أيها ـ برٱستعينوا ءامنوا ٱلذيني ةوٱلصبٱلص إنلو برينمعٱلل ـ ٱلص

O you who believe! Seek help in patience and

As-Salât (the prayer). Truly! Allâh is with As-

Sâbirun (the patient.) (153)

Approach to thyroid CA

Approach to thyroid cancer● Papillary thyroid

cancer(PTC)

● Follicular thyroid cancer(FTC)

● Anaplastic thyroid cancer(ATC)

● Medullary thyroid cancer(MTC)

Epidemiology

● Incidence is 9 cases/100000 persons per year

● 90-95 % are PTC and FTC

● More common in female

Risk factors

● External head and neck radiation

● Family H/O of thyroid cancer/MEN -2

● Iodine deficiency

Clinical diagnosis● Thyroid nodule

● Incidentaloma

● Cervical lymphadenopathy

Obstructive symptoms● Dysphagia

● Hoarseness

● Dyspnea

Other symptoms● Metastasis to lung and

bone

● ATC presents as rapidly enlarging thyroid mass

MTC ● ACTH

● Calcitonin

D/D● Solitary thyroid nodule

● Multinodular goiter

● Cyst

● Thyroiditis

Diagnosis approach● FNAC

● Surgical pathology

Laboratory tests

● TSH

● Thyroglobulin-

● Calcitonin

USG neck● Accurate needle placement

● Potential metastatic lymph node

● Planning nodal dissection

● Identification of recurrent disease

Thyroid ultrasound of a nonpalpable recurrent papillary thyroid carcinoma

Radioactive whole body scan

● To identify recurrent/residual disease

● To identify bone and soft tissue metastasis

CT/MRI neck● Identify soft tissue extension

● Cervical lymph node metastasis

PET scan● To identify sites of distant

metastases

FNAC● Accurately detects PTC

● May not distinguish between benign and malignant follicular lesions

Papillary thyroid cancer: Findings on FNAC

Treatment modalities● Surgery

● L-thyroxin

● Radioiodine treatment

● Chemotherapy

● External beam radiation

Near total thyroidectomy● Age <15 >45

● History of radiation

● Known distant metastasis

● B/L disease

● Extrathyroid invasion

● Tumour size >4 cm

● Cervical lymph node metastases

● Family H/O of thyroid CA

Lobectomy

Stage I disease

Lobectomy

Advantages

• Low risk of hypoparathyroidism

• Low risk of hypothyroidism

• Low risk of injuring recurrent laryngeal nerve

Disadvantages

• Inability to monitor for residual/recurrent disease with thyroglobulin

TSH suppression therapy● Low risk of recurrence TSH should be

suppressed to low but detectable range

● High risk of recurrence or with known distant metastasis complete suppression is indicated

● Most patients with stage I PTC/primary tumors<1.5cm

Radioactive iodine● Post surgical ablation of residual

thyroid tissue

● Treatment of residual or recurrent thyroid cancer

Indication for radioactive iodine treatment● Larger papillary carcinomas

● FTC

● Evidence of metastases

External beam radiotherapy● Treatment of specific

metastatic lesion

ATC and other forms of thyroid cancer● Multimodal therapy may be

beneficial

● Radioactive iodine can be used if there is residual uptake

● Palliative chemotherapy can be used

MTC● Surgical excision

● External beam radiation can be used for local metastases in neck

● Palliative chemotherapy

Ongoing care● TSH suppression therapy

Monitoring for recurrence● Iodine 131 /whole body scan or

thyroid USG

● Measurement of serum Tg

Surveillance● Physical examination every 3-6

months for 2 years and then annually if disease free

● TSh and Tg at 6 and 12 months and then annually if disease free

● Radioiodine scan every year until 1 negative scan

MTC monitoring● Annual measurement of

calcitonin and CEA

● Periodic USG

● Octreotide scan to localise metastatic lesion

Take home message

● PTC and FTC are most common

● USG guided FNAC is diagnostic

● Surgery can be almost curative

● Needs long term F/U

References

Uptodate 2015

Harrisons principles of internal

medicine