Thyroid cancer

Июль 24, 2022

Содержание

2. Thyroid cancers ~1% of new cancer diagnoses in the USA each year the incidence is 3
3. Thyroid malignancies classification Thyroid follicular epithelial-derived cancers Papillary carcinomas (PTC) 80% Follicular carcinomas (FTC) 10% Anaplastic
4. Total number of the histological subtypes of thyroid cancer diagnosed per year
5. Clinical picture of thyroid cancer painless, palpable, solitary thyroid nodule ~4-7% of the general population on
6. Investigation of thyroid nodules US of thyroid + TSH TSH depressed TSH normal or high FNA
7. Bethesda system diagnostic categories for reporting thyroid cytopathology
8. Papillary carcinoma the most common thyroid malignancy (80%) well-differentiated, slow-growing produce Thyroglobulin Iodine sensitive may be
9. Follicular carcinoma the second most common (10%) well-differentiated, slow-growing produce Thyroglobulin Iodine sensitive is differentiated from
10. Medullary Carcinoma ~5% of all thyroid malignancies arise from the parafollicular C-cells 25% occur familially (MEN
11. Anaplastic Carcinoma one of the least common (~1.6%) most aggressive and one of the worst survival
12. Surgical treatment of PTC/FTC Tumor no extrathyroidal extension, no LN Tumor 1-4 cm no extrathyroidal extension,
13. Complication of surgical treatment Hemorrhage Infection Reccurent laryngeal nerve injury (up to 10%) Bilateral vocal cord
14. TNM staging of differentiated and anaplastic thyroid carcinoma, 2017
15. Thyroid Cancer Classification: prognostic stage groups
16. Cause-specific survival according to pathologic TNM stage
17. ATA risk stratification to estimate risk of persistent/recurrent disease Low-risk Intermediate-risk High-risk - No local or
18. Monitoring during the first year after thyroid surgery Low-risk Intermediate-risk High-risk Non-stimulated Tg 6 mo Neck
19. Ongoing monitoring after first year
20. Treatment options for recurrent/metastatic disease more extensive resection radioiodine, if scans demonstrate uptake systemic chemotherapy (thyrosine
21. Whole body scan after serial I131 therapies in a patient with PTC
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Thyroid cancers
~1% of new cancer diagnoses in the USA each year

the incidence is 3 times higher in women than in men
the disease peaks in the 3th and 4th decades of life

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Thyroid malignancies classification
Thyroid follicular epithelial-derived cancers
Papillary carcinomas (PTC) 80%
Follicular carcinomas

(FTC) 10%
Anaplastic carcinomas 1-2% (undifferentiated)
Medullary thyroid carcinomas (MTC) 5-10%
Primary thyroid lymphomas (rare)
Primary thyroid sarcomas (rare)
Mts to thyroid

differentiated

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Total number of the histological subtypes of thyroid cancer diagnosed per

year

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Clinical picture of thyroid cancer
painless, palpable, solitary thyroid nodule
~4-7% of the

general population
on US: thyroid nodules in 20-70% of randomly selected individuals
5-10% of solitary thyroid nodules are malignant
solitary nodules are most likely to be malignant in males and patients younger than 30 or older than 60
rapid growth, hoarseness, dysphagia are suspicious
pain generally benign (hemorrhage, s/ac thyroiditis)

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Investigation of thyroid nodules
US of thyroid + TSH
TSH depressed
TSH normal or

high

FNA under US

Tc scan

“Cold” nodule

“Hot” nodule

Follow-up

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Bethesda system diagnostic categories for reporting thyroid cytopathology

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Papillary carcinoma
the most common thyroid malignancy (80%)
well-differentiated, slow-growing
produce Thyroglobulin
Iodine sensitive
may be

multicentric or bilateral (up to 50%)
locally-invasive (trachea,rec. laryngeal nerves, esophagus)
regional metastasis: cervical lymph nodes
(clinically evident LN 30%, microscopic LN 50%)
distant metastasis (5%-10%): lungs, bones
aggressive histology: tall cell, insular, columnar, Hürthle cell

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Follicular carcinoma
the second most common (10%)
well-differentiated, slow-growing
produce Thyroglobulin
Iodine sensitive
is differentiated from

benign follicular adenoma by tumor capsule invasion and/or vascular invasion
locally-invasive
cervical metastases are uncommon
higher rate of distant mts (~20%): lung and bone

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Medullary Carcinoma
~5% of all thyroid malignancies
arise from the parafollicular C-cells
25%

occur familially (MEN 2A, MEN 2B, FMTC)
produce Calcitonin
not sensitive to Iodine
metastasis to the cervical lymph nodes is common (50%)
tumor markers: Calcitonin, CEA
Chemotherapy, TKI-inhibitors
10-year survival rate is 65% overall

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Anaplastic Carcinoma
one of the least common (~1.6%)
most aggressive and one of

the worst
survival rates of all malignancies in general
age 60-70
rapid growth, hoarseness and dyspnea
large and invasive tumor
lung and other mts
most patients die within 1 year
despite all treatment efforts

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Surgical treatment of PTC/FTC
Tumor <1 cm
no extrathyroidal extension, no LN
Tumor 1-4

cm
no extrathyroidal extension, no LN

Tumor >4 cm
or extrathyroidal extension, or LN
or childhood head and neck radiation
or micro-PTC >5 foci

Multifocal
micro-PTC
(<5 foci)
Lobectomy

Total thyroidectomy
+/- LN dissection

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Complication of surgical treatment
Hemorrhage
Infection
Reccurent laryngeal nerve injury (up to 10%)
Bilateral

vocal cord parapysis (0.5%)
Hypoparathyroidism (transient, permanent 2%)
Seroma
Dysphagia

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TNM staging of differentiated and anaplastic thyroid carcinoma, 2017

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Thyroid Cancer Classification: prognostic stage groups

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Cause-specific survival according to pathologic TNM stage

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ATA risk stratification to estimate risk of persistent/recurrent disease
Low-risk
Intermediate-risk
High-risk
- No local

or distant mts
- All macroscopic tumor has been resected
- No aggressive histology
- No vascular invasion
- No 131I uptake outside the thyroid bed
- No or ≤5 pathologic LN

- Microscopic invasion into
the perithyroidal tissues
- Cervical LN mts
- Aggressive histology or
vascular invasion
- >5 pathologic LN < 3 cm
Multifocal micro-PTC with BRAF mutation

- Macroscopic invasion
- Incomplete resection with
gross residual disease
- Distant metastases
- High postoperative TG
- Pathologic LN>3 cm
- FTC with extensive
vascular invasion

Lobectomy/Total
Thyroidectomy
Initial TSH 0.1-0.5 if TG+ 0.5-2.0 if TG- or after lobectomy
Radioiodine ablation not routinely recommended

Total thyroidectomy
Initial TSH 0.1-0.5
Radioiodine ablation suggested to selected patients (microscopic or vascular invasion, significant LN mts, aggressive histology)

Total thyroidectomy
Initial TSH <0.1
Radioiodine ablation recommended

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Monitoring during the first year after thyroid surgery
Low-risk
Intermediate-risk
High-risk
Non-stimulated Tg 6 mo
Neck US 6-12

mo
Diagnostic WBS -
MRI, CT –
PET-CT -

Non-stimulated Tg 6 mo
Neck US 6-12 mo
Diagnostic WBS +/-
MRI, CT –
PET-CT -

Non-stimulated Tg 6 mo
Neck US 6-12 mo
Diagnostic WBS +/-
MRI, CT, PET-CT if Tg elevated or high clinical suspicion

Excellent response: no clinical, biochemical, or structural evidence of disease

Biochemical incomplete response:
Abnormal Tg or rising Tg antibody values

Structural incomplete response:
Persistent or newly-identified locoregional or distant mts

Indeterminate response :
Nonspecific biochemical or structural findings that can’t be classified as either benign or malignant.

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Ongoing monitoring after first year

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Treatment options for recurrent/metastatic disease
more extensive resection
radioiodine, if scans demonstrate uptake
systemic chemotherapy

(thyrosine kinase inhibitors)
external radiotherapy
radiofrequency ablation of cervical, osseous, and pulmonary metastases
palliative embolization of bone metastases

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Whole body scan after serial I131 therapies in a patient with

PTC

Thyroid cancer

Содержание

Thyroid cancers~1% of new cancer diagnoses in the USA each year

Thyroid malignancies classificationThyroid follicular epithelial-derived cancers Papillary carcinomas (PTC) 80%Follicular carcinomas

Total number of the histological subtypes of thyroid cancer diagnosed per

Clinical picture of thyroid cancerpainless, palpable, solitary thyroid nodule~4-7% of the

Investigation of thyroid nodulesUS of thyroid + TSHTSH depressedTSH normal or

Bethesda system diagnostic categories for reporting thyroid cytopathology

Papillary carcinomathe most common thyroid malignancy (80%)well-differentiated, slow-growingproduce ThyroglobulinIodine sensitivemay be

Follicular carcinomathe second most common (10%)well-differentiated, slow-growingproduce ThyroglobulinIodine sensitiveis differentiated from

Medullary Carcinoma~5% of all thyroid malignanciesarise from the parafollicular C-cells 25%

Anaplastic Carcinomaone of the least common (~1.6%)most aggressive and one of

Surgical treatment of PTC/FTCTumor <1 cmno extrathyroidal extension, no LNTumor 1-4

Complication of surgical treatmentHemorrhageInfectionReccurent laryngeal nerve injury (up to 10%) Bilateral