Thyroid Pathologies- Introduction, Benign diseases and Carcinoma Thyroid

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I have uploade a PPT presentation consist of Introduction, Benign diseases and Carcinoma Thyroid. By watching the accompanying video and reading the PPT, you will become competent in diagnosing and treating any thyroid pathologies.
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1. THYROID
INTRODUCTION
AN OVRVIEW





Dr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical college
Melaka 75150 Malaysia

2. Must To Know Core Clinical
Problems
1.Acute RLQ pain
2.Acute RUQ pain
3.Acute epigastric pain
4.Acute LLQ pain
5.Dysphagia
6.Abdominal lumps
7.Upper GI hemorrhage
8.Lower GI hemorrhage
9.Obstructive Jaundice
10.Breast lumps, Mastalgia & Nipple discharge
11.Neck swellings- Thyroid & Non thyroidal
12.Groin swellings
13.Scrotal swellings
14.Limb ischemia- Acute & Chronic
15.Varicose veins
16.Renal & Ureteric colic
17.Hematuria
18.Acute retention of urine

3. THYROID
Surgical Anatomy
Surgical Physiology
Surgical Pathology
Symptomatology
Investigations

4. ANATOMY

5. PHYSIOLOGY

6. PHYSIOLOGY

7. Thyroid- Pathology
Simple (non-toxic) goiter
Simple hyperplastic goiter
Multinodular goiter & Solitary nodule
Toxic goitre
Diffuse goiter (Graves’ disease)
Toxic multinodular goiter(Plummer’s disease)
Toxic nodule (Gotsche’s disease)
Neoplastic goiter
Benign
Adenoma
Malignant
Papillary
Follicular
Anaplastic
Medullary
Inflammatory
De Quervain’s thyroiditis
Riedel’s thyroiditis
Autoimmune
Hashimoto’s thyroiditis
Goiter- Enlargement of thyroid gland

8. Thyroid- Symptoms
Symptoms of Hyperthyroidism
Loss of weight inspite of voracious
appetite
Heat intolerance
Nervous & irritable
Loose stools
Oligomenorrhea/Amenorrhea
Symptoms of Hypothyroidism
 Weight gain- obese
Hoarseness of voice
Loss of eyebrow lashes laterally
Symptoms of pressure effects
Dyspnea
Dysphagia
Recurrent laryngeal nerve palsy
Symptoms of distant metastasis
Chest pain, cough and hemoptysis
Headache and seizures
Abdominal distension and pain
Generalised bone pain
Cardinal Symptom Enlargement of
Thyroid Goiter

9. Thyroid- Investigations
Thyroid function test
- T3, T4 and TSH
USG Neck
- Solid or cystic swelling
FNAC of the thyroid swelling
- Benign or malignant except follicular Ca
Radioactive iodine I123 scan
- Especially in Solitary nodule Warm, hot or cold

12. THYROID
CARCINOMA THYROID
AN OVRVIEW
Dr.B.SelvarajMS;Mch;FICS;
Professor of Surgery
Melaka ManipalMedical college
Melaka 75150 Malaysia

13. Ca Thyroid-Objectives
OBJECTIVES
✓Classification
✓Etiology
✓Pathophysiology
✓Histology
✓Presentation
✓Diagnosis of various Carcinomas
✓Treatment

14. Neoplastic Goiter
Classification
✓Adenoma
✓Carcinoma
✓Primary
-A.Epithelialdiffrentiated–
1.Papillary 2.Follicular
-B. Epithelial Undiffrentiated-3.Anaplastic
-C. Parafollicularcells -4. Medullary
-D. Lymphoid cell -5. Lymphoma
✓Secondary-Melanoma, Ca breast, Renal
Ca

15. Ca Thyroid-Etiology
✓Female gender
✓History of radiation administered in infancy and
childhood , [ in 9 %]
Avg. Latent Period >10 yrsPapillary Ca
✓Excessive Iodine ConsumptionPapillary Ca
✓History of goiter Anaplastic / Follicular Ca
✓FrankshiftMutation of RET genePapillary Ca
✓Point Mutation of RET gene Medullary Ca
✓P53 gene mutation Anaplastic Ca
✓Loss of Gene at 11q Follicular Ca

16. AdenomaThyroid
✓Benign lesion derived from Follicular
Epithelium
✓Usually single,wellencapsulated
✓Present as painless single nodule
✓Discrete lesions with glandular /
acinar Follicular pattern.
✓Papillary change is not typical but if
present suggests Papillary Ca
✓Trucutbiopsy to confirm diagnosis
✓FNAC can not make out
capsular/vascular invasion
✓Treatment: Hemithyroidectomy
✓Closely packed
follicles, trabeculae
or solid sheets
✓No capsular or
vascular invasion
✓Completely
enveloped by thin
fibrous capsule
✓Different from
surrounding gland

17. AdenomaThyroid-FNAC

18. Papillary Ca Thyroid
✓Most common type of Thyroid ca –75 to 80%.
✓Female : Male =2 : 1 .
✓Mean age at presentation –35 yrs.
✓More common in persons exposed
to radiation.
✓Macroscopic –Hard, whitish,
calcified,Unencapsulated
✓Slow growing malignant tumorwhich is multifocal in
origin
✓Often present as painless neck mass or lateral
cervical lymphadenopathy

19. Papillary Ca Thyroid

20. Papillary Ca Thyroid
✓Microscopic features –
1. Cuboidal cells with abundant cytoplasm
2. Intranuclearcytoplasmic inclusions
‘ORPHAN ANNIE EYED NUCLEI’ .
3. Fibrovascularstroma with calcium
deposits ‘PSAMOMMA BODIES’.
✓Lymphatic spread –Intrathyroidal~90%
and to Paratrachealand cervical LN ~50%

21. Papillary Ca Thyroid

22. Follicular Ca Thyroid
✓Female : Male =3 : 1 .
✓Accounts for 15 to 20 % of all Thyroid Ca
✓Mean age at presentation –50 yrs.
✓More frequent in IODINE DEFICIENT
AREAS.
✓History of long standing goitre .
✓PATHOLOGY -
✓Usually ENCAPSULATED & SOLITARY.
✓Spreads usually By Blood ,Most commonly to
Lungs, Brain & Bone.
✓Lymph node metastases in <10 % cases.

23. Follicular Ca Thyroid

24. Follicular Ca Thyroid
✓Currently, a follicular carcinoma cannot be
distinguished from a follicular adenoma
based on cytologic, sonographic, or clinical
features alone.
✓Pathogenesis of follicular carcinoma may be
related to iodine deficiency and various
oncogene and/or microRNA activation.
✓Follicular carcinoma tends to be more cellular
with a thick irregular capsule, and often with
areas of necrosis and more frequent mitoses.
✓It is distinguished from a follicular adenoma
on the basis of capsular invasion and
vascular invasion

25. Follicular Ca Thyroid

26. HurthleCell Carcinoma
✓Variant of FOLLICULAR CELL Ca.
✓Derived from ‘OXYPHIL CELLS’ of
thyroid. Function of these cells is not
known.
✓Cells are stuffed with mitochondria &
possess the TSH receptors and produce
thyroglobulin.
✓As compared to follicular type –
usually multifocal & bilateral and
more likely to metastatiseto LN
[ >25%].
✓HCC are encapsulated thyroid tumours that
contain more than 75% oncocyticcells, which
stain pink under the microscope as they are
packed with mitochondria
✓The characteristic feature is the distinct
granular acidophilic cytoplasm

27. Medullary Ca Thyroid
✓Female : Male =1.5 : 1 .
✓Accounts for 15 to 20 % of all Thyroid Ca
✓Mean age at presentation –50 to 60 yrs.
✓Can occur in four clinical settings:
✓1. Sporadic -~ 70 % cases,usually
unilateral
✓2. Familial -~ 30 % ,cases,usuallyBilateral

28. Medullary Ca Thyroid
✓Pathology –
1. Usually occurs in upper poles
2. Originates from Parafollicular\C cells
✓Gross: Single or multiple
✓Typically nonencapsulated
✓Solid, gray/ tan / yellow, firm, may be
infiltrative
✓Larger lesions have hemorrhageand
necrosis, tumorusually in mid or upper
portion of gland (with higher
concentration of C cells)

29. Medullary Ca Thyroid
✓Pathology –
✓Microscopic –Why called Medullary ?
✓Sheets of Spindle shaped neoplastic cells
with AMYLOID [Altered Calcitonin] in
between. Cells Stains for Calcitonin, CEA,
Serotonin, VIP
✓Spreads to LN Initially ~ 75 %
✓Cellular specimen staining positively for
calcitonin with immunoperoxidase.
✓Loosely cohesive fragments of spindle-
shaped cells; amyloid is present as
amorphous blue material intimately
associated with neoplastic cells.

30. Medullary Ca Thyroid

31. Anaplastic Ca Thyroid
✓Accounts for ~ 8 to 10 % of all Thyroid
Ca
✓Female : Male =1.5 : 1 .
✓Mean age at presentation –70 to 80
yrs.
✓Most aggressive thyroid
malignancy,withmedian survialonly ~
3 months.
✓Iodine deficiency goitre is precursor .
✓All patients are considered to have
stage IV disease.

32. Thyroid Lymphoma
✓Accounts for ~ 8 to 10 % of all Thyroid
Ca
✓Women > 70 yrsare usually affected.
✓In 70 to 80 %, it arises in Preexisting
Chronic Lymphociticthyroditiswith
Subclinical or overt Hypothyroidism,
in association with Hashimoto’s
thyroiditis.
✓Almost always Non-Hodgkin B-cell
lymphoma
✓Usually presents as Rapidly growing
mass,withobstructive symptoms as
dyspneaand dysphagia.

33. Thyroid Metastasis
✓Usually Rare
✓Common Primary sites are -
1. Skin –Melanoma ~39 %
2. Breast ~ 21%
3. Renal cell Ca ~ 10 %
✓Usually Presents as Painless
Lump with signs / symptoms
of Primary.
✓FNAC is Diagnostic

34. Recurrent Thyroid Ca
✓Approximately 10% to 30% of patients after initial treatment
✓80% recur with disease in the neck
✓20% with Distant Recurrennce.
✓Most common site of distant metastasis is the lung.
✓Median time of Recurrence ~ 2.6 yrs
✓Prognosis for clinically detectable recurrences is generally poor,
regardless of cell type.
✓Local and regional recurrences detected by I131 scan and not
clinically apparent and have an excellent prognosis

35. Staging Of Thyroid Ca

36. Clinical Presentation
✓Usual Presentation
✓-A lump in the neck
✓-Pain in the neck
✓-Hoarseness
✓-Trouble swallowing
✓-Breathing problems
✓Usual Presentation
✓-Follicular Ca -~1 % as Hyperthyroidism
✓-Medullary Ca -~ 2 –4 % as Cushing Syn .
Hypertension, Diarrhea
✓-Papillary Ca –as LATERAL ABERRANT THYROID

37. Benign Vs Malignant Thyroid Swellings
BENIGN MALIGNANT

38. Thyroid Carcinomas
Investigations

39. Thyroid Carcinomas
Pathology & Clinical Features

40. Thyroid Carcinomas
Treatment