--- title: "Papillary Thyroid Carcinoma" description: "ENT notes on Papillary Thyroid Carcinoma - Risk factors, Clinical Features, Histology, Investigations and Treatment." source: "The ENT Resident" author: "Dr. Mausumi Das" canonical_url: "https://www.theentresident.com/ent-notes-lectures/papillary-thyroid-carcinoma" categories: ["Thyroid"] video: "https://www.youtube.com/watch?v=ohhHl3DwyxQ" image: "https://media.theentresident.com/og-images/papillary-thyroid-carcinoma.png" --- # Papillary Thyroid Carcinoma ENT notes on Papillary Thyroid Carcinoma - Risk factors, Clinical Features, Histology, Investigations and Treatment. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=ohhHl3DwyxQ ## 🩺 Papillary Thyroid Carcinoma ### 📌 Definition & Key Facts **Papillary carcinoma** arises from follicular epithelial cells and characterized histologically by papillary structures with fibrovascular cores. - **Peak incidence:** 3rd–4th decades - **Sex ratio:** Female : Male ≈ **3 : 1** - **Prognosis:** Excellent (especially in younger patients) >What is the most common thyroid cancer? >What is the most common pediatric thyroid malignancy? --- ### ⚠️ Risk Factors of Papillary Thyroid Carcinoma - **Ionizing radiation** to head/neck (especially childhood exposure) - **Iodine status:** More common in iodine-sufficient areas - **Family history** (5–10% familial cases) >Which genetic alterations are commonly associated with Papillary Thyroid Carcinoma? >What Familial syndromes are associated with Papillary Thyroid Carcinoma? --- ### 🧾 Clinical Features of Papillary Thyroid Carcinoma - Often **asymptomatic thyroid nodule** (firm, non-tender) - **Multifocality** common (~up to 80% multicentric) — can involve both lobes - **Cervical lymph node metastasis** common (~30% clinically) — nodal disease more common than distant spread - **Local invasion** → hoarseness (RLN), dysphagia (esophagus), dyspnea (trachea) - **Distant metastasis** (less common) - In iodine-deficient areas: may present with multinodular goiter; in iodine-replete areas: solitary nodule more common >Which are the common sites for distant metastasis in Papillary Thyroid Carcinoma? --- ### 🔬 Gross Pathology of Papillary Thyroid Carcinoma - Solid granular cut surface with irregular outline - Often cystic changes, colloid, gritty/friable areas --- ### 🧪 Histology of Papillary Thyroid Carcinoma Principal defining features are **nuclear changes** rather than cytoplasmic architecture: - **Papillae** with fibrovascular cores (glandular cells on a stalk) - **Orphan Annie eye nuclei** - **Nuclear grooves** (longitudinal; “coffee-bean” appearance) - **Intranuclear cytoplasmic inclusions** (pseudo-inclusions) - **Psammoma bodies** — seen in ~50% - Nuclear crowding / overlap (“stacked eggs” appearance) >What are Orphan Annie nuclei? >What are Psammoma bodies? --- ### 🧩 Histologic Variants of Papillary Thyroid Carcinoma - Follicular variant - Microcarcinoma — ≤1 cm (excellent prognosis) - Diffuse sclerosing variant - Tall cell variant - Columnar / solid variants --- ### 🧭 Investigations of Papillary Thyroid Carcinoma - **Ultrasound (first-line)** - **FNAC (US-guided):** Diagnostic method of choice (Bethesda reporting) - **Thyroid function tests:** Usually euthyroid; assess baseline pre-op - **Cross-sectional imaging (CT/MRI)** - **Chest X-ray / CT chest:** If pulmonary metastasis suspected - **Molecular testing** (BRAF, RET/PTC, RAS) may guide prognosis/therapy in select cases >Name 4 ultrasound features strongly suspicious for papillary carcinoma. >What is the purpose of CT/ MRI Scan in Papillary Thyroid Carcinoma? --- ### 🛠️ Treatment of Papillary Thyroid Carcinoma **Primary modality:** Surgery ± adjuvant therapy, individualized by risk. **1. Surgery** - **Hemithyroidectomy / lobectomy**: acceptable for small (≤1 cm), unifocal, intrathyroidal tumors without nodes or high-risk features. - **Total thyroidectomy** >What are the indications of Total Thyroidectomy in Papillary Thyroid Carcinoma? - **Neck dissection:** - **Central compartment** (level VI) dissection for clinical/ radiologic positive nodes or high-risk tumors (≥4 cm, extrathyroidal extension, aggressive histology). - **Therapeutic lateral neck dissection** only if overt lateral node disease; prophylactic lateral dissection is not routinely beneficial. **2. Radioiodine (I-131) Ablation** - Post-op ablation after **total thyroidectomy** >What are the indications of Radioiodine ablation in Papillary Thyroid Carcinoma? >When is Radioiodine ablation done after total thyroidectomy? **3. Thyroid Hormone Suppression** - Levothyroxine to suppress TSH (TSH stimulates follicular cells) >What is the level of TSH to aim for post Total Thyroidectomy? **4. External Beam Radiotherapy (EBRT)** - Reserved for unresectable local disease, gross residual disease not iodine-avid, or palliation (IMRT preferred) **5. Systemic / targeted therapy** - For progressive metastatic or RAI-refractory disease (tyrosine kinase inhibitors etc.) — specialist decision --- ### 📈 Treatment Response & Follow-up of Papillary Thyroid Carcinoma **Assessment tools** - **Post-ablation scan** (2–10 days after I-131) — evaluate residual uptake / metastasis - **Serum thyroglobulin (Tg)** — tumor marker for differentiated thyroid cancer (most sensitive when stimulated) - **Neck ultrasound** — routine surveillance for local/ nodal recurrence - **Cross-sectional imaging / PET-CT** — if Tg elevated but imaging negative or for iodine-refractory disease >What are the different response categories while assessing treatment outcome in Papillary Thyroid carcinoma? What is the follow up protocol in each group? >What Tg value is highly predictive of persistent disease? --- ### 📉 Prognosis of Papillary Thyroid Carcinoma - **Overall excellent prognosis**: 10-year survival ~**90%** if thyroid-confined; ~**60%** with extrathyroidal spread >What are poor prognostic factors in Papillary Thyroid Carcinoma? --- ## About This Note This free ENT note on Papillary Thyroid Carcinoma was written by Dr. Mausumi Das and is paired with a corresponding video lecture. 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