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Dr ramakrishna PG(ENT

)

Classification
 Two lobes anterolateral to the larynx and trachea.
 Isthmus  covered anteriorly by the infrahyoid (or strap muscles)

 Blood supply
 internal jugular lymph nodes (levels 3 and 4) as well as

para-tracheal and pretracheal nodes.

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 Table 335-9 Classification of Thyroid Neoplasms  Benign  Follicular epithelial cell adenomas Macrofollicular (colloid) Normofollicular (simple) Microfollicular (fetal) Trabecular (embryonal) Hürtle cell variant (oncocytic) Malignant  Approximate Prevalence. columnar cell variants Follicular carcinomas 5–10 Minimally invasive Widely invasive Hürthle cell carcinoma (oncocytic) Insular carcinoma Undifferentiated (anaplastic) carcinomas C cell (calcitonin-producing) 10 Medullary thyroid cancer Sporadic Familial MEN 2 Other malignancies Lymphomas 1–2 Sarcomas Metastases Others . %  Follicular epithelial cell Well-differentiated carcinomas Papillary carcinomas 80–90 Pure papillary Follicular variant Diffuse sclerosing variant Tall cell.

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 Surgical resection should be avoided as initial therapy because it may spread disease that is otherwise localized to the thyroid .Thyroid lymphoma     background of Hashimoto's thyroiditis. A rapidly expanding thyroid mass Diffuse large-cell lymphoma is the most common Biopsies reveal sheets of lymphoid cells that can be difficult to distinguish from small-cell lung cancer  highly sensitive to external radiation.

-ineffective.  The prognosis is poor. and most patients die within 6 months of diagnosis. the uptake of radioiodine is usually negligible.  Because of the undifferentiated state of these tumors.  anthracyclines and paclitaxel.  External beam radiation therapy can be attempted and continued if tumors are responsive .Anaplastic carcinoma  poorly differentiated and aggressive cancer. but it can be used therapeutically if there is residual uptake.

these tumors do not take up radioiodine. MEN 2B. In general.MTC          sporadic or familial accounts for about 5–10% of thyroid cancers. surgical. External radiation treatment and chemotherapy may provide palliation in patients with advanced disease . and familial MTC without other features of MEN . Elevated serum calcitonin provides a marker of residual or recurrent disease to test all patients with MTC for RET mutations. MTC is more aggressive in MEN 2B than in MEN 2A. and familial MTC is more aggressive than sporadic MTC. There are three familial forms of MTC: MEN 2A. as genetic counseling and testing of family members can be offered to those individuals who test positive for mutations.

Neoplastic Thyroid Disease  Thyroid Nodules  Goiter  Multinodular  Diffuse  Endemic  Thyroid Cancer  Well differentiated and poorly differentiated .

mainly in women  Most thyroid nodules are benign  Less than 5% are malignant  Only 8% to 10% of patients with thyroid nodules have thyroid cancer .Thyroid Nodular Disease  Thyroid gland nodules are common in the general population  Palpable nodules occur in approximately 5% of the US population.

resulting in thyrotoxicosis  Toxic MNG is more common in the elderly .Multinodular Goiter (MNG)  MNG is an enlarged thyroid gland containing multiple nodules  The thyroid gland becomes more nodular with increasing age  In MNG. nodules typically vary in size  Most MNGs are asymptomatic  MNG may be toxic or nontoxic  Toxic MNG occurs when multiple sites of autonomous nodule hyperfunction develop.

Endemic Goiter  serious health concern in parts of the world with iodine deficiency including mountainous areas or areas with high rainfall/flooding Kaplan. et al. E. May 99 . Thyroid Disease Manager “Surgery of the Thyroid Gland” Chapter 21.

 Incidence Thyroid Carcinoma  Thyroid carcinoma occurs relatively infrequently compared to the common occurrence of benign thyroid disease  Thyroid cancers account for only 0. and 2.74% of cancers among men.3% of cancers in women in the US  The annual rate has increased nearly 50% since 1973 to approximately 18 000 cases  Thyroid carcinomas (percentage of all US cases)       Papillary (80%) Follicular (about 10%) Medullary thyroid (5%-10%) Anaplastic carcinoma (1%-2%) Primary thyroid lymphomas (rare) Metastatic from other primary sites (rare) .

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Risk factors for Malignancy   Solitary thyroid nodules in patients >60 or <30     years of age Irradiation of the neck or face during infancy or teenage years Symptoms of pain or pressure (especially a change in voice) Male sex Large Nodules (>3 or 4 cm) Growth of nodule .

et al. Williams & Wilkins. Castro MR. Endocr Pract. 2003. 2003. Braverman LE. Werner & Ingbar’s The Thyroid: A Fundamental and Clinical Text. Philadelphia. Utiger RD. Pa: Lippincott. 8th ed.Evaluating Thyroid Nodules  TSH measurement  Ultrasound of the thyroid  Fine needle aspiration  Radioactive iodine imaging Kim N. 2000. Otolaryngol Clin North Am.36:17-33. et al. eds. .9:128-136.

Thyroid Ultrasonography .

Thyroid Ultrasonography  Excellent for characterizing size and other features of nodule  Useful in localizing nodule for FNA  Cannot distinguish between benign vs. malignant .

Thyroid Ultrasonography  Certain features may suggest greater risk of cancer:  Irregular or poorly defined borders of nodule  Lack of a "halo“  Hypo-echogenicity  Evidence of microcalcifications  Increased blood flow  Growth and interval change on serial ultrasounds .

RAI imaging

 Formerly had been used extensively in the initial work up of nodular thyroid disease

FNA is now considered the gold standard

RAI imaging
 The problem:
 Although “hot” nodules are usually never cancer,

only 5% of all nodules are hyperfunctioning
 The remaining 90-95% that are warm or cold could

be cancer and thus require FNA

RAI imaging
Circumstances where RAI imaging may be useful and indicated:
 Suppressed TSH (more likely to have a autonomously

functioning nodule)  Multiple nodules, none dominant  Other

Thyroid FNA  Now considered the most cost effective and sensitive/specific diagnostic test of thyroid nodules  The use of US has expanded the role of FNA in evaluating nodules and improved the validity of the results .

20% .Thyroid FNA Possible FNA Results  Benign: 70 -75 %  Malignant: Up to 5%  Suspicious: About 10%  Nondiagnostic: About 10 .

up to 10% of ND FNA will contain CA on resection . ALWAYS require surgical pathology for dx (up to 10 – 30% of these will be CA)  Non-diagnostic results: NEVER consider equivalent to benign.Thyroid FNA Limitations  False negatives: (< 5% of FNA) more likely in large (>4cm) or small (<1cm) nodules  Suspicious FNA (Follicular and Hurhtle cell neoplasm): cannot distinguish benign vs malignant of hypercellular nodules by FNA alone.

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but be cautious in large (>4cm) or small nodules (<1cm) .Depends on FNA results (see algorithm)  Benign: Management of Thyroid Nodules  False negatives rare. repeat US in 6 to 12 months to assess for interval change  Consider surgical resection if change or suspicious  Malignant:  Surgery and RAI ablation .

Suspicious FNA  About 10% of all FNA results  CANNOT distinguish benign vs malignant of hypercellular nodules (follicular/Hurthle cell) by FNA alone  ALWAYS require surgical resection for dx  Up to 10 – 30% of these will be malignant .

then this is a ND FNA rather than benign . if limited/no follicular epithelial cells noted.Non-diagnostic FNA  About 15% of all FNA results  NEVER consider equivalent to benign FNA  Up to 10% of ND FNA will contain CA on resection  Be very cautious of a pathology report: “consistent with benign colloid nodule”.

may get valid FNA on repeat up to 30 – 50% of the time  Follow-up US in 6 months. repeat FNA or resect then if any interval change  Surgical resection now.usually reserved only for patients with history suggestive of increased risk or patients who are very anxious and do not want to wait .Non-diagnostic FNA cont’d Three options:  Repeat FNA now.

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etc.1 – 0. it has begun to fall out of favor  Some endocrinologists still recommend LT4 suppression for a TSH between 0. arrhythmias in the elderly.) .5  However. studies demonstrate lack of efficacy or improved outcome  There is significant risks associated with long term iatrogenic hyperthyroidism (loss of bone density.LT4 Suppression of Nodules  Although once more commonly used.

LT4 Suppression of Goiter  Patients with a MNG especially could later develop an autonomously functioning nodule with subsequent thyrotoxicosis if not followed closely  Is useful for goiter suppression in patients with subclinical or overt hypothyroidism  May also have a role in goiter patients with TSHs in the upper limits of normal (>3.0) who also have + thyroid autoantibodies (controversial) .

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org. J Clin Endocrinol Metab. et al. et al.36:17-33. . Mazzaferri EL. Accessed December 10. Available at: http://www. Otolaryngol Clin North Am. Thyroid Disease Manager Web site. 2001.thyroidmanager. 2003. 2003.Typical Presentation of Thyroid Cancer  Painless lump  Normal thyroid function tests  Found on routine examination or by the patient  Slow growth or no growth over several months Kim N.86:1447-1463.

American Cancer Society Web site. Accessed December 10. . 2003. Thousands Cancer facts and figures.org/downloads/ STT/CAFF2003PWSecured. Available at: http://www.cancer.pdf.Newly Diagnosed Cancer in the United States Hodgkin Multiple Myeloma Thyroid Kidney Leukemia Lymphoma Colon Lung Prostate Breast Thyroid Cancer 22 000 new cases 1400 deaths 0 50 100 150 200 250 New Cases.

.Types of Thyroid Cancer  Papillary (80%-85%): develops from thyroid follicle cells in 1 or both lobes. American Cancer Society Web site. Available at: http://www. uncommon Detailed guide: thyroid cancer. can spread quickly.asp?dt=43.org/docroot/CRI/CRI_2_3x. sporadic and familial types  Anaplastic: develops from existing papillary or follicular cancers. grows slowly but can spread  Follicular (5%-10%): common in countries with insufficient iodine consumption. usually fatal  Lymphoma: develops from lymphocytes. Accessed December 10. lymph node metastases are uncommon  Medullary: develops from C-cells. 2003. aggressive.cancer.

Papillary Thyroid Cancer  Most common type  Makes up about 80% of all thyroid carcinomas in the United States  Females outnumber males 3:1  Highest incidence in women in midlife Detailed guide: thyroid cancer. Accessed December 10.cancer.org/docroot/CRI/CRI_2_3x. Available at: http://www. Accessed December 10.asp?dt=43.thyroidmanager. 2003. Available at: http://www. 2003.org. American Cancer Society Web site. . Thyroid Disease Manager Web site.

. 2000 Thyroid Disease Manager Web site. eds. Utiger RD.Papillary Thyroid Cancer Characteristics  Unencapsulated tumor nodule with ill-defined margins  Tumor typically firm and solid  May present as nodal enlargement  Commonly metastasizes to neck and mediastinal lymph nodes  40% to 60% in adults and 90% in children  <5% of patients have distant metastases at time of diagnosis  Lung is most common site Braverman LE. Pa: Lippincott.org. Available at: http://www. 8th ed. Williams & Wilkins.thyroidmanager. Philadelphia. Accessed December 10. Werner & Ingbar’s The Thyroid: A Fundamental and Clinical Text. 2003.

Thyroid Disease Manager Web site. Jones TV. Accessed December 10. .org. Williams & Wilkins. but can spread to the bones. Werner & Ingbar’s The Thyroid: A Fundamental and Clinical Text. eds. et al. 2003.. Beers MH. usually solitary and encapsulated  Usually stays in the thyroid gland. 2003. and central nervous system  Usually does not spread to the lymph nodes Follicular Thyroid Cancer Thyroid gland disorders. Fletcher AJ. 2000. Whitehouse Station.thyroidmanager. Pa: Lippincott. Utiger RD. Available at: http://www. 8th ed.Follicular Thyroid Cancer  Second most common type of thyroid cancer  Solid invasive tumors. eds. NJ: Merck & Co. Braverman LE. lungs. Merck Manual of Medical Information – Home Edition. Philadelphia. Inc. 2nd ed..

Neoplastic Thyroid Disease  Thyroid Nodules  Goiter  Multinodular  Diffuse  Endemic  Thyroid Cancer  Well differentiated and poorly differentiated .

mainly in women  Most thyroid nodules are benign  Less than 5% are malignant  Only 8% to 10% of patients with thyroid nodules have thyroid cancer .Thyroid Nodular Disease  Thyroid gland nodules are common in the general population  Palpable nodules occur in approximately 5% of the US population.

resulting in thyrotoxicosis  Toxic MNG is more common in the elderly .Multinodular Goiter (MNG)  MNG is an enlarged thyroid gland containing multiple nodules  The thyroid gland becomes more nodular with increasing age  In MNG. nodules typically vary in size  Most MNGs are asymptomatic  MNG may be toxic or nontoxic  Toxic MNG occurs when multiple sites of autonomous nodule hyperfunction develop.

E. et al. May 99 . Thyroid Disease Manager “Surgery of the Thyroid Gland” Chapter 21.Endemic Goiter  No longer a problem in the US and the developed world  Still a serious health concern in parts of the world with iodine deficiency including mountainous areas or areas with high rainfall/flooding Kaplan.

74% of cancers among men.3% of cancers in women in the US  The annual rate has increased nearly 50% since 1973 to approximately 18 000 cases  Thyroid carcinomas (percentage of all US cases)       Papillary (80%) Follicular (about 10%) Medullary thyroid (5%-10%) Anaplastic carcinoma (1%-2%) Primary thyroid lymphomas (rare) Metastatic from other primary sites (rare) . Incidence Thyroid Carcinoma  Thyroid carcinoma occurs relatively infrequently compared to the common occurrence of benign thyroid disease  Thyroid cancers account for only 0. and 2.

.

Risk factors for Malignancy   Solitary thyroid nodules in patients >60 or <30     years of age Irradiation of the neck or face during infancy or teenage years Symptoms of pain or pressure (especially a change in voice) Male sex Large Nodules (>3 or 4 cm) Growth of nodule .

Pa: Lippincott.36:17-33. Werner & Ingbar’s The Thyroid: A Fundamental and Clinical Text. eds. Castro MR. Utiger RD. Williams & Wilkins. Endocr Pract. et al. Braverman LE. 2000. 8th ed. .9:128-136. Otolaryngol Clin North Am. Philadelphia. 2003.Evaluating Thyroid Nodules  TSH measurement  Ultrasound of the thyroid  Fine needle aspiration  Radioactive iodine imaging Kim N. et al. 2003.

Thyroid Ultrasonography .

Thyroid Ultrasonography  Excellent for characterizing size and other features of nodule  Useful in localizing nodule for FNA  Cannot distinguish between benign vs. malignant .

Thyroid Ultrasonography  Certain features may suggest greater risk of cancer:  Irregular or poorly defined borders of nodule  Lack of a "halo“  Hypo-echogenicity  Evidence of microcalcifications  Increased blood flow  Growth and interval change on serial ultrasounds .

RAI imaging  Formerly had been used extensively in the initial work up of nodular thyroid disease FNA is now considered the gold standard .

RAI imaging  The problem:  Although “hot” nodules are usually never cancer. only 5% of all nodules are hyperfunctioning  The remaining 90-95% that are warm or cold could be cancer and thus require FNA .

RAI imaging Circumstances where RAI imaging may be useful and indicated:  Suppressed TSH (more likely to have a autonomously functioning nodule)  Multiple nodules. none dominant  Other .

Thyroid FNA  Now considered the most cost effective and sensitive/specific diagnostic test of thyroid nodules  The use of US has expanded the role of FNA in evaluating nodules and improved the validity of the results .

20% .Thyroid FNA Possible FNA Results  Benign: 70 -75 %  Malignant: Up to 5%  Suspicious: About 10%  Nondiagnostic: About 10 .

up to 10% of ND FNA will contain CA on resection . ALWAYS require surgical pathology for dx (up to 10 – 30% of these will be CA)  Non-diagnostic results: NEVER consider equivalent to benign.Thyroid FNA Limitations  False negatives: (< 5% of FNA) more likely in large (>4cm) or small (<1cm) nodules  Suspicious FNA (Follicular and Hurhtle cell neoplasm): cannot distinguish benign vs malignant of hypercellular nodules by FNA alone.

.

repeat US in 6 to 12 months to assess for interval change  Consider surgical resection if change or suspicious  Malignant:  Surgery and RAI ablation .Depends on FNA results (see algorithm)  Benign: Management of Thyroid Nodules  False negatives rare. but be cautious in large (>4cm) or small nodules (<1cm) .

Suspicious FNA  About 10% of all FNA results  CANNOT distinguish benign vs malignant of hypercellular nodules (follicular/Hurthle cell) by FNA alone  ALWAYS require surgical resection for dx  Up to 10 – 30% of these will be malignant .

if limited/no follicular epithelial cells noted.Non-diagnostic FNA  About 15% of all FNA results  NEVER consider equivalent to benign FNA  Up to 10% of ND FNA will contain CA on resection  Be very cautious of a pathology report: “consistent with benign colloid nodule”. then this is a ND FNA rather than benign .

repeat FNA or resect then if any interval change  Surgical resection now.usually reserved only for patients with history suggestive of increased risk or patients who are very anxious and do not want to wait .may get valid FNA on repeat up to 30 – 50% of the time  Follow-up US in 6 months.Non-diagnostic FNA cont’d Three options:  Repeat FNA now.

.

) . arrhythmias in the elderly.5  However.LT4 Suppression of Nodules  Although once more commonly used.1 – 0. etc. studies demonstrate lack of efficacy or improved outcome  There is significant risks associated with long term iatrogenic hyperthyroidism (loss of bone density. it has begun to fall out of favor  Some endocrinologists still recommend LT4 suppression for a TSH between 0.

LT4 Suppression of Goiter  Patients with a MNG especially could later develop an autonomously functioning nodule with subsequent thyrotoxicosis if not followed closely  Is useful for goiter suppression in patients with subclinical or overt hypothyroidism  May also have a role in goiter patients with TSHs in the upper limits of normal (>3.0) who also have + thyroid autoantibodies (controversial) .

.

Typical Presentation of Thyroid Cancer  Painless lump  Normal thyroid function tests  Found on routine examination or by the patient  Slow growth or no growth over several months Kim N. Thyroid Disease Manager Web site. et al. Accessed December 10.thyroidmanager.org. 2003. Otolaryngol Clin North Am.36:17-33. 2001. .86:1447-1463. Mazzaferri EL. 2003. et al. J Clin Endocrinol Metab. Available at: http://www.

cancer. 2003.Newly Diagnosed Cancer in the United States Hodgkin Multiple Myeloma Thyroid Kidney Leukemia Lymphoma Colon Lung Prostate Breast Thyroid Cancer 22 000 new cases 1400 deaths 0 50 100 150 200 250 New Cases.org/downloads/ STT/CAFF2003PWSecured. Thousands Cancer facts and figures.pdf. Available at: http://www. American Cancer Society Web site. . Accessed December 10.

. can spread quickly. usually fatal  Lymphoma: develops from lymphocytes. 2003.asp?dt=43. grows slowly but can spread  Follicular (5%-10%): common in countries with insufficient iodine consumption. sporadic and familial types  Anaplastic: develops from existing papillary or follicular cancers. American Cancer Society Web site.cancer. Available at: http://www. Accessed December 10. lymph node metastases are uncommon  Medullary: develops from C-cells. uncommon Detailed guide: thyroid cancer.Types of Thyroid Cancer  Papillary (80%-85%): develops from thyroid follicle cells in 1 or both lobes. aggressive.org/docroot/CRI/CRI_2_3x.

2003.org. Accessed December 10. Accessed December 10. Available at: http://www. Available at: http://www.org/docroot/CRI/CRI_2_3x. .thyroidmanager.cancer. 2003.Papillary Thyroid Cancer  Most common type  Makes up about 80% of all thyroid carcinomas in the United States  Females outnumber males 3:1  Highest incidence in women in midlife Detailed guide: thyroid cancer. Thyroid Disease Manager Web site.asp?dt=43. American Cancer Society Web site.

Available at: http://www. Philadelphia. . Accessed December 10. eds. 2003. Utiger RD.thyroidmanager. Williams & Wilkins. Pa: Lippincott. Werner & Ingbar’s The Thyroid: A Fundamental and Clinical Text.Papillary Thyroid Cancer Characteristics  Unencapsulated tumor nodule with ill-defined margins  Tumor typically firm and solid  May present as nodal enlargement  Commonly metastasizes to neck and mediastinal lymph nodes  40% to 60% in adults and 90% in children  <5% of patients have distant metastases at time of diagnosis  Lung is most common site Braverman LE. 2000 Thyroid Disease Manager Web site. 8th ed.org.

Jones TV.. Williams & Wilkins. Fletcher AJ. 8th ed.Follicular Thyroid Cancer  Second most common type of thyroid cancer  Solid invasive tumors. Beers MH.org. Philadelphia. eds. Inc. 2003.thyroidmanager. and central nervous system  Usually does not spread to the lymph nodes Follicular Thyroid Cancer Thyroid gland disorders. lungs. Available at: http://www. 2003. Braverman LE. Pa: Lippincott. 2000. eds. Merck Manual of Medical Information – Home Edition. but can spread to the bones. Accessed December 10.. Whitehouse Station. Utiger RD. et al. NJ: Merck & Co. Werner & Ingbar’s The Thyroid: A Fundamental and Clinical Text. . 2nd ed. usually solitary and encapsulated  Usually stays in the thyroid gland. Thyroid Disease Manager Web site.