Thyroid tumors
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Thyroid tumors
Dr. Gehan Mohamed
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Classification of thyroid tumors
• A- benign tumors: more common than malignant thyroid neoplasm.
e.g follicular thyroid adenoma
B- Malignant thyroid tumors.
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Criteria for diagnosis of follicular adenoma
• 1- solitary nodule
• 2- encapsulated
• 3- presence of compressed thyroid tissue outside capsule of thyroid adenoma.
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Classification of Malignant Thyroid Neoplasms
• Papillary carcinoma• Follicular variant• Tall cell• Diffuse sclerosing• Encapsulated
• Follicular carcinoma• Overtly invasive• Minimally invasive
• Hurthle cell carcinoma• Anaplastic carcinoma
• Giant cell• Small cell
• Medullary Carcinoma• Miscellaneous
• Sarcoma• Lymphoma• Squamous cell carcinoma• Mucoepidermoid
carcinoma• Clear cell tumors• Plasma cell tumors• Metastatic
– Direct extention
– Kidney
– Colon
– Melanoma
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Normal Thyroid
colloid
Thyroid epithelial cells
T4 90%
T3 10%
TSH
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Types of Thyroid Cancer
• Papillary (80%-85%): develops from thyroid follicle cells in 1 or both lobes; grows slowly but can spread
• Follicular (5%-10%): common in countries with insufficient iodine consumption; lymph node metastases are uncommon
• Medullary: develops from C-cells, can spread quickly; sporadic .
• Anaplastic: develops from existing papillary or follicular cancers; aggressive, usually fatal
• Lymphoma: develops from lymphocytes; uncommon
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Risk Factors for development of thyroid carcinoma
• Radiation• High dose x-rays of the neck or face during
infancy or teenage years is a risk factor specially for papillary carcinoma
• Family History• Goiters and prolonged TSH stimulation is a risk for
follicular carcinoma.• Mutated RET oncogene
• Gender• males
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When suspect malignancy in thyroid mass
• 1-Male sex
• 2- Solitary thyroid nodules in patients >60 or <30 years of age
• 3-Large Nodules (>3 or 4 cm) with rapid Growth
• 4-Symptoms especially a change in voice,Pain,dysphagia,Stridor,hemoptysis
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Molecular Level
• Medullary Carcinoma• Mutation in RET gene
• Papillary Carcinoma• Mutated RET, RAS, or BRAF gene
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Typical Presentation of Thyroid Cancer
• Painless lump• Normal thyroid function tests• Found on routine examination or by the patient
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Papillary Carcinoma
•Most common type
•Females outnumber males 3:1– Highest incidence in women in midlife.
•Lymph node involvement is common Major route of metastasis is lymphatic
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Papillary Thyroid CancerCharacteristics
• Unencapsulated tumor nodule with ill-defined margins
• Tumor typically firm and solid
• First presentation of the patient may be lymph node
enlargment.
• Commonly metastasizes to neck and mediastinal lymph
nodes
– 40% to 60% in adults and 90% in children
• <5% of patients have distant metastases at time of
diagnosis
– Lung is most common site
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Thyroid carcinoma
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Micropapillary thyroid carcinomas
Definition - papillary carcinoma smaller
than 1.0 cm
Most are found incidentally at autopsy
Usually clinically silent
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Papillary Carcinoma(continued…)
• Pathology Gross - vary considerably in size
- often multi-focal
- unencapsulated but often have a pseudocapsule which is
normal thyroid tissue compressed by the tumor mass.
Histopathology - closely packed papillae which have
fibrovascular core.
- psammoma bodies which is a laminated calcification
- nuclei are oval or elongated, pale staining
with ground glass appearance .
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Papillary carcinoma of thyroid
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Papillary Thyroid Cancer: nuclei are oval or elongated, pale staining with ground glass
appearance
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Follicular variant of papillary carcinoma
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2- Follicular Thyroid Carcinoma
• Second most common type of thyroid cancer
• Solid invasive tumors, usually solitary and
encapsulated
• Usually stays in the thyroid gland, but can spread to
the bones, lungs, and central nervous system.
• Usually does not spread to the lymph nodes
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Follicular Carcinoma
• Pathology Gross - encapsulated, solitary
Histology - very well-differentiated.
(distinction between follicular adenoma and
follicular carcinoma is so difficult so we
depend on presence of vascular and
capsular invasion to diagnose follicular
carcinoma.
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Invasive follicular carcinoma:malignant follicles invade pink fibrous capsule
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Follicular thyroid carcinoma
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Hürthle Cell Carcinoma
• A variant of follicular cancer that
tends to be aggressive
• Microscope : there are Large,
polygonal, eosinophilic thyroid
follicular cells with abundant
granular cytoplasm and
numerous mitochondria High power magnification
Hürthle Cell Tumor
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Hürthle Cell tumor
• May be benign or malignant, based on
demonstration of vascular or capsular
invasion
• Malignancies tend to have a worse
prognosis than other follicular tumors
• Tend to be locally invasive
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3- Anaplastic Thyroid Cancer
• Often occurs in the elderly population (mean
age: 65 years)
• Three fold greater risk in iodine-deficient
areas
• Tumor is typically hard, poorly circumscribed,
and fixed to surrounding structures.
• Extremely aggressive and exceptionally
virulent
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Anaplastic Carcinoma of the Thyroid
• Pathology Classified as
Composed wholly or in part of undifferentiated cells
which may be large cell or small cell
Large cell is more common and has a worse prognosis
Histology - sheets of very poorly differentiated cells
little cytoplasm
numerous mitoses
necrosis
extrathyroidal invasion
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Medullary Thyroid Carcinoma
Tumor arising from the calcitonin-secreting C-cells of
the thyroid gland.
• Developes in 3 clinical settings: Sporadic MTC (SMTC)
Familial MTC (FMTC)
Multiple endocrine neoplasia.
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Medullary Thyroid Carcinoma characterized by presence of pink amyloid in between malignant cells.
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Medullary Thyroid CancerMetastases
• Cervical lymph node metastases occur early
• Tumors >1.5 cm are likely to metastasize,
often to bone, lungs, liver, and the central
nervous system
• Metastases usually contain calcitonin and
stain for amyloid
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Evaluation of any thyroid Nodule(Physical Exam)
• Examination of the thyroid nodule:
consistency - hard vs. soft
size – more than 4.0 cm
Multinodular vs. solitary nodule– multi nodular : 3% chance of malignancy
– solitary nodule : 5%-12% chance of malignancy
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Physical Exam (continued…)
• Examine for ectopic thyroid tissue
• Indirect or fiberoptic laryngoscopy
vocal cord mobility
evaluate airway
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Evaluation of the Thyroid Nodule
Advantages of Ultrasonography•Noninvasive and inexpensive
•Most sensitive procedure or identifying lesions in the
thyroid (can detect smaller lesions even 2-3mm size)
•90% accuracy in categorizing nodules as solid, cystic, or
mixed
•Best method of determining the volume of a nodule
•Can detect the presence of lymph node enlargement and
calcifications
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Ultrasonography (Continued…)
• Disadvantages Cannot accurately distinguish benign
from malignant nodules