Thyroid - Malignant tumors
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Transcript of Thyroid - Malignant tumors
Thyroid TumoursThyroid Tumours
Dr.B.Selvaraj MS;Mch;FICS:MMMC; Malaysia
Thyroid TumoursThyroid Tumours
Classification Classification EtiologyEtiology PathophysiologyPathophysiology HistologyHistology PresentationPresentation Clinical Diagnosis of CaClinical Diagnosis of Ca TreatmentTreatment
Classification Classification
AdenomaAdenoma CarcinomaCarcinoma Primary Primary
A - A - FOllicilar epithelium diffrentiatedFOllicilar epithelium diffrentiated – – 1. Papillary 2.Follicular 1. Papillary 2.Follicular
B - B - FOllicilar epithelium Undiffrentiated-FOllicilar epithelium Undiffrentiated- AnaplasticAnaplastic
C - C - Parafollicular cellsParafollicular cells - - MedullaryMedullary
D – Lymphoid cell - LymphomaD – Lymphoid cell - Lymphoma Secondary- Melanoma, Ca breast, Renal CaSecondary- Melanoma, Ca breast, Renal Ca
EtiologyEtiology
Female gender Female gender History of radiation administered in infancy and History of radiation administered in infancy and
childhood , [ in ~ 9 %] childhood , [ in ~ 9 %] Avg. Latent Period ~ 10 yrs. Avg. Latent Period ~ 10 yrs. Papillary CaPapillary Ca
Excessive Iodine Consumption Papillary CaExcessive Iodine Consumption Papillary Ca History of goiter History of goiter Anaplastic / Follicular CaAnaplastic / Follicular Ca Frankshift Mutation of RET gene Frankshift Mutation of RET gene Papillary CaPapillary Ca Point Mutation of RET gene Medullary CaMedullary Ca P53 gene mutation Anaplastic CaP53 gene mutation Anaplastic Ca Loss of Gene at 11q Loss of Gene at 11q Follicular Ca Follicular Ca
AdenomaAdenoma
Benign lesion derived from Follicular Epi.Benign lesion derived from Follicular Epi. Usually single,well encapsulated Usually single,well encapsulated Discrete lesions with glandular / acinar Discrete lesions with glandular / acinar
Follicular pattern.Follicular pattern. Papillary change is not typical but if + Papillary change is not typical but if +
suggests Papillary Casuggests Papillary Ca
Papillary CaPapillary Ca Most common type of Thyroid ca – 75 to Most common type of Thyroid ca – 75 to
80%.80%. Female : Male :: 2 : 1 .Female : Male :: 2 : 1 . Mean age at Mean age at
presentation – 35 yrs.presentation – 35 yrs. More common in More common in
persons exposed persons exposed to radiation.to radiation.
Macroscopic – Macroscopic – Hard, whitish, Hard, whitish, calcified,Uncapsulatedcalcified,Uncapsulated
Papillary Thyroid tumourPapillary Thyroid tumour
Macroscopic classificationMacroscopic classification
IntrathyroidalIntrathyroidal ExtrathyroidalExtrathyroidal
< 1 cm with noInvasion throughThyroid capsule
> 1 cm with noInvasion throughThyroid capsule
Locally advancedwithInvasion
throughThyroid capsule
Minimal orMinimal orOccultOccult
Papillary Thyroid tumourPapillary Thyroid tumour
Microscopic featuresMicroscopic features – – 1. Cuboidal cells with abundant cytoplasm, 1. Cuboidal cells with abundant cytoplasm, 2. Intranuclear cytoplasmic inclusions 2. Intranuclear cytoplasmic inclusions 3. ‘ORPHAN ANNIE CELL’ . 3. ‘ORPHAN ANNIE CELL’ . 4. Fibrovascular stroma with 4. Fibrovascular stroma with calcium deposits ‘PSAMOMMA calcium deposits ‘PSAMOMMA BODIES’. BODIES’.
Lymphatic spread – Intrathyroidal ~90% Lymphatic spread – Intrathyroidal ~90% and to Paratracheal and cervical LN ~50% and to Paratracheal and cervical LN ~50%
HistologyHistology
Sheath of normal thyroid epithelium
Papillary thyroid carcinomaPapillary thyroid carcinoma
Histologic preparation showing typical papillary configurations.(Hematoxylin-eosin; x50.)
Papillary thyroid carcinoma Papillary thyroid carcinoma
Follicular cells with large irregular nuclei,
nuclear grooving, and pale chromatin. (Papanicolaou; x400.)
Papillary thyroid carcinoma-7PsPapillary thyroid carcinoma-7Ps
Follicular cancer
Female : Male :: 3 : 1 .Female : Male :: 3 : 1 . Accounts for 15 to 20 % of all Thyroid CaAccounts for 15 to 20 % of all Thyroid Ca Mean age at presentation – 50 yrs.Mean age at presentation – 50 yrs. More frequent in More frequent in
IODINE DEFICIENT AREAS.IODINE DEFICIENT AREAS. History of long standing History of long standing
goitre .goitre . PATHOLOGY -PATHOLOGY - Usually ENCAPSULATED Usually ENCAPSULATED
& SOLITARY. & SOLITARY. Spreads usually By Blood ,Most commonly to Spreads usually By Blood ,Most commonly to
Lungs, Brain & Bone.Lungs, Brain & Bone. Lymph node metastases in ~ 10 % cases. Lymph node metastases in ~ 10 % cases.
Follicular cancer
MINIMALLY INVASIVEMINIMALLY INVASIVEInvasionInvasion
into but not throughinto but not through the Capsule the Capsule
at one or two sites.at one or two sites.
FRANKLY INVASIVEFRANKLY INVASIVEEvidence of VASCULAR Evidence of VASCULAR
INVASIONINVASIONOROR
Invasion through thyroid Invasion through thyroid capsule.capsule.
Mitoses.
Follicular Carcinoma showing mitoses.
Follicular cancer
Follicular thyroid carcinoma-4FsFollicular thyroid carcinoma-4Fs
Hurthle Cell TumourHurthle Cell Tumour
Type of FOLLICULAR CELL Ca.Type of FOLLICULAR CELL Ca. Derived from ‘OXYPHIL CELLS’ of thyroid. Derived from ‘OXYPHIL CELLS’ of thyroid.
Function of these cells is not known. Function of these cells is not known. Cells are stuffed with mitochondria & Cells are stuffed with mitochondria &
possess the possess the TSH receptorsTSH receptors and produce and produce thyroglobulin.thyroglobulin.
As compared to follicular type – usually As compared to follicular type – usually multifocal & bilateral and more likely to multifocal & bilateral and more likely to metastatise to LN [ ~25%].metastatise to LN [ ~25%].
Medullary CaMedullary Ca Female : Male :: 1.5 : 1 . Accounts for 15 to 20 % of all Thyroid CaAccounts for 15 to 20 % of all Thyroid Ca Mean age at presentation – 50 to 60 yrs. Can occur in four clinical settings:
1. Sporadic - ~ 70 % cases,usually unilateral
2. Familial - ~ 30 % ,cases,usually Bilateral
As Familialmedullary
thyroid cancer
As part of Multiple endocrine
neoplasia type IIa
As part of Multiple endocrine
neoplasia type IIb
Medullary CaMedullary Ca
Pathology – 1. Usually occurs in upper poles, 2. Originates from Parafollicular \ C cells..
Microscopic – Why called Medullary ? Sheets of Spindle shaped neoplastic cells
with AMYLOID [Altered Calcitonin] in between. Cells Stains for Calcitonin,CEA,Serotonin,VIP
Spreads to LN Initially ~ 75 %.
++
Medullary thyroid carcinoma Medullary thyroid carcinoma
A, Cellular specimen staining positively for calcitonin with immunoperoxidase. (x100.)
B, Loosely cohesive fragments of spindle-shaped cells; amyloid is present as amorphous blue material intimately associated with neoplastic cells.(Papanicolaou; x400.)
Medullary thyroid carcinoma-4MsMedullary thyroid carcinoma-4Ms
Anaplastic CaAnaplastic Ca
Accounts for ~ 8 to 10 % of all Thyroid CaAccounts for ~ 8 to 10 % of all Thyroid Ca Female : Male :: 1.5 : 1 .Female : Male :: 1.5 : 1 . Mean age at presentation – 70 to 80 yrs.Mean age at presentation – 70 to 80 yrs. Most aggressive thyroid malignancy,with Most aggressive thyroid malignancy,with
median survial only ~ 3 months.median survial only ~ 3 months. Iodine deficiency goitre is precursor .Iodine deficiency goitre is precursor . All patients are considered to have stage IV All patients are considered to have stage IV
disease. disease.
Anaplastic CaAnaplastic Ca
Highly pleomorphic Multinucleated giant cells
compose this tumor
Thyroid LymphomaThyroid Lymphoma Accounts for ~ 8 to 10 % of all Thyroid CaAccounts for ~ 8 to 10 % of all Thyroid Ca Women > 70 yrs are usually affected.Women > 70 yrs are usually affected. In 70 to 80 %, it arises in Preexisting In 70 to 80 %, it arises in Preexisting
Chronic Lymphocitic thyroditis with Chronic Lymphocitic thyroditis with Subclinical or overt Hypothyroidism, in Subclinical or overt Hypothyroidism, in association with Hashimoto’s thyroiditis.association with Hashimoto’s thyroiditis.
Almost always Non-Hodgkin B-cell Almost always Non-Hodgkin B-cell lymphomalymphoma
Usually presents as Rapidly growing Usually presents as Rapidly growing mass,with obstructive symptoms as mass,with obstructive symptoms as dyspnea and dysphagia.dyspnea and dysphagia.
Thyroid MetastatesThyroid Metastates
Usually RareUsually Rare Common Primary sites are - Common Primary sites are -
1. Skin – Melanoma ~39 % 1. Skin – Melanoma ~39 % 2. Breast ~ 21% 2. Breast ~ 21% 3. Renal cell Ca ~ 10 % 3. Renal cell Ca ~ 10 %
Usually Presents as Painless Lump with Usually Presents as Painless Lump with signs / symptoms of Primary.signs / symptoms of Primary.
FNAC is DiagnosticFNAC is Diagnostic
Recurrent Thyroid CancerRecurrent Thyroid Cancer Approximately 10% to 30% of patients after initial
treatment 80% recur with disease in the neck 20% with Distant RecurrennceRecurrennce. Most common site of distant metastasis is the
lung. Median time of Recurrence ~ 2.6 yrs Prognosis for clinically detectable recurrences is
generally poor, regardless of cell type. Local and regional recurrences detected by I131
scan and not clinically apparent and have an excellent prognosis
Recurrent Thyroid CancerRecurrent Thyroid Cancer Characteristic of Recurrent Thyroid CaCharacteristic of Recurrent Thyroid Ca Primary Tumour Stage [ AJCC]Primary Tumour Stage [ AJCC]
I 17 % I 17 % II 5% II 5% III 33 % III 33 %
Age at RecurrenceAge at Recurrence < 45 yrs. 12% < 45 yrs. 12% >45 yrs. 45 %>45 yrs. 45 %
HistologyHistology Papillary 38 % Papillary 38 % Follicular 9 % Follicular 9 % Hurthle 10 %Hurthle 10 %
Clinical PresentationClinical Presentation Usual PresentationUsual Presentation
- A lump in the neck- A lump in the neck
- Pain in the neck- Pain in the neck
- Hoarseness - Hoarseness
- Trouble swallowing - Trouble swallowing
- Breathing problems- Breathing problems Usual PresentationUsual Presentation
- Follicular Ca - ~1 % as Hyperthyroidism
- Medullary Ca - ~ 2 – 4 % as Cushing Syn . Hypertension, Diarrhea
- Papillary – as LATERAL ABERRANT THYROID
Clinical Diagnosis of CaClinical Diagnosis of Ca
> Symptoms of hyperthyroidism or hypothyroidism> Pain or tenderness associated with a nodule> Soft, smooth, mobile nodule> Multinodular
> Age less than 20> Age greater than 70> Male gender> New onset of swallowing Difficulties or hoarseness> History of external neck irradiation during childhood> Firm, irregular and fixed nodule> Presence of cervical lymphadenopathy
Suspicion of a Benign noduleSuspicion of a Benign nodule Suspicion of a Malignant nodule Suspicion of a Malignant nodule
Biopsy is the only way to confirmBiopsy is the only way to confirm