By Jae

Most common malignancy of endocrine system

Malignant tumors derived form follicular

epithelium are classified according to histologic features 2 main types Differentiated tumors Anaplastic Thyroid Cancer (ATC)

Differentiated tumors
Example: Papillary Thyroid Cancer (PTC) Follicular Thyroid Cancer (FTC) Often Curable Good prognosis with patients identified with early-stage disease

ATC (Anaplastic Thyroid Cancer) aggressive responds poorly to treatmnet bad prognosis

Epidemiology
9/ 100,000 per year
Increase with age, Plateauing after 50

years, <20 & > 50 with worse prognosis Women more common but men worse prognosis

Risk factors
History of head and neck irradiation
Age <20, > 45 years Bilateral disease Nodule > 4cm New and enlarging neck mass

Male sex
Famility history of thyroid cancer or MEN-2

Vocal cord paralysis, hoarseness

Nodule fixed to adjacent structure

Extrathyroidal extension
Suspected lymph node involvent

Iodine deficiency (follicular cancer)

Unique features of TC facilitate management

Thyroid nodules are readily palpable, allow early

detection & biopsy Iodine radioisotopes can be used to diagnose (123I) & to treat (131-I) differentiated TC, reflecting the unique uptake of this anion by the thyroid gland Serum markers allows detection of residual/ recurrent Thyroglobulin (Tg) for PTC, FTC Calcitonin (Medullary Thyroid Cancer) (MTC)

TC classification
- by American Joint Committee on Cancer (AJCC)

PTC/ FTC
STAGE I II III IV < 45 YEARS Any T, any N, M0 Any T, any N, M1 > 45 YEARS T1, N0, M0 T2/ T3, N0, M0 T4, N0, M0 Any T, N1, M0 Any T, any N, M1

ATC Stage IV All cases are stage IV Medullary Thyroid Cancer Stage I T1,N0, M0 Stage II T2-4, N0, M0 Stage III Any T, N1, M0 Stage IV Any T, Any N, M1

T (Size and extent) T1 1cm T2 1-4 cm T3 > 4CM T4 Direct invasion through thyroid capsule N NX cant be assessed N0 NO regional node involvement N1 Presence of regional node involvement N1a pretracheal, paratracheal, prelaryngeal LN N1b unilateral, bilateral, contralateral cervical/ retropharyngeal/ superior mediastinal LN M MO NO distant metastasis M1 distant metastasis

Management (for well-differentiated tumors) 1. Surgery

2. TSH suppression therapy

3. RadioIodine Treatment
4. External beam radiotherapy

Surgery
- Near-total thyroidectomy is preferable to almost all patients - Although lobectomy might be enough, but it is not possible to monitor Tg levels/ perform whole body scans in the presence of residual lobe. - Post- surgical radioablation to remove remnant thyroid tissue

TSH suppression therapy

most tumors are TSH-responsive, so give

Levothyroxine to suppress TSH Aim: maintain euthyroid state Avoid excess TH side effects ( atrial fibirllaiton, osteopenia, anxiety, thyrotoxicosis) Monitor unbound T4 TSH 0.1-0.5mIU/L In case of high risk recurrent, complete TSH suppression is indicated if no CI

Radioiodine Treatment
Aim: to eliminate remaining normal thyroid

tissue and to treat residual tumors cells Indications: patients with large papillary tumors spread to adjacent LNs FTC evidence of metastasis

For ablation, there are few ways to increase radioiodine reuptake: 1.Treat several weeks with liothyronine Withdraw TSH increase over 3-4 weeks 2.Give Recombinant Human TSH (rhTSH) 3.Low iodine diet

Follow-up
Initial whole-body scan 6 months after

thyroid ablation TH withdrawal / rhTSH can be used to stimulate Tg & 131-I reuptake measure Tg to check for any residual tumors

External beam Radiotherapy

Treat specific metastatic lesions
Bone pain Neurologic injury (vertebral metastasis)

Treatment for ATC

Patients die within 6-8 months
1.Radioiodine ablation if there is reuptake

presence 2.External beam radiation therapy if responsive 3.Chemotherapy usually ineffective

Thyroid lymphoma
usually due to Hashimtos thyroiditis
Most common: diffuse large-cell lymphoma External radiation is the method of choice

sensitive Avoid surgical resection as may spread the disease

MTC
Sporadic/ familial (More aggressive)
3 familial forms
MEN 2A MEN 2B (more aggressive) Familial MTC without other features of

MEN MEN Medullary Endocrine Neoplasia

 Elevated serum calcitonin as marker of

residual/ recurrent Test all patients with MTC for RET mutations if positive, test all family member Management surgical only. MTC do not reuptake iodine. Palliative treatment in advanced cases chemo and external radiation.