The document discusses various types of thyroid tumors including cancer. It describes the normal anatomy and microscopic picture of the thyroid gland. The primary types of thyroid cancer are papillary, follicular, medullary, and anaplastic originating from the follicular epithelium or parafollicular cells. Risk factors include radiation exposure, family history, iodine deficiency, and thyroiditis. Evaluation involves history, examination, FNAC, ultrasound, and radiological investigations. Treatment depends on cancer type and involves surgery, radioactive iodine, and thyroxine therapy. Prognosis depends on age, tumor size and spread.

1. THYROID TUMORS
Salma Saud Al-Sharhan
King Faisal University – Khobar
Saudi Arabia

2. NORMAL ANATOMY OF THE THYROID GLAND:

3. MICROSCOPIC PICTURE OF THE THYROID
GLAND:

4. TYPES OF THYROID CANCER:
 Primary:
 Follicular epithelium – well differentiated
papillary
follicular
 Follicular epithelium – undifferentiated
Anaplastic
 Parafollicular cells
Medullary
 Lymphoid cells
lymphoma
 Secondary : metastatic

5. THE CAUSES:
 Radiationexposure 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

6. 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.

7. TNM STAGING OF THYROID CANCER:

8. EVALUATION OF THYROID TUMOR:
 History:
Age and Gender
Rapid increase in size, dyspnea,
dysphagia and hoarseness of voice
Family Hx. Of thyroid cancer
Hx. Of irradiation
 On Examination:
Firmness, Mobility, Size and adherence
to surrounding structures
Presence of lymphadenopathy

9. 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

10. 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

11. 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

12. 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

13. Ten most common types of Cancer among
Adult Saudis by Sex, 2001

14. EASTERN REGION,2001

15. PAPILLARY THYROID CANCER:
 Cysticor Solid
 Most common (80-85%)
 Spread through lymphatic
 Female: Male is 3:1

16. PAPILLARY CANCER
Typical papillary projections and
empty (orphan annie-eyed) nuclei

17. CLINICAL PRESENTATION:
 Incidental
as a small occult tumor <1cm (papillary microcarcinoma)
 Mass in the Neck
the commonest way papillary cancer presents
 Glands in the Side of the Neck
The spread to local glands (sometimes called
erroneously quot;lateral aberrant thyroidquot;).
 Distant Spread
Spread to lungs or bone is very rare but when it
occurs unlike most other cancers, cure is possible.

18. 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%)

19. 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

21. THE PROGNOSIS IN DIFFERENTIATED
THYROID CARCINOMA:
 Thetwo 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
 Recentseveral scoring systems based on
multifactorial analysis of risk factors have been
advise

23. Low risk High risk
Patient age < 45 y > 45 y
Tumor size < 4.0 cm > 4.0 cm
Extrathyoidal absent present
extension
Distant absent present
metastases
High tumor absent present
grade

24. THE TREATMENT OF WELL
DIFFERENTIATED THYROID CANCER:
It Consists of a three- pronged attack :
 Thyroid Surgery
 Radioactive iodine therapy
 Drug - Thyroxine therapy

25. 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

27. 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
 Forgross involvement of trachea or
esophagus resection of these structures with
reconstruction
Cooper DS et al. Management guidelines for
thyroid nodules , Thyroid2006;19:109

28. 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.

29. 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

30. 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

31. THYROXIN THERAPY :
 Thedegree of thyroid suppression is
dictated by balancing the risk of
recurrent thyroid cancer and
subclinical thyrotoxicosis
particularly the cardiovascular risks

32. SURVEILLANCE:

33. CLINICAL IMPACT OF MOLECULAR
ANALYSIS ON THYROID MANAGEMENT:
PAILLARY FOLLICULAR
CARCINOMA CARCINOMA
CPTC PDPTC MIFTC WIFTC PDFTC
Recurrence 10% 50% 10% 40% 60%
Death 5% 40% 10% 40% 60%
of disease
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%

34.  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

35. 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

37. CLINCAL PRESENTATION:
 SporadicMTC:
asymptomatic thyroid mass
 FamilialMTC :
screening stimulation test for
calcitonin or with molecular analysis
( detection of RET gene mutation)

38. TREATMENT OF SPORADIC MTC:
Ccells do not concentrate
iodine so radioactive iodine is of
no value in the management

39. Surgery is the only definitive
therapy of MTC:
Total thyroidectomy
Central node dissection
Ipsilateral modified radical neck
dissection

40. A TUMOR ERODING INTO THE CHEST WALL

41. 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

42. MEN2A AND FMTC RX. :
Prophylactic thyroidectomy at age 5 to
6 years
Moley JF. Medullary thyroid carcinoma.
Curr Treat Options Onco 2003;4:339

43. MEN2B RX.:
Thyroidectomy during infancy
Moley JF. Medullary thyroid carcinoma.
Curr Treat Options Onco 2003;4:339

44. 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

45. 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

46. A woman with anaplastic A CT scan showing anaplastic
cancer of the thyroid cancer of the thyroid

47. SURGICAL TREATMENT OF ATC:
 Inthe majority of cases surgery is
limited to an open biopsy to exclude
lymphoma
Mclver B et al, Anaplastic Thyroid Carcinoma
.Surgery 2001;130;1028

48. 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

49. THYROID LYMPHOMA:
 Thyroid lymphoma is relatively rare
disease constituting <1% of all
lymphoma and accounting for 2% of
extranodal non- Hodgkin’s lymphoma
Green LD et al, anaplastic thyroid cancer
and 1ry thyroid lymphoma. J Surg Oncol
2006;94:725
 Female: Male ratio from 3:1 up to 8:1
 Median age is seventh decade of life

50. CLINICAL PRESENTATION:
 Local invasion : hoarseness, dyspnea
with stridor, or dysphagia
 Hypothyroidism in case of Autoimmune
thyroiditis or Hashimoto’s thyroiditis

51. A 70 Y. old lady with diffuse
large B cell lymphoma

52. TREATMENT :
 Primarytreatment 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

53. TREATMENT :
 Primarytreatment 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