Thyroid cancer

LITTLE ANATOMICAL REMINDER
The thyroid is a small gland weighing 20 to 30 grams located on the tracheolaryngic axis (anterior face of the neck) at the 2nd and 3rd laryngeal ring. It consists of 2 lobes connected by a ring called the thyroid isthmus. It is an organ rich in vessels. The parathyroid glands are located at its 4 poles. It is an iodine reservoir.
The thyroid is composed of different types of cells and each type plays a role in the development of cancers.
The thyroid is responsible for secreting hormones:
• Iodinated thyroglobulin secreted by the colloid which is the central light of the gland
• T3 or triiodothyronine / T4 or thyroxine secreted by the follicular cells that constitute the thyroid follicles located around the colloid
• And calcitonin secreted by the C cells that compose the follicles in smaller quantities (1 to 2%).
• These secretions are under the control of another hormone secreted by the pituitary gland, thyroid stimulating hormone or TSH.
EPIDEMIOLOGY:
Thyroid cancer is a malignant tumour of the thyroid, most often in the form of a nodule. Thyroid nodules are common. Fortunately, 95% of these nodules are benign. There are 140000 new cases of thyroid cancer diagnosed in the world, representing 1% of all cancers diagnosed. It is the most common endocrine cancer. It affects women more than men with a 5:1 ratio. The number of new cases diagnosed annually increased fivefold between 1980 and 2005 for both sexes. There is a great geographical disparity.
Thyroid cancers are classified into 4 histological types, differentiated by their cellular origin:
These 2 types of cancers are called differentiated, they can benefit from treatment with Iodine-131:
RISK FACTORS:
• Exposure to ionizing radiation, mainly during childhood, external or internal (inhaled or ingested particles), goitreous endemic area;
• Iodine deficiency;
• Female: women are more frequently affected than men, with a ratio of 5:1
Other factors are suspected: nutritional, reproductive, menstrual, hormonal and anthropometric, chemical pollutants (pesticides, etc.).
SYMPTOMS:
• Appearance of a nodule or mass in the cervical region;
• Appearance of a painful lateral-cervical lymph node;
• Recent increase of a goiter;
• Signs of thyroid hormone abnormalities: motor diarrhea, hot flashes, fatigue, weight gain, high blood pressure
• Dysphonia: voice disorder by paralysis of the vocal cord
• Otalgia reflex: persistent ear pain

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The interview is important to know if there are any signs of thyroid hormone disorders, if there is a family history, etc. The clinical examination makes it possible to palpate a nodule or goiter: it is thus possible to specify its consistency, sensitivity and mobility. Finally, clinical examination can detect signs of typo or hyperthyroid.
Thyroid ultrasound coupled with Doppler is the reference examination.
It consists in placing the ultrasound probe in contact with the thyroid by means of a gel that allows the ultrasound waves to pass through. These waves are emitted and returned to the ultrasound screen. The thyroid, potential nodules, their sizes, contours, measurements, echostructure and the existence of calcifications can be seen.

Thanks to Doppler, arterial and venous flows are measured.
Cytopunction is the most effective test to assess the nature of thyroid nodules.
During the ultrasound, a needle sample is taken: the nodules are punctured under local anaesthesia to carry out an anatomopathological examination by smear. Hormonal dosages are essential.
A standard test (such as blood count, sedimentation rate, reactive C protein) and a specific thyroid test (TSH, T4L, T3L, calcitonin, Anti-peroxidase antibody, Anti-thyroglobulin body) are performed.
Iodine-123 Scintigraphy:
It is indicated if TSH is low and/or there are signs of hyperthyroidism.
Extension assessment:
For differentiated cancer:
• Chest X-ray
• Cervical ultrasound to see the lymph node areas
• Whole body scanning with radioactive Iodine
• Thyroglobulinemia
Pour le cancer médullaire:
• Calcitoninemia
• Carcino-embryonic antigen (CEA)
• Chest X-ray
• Scanning of the neck, chest and abdomen
• Bone scan
• Phosphocalcic balance And mutation research of the proto oncogenic RET
• Eliminate a pheochromocytoma that is a cancer of the adrenals secreting catechomamines.
TREATMENTS:
Treatments are often combined and are decided after multidisciplinary consultation.
SURGERY:
Surgery is indicated for cancers as well as toxic nodules and toxic nodular goiter.
It is a key step. Usually, the surgeon removes all the thyroid gland. This is called total thyroidectomy. When the surgeon removes only a part of it, it is called a partial lobectomy.
BEFORE THE PROCEDURE:
• You will have an appointment with the surgeon who will explain all the surgical procedures.
• You will also see the anaesthetist who will ensure that there is no contraindication to a general anaesthesia during a precise examination And blood And clinical tests.

THE INTERVENTION:
It takes place under general anesthesia and lasts a few hours. The surgeon creates a horizontal incision in the trachea to remove the thyroid gland. It can sometimes remove the lymph nodes around it, this is called lymph node cleaning.
Drains are placed in the operated area to avoid hematoma and lymphodema.
The removed part is sent to pathology so the results will be received within 3 weeks. The lymph node is examined during the operation and is referred to as an extemporaneous examination.
RADIOACTIVE IODE TREATMENT or IRATHERAPY:
It is used to remove residual cancer cells after the procedure and to remove metastases. It is indicated for differentiated cancers.
This treatment is formally contraindicated in pregnant or breastfeeding women.
THE PRINCIPLE:
You ingest a radioactive iodine capsule with a large glass of water. This iodine is captured by cancer cells. This allows them to be destroyed gradually over time. The capsules are brought in a metal box.
You remain isolated in your room and those around you must take action against this radioactive iodine.
You should drink plenty of water to avoid altering the urinary tract. Sometimes laxatives are also prescribed.
This treatment can cause inflammation of the salivary glands: you then drink lemon juice or suck on lemons and candy. Your hospitalization lasts between 2 and 5 days in a special room, protected by lead walls. You will not see anyone during the hospitalization.
You can take everything you need to take care of yourself and your clothes will be washed when you leave. Clean clothes outside your room will be given to you when you leave.

After the intervention:
You stay in the recovery room for about 2 hours before going back to the room. The anaesthetist sets up a treatment for pain by the vein. The perceived pain is a bit like angina.
Potential complications:
• Hypocalcemia: decrease in calcium due to transient parathyroid involvement. Vitamin D3 And calcium supplementation is then introduced.
• voice disorder: by transient damage to the vocal cords
• transient swallowing disorders
• Lymphedema during lymph node cleaning
• Nerve damage to the neck
• Hematoma
• Wound infection
• The scar is visible and gradually regresses over the next 2 years. One year of protection per sunblock is mandatory.
Hospitalization lasts on average 3 days. At your discharge, a biological check-up is prescribed. Hormone replacement therapy is also being introduced. You will be reviewed with a biological check-up at 1 month. You will then be checked with a biological check-up and ultrasound every 6 months for 2 years and then every year for a total of 5 years.
After radioactive iodine treatment or iritherapy:
You will leave after performing a iodine-131 whole-body scan. You will pass through a dosimeter that will measure the residual radioactive iodine level you will have. At home you should not see children or pregnant women. Specific radiation protection rules will be established. You will have a check-up at 3 months and then every 6 months by consultation with the nuclear doctor and by whole body scintigraphy with iodine 131 cervical ultrasound blood test including thyroglobulin and antithyroglobulin antibodies.

About Thyroid cancer

Chemotherapy is indicated only for highly invasive, non-operable spinal cord cancers. It consists of the ingestion of one tablet of Vandetanib. It requires an opinion and agreement after multidisciplinary consultation.
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