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    Papillary and Follicular Thyroid Cancer: K. A. Ikram Hussain Final Year M.B.B.S

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    Ahsan Jamil
    Papillary and follicular thyroid cancers are the most common types of thyroid cancer. Papillary cancer accounts for 85% of cases and often spreads to lymph nodes in the neck. Follicular cancer spreads through the bloodstream and commonly metastasizes to flat bones. Both are usually treated with total thyroidectomy followed by radioactive iodine therapy and thyroid hormone suppression. Long term monitoring of serum thyroglobulin levels is important for detection of recurrence.

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    Papillary and Follicular Thyroid Cancer: K. A. Ikram Hussain Final Year M.B.B.S

    Uploaded by

    Ahsan Jamil
    59 views26 pages
    Papillary and follicular thyroid cancers are the most common types of thyroid cancer. Papillary cancer accounts for 85% of cases and often spreads to lymph nodes in the neck. Follicular cancer spreads through the bloodstream and commonly metastasizes to flat bones. Both are usually treated with total thyroidectomy followed by radioactive iodine therapy and thyroid hormone suppression. Long term monitoring of serum thyroglobulin levels is important for detection of recurrence.

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    Papillary and follicular thyroid cancers are the most common types of thyroid cancer. Papillary cancer accounts for 85% of cases and often spreads to lymph nodes in the neck. Follicular cancer spreads through the bloodstream and commonly metastasizes to flat bones. Both are usually treated with total thyroidectomy followed by radioactive iodine therapy and thyroid hormone suppression. Long term monitoring of serum thyroglobulin levels is important for detection of recurrence.

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    Download as pptx, pdf, or txt
    59 views26 pages

    Papillary and Follicular Thyroid Cancer: K. A. Ikram Hussain Final Year M.B.B.S

    Uploaded by

    Ahsan Jamil
    Papillary and follicular thyroid cancers are the most common types of thyroid cancer. Papillary cancer accounts for 85% of cases and often spreads to lymph nodes in the neck. Follicular cancer spreads through the bloodstream and commonly metastasizes to flat bones. Both are usually treated with total thyroidectomy followed by radioactive iodine therapy and thyroid hormone suppression. Long term monitoring of serum thyroglobulin levels is important for detection of recurrence.

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    Papillary and follicular

    thyroid cancer
    K. A. Ikram Hussain
    Final year M.B.B.S.
    Papillary thyroid cancer

    It is a relatively common well differentiated thyroid


    cancer
    Accounts for 85% of all thyroid cancers
    It is more common in females than males
    In more than 50% cases in spreads to lymphnodes of the
    neck
    Aetiology
    Most thyroid cancers are sporadic
    It can be a complication of Hashimoto’s thyroiditis
    Familial and genetic syndromes are associated with
    thyroid malignancies
    Cowden’s syndrome
    Gardner’s syndrome
    Carney’s syndrome
    Associated mutations: chromosomal translocations
    involving RET proto-oncogene
    Pathology

    It is made of colloid filled follicles with papillary projections.


    In some cases calcific lesions are found called psammoma bodies
    Characteristic pale empty nuclei called Orphan Annie eye nuclei
    are seen in some cases
    Can present as cystic lesions
    Can be multifocal involving both lobes
    Lymph nodes and Lungs are the usual sites of metastases
    Psammoma bodies
    Orphan Annie eye appearance
    Clinical presentation

    Young females of age group 20-40 years are commonly


    affected
    Principal sign is a firm non tender nodule in thyroid area
    with a hard consistency and ill defined borders
    Signs of hoarseness, tracheal and esophagal
    compression is present
    Very often lymph nodes in lower deep cervical region
    are involved and thyroid may or may not be palpable.
    Prognostic criteria
    Prognostic Risk Classification for Patients with
    Well-Differentiated Thyroid Cancer (AMES or
    AGES)
    Low Risk Hi2h Risk
    • Age <40 years >40 years
    • Sex Female Male
    • Extent No local extension, Capsular invasion, extra-
    intrathyroid, no caps thyroidal extension
    mvasion

    • Metastasis None Regional/distant


    • Size <2cm >4cm
    • Grade Well diff Poorly diff
    Investigations

    Thyroid profile
    Ultrasound of thyroid and central neck
    Fine needle aspiration cytology of the nodule
    Serum thyroglobulin
    TSH suppression test
    Immunohistochemisty findings

    Carcinoembryonic antigen (CEA) negative


    Calcitonin negative
    Thyroglobulin positive
    Keratin positive
    Treatment
    Total thyroidectomy
    After thyroidectomy, patients are given thyroid replacement therapy for
    approximately 4-6 weeks. Thyroid replacement is then discontinued, to induce a
    hypothyroid state and promote high serum thyroid-stimulating hormone (TSH)
    levels.
    Approximately 4-6 weeks after surgical thyroid removal, patients may have
    radioiodine therapy to detect and destroy any metastasis and residual tissue in
    the thyroid
    A diagnostic dose of radioiodine ( 131I I) is then given, and a whole-body
    scintiscan is performed to detect or
    any123
    tissue taking up radioiodine. If any normal
    thyroid remnant or metastatic disease is detected, a therapeutic dose of 13 I is
    administered to ablate the tissue. The patient is then placed back on thyroid
    1

    hormone replacement (levothyroxine) therapy.


    Therapy is administered until radioiodine uptake is completely absent
    Long term surveillance: Thyroglobulin
    Prognosis:95% adults survive over 10 years
    Complications due to surgery and radio
    iodine therapy
    Hypothyroidism
    Dysphagia
    Vocal cord paralysis
    Hypoparathyroidism
    Sialoadenitis because radioiodine is taken up by the salivary glands
    Pulmonary fibrosis in patients with large lung metastases
    Brain edema in patients with brain metastases (may be prevented
    by glucocorticoid therapy)
    Permanent sterility and transient oligospermia or menstrual
    irregularities
    A small increase in the risk for leukemias or breast and bladder
    carcinomas
    Factors affecting poor outcome

    Large primary tumor


    Age > 45 years
    Male sex
    Lymph nodal metastases
    Distant metastases
    Multifocal disease
    Extra-thyroidal extension
    Follicular carcinoma of thyroid

    It is a well differentiated tumor and 2n most common


    after papillary thyroid cancer d

    Incidence is 17% of cases


    Follicular adenomas are 20% malignant and 80% benign
    Aetiology

    Follicular carcinoma usually arises in a multinodular


    goitre especially in a cases of endemic goitre.
    It should be suspected when multinodular goitre starts
    growing rapidly
    Pathology

    Depending on invasion it is classified as


    Noninvasive
    Invasive refers to angio-invasion and capsular invasion
    Angioinvasion
    Clinical presentation
    It can present as multinodular or solitary nodular goitre.
    The diagnosis is confirmed after an ultrasound scan reveals features
    of malignancy like microcalcifications
    Metastasis in flat bones: when a patient with a thyroid swelling
    presents with metastasis in the bone in the form of bony swelling or
    pathological fractures, a diagnosis of follicular carcinoma can be
    considered.
    Common secondaries are flat bones like skull,ribs,sternum and
    vertebral column because flat bones retain red marrow for a longer
    time.
    Clinical features of a secondary are: they are rapidly
    growing,warm, vascular and pulsatile.
    Metastasis to bone
    Treatment
    Treatment of primary:
    Total thyroidectomy is always preferred

    Treatment of the metastasis:


    After total thyroidectomy a whole body scan is done to look for metastasis in
    the bone. A single secondary can be treated with oral radioiodine therapy
    followed by radiotherapy depending on the response to treatment
    Multiple secondaries are also treated with oral radio iodine.

    Postoperative thyroxine:
    Postoperative period patient should receive thyroxine 0.3mg/day to suppress
    TSH and to supplement thyroxine.
    Prognosis: 15% mortality in 10 years.
    Summary

    Characteristics Papillary carcinoma Follicular carcinoma


    Aetiology Sporadic/irradiation Endemic goitre
    Incidence 60% 17%
    Age (years) 20-40 30-50
    Diagnosis Thyroid swelling with Thyroid swelling with bony
    lymphnode metastasis metastasis
    Microscopy Orphan Annie eye nuclei, Angioinvasion,
    Psammoma bodies Capsular invasion
    Spread Lymphatic Blood
    Investigation FNAC Frozen section
    Treatment of primary Subtotal/total Subtotal/total
    thyroidectomy thyroidectomy
    Treatment of metastasis Functional neck dissection Radioiodine 131 iodine
    Hurthle cell carcinoma

    It is a variant of follicular cell carcinoma and more aggressive than follicular


    cell carcinoma
    These tumors are defined by presence of more than 75% of follicular cells
    with oncocytic features.
    Tumor contains sheets of eosinophilic cells packed with mitochondria
    They secrete thyroglobulin
    Even if hurthle cell adenoma is well encapsulated it is potentially malignant.
    It does not take up iodine 131. hence less likely to respond to radioablation.
    Mortality is high 20% in 10 years
    Criteria to diagnose

    Capsular or vascular invasion and distant metastasis


    Higher chance of spread to lymph nodes compared to follicular thyroid
    carcinoma
    Higher chances of spread to distant sites too
    TREATMENT:
    Total thyroidectomy is the treatment of choice.
    TSH suppression and follow-up is required regularly.
    Follow up

    Serum thyroglobulin- thyroid is the only organ which produces thyroglobulin.


    Levels greater than 1-2mg/ml in patients receiving replacement thyroxine
    therapy indicates presence of metastasis.
    So serum thyroglobulin response to injected recombinant TSH is assessed
    every year.
    Ultrasound or MRI scans of neck for localisation of residual or recurrent
    tumor

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