Thyroid Cancers

Question 1

papillary cancer.

Answer 1

Fine needle aspirate of a thyroid nodule showing papillary cancer. The cells and nuclei are large, and their cytoplasm has a “ground glass” appearance. Nucleoli are prominent and the nuclei have clefts, grooves, and “holes” due to intranuclear cytoplasmic inclusions (“Orphan Annie eyes”).

Question 2

Papillary carcinoma: Findings on surgical histology

Answer 2

Surgical specimen showing the classic histologic appearance of papillary cancer with papillary structure and no follicles or colloid. Follicular development can be seen in some of these carcinomas (follicular variant of papillary cancer); in them, the diagnosis is made from the cytologic features of the cells.

Question 3

Sporadic macrofollicular goiter with normal macrofollicles: Findings on surgical histology

Answer 3

Surgical specimen of a sporadic macrofollicular goiter with normal large thyroid follicules filled with colloid. These follicles are disrupted by needle biopsy so that the colloid will smear across the slide or occassionally aggregate into droplets.

Question 4

Papillary cancer Risk Factors / Clinical Signs

Answer 4

RISK FACTORS
Radiation exposure
Family history – Thyroid cancer - familial polyposis, Carney Complex, MEN2, Werner Syndrome, or Cowden syndrome up to 10-fold increased risk of thyroid cancer
Clinical signs -

• rapid growth
• thyroid nodule fixed surrounding tissues
• new onset hoarseness or vocal cord paralysis
• Ipsilateral cervical lymphadenopathy should all raise the

Question 5

American Thyroid Association Papillary thyroid Risk of recurrence

Answer 5

Low (papillary thyroid cancer confined to thyroid),

Intermediate regional metastases, worrisome histologies, extrathyroidal extension, or vascular invasion),

High (gross extrathyroidal extension, or distant metastases) risk of recurrence

Question 6

Papillary and Follicular Thyroid Cancer in Patients Younger than 45 Years of Age

Stage I Papillary and Follicular

Answer 6

the tumor is any size, may be in the thyroid, or may have spread to nearby tissues and lymph nodes. Cancer has not spread to other parts of the body.

Question 7

Papillary and Follicular Thyroid Cancer in Patients Younger than 45 Years of Age

Stage II Papillary and Follicular

Answer 7

Tumor is any size and cancer has spread from the thyroid to other parts of the body, such as the lungs or bone, and may have spread to lymph nodes - See more at: http://thyca.org/about/types/#6_STAGEEXPLANATION

Question 8

Papillary and Follicular Thyroid Cancer in Patients Older than 45 Years of Age:

Stage I Papillary and Follicular

Answer 8

cancer is found only in the thyroid and the tumor is 2 centimeters or smaller - See more at: http://thyca.org/about/types/#6_STAGEEXPLANATION

Question 9

Papillary and Follicular Thyroid Cancer in Patients Older than 45 Years of Age:

Stage II Papillary and Follicular

Answer 9

cancer is only in the thyroid and the tumor is larger than 2 centimeters but not larger than 4 centimeters

Question 10

Papillary and Follicular Thyroid Cancer in Patients Older than 45 Years of Age:

Stage III Papillary and Follicular

Answer 10

the tumor is larger than 4 centimeters and only in the thyroid or the tumor is any size and cancer has spread to tissues just outside the thyroid, but not to lymph nodes; or the tumor is any size and cancer may have spread to tissues just outside the thyroid and has spread to lymph nodes near the trachea or the larynx (voice box)

Question 11

Papillary and Follicular Thyroid Cancer in Patients Older than 45 Years of Age:

Stage IV Papillary and Follicular

Answer 11

In stage IVA, either of the following is found:
the tumor is any size and cancer has spread outside the thyroid to tissues under the skin, the trachea, the esophagus, the larynx (voice box), and/or the recurrent laryngeal nerve (a nerve with two branches that go to the larynx); cancer may have spread to nearby lymph nodes; or
the tumor is any size and cancer may have spread to tissues just outside the thyroid. Cancer has spread to lymph nodes on one or both sides of the neck or between the lungs.
In stage IVB, cancer has spread to tissue in front of the spinal column or has surrounded the carotid artery or the blood vessels in the area between the lungs; cancer may have spread to lymph nodes.
In stage IVC, the tumor is any size and cancer has spread to other parts of the body, such as the lungs and bones, and may have spread to lymph nodes

Question 12

Medullary Thyroid Cancer

Stage 0 medullary

Stage I medullary

Stage II medullary

Stage III medullary

Stage IV medullary

Answer 12

Medullary Thyroid Cancer

Stage 0 medullary

Stage 0 medullary thyroid cancer is found only with a special screening test. No tumor can be found in the thyroid.

Stage I medullary

Stage I medullary thyroid cancer is found only in the thyroid and is 2 centimeters or smaller.

Stage II medullary

In stage II medullary thyroid cancer, either of the following is found:

the tumor is larger than 2 centimeters and only in the thyroid; or
the tumor is any size and has spread to tissues just outside the thyroid, but not to lymph nodes.
Stage III medullary

In stage III medullary thyroid cancer, the tumor is any size, has spread to lymph nodes near the trachea and the larynx (voice box), and may have spread to tissues just outside the thyroid.

Stage IV medullary

Stage IV medullary thyroid cancer is divided into stages IVA, IVB, and IVC.

In stage IVA, either of the following is found:
the tumor is any size and cancer has spread outside the thyroid to tissues under the skin, the trachea, the esophagus, the larynx (voice box), and/or the recurrent laryngeal nerve (a nerve with 2 branches that go to the larynx); cancer may have spread to lymph nodes near the trachea or the larynx; or
the tumor is any size and cancer may have spread to tissues just outside the thyroid. Cancer has spread to lymph nodes on one or both sides of the neck or between the lungs.
In stage IVB, cancer has spread to tissue in front of the spinal column or has surrounded the carotid artery or the blood vessels in the area between the lungs. Cancer may have spread to lymph nodes.
In stage IVC, the tumor is any size and cancer has spread to other parts of the body, such as the lungs and bones, and may have spread to lymph nodes.
- See more at: http://thyca.org/about/types/#6_STAGEEXPLANATION

Question 13

Histologic subtypes of papillary carcinoma

Follicular variant

Answer 13

Follicular variant is probably the most common, accounting for about 10 percent of all papillary cancers

These tumors are characterized by small to medium-sized follicles, typical of follicular tumors. Cytologically, however, they display the typical features of common-type papillary cancers, including large overlapping nuclei with hypodense chromatin, nuclear pseudoinclusions, and nuclear grooves; most also contain psammoma bodies

overall rates of recurrence and survival in patients with these tumors are very similar to those of patients with common-type papillary cancers

Question 14

Histologic subtypes of papillary carcinoma

Tall-cell variant

Answer 14

Tall-cell variant form of papillary cancer is a more aggressive tumor than common-type papillary cancer

Approximately 1 percent of papillary cancers. They are characterized by tumor cells with eosinophilic cytoplasm that are twice as tall as they are wide. The primary tumors tend to be large, they are often invasive, and many patients have both local and distant metastases at the time of diagnosis

Question 15

I 131 scanning and therapy

What food to avoid what to eat?

Answer 15

Foods to avoid for two weeks before 131-I scanning and treatment

• Iodized salt or sea salt, including salty snacks
• Milk or other dairy products (small amounts in prepared foods are allowed)
• Eggs (small amounts in prepared foods are allowed)
• Seafood, especially shellfish, kelp, or seaweed
• Any item with added carrageen, agar-agar, algin, or alginates
• Cured foods, such as ham, corned beef, and sauerkraut
• Breads (usually white breads) made from iodate dough conditioners
• Foods and medicine (eg, vitamin-mineral tablets) containing red food dyes
• Chocolate
• Molasses
• Soy products
• Restaurant foods and Asian food
• Pizza
• Chili

Foods allowed

• Fresh meat
• Poultry
• Potatoes or rice
• Wheat or rye bread
• Fresh or frozen vegetables
• Fresh or frozen fruit

Question 16

Surgery is the primary mode of therapy for patients with differentiated thyroid cancer

Answer 16

• *We suggest** unilateral lobectomy and isthmusectomy < 1.0 cm in diameter and confined to one lobe of the gland. 30-year survival 100 percent.
• We suggest** regional neck dissection in patients with papillary cancer only if there is clinical evidence (on exam or preoperative ultrasound) of nodal involvement. *Prophylactic dissection has not been shown to improve survival in this group.

ATA and the National Comprehensive Cancer Network : neck dissection in patients with clinical evidence (exam or ultrasound) of nodal involvement. ATA suggests that prophylactic central neck dissection may be performed in patients with advanced papillary cancer (>4 cm and/or extrathyroidal extension) even in the absence of clinical evidence of nodal involvement National Comprehensive Cancer Network only recommends central neck dissection in the presence of grossly positive metastasis

Patients with invasion of neck structures such as the esophagus, trachea, or strap muscles should have a more extensive resection. Conservative procedures that maintain function are preferred whenever possible

Question 17

Treatment of differentiated thyroid cancer

Answer 17

Surgery
Radioiodine therapy three uses

• adjuvant ablation of residual
• imaging for possible mets
• treatment of known residual

Thyroid hormone suppression

• Stage I and II disease no distant metastases — TSH 0.1 to 2.0
• stage II w distant metastases, stage III, and IV disease TSH should < 0.1 mU/L.
• Heart disease or low bone density may necessitate a lower level suppression / TSH to rise into the normal range in low risk patients who remain disease-free for 5 to 10 years after primary therapy

External beam radiotherapy

• metastatic disease that is refractory to radioiodine, or patients whose tumors do not concentrate radioiodine.

Management of recurrent disease

• Minimal disease
• Extensive disease

Systemic chemotherapy

• New approaches
• Suggested approach

Question 18

Follow up PTC

Answer 18

Year 1
6 months - TSH / FT4 / thyroglobulin — U/S 6 - 12
Gross residual dz (on PE or US) need to confirm with

• FNA+ surgical resection considered.

12 months repeat PE, US, TSH / FT4, + TG
Stage I or II disease w –ve evaluation at 6 to 12 months / TG measurement before and after rhTSH injections - sig rise in TG (>10 ng/mL) without surgically resectable disease may lead to hormone withdrawal, a diagnostic radioiodine scan, and administration of a therapy dose if the scan indicates pathologic uptake.
Stage III or IV disease w -ve evaluation at 6 to 12 / TG measurement before and after rhTSH injections and radioiodine scan (diagnostic) / pathologic uptake on the scan leads to hormone withdrawal and repeat 131-I therapy.
Patients with detectable thyroglobulin or evidence of small suspicious lesions by ultrasound should undergo measurement of thyroglobulin and a diagnostic radioiodine scan following thyroid hormone withdrawal, with administration of a therapy dose if the scan indicates pathologic uptake.
If significant uptake is seen within the thyroid bed, one more treatment with 100 to 150 mCi (5550 MBq) of 131-I is often given to complete the ablation in patients at risk for recurrence. Generally, we are reluctant to continue to re-treat thyroid bed uptake in the absence of clear evidence of residual cancer that can respond to the therapy. If there is uptake outside of the thyroid bed, we give doses of 131-I appropriate to the site of uptake. A single negative scan/thyroglobulin combination may be sufficient in Stage III or IV patients and lower risk patients with negative thyroglobulin levels may not require follow-up scanning at all.
Years 2 to 10 — Clinical examination, measurements of serum free thyroxine, TSH, and thyroglobulin annually; neck ultrasonography every one to two years or less frequently in low-risk patients with no evidence of disease; radioiodine imaging if serum thyroglobulin increases or there is other evidence of recurrence.
Years 11 to 20 — Clinical examination and measurements of serum free thyroxine, TSH, and thyroglobulin annually; neck ultrasonography every one to three years or less frequently in low-risk patients with no evidence of disease; radioiodine imaging if serum thyroglobulin increases or there is other evidence of recurrence.
Years 21+ — Clinical examination and measurements of serum free thyroxine, TSH, and thyroglobulin annually; neck ultrasonography every three to five years or less frequently in low-risk patients with no evidence of disease; radioiodine imaging if serum thyroglobulin increases or there is other evidence of recurrence