CASE REPORT

TIROID CARCINOMA

Presentator :
dr. Yulialdi Bimanto Heryanto Putra

Moderator :
Dr. dr. Sagung Rai Indrasari, M. Kes., Sp.T.H.T.K.L. (K)., FICS.

Otorhinolaryngology And Head Neck Surgery Department,

Faculty of Medicine, Public Health, and Nursing

Gadjah Mada University / Dr. Sardjito Hospital

Yogyakarta

2020
INTRODUCTION happened to men, 0.85% were malignancies

Thyroid carcinoma is a malignancy that of the thyroid gland, whereas, in women,

occurs in the thyroid gland. Thyroid cancer thyroid malignancies accounted for 2.5% of

rarely causes gland enlargement; it often all malignancies.2

causes small growths (nodules) in the gland. The thyroid gland is an organ

Most of the thyroid nodules are benign. resembling a butterfly and is located in the

According to WHO, primary thyroid tumors lower neck, anterior to the trachea. This

are classified into epithelial and nonepithelial, gland is the most vascularized endocrine

benign or malignant, with separate categories gland, covered by a capsule originating from

for lymphoma and other malignancies. the lamina pretracheal fascia deep. This

The incidence of thyroid cancer capsule attaches the thyroid to the larynx

globally continues to increase from 3.6 per and trachea. This gland consists of two

100,000 population in 1973 to 8.7 per lateral lobes connected by a bridge of the

100,000 in 2010. In 2012 there were 230,000 isthmus, a thin thyroid under the cricoid

new cases in the world. It shows an increasing cartilage in the neck, and sometimes there

trend in the last few decades. In Indonesia, are pyramidal lobes that arise from the

thyroid cancer is ranked fourth after cervical isthmus in front of the larynx. 3

cancer, breast, and skin cancer. Besides, The thyroid gland's structural unit is a

thyroid cancer is one of the most common tightly arranged follicle in the form of a

types of malignancy found among endocrine spherical space lined with a layer of

gland malignancies. 2 epithelial cells in a flat, cubic to columnar

The majority of thyroid cancer patients shape. In conditions where the cause is not

are aged 40-60 years. The incidence of exact, these follicular cells will transform

thyroid cancer covers 90% of all endocrine into large, eosinophilic cytoplasmic cells,

gland malignancies. Of all the ferocity that sometimes with hyperchromatic nuclei,

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known as oncocytes (bulky cells) or Hürthle hormone levels acting as negative feedback

cells.3 on the anterior pituitary lobe and on

The thyroid produces two main secretions. Thyrotropin-releasing hormone,

hormones, i.e., thyroxine (T4) and namely Thyrotropin-Releasing Hormone

triiodothyronine (T3). Other hormone- (TRH) from the hypothalamus. 3

secreting cells in the thyroid gland are Most thyroid carcinomas are well-

parafollicular cells located at the base of the differentiated lesions. The major subtypes of

follicle and associated with the follicular thyroid carcinoma that are often found are

membrane, and these cells secrete the papillary carcinoma (75% -85% of cases),

hormone calcitonin. This hormone plays a follicular carcinoma (10% -29% of cases),

role in regulating calcium homeostasis.3 medullary carcinoma (5% of cases), and

The main functions of the thyroid anaplastic carcinoma (<5% of cases) . 4,5

hormones T3 and T4 are to control cellular The exact etiology of thyroid

metabolic activity; these hormones increase carcinoma is unknown. From several

the metabolic rate caused by increasing levels studies, several factors play a role in the

of specific enzymes, affect cell replication, pathogenesis of thyroid carcinoma, namely

and maintain metabolic rates in various genetics and the environment. Papillary

tissues so that they can function normally carcinoma is influenced by environmental

optimally.3 (iodine), genetic, hormonal factors, and the

Thyroid hormone secretion is interactions between these three factors.

controlled by the thyroid-stimulating hormone Whereas in follicular carcinoma, radiation is

level, namely Thyroid-Stimulating Hormone a factor causing this carcinoma. 5

(TSH) produced by the anterior pituitary lobe. Genetic factors that play a role in

This gland is directly influenced and medullary carcinoma are unknown to date,

regulated by its activity by circulating thyroid which is the cause of the development of

2
medullary and anaplastic carcinomas. It is a history of head radiation, compressive

thought that anaplastic carcinoma of the symptoms, such as problems with

thyroid originates from changes in well- swallowing or breathing, nodules large

differentiated (papillary and follicular) (more than 4 centimeters), hard texture,

thyroid carcinoma with two times the nodules that are fixed in the surrounding

likelihood of a follicular type. 5 tissue, vocal cord paralysis or hoarseness of

Most of the thyroid nodules are found the voice, and enlarged lymph nodes. 2,3

alone by the patient or moment physical Measurement of serum thyroid-

examination. Palpation can estimate the stimulating hormone (TSH) levels is

location and size of the nodule, although not performed to rule out thyroid dysfunction.

accurately. The palpable nodule is usually However, this examination is not useful in

more than 1.5 cm in size, but this also differentiating between benign or malignant.

depends on the patient's neck's location and The examination of the serum thyroglobulin

shape. A physical examination can also see level is a tumor marker that is useful for

when nodule movement to swallow. post-thyroid carcinoma surgery. 6

Estimating the presence of enlarged lymph The role of thyroid scintigraphy in the

nodes around the neck, namely in the diagnostic evaluation of thyroid nodules can

supraclavicular and jugular-carotid areas, distinguish between hot nodules, which are

which often occurs in papillary carcinoma, usually benign, and cold nodules. This

can also be detected by examining the neck scintigraphy test has a low sensitivity for

area. 5 detecting small thyroid nodules and is not

Symptoms leading to malignancy are useful for cystic nodules.7

characterized by rapid growth, a family High-frequency (7.5-13 MHz) thyroid

history of medullary thyroid carcinoma, ultrasound (USG) is used as the first choice

family history, young age (less than 20 years), for nodule evaluation. Ultrasound can detect

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solid nodules that are 3 mm in size and cystic disease. After total or near-total

nodules that are 2 mm in size. The imaging thyroidectomy to treat thyroid carcinoma, it

technique of ultrasound can also distinguish is vital to ensure that no carcinoma cells

the nodule components, i.e., solid, cystic, or remain. Unlike most other carcinoma types,

mixed, and estimate the nodule's size. Some chemotherapy is not very effective for

of the features obtained from ultrasound treating carcinoma that has spread beyond

results can lead to malignancy, such as the thyroid gland. On the other hand, the

hypoechoic nodules, irregular edges, natural glandular connection of the thyroid

microcalcification, and hypervascularization. to absorb iodine is utilized uniquely: the

A CT-Scan examination can be used to assess administration of radiation therapy

the tumor's spread around the structure of the combined with iodine. 8,9

cervical lymph nodes. 8,9 CASE REPORT

Fine needle aspiration biopsy is the A 59-year-old man came to the ENT

removal of a small portion of cells or fluid clinic at Sardjito Hospital with complaints

from the thyroid nodule using a very small of a lump in the front of the neck since 6

needle. This procedure is safe to perform. The months ago. The lump was getting bigger.

cells extracted will be analyzed under a The patient had no pain complaints, denied

microscope by a cytologist and can then be swallowing difficulties, denied shortness of

categorized as benign or malignant. 6,7 breath, and complained of heart palpitations.

Treatment of thyroid carcinoma can be Palpitations were denied, frequent sweating

performed by operative measures such as total undeniable voice changes, weight loss

or near-total thyroidectomy, radioactive denied, ear, nose, and throat complaints.

iodine ablation, and thyroid hormone therapy. On examination of vital signs, blood

The choice of modality needs to be adjusted pressure was 132/84, pulse 88x/minute,

according to the stage and prognosis of the respiration 20x/minute, and temperature

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36.4ºC. On the examination, otoscopy, the left thyroid (inferior aspect) was very

rhinoscopy, and oropharynx were within likely accompanied by infiltration into the

normal limits. There was a mass on the front muscle strap, according to TI-RADS 5.

of the neck on neck examination, round in There were no visible abnormalities in the

shape with a diameter of approximately 4 cm, submandibular and parotid glands.

solitary, well-defined, solid consistency, Lymphadenopathy with signs of bilateral

fixed, tender (-), signs of inflammation (-). malignant colli region, especially the left

There was a mass of approximately 4 cm in (left level IIB, IV, VA and VB, and bilateral

the front of the neck, hard consistency, well- level III) was present.

defined, fixed, tender (-), signs of On CT-scan, there was a solid mass in

inflammation (-). the left thyroid gland with a malignant

On examination of thyroid function, the appearance that pushed the trachea to the

results obtained, free T3: 4.29 pg/ml, free T4: right and narrowed it with patency of the

1.13 ng/dl, TSH: 2.24 IU/ml. On fine needle airway. 55%, multiple nodal metastasis colli

aspiration examination, ultrasound-guided left level 3, spondylosis cervicales.

FNA and left thyroid region cell block were Based on the history, physical

obtained: Malignant cells were found. The examination, and investigation, the patient

Bethesda system for reporting thyroid was diagnosed with Ca Thyroid (PA:

cytopathology class VI: Papillary thyroid Papillary Thyroid Carcinoma Bethesda

carcinoma. Ultrasound-guided FNA and left Class VI) T4aN1aM0 Stage III, and a total

colli region cell block: Malignant cells were thyroidectomy + selective neck dissection

detected. Opinion: Expansion of the papillary level III, IV, VI was planned. The problem

thyroid carcinoma. On ultrasound we raise in this case is diagnosis.

examination, a left thyroid malignant mass DISCUSSION

that extended to the left isthmus and part of Thyroid carcinomas can be classified

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 into 2 types, namely those arising from the examination. Palpation can estimate the

follicular epithelium and from parafollicular location and size of the nodule, although

or C cells. Carcinomas arising from the not accurately. The palpable nodule is

epithelium consist of papillary, follicular, usually about 2 cm in size, but this also

and anaplastic cell types. Cancer depends on the patient's neck's location and

Papillary cancer accounts for about 70% shape. Thyroid nodules are painless except

of thyroid carcinoma, follicular cancer about in acute or subacute thyroiditis. Most of the

15% -20%, and anaplastic carcinoma about thyroid malignancies have no severe

5% of thyroid cancer. The remaining about symptoms, except for the type anaplastic

5% - 10% is a medullary carcinoma arising that enlarges rapidly even within weeks,

from C cells. Medullary cancer can occur as a sometimes accompanied by symptoms of

sporadic form and as a familial form in compression of the esophagus and trachea.

women; the incidence of thyroid nodules is The patient noticed a lump in the neck

approximately 5% in women and 1% in men, about 6 months ago when he felt his left

the patient is a male.8,9 neck, and the patient did not feel any other

The exact etiology of this carcinoma is complaints. 8,10

unknown. From several studies, several Nodules are identified based on their

factors play a role in the pathogenesis of consistency, hard or soft, presence or

thyroid carcinoma, namely genetics and the absence of pain, the surface of the nodule is

environment. Environmental factor (iodine) flat or lumpy, single or multiple numbers,

genetic and hormonal and the interaction has a clear border or not, and the state of

between these three factors are suspected of the mobility of the nodule. Papillary

triggering thyroid cancer incidence. 8,11 carcinoma of the thyroid is a tumor that is

Most of the thyroid nodules are found well-defined, palpable, painless, and

alone by the patient or moment physical encapsulated. On physical examination,

6
there was a nodule on the neck. When underwent surgery, the postoperative

palpation was done, it was hard, no pain on outcome showed a malignancy of 3.2%. On

palpation, the surface of the nodule was flat examining the patient's fine needle, there

and firmly demarcated. 9,12 were malignant cells, the impression:

Needle biopsy as a tool to diagnose papillary thyroid carcinoma, metastases to

thyroid nodules was first introduced by lymph nodes colli. 10,13

Martin and Ellis in 1930 using an 18-gauge Ultrasound, along with fine-needle

needle. Fine needle biopsy cytology is aspiration, is the gold standard for

particularly indicated in solitary thyroid diagnosing thyroid cancer. Ultrasound can

nodules or dominant nodules on goiter multi tell whether the nodule lesion is intra- or

nodules. The accuracy of fine-needle extrathyroidism. In addition, it can also

aspiration in cytology diagnosis depends on differentiate cystic lesions from solid

several factors, including operator skill, lesions, with a diagnostic accuracy of

aspiration technique, specimen preparation, 100%. In the patient under ultrasound

and cytological interpretation. Fine-needle examination, there was a solid isoechoic

aspiration with guiding ultrasound enhances lesion in the left thyroid, amorphous,

the visualization of needle placement in the lobulated, partially defined, regular edges,

target nodule, reducing the false-negative with macrocalcification, taller than wider

rate of benign cytologic diagnosis. A (TIRADS V). 9,10

difference in outcome from the previously A CT scan can be used to assess the

benign and postoperative malignant outcome spread of thyroid carcinoma. CT scan has a

of only 1% -2% has been reported in sensitivity to assess spread to cervical

retrospective studies. A pooled analysis of lymph nodes from 80 to 90.6%. In this

12 studies by Tee et al. showed that of 4055 patient, a CT scan was performed, found

patients with benign AJH cytology who nodules in the right thyroid, and multiple

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nodules in the left thyroid accompanied by planned to undergo radioablation using

calcifications extending to the isthmus, radioactive Iodin 131.

suspected malignancy, and multiple bilateral

colli lymphadenopathies. 11,12 REFERENCES

Management of thyroid carcinoma 1. Carlo La Vecchia,et al. Thyroid cancer

includes total thyroidectomy, radioactive mortality and incidence: A global

iodine ablation, and thyroid hormone overview. International Journal Cancer

therapy. The choice of modality needs to be 2011; 136: 2187–95.

adjusted according to the stage and 2. Hussein K. Radiasi Interna Pada kanker

prognosis of the disease. After a total Tiroid Indikasi dan Komplikasi.

thyroidectomy to treat thyroid carcinoma, it Pertemuan Ilmiah Tahunan

is essential to ensure that no carcinoma cells Perhimpunan Ahli Bedah Onkologi

are left. Unlike most other carcinoma types, Indonesia.2011; 114:201-12.

chemotherapy is not very effective for 3. Zhang I, Demuaro S. Treatment of

treating carcinoma that has spread beyond Thyroid Neoplasms. In: Bailey BJ,

the thyroid gland. In these patients, a total Jhonson JT eds. Head and

thyroidectomy was performed and followed necksurgeryOtotlaryngology, 4th ed,

by radioactive iodine ablation. 11,14 volume 1. Philadephia: Lippincott

Williams & Wilkins, 2014. p.2115-30.

CONCLUSION
4. Baxter J et al. Greespan Basic And
We reported a male, 59-year-old
th..
Clinical Endocrinology 6 2006;206
patient, diagnosed with Thyroid Carcinoma
289.
(PA: Papillary Thyroid Carcinoma Bethesda
5. Charles Roehriget et al. Thyroid-
Class VI) T4aN1aM0 Stage III. This patient
Cancer “Epidemic. New England
has undergone a Total Thyroidectomy +
Journal Med.2014; 371-89.
Selective Neck Dissection and is also

8
6. Abdulkader A et al.Histopathological Lippincott Williams & Wilkins. 2014.

Patterns of Thyroid Disease in Al- 2115-21.

Madinah Region of Saudi Arabia, Asian 13. Badwal JS. Management of Papillary

Pac J Cancer Prev.2014; 15 : 5565-70 Thyroid Cancer : Total Versus

Williams & Wilkins, 2006 P: 319-34. Hemithyroidectomy. 2016,2(6), 208-

7. Maria F S et al. Effectiveness Of 210.

Routinely Used Thyroid Drugs in 14. Nguyen TQ, Lee EJ, Huang GM.

Punjab, Pakistan. J App Pharm.2014; 4: Diagnosis and Treatment of Patients

380-87. with Thyroid Cancer. American Health

8. Samuel A. et al. Revised American Drug Benefits.2015;8(1):1-1

Thyroid Association Guidelines for the

Tiroid.Elseveir.2014;33-45.

9. Paula A.et al.Role of Estrogen in Thyroid

Function and Growth Regulation, Journal

of Thyroid. 2011;125-37.

10. Charles Marcus et al.PET/CT in the

Management of Thyroid Cancers.

American Roentgen Ray Society.

2013:46-49.

11. Bryan R. Haugen et al. American Thyroid

Association Management Guidelines for

Adult Patients with Thyroid Nodules and

Differentiated Thyroid Cancer. American

Thyroid Association. 2015:45-57.

12. Irene Z et al. Bailey’s.Head and

Neck Surgery Otolaryngology 5th.

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