THYROID NEOPLASMS

A. BENIGN

A. FOLLICULAR ADENOMA –
COLLOID, EMBRYONAL, FETAL

B. HURTHLE CELL ADENOMA.

COLLOID ADENOMA (commonest adenoma).
PAPILLARY ADENOMA – Its existence is doubtful. It is invariably low-grade papillary carcinoma.

B. MALIGNANT
(DUNHILL CLASSIFICATION)

A. DIFFERENTIATED. 1. PAPILLARY CARCINOMA (60%).

2. FOLLICULAR CARCINOMA (17%).
3. PAPILLOFOLLICULAR CARCINOMA
4. HURTHLE CELL CARCINOMA

B. UNDIFFERENTIATED. ANAPLASTIC CARCINOMA (13%).

C. MEDULLARY CARCINOMA (6%).

D. MALIGNANT LYMPHOMA (4%)

E. SECONDARIES IN THYROID (RARE) –

FROM COLON, KIDNEY, MELANOMA.

Annual incidence of thyroid cancers is 3.7 per 1,00,000 population. It is common in females (3:1).

AETIOLOGY OF THYROID MALIGNANCY

1. RADIATION either external or radioiodine can cause papillary carcinoma thyroid.

 There is increased incidence of thyroid carcinoma among children following exposure to

IONISING RADIATION.
 Earlier irradiation was practiced to head and neck region to treat benign conditions like tonsillitis,
adenoids, thymus enlargement, acne vulgaris, Haemangiomas during first two decades of life. As
a consequence papillary carcinoma of thyroid became common in these individuals.
 Radiotherapy received in adolescent period for Hodgkin‘s lymphoma may predispose to
papillary carcinoma.

2. PRE-EXISTING MULTINODULAR GOITRE It turns into follicular carcinoma of thyroid.

3. Medullary carcinoma thyroid is often FAMILIAL.
4. HASHIMOTO’S THYROIDITIS may predispose to NHL/ PAPILLARY CARCINOMA of thyroid.
5. FAMILIAL.
6. ELEVATED TSH is observed in papillary carcinoma of thyroid.
 PAPILLARY CARCINOMA

 It is 60% common.
 Common in females and younger age group.

AETIOLOGY:-

 Radiation either external or radioactive iodine therapy.

 TSH levels in the blood of these patients are high and so it is called as HORMONE DEPENDENT
TUMOUR.

WOOLNER CLASSIFICATION TYPES:-

I. OCCULT PRIMARY (< 1.5 cm).

II. INTRATHYROIDAL.
III. EXTRATHYROIDAL.

Micropapillary carcinoma is a tumour, clinically not detectable or less than 1 cm.

GROSS
 It can be soft, firm, hard, and cystic.
 It can be solitary or multinodular. It contains brownish black fluid.

MICROSCOPY

 It shows cystic spaces, papillary projections with PSAMMOMA BODIES, malignant cells with
‗ORPHAN ANNIE EYE’ nuclei (intranuclear cytoplasmic inclusions). ORPHAN ANNIE EYE
NUCLEI are identified in histology (paraffin section of formalin tissue).
 It is not seen in FNAC.
 Orphan Annie is strip cartoon character with empty circled eyes.

CLINICAL FEATURES

 SOFT or HARD or FIRM, SOLID OR CYSTIC, SOLITARY or MULTINODULAR thyroid

swelling.
 Compression features are uncommon in papillary carcinoma thyroid.
 Often discrete lymph nodes in the neck (40%) are palpable.
 May present with secondaries in neck lymph nodes with occult primary.

DIAGNOSIS
 FNAC of THYROID NODULE and lymph node.
 RADIOISOTOPE SCAN shows cold nodule.
 TSH level in the blood is higher.
 Plain X-ray neck shows FINE CALCIFICATION whereas NODULAR GOITRE shows coarse –
ring/rim calcification.
 U/S NECK or CT SCAN NECK (better) to identify non-palpable nodes in neck.

TREATMENT
 TOTAL OR NEAR TOTAL THYROIDECTOMY.
 SUPPRESSIVE DOSE OF L-THYROXINE 0.3 mg OD life long.
 MRND (modified radical neck dissection)
 Occasionally if small lymph nodes are present, ‗BERRY PICKING’ may be done
(universally not accepted). (Not done now).
 Present concept is EXTRATHYROIDAL TYPE also responds well to RADIOACTIVE I131
therapy.
Note: If tumour is < 1.0 cm, solitary, low grade, probably unicentric, hemithyroidectomy is done with
proper follow up at regular intervals.
Note: Suppressive dose of L-thyroxine can cause osteoporosis and so often needs calcium and Vitamin
D supplementation.

PROGNOSIS
Prognosis is good and it is one of the curable malignancies.

AMES SCORING

A: Age. Age less than 40 years has got better prognosis

M: Distant metastasis
E: Extent of the primary tumour
S: Size of the tumour. Size less than 4 cm has got better prognosis

AGES SCORING

A: Age less than 40 years has got better prognosis

G: Pathologic grade of the tumour
E: Extent of the primary tumour
S: Size of the primary tumour. Size less than 4 cm has got better prognosis
 FOLLICULAR CARCINOMA

 It is 17% common.
 It is common in FEMALES.
 It can occur either de novo or in a pre-existing multinodular goitre.

TYPES:-
A. NONINVASIVE—Blood spread not common.
B. INVASIVE—Blood spread common.

CLINICAL FEATURES:-

1. SWELLING IN THE NECK, FIRM or HARD and NODULAR.

2. TRACHEAL COMPRESSION and STRIDOR.
3. DYSPNOEA, HAEMOPTYSIS, CHEST PAIN when there are lung secondaries.
4. RECURRENT LARYNGEAL NERVE INVOLVEMENT causes hoarseness of voice.
5. +VE ‘BERRY’S SIGN’ Signifies advanced malignancy (infiltration into the carotid sheath and so
absence of carotid pulsation).
6. PULSATILE SECONDARIES in the skull and long bones.

INVESTIGATIONS:-

 Most often FNAC is inconclusive, because capsular and angioinvasion, which are the main
features of follicular carcinoma, cannot be detected by FNAC.
 FROZEN SECTION BIOPSY is very useful. In 15% cases frozen section biopsy may be
inconclusive or facility for frozen section biopsy may not be available in many places, then initial
hemithyroidectomy is done.
 U/S ABDOMEN, CHEST X-RAY, X-RAY BONES are the other investigations required.
 TRUCUT BIOPSY gives tissue diagnosis, but danger of haemorrhage and injury to vital
structures like trachea, recurrent laryngeal nerve, vessels are likely.

TREATMENT

 TOTAL THYROIDECTOMY is done, along with block dissection whenever lymph nodes are
enlarged.
 Maintenance dose of L-Thyroxine 0.1 mg O.D or T3 80 μg/day is given lifelong.
 On table FROZEN SECTION BIOPSY is useful in negative FNAC but doubtful cases. Definitive
procedure is undertaken once FROZEN SECTION REPORT comes on table. But in FROZEN
SECTION BIOPSY itself, 15% OF FOLLICULAR CARCINOMA report may be inconclusive or
negative which causes difficulty in taking decision.

HURTHLE CELL CARCINOMA

 It is a VARIANT OF FOLLICULAR CARCINOMA of thyroid which contains abundant oxyphill

cells.
 It SPREADS MORE COMMONLY TO REGIONAL LYMPH nodes than follicular carcinoma of
thyroid.

NOTE:

 Hurthle cell carcinoma DOES NOT TAKE UP I131

 It secretes THYROGLOBULIN
 It has got POORER PROGNOSIS than follicular cell carcinoma
 99mTc sestamibi scan is very useful for Hurthle cell carcinoma
 Regional nodes are commonly involved than follicular carcinoma
 ABUNDANT OXYPHILL cells are specific
 TOTAL THYROIDECTOMY, MRND and TSH suppression is the treatment
 ANAPLASTIC CARCINOMA

 It occurs in elderly.
 It is a very aggressive tumour of short duration, presents with a swelling in thyroid region which
is rapidly progressive causing—
I. STRIDOR AND HOARSENESS OF VOICE due to tracheal obstruction.
II. DYSPHAGIA.
III. FIXITY TO THE SKIN.
IV. POSITIVE BERRY’S SIGN—involvement of carotid sheath leads to absence of carotid
pulsation.

SWELLING IS HARD, WITH INVOLVEMENT OF ISTHMUS AND LATERAL LOBES.

 FNAC is diagnostic.
 TRACHEOSTOMY and ISTHMECTOMY has got a role to relieve respiratory obstruction
temporarily.
 Treatment is EXTERNAL RADIOTHERAPY, as usually thyroidectomy is not possible.
 ADRIAMYCIN as chemotherapy.
 However prognosis is poor.

TNM STAGING FOR THYROID CANCER

TUMOUR
Tx—Primary not assessed
T0—No primary
T1—< 1 cm limited to thyroid
T2—1-4 cm limited to thyroid
T3—> 4 cm limited to thyroid
T4—Any size extending beyond capsule
NODES
Nx—Nodes cannot be assessed
N0—No regional nodes
N1—Regional nodes present
N1a—Same side neck nodes
N1b—Bilateral, midline, mediastinal nodes
METASTASES
Mx—Cannot be assessed
M0—No metastases
M1—Metastases present

FEATURES OF THYROID CARCINOMA

Any thyroid can be malignant of any size, of any texture- solid / cystic, of any number- single /
multiple, in any age group.
Features of infiltration

 Infiltration of strap muscles often with STERNOMASTOID MUSCLE

 Infiltration of laryngotracheal complex causing STRIDOR and often HAEMOPTYSIS
 Infiltration of recurrent laryngeal nerve causes HOARSENESS OF VOICE
 Infiltration of oesophagus causes DYSPHAGIA/ ODYNOPHAGIA (painful swallowing)
 Infiltration into carotid sheath causing ABSENCE OF CAROTID PULSATION- BERRY’S SIGN
 Infiltration of cervical sympathetic chain causing HORNER’S SYNDROME
 Rarely INFILTRATION INTO CRANIAL NERVES or BRACHIAL PLEXUS can occur
 MEDULLARY CARCINOMA OF THYROID (MCT)

 It is uncommon (5%) TYPE OF THYROID MALIGNANCY.

 It arises from the PARAFOLLICULAR ‘C’ CELLS
 C- cells are more in upper pole of the thyroid gland.
 It contains characteristic ‗AMYLOID STROMA’ wherein malignant cells are dispersed.
 Immunohistochemistry reveals calcitonin in amyloid.
 In these patients blood levels of CALCITONIN both basal as well as that following CALCIUM
OR PENTAGASTRIN stimulation is high, a very useful tumour marker.
 Tumour also secretes 5-H.T. (SEROTONIN), PROSTAGLANDIN, ACTH and VASOACTIVE
INTESTINAL POLYPEPTIDE (VIP).
 It spreads mainly to LYMPH NODES (60%).

 It may be associated with MEN II SYNDROME and PHEOCHROMOCYTOMA with

HYPERTENSION.
 MCT associated with MEN type II B with PHAEOCHROMOCYTOMA (SIPPLE’S
DISEASE) is most aggressive.

 There may be MUCOSAL NEUROMAS in lips, oral cavity, tongue, eyelids with MARFANOID
FEATURES.
 MCT is not TSH dependent and does not take up radioactive iodine.

CLINICAL FEATURES:-

 THYROID SWELLING often with enlargement of neck lymph node.

 DIARRHOEA, FLUSHING (30%).
 HYPERTENSION, PHAEOCHROMOCYTOMAS and MUCOSAL NEUROMAS when
associated with MEN II SYNDROME.

TYPES:-
1. SPORADIC.
2. MCT with MEN II syndrome.
3. FAMILIAL MCT (20%).

INVESTIGATIONS:-

 FNAC: shows amyloid deposition with dispersed malignant cells and ―C‖ cell hyperplasia.
 TUMOUR MARKER: Calcitonin level will be higher. Increased levels of calcitonin after injection
of CALCIUM 2 mg/kg or PENTAGASTRIN 0.5 μg/kg.
Calcitonin is undetectable in the serum of normal individuals (< 0.08 ng/L).
 U/S ABDOMEN.
 U/S NECK to see neck nodes. CT neck and chest is preferred method to identify neck and
mediastinal nodes.
 URINARY VMA, URINARY CATECHOLAMINES, URINARY METANEPHRINE, SERUM
CALCIUM, SERUM PARATHORMONE estimation.
 111 INDIUM OCTREOTIDE scanning is useful in detecting medullary carcinoma thyroid (70%

sensitivity). It is also useful in postoperative follow up to find out residual/metastatic disease.

 TREATMENT

 TOTAL THYROIDECTOMY WITH CENTRAL NODE DISSECTION (LEVEL 6) in all patients

even if there are no nodes in the neck. + maintenance dose of L-thyroxin.
 Neck lymph nodes block dissection if lymph nodes are involved (BILATERAL MODIFIED
RADICAL DISSECTION OF NECK NODES should include levels – II, III, IV, V and VI). Later
regular U/S neck is done to detect early neck nodes.
 ADRIAMYCIN is the drug used as chemotherapy with limited results.
 If there is associated phaeochromocytoma it should be treated surgically by ADRENALECTOMY
first and later only total thyroidectomy is done.
 THYROIDECTOMY

TYPES:-
1.
Hemithyroidectomy: Along with REMOVAL
OF ONE LOBE, ENTIRE
ISTHMUS is removed.
It is done in benign
diseases of only one lobe.

2. Subtotal commonly done in

thyroidectomy TOXIC THYROID either
primary or secondary and
also often for
NONTOXIC
MULTINODULAR
GOITRE.
Here about 8 grams, or a
tissue, size of pulp of
finger is retained on
lower pole, on both sides
and rest of the thyroid
gland is removed.
It is also done in MNG.

3. Partial Tissue in the TRACHEO

thyroidectomy OESOPHAGEAL
GROOVE is retained.
It is not commonly ISTHMUS and GLAND
done now. WITH NODULES in front
is removed. There is
removal of the GLAND
IN FRONT OF
TRACHEA after
mobilisation. It is done in
nontoxic multinodular
goitre. Its role is
controversial.

4. Near total Here both lobes EXCEPT

thyroidectomy: the lower pole (ONE OR
BOTH SIDES) WHICH
IS VERY CLOSE TO
RECURRENT
LARYNGEAL NERVE
AND PARATHYROID IS
REMOVED (To retain
blood supply to
parathyroids). It is done in
case of papillary
carcinoma of thyroid.
5. Total ENTIRE GLAND is
thyroidectomy: removed. It is done in
case of follicular
carcinoma of thyroid,
medullary carcinoma
of thyroid.

6. Hartley Dunhill is removal of ONE

operation ENTIRE LATERAL
LOBE with
ISTHMUS and
partial/subtotal
removal of opposite
lateral lobe.
It is done in non toxic
multinodular goitre.
 COMPLICATIONS OF THYROIDECTOMY

1. HAEMORRHAGE:
May be due to slipping of ligatures either of SUPERIOR THYROID ARTERY or other
pedicles or small veins. It causes tachycardia, hypotension, breathlessness and compression
over the trachea may cause severe stridor, respiratory obstruction due to tension haematoma
under strap muscles.

As a first aid, immediate release of sutures including that of deep fascia has to be done and pressure over the
trachea is released. Then patient is shifted to operation theatre and under general anaesthesia exploration is done
and bleeders are ligated. Blood transfusion may be required.

2. RESPIRATORY OBSTRUCTION: It may be due to HAEMATOMA or due to LARYNGEAL

OEDEMA, or due to BILATERAL RLN PALSY

(Emergency endotracheal intubation is done along with steroid injections). Often emergency tracheostomy may be
required as a life-saving procedure.

3. RECURRENT LARYNGEAL NERVE PALSY: It can be transient or permanent. Transient is

3% common. They usually recover in 3 weeks to 3 months. Often they require steroid
supplement and speech therapy. Permanent paralysis is rare. LEADS TO HOARSENESS of
Voice.

4. HYPOPARATHYROIDISM:- is rare 0.5% common.

Mostly it is temporary due to vascular spasm of parathyroid glands, occurs in 2nd-5th
postoperative day.
Present with WEAKNESS, +VE CHVOSTEK’S SIGN, CARPOPEDAL SPASM,
CONVULSIONS.

5. THYROTOXIC CRISIS (THYROID STORM): Occurs in a THYROTOXIC PATIENT

inadequately prepared for thyroidectomy and often a thyrotoxic patient presents in a crisis
following an unrelated operation or stress. They present in 12-24 hours with
SEVERE DEHYDRATION, CIRCULATORY COLLAPSE, HYPOTENSION,
HYPERPYREXIA, and often CARDIAC FAILURE.

TREATMENT OF THYROTOXIC CRISIS

 Injection HYDROCORTISONE HIGH DOSE—500-1000 mg IV

 Rehydration with adequate IV FLUIDS to control circulatory collapse
 INJECTION SODIUM IODIDE IV – 1 gram
 INJECTION PROPRANOLOL – 2 mg
 ORAL IODIDES - LUGOL’S IODINE
 ORAL ANTITHYROID DRUGS
 TEPID SPONGING
 DIGITOXIN
 FLUID AND ELECTROLYTE MANAGEMENT
 ICU CARE, VENTILATOR SUPPORT and CARDIAC MONITOR

6. INJURY TO EXTERNAL LARYNGEAL NERVE causes weakness of cricothyroid muscle

leading to ALTERATION IN PITCH OF VOICE.

7. HYPOTHYROIDISM:- Revealed clinically after 6 months.

8. WOUND INFECTION, STITCH GRANULOMA FORMATION.
9. KELOID FORMATION.
 HYPOTHYROIDISM
CAUSES:-

1. Agenesis or dysgenesis
2. Enzyme deficiency
3. Iodine deficiency
4. Hashimoto‘s thyroiditis
5. Antithyroid drugs
6. Radioiodine
7. Drugs: Lithium, Amiodarone
8. After thyroidectomy

CLINICAL FEATURES:-

 GENERAL: Tiredeness, weight gain, cold intolerance, goitre, hyperlipidaemia.

 CARDIOVASCULAR: Bradycardia, angina, cardiac failure, pericardial effusion.
 HAEMATOLOGICAL: Anaemia.
 DERMATOLOGICAL: Dry skin, Vitiligo, Alopecia, erythema.
 REPRODUCTIVE: Infertility, menorrhagia, galactorrhoea.
 GASTROINTESTINAL: Constipation, ileus.
 DEVELOPMENTAL: Growth and mental retardation, delayed puberty.
 OTHER FEATURES: Carpal tunnel syndrome, myalgia, hoarseness, deafness, ataxia,
depression, psychosis

INVESTIGATIONS:-

 T3, T4 estimation.
 TSH level estimation which is higher.

TREATMENT:-

 Replacement with L-thyroxine 100 to 150 μg/day. In old patients with ischaemic heart disease
initial therapy is with 25–50 μg/day and then gradually increased upto the required dose.