MOHD HELMY B ABU BAKARFARRAH HANNA BT MOHD NASIR

KHAIRUNISA BT JUHARI

Thyroid Malignancies Majority are primary tumors. Female > male (3:1).

Typical Presentation of Thyroid Cancer

Painless lumpNormal thyroid function testsFound on routine examination or by the

patientSlow growth or no growth over several

months

Signs & Symptoms of Malignant goitres:Patients are usually euthyroid.Thyroid nodule/ mass.Cervical nodes enlargement- local

discomfort in neck.Bone painCough- lung metastasisStridorDysphagiaHoarseness

Risk factors for MalignancySolitary thyroid nodules in patients >60 or

<30 years of age Irradiation of the neck or face during infancy

or teenage yearsSymptoms of pain or pressure (especially a

change in voice)Male sexLarge Nodules (>3 or 4 cm)Growth of nodule

Types of Thyroid Gland Malignancies1) Papillary : 60% Well-Differentiated

2) Follicular : 20%

3) Anaplastic : 5-8 % Poorly differentiated

4) Medullary : 5% Moderately differentiated

Papillary Carcinoma

Most common form, esp in young adults.Assc. with previous exposure to ionizing

radiation.Slow growing, painless nodule & often

multifocal within the gland.TSH dependent.Non functional tumor.

Spread:i) Lymphatic (early) - int jugular, para aortic,

jugulodigastric nodes.ii) Distant metastasis (rare) via blood –lungs,

bone, liver,etc.

Managements:- Total thyroidectomy + removal of involved

LN- Thyroxine: lifelong hormone replacement, to

suppress TSH secretion.

Prognosis: Excellent (10 yrs survival rate 85%)

Follicular CarcinomaOlder age gp, peak at 40-50 years old.Predisposition: Iodine-deficiency goitre.Slow growing, painless, solitary, cold

nodule.Spread: Hematogenous to lungs, bones,

liver.More aggressive than papillary ca.

Managements:- Total thyroidectomy + preservation of

parathyroid gland.- Thyroxine replacement.- Radioactive iodine: for mets- Thyroglobulin estimation every 6 months-marker

of recurrence.

Prognosis in 10 yrs survival rate:- No mets: 90%

- Mets: 30%

Medullary CarcinomaNeuroendocrine neoplasm of

parafollicular cell (C cell)- secrete calcitonin,VIP, serotonin, etc.

Aetiology:1)Sporadic (80%): 40-50 yrs old.2)Assoc. with MEN IIa/IIb : 20-30 yrs old.

Others: Familial MTC, Von Hippel Lindau Syndrome, Neurofibromatosis

Presentation:- Thyroid mass (hard enlargement).- Compression symptoms: dysphagia, hoarsness- Diarrhea : secretion of VIP

Spread: -Lymphatic: regional LN

-Hematogenous: lungs, liver, bones

Anaplastic CarcinomaRapidly growing,large and bulky, highly

malignant & metastasize widely.> elderly.Predisposition: endemic goitre.

Spread:1) Local invasion:- Recurrent laryngeal nerve: hoarseness- Trachea: dyspnoea,stridor- Esophagus: dysphagia- Cervical symphathetic nerves: Horner’s

syndrome.

2) Lymphatic3) Hematogenous: lungs (common), etc.

Managements:- Resection rarely possible.- Mainly palliative to relieve pressure symptoms:

surgery debulking.

- Chemo/radiotherapy: not effective.

Prognosis: Fatal within 1 yr of diagnosis.

Managements:-Total thyroidectomy + removal of affected lymph

nodes.-Calcitonin level: monitor progress (any residual or

recurrence) and screen relatives (if inherited).- Inoperable tumor: Irradiation.- Prophylactic thyroidectomy for MEN IIa/IIb.

Prognosis: 30-50% for 10 yrs survival.

TNM Staging Tumor (T) Stage

TX: Tumor cannot be evaluated. T0: There is no evidence of tumor. T1: Thyroid tumor is 2 centimeters (cm) or less. T2: Thyroid tumor is 2 cm to 4 cm, and within the thyroid. T3: The thyroid tumor is larger than 4 cm and within the thyroid, or any tumor that has

minimal extension outside of the thyroid. T4: The thyroid tumor has spread beyond the thyroid and involves other neighboring tissues

within the neck. All anaplastic thyroid cancers are considered T4 tumors. Tumors may be divided to T4a and T4b.

T4a: This refers to a thyroid tumor regardless of size, which extends beyond the capsule surrounding the thyroid gland invading the esophagus, trachea, and larynx .

T4b: The thyroid tumor invades blood vessels (the carotid artery or blood vessels in chest) and the covering around the vertebrae.

Note: All anaplastic thyroid cancers are considered T4 tumors, with T4a being surgically resectable and T4b being surgically unresectable.

Lymph Nodes (N) Stage NX: Nodes cannot be evaluated. N0: There are no cancer cells in the regional lymph nodes. N1: There are cancer cells in lymph nodes of the neck (cervical lymph nodes) or upper chest

(upper mediastinal lymph nodes). N1 nodes may be divided to N1a and N1b, depending on the distance from the thyroid.

Distant Metastasis (M) Stages MX: Presence of metastasis cannot be evaluated. M0: There is no distant metastasis. M1: There is distant metastasis, such as to distant lymph nodes, liver, lungs, and/or brain.

Overall Stage Staging of follicular and papillary thyroid cancers also takes into account on the

age, since the disease has a higher mortality rate in people over the age of 45.

Staging for Follicular or Papillary Thyroid Cancer Stage I: T1, N0, M0 Stage II: T2, N0, M0 Stage III:

T3, N0, M0 T1-3, N1a, M0

Stage IV: T4a, N0-N1a, M0 T1-4a, N1, M0 T4b, any N, M0 T1-4, any N, M1

Staging for Medullary Thyroid Cancer Stage I: T1, N0, M0 Stage II: T2, N0, M0 Stage III: T1-3, N1a, M0 Stage IV: Any T, any N, M1

Staging for Anaplastic Thyroid Cancer

- All anaplastic thyroid cancers are considered to be Stage IV because of the aggressive, fast-growing nature of the disease. Stage IV is made up of any T, any N, and any M.

InvestigationsBlood test:- Thyroid function test: TSH, T4, T3.- Calcitonin and serum calcium levels: if medullary

ca is suspected.

Ultrasound of thyroid gland.FNAC – for histological diagnosis.Thyroid scan (scintigraphy)- evaluate how

the cells in the nodule are functioning.Chest Xray- lung mets.Bone scan & radiographs – secondary

deposits.CT scan, MRI- staging.

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