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أيها ـ برٱستعينوا ءامنوا ٱلذيني ةوٱلصبٱلص إنلو برينمعٱلل ـ ٱلص
O you who believe! Seek help in patience and
As-Salât (the prayer). Truly! Allâh is with As-
Sâbirun (the patient.) (153)
Approach to thyroid CA
Approach to thyroid cancer● Papillary thyroid
cancer(PTC)
● Follicular thyroid cancer(FTC)
● Anaplastic thyroid cancer(ATC)
● Medullary thyroid cancer(MTC)
Epidemiology
● Incidence is 9 cases/100000 persons per year
● 90-95 % are PTC and FTC
● More common in female
Risk factors
● External head and neck radiation
● Family H/O of thyroid cancer/MEN -2
● Iodine deficiency
Clinical diagnosis● Thyroid nodule
● Incidentaloma
● Cervical lymphadenopathy
Obstructive symptoms● Dysphagia
● Hoarseness
● Dyspnea
Other symptoms● Metastasis to lung and
bone
● ATC presents as rapidly enlarging thyroid mass
MTC ● ACTH
● Calcitonin
D/D● Solitary thyroid nodule
● Multinodular goiter
● Cyst
● Thyroiditis
Diagnosis approach● FNAC
● Surgical pathology
Laboratory tests
● TSH
● Thyroglobulin-
● Calcitonin
USG neck● Accurate needle placement
● Potential metastatic lymph node
● Planning nodal dissection
● Identification of recurrent disease
Thyroid ultrasound of a nonpalpable recurrent papillary thyroid carcinoma
Radioactive whole body scan
● To identify recurrent/residual disease
● To identify bone and soft tissue metastasis
CT/MRI neck● Identify soft tissue extension
● Cervical lymph node metastasis
PET scan● To identify sites of distant
metastases
FNAC● Accurately detects PTC
● May not distinguish between benign and malignant follicular lesions
Papillary thyroid cancer: Findings on FNAC
Treatment modalities● Surgery
● L-thyroxin
● Radioiodine treatment
● Chemotherapy
● External beam radiation
Near total thyroidectomy● Age <15 >45
● History of radiation
● Known distant metastasis
● B/L disease
● Extrathyroid invasion
● Tumour size >4 cm
● Cervical lymph node metastases
● Family H/O of thyroid CA
Lobectomy
Stage I disease
Lobectomy
Advantages
• Low risk of hypoparathyroidism
• Low risk of hypothyroidism
• Low risk of injuring recurrent laryngeal nerve
Disadvantages
• Inability to monitor for residual/recurrent disease with thyroglobulin
TSH suppression therapy● Low risk of recurrence TSH should be
suppressed to low but detectable range
● High risk of recurrence or with known distant metastasis complete suppression is indicated
● Most patients with stage I PTC/primary tumors<1.5cm
Radioactive iodine● Post surgical ablation of residual
thyroid tissue
● Treatment of residual or recurrent thyroid cancer
Indication for radioactive iodine treatment● Larger papillary carcinomas
● FTC
● Evidence of metastases
External beam radiotherapy● Treatment of specific
metastatic lesion
ATC and other forms of thyroid cancer● Multimodal therapy may be
beneficial
● Radioactive iodine can be used if there is residual uptake
● Palliative chemotherapy can be used
MTC● Surgical excision
● External beam radiation can be used for local metastases in neck
● Palliative chemotherapy
Ongoing care● TSH suppression therapy
Monitoring for recurrence● Iodine 131 /whole body scan or
thyroid USG
● Measurement of serum Tg
Surveillance● Physical examination every 3-6
months for 2 years and then annually if disease free
● TSh and Tg at 6 and 12 months and then annually if disease free
● Radioiodine scan every year until 1 negative scan
MTC monitoring● Annual measurement of
calcitonin and CEA
● Periodic USG
● Octreotide scan to localise metastatic lesion
Take home message
● PTC and FTC are most common
● USG guided FNAC is diagnostic
● Surgery can be almost curative
● Needs long term F/U
References
Uptodate 2015
Harrisons principles of internal
medicine