This presentation gives general overview of different types of thyroid neoplasm especially surgical management and recent advances

1. Thyroid Neoplasms
Muhammad Haris Aslam Janjua
Resident, Surgical Unit I
SIMS/Services Hospital, Lahore

2. OUTLINE
 Introduction
 Epidemiology
Etiology
Pathophysiology
 Clinical presentation
Workup
 Staging
Treatment
Followup
Prognosis
Case Presentation

4. Introduction
 Most common endocrine tumour
 Responsible for about 6 deaths per million persons annually
 It accounts roughly for about 0.5% of all cancers in men and
1.5% of all cancers in women
 5% of all thyroid nodules are malignant
 Single nodule more likely to be malignant than multiple
nodules

5. Classification of Thyroid Neoplasms
Benign
i)Follicular adenoma.
ii)Hurthle cell adenoma
iii)Colloid
adenoma(commenest)
Malignant
(dunhill classification)
Differenciated
i) Papillary Carcinoma (80%)
ii) Follicular Carcinoma (10%)
iii) Hurthle cell carcinoma (3%)
iv) Papillofollicular carcinoma
Undifferenciated
i)Anaplastic carcinoma (1-2%)
Medullary Carcinoma (5-10%)
Malignant lymphoma (~1%)
Secondaries from colon, kidney, Melanoma

6. Woolner classification
Papillary
carcinoma
Occult
primary<1.5cm intrathyroidal extrathyroidal
• Other variants of papillary carcinoma include
• Tall cell
• Insular
• Columnar
• Diffuse sclerosing
• Clear cell
• Trabecular and
• Poorly differenciated

7. *Micropapillary carcinoma is a tumour,
clinically not detectable or less than 1cm with
no evidence of local invasiveness through the
thyroid capsule or angioinvasion.....

9. Epidemiology
 Annual incidence is 0.5 to 10 per 100,000 persons
 Highest Incidence  Northren america
 Female to male ratio is 3:1
 Differenciated carcinomas peaks in 3rd and 4th Decade
of life
 Medullary thyroid carcinoma peaks in 5th and 6th
decade
 Anaplastic carcinomas peaks in 7th and 8th decade.

10. Epidemiology
In Pakistan thyroid cancer is responsible for
1.2% cases of all malignant tumors
Papillory thyroid carcinoma iodine sufficient
areas
Medullary thyroid carcinoma iodine
deficient areas

11. Prevalence according to age
Carcinoma Age group
a) Papillary Thyroid carcinoma
b) Medullary thyroid carcinoma
associated with MEN type 2.
Children
a) Follicular thyroid carcinoma
b) Anaplastic carcinoma
c) Sporadic Medullary thyroid
carcinoma
Elderly

13. Etiology
 Thyroid cancer Arises from 2 types of Cells
Endodermally derived
Follicular cells
• Papillary
• Follicular
• anaplastic
Neuroendocrine derived
calcitonin producing C cells
• Medullary thyroid
carcinomas
 Thyroid lymphomas  Intrathyroid lymphoid Tissue
 Sarcomas  connective tissue of thyroid gland

14. Etiology
 Radiation*  Papillary thyroid carcinoma
 Signal most imp factor in differenciated carcinoma is irradiation of
thyroid under 5 years of age
 Pre-existing Multinodular goiterFollicular Carcinoma.
 Hashimotos thyroiditisPapillary Thyroid carcinoma
 Familial
*Increased incidence of thyroid carcinoma among children following
exposure to ionising radiation after Chernobyl nuclear disastor in
Ukraine in 1986
*Radiotherapy received in adolescents for Hodgkins lymphoma may
predispose to PTC

15. Familial cancer syndromes involving
non medullary thyroid cancer
Syndrome Thyroid tumor
Cowdens syndrome FTC and rarely PTC and hurthle
cell tumors
FAP PTC
Werners syndrome PTC, FTC , Anaplastic Cancer
Carney complex type 1 PTC, FTC
McCune Albright syndrome PTC Clear cell
 Medullary carcinoma multiple endocrine neoplasia (MEN) 2A or 2B
syndrome, as well as familial MTC (FMTC) syndrome..

16. Genes implicated in thyroid
tumorigenesis
Cancer Oncogenes Tumour suppressor
genes
 Papillary thyroid
Carcinoma
RET, MET, TRK1,RAS,
BRAF
p53
 Medullary
thyroid
carcinoma
RET
 Follicular
carcinoma
Ras, PAX8/PPAR P53, PTEN
 Anaplastic BRAF p53.

18. Pathophysiology
 Commonest site  junction of isthmus with one
of the lateral lobes
Types
Toxic solitory nodule
Non toxic solitory nodule

19. Pathophysiology
GROSS  Soft , firm, hard, cystic.
 Solitory /multinodular
 Contain brownish black fluid
 Microscopy  Nuclear groves
 Orphan annie eye nuclei characteristic
 Psamomma bodies (50%)
Spread  Slowly progressive and less aggressive
 Spread through lymphatics
 Most commonly to lungs followed by bone,
liver and brain
 Blood spread less often

20. Orphan annie is strip cartoon character
with empty circled eyes

21. Lymph node involvement in Papillary carcinoma
Central compartment(Level 6) medial to the
carotid sheaths on both sides, from the hyoid
bone superiorly to the sternal notch inferiorly
Jugular lymph node chains (levels 2-4)
posterior triangle of the
neck (level 5)

22. Pathophysiology
Types  Invasive
Blood spread common
 Non invasive
Blood spread not common
 Typical features  Capsular invasion
 Angioinvasion
Spread  More aggressive tumour.
 Through blood into bones*, lungs,
liver.
 Occasional spread to lymph nodes
in neck (10%)
*Bone secondaries typically vascular , warm , pulsatile, localised, commonly in
skull, long bones, ribs

23. Pathophysiology
 Variant of Follicular carcinoma according to WHO
 75-100% of the tumor is composed of Hürthle cells,
also known as oxyphilic, oncocytic, Askanazy, or large
cells
 Large, polygonal follicular cells  abundant granular
acidophilic cytoplasm
 Differ from follicular cancer in
 Multifocal and bilateral(30%)
 Donot take radio iodine(5%)
 More likely to metastasize to local nodes (25%) and distant
metastasis
 Associated with higher mortality rate( ~20 % in 10 years)

24. Pathophysiology
 Arise from de-differenciation of differenciated thyroid
carcinoma
GROSS  Firm and whitish
 Microscopy  Sheats of cells with marked heterogenicity
Spread  One of the Most aggressive thyroid
malignancy
 Spread through lymphatics commonly to
lungs, brain and bones

25. Pathophysiology
Types  Sporadic(75%)
 Familial (25%)
Gross  Well circumscribed
 Unencapsulated
 Microscopy  Amyloid stroma wherein malignant
cells are dispersed
 Calcitonin in amyloid on
immnunochemistry
Spread  Mainly to lymph nodes (60%)
 MCT associated with MEN type IIB
with pheochromocytoma (sipple
syndrome) is MOST AGGRESSIVE

26. Features of Medullary Thyroid Cancer
Syndromes
Syndrome Manifestations
MEN2A MTC, pheochromocytoma, primary
hyperparathyroidism, lichen planus amyloidosis
MEN2B MTC, pheochromocytoma, Marfanoid habitus,
mucocutaneous ganglioneuromatosis
Familial MTC MTC
MEN2A and
Hirschsprung's
disease
MTC, pheochromocytoma, primary
hyperparathyroidism, Hirschsprung's disease

27. Pathophysiology
Most common  non hodgkin B cell
lymphomas.
Commonly arise from chronic lymphocytic
thyroiditis
Chronic antigenic lymphocyte stimualtion 
lymphocyte transformation

29. Presentation
History
Most commonPainless, palpable, solitary
thyroid nodule.
 Solitory nodules presenting before 30 years and
after 60 years  increased chances of malignancy
Nodules in males higher chances of malignancy

30. Rapidly growing nodule is an ominous sign of
malignancy.......

31. History
• Hoarseness  involvement of the recurrent
laryngeal nerve and vocal fold paralysis.
• Dysphagia impingement of the digestive
tract
• Heat intolerance and palpitations suggest
autonomously functioning nodules.

32. Carcinoma Clinical Features
 Papillary thyroid
carcinoma
 Slow growing painless mass
 Discrete neck lymph nodes (40 %)
 Lateral aberrant thyroidcervical lymph
node invaded by metastatic cancer
 Compression featureuncommon
 Follicular carcinoma  Solitory thyroid nodules with history of
rapid size increase and long standing goiter
 Tracheal compressionstridor
 +ive Berrys sign* advanced malignancy
 Dyspnoea, hemoptysis and chest pain
when there are lung secondaries
 Pulsatile secondaries in skull and long
bones
 Cervical lymphadenopathyuncommon
 Signs and symptoms of thyrotoxicosis
 *Infiltration of carotid sheath and absence of carotid pulsations
 James berry is a surgeon who named it

33. Secondaries in skull from thyroid
primary ( well localised, warm
pulsatile vascular tumour with
underlying bone erosion).

34. • Anaplastic carcinoma

35. Carcinoma Clinical features
 Anaplastic carcinoma  Long standing neck mass >5cm which enlarges
rapidly , may be painful
 Tracheal obstruction stridor
 Hoarseness and dysnea common (50%)
 Vocal cord paralysis(30%)
 Hard Mass fixed to surrounding structures , may be
ulcerated,cervical mets (40%)
 +ive berry’s sign
 Medullary thyroid
carcinoma
 Develops in superolateral part of thyroid lobes
 Neck mass with palpable cervical lymphadenopathy (15
to 20%)
 Pain common
 Local invasion dysphagia, dysnea, dysphonia
 Sporadic  unilateral(80%)
 Familial  bilateral (90%)

36. Clinical presentation of thyroid cancer patients
in Pakistan--AKUH experience,
• Thyroid cancer is a more aggressive disease in
Pakistan, with majority of patients presenting with
multinodular goiters, and a significant number have
lymph node metastases. A higher degree of
vigilance and a lower threshold for fine needle
aspiration (FNA) is needed while evaluating patients
with thyroid goiter......

37. Physical examination
 Head and neck examination with careful attention to the
thyroid gland and cervical lymph nodes, as well as indirect
laryngoscopy.
Features suggestive of malignancy in a solitory nodule
include
 Any nodule can be malignant ( hard, firm,
cystic,small,large,asymtomatic)
 Rapid onset/rapid recent increase in size
 Hoarseness of voice/dysphagia/ stridor/dyspnea
 Fixity of the nodule
 Palpable neck nodes

38. Thyroid paradox
Cellular tumours are soft and cystic tumors
are firm and hard
Observed in papillary carcinoma of thyroid

39. Differential diagnosis of CA thyroid
• Multinodular goiter
• Reidels thyroiditis
– Presents as hard fixed swelling.May have local
invasion and fibrosis but is BENIGN.
• Thyroid adenoma
– Follicular- colloid , embroyal, fetal
– Hurthle cell
• Thyroid cyst
• Only one nodule palpable in MNG

41. Workup
Fine needle aspiration biopsy
Laboratory investigation
Imaging studies

42. Fine Needle Aspiration Biopsy
Most important diagnostic tool. Safe and
minimally invasive
Ultrasonographic guidance  increases the
accuracy of FNAB
 Gharib and Goellner (1993) found that
 69% of FNAB results were benign,
 4% were malignant,
 10% were indeterminate, and
 17% were nondiagnostic.
 Sensitivity 83%
 Specificity 92%
False-positive rate was 2.9%, and their false-negative
rate was 5.2%.

43. Fine Needle Aspiration Biopsy

44. Fine needle aspiration biopsy
• Complications
• Minor hematoma and ecchymosis  most common
• Puncture of the trachea, carotid artery, or jugular
vein may occur
– Can be managed by applying local pressure

45. FNAB
• Limitation
• Difficult to differenciate between follicular
adenoma and carcinoma on cytology as it
depends upon capsular and angioinavision
Options in Follicular carcinoma
 Frozen section biopsy
 Hemithyroidectomy
 Trucut biopsy
 Danger of hemmorhage and injury to trachea, recurrent
laryngeal nerve and vessels

46. *Except in patients with history of external radiation or family history of thyroid cancer

47. Workup
• Laboratoty investigation
• Serum TSH levels
– Low level suggests autonomously functioning nodule
(usually benign)
– Dosnt rule out malignancy
• Serum calcitonin levels
– Highly suggestive of MTC if increased
– More senstive marker than CEA
• PCR assays for germline mutations in the RET proto-oncogene
– Diagnostic in Familial medullary thyroid carcinoma

48. Laboratoty investigation
• Pentagastrin-stimulated calcitonin used as tumor markers
to monitor patients who have been treated for MTC
• Serum thyroglobulin levels
– Cannot differenciate between benign and malignant disease
– Used in patients who underwent total thyroidectomy * for
thyroid cancer
– Patients undergoing non operative managment of thyroid
nodule
*increased levels indicate recurrence

49. Laboratoty investigation
• Urinary VMA, metanephrine and catecholamine
– To rule out coexisting Pheochromocytoma in MTC
• Serum levels of CEA
– Increased in MTC but nonspecific
– Better indicator of prognosis than Calcitonin
• New patients with MTC should be screened for
RET point mutations, pheochromocytoma and
HPT.

50. Imaging studies
Ultrasonography
Highly sensitive for thyroid nodules
Can depict nodules only a few millimeters in size
Can detect non palpable thyroid nodules
Differenciate solid from cystic nodules
Can detect adjacent lymphadenopathy

51. Ultrasonography
• Features suggestive of malignancy on USG
include
– Fine stippled calcification
– Enlarged regional lymph nodes
• Used to follow the size of suspected benign
nodules

52. Ultrasonograpy
Thyroid nodule with few, easily
countable microcalcifications
Solid, hypoechoic, and
coarse central calcifications
Later proved to be medullary
carcinoma

53. Workup
Radio iodine studies
 Recommended in patients having Follicular CA on FNAB and
suppressed TSH.
 Determine functional status of a nodule
• Based on radioisotope studies nodule can be
 Hot
 Autonomous toxic nodule
 Warm
 Normally functioning
 Cold
 Non functioning nodule (likely to be malignant but not always)

55. Thyroid Scan showing cold nodule Thyroid scan showing hot nodule

56. Workup
• 111 indium octreotide scanning MTC (70
%sensitive)
Xrays
• CXR and Xray skull to rule out metastatic deposits
– Skull mets more likely in Follicular carcinoma
CT scanning and MRI
– used to evaluate soft-tissue extension of large or
suspicious thyroid masses into the neck, trachea, or
esophagus.
– To assess metastases to the cervical lymph nodes

57. X-ray of skull showing a couple of painless, progressively increasing
swellings in the occipitoparietal region of the scalp.
World J Radiol. 2012 June 28; 4(6): 286-290.

59. Staging
TNM Classification of Thyroid Tumors
Papillary or Follicular Tumors
• Stage TNM
• <45 y
• I Any T, any N, M0 (cancer in thyroid only)
• II Any T, any N, M1 (Distant metastasis)
• ≥45 y
• I T1, N0, M0
• II T2, N0, M0
• III T3, N0, M0; T1–3, N1a, M0
• IVA T4a, N0–1a, M0; T1–4a, N1b, M0
• IVB T4b, any N, M0
• IVC Any T, any N, M1

60. Medullary Thyroid Cancer
• Stage TNM
• I T1, N0, M0
• II T2–3, N0, M0
• III T1–3, N1a, M0
• IVA T4a, N0–1a, M0; T1–4a, N1b, M0
• IVB T4b, any N, M0
• IVC Any T, any N, M1
Anaplastic Cancer
• Stage TNM
• IVA T4a, Any N, M0
• IVB T4b, Any N, M0
• IVC Any T, Any M, M1

61. Definitions
Primary tumor (T)
• TX = Primary tumor cannot be assessed
• T0 = No evidence of primary tumor
• T1 = Tumor ≤2 cm in diameter, limited to thyroid
• T2 = Tumor >2 cm but <4 cm in diameter, limited to thyroid
• T3 = Tumor >4 cm in diameter, limited to thyroid, or any tumor with minimal extrathyroidal invasion
• T4a = Any size tumor extending beyond capsule to invade subcutaneous soft tissue, larynx, trachea,
esophagus, or recurrent
• laryngeal nerve, or intrathyroidal anaplastic cancer
• T4b = Tumor invading prevertebral fascia, or encasing carotid artery or mediastinal vessels; or
extrathyroidal anaplastic cancer
Regional lymph nodes (N)—include central, lateral cervical, and upper mediastinal nodes
• NX = Regional lymph nodes cannot be assessed
• N0 = No regional lymph node metastasis
• N1 = Regional lymph node metastasis
• N1a = Metastases to level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes)
• N1b = Metastases to unilateral, bilateral, or contralateral cervical or superior mediastinal lymph
nodes
• Distant metastasis (M)
• MX = Distant metastases cannot be assessed
• M0 = No distant metastasis
• M1 = distant mets present

62. Staging
Stage 1 Malignancy is intrathyroidal
Stage 2 Cervical nodal metastasis
Stage 3 Extrathyroidal invasion
Stage 4 Distant metastasis
*Applicable in all thyroid malignancies but mainly used in
follicular carcinoma

63. Prognostic indicators in PTC
 Classify patients into LOW RISK and HIGH RISK groups
AGES scoring system
• Age, Grade, Extrathyroidal invasion and Size.
– LOW RISK patients are
• Young <40 years
• Well differenciated tumor
• No mets
• Small primary lesions (<4cm)
– HIGH RISH include
• Older >40 years
• Poorly differenciated tumor
• Distant metastasis
• Large primary lesion >4cm

64. MACIS scoring system
Post operative system modified from
AGES
• Include Metastasis, Age , Completeness of
excision, extrathyroidal Invasion and Size.
• The final prognostic score was defined as
– MACIS = 3.1 (if aged less than or equal to 39 years) or 0.08 x
age (if aged greater than or equal to 40 years), + 0.3 x tumor
size (in centimeters), +1 (if incompletely resected), +1 (if
locally invasive), +3 (if distant metastases present).

65. AMES Scoring system
• Proposed by Cady
• Include Age, Metastasis, Extent of primary tumour, Size
• LOW RISK include
– Age <40 in men and <50 in women
– No mets
– No extrathyroidal invasion
– Size <5 cm
• HIGH RISK include
– Age > 40 in men and >50 in women
– Distant mets +ive
– Extrathyroidal invasion
– Size >5cm

66. Tid Bits
Lymph node involvement does not alter the
prognosis of papillary carcinoma of thyroid.
All scoring systems catagorise the patient as
High risk of death i.e 40 % in 20 years
Low risk of death i.e 1 % in 20 years
 Low risk is acheived by complete clearance of
macroscopic tumor during first surgery

67. Lymph node levels in neck

68. Unilateral thyroid lobectomy is
recommended
Cyst persist after 3 attempts for aspiration
Cyst >4cm
Complex cyst with solid and cystic
components higher chances of
malignancy (15 %)

69. Papillary thyroid carcinoma
HIGH RISK or BILATERAL  Total or near total
thyroidectomy
Minimal papillary carcinoma in
thyroid specimen
 Unilateral thyroid lobectomy
and isthmectomy
Large , Locally aggressive/
metastatic tumours
 Total thyroidectomy with excision of
adjacent involved structures if
necessary and appropriate nodal
surgery followed by radioablation
with long term TSH suppression
 Modified Radical neck dissection type III is done in case of
lymph node involvement

70. Low risk groups
Points in favour of total thyroidectomy Point in favour of lobectomy
 Enables the use of RAI to detect and
treat residual thyroid tissue/mets
 Lobectomy has less complication rate
 Makes serum Tg level more sensitive for
recurrent or persistent disease
 Recurrence in remaining tissue is unsual
(5%) and mostly curable by surgery
 Removes contralateral occult cancer as
sites of recurrence ( 85% bilateral)
 Tumour multicetricity has little
prognostic significance
 Reduces recurrence risk and improved
survival
 Prognosis is comparable to total
thyroidectomy
 Decreases the 1 % risk of progression to
anaplastic cancer
 Reduces rate of re-operation and
complication
Generally total or near total thyroidectomy is recomended in low risk groups provided
complication rates are low <2 %

71. Indication of total thyroidectomy
NCCN guidelines
If any present If all present
(thyroidectomy/lobectomy)
 Age <15y or >45y  Age 15 – 45 y
 Radiation history  No radiation history
 Known distant mets  No distant mets
 Bilateral nodularity  No nodularity
 Extrathyroidal invasion  No extrathyroidal invasion
 Tumour > 4cm  Tumour <4 cm
 Cervical lymph node mets  No cervical lymph nodes
mets
 Aggressive variant  No aggressive variant

72. • Prophylactic lateral neck node dissection is
NOT recommended in PTC
– Cancer dosnt metastatise systemically from lymph
nodes
– Micrometastasis can be ablated by RAI therapy

73. Residual disease Post operatively
• TSH + Tg and antithyroglobulin antibodies
– 2 to 12 weeks post operatively
• Total body RAI imaging
– Suspected or proven RAIEBRT
– Adequate RAI uptake  Radioiodine treatment and post
treatment I131 imaging
• If no imaging performed  EBRT
• In all these cases suppress TSH with Levothyroxine.

74. • Using the Surveillance, Epidemiology, and End
Results (SEER) database, one study compared the
overall survival (OS) and cause-specific survival
(CSS) of 23,605 subjects with papillary or
follicular thyroid cancer treated with local
excision, lobectomy, near-total thyroidectomy, or
total thyroidectomy.
• The 10-year OS and CSS results concluded that
total thyroidectomy resulted in improved survival
over other techniques
– Poorer outcomes were associated with age, stage
T3/T4 disease, positive nodes, and tumor size

75. Metastatic disease
• CNS  Neurosurgical resection and/or image guided
EBRT
• BONE Surgical paliation ( weight bearing extremities
and/or RAI treatment and/or EBRT
– bisphosphonate or denosumab therapy
– Embolization of mets
• Other than CNS  surgical resection and/or EBRT of
selected mets and/or radioiodine
– Best supportive care

76. Follicular carcinoma
• Follicular lesion on FNAB  thyroid lobectomy (80 % are
adenomas)
• Total thyroidectomy is recommended in
– Older patients
– Lesion >4cm ( cancer risk is 50 %)
• Intraoperative frozen section examination if
– Evidence of vascular or capsular invasion
– Adjacent lymphadenopathy is present
• If non diagnostic then hemithyroidectomy is done and sent for
histopathology
• Thyroid specimen  follicular carcinoma total thyroidectomy
• Nodal mets  therapeutic neck dissection

77. Hurthle cell carcinoma
• Unilateral lobectomy and isthmectomy
• Invasive  total thyroidectomy + central neck node
removal
• Modified radical neck dissection if lateral nodes are
involved
• TSH suppression
Rediffereciating therapies such as retinoic acid and PPAR gamma
have shown some benefit in these tumors but require futher
research

78. Post operative management of DTC
Radioiodine scanning and ablation
• RAI ablation is recommended in
– All patients with stage 3 and 4 disease
– All Patients with stage 2 disease <45 years
– Usually in patients >45 years and stage 2 disease
– Stage 1 disease with
• Aggresive histology
• Nodal mets
• Multifocal disease
• Extrathyroidal or vascular invasion

79. • More senstive than xray/ CT in detecting metastatic disease
• Less senstive than Tg level except in Hurthle cell Tumours
• 4-6 weeks after thyroidectomy, hypothyroid can be induced by
discontinuing replacement (T4 for 4 weeks or T3 for 2 weeks) to
obtain high serum TSH levels.
• A diagnostic dose of131 I or123 I is given initially.
• Whole-body scanning is performed to detect any tissue taking
up radioiodine.
• If any normal thyroid remnant or metastatic disease is detected,
a therapeutic dose of131 I is administered to ablate the tissue.

80. • If a treatment dose of131 I is required, diagnostic
thyroid scanning is repeated after 6 months after initial
treatment,
• If the diagnostic scan Positive  additional therapeutic
dose is given. Process is repeated until the diagnostic
scan is negative
Role of recombinant human TSH
• Thyrogen stimulation avoids the discomfort of patients
having to discontinue thyroid replacement
– t4 stopped 1 day before TSH stimulation

81. Recent advances
• Sorafenib* (Nexavar) was approved in
November 2013 for differentiated thyroid
cancer (DTC) that is refractory to radioactive
iodine treatment.
• *Sorafenib is a small molecular inhibitor of
several tyrosine protein kinases

82. Thyroid suppression
• Used after thyroidectomy and radioablation
• Reduces tumoural growth and recurrence
rates
• Suppressive dose is 0.3 mg OD lifelong
• TSH levels should be < 0.1 mU/L

83. External beam radiotherapy
• Used in unresectable, locally invasive or
recurrent disease
• In bone mets to decrease
– Risk of fractures
– Bone pain

84. Chemotherapy
• Generally has no role
• Doxorubicin is used as radiation sensitizer in
patients undergoing external beam radiation

85. Medullary thyroid carcinoma
• If pheochromocytoma present  operated first
• Total thyroidectomy is the treatment of choice
with bilateral central neck node dissection
• Palpable cervical lymph nodes modified
radical neck dissection
• Tumour >1 cm  ipsilateral Prophylactic
modified radical neck dissection
– If +ive than contralateral node dissection is done

86. Medullary thyroid carcinoma
• If unresectable
– Tumour debulking to reduce symptoms
– External beam radiation
Recent advances
 Tyrosine kinase inhibitors
 Imitanib
 Zactima (reduces calcitonin and CEA levels
 Anti CEA monoclonal antibody
 Labetuzumab
 Laproscopic Radiofrequency ablation
 For Liver mets >1.5 cm (palliative)

87. • If patient is hypercalcemic at thyroidectomy
– Only enlarged parathyroid gland is removed
• RET mutation carrier  total thyoroidectomy
– MEN2A  before 6 years
– MEN2B  before 1 year
• Central neck node dissection
– Avoided in calcitonin negative and normal USG
exam
– Done prophylactically in calcitonin positive and if
USG suggests cancer
• Maintenance dose of L-thyrosine

88. • All family members of patients with MTC
should be evaluated with serum calcitonin (
genetic evaluation can also be done ) and if it
is high they should undergo prophylatic
thyroidectomy ......

89. Anaplastic carcinoma
• If resectable
– Adjuant chemoradiotherapy
• Adriamycin is used for chemo.
• Tracheostomy and isthemectomy to relieve
airway obstruction in unresectable cases

90. Lymphomas
• Mainstay  Chemotherapy
– CHOP ( Cyclophosphamide, Doxorubicin,
vincristine, and prednisolone)
• Radiotherapy may also be given
• Thyroidectomy and nodal resection to
alleviate airway obstruction

92. Differenciated thyroid carcinoma
Throglobulin levels
 Thyroglobulin is a useful marker of tumor recurrence
because well-differentiated thyroid cancers synthesize
thyroglobulin
• After total thyroidectomy levels should be
– <2 ng/ml if taking t4
– <5ng/ml if hypothyroid
– Levels >2ng/ml suggest metastatic or persistant normal tissue.
(>95%)
• Tg and Tg antibodies measuresd initially 6 months
interval then annualy if disease free.

93. Follow up imaging
• In low risk and –ive TSH stimulated Tg and cervical USG
routine whole bodyscan is not recommended after first post
operative scan
• After remnant ablation routine whole body scan after 6 to 12
months is recommended
Cervical USG
• To evaluate thyroid bed and lymph node  6 to 12 months
post thyroidectomy then annually for 4 to 5 years
FDG PET SCAN
• If RAI and USG normal but Tg remain elevated

94. Medullary thyroid carcinoma
• Annual measurements of calcitonin and CEA
levels.
• Regular USG , CT , MRI if required
• FGD PET scans
– Superior to other radionuclide based studies

95. Management of recurrence
• Localised
– Surgical excision
• Non localised
– 131 I radioablation
– External beam radiotherapy

97. According to stage
Stage Age < 45 Age > 45
Local
Recurrence
Distant
Recurrence
10 year
Survival
I Any T Any N M0 T1 N0 M0 5.5% 2.8% 98%
II Any T Any N M1 T2 N0 M0 7% 7% 89%
III - T3 N0 M0
T1-3 N1a M0
27% 13.5% ~82%
IVa - T4a N0 M0
T1-4 N1b M0
IVb - T4b N0-1b M0
IVc - Any T Any N M1 60.9% 100% 50%
• This table is extrapolated from a number of sources including the American Cancer Society, The National Cancer Institute,
and the National Comprehensive Cancer Network, among others

98. According to cancer type
5-Year Survival for Papillary
Thyroid Cancer
Stage 5-Year
Survival
I Nearly 100%
II Nearly 100%
III 93%
IV 51%
5-Year Survival for
Follicular Thyroid Cancer
Stage 5-Year
Survival
I Nearly
100%
II Nearly
100%
III 71%
IV 50%
5-Year Survival for
Medullary Thyroid
Cancer
Stage 5-Year
Survival
I Nearly
100%
II 98%
III 81%
IV 28%

99. Papillary carcinoma
• Good prognosis
• Age is most important factor
AGES system
AGES Prognostic score = 0.05 × age (if age ≥40)
+ 1 (if grade 2)
+ 3 (if grade 3 or 4)
+ 1 (if extrathyroid)
+ 3 (if distant spread)
+ 0.2 × tumor size (cm maximum diameter)
AGES score Survival (20-yr)
≤3.99 99%
4-4.99 80%
5-5.99 67%
≥6 13%

100. • Survival by AMES risk-groups (20-yr)
Low risk 99%
High risk 61%
• Survival by MACIS score (20-yr)
MACIS score Survival
<6 99%
6-6.99 89%
7-7.99 56%
≥8 24%

101. Follicular carcinoma
• Cumulative mortality is
– 15% at 10years
– 30 % at 20 years
• Poor prognosis is associated with
– Age >50
– Tumour size > 4cm
– High tumor grade
– Marked vascular and extrathyroidal invasion
– Distant metastasis

102. Medullary thyroid carcinoma
• 10 yr survival rate is 80 %
• Decreases to 45 % with lymph node involvement
• From best to worst prognosis
– Non MEN familial  MEN 2A  sporadic  MEN2B
• MEN2B has survival rate of 35 % at 10 years

103. Anaplastic carcinoma
• Few patients survive 6 months beyond
diagnosis
Lymphomas
• Depends upon
• Histologic grade
• Tumour within thyroid or disseminated
• Overall 5 yr survival rate is 50 %
• Extrathyroidal disease  lower survival
rates

104. Patient education
• Patients who discover a neck deformity or
thyroid lumps or have a history of prior
exposure to ionizing radiation must consult
their physician

106. Case Presentation
• A 40 year old male, resident of Chichawatni, electrician by profession
presented with complain of swelling on the right side of neck for 3 months.
• Swelling was gradual in onset, progresively increasing in size and number.
Noticed by the patient by self palpation.
• Associated with
– Hoarseness of voice
– Anorexia and weightloss for last 1 month
• No h/o pain, fever, palpitation, sweating, heat/cold intolerence, dysphagia,
dysnea, radiation exposure , sleep disturbance or neck trauma.
• Past medical and surgical history unremarkable except HCV infection (7
years)

107. • Drug history : Took interferon injections for 6
months for HCV.
• Personel history : Non smoker, non addict
• Socio economic History: Lower class with
7000/ month income.
• Family history : Mother is diabetic .
• Allergic history: Not significant .

108. General physical examination
• A middle aged male of lean physique sitting comfortably on
bed well oriented in time place and person
– B.P= 130/90 mmHg
– Pulse= 90/ min regular rhythm, volume and character
– Resp rate = 14/min
– Temp= 98.6 F
– Weight =50 kg BMI=16.03
• Bilateral cervical lymphadenopathy
– Right Post triangle nodes
– Bilateral along anterior border of sternocleidomastoid
– Bilateral supraclavicular nodes
• Right axillary medial group of lymph nodes are also palpable
• No Pallor, cyanosis, jaundice, clubbing or edema

109. Local examination
• A 3*2 cm soft, globular, nontender,
nonfluctuant, non pulsatile, normothermic
swelling on the right side of anterior triangle
that moves upward with deglutition.
• Not fixed to overlying skin but fixed to
underlying tissues ,with smooth surface and
irregular borders but no prominent veins,
pulsations or stridor.
• Carotid pulse palpable i.e berry’s sign –ive

110. Systemic examination
• No eye signs
• CNS : GCS= 15/15 intact
• CVS : S1 + S2 + 0
• Chest : NVB + 0
• Abdomen: Soft nontender, no viceromegaly, Liver
span = 12 cm in midclavicular line, bowel sounds
present

111. Investigation
• Laboratory investigation:
– CBC, LFTS, RFTS, and COAGULATION is NORMAL
– Thyroid function test are normal
• FNAC
– Thyroid nodule
• Nuclear overlapping, nuclear groves with papillary cores
suggestive of Papillary carcinoma of thyroid
• No inclusion or psamomma bodies
– Cervical lymph node
• Sheets of pleomorphic cells with nuclear grooves against
hemorrhagic background

112. Imaging studies
• CT scan of neck with I/V contrast
– Large heterogenous enhancing mass involving
right side of isthmus and right lobe of thyroid with
extrinsic compression of trachea.
– Calcification also noted in mass
– Multiple enlarged lymph nodes in right axilla,
supraclavicular and cervical region
– Oro/hypopharynx and larynx appear normal.
Esophagus is normal. Great vessels in the neck are
un remarkable

113. • 99m Tc MDP bone scan:
– Normal ( homogenious and bilateral symmetrical tracer
distribution)
• CHEST X RAY:
– Normal
• Indirect laryngoscopy:
– Bilateral normal mobile vocal cords
Plan
• Total thyroidectomy with neck block dissection
followed by lifelong thyroid hormone replacement
therapy

114. Intraoperative findings
Level IIb , III , IV and V lymph node chains with
pericapsular fibrosis invading carotid sheath.
Right lobe hard fixed infiltrating right wall of
trachea
Hard fixed mass extending retrosternally and
fixed with trachea....

115. Procedure done
• Modified radical neck dissection
– Accessory nerve saved . Internal jugular vein and
sternocleidomastoid removed
• Left lobectomy and isthmectomy + right
nodulectomy