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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.

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Thyroid Carcinoma

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  1. Thyroid Carcinoma Vic V. Vernenkar, D.O. St. Barnabas Hospital Department of Surgery

  2. Introduction • Infrequent cancer -1% of all cancers • Benign diseases common • 1200 pts die annually • Requires multidisciplinary approach

  3. Anatomy

  4. 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 5-10%, anaplastic 1-2%.

  5. 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.

  6. 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

  7. 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).

  8. Physical Exam • Thorough HEENT exam includes: • Thyroid gland • Soft tissues of neck • Solid, soft, mobile, or fixed? • Tenderness? • Laryngoscopy if hoarse preop!

  9. The Goal….. • Differentiate malignant from benign. • Determine which patients require intervention. • Who can be monitored? • Avoid unnecessary surgery.

  10. 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%

  11. 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

  12. 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.

  13. 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 basedon scans, with 4% of hot nodules being malignant. May be useful with indeterminate however. • CT and MRI not used routinely.

  14. 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.

  15. 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.

  16. 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.

  17. 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.

  18. 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 basedon FNA.

  19. 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.

  20. 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.

  21. 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

  22. 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.

  23. Postoperative Radioiodine and Ablation • Radioiodine targets residual thyroid tissue and tumor after thyroidectomy. • Given in diagnostic doses and therapeutic doses to ablate tissue.

  24. 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.

  25. 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 olderthan 60 years. • Men are twice more likely as women to die. • Tumors greater than 4 cm have higher recurrence, death.

  26. 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.

  27. 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.

  28. 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.

  29. 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.

  30. 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.

  31. 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%.

  32. Anaplastic Thyroid Carcinoma • Bad.

  33. Indications for Thyroid Lobectomy • Suspicion for malignancy • Compressive symptoms • Cosmetic issues • Well-differentiated thyroid carcinoma in low risk patient (controversial)

  34. Indications for Total Thyroidectomy • Well-differentiated thyroid cancer • Medullary thyroid cancer • Sarcoma of thyroid • Lymphoma of thyroid • Obstructive goiter

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