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