thyroid tumor
TRANSCRIPT
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THYROID TUMORS
Salma Saud Al-SharhanKing Faisal University – Khobar
Saudi Arabia
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NORMAL ANATOMY OF THE THYROID GLAND:
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MICROSCOPIC PICTURE OF THE THYROID GLAND:
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TYPES OF THYROID CANCER:
Primary: Follicular epithelium – well differentiated papillary follicular Follicular epithelium – undifferentiated Anaplastic Parafollicular cells Medullary Lymphoid cells lymphoma Secondary : metastatic
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THE CAUSES:
Radiation exposure to thyroid gland in child hood Schneider AB etal,Radation-induced endocrine tumor Cancer treat res
1997;89:141
Family hx. : a 4 to 10 fold increased risk of well differentiated thyroid cancer in 1st degree relatives with this neoplasia
Galanti MR et al, risk of papillary and follicular thyroid carcinoma , Br J Cancer 1997;75:451
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THE CAUSES:
Iodine: Iodine-deficient diets may lead to increase the TSH level and considered goitrogenic
Thyroiditis: (Hashimoto's Disease) may develop into a form of cancer called lymphoma.
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TNM STAGING OF THYROID CANCER:
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EVALUATION OF THYROID TUMOR:
History:Age and GenderRapid increase in size, dyspnea,
dysphagia and hoarseness of voiceFamily Hx. Of thyroid cancerHx. Of irradiation On Examination:Firmness, Mobility, Size and adherence
to surrounding structuresPresence of lymphadenopathy
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INVESTIGATIONS:
FNAC: The accuracy cytological diagnosis
from FNA ranges from 70% to 97% and highly dependent on the skill of the physician and the cytopathologist interpreting it.
Burch HB. Endocrinol Metab Clin North Am 1995;24:663
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INVESTIGATIONS:
US: For the presence of malignant assosciations Microcalcification Irregular margins Hypervascularity Extra glandular extension
Frates MC et al, Doppler sonography aid in the predfcation of malignancy of predication of thyroid of nodules J US Med 2003;22:127
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INVESTIGATIONS:
US guided FNA : Decrease the nondiagnostic specimen Increase the sensitivity and specificity Avoiding vascular structures
Carmeci C et al, US guided FNA of thyroid masses 1998;8:283
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INVESTIGATIONS:Radionuclide Scan:To determine the functional status of the
nodule Hypofunctional “cold nodule”ule”Serum Calcitonin level:Routine measurement of calcitonin level
advocated by some authors to Dx. Medullary cancer is unknown
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Ten most common types of Cancer among Adult Saudis by Sex, 2001
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EASTERN REGION,2001
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PAPILLARY THYROID CANCER:
Cystic or Solid Most common (80-85%)Spread through lymphaticFemale: Male is 3:1
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PAPILLARY CANCER
Typical papillary projections and empty (orphan annie-eyed) nuclei
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CLINICAL PRESENTATION:Incidental as a small occult tumor <1cm (papillary
microcarcinoma)Mass in the Neck the commonest way papillary cancer presentsGlands in the Side of the NeckThe spread to local glands (sometimes called
erroneously "lateral aberrant thyroid"). Distant Spread Spread to lungs or bone is very rare but when it
occurs unlike most other cancers, cure is possible.
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THE FOLLICULAR CANCER:It is unifocal, thickly encapsulated
and shows invasion of both capsule and blood vessels
Spread by the blood stream and rarely
through lymphatic It is unusual tumor (5 -10%)
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CLINICAL PRESENTATION:
As a single lump in the thyroid: This is the common mode of presentation. As pain in a bone or a spontaneous
fracture: in case of metastases to bone through the
blood stream
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THE PROGNOSIS IN DIFFERENTIATEDTHYROID CARCINOMA:
The two dominant factors are the age at the diagnosis and the presence of distant metastases.
Mazzafferi El etal, Long term impact of initial surgical and medical therapy on thyroid cancer .Am J Med 1994;97:418
Recent several scoring systems based on multifactorial analysis of risk factors have been advise
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Low risk High risk
Patient age < 45 y > 45 y
Tumor size < 4.0 cm
> 4.0 cm
Extrathyoidal extension
absent present
Distant metastases
absent present
High tumor grade
absent present
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THE TREATMENT OF WELL DIFFERENTIATED THYROID CANCER:
It Consists of a three- pronged attack :
Thyroid Surgery Radioactive iodine therapy Drug - Thyroxine therapy
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SURGERY: Acceptable surgical procedure to remove
thyroid tumor include Ipsilateral lobectomy Near total thyroidectomy Total thyroidectomy The recent American Thyroid Association
Guide lines recommended for more aggressive (total thyroidectomy ) for well differentiated thyroid carcinonoma
Cooper DS et al. Management guidelines for thyroid nodules ,Thyroid2006;19:109
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SURGERY : With a 20-year follow up the incidence of
local recurrence with unilateral resection was (14%),whereas, for bilateral resection it was (2%) Brauckhoff M, et al surgery 2006;140:953
For gross involvement of trachea or esophagus resection of these structures with reconstruction
Cooper DS et al. Management guidelines for thyroid nodules , Thyroid2006;19:109
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RADIOIODINE THERAPY:
The Indications: 1.After Surgery to destroy any residual
thyroid cancer cells or residual normal thyroid tissue.
2.To treat thyroid cancer that has spread to the lymph nodes, lungs or bones.
3.To treat thyroid cancer recurrence after initial treatment by surgery or previous radioactive iodine or both.
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RADIOIODINE THERAPY: Recent American thyroid association
guide lines recommended radioiodine ablation for:
Pt. with stage III or IV disease All Pt. with stage II disease <45 yrs or > 45 yrs Selected Pt. with stage I disease those
with: large tumor ( >1.5 cm ) multifocality residual disease nodal metastasis
Cooper DS et al . Management guide line for patient with thyroid nodules and cancer . Thyroid 2006;16:109
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THYROXIN THERAPY :
Recent meta-analysis supported the efficacy of TSH suppression in preventing adverse clinical effect
High risk pt. are maintained at TSH level below 0.1 mU/ L
Low risk pt. TSH level at or below the normal range (0.1- 0.5 mU/ L)
McGriff NJ, et al. effect of thyroid hormone suppression therapy on thyroid cancer. Ann Med 2002;34:557
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THYROXIN THERAPY :
The degree of thyroid suppression is dictated by balancing the risk of recurrent thyroid cancer and subclinical thyrotoxicosis particularly the cardiovascular risks
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SURVEILLANCE:
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CLINICAL IMPACT OF MOLECULAR ANALYSIS ON THYROID MANAGEMENT:
PAILLARY CARCINOMA
FOLLICULAR CARCINOMA
CPTC PDPTC
MIFTC WIFTC PDFTC
Recurrence 10% 50% 10% 40% 60%Deathof disease
5% 40% 10% 40% 60%
RET/PTC 30% 10% 0% 0% 0%
BRAF 40% 70% 0% 0% 0%
P53 <5% <5% <5% <5% 40%
RAS <5% 40% 40% 50% 60%
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Looking at BRAF mutation detection of thyroid cancer in FNAB samples demonstrate a 100% specificity and sensitivity in cases of PTC carrying BRAF mutation.
Chung KW,etal. Detection of BRAF in FNA specimen of tyroid nodule.Clin Endocri
2006;65:660-6
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MEDULLARY THYROID CANCER:
These are tumors of parafollicular (C cells), which produce a hormone called calcitonin
Types of MTC : Sporadic MTC Familial MTC MEN 2A MEN 2B Familial Non- MEN
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CLINCAL PRESENTATION:
Sporadic MTC: asymptomatic thyroid mass Familial MTC : screening stimulation test for
calcitonin or with molecular analysis ( detection of RET gene mutation)
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TREATMENT OF SPORADIC MTC:
C cells do not concentrate iodine so radioactive iodine is of no value in the management
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Surgery is the only definitive therapy of MTC:
Total thyroidectomy Central node dissection Ipsilateral modified radical neck dissection
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A TUMOR ERODING INTO THE CHEST WALL
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TREATMENT OF FAMILIAL MTC:
Based on the genetic test for the mutation of RET gene
Since different mutations in the RET gene are associated with variable disease aggressiveness
this leading to individualized treatment of pt. with inherited MTC
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MEN2A AND FMTC RX. :
Prophylactic thyroidectomy at age 5 to 6 years
Moley JF. Medullary thyroid carcinoma.
Curr Treat Options Onco 2003;4:339
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MEN2B RX.:
Thyroidectomy during infancy
Moley JF. Medullary thyroid carcinoma.
Curr Treat Options Onco 2003;4:339
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ANAPLASTIC CANCER OF THE THYROID:
It is a very aggressive tumor with a poor prognosis
A female to male ratio 1.5:1 and a mean age is 67 years
It is commonest in areas of endemic goiter where there is chronic iodine deficiency.
ATC commonly related to prior diagnosis of well differentiated thyroid cancer
Mclver B et al, Anaplastic Thyroid Carcinoma surgery 2001;130;1028
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CLINICAL PRESENTATION:
a long-standing goiter that suddenly increases in size.
Local invasion lead to obstructive symptoms, hemoptysis, dysphagia and hoarseness
At the time of Dx. 25 to 50 % of Pt. have synchronous pulmonary metastases
Mclver B et al, Anaplastic Thyroid Carcinoma .Surgery 2001;130;1028
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A CT scan showing anaplastic cancer of the thyroid
A woman with anaplastic cancer of the thyroid
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SURGICAL TREATMENT OF ATC:
In the majority of cases surgery is limited to an open biopsy to exclude lymphoma
Mclver B et al, Anaplastic Thyroid Carcinoma .Surgery 2001;130;1028
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RADIOTHERAPY AND CHEMOTHERAP:
External beam radiotherapy (EBRR) as been used with limited success to treat locally recurrent ATC
Doxorubicin is the single most effective chemotherapeutic for ATC
Ain KB etal, treatment of anaplastic carcinoma of thyroid. (CATCHIT) Group. Tyroid 2000;10;587
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THYROID LYMPHOMA:
Thyroid lymphoma is relatively rare disease constituting <1% of all lymphoma and accounting for 2% of extranodal non- Hodgkin’s lymphoma
Female: Male ratio from 3:1 up to 8:1 Median age is seventh decade of life
Green LD et al, anaplastic thyroid cancer and 1ry thyroid lymphoma. J Surg Oncol 2006;94:725
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CLINICAL PRESENTATION:
Local invasion : hoarseness, dyspnea with stridor, or dysphagia
Hypothyroidism in case of Autoimmune thyroiditis or Hashimoto’s thyroiditis
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A 70 Y. old lady with diffuse large B cell lymphoma
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TREATMENT :
Primary treatment should be EBRT combined with Chemotherapy regimen based on histopathological subtype of lymphoma
Green LD et al, anaplastic thyroid cancer and 1ry thyroid lymphoma. J Surg Oncol 2006;94:725
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TREATMENT :
Primary treatment should be EBRT combined with Chemotherapy regimen based on histopathological subtype of lymphoma
Green LD et al, anaplastic thyroid cancer and 1ry thyroid lymphoma. J Surg Oncol 2006;94:725