This document outlines the TNM staging system for thyroid malignancies and describes treatment approaches for the main types of thyroid cancer. It discusses staging based on tumor size and extent, node involvement, and presence of metastases. Total thyroidectomy is the primary treatment for papillary and follicular carcinomas to allow for radioiodine ablation and TSH suppression. Lobectomy may be an option for smaller papillary cancers. Lymph nodes are typically removed through functional neck dissection. Anaplastic carcinoma has a low resectability rate due to local invasion, and radiotherapy is used palliatively. Total thyroidectomy with radical neck dissection is recommended for medullary carcinoma.

1. THYROID MALIGNANCY
TREATMENT
-NISHMITA.T.J
33

2. TNM Staging
• Tumour
Tx: Primary cannot be assessed.
T0: No evidence of primary.
T1: Limited to thyroid, 2cm or less.
T1a:</=1cm
T1b:1cm </=2cm
T2:Limited to thyroid>2cm but <4cm.
T3:Limited to thyroid >4cm.
T4:Extending beyond the capsule any size.
T4a: moderately advanced
T4b:very advanced

3. • Nodes
Nx: Cannot be assessed.
N0: No regional node metastasis.
N1: Regional node metastasis.
N1a: level VI
N1b:any level
• Metastases
Mx: Cannot be assessed.
M0: No metastasis.
M1:Metastasis is present.

4. Stage under 45 yrs
I. Any T, any N,M0
II. Any T, any N,M1
III.
IVA.
IVB.
IVC
Over 45 yrs
T1,N0,M0
T2,N0,M0
T3,or T1,T2&N1a,M0
T4orT1,T2,T3,T4a&N1b,M0
T4b,anyN,M0
AnyT,anyN,M1

5. Papillary carcinoma thyroid
• Treatment of primary
A.Total thyroidectomy
-Treatment of choice.
-Entire thyroid gland is removed.
-Reasons:
a. Rich intrathyroidal lymphatic spread.
b. Multicentric origin.

7. Procedure
]
• Horizontal anterior neck incision
• Create upper and lower flaps between
the platysma and strap muscles
• Divide vertically between the strap
muscles and anterior jugular veins
• Separate the strap muscles from the
thyroid gland
• Divide the middle thyroid vein

8. • Mobilize the superior pole of the thyroid lobe. Divide
the superior thyroid artery and vein close to the
thyroid gland (avoid injury to the external branch of
the superior laryngeal nerve and the superior
parathyroid gland)
• Identify the recurrent laryngeal nerve whenever
possible using the nerve monitoring device
• Identify the inferior parathyroid artery
• Divide the inferior thyroid artery and vein

9. • Separate the thyroid lobe and isthmus from the
trachea
• Repeat this process for the other thyroid lobe.
Remove the thyroid gland
• Reapproximate the strap muscles
• Reapproximate the platysma muscle
• Close the skin with a subcuticular stitch

10. -Advantages:
1. Easy to detect and treat residual and
metastatic diseases.
2. Eliminates contralteral occult cancer.
3. Eliminates resurgery.
4. Eliminates risk of recurrence, thus improving
survival.
.

11.  After total thyroidectomy, thyroxine is not
given for a period of 4 weeks so that thyroid
remnants can be ablated with radioiodine.
Dose:30-100mCi.

12. B. Lobectomy
-Removal of one lobe and entire isthumus.
-Total thyroidectomy is recommended for
tumours greater than 2 cm and those with
nodal involvement or metastasis.
-So lobectomy can be done for the remainder.

13. Advantages of lobectomy:
a. No hormone replacement therapy.
b. No hypoparathyroidism.
c. Need not test thyroid function tests regularly.

14. • Treatment of secondaries in the lymph
nodes
Mostly central neck nodes are cleared. If
nodes are enlarged in the anterior triangle
they are dissected and removed along with fat
and fascia. This is called functional block
dissection.
Structures such as internal jugular vein,
sternomastoid muscle, accessory nerves are
not removed because lymph nodes are slow
growing and they rarely spread outside the
capsule of the node.

15. • Suppression of the TSH
This is an aspect in the postoperative period
because papillary carcinoma is a TSH
dependent tumour.
 To prevent the patient developing
hypothyroidism in the post op period and to
suppress TSH, thyroxine 0.3 mg/day is given.

16. Patients who require regular radioiodine for
scanning and ablation should be given T3
because it acts quickly and can be stopped
and restarted quickly.
On the other hand, T4 has to be stopped
almost 30 days prior to scanning and ablation
rendering patients severely hypothyroid for 4
weeks. Dose:40-60micro gm/day.

17. Follicular carcinoma
• Treatment of primary
 When a patient has enlarged thyroid gland
and scalp swelling, total thyroidectomy is the
treatment of choice.
 Secondaries donot take up the radioisotope
in the presence of primary tumour. Hence
lobectomy or hemithyroidectomy should not
be done.

18. • Treatment of metastasis
After total thyroidectomy a whole body bone
scan is done to look for metastasis in the
bone.
The secondaries can be treated by oral
radioiodine therapy.

19. • Postoperative thyroxine
In the post op period patient should receive
thyroxine 0.3mg/day to suppress TSH and to
supplement thyroxine.

20. Anaplastic carcinoma
• Due to the gross local infiltration into the vital
structures in the neck such as common crotid
artery and trachea, the resectabilty rate is low.
• However rarely isthumus can be excised so as
to relieve compression of the trachea.
• Post operative radiotherapy is given as a
palliative treatment.

21. Medullary carcinoma of thyroid
• Total thyroidectomy with radical neck
dissection.
• The lymph nodes are treated by radical block
dissection because they are fast growing when
compared to papillary carcinoma.
• If there are multiple secondaries in the bone,
oral 131I has no role because this tumour
does not arise from thyroid cells. Only
palliative radiotherapy can be given.