APPROACH TO MANAGEMENT OF THYROID CANCER

1. ‫ا‬َ‫ه‬ُّ‫ي‬َ‫أ‬ٰٓ‫ـ‬َ‫ي‬ََ‫ين‬ِ‫ذ‬َّ‫ٱل‬َ‫وا‬ُ‫ن‬َ‫م‬‫ا‬َ‫ء‬َ‫وا‬ُ‫ن‬‫ي‬ِ‫ع‬َ‫ت‬ ۡ‫ٱس‬َِ‫ر‬ۡ‫ب‬َّ‫ص‬‫ٱل‬ِ‫ب‬ََّ‫ص‬‫ٱل‬ َ‫و‬َِۚ‫ة‬‫و‬َ‫ل‬ََّ‫ن‬ِ‫إ‬ََ َّ‫ٱّلل‬ََ‫ع‬َ‫م‬ََ‫ين‬ ِ‫ر‬ِ‫ب‬‫ـ‬َّ‫ص‬‫ٱل‬
O you who believe! Seek help in patience and
As-Salât (the prayer). Truly! Allâh is with As-
Sâbirun (the patient.) (153)

2. Approach to thyroid CA

3. Approach to
thyroid cancer
● Papillary thyroid
cancer(PTC)
● Follicular thyroid
cancer(FTC)
● Anaplastic thyroid
cancer(ATC)
● Medullary thyroid
cancer(MTC)

4. Epidemiology
● Incidence is 9 cases/100000
persons per year
● 90-95 % are PTC and FTC
● More common in female

5. Risk factors
● External head and neck radiation
● Family H/O of thyroid cancer/MEN -2
● Iodine deficiency

6. Clinical diagnosis
● Thyroid nodule
● Incidentaloma
● Cervical lymphadenopathy

7. Obstructive symptoms
● Dysphagia
● Hoarseness
● Dyspnea

8. Other symptoms
● Metastasis to lung and
bone
● ATC presents as rapidly
enlarging thyroid mass

9. MTC
● ACTH
● Calcitonin

10. D/D
● Solitary thyroid nodule
● Multinodular goiter
● Cyst
● Thyroiditis

11. Diagnosis approach
● FNAC
● Surgical pathology

12. Laboratory tests
● TSH
● Thyroglobulin-
● Calcitonin

13. USG neck
● Accurate needle placement
● Potential metastatic lymph node
● Planning nodal dissection
● Identification of recurrent
disease

14. Thyroid ultrasound of a
nonpalpable recurrent papillary
thyroid carcinoma

15. Radioactive whole body scan
● To identify recurrent/residual
disease
● To identify bone and soft tissue
metastasis

16. CT/MRI neck
● Identify soft tissue extension
● Cervical lymph node
metastasis

17. PET scan
● To identify sites of distant
metastases

18. FNAC
● Accurately detects PTC
● May not distinguish between
benign and malignant follicular
lesions

19. Papillary thyroid cancer: Findings on
FNAC

20. Treatment modalities
● Surgery
● L-thyroxin
● Radioiodine treatment
● Chemotherapy
● External beam radiation

21. Near total thyroidectomy
● Age <15 >45
● History of radiation
● Known distant metastasis
● B/L disease
● Extrathyroid invasion
● Tumour size >4 cm
● Cervical lymph node metastases
● Family H/O of thyroid CA

22. Lobectomy
Stage I disease

23. Lobectomy
Advantages
• Low risk of
hypoparathyroidism
• Low risk of hypothyroidism
• Low risk of injuring recurrent
laryngeal nerve
Disadvantages
• Inability to monitor for
residual/recurrent
disease with
thyroglobulin

24. TSH suppression
therapy
● Low risk of recurrence TSH should be
suppressed to low but detectable range
● High risk of recurrence or with known
distant metastasis complete suppression
is indicated
● Most patients with stage I PTC/primary
tumors<1.5cm

25. Radioactive iodine
● Post surgical ablation of residual
thyroid tissue
● Treatment of residual or recurrent
thyroid cancer

26. Indication for radioactive
iodine treatment
● Larger papillary carcinomas
● FTC
● Evidence of metastases

27. External beam radiotherapy
● Treatment of specific
metastatic lesion

28. ATC and other forms of
thyroid cancer
● Multimodal therapy may be
beneficial
● Radioactive iodine can be used if
there is residual uptake
● Palliative chemotherapy can be used

29. MTC
● Surgical excision
● External beam radiation can be
used for local metastases in neck
● Palliative chemotherapy

30. Ongoing care
● TSH suppression therapy

31. Monitoring for
recurrence
● Iodine 131 /whole body scan or
thyroid USG
● Measurement of serum Tg

32. Surveillance
● Physical examination every 3-6
months for 2 years and then
annually if disease free
● TSh and Tg at 6 and 12 months
and then annually if disease free
● Radioiodine scan every year until 1
negative scan

33. MTC monitoring
● Annual measurement of
calcitonin and CEA
● Periodic USG
● Octreotide scan to localise
metastatic lesion

34. Take home message
● PTC and FTC are most common
● USG guided FNAC is diagnostic
● Surgery can be almost curative
● Needs long term F/U

35. References
Uptodate 2015
Harrisons principles of internal
medicine