CARCINOMA OF THE THYROID GLAND

The majority of the neoplasms in the thyroid gland that present as a lump in the
neck are primary thyroid tumors.
There are three varieties of carcinoma of the thyroid follicles:
Papillary carcinoma (70%) (most common)
Follicular carcinoma (20%)
Anaplastic carcinoma. (<5%)
Medullary carcinoma.
(5%)
Lymphoma.

Papillary carcinoma
A TSH dependant tumor that usually occurs following history of irradiation
to the neck.
Papillary carcinoma is a tumor of children and young adults.
Females are more often than males.
It is presented by a slowly growing lump in the neck. The lump may be in
the region of the thyroid gland or, if it is caused by secondary deposit in the
lymph glands, in the antero-lateral part of the neck (metastasize early to
regional nodes).

Palpable nodule in a case of papillary carcinoma

Follicular carcinoma
Another TSH dependent tumor that occurs in adults between the age of 40
and 60 years.
Females are more affected than males.
The common presenting symptom is a lump in the neck, which may have
been present for many years.
Distant metastasis via blood stream to lung and bones (breathlessness,
chest pain or pain or swelling in a bone) is common.
Anaplastic carcinoma
This is the worst variety of thyroid cancer because it spreads rapidly.
Most patients with this disease are dead within 1 year of diagnosis.
It appears between the ages of 60 and 80 years. Females are affected more
often than males.
The common complaint is a rapidly growing indistinct and hard nodular
swelling of the neck rather than a lump.
A dull aching pain in the neck is quite common.
Dyspnea (due to tracheal compression or multiple pulmonary metastases).
Hoarseness or a change in the quality of the voice (due to infiltration of the
recurrent laryngeal nerve).
Pain in the ear, caused by infiltration of the vagus nerve, is not uncommon.
There may be bone pain. Any bone can be the site of a secondary deposit,
and pathological fractures can occur.
General malaise and weight loss appear when there is disseminated disease.

Anaplastic carcinoma

Medullary carcinoma
A rare neoplasm that arises from the parafollicular (C) cells.
The majority of patients are between the ages of 50 and 70 years. When the
condition occurs in young adults (20-30 years), it may be a familial or a
manifestation of the multiple endocrine neoplasia (MEN) syndrome type
2a or 2b (in association with pheochromocytoma and parathyroid tumors).
The symptoms which should make you think of medullary tumor, apart from
a lump in the neck and the presence of the above lesions in the patient or
their family, are diarrhea and flushing.
If this tumor is suspected, it is important to measure the serum calcitonin
level.
Lymphoma
The lymphoid tissue in the gland can also undergo malignant change to
become a lymphoma, but this is not a true thyroid tissue neoplasm.
Rapidly growing mass and obstructive symptoms.
Seen in patients with a long-standing history of Hashimotos thyroiditis.
Investigations of thyroid cancer

Routine.
FNAC.
Metastasis work-up: Chest X-ray, bone scan.
CT for staging of lymphoma.
For medullary carcinoma: serum calcitonin, exclude other endocrinal
disorders (by measuring serum calcium and urinary metanephrins).

Treatment
Well differentiated tumors (Papillary/Follicular):
Total thyroidectomy with neck dissection.
Radio-iodine 123I ablation.
Life-long thyroxine treatment (as a replacement and to achieve TSH
suppression, and hence, avoid recurrence).
Annual thyroglobulin measurements ( to detect recurrence )
10-year survival is 90%.
Anaplastic carcinoma:
Surgical debulking to relieve pressure (Poor response to radio and
chemotherapy).
Palliative care is usually involved (eg. tracheal stenting).
90% will die within a year.
Medullary carcinoma:
Total thyroidectomy with neck dissection.
Life-long thyroxine treatment (as a replacement therapy only).
Follow-up includes regular calcitonin levels (detectable calcitonin levels
suggest tumor recurrence).
Lymphoma:
Radiotherapy chemotherapy.
Thyroid surgery may be indicated in localized disease or for persistent
disease.
Lymphoma patients have a good prognosis and 10-year survival rate.

A SCHEME FOR THE DIAGNOSIS OF THYROID SWELLINGS

Once you have examined the patient you should be able to draw conclusions as to
the nature and texture of the gland and to its endocrine activity.
The gland
1. Solitary palpable nodule
2. Multinodular goiter (MNG)
3. Diffusely enlarged gland
Activity of the gland
1. Normal (Euthyroid)
2. Hypersecretion (hyperthyroidism/thyrotoxicosis)
3. Hyposecretion (hypothyroidism/myxedema)
Having established the configuration of the gland and its endocrine activity, a table
can be drawn up as to possible differential diagnoses (see table below). This allows
a degree of clarity in interpreting the presenting clinical features and in arriving at
a working diagnosis.

If only one lump is palpable it may be:

The only palpable nodule

of a multinodular goiter

A benign adenoma

A Cyst

Carcinoma(pap, foll., med.)

LNs may be felt esp. in
papillary type

If more than one lump is palpable the swelling may be:

A multinodular
goiter

Anaplastic carc.
esp. if the mass
fixed to surroundings

If there is diffuse, homogeneous enlargement of the whole gland the

swelling may be:

Graves disease
Soft with bruit

Simple hyperplastic
goiter

Thyroiditis
Hard, tender

Correlation between clinical state of the thyroid, endocrine

function and pathological diagnosis

Diffuse
enlargement

Hypothyroid
Thyroiditis

Multinodular Late cases of

enlargement Multinodular
goiter (MNG)

Solitary
nodule

No palpable
goiter

Myxedema
Following
treatment

Euthyroid
Simple hyperplastic
goiter

Simple MNG
Anaplastic
carcinoma
Cyst
Dominant
nodule
Adenoma
Carcinoma
Normal

Hyperthyroid
Primary
Hyperthyroidism
(Graves
disease=Diffuse
toxic goiter)
Secondary
hyperthyroidism
(=Plummers
disease=toxic
MNG)
Solitary toxic
nodule

Early Graves
disease

Thyroidectomy
A thyroidectomy is an operation that involves the surgical removal of all or part of
the thyroid gland.
Indications:

Thyroid cancer
Toxic thyroid nodule
Multinodular goiter (MNG), especially if compressing nearby structures
Graves' disease, especially if there is exophthalmos (bulging eyes)
Thyroid nodule, if fine needle aspirate (FNA) results are unclear.

Post-operative complications following thyroidectomy

These should be outlined when consenting patients.
Immediate
Early
Late
Recurrent laryngeal nerve (RLN) Thyroid crisis(storm) Keloid/ Hypertrophic
injury
scar
External laryngeal nerve (ELN)
Hypoparathyroidism Hypothyroidism
injury
Bleeding/Hematoma
Infection
Bleeding: This may cause airway obstruction. Treatment is by opening
the wound, evacuating the hematoma and securing hemostasis.
Nerve damage:
ELN damage can go unnoticed but patients can complain of a weak
voice when trying to sing or shout, so professional singers and speakers
should be warned of this.
RLN damage: Unilateral Hoarsness of voice. Treated by speech therapy.
Bilateral Stridor. Needs emergency tracheostomy
Thyroid crisis (storm): If patients are inadequately prepared for theatre, she
may show signs of exaggerated hyperthyroidism. Treated by antithyroid
drugs, propranolol and cortisol in ICU.
Hypothyroidism
Hypocalcaemia (Hypoparathyroidism): Due to excision or ischemia of the
parathyroids (usually 2-5 days postoperatively).
Clinically, circumoral parasthesia, tingling, and (if untreated) spasm of
respiratory muscles and convulsions. It is treated by slow infusion of
intravenous calcium gluconate followed by calcium tablets.
Stridor: due to RLN injury or laryngeal compression due to hematoma.
Keloid/hypertrophic scar