1. What is your clinical impression? What are the differential diagnosis?

2. Differential Diagnoses PatientThyroid CarcinomaToxic Multinodular Goiter Rapid increase in size of the mass  Hoarseness and difficulty in swallowing Weight loss  Tremors  Exophthalmos  Easy Fatigability  Palpable cervical lymphadenopathy 

3. Thyroid cancer Most common malignancy of the endocrine system Accounts for less than 1% of all malignancies Lymph node with papillary thyroid CA

4. Risk factors for thyroid carcinoma in patients with thyroid nodule History of head & neck irradiation Age 70 y/o Increased nodule size (>4cm) New or enlarging neck mass Male gender

5. Family history of thyroid cancer or MEN 2 Vocal cord paralysis, hoarse voice Nodule fixed to adjacent structures Suspected lymph node involvement Iodine deficiency (follicular)

6. Clinical features: Lump in the neck Gradually enlarging mass Firm or hard Rapidly growing: soft or fluctuant May be painful May present with hoarseness, dysphagia, dysphonia, dyspnea Rare: hyperthyroidism

7. Papillary Carcinoma 80-85% Predominant: children & individuals exposed to external radiation 2:1 F:M ratio Mean age: 30-40 y/o S/Sx: slow growing painless mass – Dysphagia, dyspnea, dsyphonia – Lymph nodes metastases (common) – Distal mets uncommon (lungs, bone, liver, brain)

8. Characteristic cellular patterns: Orphan Annie nuclei Psamomma bodies Multifocality (85%) Prognosis: excellent (95% 10 yr survival rate) Orphan Annie NucleiPsammoma Body

9. Diagnosis discovered when a hard nodule is found in multinodular goiter when enlarged cervical lymph nodes are detected when there are unidentified metastatic lesions elsewhere in the body Other clinical signs that could indicate papillary thyroid are: – fixation to the trachea, stony hardness, damage to recurrent laryngeal or cervical sympathetic nerves.

10. Follicular Carcinoma Second most common (10%) Iodine deficient areas 3:1 F:M ratio Mean age: 50 y/o Usually solitary (rapid size increase & goiter) s/sx: pain & cervical lymphadenopathy uncommon initial presentation

11. 1%: hyperfunctioning - thyrotoxicosis Solitary & encapsulated Prognosis: mortality 15% at 10 yrs, 30% at 20 yrs Follicles are present but may be devoid of colloid. Has capsular and/or vascular invasion

12. Hurthle Cell CA 3-5% Variant of follicular CA Vascular or capsular invasion Char. By multifocal & bilateral-cannot be diagnosed by FNAB Metastasize to local & distant sites Higher mortality rate Tumors has eosinophilic cells packed with mitochondria w/c are from oxyphilic cells of the thyroid

13. Medullary CA 5% From parafollicular or C cells Has C-cell hyperplasia 1.5:1 F:M ratio Mean age: 50-60 y/o 70-80% are sporadic 20-30% familial autosomal dominant syndromes

14. s/sx:neck mass w/ cervical lymphadenopathy - local pain - dysphagia, dyspnea or dysphonia 2-4%: Cushing’s syndrome Unilateral (sporadic); multicentric (familial) SyndromeManifestations MEN 2AMTC, pheochromocytoma, primary hyperparathyroidism MEN 2BMTC, pheochromocytoma, muocutaneous ganglioneurofibromatosis Familial MTCMTC

15. Anaplastic CA 1% F>M Mean age: 65 y/o s/sx: rapidly enlarging, long standing neck mass, painful - dysphonia, dysphagia, dyspnea Tumor: large, hard, poorly circumscribed & fixed

16. Palpable lymph nodes Metastatic spread Dx: FNAB will reveal giant and multinucleated cells Prognosis: one of the most aggressive, few survive beyond 6 months

17. Lymphoma <1% Most: Non-Hodgkin’s B-cell type 2-3xF>M Age: 62 y/o Patients with chronic lymphocytic thyroiditis Prognosis: overall 5 yr survival rate: 50%