for evaluation of the architecture of the thyroid gland.
 size and location of palpable nodules
 can delineate nonpalpable nodules
 distinguishes between solid, cystic, and mixed nodules.
 Cystic lesions are reported to carry a lower risk of malignancy
(0.5%to 3%) and solid nodules (10%).
Ultrasound features suggesting malignancy
1.
2.
3.
4.
5.
6.
Absent ‘‘halo’’ sign
Solid or hypoechogenicity
Heterogeneous echo structure
Irregular margin
Fine calcifications
Extraglandular extension
FNAC
 Gold standard’’ in the evaluation of thyroid nodule.
 Most nodules are benign, and surgical excision is not required in most
cases.
 safe and quick procedure with few complications
 does not involve radiation exposure.
 decreased overall cost
 Easily available
 Air-dried smears and wet smears
 Air-dried smears include the Diff-Quick and the May-Grunwald
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Giemsa methods.
air dry method is best for immediate reading by a cytopathologist.
Airdried smear highlights the background colloid, the cell architecture,
and the cytoplasmic details. This technique is helpful for the diagnosis
of medullary and lymphoid tumors.
The Papanicolaou stain is a wet smear that requires immediate fixation
with 95% alcohol.
This method enhances nuclear morphology, such as grooving and
inclusions, and is better suited for detecting papillary cancer .
Zubair et al reported a definitive diagnosis in 65% of Diff-Quick
smears and in 88% of Papanicolaou smears.
 4 recognized categories of FNA are
 malignant (3.4% to 5%)
 benign (60% to 75%)
 suspicious (7.2% to 30%)
 insufficient (7% to 29.5%)
CT or MRI
 evidence of substernal extension
 invasion of contiguous structures
 metastatic adenopathy
 anatomic detail
 Vascular invasion
 Nodal disease
 Distant metastatic spread
 Lymphoma staging
 Exclusion of pheochromocytoma
Radionuclide scans
 commonly used radioisotopes are technetium (99mTc) and 123I.
 123I is more physiologic than 99mTc.
 99mTc
 quickly washes out of the thyroid gland before being organified inside the
gland.
 shorter scanning time (20–30 minutes)
 scanning can be performed immediately after the administration of 99mTc.
 123I
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imaging needs to be performed 24 hours after administration of 123I
 scanning time can run 4 to 6 hours in length.
 Radiation exposure is comparable for both agents, and is not
significant.
 The whole body exposure from 123I and 99mTc scanning is 0.04 cGy
and 0.07 cGy, respectively .
 Imaging resolution is better with 99mTc than radioiodine.
 Nodules that are smaller than 1 cm cannot be detected reliably by either
scan, as they are below the discriminating power of scintigraphic
devices.
 >90% lesions not concentrate--cold nodules
 Likelyhood of malignancy—20%
 if semisolid or solid nodule—50%
 Truly functioing nodules(hot
nodules) are unlikely to be
malignant
 Confusion occurs when warm nodules or indeterminate nodules
 This is false positive result
 Vascularity
 Lesion overlapped by normal functioning thyroid tissue
 Perform repeat scan after 12hrs
I-131 scanning
 Results of TBS depend upon ability of cancer tissue to take up I131 in
presence of highTSH con.
 Prerequisites
 Withdraw thyroxine for 4-6 wks
 Serum TSH >30 micro unit /ml
 Stop iodine containing food /medications at least 10 days prior
 To exclude pregnancy/child bearing age
 Problem of hypothyroidism
Procedure
 Pt receive a dose of 74-185 MBq(2-5mCi)of I131 for routine diagnostic
TBS.
 Scanning performed 2-3 days after.
 Double head camera equipped with thick crystals and high energy
collimators and uptake if any , is measured.
Recombinant TSH
 Alternative to thyroid hormone withdrawl.
 Absolute indications:
 Hypopituitarism
 Severe IHD
 Previous history of psychiatric disturbance
 Advanced disease or frailty
 Functional metastases with supression of TSH
Treatment
 Surgical resection is the mainstay of treatment
 Extent --matter of debate
 Arguments in favor of total or near-total thyroidectomy :
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relatively high risk (particularly with papillary) for contralateral
malignancy
enhanced postoperative I131 ablation
better postoperative surveillance by palpation and thyroid scans
ability for following thyroglobulin levels as an indicator of early
recurrence of disease.
Recurrent cancer in contralateral lobe in 5-15 % of pts and ½ pts
may die of thyroid cancer
 Several studies indicated that for patients with follicular carcinoma,
and those with papillary carcinoma either greater than 1 cm to 1.5 cm or
with lymph node metastasis, total or near-total thyroidectomy results
in a decreased likelihood of recurrence and mortality
 Recurrence rates for total or near-total thyroidectomy versus less than
near total thyroidectomy were 26% and 40%, respectively.
Mazzaferri and Jhiang et al. Am J Med 1994;97(5):418–28.
 Argument against
 in early stage tumors
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is that the increased risk of bilateral recurrent
laryngeal nerve injury that results in airway obstruction
increased risk of permanent hypocalcaemia are not justified by an
improvement in disease control or survival rates over those attained by
unilateral thyroid lobectomy
Most local recurrences treated with surgery
Excellent outcome with lobectomy in low risk patients
Most patients are low risk and excellent prognosis
 Decision about the extent of thyroidectomy for patients with WDTC
have to be based on the risk of treatment failure and the need for
adjuvant radioactive iodine treatment .
 At the extremes, there is no controversy.
 A small papillary carcinoma identified in a younger patient with no
evidence of metastasis or extrathyroidal extension probably merits
nothing more than an ipsilateral lobectomy.
 patients older than 45 years with larger tumors (greater than 4 cm),
and with evidence of extrathyroidal extension or metastasis are at a
high-risk of tumor recurrence and should be treated with total
thyroidectomy and adjuvant postoperative radioactive iodine.
UK National thyroid cancer guidelines
 Low risk pt with low risk tumour—Lobectomy
 Low risk pt with high risk tumour— Lobectomy or total thyroidectomy
 High risk pt with low risk tumour-- Lobectomy or total thyroidectomy
 High risk pt with high risk tumour—Total thyroidectomy
Complications of surgery
Early
Intermediate
Late
Haemorrhage
Seroma
Subclinical
hypothyroidism
Voice change
infection
Permanent
hypoparathyroidism
Airway obs.
Temporary RLN palsy or
Permanent nerve injury
Temporary hypopara.
Ext. branch of sup. Lary.
Nerve
Poor scar
Neck dissection
 When gross nodal disease is present, regardless of the histology, a neck
dissection is typically indicated
 Zone I (submental and submandibular triangles) is considered at very
little risk for thyroid metastasis and is often omitted from dissection
 Role for elective neck dissection remains controversial.
 Most thyroid surgeons recommend intraoperative inspection of the
central compartment.
external radiation therapy
 Indications
 unresectable large tumors that are locally invasive into the visceral
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compartments or deep muscles of the neck
recurrent tumors that failed 131I therapy
Older pts
Large lymph node metastases
Poorly diff. CA.
 Whether adjuvant postoperative XRT offers a definite therapeutic
advantage over 131I therapy is still debatable .
 Technique:
 Initiated 2 mths after surgery
 Mega voltage photon beams
 50 Gy/25#/5wks
 Target volume: Thyroid bed,B/L neck Lymph node areas, upper part of
mediastinum
 5Gy boost to residual lesion
 Institut Gustave Roussy---Local failure rate at 5yrs without RT was 43%
and was 16% with RT.
Chemotherapy
 Reserved for the palliative management of patients with inoperable,
advanced disease that does not concentrate 131I
 Doxorubicin, used either alone or in combination with cisplatinum,
demonstrated modest response rates
 Higher response rates were reported with combined low-dose
doxorubicin and XRT
Postoperative management for
thyroid cancer
 Radioiodine remnant ablation
 Adminstration of Thyroid Hormone To suppress TSH and growth of any residual thyroid
 To maintain patient euthyroid
 Maintain TSH level 0.1microU/ml in low risk pts
 Maintain TSH Level < 0.1microU/ml in high risk pts
Radioiodine ablation
 Radioiodine has three uses in the postoperative treatment of patients
with thyroid cancer:
 Ablation of residual thyroid tissue
 Ablation of residual normal thyroid tissue facilitates the use of 131I
whole body scanning (WBS) and serum thyroglobulin (Tg) to detect
recurrent thyroid carcinoma or metastatic disease during the
follow-up period.
 Ablation of microscopic metastases that are not clinically apparent
RAI
 Indications
 Distant metastases
 Incomplete tumour resection
 Complete resection of tumour but high risk for mortality/recurrence pTNM
stages 2,3
Not indicated in pTNM1
Procedure
 4-6 wks after surgery
 Withdraw thyroid hormones
 Administer a dose of 1.1GBq(30mCi) or 3.7GBq(100mCi)
 Ablation verified 6-12 mths after treatment on TBS performed with 74-
185MBq(2-5mCi) of I131
 Necessary to perform near total or total thyroidectomy in all pts as total
ablation with 30 mCi is achieved only in 2/3 of pts
 Ablation achieved when >300 Gy is delivered to thyroid remnants.
 Side effects:
 Nausea and gastric pain
 Sialenodinitis,xerostomia
 Loss of taste
 Neck odema
 Radiation fibrosis
 2nd cancers
Radioiodine ablation reduces recurrence and mortality in stage II
and Stage III thyroid cancer
 Positive radioiodine scans-radioiodine therapy
 Negative radioiodine scans but positive PET- Ext. radiotherapy
 Negative radioiodine scans but positive PET- Free of disease and close
follow up
Jatin p.Shah et al 3rd edition
Medullary Thyroid Carcinoma
 3-10% of all thyroid malignancies
 Arises from the parafollicular cell or C-cells of the thyroid gland
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derivatives of neural crest cells of the branchial arches
secrete calcitonin which plays a role in calcium metabolism
Medullary Thyroid Carcinoma
(Continued…)
 Developes in 4 clinical settings:
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Sporadic MTC (SMTC)
Familial MTC (FMTC)
Multiple endocrine neoplasia IIa (MEN IIa)
Multiple endocrine neoplasia IIb (MEN IIb)
Medullary Thyroid Carcinoma
(continued…)
 Sporadic MTC:
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70%-80% of all MTCs (Colson, 1993, Marzano, 1995)
Mean age of 50 years (Russell, 1983)
75% 15 year survival (Alexander, 1991)
Unilateral and Unifocal (70%)
Slightly more aggressive than FMTC and MEN IIa
74% have extrathyroid involvement at presentation (Russell,
1983)
Medullary Thyroid Carcinoma
(Continued…)
 Familial MTC:
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Autosomal dominant transmission
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Not associated with any other endocrinopathies
Mean age of 43
Multifocal and bilateral
Has the best prognosis of all types of MTC
100% 15 year survival
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(Farndon, 1986)
Medullary Thyroid Carcinoma
(continued…)
 Multiple endocrine neoplasia IIa (Sipple’s Syndrome):
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MTC, Pheochromocytoma, parathyroid hyperplasia
Autosomal dominant transmission
Mean age of 27
100% develop MTC (Cance, 1985)
85%-90% survival at 15 years (Alexander, 1991, Brunt, 1987)
Medullary Thyroid Carcinoma
(continued…)
 Multiple endocrine neoplasia IIb (Wermer’s Syndrome,
MEN III, mucosal syndrome):
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Pheochromocytoma, multiple mucosal neuromas, marfanoid body
habitus
90% develop MTC by the age of 20
Most aggressive type of MTC
15 year survival is <40%-50%
(Carney, 1979)
Clinical presentation and diagnosis
 most common presentation – painless lump in the thyroid.
 Less commonly, the patient may present with pain, dysphagia, or
hoarseness. Rarely, the patient may present with diarrhea
 At initial presentation, the thyroid swelling may be associated with
cervical lymphadenopathy in up to 75% of patients which may not be
always palpable
 Component of MEN that presents with another neoplasm, or a family
member of a patient with MEN.
FNAB
 Macroscopically:tumour is grey or white with gritty texture with areas
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of haemorrhage,necrosis ,fibrosis,calcification
polygonal or triangular cells that are commonly binucleated with
eccentric nuclei containing a coarse, granular chromatin pattern. The
cytoplasm is abundant or moderate in amount with fine granularity
and azurophylic granules.
amyloid is found in variable amounts in the amorphous substance in
the background
calcitonin staining which is expressed in 80% of tumors
USG,CT,MRI
 rapid, easy, noninvasive tool
 size and multiplicity
 neck adenopathy
 US can also guide FNAB to increase the accuracy of diagnosis
 Limitations of ultrasound include the operator-dependency
of the evaluation as well as the lack of surgical-anatomic tangible
findings for surgical planning.
 MTC will require a CT scan that includes the whole neck and
mediastinum.
 MRI is not routinely performed and is reserved for patients in whom
there is concern about soft tissue invasion or those patients who are
allergic to iodine
calcitonin
 exploited for screening, diagnosis, and follow-up of the disease.
 It is routine to measure the basal and ‘‘pentagastrin’’- stimulated serum
calcitonin levels in all patients who are suspected of having MTC
 May also hint to the amount of tumor load
 confined to the thyroid gland (levels less than 1000 pg/mL)
 with possible microscopic evidence of disease (levels 1000–10,000
pg/mL)
 with gross metastatic disease (levels more than 10,000 pg/mL)
 normal preoperative level does not definitively exclude the
diagnosis of MTC
Treatment
 Total thyroidectomy with central compartment neck dissection has
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become a standard therapy for sporadic and hereditary types.
lateral neck is inspected and palpated
For the positive neck, a comprehensive neck dissection is indicated
removing levels II through V in addition to the central compartment
RLN only resected if it is grossly invaded by the neoplasm.
An invasive medullary carcinoma may require resection of a part or a
sleeve of trachea or a part of pharyngeal musculature; rarely does it
require a laryngectomy.
Radiation therapy is used as an adjuvant for patients with extensive soft
tissue invasion or those with significant extracapsular extension in
positive nodes after removal of all gross disease . It may also be
considered for palliative control of inoperable disease
 Treatment is first directed to pheochromocytoma to avoid the possible
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hazardous effects
Preoperative serum calcitonin and CEA should be assessed in every pt.
Following surgical treatment the patients are best monitored with a
regular measurement of basal and pentagastrin-stimulated serum
calcitonin levels.
Calcitonin and CEA levels should usually be assessed for baseline
levels approximately 4 weeks after surgery
persistent or re-elevating level may indicate loco-regional failure or
metastatic disease.
 Future directions include
 the use of gene therapy
 treatments that target inactivation or destruction of
RET
 131iodine metaiodo benzyl guanidine (MIBG) for the treatment of
advanced and metastatic disease
Anaplastic carcinoma
 Aggressive course of rapid growth and local tissue invasion
 Mean survival of 6 months after diagnosis
 Rarity of this tumor has contributed to the difficulty to formulate
treatment protocols
 Presents most commonly in the elderly as a rapidly enlarging thyroid
mass marked by pain, dysphagia, hoarseness, andoccasional dyspnea
with extensive local invasion of surrounding tissues
 Distant foci of tumor are seen in 20% to 50% of patients, with lung and
bone the most common sites of metastasis
Etiology of the tumor is unclear, although most cases of anaplastic
carcinoma likely grow out of a pre-existing goiter or differentiated thyroid
carcinoma
 Molecular biology studies point to either p53 gene mutation
or alteration in transforming growth factor B receptor number as
possible contributing factors in the transformation from benign disease
or differentiated carcinoma to anaplastic carcinoma
Pathology
 Tumor generally replaces most of the thyroid gland and invades local
structures.
 3 histologic patterns
 squamoid
 spindle cell
 giant cell
 A small cell variant of anaplastic carcinoma was described but is now
thought to represent a form of lymphoma
 Various pathologic subtypes have identical clinical behaviors and
portend no prognostic significance
Treatment
 Most promising protocols involve a combination of surgery, radiation,
and chemotherapy
 Achievement of local tumor control is a significant predictor of
survival, as even patients with distant metastasis but locally free of
disease have a median survival of 7.5 months compared with 1.6
months for those with residual local disease
Levandag et al ,Int J Radiat Oncol Biol Phys 1993;26:125–8.
Squamous cell carcinoma
 Extremely rare neoplasm, represents less than 1%
 Diagnosis of primary SCC of the thyroid requires the exclusion of
squamous cell carcinoma that has spread from adjacent upper
aerodigestive tract sites, as well as metastasis from distant sites, such as
the lung, kidney, or gastrointestinal tract.
 Believed to arise as the result of metaplasia of the papillary or follicular
cells of the thyroid
 Histopathologic diagnosis requires the microscopic identification of
keratin or intercellular bridge structures
 Extremely aggressive
 Mimics the natural course of anaplastic carcinoma with extensive local
tissue invasion
 Has a dismal prognosis with survival rates generally less than 1 year
 The best survival rates have been achieved with aggressive surgical
resection of disease in the thyroid and neck followed by postoperative
radiation therapy
 Poor responsiveness to chemotherapy
Lymphoma
 Comprises between 1% and 6% of thyroid tumors and 1% of all
lymphomas
 Gland may acquire lymphoid tissue through pathological conditions,
such as autoimmune thyroid disease.
 Hashimoto’s thyroiditis
Clinical presentation
 occurs in the sixth or seventh decade with a female preponderance.
 The most common presentation is that of a slowly enlarging thyroid
mass, although approx. one third of patients present with a more
rapidly growing tumor.
 Symptoms of mass compression or tissue infiltration such as dyspnea,
dysphagia, choking, coughing, and hemoptysis are more commonly
seen in patients with rapidly growing tumors .
 fever, night sweats, and weight loss only occur in about 20%of patients
with thyroid lymphoma and seem to be associated with the diffuse
large B-cell lymphoma (DLBCL) subtype
Pathology
WHO classification divides primary thyroid lymphomas histologically
into
 diffuse large B-cell lymphoma
 Marginal zone B cell
lymphoma of mucosa-associated lymphoid
tissue type (MALT)
 follicular cell lymphoma (FCL)
 A mixed MALT and DLBCL subtype also exists, which is often
described as DLBCL transformed MALT lymphoma.
 Surgery is advocated for patients with localized MALT lymphomas,
where complete excision is possible
 combination chemotherapy and radiation are recommended for
patients with DCBCL and more advanced staged lymphoma
 CHOP (cyclophosphamide, adriamycin, vincristine, prednisone) or
CHOP-like regimens have been the most successful.
 In disseminated MALT cases, total thyroidectomy and single agent
chemotherapy, such as chlorambucil, have proven efficacious.
Sarcoma
 rare neoplasm
 may be confused pathologically with the spindle cell variant of
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
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anaplastic carcinoma of the thyroid.
Various subtypes are liposarcoma, angiosarcoma, leiomyosarcoma,
and dendritic cell sarcoma
Treatment for sarcomas primarily surgical and consists of total
thyroidectomy with excision of any locally-involved tissue along with
neck dissection for involved cervical lymph nodes
Postoperative radiotherapy is indicated for aggressive disease, which
includes extracapsular spread, high mitotic count, abundant nuclear
pleomorphism, or surgically unresectable disease.
Adjuvant chemotherapy was recommended for aggressive subtypes of
sarcoma, such as the follicular dendritic cell sarcoma
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