Thyroid Cancer -- Papillary

1
Thyroid Cancer -- Papillary

• Papillary Carcinoma
• 80 of thyroid cancers
• Follicular variant of papillary has same behavior
• Average age 30 -40
• Women twice as frequent as men
• Most common thyroid malignancy in children
• Most common after low dose radiation

2
Thyroid Cancer -- Papillary

• Papillary Carcinoma
• Psammoma bodies, intranuclear cytoplasmic
  inclusions (Orphan Annie nuclei)
• Poor prognosis, aggressive, radioiodine
  resistant
• Tall cell, insular, columnar, clear cell variants
• Multicentric
• Intrathyroidal lymphatic spread
• Cervical Lymph node spread

3
Thyroid Cancer -- Papillary

• Papillary Carcinoma
• 88 10 year survival without treatment
• 98 10 year survival with thyroidectomy / RAI
• 95 20 year survival with thyroidectomy / RAI
• But, 35 5 year survival for radioresistant
  variants (tall cell, insular, columnar) or
  extensive radioresistant differentiated tumors

4
Thyroid Cancer -- Papillary

• Papillary Carcinoma
• Lower risk
• Men age 20 - 40, Women age 20-50
• Tumor lt 1 cm - 1.5 cm
• Unilateral thyroidectomy and isthmusectomy
• Recurrence risk 7
• 50 mortality in 15-25 years if recurrence
• Berry picking of gross lymph nodes
• LNs present in 30 of all papillary CAs
• LNs present in 90-100 if age lt15

5
Thyroid Cancer -- Papillary

• Papillary Carcinoma
• Higher risk
• Age
• Aggressive variants
• Size gt 1.5 cm or extends beyond capsule of
  thyroid
• Cervical LNs or distant mets
• 20 pulmonary mets if age lt 15
• Radiation history
• Total thyroidectomy, LN berry picking
• Children often require mod. neck dissections

6
Thyroid Cancer -- Papillary

• Papillary Carcinoma
• Post-thyroidectomy follow-up
• Thyroglobulin
• RAI (I-131)
• Not useful in radioresistant variants
• 20 of all papillary CAs do not trap RAI
• Many patients over 60 have radioresistant CAs
• Not useful if normal thyroid tissue remains
• Initial scan 6 weeks after thyroidectomy

7
Thyroid Cancer -- Papillary

• Papillary Carcinoma
• RAI identified LNs or residual thyroid
• Resect if palpable
• Often implies good prognosis if enlarging in
  post-op period due to increased post-op TSH
• High dose ablative I-131 if no palpable disease
  but suspect residual tumour other than
• Ligament of Berry
• Can be used repeatedly, and can ablate pulmonary
  mets, if used early

8
Thyroid Cancer -- Papillary

• Therapeutic radioactive I-131
• 2-3 days in hospital
• Start levothyroxine 2-3 days after treatment
• F/U scan in 1 year
• Treat and repeat each year until gone

9
Thyroid Cancer -- Follicular

• Follicular CA
• 10 of thyroid CAs (increased with goiter)
• Hurthle cell variant is 2 of thyroid CAs
• Hematogenous spread early
• Locoregional / lymph node spread late
• 5 of follicular CAs have LN spread
• Average age 50
• WomenMen 31
• Generally radiosensitive

10
Thyroid Cancer -- Follicular

• Follicular CA
• Low risk
• Age lt 40
• Low grade encapsulated (microinvasion)
• Negative bone scan
• FNA follicular cells
• Ipsilateral thyroidectomy/isthmusectomy
• Frozen section to check if extension through
  capsule, then total thyroidectomy
• Total thyroidectomy if gt 4 cm (80 malignancy)

11
Thyroid Cancer -- Follicular

• Follicular CA
• Low risk
• Tc-99 bone scan following lobectomy
• low recurrence rate if negative and small tumor
  with no capsule macroinvasion
• does not need total thyroidectomy
• Followup 1 year RAI scan
• 6 week post-op RAI scan after total thyroidectomy

12
Thyroid Cancer -- Follicular

• Follicular CA
• High risk
• Age gt 50
• Macroinvasion, size gt 4 cm
• Distant mets or regional LNs
• Thyroidectomy
• 6 week F/U I-131 scan then I-131 ablation as
  indicated

13
Thyroid Cancer -- Follicular

• Follicular CA
• 70 10 year survival without treatment
• 85-90 10 year survival with thyroidectomy / RAI
• 70 20 year survival with thyrodiectomy / RAI

14
Thyroid Cancer -- Hurthle

• Hurthle cell aggressive variant of follicular
• Radioresistant (does not take up RAI)
• LN spread as well as hematogenous to bone / lung
• Produces thyroglobulin
• FNA Hurthle cell --gt lobectomy
• If age gt 50 or macroinvasion or gt 4 cm or LNs or
  mets then total thyroidectomy
• If central LNs, resect them
• If lateral LNs, then mod. rad. neck dissection
• RAI , radiation, chemo not useful for mets

15
Thyroid Cancer -- Medullary

• Medullary CA
• 7 of thyroid tumors
• Sporadic cases are 70 - 80
• Usually solitary nodule
• Average age gt 30
• Hereditary case are 20 - 30
• Bilateral, multicentric
• MEN IIa -- pheochromocytomas, parathyroids
• MEN IIb -- pheochromocytoma, neurofibromas
• more aggressive medullary CA
• starts around age 2