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Thyroid Cancer -- Papillary

Thyroid Cancer -- Papillary. Papillary Carcinoma 80% of thyroid cancers Follicular variant of papillary has same behavior Average age 30 -40 Women twice as frequent as men Most common thyroid malignancy in children Most common after low dose radiation. Thyroid Cancer -- Papillary.

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Thyroid Cancer -- Papillary

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  1. Thyroid Cancer -- Papillary • Papillary Carcinoma • 80% of thyroid cancers • Follicular variant of papillary has same behavior • Average age 30 -40 • Women twice as frequent as men • Most common thyroid malignancy in children • Most common after low dose radiation

  2. Thyroid Cancer -- Papillary • Papillary Carcinoma • Psammoma bodies, intranuclear cytoplasmic inclusions (Orphan Annie nuclei) • Poor prognosis, aggressive, radioiodine resistant: • Tall cell, insular, columnar, clear cell variants • Multicentric • Intrathyroidal lymphatic spread • Cervical Lymph node spread

  3. Thyroid Cancer -- Papillary • Papillary Carcinoma • 88% 10 year survival without treatment • 98% 10 year survival with thyroidectomy / RAI • 95% 20 year survival with thyroidectomy / RAI • But, 35% 5 year survival for radioresistant variants (tall cell, insular, columnar) or extensive radioresistant differentiated tumors

  4. Thyroid Cancer -- Papillary • Papillary Carcinoma • Lower risk • Men age 20 - 40, Women age 20-50 • Tumor < 1 cm - 1.5 cm • Unilateral thyroidectomy and isthmusectomy • Recurrence risk 7% • 50% mortality in 15-25 years if recurrence • “Berry picking” of gross lymph nodes • LN’s present in 30% of all papillary CA’s • LN’s present in 90-100% if age <15

  5. Thyroid Cancer -- Papillary • Papillary Carcinoma • Higher risk • Age • Aggressive variants • Size > 1.5 cm or extends beyond capsule of thyroid • Cervical LNs or distant mets • 20% pulmonary mets if age < 15 • Radiation history • Total thyroidectomy, LN berry picking • Children often require mod. neck dissections

  6. Thyroid Cancer -- Papillary • Papillary Carcinoma • Post-thyroidectomy follow-up • Thyroglobulin • RAI (I-131) • Not useful in radioresistant variants • 20% of all papillary CA’s do not trap RAI • Many patients over 60 have radioresistant CA’s • Not useful if normal thyroid tissue remains • Initial scan 6 weeks after thyroidectomy

  7. Thyroid Cancer -- Papillary • Papillary Carcinoma • RAI identified LN’s or residual thyroid • Resect if palpable • Often implies good prognosis if enlarging in post-op period due to increased post-op TSH • High dose ablative I-131 if no palpable disease but suspect residual tumour other than: • Ligament of Berry • Can be used repeatedly, and can ablate pulmonary mets, if used early

  8. Thyroid Cancer -- Papillary • Therapeutic radioactive I-131 • 2-3 days in hospital • Start levothyroxine 2-3 days after treatment • F/U scan in 1 year • Treat and repeat each year until gone

  9. Thyroid Cancer -- Follicular • Follicular CA • 10% of thyroid CA’s (increased with goiter) • Hurthle cell variant is 2% of thyroid CA’s • Hematogenous spread early • Locoregional / lymph node spread late • 5% of follicular CA’s have LN spread • Average age 50 • Women:Men 3:1 • Generally radiosensitive

  10. Thyroid Cancer -- Follicular • Follicular CA • Low risk: • Age < 40 • Low grade encapsulated (microinvasion) • Negative bone scan • FNA “follicular” cells • Ipsilateral thyroidectomy/isthmusectomy • Frozen section to check if extension through capsule, then total thyroidectomy • Total thyroidectomy if > 4 cm (80% malignancy)

  11. Thyroid Cancer -- Follicular • Follicular CA • Low risk: • Tc-99 bone scan following lobectomy • low recurrence rate if negative and small tumor with no capsule macroinvasion • does not need total thyroidectomy • Followup 1 year RAI scan • 6 week post-op RAI scan after total thyroidectomy

  12. Thyroid Cancer -- Follicular • Follicular CA • High risk: • Age > 50 • Macroinvasion, size > 4 cm • Distant mets or regional LN’s • Thyroidectomy • 6 week F/U I-131 scan then I-131 ablation as indicated

  13. Thyroid Cancer -- Follicular • Follicular CA • 70% 10 year survival without treatment • 85-90% 10 year survival with thyroidectomy / RAI • 70% 20 year survival with thyrodiectomy / RAI

  14. Thyroid Cancer -- Hurthle • Hurthle cell = aggressive variant of follicular • Radioresistant (does not take up RAI) • LN spread as well as hematogenous to bone / lung • Produces thyroglobulin • FNA = Hurthle cell --> lobectomy • If age > 50 or macroinvasion or > 4 cm or LN’s or mets then total thyroidectomy • If central LN’s, resect them • If lateral LN’s, then mod. rad. neck dissection • RAI , radiation, chemo not useful for mets

  15. Thyroid Cancer -- Medullary • Medullary CA • 7% of thyroid tumors • Sporadic cases are 70 - 80% • Usually solitary nodule • Average age > 30 • Hereditary case are 20 - 30% • Bilateral, multicentric • MEN IIa -- pheochromocytomas, parathyroids • MEN IIb -- pheochromocytoma, neurofibromas • more aggressive medullary CA • starts around age 2

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