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Examination of Thyroid
https://t.me/med1917
U/S neck for thyroid and neck nodes. X-ray neck to
see calcifications (speckled fine calcification in
papillary carcinoma of thyroid; coarse, ring-like
calcification in MNG) and tracheal deviation.
FNAC thyroid and lymph node.
CT neck in malignancies or large goitre.
Trucut biopsy if two trials of FNAC are inconclu-
sive. It can injure deeper structures like recurrent
laryngeal nerve and also can cause hemorrhage.
Frozen section biopsy on table and proceed may be
needed to rule out malignancies.
Special blood analysis: Serum calcitonin, serum
thyroglobulin estimation in neoplasms of thyroid.
Role of ultrasound (U/S) in thyroid diseases
To detect number, size, nature of the nodules (cystic/
solid/complex) (complex means cystic and solid together—
more suspicious of carcinoma). Size up to 2 mm can
be detected.
U/S guided FNAC is very useful.
U/S at regular intervals is advisable to observe a small
nodule in thyroid.
To detect recurrent nodule.
To find out the invasion/spread/vascularity/status of carotid
artery and internal jugular vein.
To find out enlarged lymph nodes in neck.
Role of FNAC in thyroid swelling
Highly sensitive in papillary carcinoma of thyroid and also
its nodal spread.
Useful to differentiate between benign and malignancy
(Fig. 14.39).
Useful in lymphoma/anaplastic carcinoma/medullary
carcinoma thyroid/Hashimotos thyroiditis.
It is not very useful in follicular carcinoma as it is difficult
to differentiate it from follicular adenoma as capsular
invasion/vascular invasion is main feature in follicular
carcinoma.
Note:
On table frozen section biopsy is useful in negative
FNAC but doubtful cases. Definitive procedure is
undertaken once frozen section report comes on table.
But in frozen section biopsy itself, 15% of follicular
carcinoma report may be inconclusive or negative
which causes difficulty in taking decision. In such
occasion hemithyroidectomy is done and once histology report of follicular carcinoma is obtained completion thyroidectomy is done usually immediately within
a week. If biopsy report is delayed then completion
thyroidectomy is done after 6 weeks.
341
Fig. 14.39: FNAC thyroid is an important
investigation in thyroid diseases.
Trucut biopsy gives tissue diagnosis but danger
of haemorrhage and injury to vital structures like
trachea, recurrent laryngeal nerve, vessels are likely.
Solitary Thyroid Nodule
It is a single palpable nodule in thyroid on clinical
examination, in an otherwise normal gland. Causes:
(1) Thyroid adenomas—Follicular—common (40%
of actual single nodule excluding solitary nodule of
MNG); Hurthle cell. (2) Papillary carcinoma of
thyroid—15%. (3) Only one nodule palpable in an
underlying multinodular goiter – commonest cause
only clinically—50%. (4) Thyroid cyst.
Types:
Based on function: (1) T oxic solitary nodule. (2) Nontoxic solitary nodule.
Based on radioisotope study: (1) Hot—Means auto-
nomous toxic nodule. (2) Warm—Normally function-
ing nodule. (3) Cold—Non-functioning nodule; may
be malignant-20% (need not be always). Cold nodule
may be due to malignancy, thyroiditis, thyroid cyst or
haemorrhage. (4) Hot or warm in
but cold in I
123
scan—commonly they are malignant.
Note: Thyroid nodule in children and elderly can be
malignant. Rapid enlargement of thyroid nodule can
be malignant. 30% of solitary nodules are cystic.
Features: Single nodule palpable in one or other lobes
of the thyroid which is usually smooth, globular, firm
99m
T echnetium scan
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SRB’s Clinical Surgery
with well-defined margin. Overlying skin is normal.
Lahey’s test does not show any other nodules in
posterior part of the gland. Tracheal deviation towards
opposite side is common-confirmed by trail sign, three
finger test and auscultation. U/S neck is very useful.
FNAC is essential. When FNAC is inconclusive T rucut
needle biopsy may be done but it can cause pain/
bleeding/recurrent laryngeal nerve injury . T3, T4, TSH
are done to find out the function. Radioisotope study
123/I131/ 99m
(I
Tc) may be often needed. CT scan or
MRI neck is done only in selected cases but not
routinely (large swelling/to see vascularity/retrosternal
extension are the indications) (Figs 14.40A to 14.42).
Indications for surgery in solitary nodule thyroid
Malignant nodule
Follicular neoplasm
Toxic nodule in young
Nodules with obstruction
Recurrent cystic nodule
Complex cyst (both solid and cystic component)
Cosmetics.
Possible features of suspected malignancy in solitary
nodule thyroid
Any nodule can be malignant whether nodule is hard/
firm/cystic/small/large/asymptomatic
Rapid onset/rapid recent increase in size
Hoarseness of voice/dysphagia/stridor/dysphagia
Fixity of the nodule
Palpable significant neck nodes.
A
Diffuse Hyperplastic Goitre
Initial persistent increase in TSH level causes diffuse
active lobules. In late stages of diffuse hyperplasia,
TSH stimulation decreases and many follicles become
inactive and gets filled with colloid , called as colloid
goitre. As diffuse hyperplastic goitre is a reversible
stage, l- thyroxine is beneficial.
Nodular Goitre
Pathogenesis
Persistent TSH stimulation → Diffuse hyperplasia of
gland (all active lobules) → Later with fluctuation of
TSH level → Mixed areas of active and inactive
lobules develop → Active lobules become more
vascular and hyperplastic → Haemorrhages occur with
necrosis in the centre → Nodule formation → Centre
of nodule is inactive and only margin is active, i.e.
B
Figs 14.40A and B: Solitary nodule involving isthmus.
internodular tissue is active → Formation of many
nodules → Multi-Nodular Goitre (MNG). Other
factors involved are growth stimulating
immunoglobulins and growth prone cell clones.
Features
It is a slowly progressive disease with many years
of history; multiple nodules of different sizes are
formed in both lobes, also in isthmus, which is firm,
Examination of Thyroid
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343
A
B
Figs 14.41A and B: Solitary nodule right
lateral lobe. It is a clinical entity.
nodular, nontender, moves with deglutition; recent
increase in size signifies malignant transformation or
haemorrhage (Figs 14.43 and 14.44). Investigations
are T3, T4, TSH, U/S neck, FNAC, X-ray neck shows
ring or rim calcification.
Complications of MNG
Secondary thyrotoxicosis (30%); follicular carcinoma
of thyroid (10%); haemorrhage in a nodule; tracheal
obstruction; calcification.
Fig. 14.42: Solitary nodule thyroid causes deviation of
trachea to opposite side.
Fig. 14.43: Diagrammatic representation of
multinodular goitre.
Thyroid cyst
It is thyroid swelling which is cystic in nature eliciting
positive fluctuation.
Common cause is colloid degeneration.
30% of solitary nodules are cystic.
15% cystic swellings in thyroid are malignant.
A cyst if contains both solid and cystic areas is called
as complex cyst which is more likely to be malignant.
FNAC may cause regression in simple cyst. Surgery is
needed if recurrence occurs after three repeated
aspirations.
Surgery is indicated in complex cyst and if cyst is more
than 4 cm in size.
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Fig. 14.44: Large multinodular goitre.
Thyrotoxicosis and Hyperthyroidism
SRB’s Clinical Surgery
It is complex of symptoms and signs due to raised
levels of thyroid hormones.
stimulating antibodies (Ts Ab) and long acting thyroid
stimulator (LATS) cause pathological changes in the
thyroid. Histologically there is acinar cell hypertrophy
and hyperplasia with absence of normal colloid in the
tall columnar epithelium (normal is flat epithelium with
colloid). As cells are empty, they look vacuolated.
Tissues are highly vascular . Exophthalmos producing
substance (EPS) causes Grave’ s ophthalmopathy (Fig.
14.45).
Types
(1) Diffuse toxic goitre-(Grave’s disease, Basedow’s
disease, Primary thyrotoxicosis). (2) Toxic multi-
nodular goitre (Secondary thyrotoxicosis; Plummer
disease). (3) Toxic nodule. (4) Hyperthyroidism of
rarer causes: Thyrotoxicosis factitia- drug induced due
to intake of L-thyroxine more than normal; Jod
Basedow thyrotoxicosis—because of consumption of
large doses of iodides given to a hyperplastic endemic
goitre; Autoimmune thyroiditis or de‘ Quervain’s
thyroiditis; Occasionally carcinoma thyr oid; Neonatal
thyrotoxicosis—It subsides in 3-4 weeks as T sAb titres
fall in the baby’ s serum. Note: Wolf-Chaikoff effect—
iodides inhibit the further release of hormone causing
hypothyroidism. It is eight times more common in
females; occurs in any age group; primary type is
seen commonly in younger age group; secondary is
common in older age group. Grave’s disease is an
autoimmune disease with increased levels of specific
antibodies in the blood (TSH receptor antibodies).
It is often associated with vitiligo. It is often familial.
Thyroid stimulating immunoglobulins (TSI)/thyroid
Fig. 14.45: Thyrotoxicosis (primary). Note the exophthalmos
and also toxic thyroid enlargement.
Symptoms of Hyperthyroidism
Gastrointestinal system: Weight loss in spite of
increased appetite; diarrhoea (due to increased activity
at ganglionic level).
Cardiovascular system: Palpitations, chest pain;
shortness of breath at rest or on minimal exertion;
angina; irregularity in heart rate; cardiac failure.
Neuromuscular system: Undue fatigue and muscle
weakness, exaggerated tendon reflexes, myasthenia
like syndrome; tremor, hyperkinesias, increased
sweating.
Skeletal system: Increase in linear growth in children.
Genitourinary system: Oligo- or amenorrhoea;
occasional urinary frequency.
Integument: Hair loss; pruritus; palmar erythema.
Examination of Thyroid
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Wayne’s Diagnostic Indices (Clinical)
Symptoms Present Absent
1 Dyspnoea on effort +1
2 Palpitation +2
3 Tiredness +2
4 Preference for heat –5
5 Preference for cold (Heat intolerance) +5
6 Excessive sweating +3
7 Nervousness +2
8 Appetite increased +3
9 Weight decreased +3
Signs Present Absent
1 Bruit over thyroid +2
2 Exophthalmos +2
3 Lid retraction +2
4 Lid lag +1
5 Hyperkinetic movements +4 –2
6 Fine finger tremors +1
7 Hands Hot +2 –2
Moist +1 –1
8 Atrial fibrillation +4
9 Pulse rate 80/minute. –3
80-90/minute 0
More than 90/minute +3
10 Palpable thyroid
+3
< 11 points –non toxic 11-19 –equivocal > 19 points –toxic goitre
345
Psychiatry: Irritability; nervousness; insomnia.
Sympathetic overactivity causes dyspnoea, palpitation,
tiredness, heat intolerance, sweating, nervousness,
increased appetite and decrease in weight. Because
of the increased catabolism they have increased
appetite, decreased weight and so also increased
creatinine level which signifies myopathy (due to more
muscle catabolism). Fine tremor is due to diffuse
irritability of grey matter. Thrill is felt in the upper
pole of the thyroid and also bruit is heard on
auscultation. It is because superior thyroid artery enters
the gland superficially in upper pole, and so thrill and
bruit can easily be assessed. Inferior thyroid artery
enters the gland in lower pole at deeper plane and
so thrill cannot be felt (Fig. 14.46).
Signs of Hyperthyroidism
(1) Eye signs in toxic goitre (Refer above). (2) Cardiac
manifestations: Tachycardia is common. Sleeping
pulse rate is usually checked for three consecutive
Fig. 14.46: Diffuse toxic goitre. Note the involvement
of both lobes bilaterally.
nights and average is taken as the value; ectopic;
pulsus paradoxus; wide pulse pressure; multiple
extrasystoles; paroxysmal atrial tachycardia;
paroxysmal atrial fibrillation; persistent atrial
fibrillation (not responsive to digoxin). (3) Myopathy:
Weakness of proximal muscles occurs, i.e. the front
thigh muscles, or arm muscles; weakness is more when
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muscle contracts isometrically, i.e. either while
climbing down steps, or lifting a full bucket etc. often
when it is severe it resembles myasthenia gravis. Once
hyperthyroidism is controlled recovery occurs. (4)
Pretibial myxoedema is often a feature of primary
thyrotoxicosis (It is a misnomer)—It is usually
symmetrical, shiny, red thickened skin, with coarse
hair; in severe cases skin of whole leg below the knee
with foot and ankle is involved: it is due to deposition
of myxomatous tissues (mucin like deposits) in skin
and subcutaneous plane; it might or might not regress
completely after treatment for toxicity; it is associated
with exophthalmos with high levels of thyroid
stimulating antibodies. (5) Thyroid Acropachy is
clubbing of fingers and toes in primary thyrotoxicosis;
hypertrophic pulmonary osteoarthropathy also may
develop.
Cardinal signs of toxic thyroid
• Palpable thyroid often with thrill and bruit
• Tremor of hands and tongue
• Tachycardia
• Exophthalmos
SRB’s Clinical Surgery
Thyrocardiac: Severe cardiac damage resulting from
hyperthyroidism usually secondary type requires
proper opinion from cardiologists and treatment with
propranolol.
thyrotoxicosis should be suspected if the clinical
T
3
picture is suggestive of toxicosis, but routine tests for
thyroid function are within normal range.
Investigations
(1) Serum T3 and T4 levels are very high. TSH is very
low or undetectable. Sometimes, only T3 level is
increased and is called as T3 toxicosis. In T3 toxicosis,
free T3 estimation is important. Radioisotope study
131
by I
will show more uptake, i.e. hot nodules or hot
areas. This is very useful to detect autonomous solitary
toxic nodule. (2) TRH estimation. (3) ECG—T o look
for cardiac involvement and if required opinion from
cardiologists’ is taken and cardiac problems are
managed accordingly . (4) Total count and neutrophil
count are very essential base line investigations before
starting antithyroid drugs (as it may cause agranulocytosis).
T oxic nodule: It is a solitary overactive nodule. There
is an autonomous hypertrophy and hyperplasia of
the part of the gland where there is a nodule. [It is
not due to Thyroid stimulating antibody (Ts Ab)].
Here high levels of circulating thyroid hormones
suppress TSH secretion and so normal thyroid tissue
Differential Diagnosis of Thyrotoxicosis
Anxiety neurosis—hands are cold and moist, sleeping
pulse rate is normal, thyroid enlargement is not present;
phaeochromocytoma; malabsorption syndrome; diabetes mellitus.
surrounding the nodule is been suppressed and
inactive.
Toxic thyroid in pregnancy and children: Radioiodine therapy is absolutely contraindicated in
pregnancy (High risk to foetus) and children (high
risk of developing thyroid carcinoma).
Differentiating Points Between Primary and Secondary Hyperthyroidism
Primary thyrotoxicosis Secondary thyrotoxicosis
1. Symptoms appear first, then swelling. 1. Swelling appears first
2. Goitre is diffuse, smooth, firm or soft, 2. Swelling is large nodular, obvious
both lobes are involved 3. Symptoms appear after long time, which is less
3. There is thrill and bruit severe and slowly progressive compared to
4. Features are much more severe compared primary toxicosis.
to that of secondary toxicosis. 4. Cardiac features are more common.
5. Eye signs and exophthalmos are common. 5. Eye signs are not common.
6. As it is an autoimmune disease, there may be
hepatosplenomegaly.
Histologically, there is hyperplasia of acini, lined by
columnar epithelium, often containing vacuolated colloid.
Thyroid Neoplasms
Classification of Thyroid Neoplasm
Benign: Follicular adenoma; Hurthle cell adenoma;
colloid adenoma—commonest; papillary adenoma—
its existence is doubtful. It is invariably low grade
Examination of Thyroid
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papillary carcinoma.
Malignant (Dunhill classification): (a) Differentia-
ted—Papillary carcinoma 60%); Follicular carcinoma
(7%); papillofollicular carcinoma behaves like
papillary carcinoma of thyroid; Hurthle cell carcinoma
behaves like follicular carcinoma. (b) Undifferentiated.
Anaplastic carcinoma (13%). (c) Medullary carcinoma
(6%). (d) Malignant lymphoma (4%). (e) Secondaries
in thyroid (rare)—from colon, kidney , melanoma (Fig.
14.47).
Aetiology of thyroid malignancy: (1) Radiation either
347
Fig. 14.47: Carcinoma thyroid. Note the superficial
tissue infiltration. Dilated veins are also seen.
external or radioiodine can cause papillary carcinoma
thyroid. There was increased incidence of thyroid
carcinoma among children following exposure to
ionizing radiation after the Chernobyl nuclear disaster
in Ukraine in 1986. Irradiation to head and neck region
used to be the therapy for benign conditions like adenoids, acne vulgaris, thymus enlargement, haemangiomas which predisposed papillary carcinoma of
thyroid. Radiotherapy for Hodgkin’s lymphoma in
younger age group may later cause papillary carcinoma
of thyroid. (2) Pre-existing multinodular goitre. It turns
into follicular carcinoma of thyroid. (3) Medullary
carcinoma of thyroid commonly and 6% of papillary
carcinoma of thyroid can be familial. (4) Hashimoto’s
thyroiditis may predispose to papillary carcinoma of
Fig. 14.48: Carcinoma thyroid in a male patient
showing vascularity.
thyroid and also NHL (Fig. 14.48).
Papillary Carcinoma
It is 60% common; common in females (3: 1) and young
age group. TSH levels in the blood of these patients are
high and so it is called as hormone dependent tumour.
It is a slowly progressive and less aggressive tumour.
It is commonly multicentric. It spreads within the gland
through intrathyroidal lymphatics to other lobe, comes
out of the capsule and spreads to lymph nodes. Usually
there is no blood spread.
Types: Occult (< 1.5 cm); Intrathyroidal; Extrathyroidal; Micropapillary carcinoma is less than 1 cm in
size or clinically not detectable.
Gross: It can be soft, firm, hard, and cystic. It can be
solitary or multinodular. It contains brownish black fluid.
Microscopy: It shows cystic spaces, papillary
projections with psammoma bodies, malignant cells
with ‘Orphan Annie eye’ nuclei (intranuclear
cytoplasmic inclusions, nuclear grooving).
Clinical features: (1) Soft or hard or firm, solid or
cystic, solitary or multinodular thyroid swelling.
(2) Compression features are uncommon in papillary
carcinoma thyroid. (3) Often discrete lymph nodes
in the neck are palpable.
Diagnosis: FNAC of thyroid nodule and lymph node,
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Fig. 14.49: Papillary carcinoma of thyroid with lymph
nodal spread.
SRB’s Clinical Surgery
to see psammoma bodies, nuclear changes; Radioisotope scan shows cold nodule; TSH level in the blood
is higher (Fig. 14.49).
AMES scoring
A: Age less than 40 years has got better prognosis.
M: Distant metastasis.
E: Extent of the primary tumour.
S: Size of the tumour. Size less than 4 cm has got
better prognosis.
AGES scoring
A: Age less than 40 years has got better prognosis.
G: Pathologic grade of the tumour.
E: Extent of the primary tumour.
S: Size of the primary tumour. Size less than 4 cm
has got better prognosis.
Psammoma bodies are seen in
Papillary carcinoma thyroid
Meningioma
Serous cystadenoma of ovary
Berry’s in thyroid
Berry ligament
Berry sign
Berry picking
Lateral aberrant thyroid is a misnomer . It is actually
secondaries in neck lymph nodes which are palpable
from an occult primary from papillary carcinoma of
thyroid (which is clinically not palpable).
Thyroid Paradox
Cellular tumours are soft, and cystic tumours are firm
or hard (tensely cystic). It is observed in papillary
carcinoma of thyroid.
Features of thyroid carcinoma
Any thyroid of any size, any texture—solid/cystic, with
nodules of any number—single/multiple, in any age group
can be malignant
Features of infiltration
Infiltration of strap muscles often with sternomastoid
muscle
Infiltration of laryngotracheal complex causing stridor and
often haemoptysis
Infiltration of recurrent laryngeal nerve causes hoarseness
of voice
Infiltration of oesophagus causes dysphagia/odynophagia
(painful swallowing)
Infiltration into carotid sheath causes absence of carotid
pulsation—Berry’s sign
Infiltration of cervical sympathetic chain causing Horner’s
syndrome
Rarely infiltration into cranial nerves or brachial plexus
can occur
Features of lymph nodal spread
Discrete neck node involvement can occur commonly in
papillary carcinoma of thyroid, often in medullary carcinoma and occasionally in follicular carcinoma. Lymph
node is often cystic (20%) and contains brownish-black
material in papillary carcinoma.
Central neck (level VI) and mediastinal nodes often can
get involved in thyroid malignancy. Primary nodes may
be involved but clinically not palpable. Superior mediastinal
nodes (level VII) can cause compression of SVC, recurrent
laryngeal nerve with often dullness in the sternum. These
nodes can get involved without palpable neck nodes.
In the neck, palpable nodes are commonly levels—II, III
and IV occasionally level V. Secondary nodes—clinically
palpable.
Only palpable neck node may be presentation without
clinically palpable thyroid-secondary of occult primary
(papillary) thyroid carcinoma. FNAC of the node concludes
the diagnosis.
Central node dissection is the common practice while
doing total thyroidectomy in carcinoma thyroid especially
in medullary carcinoma of thyroid.
Features of blood spread
Follicular carcinoma commonly spreads through blood
to bone, lungs, and liver. Bone secondary is typical. It
is well-localised, smooth, soft/hard, warm, nonmobile,
vascular and pulsatile. It is common in the skull bone—
frontal/parietal bone. It can occur in other bones also.
Lung secondaries present with chest pain, dyspnoea
and haemoptysis.
Liver secondaries cause hepatomegaly and jaundice.
Blood spread also can occur in medullary carcinoma of
thyroid.
Examination of Thyroid
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Follicular Carcinoma
It is 17% common. It is common in females. It can
occur either de novo or in a pre-existing multinodular
goitre. It is a more aggressive tumour . It spreads mainly
through blood into the lung, bones, liver. Bone
secondaries are typically vascular, warm, pulsatile,
localised, commonly in skull, long bones, ribs. It can
also spread to lymph nodes in the neck (10%)
occasionally.
Types: Non-invasive—blood spread is not common.
Invasive—blood spread is common.
Typical feature: Angioinvasion and capsular invasion (Figs 14.50 and 14.51A to C).
Clinical features: Swelling in the neck, firm or hard
and nodular; tracheal compression/infiltration and
stridor; dyspnoea, haemoptysis, chest pain when there
are lung secondaries; recurrent laryngeal nerve involvement causes hoarseness of voice, positive ‘Berry’s
sign’ signifies advanced malignancy (Infiltration into
the carotid and so absence of carotid pulsation);
pulsatile, warm, well localised, vascular secondaries
in the skull (frontal/parietal bones), long bones.
349
A
Fig. 14.50: Follicular carcinoma of thyroid in a male patient.
It is involving mainly left lobe but it is extensive and spreading
to adjacent soft tissues.
B
C
Figs 14.51A to C: Follicular carcinoma of thyroid causing
secondaries in skull. It is localized, vascular, smooth,
pulsatile, warm secondaries (in skull). CT scan is head
diagnostic.
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SRB’s Clinical Surgery
Investigations: Most often FNAC is inconclusive,
because capsular and angioinvasion which is the main
feature in follicular carcinoma cannot be detected by
FNAC. Frozen section biopsy is very useful. But in
15% cases it shows negative results. U/S abdomen,
Chest X-ray, X-ray bones are the other investigations
required (Fig. 14.52).
Fig. 14.52: X-ray skull showing secondaries from
follicular carcinoma thyroid.
Hurthle cell carcinoma is a variant of follicular
carcinoma of thyroid which contains abundant oxyphill
cells. It spreads more commonly to regional lymph
nodes than follicular carcinoma of thyroid.
99m
Tc
sestamibi scan is very useful for Hurthle cell
carcinoma. It does not take up I
131
; has got poorer
prognosis than follicular carcinoma.
Differential diagnosis for carcinoma thyroid
Multinodular goitre
Solitary nodule of other causes
Riedel’s thyroiditis.
Note: Toothpaste colloid—follicular carcinoma;
Chewing gum colloid—papillary carcinoma; Nuclear
grooving— papillary carcinoma; Psammoma bodies—
papillary carcinoma; Amyloid –medullary carcinoma;
Follicular adenoma—aneuploid and in follicular
carcinoma—diploid—DNA ploid study (Fig. 14.53).
Anaplastic Carcinoma
It is a very aggressive tumour of short duration,
presents with a swelling in thyroid region which is
rapidly progressive causing—stridor and hoarseness
of voice; dysphagia; fixity to the skin; infiltration into
the carotid sheath-positive Berry’s sign; swelling is
Fig. 14.53: Carcinoma thyroid with dilated
veins on the surface.
TNM staging for thyroid cancer
Tumour
Tx Primary not assessed
T0 No primary
T1 < 1 cm limited to thyroid
T2 1-4 cm limited to thyroid
T3 > 4 cm limited to thyroid
T4 Any size extending beyond capsule.
Nodes
Nx Nodes cannot be assessed
N0 No regional nodes
N1 Regional nodes present
N1a Same side neck nodes
N1b Bilateral, midline, mediastinal nodes
Metastases
Mx Cannot be assessed
M0 No metastases
M1 Metastases present
Under the age of 45 years only Stage I —[any T/N and
M0] and II [any T/N and M1]. After the age 45 years,
Stage I, II, III and IV. Anaplastic carcinoma is always stage
IV.
hard, with involvement of isthmus and bilateral lobes;
FNAC is diagnostic; tracheostomy and isthmectomy
has got a role to relieve respiratory obstruction
temporarily . It carries poor prognosis (Figs 14.54 and
14.55).
Medullary Carcinoma of Thyroid (MCT)
It is uncommon (5%) type of thyroid malignancy. It
arises from the para-follicular ‘C` cells which is
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