An overview of management of

thyroid carcinoma

Dr. Mazharul Islam

MBBS,MRCP(UK), MRCPS(Glasgow)
Medical officer, INMAS,DMCH
Normal Anatomy of the Thyroid Gland
Lymphatic drainage
 PATHOLOGICAL CLASSIFICATION

BASED ON DIFFERENTIATION
WELL DIFFERENTIATED (LOW GRADE MALIGNANCY)
• Usual papillary thyroid carcinoma(PTC)
•Microcarcinoma (lesions <1cm)
•Cystic
•Follicular variant of PTC
•Usual follicular thyroid carcinoma (FTC)
•Hurthle cell carcinoma (HCC)
INTERMEDIATE DIFFERENTIATION
•Medullary thyroid carcinoma(MTC)
•Diffuse sclerosing variant of papillary carcinoma
•Columnar cell variant of papillary carcinoma
•Insular carcinoma
•Tall cell variant of papillary carcinoma

POORLY DIFFERENTIATED( HIGH GRADE)

Anaplastic (undifferentiated)
TNM staging of thyroid cancer
 Causes
• Radiation exposure to thyroid gland in child hood

• Family history : a 4 to 10 fold increased risk of well

differentiated thyroid cancer in 1st degree relatives with
this neoplasia

• Iodine: Iodine-deficient diets may lead to increase the

TSH level and considered goitrogenic

• Thyroiditis: (Hashimoto's Disease) may develop into a

form of cancer called lymphoma.
 EPIDEMIOLOGY

Thyroid cancer is the most commonly diagnosed endocrine

cancer.

• There will be an estimated 48,000 new thyroid cancer

diagnoses and 1,740 thyroid cancer deaths in the United
States by the end of 2011.

• There is a strong female prevalence.

• DTC comprises the overwhelming majority (94%) of

new thyroid cancer diagnoses.
• Approximately 5% are medullary thyroid carcinoma and 1%
are anaplastic thyroid carcinoma.
• The incidence of thyroid cancer increases with age with a peak
incidence at
• 40 to 44 years for women and
• 65 to 69 years for men.
• The peak incidence for ATC is at 60 years for both sexes.

• Siegel R, Ward E, Brawley O, et al. Cancer statistics, 2011: the impact of eliminating
socioeconomic and racial disparities on premature cancer deaths. CA Cancer J Clin
2011;61:212–236.

• Aschebrook-Kilfoy B, Ward MH, Sabra MM, et al. Thyroid cancer incidence patterns in
the United States by histologic type, 1992–2006. Thyroid 2011;21:125–134.
 Evaluation of Thyroid Tumor

 History:
Age and Gender
Rapid increase in size, dyspnea, dysphagia and hoarseness
of voice
Family history of thyroid cancer
History. of irradiation

 On Examination:
Firmness, mobility, size and adherence to surrounding structures
Presence of lymphadenopathy

• .
 LABORATORY STUDIES

● serum TSH

● Routine measurement of serum Tg for initial evaluation of

thyroid nodules is not recommended.

● Serum calcitonin can be measured during the initial evaluation

of patients with MTC and is essential during follow-up for
these patients.
● USG and USG guided FNA
● Radionuclide Scan
 USG finding of thyroid nodule

characteristics of a thyroid nodule associated with a higher

likelihood of malignancy include

• nodule hypoechogenicity compared to the normal thyroid

parenchyma
• increased intranodular vascularity
• irregular infiltrative margins
• the presence of micro calcifications
• an absent halo.
USG findings of suspicious thyroid nodule
Indications for FNA in subcentimeter nodules
1) family history of PTC
2) history of external beam radiation exposure as a child
3) exposure to ionizing radiation in childhood or adolescence
4) history of with discovery of thyroid cancer; and prior .
hemithyroidectomy .
5)FDG-PET–positive thyroid nodules.

Subcentimeter nodule with a suspicious appearance and when

detection of abnormal lymph nodes should lead to FNA of the
lymph node.

Routine FNA is not recommended for subcentimeter nodules.

COMPUTED TOMOGRAPHY AND MAGNETIC
RESONANCE IMAGING

CT and MRI commonly detect otherwise clinically occult

thyroid nodules. MRI is superior to CT for establishing the
local extent of a known cancer, because it will more clearly
show esophageal or tracheal invasion.

MRI is indicated in the presence of hoarseness, stridor and

dysphagia .

The ATA doesn’t recommend the routine preoperative use of

imaging studies (CT, MRI, PET).
 The Treatment of well
differentiated Thyroid cancer

It Consists of a three- pronged attack :

• Thyroid Surgery
• Radioactive iodine therapy
• Drug - Thyroxin therapy
 Surgical management of thyroid carcinoma

Surgery is the primary treatment of localized thyroid cancer of

all histology's.

A total thyroidectomy is the preferred surgery.

Subtotal thyroidectomy, leaving >1 g of tissue with the

posterior capsule on the uninvolved side, is an inappropriate
operation for thyroid cancer.
Total thyroidectomy recommendations-

● If the primary thyroid carcinoma is >1 cm

● There are contralateral thyroid nodules present or
regional or distant metastases are present,
● The patient has a personal history of radiation therapy to the head
and neck,
● The patient has first-degree family history of DTC.

Older age (>45 years) may also be a criterion for recommending near-total
or total thyroidectomy even with tumors <1–1.5 cm, because of higher
recurrence rates in this age group.
Bilimoria KY, Bentrem DJ, Ko CY, Stewart AK, Winchester DP, Talamonti MS, Sturgeon C 2007 Extent of surgery affects
survival for papillary thyroid cancer. Ann Surg 246:375–381.
Thyroid lobectomy is sufficient when

small (<1 cm),
low-risk,
unifocal,
intrathyroidal papillary carcinomas in the absence of
prior head and neck irradiation or radiologically or clinically
involved cervical nodal metastases.
 LYMPH NODE DISSECTION

Therapeutic central-compartment (level VI) neck dissection for

patients with clinically involved central or lateral neck lymph
nodes should accompany total thyroidectomy to provide
clearance of disease from the central neck.

Prophylactic central-compartment neck dissection (ipsilateral or

bilateral) may be performed in patients with papillary thyroid
carcinoma with clinically uninvolved central neck lymph
nodes, especially for advanced primary tumors (T3 or T4).
Near-total or total thyroidectomy without prophylactic central
neck dissection may be appropriate for small (T1 or T2),
noninvasive, clinically node-negative PTCs and most follicular
cancer.

Therapeutic lateral neck compartmental lymph node dissection

should be performed for patients with metastatic lateral
cervical lymphadenopathy.

White ML, Gauger PG, Doherty GM 2007 Central lymph node dissection in differentiated thyroid
cancer. World J Surg 31:895–904
The ATA Surgery Working Group 2009 Consensus Statement on the Terminology and Classification
of Central Neck Dissection for Thyroid Cancer. Thyroid 19:1153–1158
.Kupferman ME, Patterson M, Mandel SJ, LiVolsi V, Weber RS 2004 Patterns of lateral neck
metastasis in papillary thyroid carcinoma. Arch Otolaryngol Head Neck Surg 130:857–860
Low-risk patients

1) No local or distant metastases;

2) All macroscopic tumor has been resected;
3) There is no tumor invasion of locoregional tissues or structures;
4) The tumor does not have aggressive histology (e.g., tall cell,
insular, columnar cell carcinoma) or vascular invasion;
5) And, if 131I is given, there is no 131I uptake outside the thyroid
bed on the first post treatment whole-body RAI scan.
Intermediate-risk patients
1) Microscopic invasion of tumor into the perithyroidal soft
tissues at initial surgery;
2) Cervical lymph node metastases or 131I uptake outside the
thyroid bed on the Rx WBS done after thyroid remnant ablation or
3) Tumor with aggressive histology or vascular invasion.

High-risk patients

1) macroscopic tumor invasion,

2) incomplete tumor resection,
3) distant metastases, and possibly
4) thyroglobulinemia out of proportion to what is seen on the
post treatment scan.
How should patients be prepared for
RAI ablation
Remnant ablation requires TSH stimulation.
TSH of >30 mU/L is associated with increased RAI uptake in
tumors ,
Endogenous TSH elevation can be achieved by two basic
approaches to thyroid hormone withdrawal,
• stopping LT4 and switching to LT3 for 2–4 weeks followed by
withdrawal of LT3 for 2 weeks, or
• discontinuation of LT4 for 3 weeks without use of LT3.
Both methods of preparation can achieve serum TSH levels
>30 mU/L in >90% of patients.
 A low-iodine diet for 1–2 weeks is recommended for patients
undergoing RAI remnant ablation, particularly for those
patients with high iodine intake.
For most patients, including those unable to tolerate
hypothyroidism or unable to generate an elevated TSH,
remnant ablation can be achieved with rh TSH.

A recent study has shown that ablation rates were similar with
either withdrawal or preparation with rh TSH.

Recombinant human TSH is approved for remnant ablation in

the United States, Europe, and many other countries around
the world.
 Activity of I-131 should be used for remnant
ablation

The minimum activity (30–100 mCi) necessary to achieve

successful remnant ablation and should be utilized, particularly
for low-risk patients.

If residual microscopic disease is suspected or documented,

or if there is a more aggressive tumor histology (e.g., tall cell,
insular, columnar cell carcinoma), then higher activities (100–
200 mCi) may be appropriate.
 Post surgery and RAI early management of DTC

Initial TSH suppression to below 0.1 mU/L is recommended for

high-risk and intermediate-risk thyroid cancer patients.

Maintenance of the TSH at or slightly below the lower limit

of normal (0.1–0.5 mU/L) is appropriate for low-risk patients.
 Management of DCT in special situations

Loco regional metastasis:

• Surgerical resection of lymph nodes followed by RAI.
• If surgery is not possible, EBRT followed by RIT.
• Ethanol injection is considered in cases of enlarged lymph nodes
less than 2cm in size where operation not possible ,multiple
radioiodine therapy failed.

Pulmonary metastasis :
Radio iodine avid pulmonary metastasis: frequent radio iodine
therapy 6 -12 months interval with steroids
Non Radio iodine avid pulmonary metastasis: doxorubicin with
cisplatin .
Bone metastasis:
Complete surgical resection followed by frequent radio iodine
ablation until WBS negative.
EBRT and zoledronic acid may be considered in each session
before RIT.

Brain metastasis:
Radio iodine avid - surgical resection followed by RIT. EBRT
can be applied to decrease the tumour size. steroid is highly
recommended
Tg positive WBS negative

99m Tc scan may be done to detect metastasis or empherical RAI

therapy 100-200 mCi may be given.
If Rx WBS is negative ,no further RAI therapy should be
administered.
RAI negative PET positive patients have poor survival.

Hypocalcaemia:
check serum calcium, serum albumin, and PTH .
Calcium with calcitriol is recommended on the basis of
requirement.
 Follow up Schedules

In our centre every 4months interval for two times in first year.
TSH,T4,Tg , anti Tg and USG of neck is recommended during
each follow up.
After one year WBS is recommended.
Another WBS is to be repeated after 2 years of radioiodine
ablation.
Follow up will be scheduled according to severity of the disease
of the patients after 1 year.
 EXTERNAL BEAM RADIOTHERAPY FOR
THYROID CANCER

 There are no randomized control trials defining the indications

for external beam radiotherapy (EBRT) in thyroid cancer.

 In general, only patients with unresectable tumor are treated

with primary EBRT.
 ATA recommends EBRT

• age</=18 yr- metastasis(symptomatic), critical locations

that are otherwise untreatable.

• age 19 to 45 yr-metastasis(symptomatic), critical

locations that are otherwise untreatable.

• age> 45yr- gross extra thyroidal extensions, gross

residual tumor not amenable to further surgery.
FOLLOW UP OF DTC
 Medullary Thyroid Cancer

• These are tumors of parafollicular (C cells), which produce a

hormone called calcitonin
• Types of MTC :
 Sporadic MTC
 Familial MTC
MEN 2A
MEN 2B
Familial Non- MEN
• Surgery is the only definitive therapy of MTC:
Total thyroidectomy
Central node dissection
Ipsilateral modified radical neck
dissection
I 131 MIBG plays a vital role in management of this
tumour.
Recently two TKIs have been approved for treatment of
MTC: Cabozantinib , Vandetanib(CAPRELSA)
 Treatment of familial MTC

• Based on the genetic test for the mutation of RET gene.

• Since different mutations in the RET gene are associated with

variable disease aggressiveness
 this leading to individualized treatment of patient with
inherited MTC
MEN2a and FMTC Rx
Prophylactic thyroidectomy at age 5 to 6 years
MEN2b Rx
Thyroidectomy during infancy
 Anaplastic Cancer of the Thyroid

• It is a very aggressive tumor with a poor prognosis

• A female to male ratio 1.5:1 and a mean age is 67 years
• It is commonest in areas of endemic goiter where there is
chronic iodine deficiency.
• ATC commonly related to prior diagnosis of well
differentiated thyroid cancer .

Clinical Presentation:
• a long-standing goiter that suddenly increases in size.
• Local invasion lead to obstructive symptoms, hemoptysis,
dysphagia and hoarseness
At the time of diagnosis 25 to 50 % of Pt. have synchronous
pulmonary metastases

Rx: In the majority of cases surgery is limited to an open biopsy

to exclude lymphoma.
• External beam radiotherapy (EBRR) as been used with limited
success to treat locally recurrent ATC
• Doxorubicin is the single most effective chemotherapeutic for
ATC
ADVERSE EFFECTS OF IODINE-131
 RADIATION SAFETY AFTER TREATMENT WITH
131I OF PATIENTS

 To release a patient treated with 131I from physician’s control

●The radiation exposure to any other individual (generally,

a family member) encountering the patient will likely not
exceed 5 mSv per annum,

● The radiation dose to a child, a pregnant woman, or an

individual not involved in the care of the patient will not
exceed 1 mSv per annum
 Patients should avoid public transportation.
 The patient must be capable of self-care, cannot live in a
nursing home or communal living facility
 Patients must be given radiation safety instructions.
 Women receiving RAI therapy should avoid pregnancy for at
least 2 years.
 Patients receiving therapeutic doses of RAI should have
baseline CBC and assessment of renal function.
● Patients should sleep alone and at least 6 feet away from any
other individual throughout the night time restricted period.
Use of a separate bedroom or sleeping area would be best.

● Urine is the primary excretion route for RAI and is maximal

during the first 48 hours after treatment. Sufficient fluid (3–4
L/day) should be consumed to enable frequent urination.

● Emptying of the bowel moderately reduces radiation to the

patient and also to individuals nearby.

● Since RAI concentrations are present in the saliva for as long

as 7 days, patients should avoid kissing, especially of children,
for the period.
Thanks for the patient hearing