THYROID TUMOURS

BY
DR(MRS) R.M NGOSHE
NILE UNIVERSITY OF NIGERIA
Thyroid neoplasm/tumours
• Thyroid neoplasm is a neoplasm or tumor of the thyroid. It can be a
benign tumor such as thyroid adenoma, or it can be a
malignant neoplasm (thyroid cancer), such as papillary, follicular,
medullary or anaplastic thyroid cancer.
• Most patients are 25 to 65 years of age when first diagnosed;
• women are more affected than men.
• Thyroid nodules are a major presentation of thyroid neoplasms.
Nodules are of particular concern when they are found in those under
the age of 20. The presentation of benign nodules at this age is less
likely, and thus the potential for malignancy is far greater.
Benign neoplasms
• Thyroid adenoma is a benign neoplasm of the thyroid.
Thyroid nodules are very common and around 80 percent of adults
will have at least one by the time they reach 70 years of age.
Approximately 90 to 95 percent of all nodules are found to be benign
Pathogenesis
• Most thyroid nodules are adenomatous. Most are multiple and that is
usually shown on ultrasound, scintigraphy and at surgery. The nodules
are usually non-functioning (cold at scintigraphy), although a few may
be hyper-functioning toxic adenomas (hot on scintigrams). They may
also be a hyper-functioning adenoma in a multinodular goitre.
• When solid, the nodules are poorly encapsulated, not well defined
and merge into the surrounding tissue. Cystic adenomatous nodules
are haemorrhagic, with irregular internal walls and particulate fluid
content. Intratumoral calcification is occasionally seen.
• Follicular adenomas are the most common and arise from follicular
epithelium. They are usually single, well-encapsulated lesions. On
ultrasound, adenomas may be hyperechoic or hypoechoic solid
nodules with a regular hypoechoic area surrounding ring called the
halo sign. Rarely, a parathyroid adenoma has an ectopic intrathyroid
location. Whether solitary adenomas transform into follicular
carcinoma is uncertain. Follicular adenomas are further classified
according to their cellular architecture and relative amounts of
cellularity and colloid into fetal (microfollicular), colloid
(macrofollicular), embryonal (atypical) and Hürthle (oxyphil) cell
types.
Epidemiology
• About 40% of the general adult population have a single nodule or
multiple ones. They are more common in women. Most nodules are
benign. In most series, 8-65% of patients with clinically normal thyroid
glands had one or more grossly visible nodules, whereas the
incidence of malignancy was 2-4%
Presentation
• Most patients with thyroid nodules are asymptomatic and most
nodules are found on clinical examination or self-palpation.
• A single dominant or solitary nodule is more likely to represent
carcinoma (malignancy incidence 2.7-30%) than a single nodule
within a multinodular gland (malignancy incidence 1.4 to 10%)..
• They may sometimes cause pain if spontaneous haemorrhage has
occurred into the nodule
• and (rarely) present with features of compression of the trachea.
Signs
• Ask the patient to drink some water and note the thyroid move as
they swallow.
• Note enlargement or asymmetry.
• Stand behind a seated patient and use the second and third fingers of
both hands to examine the gland as they swallow again.
• Note lumps, asymmetry, size and tenderness.
• Check for regional lymphadenopathy
• Examination findings that increase the concern for malignancy
include:
• Nodules larger than 4 cm in size.
• Firmness to palpation.
• Fixation of the nodule to adjacent tissues.
• Cervical lymphadenopathy.
• Vocal cord immobility
• Initial evaluation of a thyroid nodule consists of testing for
• Thyroid-stimulating hormone (TSH)
• Antithyroid peroxidase antibodies
• If thyroid-stimulating hormone (TSH) is suppressed, radioiodine
scanning is done. Nodules with increased radionuclide uptake (hot)
are seldom malignant. If thyroid function tests do not indicate
hyperthyroidism or Hashimoto thyroiditis, fine-needle aspiration
biopsy done under ultrasound guidance is done to distinguish benign
from malignant nodules. Early use of fine-needle aspiration biopsy is a
more economic approach than routine use of radioiodine scans.
• Ultrasonography is useful in determining the size of the nodule; fine-
needle aspiration biopsy is not routinely indicated for nodules <1 cm
on ultrasonography or for nodules that are entirely cystic.
Ultrasonography is rarely diagnostic of cancer, although cancer is
suggested by certain ultrasonographic or x-ray findings:
• Fine, stippled, psammomatous calcification (
papillary thyroid carcinoma )
• Hypoechogenicity, irregular borders, height greater than width on
transverse section, irregular macrocalcifications, or rarely dense,
homogeneous calcification (medullary thyroid carcinoma )
Investigations
• TFTs will show most patients to be euthyroid - refer those which are
abnormal for endocrine opinion.
• Ultrasound is useful to detect and characterise most thyroid nodules.
It can show cystic lesions 2 mm wide and solid lesions 3 mm wide.
Ultrasound examination is far more sensitive than clinical examination
and only 4-7% of nodules detected by ultrasound are clinically
palpable.
• Fine-needle aspiration (FNA) gives tissue for cytology. It is performed
under ultrasound guidance (for maximum accuracy). It is safe,
inexpensive and provides direct information. The false negative rate
varies with the experience of the person performing the procedure.
However, the false negative rate for cancer can vary from 1-6% (owing
to wrong diagnosis or sampling errors) even when the operator is
experienced and the sample is sufficient for diagnosis. These errors
occur more commonly in nodules smaller than 1 cm or larger than 4
cm
• Radionuclide isotope scanning looks at iodine uptake by the thyroid
and has a limited role in the diagnosis of thyroid cancer. The British
Thyroid Association (BTA) does not support its routine use - it is
'usually non-diagnostic of cancer’. The American Thyroid Association
recommends its use only in specific situations.
• CT scans and MRI scans are valuable to detect local and mediastinal
spread and regional lymph nodes.
Referral
• Patients with thyroid nodules who may be managed in primary care:
• Patients with a history of a nodule or goitre which has not changed for several
years and who have no other worrying features (ie adult patient, no history of
neck irradiation, no family history of thyroid cancer, no palpable cervical
lymphadenopathy, no stridor or voice change).
• Patients with a non-palpable asymptomatic nodule <1 cm in diameter
discovered incidentally on neck ultrasound/CT/MRI scanning without other
worrying features.
• Patients who should be referred non-urgently:
• Patients with nodules who have abnormal TFTs. These patients should be
referred to an endocrinologist because thyroid cancer is very rare in this
group.
• Patients with a history of sudden onset of pain in a thyroid lump (likely to
have bled into a benign thyroid cyst).
• Symptoms needing urgent referral (two-week rule):
• Unexplained hoarseness or voice changes associated with a goitre.
• Thyroid nodule in a child.
• Palpable cervical lymphadenopathy (usually deep cervical or supraclavicular
region).
• A rapidly enlarging, painless thyroid mass over a period of weeks (a rare
presentation of thyroid cancer and usually associated with anaplastic thyroid
cancer or thyroid lymphoma).
• Symptoms needing immediate (same day) referral:
• Stridor associated with a thyroid mass.
Fine needle aspiration cytology (FNAC)
• FNAC is now considered the most accurate test for the diagnosis
of thyroid nodules. It is performed in an outpatient setting. One to
two aspirations are carried out at different sites for each nodule.
Cytologic findings are satisfactory or diagnostic in approximately 85%
of specimens and non-diagnostic in the remainder.
• In experienced hands, FNAC is an excellent diagnostic technique,
• Non-palpable nodules (discovered incidentally during other imaging
procedures) have the same risk of malignancy as palpable nodules
of similar size. US-guided FNAC can be performed for non-palpable
nodules and for nodules that are technically difficult to aspirate using
palpation methods alone, such as predominantly cystic or posteriorly
located nodules. In patients with large nodules (>4cm), US-guided
FNAC directed at several areas within the nodule may reduce the risk
of a false –ve biopsy.
• Repeat FNAC after 3–6 months further reduces the proportion of false
–ves.
• It is impossible to differentiate between benign and malignant
follicular neoplasm using FNAC. Therefore, surgical excision of a
follicular neoplasm is always indicated).
Diagnostic features of FNAC
Feature Range (%) Mean value (%)

Accuracy 85–100 95

Specificity 72-100 92

Sensitivity 65-98 83

False –ve 1-11 5

Diagnostic categories from FNAC
Category Action
Thy 1 Non-diagnostic. Repeat sampling, using US if
Inadequate necessary
Thy 2 Non-neoplastic Two samples, 3–6 months apart,
showing benign appearances are
indicated to exclude neoplasia. If
rapid growth/pressure effects/high
risk, diagnostic lobectomy may be
indicated
Thy3 (i) Follicular lesions Lobectomy, with completion
thyroidectomy if malignant (up to
20% risk of malignancy)

(ii) Other suspicious findings Discussion at thyroid cancer MDT

Diagnostic categories from FNAC
Category Action

Thy 4 Suspicious of malignancy, e.g. papillary, medullary, or Surgical excision for differentiated
anaplastic carcinoma/lymphoma tumour (80% risk of malignancy)

Thy 5 Diagnosis of malignancy Surgical excision for differentiated

thyroid cancer (>95% risk of
malignancy). Radiotherapy/
chemotherapy for anaplastic
thyroid cancer,
lymphoma/metastases
Management
• Most benign thyroid nodules do not require any specific intervention,
unless there are local compressive symptoms from significant
enlargement, such as dysphagia, choking, shortness of breath,
hoarseness, or pain, in which case thyroidectomy should be
performed. Other indications for surgery in benign nodules include
the presence of a single toxic nodule, or a toxic multinodular goitre.
Aspiration is the treatment of choice for thyroid cysts but the
recurrence rate is high.
• After removing the thyroid, the patient must be supplied with a
replacement thyroid hormone for the rest of their life.
• Associated hyperthyroidism needs to be treated in the usual way.
Prognosis
• After exclusion of malignancy, prognosis for thyroid disease is
excellent.
Malignant neoplasms
• Thyroid cancers are mainly papillary, follicular, medullary or
anaplastic thyroid cancer.[
• women are more affected than men.
• Nearly 80 percent of thyroid cancer is papillary and about 15 percent
is follicular; both types grow slowly and can be cured if caught early.
• Medullary thyroid cancer makes up about 3 percent of this cancer. It
grows slowly and can be controlled if caught early.
• Anaplastic is the most deadly and makes up around 2 percent.
• This type grows quickly and is hard to control.
• Other thyroid malignancies include thyroid lymphoma, various types
of thyroid sarcoma, and other rare types of tumors
THYROID CANCER
• 90% present as thyroid nodules or occasionally as cervical
lymphadenopathy (5%) or with lungs, cerebral, hepatic or bone
metastases.
• Although thyroid nodules are common, clinically detectable
thyroid cancer is rare
• It accounts for <1% of all cancers and <0.5% of cancer deaths.
• Commonest in adults aged 40 -50yrs
• Rare in children and adolescents
• Women are affected more frequently than men
CLASSIFICATION OF THYROID
CANCER
1. Differentiated
- Papillary carcinomas
- Follicular carcinomas
2. Undifferentiated
- Anaplastic
3. Others
- Medullary thyroid cancers
- Lymphomas
- Sarcomas
4. Metastases
RISK FACTORS
• Exposure to ionizing radiation especially in infancy or childhood
• Family hx of thyroid cancer or Hereditory syndrome like MEN2
• Thyroiditis (Hashimoto’s)
• Female gender
• Age < 20 years
• Solitary nodule
• Increasing size ( particularly rapid growth or growth while
receiving thyroid suppression treatment)
TREATMENT OF THYROID
CANCERS
Surgery is the primary mode of therapy for most patients with
thyroid cancers.
1. For most patients with differentiated thyroid cancers e.g.
papillary or follicular cancers
a. Give as near total thyroidectomy as possible followed by post
operative radioiodine therapy (I131 ablation)
b. Chronic suppression of TSH to levels <0.10mU/L with
Levothyroxine is given to reduce recurrence and cancer
specific mortality rates (Differentiated thyroid cancers contain
TSH receptors and TSH stimulates their growth).
c. Follow up: This should be for life with:

- Annual clinical review with physical examination, biochemical

tests (serum TSH & Thyroglobulin) 131I uptake scan, ultrasound

scan of the neck, CT scan of the lungs or bone scan.

• Recurrent disease/distant metastases
• In the case of recurrence, treatment employs all methods used in primary and
adjuvant therapy.
• Surgery for local metastases.
• Radioactive iodine for those tumours with uptake.
• External radiotherapy is indicated in non-resectable tumours that do not take
up 131I.
• Bony and pulmonary metastases (usually osteolytic) may be treated with 131I.
• Unfortunately, only 50% of metastases concentrate 131I.
• External beam radiation is given to patients who have gross residual disease
after attempted surgery and radioiodine. Radiation therapy may be of value in
controlling local disease. If thyroidectomy is not possible, it is given alone for
palliation.
• Due to the low efficacy of traditional cytotoxic chemotherapies, consensus
guidelines now recommend consideration of clinical trials of novel agents
when patients require therapy for progressive, locally advanced, or metastatic
differentiated thyroid cancer.
• Tyrosine kinase inhibitors (TKIs) (e.g. sorafenib, sunitinib, pazopanib,
gefitinib) have been of interest for the treatment of advanced
differentiated thyroid cancer.
• Partial responses are reported in approximately 15–30% of patients.
• Complete responses are absent, and no study has evaluated survival.
• Side effects that are common to all of the VEGF-targeted TKIs include
• hypertension, renal toxicity, bleeding, myelosuppression, arterial
thromboembolism, cardiotoxicity, thyroid dysfunction (typically
hypothyroidism), cutaneous toxicity, including hand-foot skin
reaction, delayed wound healing, hepatotoxicity, and muscle wasting.
• Selumetinib, a selective mitogen-activated protein kinase (MAPK)
pathway antagonist, increases iodine uptake in a subgroup of patients
refractive to radioiodine.
• 2. For those with undifferentiated cancers (aplastic cancers)
total thyroidectomy with lymph node clearance is offered
followed by external beam irradiation and chemotherapy with
doxorubicine and cisplatin
3. For medullary thyroid cancers, total thyroidectomy and central
node dissection is the primary treatment modality
- Radioiodine and TSH suppression do not play a role
- External radiotherapy is of little benefit
- For patients with metastatic tumors >/= 2cm or growing by at
least 20% per year, or for patients with symptoms related to
multiple metastatic foci that cannot be alleviated with surgery or
external beam radiotherapy, systemic chemotherapy with a
tyrosine kinase inhibitor (TKI) vandetanib as part of clinical
trial is considered
-All patients should have life long follow up
4. For patients with thyroid sarcomas total thyroidectomy is
offered followed by radiation therapy. Sarcomas are
unresponsive to chemotherapy.
5. For patients with lymphoma, treatment with radiotherapy or
chemotherapy, if more extensive often produces good results.
Surgery is not a form of treatment unlike other forms of thyroid
cancers.
Thank You!