papillary thyroid carcinoma, case presentation & discussion, power point presentation

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2. DR TARIQUE AHMED MAKA
REGISTRAR ENT
Management of Complicated
Papillary Thyroid Carcinoma
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3. 3
CASE I PRESENTATION
Management of Complicated
Papillary Thyroid Carcinoma

4. Patient Profile
 Name XYZ
 Age 70 years
 Gender Male
 Residence Chakwal
 Date of admission 15.04.13
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5. Present History
 Known Hypothyroidism/ goitre
- 1 year
 Rapid increase in neck swelling
- 2 months
 Difficulty in breathing
- 2 weeks
 No hoarseness
 No dysphagia
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6. History- cont’d…
 Past history
Known case of DM, Hypertension
Had been op for Fr femur 2 yrs ago
 Personal history
Poor socioeconomic class, smoker
 Family history
Not positive for thyroid diseases
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7. General Physical Examination
 Vital signs
 Pulse : 84/min
 BP : 135/90mmHg
 R/ R : 19/min
 Temp : 98.4°F
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8. General Physical Examination
 Pallor
 Jaundice Negative
 Cyanosis
 Lymph nodes Not palpable
 Clubbing
 Koilonychia Negative
 Oedema
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9. Systemic Examination
 Cardiovascular system
 Respiratory system
 Gastrointestinal system
 Central nervous system
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NAD

10. ENT Examination
 Neck
 Massive multinodular swelling
 Inferior extent could not be assessed
 Moved on swallowing
 Normothermic, non tender
 Mobile overlying skin
 No bruit
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11. ENT Examination
 Throat
NAD
 IDL & fibreoptic laryngoscopy
 Normal laryngeal structures
 No mass or lesion seen
 Both vocal cords normal &
mobile
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12. ENT Examination
 Ear
 Nose NAD
 Oral cavity
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13. Provisional Diagnosis
MULTI-NODULAR GOITER
WITH TRACHEAL COMPRESSION
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14.  Shift to ENT care
 Nurse in propped up position
 Observation & continuous monitoring
of vitals & SpO2
Immediate management
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15.  Thyroid profile - WNL
 FNAC
 Thyroid Scan
 CT scan Neck
 Carotid Doppler USG
Investigations
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16. 16
FNAC

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Thyroid Scan

18. CT Scan
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19. Enlarged thyroid gland with multiple nodules
displacing the vessels (with normal flow)
Carotid Doppler USG
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20. Final Diagnosis
MNG WITH SUSPICION OF MALIGNANCY
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21. Management Plan
TOTAL THYROIDECTOMY
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22. Pre Op Investigations
 Blood complete picture
 Urine RE
 Serum urea & electrolytes
 PT, PTTK
 LFTs
 Blood Glucose levels
 ECG , 2-D echo
 X-Ray Chest
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Within normal
limits

23. Pre Op Work Up
 Counseling
 Informed written consent
 Pre-anesthesia assessment ASA-IV
 02 Units RCC arranged
 NPO over night
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25. Operative Steps
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26. Operative Steps
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27. Operative Steps
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28. Operative Steps
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29. Operative Steps
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30. Operative Steps
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31. Operative Steps
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32. Operative Steps
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33. Operative Steps
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34. Operative Steps
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35. Operative Steps
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36. Operative Steps
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37. Operative Steps
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38. Operative Steps
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39. Operative Steps
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40. Post OP Management
 Nursed in ITC
 Inj Ceftriaxone 1g I/V 12 hourly (ATD)
 Inj Coamoxiclav 1.2g I/V 8 hourly (ATD)
 Inj Ketorolac 30mg I/V 08 hourly
 Inj Dexamethasone 8 mg I/V 08 hourly
 Inj Ca Gluconate 10 mg I/V 08 hourly
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41. Post OP Management
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 7th Post op day
- Shifted to ward
 10th Post op day
- Fibreoptic laryngoscopy
- Decannulation
 14th Post op day
- Grillo’s sutures removed

42. 42
CASE II PRESENTATION
Management of Complicated
Papillary Thyroid Carcinoma

43. Patient Profile
 Name XYZ
 Age 23 years
 Gender Male
 Profession Serving
 DOA 23.01.2013
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44. Case Summary
 Painless swelling on Rt side neck
 Metastatic Papillary Thyroid Ca on FNAC
 Nodule Rt lobe thyroid & Rt Metastatic lymph
nodes Level III, V on CT
 Near Total Thyroidectomy with ‘Berry picking’
Cervical Nodes (Rt)
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45. 45
Case Summary cont’d…
 Thyroid Scan

46.  Completion thyroidectomy
 Post-op Complications
- Hoarseness & dyspnea on
exertion
 IDL/ Fibreoptic Laryngoscopy
- Both Vocal Cords immobile,
paramedian
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Case Summary cont’d…

47. 47
Case Summary cont’d…
 Whole Body Scan

48. Management Plan
COMPLETION THYROIDECTOMY &
RIGHT RADICAL NECK DISSECTION
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49. Management
 Pre-op work up
 Counselling
 Details of the nature and severity of the
disease
 Treatment options available
 Specific risk of surgery and GA
 Informed written consent
 Pre-anesthesia assessment: ASA-I
 02 Units RCC arranged
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51. Operative Steps
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52. Operative Steps
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53. Operative Steps
53 53

54. Operative Steps
54 54

55. Operative Steps
55 55

56. Post OP Management
 Nursed in Surgical ITC
 Inj Ceftriaxone 1g I/V 12 hourly (ATD)
 Inj Coamoxiclav 1.2g I/V 8 hourly (ATD)
 Inj Ketorolac 30mg I/V 08 hourly
 Inj Dexamethasone 8 mg I/V 08 hourly
 Inj Ca Gluconate 10 mg I/V 08 hourly
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57. Post OP Management
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 2nd Post operative day
- Fibreoptic laryngoscopy
 3rd Post operative day
- Shifted to Surg HDU
 5th Post op day
- Shifted to ward
 14TH Post op day
-Stitches removed
-Thyroid profile

58. Follow Up
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59. 59
LITERATURE REVIEW
Management of Complicated
Papillary Thyroid Carcinoma

60. Case Summary
 Commonest thyroid tumour 80%*
 Age incidence 20-50 years
 Male : Female 1 : 3
 Multifocal 80%†
 Spread by lymphatics
 Local invasion 10-20%
 10 year survival 93%
* Murray D. The thyroid gland, in: Kovacs L, Asa SL (eds). Functional endocrine pathology. Oxford:
Blackwell. Science, 1998: 295-369
† Baloch ZW, LivoIsi VA. Pathology of thyroid gland. In: LivoIsi VA, Asa SL (eds). Endocrine
pathology. Philadelphia, PA: Churchill Livingstone, 2002: 61-101
Papillary Thyroid Carcinoma
60

61. Etiology / Risk Factors
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 Prolonged stimulation by  TSH*
 Persistent solitary thyroid nodule
 Radiation exposure
 Familial & Genetic factors
- Gardner’s Syndrome
* Williams ED, Abrosimov A, Bogdanova T et al. Thyroid carcinoma after
Chernobyl latent period, morphology and aggressiveness. British Journal
of Cancer 2004; 90: 2219-24

62. Case Summary
Classification
62* Hedinger C, ed. Histological Typing of Thyroid
Tumours. 2nd ed. Berlin: Springer-Verlag; 1988

63. Case Summary
Classification
63
Papillary carcinoma
i. Papillary microcarcinoma
ii. Encapsulated variant
iii. Follicular variant
iv. Diffuse sclerosing variant
v. Oxyphilic(Hurthe) cell type

64. Case Summary
 Solitary nodule
 Prominent nodule in MNG
 Palpable Cervical Lymph Nodes 30% *
 Hoarseness
 Difficulty in breathing 3-5%
 Difficulty in swallowing
*Wang TS, Dubner S, Sznyter LA, Heller KS. Incidence of metastatic well-differentiated
thyroid cancer in cervical lymph nodes. Archives of Otolaryngology - Head and Neck
Surgery 2004; 130: 110-13
Clinical Presentation
64

65. Case Summary
 Examination of Neck
 Firm, solitary or dominant nodule in MNG
 Movement of swelling on swallowing
 Mobility
 Consistency
 Extent
 Cervical lymph nodes
 Examination of Pharynx & Larynx
 IDL/ Fibreoptic endoscopy
- Vocal cord paralysis/ compression of airway
Physical Examination
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66. Case Summary
 FNAC
 Thy 1 – inadequate for diagnosis
 Thy 2 – benign disease
 Thy 3 – suspicious for neoplasia
 Thy 4 – suspicious for malignancy
 Thy 5 – positive for malignancy
Investigations
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67. Case Summary
 Serum Thyroid Profile
 T3, T4 Euthyroid
 ↑ TSH Malignancy*
 ↑ Thyroglobulin Recurrence
* Boelaert K, Horacek J, Holder RL et al. Serum thyrotropin concentration as a novel
predictor of malignancy in thyroid nodules, investigated by fine-needle aspiration. Journal
of Clinical Endocrinology and Metabolism 2006; 91:4295-301
Investigations cont’d…
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68. Case Summary
 USG Neck*
 Nodularity, size, consistency,
cacifications
 Disease in contralateral lobe
 Cervical lymph nodes
 US guided FNAC
 Colour Flow Doppler Sonography
 Type III flow (Intranodular/central)
* Appetecchia M, Solivetti FM. The association of colour flow Doppler sonography and
conventional ultrasonography improves the diagnosis of thyroid carcinoma. Hormone Research
2006; 66: 249-56
Investigations cont’d…
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69. Case Summary
 Thyroid Isotope Scan
 Iodine-123 or Iodine-131
 Technetium-99m
 Show nodules greater than 5 mm
 Cold nodules may be malignant
 Hot or warm nodules are unlikely to be
malignant
Mehahna H, Jain A, Morton RP et al. Investigating the thyroid nodule. British Medical
Journal 2009; 338: 733
Investigations cont’d…
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70. Case Summary
 CT MRI Neck & Thorax
 Local invasion
 Retrosternal extension
Som PM, Brandwein M, Lidov M et al. The varied presentations of papillary thyroid carcinoma
cervical nodal disease: CT and MR findings. AJNR. American Journal of Neuroradiology 1994;-15:
1123-8
Investigations cont’d…
70

71. Case Summary
Prognostic Factors
71
Lundgren CI, Hall P, Dickman PW. Zedenius J. Clinically significant prognostic factors for
differentiated thyroid carcinoma: a population-based, nested case-control study. Cancer 2006;
106: 524-3

72. Case Summary

TNM Staging
72
Edge SB, Byrd DR, Carducci M et al. AJCC cancer staging manual, 7th edn. New York: Springer, 2009

73. Case Summary

Staging
73
Edge SB, Byrd DR, Carducci M et al. AJCC cancer staging manual, 7th edn. New York: Springer, 2009

74. Case Summary
Classification
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 Minimal or Micro carcinoma < 1 cm
 Intrathyroidal > 1 cm
 Extrathyroidal Beyond capsule/
Lymph node
metastasis

75. Case Summary
 Surgery is the mainstay of treatment*
 Radio-ablation of thyroid remnant
 Thyroxine suppression
 External beam radiation
Treatment
75
*Mazzaferri EL, Kloos RT. Clinical review 128: Current approaches to primary therapy for papillary
and follicular thyroid cancer. Journal of Clinical Endocrinology and Metabolism 2001; 86: 1447-63.

76. Case Summary
Surgical Treatment
76
*Head and Neck Cancer:Multidisciplinary Management Guidelines 2011
British Association of Head and Neck Oncologists, British Association of Endocrine and Thyroid
Surgeons, British Association of Otolaryngology– Head and Neck Surgery
*

77. Case Summary
 Extent of Surgery for cervical lymph nodes
 Selective nodal excision (Not recommended)*
- Berry/ Cherry picking
 Anterior/ Central (Level VI) Neck Dissection
 Lateral/ Selective or Modified Radical Neck†
Dissection (Level III, II, IV, I, V)
Surgical Treatment
77
*Scheumann GF, Gimm 0, Wegener G ef al. Prognostic significance and surgical management of locoregional lymph node
metastases in papillary thyroid cancer. World Journal of Surgery 2009; 18: 559-67
†Pingpank JFJr, Sasson AR, Hanlon AL et.al. Tumor above the spinal accessory nerve in papillary thyroid cancer that involves
lateral neck nodes: a common occurrence. Archives of Otolaryngology - Head and Neck Surgery 2002; 128: 1275-8.

78. Case Summary
 Post Op TSH suppression by exogenous thyroxine*
 TSH levels of < 0.1 mU/L in high risk and between 0.1-
0.5mU/L in low risk patients
 TSH suppression is discontinued 2-4 weeks before
radio ablation
TSH Suppression Therapy
78
*Cooper DS, Specker B, Ho M et al. Thyrotropin suppression and disease progression in patients with
differentiated thyroid cancer: results from the National Thyroid Cancer Treatment Cooperative Registry.
Thyroid 1998; 8:737-44

79.  Radioiodine is used for ablation of normal thyroid*
tissue & to treat residual thyroid tumour
 Pre therapy whole body diagnostic scan
 Therapeutic doses of 100-200 mCi
 Not recommended in low risk group†
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Radio Ablation
*Sawka AM, Thephamongkhol K, Brouwers M et al. Clinical review 170: A systematic review and metaanalysis of the
effectiveness of radioactive iodine remnant ablation for well-differentiated thyroid cancer. Journal of Clinical Endocrinology
and Metabolism 2004; 89: 3668-76
†British Thyroid Association and Royal College of Physicians. Guidelines for management of thyroid cancer, 2007.
Available from www.british-thyroidassociation.org

80.  EBRT along with Doxirubicin improves local control
80
External Beam RT & Chemotherapy
British Thyroid Association and Royal College of Physicians. Guidelines for management of thyroid cancer,
2007. Available from www.british-thyroidassociation.org

81. Case Summary
 30% recurrence*
 Regular TSH levels
 Serial Thyroglobulin levels†
 Diagnostic Radio iodine scans
 US Neck
 FDG-PET Scans
Follow up/ Monitoring
81
*Mazzaferri EL, Kloos RT. Clinical review 128: Current approaches to primary therapy for papillary and
follicular thyroid cancer. Journal of Clinical Endocrinology and Metabolism 2001; 86: 1447-63
† Mazzaferri EL Empirically treating high serum thyroglobulin levels. Journal of Nuclear Medicine 2005; 46:
1079-88.

82. Case Summary
DATA ANALYSIS
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83. Case Summary
13
5
2
3
2
n = 25
Papillary
Follicular
Anaplastic
Lymphoma
undifferentiated
Data Analysis
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84. Data Analysis
0
10
20
30
40
50
60
70
CMH Data
JPMC Data
UK Data
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85. Conclusion
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 Thyroid cancer is relatively rare , one of the
most curable cancers
 Surgery is the treatment of choice
 Complications to be kept minimal
 Low recurrences to be ensured

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DEPARTMENT OF ENT,
HEAD AND NECK SURGERY
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