Papillary Thyroid Cancer

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Papillary thyroid cancer or papillary thyroid carcinoma , is one of the most common thyroid cancer form to exist. Its incidence rate is as high as 75%-85% and usually occurs in females in age group of 20-55. There is a high risk of occurrence if a patient has a history of childhood irradiation. Even though has a very high occurrence, it has a very good prognosis. Papillary cancer often presents as a thyroid nodule which does not take up radioactive iodine or as an enlarged lymph node showing metastasis [1].

The course of disease depends on extension stages: occult carcinoma, intrathyoid carcinoma and extrathyroid carcinoma. But, in a study published in 1961 shows that results are more favourable if patient is below 40 years [2].

Diagnosis of Papillary Thyroid Cancer

Fine needle aspiration is the gold standard for diagnosis with the help of Ultrasound. Among other imaging techniques CT/MRI is used to check  hot nodules. Blood markers should be checked and most frequently used is Thyroglobulin – a marker for a well differentiated tumor.

In case of suspicion of lung metastasis, broncho-alveolar lavage is done [3].

Pathology of Papillary Thyroid Cancer

Empty appearing nuclei or commonly known as ORPHAN ANNIE’S EYES are a histological characteristic of papillary thyroid carcinoma. Histologically , its multifocal and unencapsulated.

Hematogenous spread is less common than lymphatic spread, hence, Usually metastasize to near-by lymph nodes. It usually metastasizes to lung and form small nodules.

Lateral Aberrant Thyroid- This is a result of lymph node metastasis as a result of papillary carcinoma.

Genetic association of Papillary Thyroid Cancer

Most of the associated mutations result in activation of a common carcinogenic pathway called – the  MAPK/ERK pathway. Mutation can be a chromosomal translocation involving RET proto-oncogene and NTRK-1 or a point mutation in BRAF oncogene. Most commonly seen is point mutation in nearly 50% of the cases [4].

Staging of Papillary Thyroid Cancer

For staging we use TMN classification, and divide it into stage I- IV. Survival rate decreases as the staging progresses.

Treatment of Papillary Thyroid Cancer

Age of the patient and size of the nodule mainly determine the choice of treatment [5].

Stage I and II

  1. Total thyroidectomy which means total removal of thyroid gland is used when in suspicion of a large spread.
  2. Lobectomy, or removal of a lobe and all of thyroid is also used to salvage the healthy tissue.

Stage III

  1. Total thyroidectomy along with Lymph node removal and any other extra thyroid spread is the most common intervention
  2. After surgery, I 131 Ablation is used to remove any remnants from surgery.
  3. And only if I 131 don’t work then External beam radiation is used.

Stage IV

  1. Usually cancer metastasizes in this stage, so I 131 ablation is used as a therapeutic dose to kill the cancerous cell.
  2. External beam radiation is used for patients who are unresponsive to I 131 treatment
  3. Resection of metastases is done only when cells don’t exhibit I 131 uptake.
  4. As an alternative, TSH suppression therapy along with thyroxine can be used if patient seems unresponsive to I 131 treatments [6].

 

References


[1] “Independent Clonal Origins of Distinct Tumor Foci in Multifocal Papillary Thyroid Carcinoma Trisha” by M. Shattuck, B.S., William H. Westra, M.D., Paul W. Ladenson, M.D., and Andrew Arnold, M.D.,N – Engl J Med 2005; 352:2406-2412 – June 9, 2005 – DOI: 10.1056/NEJMoa044190, http://www.nejm.org/doi/full/10.1056/NEJMoa044190#t=articleBackground


[2] “Papillary thyroid carcinomas” – Jacqueline Tscholl-Ducommun, Chr. E. Hedinger, http://link.springer.com/article/10.1007/BF00428498#page-1


[3] “Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate Cytology” – N Engl J Med 2012; 367:705-715 – August 23, 2012 – DOI: 10.1056/NEJMoa1203208, http://www.nejm.org/doi/full/10.1056/NEJMoa1203208#t=articleBackground


[4] “Independent Clonal Origins of Distinct Tumor Foci in Multifocal Papillary Thyroid Carcinoma” – Trisha M. Shattuck, B.S., William H. Westra, M.D., Paul W. Ladenson, M.D., and Andrew Arnold, M.D.,N Engl J Med 2005; 352:2406-2412 – June 9, 2005 – DOI: 10.1056/NEJMoa044190, http://www.nejm.org/doi/full/10.1056/NEJMoa044190#t=articleBackground


[5] http://www.webmd.com/cancer/tc/thyroid-cancer-treatment-pdq-treatment—health-professional-information-nci-stage-iv-papillary-and-follicular-thyroid-cancer


[6] Simpson WJ, Carruthers JS: The role of external radiation in the management of papillary and follicular thyroid cancer. Am J Surg 136 (4): 457-60, 1978 – http://www.webmd.com/cancer/rm-quiz-cancer-myths-facts

 

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