SOEPEL

Abdul Waris Khan Dept: Internal medicine

SOEPEL

• Subjective: A 32 years old male previously known case of goitre presents with history of dysphagia, hoarseness of voice, painful front part of the neck, trouble breathing for the past few weeks, but this time symptoms have worsened even more.

• Objective: History taking & Physical exam

• Evaluation: dysphagia, , Goitre, Thyroid CA

• Plan: ultrasound, FNAC

• Treatment: Thyroidectomy

• Learning goals: Thyroid malignancy

Epidemiology

These tumours are responsible for 400 deaths annually in the UK and an annual incidence of 30 000 cases in the USA.

Over 75% occur in women.

In 90% of cases they present as thyroid nodules, but occasionally with cervical lymphadenopathy (about 5%), or with lung, cerebral, hepatic or bone metastases.

• Carcinomas derived from thyroid epithelium may be papillary or follicular (differentiated).

• Anaplastic (undifferentiated).

• medullary carcinomas (about 5% of all thyroid cancers) arise from the calcitonin-producing C cells.

• Papillary thyroid cancer (75% to 85% of cases) – often in young females – excellent prognosis.

• Follicular thyroid cancer (10% to 20% of cases)

• Anaplastic thyroid cancer (less than 5% of cases) is not responsive to treatment and can cause pressure symptoms.

• Medullary thyroid cancer (5% to 8% of cases).

• 90% of these tumors secrete thyroglobulin, which can therefore act as a tumour marker.

Signs & Symptoms A lump in the neck, sometimes growing quickly

Swelling in the neck

Pain in the front of the neck, sometimes going up to the ears

Hoarseness or other voice changes that do not go away

Trouble swallowing

Trouble breathing

A constant cough that is not due to a cold

Diagnosis • After a thyroid nodule is found during a physical examination, refer to

endocrinologist.

• Most commonly an ultrasound is performed to confirm the presence of a nodule, and assess the status of the whole gland.

• Measurement of TSH and anti-thyroid antibodies will help decide if there is a functional thyroid disease such as Hashimoto's thyroiditis present, a known cause of a benign nodular goiter.

• Measurement of calcitonin is necessary to exclude the presence of medullary thyroid cancer.

• Finally, to achieve a definitive diagnosis before deciding on treatment, a FNAC test is usually performed.

Treatment

• Papillary and follicular carcinomas:– Primary treatment is surgical. Total or near total

thyroidectomy for local disease.

– radioactive iodine (RAI) ablation of residual thyroid tissue post-operatively for most patients with differentiated thyroid cancer.

– When recurrence does occur, local invasion and lymph node involvement is most common, and lungs and bone are the most common sites of distant metastases.

• Patients are treated with suppressive doses of levothyroxine (sufficient to suppress TSH levels below the normal range) in order to minimize risk of recurrence.

• Patient progress is monitored using serum thyroglobulin levels as a tumour marker.

• The measurement of thyroglobulin is most sensitive when TSH is high but this requires the withdrawal of levothyroxine therapy.

• Recombinant TSH (thyrotropin alfa, rhTSH) 900 μg (2 doses over 48 hours) is used to stimulate thyroglobulin without stopping thyroxine therapy.

• Detectable thyroglobulin suggests recurrence, in which case whole body 131I scanning is required.

• The prognosis is extremely good when these types of tumour are excised while confined to the thyroid gland.

• Accepted markers of high risk include greater age (> 40 years), larger primary tumour size (> 4 cm) and macroscopic invasion of capsule and surrounding tissues.

• Anaplastic carcinomas and lymphoma– These do not respond to radioactive iodine, and

external radiotherapy produces only a brief respite.

• Medullary carcinoma– Total thyroidectomy and wide lymph node

clearance is usually indicated in MTC.

– Local invasion or metastasis is frequent, and the tumour responds poorly to treatment, although progression is often slow.

References

• Kumar & Clark internal medicine 7th edition• Wikipedia • Cancer.org