Thyroid cancers

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  • 1. Thyroid cancersInfrequent cancers-3% of all cancersBenign diseases commonRequires multidisciplinary actionWomen are affected 3 times more thanmenPeak incidence 30-40yrs

2. Types- Papillary-80% Folllicular-10% Medullary-5-10% Anaplastic-1-2% Lymphoma Sarcoma 3. Etiology & Risk factors Arise from 2 types of cells Follicular cells makes papillary,follicular &anaplastic Parafollicular C cells makes medullary Radiation exposure & Hashimotosthyroiditis are risk factors for papillary ca. Low dietary iodine is riskfactor for follicular& anaplastic 4. History Present as Painless palpable thyroidnodule Nodules are present in 4-7% of populationbut most are benign,5% are mlignant Peak incidence occurs between age of 30-50yrs More common in females Malignant nodules are usually painless Hoarseness suggests malignancy-nerveinvolvement 5. Dysphagia Family history present in case ofmedullary cancer 6. Examination Thyroid gland Soft tissues of neck Tenderness? Consistency(Hard/firm/soft) mobility(fixedor not) Laryngoscopy if hoarseness presents 7. GOAL is To differentiate malignant from benignnodules Determine which patient requireintervention / who can be monitered Avoid unnecessary surgery 8. FNACFirst intervention in evaluation of noduleInexpensive,easy,few complicationsNeeds a good cytopathologistFour types of results-benign-69%mallignant-4%indeterminate-10%nondiagnostic-17%Sensitivity-83%,specificity-91% 9. If nondiagnostic-repeat If benign-followup If malignant-surgery If indeterminate-surgery 10. Lab TSH-to know the hyper/hypo thyroidism,not helpful in malignancy Sr.Thyroglobulin as a tumour marker inpost op to assess Calcitonin for medullary ca. 11. Imaging U/S-to differenciate solid & cysticlesions,for FNA accuracy & for monitoringof benign lesions Scans-determine function of nodule Carcinoma can not be ruled out based onscans as 4%of hot nodules also malignant CT/MRI not used routinely 12. Papillary cancer Most common(80%) Women-3 tims more common 30-40yrs of age Risk factors-radiation exposure inchildhood, Hashimotos thyroiditis Slow growing,TSH sensitive,take upiodine,TSH stimulation produces Tgresponse 13. Pathology Unencapsulated,arborizing papillae,welldifferentiated,rare mitoses50% havePsammaoma bodies-calcificconcretions,circular laminations Multicentric Histology-Orphan anney eye with nucleargrooving 14. Loacl invasion through capsule, invadingtrachea, nerve causing dyspnea,hoarseness Propensity to spread to the cervicallymphnodes,clinically evident in 1/3 ofpatients-mostly central compartment Distal spread to lung & bones 15. Follicular carcinoma Second most common(10%) Iodine deficient areas 3 times more in Women Presents more in advanced stage thanpapillary Late 40s Also TSH sensitive, takes up iodine,produces Tg 16. pathology Round, encapsulated, cysticchanges,fibrosis, haemorrhages Microscopically neoplastic follicular cells Differentiated by follicular adenoma bycapsular invasion & angioinvasion Cannot reliably diagnose based on FNA 17. Local invasion is similar to papillary cancerwith same presentation Cervical metastases are uncommon Distant metastases is significantlyhigher(20%),with lung & bone as mostcommon sites 18. Treatment & Prognosis Total thyroidectomy with lymphnodedissection if positive nodes present ismainstay of treatment for differentiatedthyroid cancers Post surgery radioiodine scan fordetection & ablation of remnant thyroidtissue in neck or in metastatic sites 19. Post operative radioiodine & Ablation I-131 targets residual thyroid tissue &tumour after thyroidectomy First given in diagnostic dose to detect &then in therepeutic dose to ablate it Hypothyroid state (TSH>30mIU/l) isrequired for better iodine uptake for thatroutine eltroxin supplimentation aftersurgery is to be avoided 20. Thyroid supression therapy Low TSH levels reduce the tumour growthrates & recurrence rates,so after surgery &radioablation patients should bemaintained on thyroxin Most recommended TSH level is4cm have high recurrencerate & deaths 22. 30yr cancer related death rate is 6% forpapillary & 15% for follicular cancer Local invasion portends poorer prognosis LN metastases is not important forprognosis Distant metastases associated with 68foldincrease in disease specific death rate 23. Hurthle cell carcinoma A Variant of follicular cancer,also known asoncocytic carcinoma 5yr survival-50% More common in females and in 5th decade of life Same clinical presentation as follicular ca. Can not be diagnosed on FNA Does not take up Iodine, so treat aggressively Radio iodine, Thyroid suppression does not work 24. Medullary carcinoma 5% female preponderance 75% sporadically,25% familial. In familial cases, the lesions are usually allover the gland whereas in sporadic theyare not Associated with MEN 2a,2b & FMTCsyndromes 25. MEN 2a - also known as Sipple syndromeMTC, pheochromacytoma,pitutory,parathyroid adenomas MEN 2b MTC, pheochromacytoma,ganglionomas/neuromas,morphanoid habitus FMTC only MTC MTC in familial cases are moreaggressive, presents in younger age, withrapid growth & metastases Whereas in sporadic cases presents aspainless nodule/symptoms of invasion 26. Biochemical test in MTC Calcitonin levels are used as tumour marker forMTC in post op to detect recurrence Stimulating Calcitonin release with IVpentagastrin increases sensitivity of test- firstmeasures baseline calcitonin, then givespentagastrin, then measure calcitonin serially at1.5 & 5min intervals Genetic test to detect RET gene for screening Histologically test for Calcitonin,CEA 27. Treatment for MTC Total thyroidectomy Lymphnode dissection of level 6 Parathyroid reimplantation if necessary Prophylactic thyroidectomy in children withMEN 2a,b (>90% penetrance) Survielance with Calcitonin, CEA Does not take up iodine, so no radioiodine Prognosis-10yr survival rate is 65% 28. Anaplastic cancer Bad Aggressive, much invasive Surgery is not indicated Radio/chemotherapy 29. Indications for total thyroidectomy Well differentiated thyroid cancer Medullary thyroid cancer Sarcoma of thyroid Lymphoma of thyroid Obstructive goitre 30. Thank you