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

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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

12. 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

13. 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

14. 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

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