Michele Zini 2010

THYROID CARCINOMASelected clinical cases for discussion

Michele Zini

Servizio di Endocrinologia - Arcispedale S. Maria Nuova, Reggio Emilia

michele.zini@asmn.re.it

Patient #1 - Anna, age 48, ♀

Michele Zini 2010

• She is a nurse

• 2 sons

• Summer 2009: in Poland for holidays she complaints for abdominal pain

• Evidence for gallbladder stones

• Back in Italy:– CT scan: two large liver masses 7 x 6.4 cm and 3 x

3.5 cm

Patient #1 - Anna, age 48, ♀

Michele Zini 2010

• Liver biopsy:– Poorly differentiated carcinoma.

Primary neoplasia not identifiable on the basis of morphology

• FDG-PET:– Intense glucose uptake in the liver left lobe, from

neoplastic mass– Focal uptake in the neck, left side, supposedly in the

thyroid left lobe

Patient #1 - Anna, age 48, ♀

Michele Zini 2010

• Phone call form the oncologist: “Here is a patient with liver metastasis, may be from thyroid carcinoma. Could you please see her this morning ?”

• Colonoscopy: negative• Gastroscopy: hiatal hernia• Thyroid US:

– In the upper part of the left lobe: hypoechoic nodule, irregular burdens, disomogeneous content, no microcalcifications. No pathological cervical nodes.

Patient #1 - Anna, age 48, ♀

Michele Zini 2010

Patient #1 - Anna, age 48, ♀

Michele Zini 2010

Patient #1 - Anna, age 48, ♀

Michele Zini 2010

• General Practinioner’s mail:

“I have a patient with liver metastases from thyroid cancer: could you please perform FNA A.S.A.P. ?”

Patient #1 - Anna, age 48, ♀

Michele Zini 2010

• FNA report:

“Papillary sheets of epithelial thyroid cells with nuclear grooves and pseudoinclusions. Dense hyperchromatic colloid.Diagnostic for papillary thyroid carcinoma. Thy 5.”

Patient #1 - Anna, age 48, ♀

Michele Zini 2010

• Liver malignancy (Primary ? Metastatic ?)

• Papillary thyroid carcinoma• Not likely liver metastases from thyroid

PTC (oncologist and GP agree)

• Excluded MTC

Patient #1 - Anna, age 48, ♀

Michele Zini 2010

• Plasma calcitonin: < 4 pg/ml

• The pathologist is requested to perform staining for thyroglobulin and calcitonin on the liver biopsy:– Negative for thyroglobulin, calcitonin,

chromogranin A, synaptophysin

Patient #1 - Anna, age 48, ♀

Michele Zini 2010

• June 2010: Operated on for partial left liver resection

• Histology:– Poorly differentiated cholangiocarcinoma

• Currently waiting for thyroidectomy

Patient #1 - Anna, age 48, ♀

Michele Zini 2010

Issues for discussion:

PTC of incidental diagnosis Epidemiology & Clinical relevance How to manage

PET thyroid incidentalomas Epidemiology & Clinical relevance Role of FDG-PET in thyroid carcinoma diagnosis & follow-up

Thyroid cancer diagnosed in metastatic patients (nodes, lungs, liver, brain) without a known primary neoplasia

Patient #2 – Giovanna, age 50, ♀

Michele Zini 2010

• December 2006 - Due to family history of goiter the GP orders a thyroid US:– Right lobe:

3 cm. node, growing outward the capsule2 more nodules, 4 and 7 mm.

– Left lobe:mixed nodule, 3 cm.2 more nidules, 6 mm.

– 15 mm lymphnode, left laterocervical

Michele Zini 2010

Michele Zini 2010

Michele Zini 2010

Patient #2 – Giovanna, age 50, ♀

Michele Zini 2010

• TSH = 0.9 µU/ml

• FNA:– thyroid - right side: Thy5– thyroid - left side: Thy2– right lymphnode:

• Cytology: bloody specimen• Intranodular Tg: 1.5 ng/ml

Patient #2 – Giovanna, age 50, ♀

Michele Zini 2010

• April 2007: Total thyroidectomy with central compartment dissection

• Histology: tall cell papillary carcinoma of the right lobe. Extension to perithyroidal soft tissues including the muscle. Surgical margins are multifocally involved by the tumor. No vascular invasion. 3 metastatic paratracheal nodes. Parathyroid adenoma.

MACIS 5,9 pTNM pT3N1AM0 Stage III

Patient #2 – Giovanna, age 50, ♀

Michele Zini 2010

• September 2007: – 150 mCi radioactive iodine– Thyroglobulin: 5.1 ng/ml

• TSH = 78 µU/ml• Tg antibodies: negative

– Whole body scan: thyroid remnant

Patient #2 – Giovanna, age 50, ♀

Michele Zini 2010

• December 2008:

– Tg levels:• Basal: 0.6 ng/ml• rhTSH stimulated: 4.3 ng/ml

– Neck US:• right side, level 5: 1 cm. lymphnode• right side, level 2: round-shaped lymphnode located

in front of jugular vein and carotid artery, with hylus T 15 mm x AP 6 mm + further similar lymphnode L 32 mm x AP 10 mm

Patient #2 – Giovanna, age 50, ♀

Michele Zini 2010

• FNA – neck right side:– level 5:

• cytology: papillary clusters of follicular cells with grooves

• intranodular Tg: 88 ng/ml

– level 2:• cytology: bloody, stromal cells• intranodular Tg: 0.5 ng/ml

Michele Zini 2010

Michele Zini 2010

Michele Zini 2010

Patient #2 – Giovanna, age 50, ♀

Michele Zini 2010

• April 2009:– lateral neck dissection (levels 2-3-4-5)

• Histology:– level 3: PTC metastases (2/9 nodes)– level 4: PTC metastases (2/22 nodes)– level 5a: PTC metastases (3/13 nodes)– level 5b: adipose tissue, no lymphnodes

MACIS 5,9 pTNM pT3N1BM0 Stage IVA

MACIS 5,9 pTNM pT3N1AM0 Stage III

Initial staging: Restaging:

Patient #2 – Giovanna, age 50, ♀

Michele Zini 2010

• Follow-up:– further RAI only if detectable thyroglobulin

December 2008:

Tg levels (ng/ml):

Basal: 0.6rhTSH stimulated: 4.3

node surgery

August 2009:

Tg levels (ng/ml):

Basal: 1.2rhTSH stimulated: 5.0

Patient #2 – Giovanna, age 50, ♀

Michele Zini 2010

• October 2009: RAI 200 mCi– Tg = 13 ng/ml TgAb = 38 U/ml (30-100)– Whole body scan: no RAI uptake

December 2008:

Tg levels (ng/ml):

Basal: 0.6rhTSH stimulated: 4.3

August 2009:

Tg levels (ng/ml):

Basal: 1.2rhTSH stimulated: 5.0

April 2010:

Tg levels (ng/ml):

Basal: 1.5rhTSH stimulated: 7.7

node surgery RAI 200 mCi

Patient #2 – Giovanna, age 50, ♀

Michele Zini 2010

• March 2010: whole-body PET

Neoplastic uptake in thyroid bed, right sided

Patient #2 – Giovanna, age 50, ♀

• Neck US:– level 6, right side: little paratracheal

hypoechoic area, 6 mm.

• FNA:– cytology: localization of PTC– FNA-Tg = 7500 ng/ml

Michele Zini 2010

Patient #2 – Giovanna, age 50, ♀

• June 2010:– reoperated on for central neck dissection (3° surgical

procedure)– calcemia = 6.6 mg/dl (8.5-10.5)

• Histology:– one cystic lymphatic metastasis form PTC– one soft tissue metastasis form PTC

Michele Zini 2010

Patient #2 – Giovanna, age 50, ♀

December 2008:

Tg levels (ng/ml):

Basal: 0.6rhTSH stimulated: 4.3

August 2009:

Tg levels (ng/ml):

Basal: 1.2rhTSH stimulated: 5.0

April 2010:

Tg levels (ng/ml):

Basal: 1.5rhTSH stimulated: 7.7

node surgery RAI 200 mCi further surgery

Michele Zini 2010

August 2010:

Tg levels (ng/ml):

Basal: 1.5rhTSH stimulated: 5.8

“LAST EPISODE”

Michele Zini 2010

Issues for discussion:

Histologic variants prognosis modalities of treatment timing of follow-up

Recurrent thyroid carcinoma role of repeated surgery role of repeated RAI role of external beam radiotherapy

Patient #2 – Giovanna, age 50, ♀