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THYROID
TUMOURS

Dr Khalid Azim
Dept. of Surgery
Islam Medical College
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 Classification of Thyroid Neoplasms.
 Benign - Follicular adenoma
– differentiated
 Malignant - Primary - Follicular Ca
- Papillary Ca
– undifferentiated
- Anaplastic Ca

 Parafollicular cells
- Medullary Ca
 Lymphoid cells
-
- Lymphoma

 Metastatic Ca
 - Secondary
 Local infiltration
 Benign tumours
 Follicular adenomas present as clinically
solitary nodules.
 The distinction between a follicular
carcinoma and an adenoma can only be made
by histological examination;
 In the adenoma there is no invasion of the
capsule or of pericapsular blood vessels.
 Treatment is, therefore, by wide excision,
i.e. lobectomy.
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 Malignant tumours
 The vast majority of primary malignancies are
carcinomas derived from the follicular cells

Histologically
 Classified as differentiated and undifferentiated:
- and the differentiated carcinomas are
subdivided into follicular and papillary.
 Lymphoma and medullary cancers make up
the remainder of primary malignancies.
 Metastases to the thyroid

 Most commonly occur from kidney and breast,

are rare.

 Direct invasion by upper aero digestive

squamous cancer is also a rare but lethal event.

 Lymph node and blood-borne metastases to

bone and lung occur and may be the mode of
presentation
 Aetiology of malignant thyroid tumors

 The single most important aetiological factor in

differentiated thyroid carcinoma, particularly
papillary, is irradiation of the thyroid under five
years of age.
 The incidence of follicular carcinoma is high in

endemic goitrous areas, possibly due to TSH

stimulation.
 Malignant lymphomas sometimes develop in

autoimmune thyroiditis.
lymphocytic infiltration in the autoimmune process
may be an aetiological factor.
 Clinical features of thyroid cancers

 Incidence is about 3.7 per

100 000 of the population
and the sex ratio is three
females to one male.
 The most common
presenting symptom is a
thyroid swelling.
 Enlarged cervical lymph
nodes may be the
presentation of papillary
carcinoma.
 Clinical features of thyroid cancers

 Recurrent laryngeal nerve

paralysis is very
suggestive of locally
advanced disease.
 Anaplastic growths are
usually hard, irregular
and infiltrating.
 A differentiated
carcinoma may be
suspiciously firm and
irregular
 Diagnosis of thyroid neoplasms
 Diagnosis is obvious on
clinical examination in
most cases of anaplastic
carcinoma.

 Failure to take up
radioiodine is
characteristic of almost
all thyroid carcinomas.
 Diagnosis of thyroid neoplasms

 FNAC - . Incisional
biopsy may cause
seeding of cells and
local recurrence.
 When a preoperative
diagnosis is made,
imaging with either
Ultrasound or MRI is
required.
 CT scan.
 Tumour–node–metastasis (TNM)
staging of thyroid cancer.

 Tumour

 TX Primary cannot be assessed

 T0 No evidence of primary
 T1 Tumour _2 cm
 T1a: _1 cm
 T1b: >1 cm _2 cm
 T2 Limited to thyroid, >2 cm but _4 cm
 T3 Limited to thyroid, >4 cm or any tumour with minimal
 extra thyroid extension
 T4 Any size with extensive extra thyroidal extension
 T4a: moderately advanced
 T4b: very advanced
 TNM
 Nodes

 NX Cannot be assessed
 N0 No regional node metastases
 N1 Regional node metastases
 N1a: level VI
 N1b: any/all other levels

 Metastases

 MX Cannot be assessed
 M0 No metastases
 M1 Metastases present
 Staging
 I - Any T, any N, M0 T1, N0, M0

 II - Any T, any N, T2, N0, M0

 III - T3 or T1, T2 and N1a M0

 IVA -T4 or T1,T2,T3, T4a and N1b M0

 IVB - T4b Any N M0

 IVC - Any T Any N M1

Staging of Thyroid Carcinoma
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 Papillary carcinoma

 Most papillary tumours contain a mixture of

papillary and colloid-filled follicles
 Histologically the tumour shows papillary
projections and characteristic pale, empty
nuclei (Orphan Annie-eyed nuclei).
 Papillary carcinomas are very seldom
encapsulated.
 Multiple foci may occur in the same lobe as the
primary tumour or, less commonly, in both
lobes.
 Papillary carcinoma
 Spread to the lymph nodes is common.
 Blood-borne metastases are unusual unless the tumour is
extrathyroidal.
 Extrathyroidal indicates that the primary tumour has
infiltrated through the capsule of the thyroid gland.

 Foci of papillary carcinoma may also be discovered in thyroid

tissue resected for other reasons, for example Graves’ disease.
 The term ‘occult’ was formally applied to all papillary
carcinomas less than 1.5 cm in diameter but the preferred
terminology now is microcarcinoma for cancers less than 1
cm.
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 Follicular carcinoma

 These appear to be macroscopically encapsulated

but, microscopically, there is invasion of the capsule
and of the vascular spaces.
 Multiple foci are seldom seen and lymph node
involvement is much less common than in papillary
carcinoma.
 Blood-borne metastases are more common and the
eventual mortality rate is twice that of papillary
cancer.
 Prognosis in differentiated thyroid carcinoma
( Follicular & Papillary )

 Excellent in most cancers.

 Influenced by histological type.
 Dependent on age at diagnosis, size of the
tumour, metastatic disease and the presence of
either extrathyroidal spread.
 Approximately 80 % of patients are at a low risk
of dying of thyroid cancer but suboptimal
treatment, i.e. failure to eradicate all macroscopic
disease at the first operation, may lead to
increased recurrence and avoidable deaths.
 Surgical treatment

 Total thyroidectomy is recommended for tumours greater than 2

cm and those with nodal involvement or metastases and lobectomy
for the remainder.

 Patients with large, locally aggressive or metastatic differentiated

thyroid cancer (DTC) require total thyroidectomy, with excision of
adjacent involved structures if necessary, and appropriate nodal
surgery followed by radioiodine ablation with long-term TSH
suppression.

 Total thyroidectomy facilitates the use of radioiodine for

postoperative scanning to detect and subsequently ablate
metastases
 Additional measures

 Thyroxine
 It is standard practice to prescribe thyroxine in a dose of 0.1–
0.2 mg daily, to suppress endogenous TSH production for all
patients after operation for differentiated thyroid carcinoma
on the basis that most tumours are TSH dependent.
 Radioiodine
 If metastases take up radioiodine, they may be detected by
scanning and treated with large doses of radioiodine.
 Radioiodine is indicated in patients with unresectable
disease, local recurrence or metastatic disease, high-risk
patients, and in those with a rising serum thyroglobulin
level
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 Thyroglobulin
 The measurement of serum thyroglobulin is
invaluable in the follow up and detection of
metastatic disease in patients who have undergone
surgery for differentiated thyroid cancer.

 This measurement reduces the need for serial

radioactive iodine scanning but, when a rise
occurs, imaging with neck ultrasound is
appropriate.
 Careful clinical palpation of the neck will be the
first indication of local recurrence.
 Undifferentiated (anaplastic) carcinoma

 Occurs mainly in elderly women

 Local infiltration is an early feature of these
tumours with spread by lymphatics and by the
bloodstream.
 They are extremely lethal tumours and survival
is calculated in months.
 Complete resection should be done.
 Radiotherapy should be given in all cases and
may provide a worthwhile period of palliation.
 Medullary carcinoma

 These are tumours of the parafollicular (C cells)

 High levels of serum calcitonin and carcinoembryonic
antigen are produced by many medullary tumours.
 Calcitonin levels fall after resection and rise again with
recurrence making it a valuable tumour marker in the follow
up of patients with this disease.
 10–20 per cent of all cases are familial.

 Medullary carcinoma may occur in combination with

adrenal phaeochromocytoma and hyperparathyroidism in
the syndrome known as multiple endocrine neoplasia (MEN)
type 2A (MEN-2A).
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 When it is associated with mucosal neuromas

involving the lips, tongue and inner aspect of
the eyelids, with a Marfanoid habitus, the syndrome
. is referred to as MEN type 2B.
 Involvement of lymph nodes occurs in 50–60% &

blood-borne metastases are common.

 Treatment
 Treatment is by total thyroidectomy and either
prophylactic or therapeutic resection of central and
bilateral cervical lymph nodes.
 Malignant lymphoma

 The diagnosis may be made or suspected on FNAC,

but core needle or open biopsy is usually necessary.

 The prognosis is good if there is no involvement of

cervical lymph nodes.

 Rarely, the tumour is part of widespread malignant

lymphoma disease, and the prognosis in these cases
is worse.
 .Treatment Modalities
 Surgery
Road
 L- Thyroxine to
Recovery
 Radioactive Iodine treatment

 Chemotherapy

 External beam radiation

 Summary

 Thyroid cancer
 Know the different pathological types and their
behavior
 _ Use appropriate investigations
 _ Be aware of the controversies in treatment
 _ Know about risk stratification and the possible
effect on treatment
 _ Describe total thyroidectomy and node dissection
 _ Know how to manage the complications
 _ Understand the role of postoperative radioiodine
therapy
 Treatment - Summary.
Papillary & Follicular Thyroid Cancer
 - Generally excellent prognosis
 - Risk for recurrence for as long as 30 yrs.
Initial management
 - Surgery & Radioactive Iodine
 - Thyroxine suppressive therapy
Follow up
 - Physical examination
 - Radioactive Iodine scans
 - Serum Tg
 - TSH
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