Tumours of Thyroid Gland

7/28/2019 Tumours of Thyroid Gland

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TUMOURS OF THYROID

GLAND

PRESENTED BY

PALAK GUPTA1


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CLASSIFICATION OF TUMOURS

OF THYROID GLAND

BENIGN ADENOMAS

I. Follicular adenoma

II. Papillary adenoma

III. Hurthle cell adenoma

IV. Colloid adenoma

MALIGNANT TUMOURS (Dunhill

classification )I. PRIMARY

WELL DIFFERENTIATED CARCINOMA

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Papillary carcinoma (60 % )

Follicular carcinoma ( 17 % )

Papillofollicular carcinoma behaves like

papillary carcinoma of thyroid

Hurthle cell carcinoma behaves likefollicular carcinoma

POORLY DIFFERENTIATED CARCINOMA

Anaplastic carcinoma ( 13 % ) ARISING FROM PARAFOLLICULAR CELLS

Medullary carcinoma (6 % )

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ARISING FROM LYMPHATIC TISSUE

Malignant lymphoma (4 % )II. SECONDARY ( METASTASIS )

Malignant melanoma ( rare )

Renal cell carcinoma Breast carcinoma produce secondaries in

the thyroid due to blood spread

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ETIOLOGY OF THYROID

MALIGNANCY

Radiation either external or radioiodine

can cause papillary carcinoma thyroid.

Pre existing multinodular goiter. It turns

into follicular carcinoma of thyroid.

Medullary carcinoma thyroid is often

familial.

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PAPILLARY CARCINOMA It is 60 % common.

Common in females and young age group.

TSH levels in the blood of these patients arehigh, so it is called HORMONE DEPENDENT

TUMOUR. Slowly progressive and less aggressive

tumour.

Commonly multicentric. Spreads within the gland through intra

thyroidal lymphatics.

No blood spread.6


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ADENOMAS

The benign tumours of thyroid gland are notuncommon. They are present as a solitary

nodule.

Diagnosis is established by histologicalexamination.

Treatment by

hemithyroidectomy/lobectomy.

FNAC cannot distinguish follicular adenoma

from follicular carcinoma. Hence a frozen

section is arranged.7


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ETIOLOGY

Irradiation to the neck during childhood.

Complication of Hashimotos thyrioditis.

TYPES

i. Occult ( < 1.5 cm )

ii. Intrathyroidal

iii. Extrathyroidal

GROSS FEATURESIt can be soft, firm, hard, cystic.

It can be multinodular or solitary.

It contains brownish black fluid. 8


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MICROSCOPY

Made up of colloid filled follicles with

papillary projections. In some cases calcifiedlesions are found which are called asPSAMMOMA bodies. These are diagnostic ofpapillary carcinoma of thyroid.

Characteristic pale, empty nuclei arepresent which are called as ORPHAN ANNIEEYED NUCLEI. (intranuclear cytoplasmic

inclusions ) CLINICAL PRESENTATION

o Young females are commonly affected. ( ageof 20 40 years ).

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o It can be present as soft or hard or firm,

solid or cystic, solitary or multinodular

swelling.o Compression features are uncommon.

o Often discrete lymph nodes in the neck are

palpable.o Thyroid may or may not be palpable. When

not palpable it is called as occult( hidden )

o Few patients present late to the hospitalwith fixed nodes in the neck, and fixed

thyroid to the trachea with or without

recurrent laryngeal nerve paralysis. 10


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DIAGNOSIS

Routine investigations such as blood

examination, chest x ray, laryngoscopy, areto be done.

Radioisotopes scan shows cold nodule.

TSH level in the blood is higher.FNAC ( fine needle aspiration cytology ) can

demonstrate colloid filled follicles with

papillary projections, hence preoperativediagnosis is possible with FNAC.

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TREATMENT

o Near total thyroidectomy

o Suppressive dose of L THYROXINE 0.3 mgOD life long.

o Block dissection ( functional block ) is

required if lymphnodes are involved.

o If small lymph nodes are present Berry

picking may be done ( not accepted now ).

PROGNOSIS

Prognosis is good

One of the curable malignancies.12


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AMES scoring.

A: age, < 40 years has better prognosis.

M: distant metastasis

E: extent of the primary tumor.

S: size of the tumor.

AGES scoring

A: age, < 40 years has better prognosis.

G: pathologic grade of the tumor.E: extent of the primary tumor.

S: size of the primary tumor. Size < 4 cm has

better prognosis. 13


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FOLLICULAR CARCINOMAIncidence: constitutes 17 % of cases.

Common in females.Can occur either de novo or in a pre

existing multinodular goitre.

More aggressive tumor.

Spreads mainly through blood into the

lungs, bones and liver.

Spreads to lymph nodes of neckoccassionaly.

Bone secondaries are vascular, warm,

pulsatile and localised. 14


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ETIOLOGY

Usually arises in a multinodular goitre,

especially endemic goitre.Occurs in de novo.

CLASSIFICATION

NON INVASIVE, which means minimalinvasion.

INVASIVE refers to angio invasion and

capsular invasion. The tumor cells lines theblood vessels and get dislodged into the

systemic circulation producing secondaries

in the bone. 15


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CLINICAL PRESENTATION

Swelling in the neck, firm or hard and

nodular.

Peak age group is around 40 years.

Tracheal compression and stridor.

Dyspnea, hemoptysis, chest pain duringlung secondaries.

Recurrent laryngeal nerve involvement

causes hoarsness of voice, +ve Berrys sign.Pulsatile secondaries in the skul and long

bones. ( metastasis in the flat bones ).

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INVESTIGATIONS

Routine investigations

Thyroid scan can demonstrate cold nodule.

FNAC of the cold nodule is inconclusive

because capsular and angio invasion is not

detected by FNAC.Frozen section biopsy is useful.

Ultrasound abdomen, chest x ray, bone x

ray are done to reveal osteolytic lesions.

Alkaline phosphatase if increased, bone

scan should be done.17


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TREATMENT

Near - total thyroidectomy is done, along

with block dissection if lymph nodes areenlarged.

Maintenance dose of L thyroxine 0.1 mg

OD is given lifelong.After near total thyroidectomy, a whole

body, bone scan is done to see for metastasis

in the bone. A single secondary can betreated by radiotherapy followed by oral

radioiodine therapy. Multiple secondaries

are treated by oral radioiodine therapy.18


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HURTHLE CELL CARCINOMA It is a variant of follicular carcinoma. It is

more aggressive than follicular carcinoma. These tumors have more than 75 % of

follicular cells having oncocytic features.

Do not take up

131

I. Secretes thyroglobulin.

Hurthle cell adenoma even if wellcapsulated is highly malignant.

It contains abundant oxyphill cells.

It spreads to regional lymph nodes morethan follicular carcinoma of thyroid.

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TREATMENT

Total thyroidectomy.

In many cases lymph nodes are enlarged,hence modified radical neck dissection (

MRND ) is done.

TSH suppression, follow up regularly done.

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ANAPLASTIC CARCINOMAIncidence: 10 % 12 % of cases.

The most rapidly growing thyroidmalignancy.

Advanced age group at presentation.

Advanced nature of presentation. CLINICAL FEATURES

Common in elderly woman around 60 70

years of age.Rapidly growing thyroid swelling of short

duration. The surface is irregular andconsistency is hard.

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Very aggressive tumor causing

i. Stridor and hoarseness of voice.

ii. Dysphagiaiii. Fixity to the skin.

Involvement of isthmus and bilateral

lateral nodes.

Early infiltration of trachea ( stridor )

Infiltration of carotid sheath ( carotid

artery pulsation not palpable ). +ve Berryssign.

Differential diagnosis intrinsic

carcinoma of larynx. 22


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DIAGNOSIS

FNAC is diagnostic.

TREATMENTTracheostomy and isthmectomy are done

to relieve respiratory obstruction

temporarily.External radiotherapy.

Prognosis is poor.

Death occurs within 6 8 months.

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MEDULLARY CARCINOMA OF


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MEDULLARY CARCINOMA OF

THYROID ( MCT )

Uncommon ( 5 % ) type of thyroidmalignancy.

Arises fromparafollicular C cells, which is

derived from ultimobronchial body.

Contains characteristic amyloid stroma

wherein malignant cells are dispersed.

There maybe mucosal neuromas in lips,oral cavity. ( Sipple syndrome, MEN IIb )

TYPES

Sporadic ( 80 - 90 % ). 24


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Familial MCT

MCT with MEN II syndrome.

CLINICL FEATURES

Thyroid swelling often with enlargment of

neck lymph nodes.

Diarrhea, flushing.

Hypertension, pheochromocytomas and

mucosal neuromas.

Sporadic and familial types occur in

adulthood whereas MEN syndrome II occurs

in younger age groups.25


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HORMONES PRODUCED BY MCT

Calcitonin

Prostaglandins

Serotonin ( 5 HT )

ACTH

SPREAD

Both by lymphatics and blood

INVESTIGATIONS

FNAC shows amyloid deposition with

dispersed malignant cells and C cells

hyperplasia.26


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Tumor marker calcitonin levels will be high.

Ultrasound neck thyroid region.

TREATMENT

Total thyroidectomy + central node dissection+ maintenance dose of L thyroxine.

Neck lymph node block dissection if lymph

nodes are involved.Adriamycin is drug used for chemotherapy.

PROGNOSIS

Sporadic MCT and MCT with MEN II areaggressive.

Familial MCT with no MEN II has betterprognosis.

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MALIGNANT LYMPHOMAIt is rare. Hashimoto thyroiditis can pre

dispose to malignant lymphoma.Older patients are commonly affected.

Tumor is rapidly growing, large thyroid

swelling. ( Primary lymphoma ).FNAC used to diagnose the condition.

Chemotherapy is the main treatment.

Often total thyroidectomy is done to

enhance the results.

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Tumours of Thyroid Gland

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