MALIGNANT THYROID DISEASE

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MALIGNANT THYROID DISEASE

• Dr. ADEFEMI O. AFOLABI
• DIVISION OF HEPATOBILIARY AND ENDOCRINE SURGERY,
• DEPARTMENT OF SURGERY,
• COLLEGE OF MEDICINE,
• UNIVERSITY OF IBADAN,
• UNIVERSITY COLLEGE HOSPITAL,
• IBADAN, NIGERIA.

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INTRODUCTION

• DISTRIBUTION OF PATHOLOGICAL CLASSES
• ( AN AMERICAN POPULATION)
• PAPILLARY 67
• FOLLICULAR 18
• MEDULLARY lt10
• ANAPLASTIC 10-15

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INTRODUCTION

• HISTOPATHOLOGY OF THYROIDECTOMY
• SPECIMENS U.C.H., IBADAN (1981-1990)
• NEOPLASTIC GOITRE 26.24
  
• MALIGNANT GOITRE 10.77
• FOLLICULAR 50.58
• PAPILLARY 34.48
• MEDULLARY 9.2
• ANAPLASTIC 2.3
• METASTATIC 2.3
• TERATOMA 1.15

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PAPILLARY CARCINOMA

• EPIDEMIOLOGY
• CLINICAL FEATURES
• PATHOLOGY
• TREATMENT

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EPIDEMIOLOGY

• 2/3 OF ALL THYROID CARCINOMA
• ¾ OF CHILDHOOD THYROID CA.
• 90 OF POST-RADIATION CA.
• PEAK INCIDENCE-3RD 4TH DECADE
• FEMALEMALE-31

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CLINICAL FEATURES

• MOSTLY EUTHYROID
• GOITRE WITH CERVICAL LYMPHADENOPATHY ESPECIALLY
  IN YOUNG PATIENTS
• ADVANCED LESION-DYSPHAGIA, DYSPNOEA, HOARSENESS
• MORE VIRULENT IN THE ELDERLY

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PAPILLARY CARCINOMA
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PATHOLOGY

• PAPILLARY STRUCTURES WITH CROWDED VESICULAR
  NUCLEI
• PSAMMOMA BODIES
• MULTICENTRIC CONTRALATERAL FOCI
• LYMPHATIC SPREAD, LOCAL SPREAD
• LATERAL ABERRANT THYROID REST
• OCCULT PAPILLARY CA.-lt1.5CM

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TREATMENT

• DIFFERENT OPINIONS
• MINIMAL PAPILLARY CA-lt1CM,INCIDENTALOMA-LOBECTOMY
• STANDARD TOTAL THYROIDECTOMY MODIFIED RADICAL
  NECK DISSECTION
• RADIOACTIVE IODINE THERAPY
• -THYROGLOBULIN TUMOUR MARKER

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PROGNOSIS

• DNA ANEUPLOIDY-AGGRESSIVE
• LOW RISK GROUP(85)
• -2 MORTALITY
• HIGH RISK GROUP(15)
• -46 MORTALITY
• AGE, GRADE, EXTENT, SIZE (A.G.E.S.)
• AGE, METASTASIS, EXTENT, SIZE
• (A.M.E.S.)
• CHICAGO-INCL. ALL DATA, TOTAL BODY SCAN _at_6/12
  POST-OP.

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FOLLICULAR CARCINOMA

• EPIDEMIOLOGY
• PATHOLOGY
• CLINICAL FEATURES
• TREATMENT PROGNOSIS

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EPIDEMIOLOGY

• lt25 OF THYROID CARCINOMA
• OLDER AGE GROUP
• PEAK IN 5TH DECADE
• FEMALEMALE -31

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PATHOLOGY

• FOLLICLES OF CROWDED CELLS
• CAPSULAR AND VASCUAR INVASION
• MOST UNICENTRIC
• LESS LYMPHATIC SPREAD
• HAEMATOGENOUS SPREAD
• -BONE,LUNG, LIVER

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CLINICAL FEATURES

• LONG HISTORY OF GOITRE
• LATE FEATURES-PAIN LOCAL INVASION
• SELDOM LYMPHADENOPATHY
• DISTANT METASTASIS-BONE
• - CONCENTRATE IODINE

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FOLLICULAR CARCINOMA(M. Shutgens, University of
Malawi)
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TREATMENT

• HEMITHYROIDECTOMY ISTHMUSECTOMY-YOUNG PT.
  MINIMAL CAPSULAR INVASION
• OLDER PATIENT- NEAR-TOTAL/TOTAL THYROIDECTOMY
• -POST-OP. SCANNING
• LOCAL METASTASIS- NECK DISSECTION

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PROGNOSIS

• MORE VIRULENT cf PAPILLARY CA.
• 10-YR SURVIVAL RATE
• -72 (BLACK ET AL)
• -WITHOUT INVASIVENESS- 86
• -WITH INVASIVENESS- 44

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OTHER TREATMENTS OF D.T.C.

• l-THYROXINE
• RADIOIODINE THERAPY- 131I
• EXTERNAL RADIATION- LOCAL INVASION
• CHEMOTHERAPY- 131I RESISTANT DISTANT MET.-
  DOXORUBICIN

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HURTHLE CELL TUMOURS

• VARIANTS OF FOLLICULLAR
• NEOPLASM- MORE DIFFICULT TO TREAT-DOES NOT
  CONC. IODINE
• CONTROVERSIAL TREATMENT
• -BENIGN- LOBECTOMY
• -CARCINOMA- TOTAL
• THYROIDECTOMY

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MEDULLARY CARCINOMA

• C-CELL CALCITONIN PRODUCING TUMOUR
• PATHOLOGY-CELL CLUSTERS, AMYLOID
• -SPORADIC SINGLE NODULES
• -FAMILIAL BILATERAL, MULTICENTRIC
• -SPREAD- LYMPHATIC
• -LATER DISTANT SPREAD-BONE, LUNGS,
• LIVER,ADRENALS
• MEDULLARY CANCER SYNDROME
• M.E.N.- II A, M.E.N.- II B

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CLINICAL FEATURES

• NO SEX PREDILECTION
• AGE-2-80 YEARS
• FAMILIAL- MEDIAN AGE- EARLY 20S
• MOST ARE SPORADIC
• FAMILIAL-AUTOSOMAL DOMINANT
• GENE- CHROMOSOME 10

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CLINICAL FEATURES

• DIARRHOEA
• EPISODIC FLUSHING
• ASSOCIATED WITH
• -CUSHINGS SYNDROME
• -RENAL STONES
• -PHAEOCHROMOCYTOMA

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FAMILIAL MEDULLARY THYROID Ca.

• M.E.N. IIA
• MULTICENTRIC TH. CA
• PHAEOCHROMOCYTOMA
• PRIMARY HYPERPARATHYROIDISM

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FAMILIAL MEDULLARY THYROID Ca.

• M.E.N. II B
• MEDULLARY CARCINOMA
• PHAEOCHROMOCYTOMA
• MUCOSAL NEUROMAS
• BOWEL GANGLIONEUROMAS
• MARFAN-LIKE HABITUS

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DIAGNOSIS

• ELEVATED SERUM CALCITONIN
• SCREENING OF FAMILY MEMBERS
• SERUM CALCIUM
• SERUM CATECHOLAMINE, URINARY VMA
• CARCINOEMBRYONIC ANTIGEN.

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TREATMENT

• TOTAL THYROIDECTOMY
• LYMPH NODE DISSECTION
• ADRENALECTOMY-BILATERAL EXCEPT IN CHILDREN
• REPLACEMENT THERAPY- ADRENOCORTICAL HORMONES IN
  CHILDREN- FOLLOW-UP OTHER ADRENAL
• PARATHYROIDECTOMY-LEAVE ONE GLAND

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PROGNOSIS

• MAYO CLINIC
• -5-YR SURVIVAL-80
• -10-YR- 57 WITH LYMPH
• NODE METASTASIS
• -68 WITHOUT METASTASIS
• OTHER INSTITUTION
• - OVERALL 5-YR SURVIVAL-
• 55

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ANAPLASTIC CARCINOMA

• EPIDEMIOLOGY- 5-10
• PATHOLOGY-SHEETS OF UNDIFFERENTIATED SMALL OR
  GIANT CELLS
• CLINICAL FEATURES-AIRWAY OBSTRUCTION, DYSPHAGIA
• TREATMENT- RADIOSENSITIVE
• PROGNOSIS- POOR

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LYMPHOMA

• EPIDEMIOLOGY
• CLINICAL FEATURES
• TREATMENT- RADIOTHERAPY
• PROGNOSIS

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METASTATIC CARCINOMA

• EPIDEMIOLOGY
• TREATMENT
• PROGNOSIS