Surgery: Thyroid Ca - Details

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How to classify thyroid ca.

☻Is the thyroid nodular or diffuse? most likely nodular: common: solitary thyroid nodule, rare: multinodular goitre ☻Is the patient euthyroid, thyrotoxic, hypothyroidism? euthyroid ☻Any compression sx? sob, hoarseness of voice, dysphagia ☻Family hx of thyroid abnormalities ☻constitutional sx

Presentation of thyroid ca.

The thyroid gland is made up of thousands of follicles, which are small spheres lined with follicular cells. Follicular cells convert thyroglobulin, a protein found in follicles, into two iodine-containing hormones, tri-iodo-thyronine or T3, and thyroxine or T4. Once released from the thyroid gland, these hormones enter the blood and bind to circulating plasma proteins. Inside the cell T4 is mostly converted into T3, at which point it can exert its effect. The thyroid is also made up of parafollicular or C cells, which are near the follicles. These cells produce calcitonin, a hormone that lowers blood calcium levels.

Physiology of thyroid.

☻Thyroid adenomas which are benign and solitary growths of the thyroid. ☻These nodules are non-functional, so they don't produce thyroid hormones, and these are called "cold" nodules. ☻Thyroid adenomas are follicular and there’s no capsular or vascular invasion.

Fill in the blanks. ☻Thyroid adenomas which are _______ and ______ growths of the thyroid. ☻These nodules are ______, so they don't produce thyroid hormones, and these are called "____" nodules. ☻Thyroid adenomas are ______and there’s no capsular or vascular invasion.

The cancer arises from follicular cells, and it's known as differentiated because the cancer cells look like normal thyroid cells.

Why are papillary ca & follicular ca under differentiated thyroid ca?

☻Papillary carcinomas are the most common form of thyroid ca. ☻They have an excellent prognosis. ☻“papillary” refers to the fact that these tumors have finger-like prolongations of follicle cells known as papillae that tend to grow slowly towards nearby lymphatic vessels and invade nearby lymph nodes in the neck. ☻Risk factors include radiation exposure, polyposis syndrome & +ve family hx.

Fill in the blanks. ☻______ are the most common form of thyroid cancer. ☻They have an ______ prognosis. ☻Spread by _______. ☻Risk factors include radiation exposure, _______ & _______.

☻Orphan annie nuclei Under the microscope, the nuclei of papillary carcinomas cells contain very few proteins and a small amount of DNA, and that gives the appearance of an empty nucleus, sometimes called an “Orphan Annie eye” nucleus based on an old famous cartoon character. ☻Psammoma bodies Calcium deposits within the papillae

Pathological features of papillary ca.

☻Follicular ca is the remaining 10% type of differentiated thyroid ca. ☻It is solitary nodule primarily spread haematogenously. ☻Follicular adenoma is not risk factor for follicular ca. ☻Risk factor: iodine deficiency

Fill in the blanks. ☻_________ is the remaining 10% type of differentiated thyroid ca. ☻It is solitary nodule primarily spread _______.

☻capsular/vascular invasion Unlike papillary thyroid carcinomas, from there, follicular carcinomas can invade into nearby blood vessels and spread to other parts of the body.

Pathological features of follicular ca.

☻Medullary ca is non differentiated thyroid ca which arise from C-cells. ☻risk factor: Hereditary condition called multiple endocrine neoplasia, or MEN, type 2A and 2B. In these conditions, one or more of the endocrine glands like the thyroid gland, parathyroid gland, and adrenal gland develop tumors. ☻sporadic: solitary growth ☻familial: multicentric growth ☻Spread locally, lymphatic & haematological. ☻aggrasive growth

Fill in the blanks. ☻_________ is non differentiated thyroid ca which arise from C-cells. ☻risk factor: significant family hx of MEN-2 ☻sporadic: ______ growth ☻familial: ______ growth ☻Spread locally, _______ & ________.

Under the microscope, medullary thyroid carcinoma is made up of spindle-shaped cells as they’re long and skinny, like a spindle that’s used to spin fibers into thread. C-Cells in the tumor make excessive amounts of calcitonin which deposits between the C-Cells. As the calcitonin deposits, the resulting clumps of protein stick together and form fibrous deposits called amyloid around the C-cells, which can be seen with Congo red stain.

Pathological features of medullary thyroid ca.

☻Anaplastic thyroid ca is thyroid cancer that usually appears in older individuals and has a poor prognosis (60-70y/o). ☻These tumors derive from an existing papillary or follicular cancer where the cells mutate even more and become unrecognizable. ☻risk factors include longstanding goitre and hx of prev differentiated thyroid ca.

☻________ thyroid ca is thyroid cancer that usually appears in older individuals and has a poor prognosis. ☻risk factors include longstanding _______ and hx of prev differentiated thyroid ca.

Pathological feature of anaplastic ca is small blue round cells that is highly anaplastic.

Pathological feature of anaplastic ca is small ______(colour), ______(shape) cells that is highly anaplastic.

1. TSH, US 2. If abnormal, consider T4 autoab - if suspect Hashimoto/Graves Disease CXR with thoratic inlet - tracheal goitre, metastases Radionuclide scan - hot or cold nodule FNAC - diagnosis

Investigations for thyroid ca.

1. Surgical resection - low risk: hemithyroidectomy, mostly total thyroidectomy 2. LN clearance - node excision 3. Adjuvant therapy - radioactive iodine to ablate remnant thyroid 4. TSH suppression - give L-thyroxine to suppress TSH level 5. Follow up - check TSH level, thyroglobulin as tumour marker for recurrence, radioactive iodine scan: recurrence

Management of differentiated thyroid ca

1. Surgical resection - aggrasive resection as it is aggrasive growth (Total thyroidectomy with level VI node clearance 2. Follow up - ☻thyroxine replacement to maintain euthyroid since pt will be hypothyroid ☻serum calcitonin & CEA 6/12 after surgery

Management of medullary thyroid ca.

Palliative therapy. ☻for compression effect ☻chemotherapy to shrink tumour ☻surgical debulked ☻tracheostomy

Management of anaplastic ca.

☻pressure symptoms ☻carcinoma ☻cosmetics reasons ☻symptomatics pt planning pregnancy

What are the indication for surgical resection?