Thyroid Cancer -- Papillary Papillary Carcinoma 80% of thyroid cancers Follicular variant of papillary has same behavior Average age 30 -40 Women twice as frequent as men Most common thyroid malignancy in children Most common after low dose radiation

Thyroid Cancer -- Papillary Papillary Carcinoma Psammoma bodies, intranuclear cytoplasmic inclusions (Orphan Annie nuclei) Poor prognosis, aggressive, radioiodine resistant: Tall cell, insular, columnar, clear cell variants Multicentric Intrathyroidal lymphatic spread Cervical Lymph node spread

Thyroid Cancer -- Papillary Papillary Carcinoma 88% 10 year survival without treatment 98% 10 year survival with thyroidectomy / RAI 95% 20 year survival with thyroidectomy / RAI But, 35% 5 year survival for radioresistant variants (tall cell, insular, columnar) or extensive radioresistant differentiated tumors

Thyroid Cancer -- Papillary Papillary Carcinoma Lower risk Men age 20 - 40, Women age 20-50 Tumor < 1 cm - 1.5 cm Unilateral thyroidectomy and isthmusectomy Recurrence risk 7% 50% mortality in 15-25 years if recurrence “Berry picking” of gross lymph nodes LN’s present in 30% of all papillary CA’s LN’s present in 90-100% if age <15

Thyroid Cancer -- Papillary Papillary Carcinoma Higher risk Age Aggressive variants Size > 1.5 cm or extends beyond capsule of thyroid Cervical LNs or distant mets 20% pulmonary mets if age < 15 Radiation history Total thyroidectomy, LN berry picking Children often require mod. neck dissections

Thyroid Cancer -- Papillary Papillary Carcinoma Post-thyroidectomy follow-up Thyroglobulin RAI (I-131) Not useful in radioresistant variants 20% of all papillary CA’s do not trap RAI Many patients over 60 have radioresistant CA’s Not useful if normal thyroid tissue remains Initial scan 6 weeks after thyroidectomy

Thyroid Cancer -- Papillary Papillary Carcinoma RAI identified LN’s or residual thyroid Resect if palpable Often implies good prognosis if enlarging in post-op period due to increased post-op TSH High dose ablative I-131 if no palpable disease but suspect residual tumour other than: Ligament of Berry Can be used repeatedly, and can ablate pulmonary mets, if used early

Thyroid Cancer -- Papillary Therapeutic radioactive I-131 2-3 days in hospital Start levothyroxine 2-3 days after treatment F/U scan in 1 year Treat and repeat each year until gone

Thyroid Cancer -- Follicular Follicular CA 10% of thyroid CA’s (increased with goiter) Hurthle cell variant is 2% of thyroid CA’s Hematogenous spread early Locoregional / lymph node spread late 5% of follicular CA’s have LN spread Average age 50 Women:Men 3:1 Generally radiosensitive

Thyroid Cancer -- Follicular Follicular CA Low risk: Age < 40 Low grade encapsulated (microinvasion) Negative bone scan FNA “follicular” cells Ipsilateral thyroidectomy/isthmusectomy Frozen section to check if extension through capsule, then total thyroidectomy Total thyroidectomy if > 4 cm (80% malignancy)

Thyroid Cancer -- Follicular Follicular CA Low risk: Tc-99 bone scan following lobectomy low recurrence rate if negative and small tumor with no capsule macroinvasion does not need total thyroidectomy Followup 1 year RAI scan 6 week post-op RAI scan after total thyroidectomy

Thyroid Cancer -- Follicular Follicular CA High risk: Age > 50 Macroinvasion, size > 4 cm Distant mets or regional LN’s Thyroidectomy 6 week F/U I-131 scan then I-131 ablation as indicated

Thyroid Cancer -- Follicular Follicular CA 70% 10 year survival without treatment 85-90% 10 year survival with thyroidectomy / RAI 70% 20 year survival with thyrodiectomy / RAI

Thyroid Cancer -- Hurthle Hurthle cell = aggressive variant of follicular Radioresistant (does not take up RAI) LN spread as well as hematogenous to bone / lung Produces thyroglobulin FNA = Hurthle cell --> lobectomy If age > 50 or macroinvasion or > 4 cm or LN’s or mets then total thyroidectomy If central LN’s, resect them If lateral LN’s, then mod. rad. neck dissection RAI , radiation, chemo not useful for mets

Thyroid Cancer -- Medullary Medullary CA 7% of thyroid tumors Sporadic cases are 70 - 80% Usually solitary nodule Average age > 30 Hereditary case are 20 - 30% Bilateral, multicentric MEN IIa -- pheochromocytomas, parathyroids MEN IIb -- pheochromocytoma, neurofibromas more aggressive medullary CA starts around age 2