Current Otolaryngology > X. Thyroid & Parathyroid > Chapter 41.

Malignant Thyroid Disorders >

INTRODUCTION: MALIGNANT THYROID DISORDERS

Essentials of Diagnosis

History of previous exposure of ioni ing radiation to the ne!". Painless# fir$ thyroid nodule. %uthyroid. &ine'needle aspiration (&)*+ ,iopsy is diagnosti!.

General Consi erations

Thyroid !an!er a!!ounts for approxi$ately 1.-. of all !an!ers in the /nited 0tates. Thyroid !an!er# $oreover# $a"es up 12. of endo!rine gland !an!ers and a!!ounts for approxi$ately 12#333 ne4 !ases in the /nited 0tates annually. Ho4ever# only 1233 people su!!u$, to thyroid !an!er ea!h year in the /nited 0tates# $a"ing it one of the $ore surviva,le !an!ers. The in!iden!e of 4ell'differentiated thyroid !an!er is approxi$ately 256 ti$es $ore li"ely in 4o$en than in $en. Poorly differentiated thyroid !an!ers are seen in e7ual proportions in $en and 4o$en. The spe!tru$ of $alignant thyroid disorders ranges fro$ very indolent tu$ors# su!h as papillary !ar!ino$a# to highly aggressive tu$ors# su!h as anaplasti! or undifferentiated !ar!ino$a. Papillary !ar!ino$a typi!ally is seen in young adults and often $etastasi es regionally to the ly$phati!s of the ne!". %ven in the presen!e of regional $etastasis# ho4ever# patients 4ith papillary !ar!ino$a have very lo4 $ortality rates. Conversely# patients are typi!ally in their sixth or seventh de!ade 4hen a diagnosis of anaplasti! thyroid !an!er is $ade. 8nly 13. of patients 4ith anaplasti! thyroid !an!er 4ill survive one year after the diagnosis# 4ith a $edian survival of approxi$ately 9 $onths.

!at"ogenesis
The t4o types of !ells found in thyroid gland tissue in!lude the neuroendo!rine !al!itonin' produ!ing C !ell (the parafolli!ular !ell+ and the folli!ular !ell# derived fro$ the endoder$# 4hi!h synthesi es thyroglo,ulin. Malignant thyroid disorders derive fro$ these t4o types of !ells. Papillary !ar!ino$a# folli!ular !ar!ino$a# H:rthle !ell neoplas$s# and anaplasti! !ar!ino$a are derived fro$ the folli!ular !ells. Medullary !ar!ino$a is derived fro$ the parafolli!ular !ells. The !ause of $ost $alignant thyroid gro4ths is un"no4n; ho4ever# patients 4hose thyroid glands have ,een exposed to lo4'dose therapeuti! radiation therapy are at an in!reased ris" of developing thyroid !an!er. <n general# there is a long laten!y period (> 23 years+ ,et4een the exposure to radiation and the onset of !ar!ino$a. Children 4ho re!eive ioni ing radiation (as little as 13 !=y+ are $ore li"ely to develop thyroid !ar!ino$a later in life than adults 4ho re!eive e7ual a$ounts of ioni ing radiation. *lso# $edi!al personnel and others exposed to radiation have a signifi!antly higher prevalen!e of thyroid !ar!ino$a than do !ontrol groups. Medullary thyroid !ar!ino$a is fa$ilial approxi$ately 2-. of the ti$e. The sporadi! for$

of $edullary thyroid !an!er tends to ,e unilateral and the fa$ilial for$ is al$ost al4ays ,ilateral. Papillary !ar!ino$a !an also ,e fa$ilial and also o!!urs in asso!iation 4ith fa$ilial adeno$atous polyposis# =ardner syndro$e# and Co4den syndro$e.

Clini#al $in ings

SYM!TOMS AND SIGNS Co$$only# the only presenting sy$pto$ of a patient 4ith thyroid !an!er is the presen!e of a palpa,le thyroid $ass or an enlarged !ervi!al ly$ph node. <t is unusual for these $asses to ,e sy$pto$ati!. 8!!asionally# patients present 4ith $ore pro,le$ati! sy$pto$s and signs# 4hi!h alert the physi!ian to the possi,ility of a $alignant !ondition. These sy$pto$s and signs in!lude hoarseness# lo!ali ed pain# dysphagia# shortness of ,reath# he$optysis# and a hard# fixed thyroid nodule or ne!" $ass. *lthough these sy$pto$s $ay also o!!ur 4ith ,enign disease# their presen!e in!reases the suspi!ion of a $alignant gro4th. The physi!al exa$ination of patients 4ith possi,le thyroid !an!er should in!lude a thorough exa$ination of the head and ne!". >aryngos!opy is essential to evaluate vo!al !ord fun!tion ,e!ause invasive !an!ers !an invade the re!urrent laryngeal nerve and !ause vo!al !ord paralysis. *lso# it is i$portant to do!u$ent any preexisting fun!tional a,nor$alities of the vo!al !ords prior to thyroide!to$y. LA%ORATORY $INDINGS &)* ,iopsy is a very a!!urate diagnosti! test and is the pri$ary diagnosti! test for the evaluation of a thyroid nodule. The $ost i$portant fa!tors that influen!e the a!!ura!y of &)* for thyroid nodules are the experien!e of the !ytopathologist and the ade7ua!y of the !ytopathologi! spe!i$en. The !ytopathologi! finding is reported as ,eing $alignant# ,enign# indeter$inate (eg# for folli!ular or H:rthle !ell neoplas$+# or insuffi!ient for the diagnosis. <f an &)* ,iopsy is dee$ed insuffi!ient# it should ,e repeated. Patients 4ith thyroid neoplas$s are typi!ally euthyroid. Ho4ever# the seru$ thyroid' sti$ulating hor$one (T0H+ and seru$ !al!iu$ levels should ,e !he!"ed preoperatively in order to deter$ine thyroid and parathyroid fun!tion. IMAGING STUDIES Ra ionu#li e I&aging <f an &)* ,iopsy is indeter$inate or insuffi!ient for the diagnosis# other i$aging studies !an ,e used to help deter$ine the possi,ility of a thyroid nodule ,eing $alignant. ?adionu!lide i$aging 4ith radioiodine (126<+ de$onstrates the a,ility of the thyroid nodule to !on!entrate iodine. )odules that a!tively !on!entrate radiola,eled iodine are !onsidered to ,e @hot@ nodules. *l$ost all @hot@ nodules (11.9.+ are ,enign. @Cold@ nodules# 4hi!h do not upta"e radioiodine Ultrasonogra'"y /ltrasonography is another i$aging $odality that !an ,e used to deter$ine the nature of a thyroid nodule. 8ne advantage of ultrasound is its a,ility to deter$ine if a thyroid nodule has a !ysti! !o$ponent. <n addition# other nonpalpa,le nodules $ay ,e dete!ted.
161

<# are $ore li"ely to ,e $alignant. Ho4ever#

$ost @!old@ nodules (A3.+ are also ,enign.

Purely !ysti! $asses are al4ays ,enign; ho4ever# $any nodules are @$ixed#@ 4ith a !ysti! and solid !o$ponent. Mixed lesions and !o$pletely solid lesions are potentially $alignant. /ltrasound !an also help guide &)* 4hen thyroid nodules are s$all and diffi!ult to palpate. Ot"er I&aging Stu ies Bhen further evaluation of the ne!" is i$portant to deter$ine the extent of regional $etastases in thyroid !an!er# $agneti! resonan!e i$aging (M?<+ !an ,e useful. <n general# !o$puted to$ography (CT+ s!anning 4ith !ontrast is to ,e avoided ,e!ause iodinated !ontrast $aterial !an interfere 4ith su,se7uent
161

< s!anning or therapy# if they

,e!o$e ne!essary. M?< is not typi!ally e$ployed as a first'line diagnosti! study# ,ut it $ay aid in evaluating the extent of disease in patients 4ith "no4n thyroid !an!er. DIAGNOSTIC SURGERY * diagnosti! thyroid lo,e!to$y and isth$e!to$y are indi!ated for nodules that exhi,it suspi!ious !ytology on &)*# folli!ular neoplas$s# nodules that enlarge on thyroid suppression therapy# or !lini!ally suspi!ious nodules. <ntraoperative fro en se!tions are not helpful in differentiating folli!ular adeno$as fro$ folli!ular !ar!ino$as.

%ENIGN THYROID NEO!LASMS

Cenign nodules of the thyroid in!lude thyroid !ysts# adeno$as# lo!ali ed thyroiditis# granulo$atous disease# and a,s!esses. 8f these# only adeno$a represents a ,enign neoplas$. Thyroid adeno$as are derived fro$ folli!ular !ells and represent the $ost !o$$on neoplas$ of the thyroid gland. *deno$as typi!ally o!!ur in 4o$en older than 63 years of age. 0urgi!al ex!ision of thyroid adeno$as is appropriate (1+ 4hen there is a history of ioni ing radiation to the thyroid; (2+ if the $ass is sy$pto$ati! or !os$eti!ally displeasing; or (6+ if it is overa!tive# resulting in hyperthyroidis$.

THYROID CARCINOMAS (ell)Differentiate

STAGING
The three $ost !o$$only used staging syste$s for 4ell'differentiated thyroid !ar!ino$a are the M*<C0# T)M# and *M%0 syste$s. *ll three have in !o$$on the age of the patient as one of the prognosti! indi!ators. The MAICS staging syste& evaluates Metastasis# Age# Invasion# Co$pleteness (of surgi!al rese!tion+# and Si e (of the tu$or+. %a!h varia,le is $athe$ati!ally s!ored to deter$ine the predi!ted survival rate (Ta,le 4151+.

T"yroi

Car#ino&as

Ta*le +,-,. MAICS S#oring Syste&.

!rognosti# /aria*les
Presen!e of distant Metastasis Age at the ti$e of diagnosis

S#ore
Des E 6# )o E 3 F 61 years E 6.1# > 43 E 3.3A x age

!rognosti# /aria*les

S#ore

Invasion ,eyond the thyroid gland in Co$plete surgi!al rese!tion Si e of the tu$or

Des E 1# )o E 3 Des E 1# )o E 3 3.6 x si e in !enti$eters

01)year sur2i2al rate a##or ing to MAICS s#ore. MAICS S#ore 3 4.11 4.11-4.55 6.11-6.55 A1. -9. 7 8.11 24.

23'year survival 11.

<n addition to patient age# the TNM staging syste& of the *$eri!an Goint Co$$ittee on Can!er (*GCC+ prognosti!ates the survival rate ,ased on Tu$or si e# Nodal $etastasis# and distant Metastasis (Ta,le 4152+.

Ta*le +,-0. TNM Staging Syste& for (ell)Differentiate Car#ino&a.

T"yroi

Stage Age Age 7 In#i en#e of 3 +9 +9 Lo#al Re#urren#e

< *ny T *ny ) M3 *ny T *ny ) M1 nIa T1 )3 M3 -.-.

In#i en#e of Distant Re#urren#e

2.A.

Mortality

1.A.

<<

T2 or T6 )3 M3

H.

H.

11.9.

<<<

T4 )3 M3 2H. *ny T *ny ) M1 *ny T 13. *ny ) M1

16.-.

6H.A.

<J

nIa

133.

13.

The AMES staging syste& uses Age# Metastases# Extent of the pri$ary tu$or# and Si e of the tu$or to predi!t surviva,ility (Ta,le 4156+. <n this syste$# patients are !lassified as either lo4'ris"# 4ith a $ortality rate of 1.A.# or high'ris"# 4ith a $ortality rate of 49..

Ta*le +,-:. AMES Staging Syste&.

Lo; Ris< = ,.8> Mortality Rate

Men F 41 years old and 4o$en F -1 years old *ll patients 4ithout distant $etastases *ll $en > 41 years old and 4o$en > -1 years old 4ithK 1. <ntrathyroidal papillary !ar!ino$a 8? 2. &olli!ular !ar!ino$a 4ith $inor !apsular involve$ent *)D 6. Pri$ary tu$or F - !$ in dia$eter *)D 4. )o distant $etastases.

Hig" Ris< = +4> Mortality Rate

*ll patients 4ith distant $etastases

*ll $en > 41 years old and 4o$en > -1 years old 4ithK 1. %xtra'thyroidal papillary !ar!ino$a 8? 2. &olli!ular !ar!ino$a 4ith $aLor !apsular involve$ent *)DI8? 6. Pri$ary !an!er M - !$ in dia$eter.

!A!ILLARY CARCINOMA
The $ost !o$$on $alignant disorder of the thyroid gland is papillary !ar!ino$a# 4hi!h represents approxi$ately A3. of all $alignant thyroid disorders. Papillary !ar!ino$a# a 4ell'differentiated !ar!ino$a# arises fro$ thyroid folli!ular !ells. Bo$en are affe!ted 256 ti$es $ore fre7uently than $en# and the in!iden!e pea"s ,et4een the third and fourth de!ades of life. Papillary !ar!ino$as are often $ulti!entri! and are found in ,oth lo,es of the thyroid up to A3. of the ti$e. * $ultifo!al presentation is parti!ularly !o$$on in patients 4ith prior lo4'dose radiation therapy to the ne!". This tu$or spreads via the regional ly$phati!s to the !entral and lateral !ervi!al ly$ph nodes. /p to 43. of patients present 4ith !ervi!al or $ediastinal $etastases at the ti$e of the initial diagnosis. Despite the high in!iden!e of !ervi!al $etastases# their presen!e does not in!rease the overall $ortality. Ho4ever# patients 4ith $etastati! ne!" disease have a greater ris" of regional re!urren!e. The 23'year survival rate of noninvasive papillary !ar!ino$a is very high (1-.+. Histologi!ally# papillary !ar!ino$a is !hara!teri ed ,y finger'li"e proLe!tions of folli!ular !ells interposed 4ith !al!ifi!ations# intranu!lear va!uoles# and psa$$o$a ,odies. <ntranu!lear va!uoles are often referred to as @8rphan *nnie %yes@ ,e!ause of their !hara!teristi! rounded appearan!e. Psa$$o$a ,odies are present in Lust over -3. of papillary !ar!ino$as# and 4hen they are found in extrathyroidal tissue# they are strongly suggestive of $etastati! papillary !ar!ino$a. The folli!ular variant of papillary !ar!ino$a has a si$ilar ,ehavior to true papillary !ar!ino$a. 8ther histopathologi! variants# in!luding tall !ell# !olu$nar !ell# and insular !ell papillary !ar!ino$as# have $ore aggressive ,ehaviors than true papillary !ar!ino$a. Treat$ent of papillary !ar!ino$a is thyroide!to$y as 4ell as the re$oval of regional ne!" ly$phati!s ,y $odified radi!al ne!" disse!tion 4hen ly$ph nodes are involved. Total

thyroide!to$y is re!o$$ended ,y $ost surgeons# although lo,e!to$y and isth$e!to$y is a!!epta,le for $i!ro!ar!ino$as (ie# F 1.3 !$+. The advantages of total thyroide!to$y in!lude a de!reased re!urren!e rate and the a,ility to use thyroglo,ulin and radioa!tive iodine s!ans for the diagnosis of re!urrent disease postoperatively. Patients 4ith tu$ors > 1.- !$ and all high'ris" patients ,enefit fro$ postoperative suppressive doses of l'thyroxine (levothyroxine+.
161

< therapy. <n addition# all

patients 4ith 4ell'differentiated thyroid !ar!ino$as should ,e treated indefinitely 4ith

$OLLICULAR CARCINOMA
&olli!ular !ar!ino$a# li"e papillary !ar!ino$a# is another 4ell'differentiated thyroid !ar!ino$a. *pproxi$ately 1351-. of all thyroid !an!ers have a folli!ular histology. <t o!!urs 256 ti$es $ore fre7uently in 4o$en than in $en. <t typi!ally o!!urs later in life than papillary !ar!ino$a and arises !lassi!ally 4ith a $ean age at presentation in the fifth or sixth de!ade of life. %ven though papillary !ar!ino$a is asso!iated 4ith a lo4er $ortality than folli!ular !ar!ino$a# folli!ular !ar!ino$a is still !onsidered a highly surviva,le !an!er. The 13'year survival rate is approxi$ately A-. and the 23'year survival rate is approxi$ately H3.. Co$pared 4ith papillary !ar!ino$a# folli!ular !ar!ino$a does not $etastasi e via the ly$phati!s as fre7uently and fe4 patients have regional $etastases at the ti$e of the initial diagnosis. &olli!ular !ar!ino$a is $ore li"ely than papillary !ar!ino$a to spread via he$atologi! path4ays and !an spread to the lungs# the liver# and ,one. Histologi!ally# folli!ular !ar!ino$a !an ,e diffi!ult to distinguish fro$ nor$al thyroid tissue. Clusters of en!apsulated neoplasti! folli!ular !ells are seen. The presen!e of !apsular or vas!ular invasion differentiates folli!ular !ar!ino$a fro$ folli!ular adeno$a. The degree of !apsular or vas!ular invasion in folli!ular !ar!ino$a is related to the overall prognosis# 4ith higher rates of invasion ,eing asso!iated 4ith higher $ortality rates. The treat$ent of folli!ular !ar!ino$a is total thyroide!to$y follo4ed ,y thyroxine suppression therapy.
161

< a,lation and l'

H?RTHLE CELL CARCINOMA

H:rthle !ell !ar!ino$a is !onsidered to ,e an aggressive variant of folli!ular !ar!ino$a and !o$prises approxi$ately 2. of thyroid !ar!ino$as. H:rthle !ell !ar!ino$a is !o$prised of H:rthle (oxyphili!+ !ells# 4hi!h are eosinophili! !ells that !ontain large a$ounts of $ito!hondria. *pproxi$ately H3. of patients 4ith H:rthle !ell !ar!ino$a present 4ith intrathyroid disease alone# 23. 4ith regional !ervi!al ly$ph node $etastasis# and 13. 4ith distant $etastases. The treat$ent of H:rthle !ell !ar!ino$a is total thyroide!to$y. Patients 4ith regional $etastases re7uire $odified radi!al ne!" disse!tion. Most H:rthle !ell !ar!ino$as exhi,it lo4
161

< upta"e.

IN/ASI/E (ELL)DI$$ERENTIATED CARCINOMA

Coth papillary !ar!ino$a and folli!ular !ell !ar!ino$a !an invade stru!tures# in!luding the tra!hea# the larynx# the esophagus# and ,lood vessels. <nvasive 4ell'differentiated !ar!ino$as are $u!h $ore li"ely to $etastasi e (up to A3.+ and are asso!iated 4ith

higher $ortality rates than noninvasive 4ell'differentiated !ar!ino$a (up to 23. at 13 years+. Patients presenting 4ith either he$optysis or dyspnea and thyroid !ar!ino$a are parti!ularly li"ely to har,or an invasive for$ of !ar!ino$a. These neoplas$s are ,est treated 4ith !o$plete surgi!al rese!tion# in!luding total thyroide!to$y 4ith postoperative
161

< therapy. 0ele!t !ases $ay also ,enefit fro$ adLuvant external ,ea$ radiation

therapy.

Ot"er T"yroi

Car#ino&as

MEDULLARY CARCINOMA
Medullary thyroid !ar!ino$a originates fro$ the parafolli!ular !ells (C !ells+ of the thyroid. <t a!!ounts for approxi$ately -513. of $alignant thyroid neoplas$s. The in!iden!e is al$ost e7ual in $en and 4o$en. *pproxi$ately H-. of $edullary !ar!ino$as o!!ur sporadi!ally# ,ut 2-. are fa$ilial in origin. &a$ilial $edullary !ar!ino$a o!!urs in three for$sK (1+ M%) 2a ($ultiple endo!rine neoplasia syndro$e+# (2+ M%) 2,# and (6+ non' M%) fa$ilial. Patients 4ith M%) 2a and non'M%) fa$ilial $edullary !ar!ino$a have a ,etter prognosis than patients 4ith either M%) 2, or the sporadi! type. The $ean survival rate for all $edullary thyroid !an!ers is approxi$ately -3.. &a$ilial $edullary !ar!ino$as tend to ,e $ultifo!al 4ithin the thyroid gland. <n addition# regional ly$ph node involve$ent is fre7uent (-3.+. The diagnosis of $edullary !ar!ino$a is typi!ally $ade ,y an &)* ,iopsy. *n elevated seru$ !al!itonin level is !hara!teristi!. 0eru$ !ar!inoe$,ryoni! antigen (C%*+ levels $ay also ,e elevated. Mutation of the RET proto'on!ogene is seen in $ost !ases of fa$ilial $edullary !ar!ino$a. The fa$ily $e$,ers of patients 4ith $edullary thyroid !ar!ino$a should ,e !onsidered for s!reening for this point $utation in RET. Patients deter$ined to have the $utation for M%) 2a should undergo prophyla!ti! total thyroide!to$y ,efore 9 years of age. <n patients 4ith the $ore aggressive M%) 2,# prophyla!ti! thyroide!to$y is re!o$$ended ,efore the age of 2. 0urgery is the only effe!tive therapy for $edullary !ar!ino$a. Prior to surgery# it is i$portant to rule out a !on!o$itant pheo!hro$o!yto$a. Total thyroide!to$y and a !entral ne!" disse!tion are re!o$$ended for all patients 4ith $edullary !ar!ino$a. * $odified radi!al ne!" disse!tion is re!o$$ended for !ervi!al $etastases. 0ele!t patients $ay ,enefit fro$ external ,ea$ radiation therapy postoperatively. Postoperatively# a seru$ !al!itonin level should ,e o,tained. %levation of the seru$ !al!itonin level indi!ates persistent disease. >o!ali ing studies for residual !ar!ino$a in!lude ultrasound# M?<# and radionu!lide s!ans# su!h as DM0* sele!tive venous sa$pling of !al!itonin !an also ,e perfor$ed. 0urgi!al rese!tion is re!o$$ended for identifia,le residual disease.

ANA!LASTIC CARCINOMA
*naplasti! (undifferentiated+ !ar!ino$a is a highly lethal !an!er that is asso!iated 4ith a $ortality rate > 13. 4ithin 2 years of the initial diagnosis. *naplasti! !ar!ino$a !onstitutes approxi$ately 1. of all $alignant thyroid disorders. <ts in!iden!e is e7ual in $en and 4o$en and patients typi!ally are older than 9- years of age. This disorder

usually arises fro$ a 4ell'differentiated thyroid !ar!ino$a. *pproxi$ately A3. of patients 4ith anaplasti! !ar!ino$a are found to have a !oexisting papillary or folli!ular thyroid !ar!ino$a. Patients 4ith a rapidly expanding thyroid goiter or $ass should ,e evaluated to rule out a $alignant transfor$ation to this !ar!ino$a. The differentiation of anaplasti! !ar!ino$a fro$ ly$pho$a is i$portant as ,oth entities $ay present in a si$ilar fashion. *naplasti! !ar!ino$a is fre7uently lo!ally invasive into adLa!ent stru!tures. <t often $etastasi es regionally as 4ell as distally. Histologi!ally# this tu$or has large nu$,ers of $itoses and is seen in three $ain for$sK spindle !ell# giant !ell# and s$all !ell. Treat$ent is generally palliative 4ith radiation therapy and !he$otherapy. <nfre7uently# lo!ali ed anaplasti! !ar!ino$as !an ,e !ured 4ith surgery and postoperative radiation therapy. Tra!heoto$y and gastrosto$y tu,e pla!e$ent are often ,enefi!ial adLun!ts for the palliative !are of $ost patients.

THYROID LYM!HOMA
Thyroid ly$pho$a represents 15-. of $alignant thyroid disorders and its in!iden!e is in!reasing. Patients 4ith Hashi$oto thyroiditis have a seventy'fold in!reased ris" of thyroid ly$pho$a !o$pared 4ith the general population. Thyroid ly$pho$a o!!urs approxi$ately eight ti$es $ore fre7uently in 4o$en than in $en. The $ean age of patients diagnosed 4ith thyroid ly$pho$a is greater than 93 years. Patients typi!ally present 4ith a rapidly gro4ing thyroid $ass# ne!" s4elling# hoarseness# ne!" pain# and dysphagia. Non)Ho g<in ly&'"o&a ()H>+ a!!ounts for the $aLority of thyroid ly$pho$as and is often !lassified as histio!yti! ly$pho$a. )H> of the thyroid gland usually arises fro$ the thyroid gland itself. Hodg"in ly$pho$as tend to o!!ur in other lo!ations and either invade or $etastasi e to the thyroid gland. Differentiating thyroid ly$pho$a fro$ anaplasti! !ar!ino$a !an ,e pro,le$ati! and an open ,iopsy $ay ,e ne!essary. The treat$ent of thyroid ly$pho$a is pri$arily radiotherapy for lo!ali ed disease and !he$otherapy for syste$i! disease. The -'year survival rate 4ith ly$pho$a !onfined to the thyroid gland is $ore than t4i!e as high (A-.+ as 4ith extrathyroidal !ervi!al disease (6-.+.

THYROGLOSSAL DUCT CARCINOMA

Car!ino$a of the thyroglossal du!t is typi!ally papillary !ar!ino$a# although other $alignant types# ex!ept $edullary thyroid !ar!ino$a# !an o!!ur. The diagnosis !an ,e $ade ,y &)* or follo4ing the re$oval of a presu$ed thyroglossal du!t !yst. Treat$ent is surgi!al rese!tion ,y the 0istrun" pro!edure and l'thyroxine suppression therapy.

METASTATIC CARCINOMA TO THE THYROID

Melano$a# lung !ar!ino$a# ,reast !ar!ino$a# and renal !ell !ar!ino$a are the $ost !o$$on neoplas$s to $etastasi e to the thyroid gland. &)* ,iopsy is usually helpful in the diagnosis of $etastati! !ar!ino$a of the thyroid gland. <n parti!ular# renal !ell !ar!ino$a $ay ,e diffi!ult to differentiate fro$ a pri$ary thyroid neoplas$ unless proper

i$$unohisto!he$i!al staining is perfor$ed.

TREATMENT CONSIDERATIONS
COM!LICATIONS O$ THYROIDECTOMY
The !o$pli!ations of thyroide!to$y are unusual and in!lude ne!" he$ato$as# re!urrent laryngeal nerve inLuries# and hypoparathyroidis$. He$ato$as !an !ause air4ay !o$pro$ise and $ust ,e eva!uated i$$ediately. He$ato$as typi!ally o!!ur several hours i$$ediately follo4ing surgery. <nLury to the re!urrent laryngeal nerve !auses ipsilateral vo!al !ord paralysis and o!!urs in approxi$ately 1. of !ases. Cilateral re!urrent laryngeal nerve inLury !an !ause air4ay o,stru!tion# 4hi!h often re7uires a tra!heoto$y. Hypoparathyroidis$ o!!urs in less than 2. of patients 4ho undergo total thyroide!to$y or thyroid lo,e!to$y follo4ing prior !ontralateral lo,e!to$y. The treat$ent of hypoparathyroidis$ re7uires supple$ental !al!iu$ repla!e$ent therapy# 4ith or 4ithout !al!itriol (ie# ?o!altrol+. <f the intraoperative re$oval of all parathyroid tissue is suspe!ted# parathyroid tissue !an ,e autotransplanted into a $us!le and should# in $ost !ases# regain fun!tion. *ustin G?# el')aggar *N# =oepfert H. Thyroid !an!ers# <<K $edullary# anaplasti!# ly$pho$a# sar!o$a# s7ua$ous !ell. Otolaryngol Clin North Am. 1119;21(4+K911. (* revie4 arti!le on $alignant thyroid disorders.+ OPM<DK AA44H66P Dean D0# Hay <D. Prognosti! indi!ators in differentiated thyroid !ar!ino$a. Cancer Control. 2333;H(6+K221. (* revie4 arti!le on the prognosis of $alignant thyroid disorders.+ OPM<DK 13A62131P =hari, H. Changing !on!epts in the diagnosis and $anage$ent of thyroid nodules. Endocrinol Metab Clin North Am. 111H;29(4+KHHH. (* revie4 arti!le on the diagnosis and treat$ent of thyroid nodules.+ OPM<DK 1421A93P =old$an )D# Coniglio G/# &al" 0*. Thyroid !an!ers# <K papillary# folli!ular# and H:rthle !ell. Otolaryngol Clin North Am. 1119;21(4+K-16. (* revie4 arti!le on 4ell'differentiated $alignant thyroid disorders.+ OPM<DK AA44H62P Herran '=on ales G# =avilan G# Martine 'Jidal G# =avilan C. Co$pli!ations follo4ing thyroid surgery. Arch Otolaryngol Head Neck Surg. 1111;11H(-+K-19. (* retrospe!tive study des!ri,ing the in!iden!e of !o$pli!ations in thyroid surgery.+ OPM<DK 2321491P 0egal N# &riedental ?# >u,in % et al. Papillary !ar!ino$a of the thyroid. Otolaryngol Head Neck Surg. 111-;116(4+K6-9. (* retrospe!tive analysis of -36 patients 4ith papillary thyroid !an!er.+ OPM<DK H-9H334P Treseler P*# Clar" 8H. Prognosti! fa!tors in thyroid !ar!ino$a. Surg Oncol Clin North Am. 111H;9(6+K---. (* revie4 arti!le dis!ussing prognosti! fa!tors in $alignant thyroid disorders.+ OPM<DK 12136-9P

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