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Karsinoma Tiroid / Ca Thyroid

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//Gambar Penyakit//

Kompetensi  :  2
Sistem Terkait :  Endokrin, Metabolik, Nutrisi
Fisiologi Terkait :  
Anatomi Terkait :  Tiroid
Keyword :  Kelenjar Endokrin

//Gambar Penyakit//

Kompetensi  :  2
Sistem Terkait :  Endokrin, Metabolik, Nutrisi
Fisiologi Terkait :  
Anatomi Terkait :  Tiroid
Keyword :  Kelenjar Endokrin

Definisi

Neolasma primer tiroid, 4 tipe utama papiller, follikuler, anaplastik, dan medulla.

Epidemiologi :

  • Merupakan jenis keganasan jaringan endokrin yang terbanyak.
  • Lebih banyak pada wanita, Female/male ratio is 3:1. 
  • Usia penderita <20 tahun atau >50 tahun, Median age at diagnosis: 45 to 50 yr. 

Etiologi

Etiologi yang pasti belum diketahui.

  • Risk factors: prior neck irradiation
  • Multiple endocrine neoplasia II (medullary  carcinoma)
  • Inherited syndromes associated with thyroid cancer
  • GLP-1 receptor agonists for the treatment of type 2 DM (e.g., exenatide, albiglutide) can increase the risk of medullary thyroid carcinoma (MTC)

Faktor predisposisi:

  • Penyinaran di daerah kepala leher dan dada.
  • Stimulasi terus menerus TSH pada goitre.
  • Hashimoto / Tiroiditis Otoimun
  • Genetika yang abnormal.
  • Kekurangan yodium atau kelebihan yodium.
  • Penyakit Grave dan Stimulator Endogen.
  • Inborn Error Metabolisme Tiroid.

Faktor Resiko :

  • Paparan radiasi pada tiroid
  • Age and Sex
    • Nodul jinak → paling sering pada wanita 20-40 years (Campbell, 1989)
    • 5%-10% of these are malignant (Campbell, 1989)
    • Laki-laki memiliki risiko lebih tinggi memiliki nodul yang ganas
  • Family History
    • History of family member with medullary thyroid carcinoma
    • History of family member with other endocrine abnormalities (parathyroid, adrenals)
    • History of familial polyposis (Gardner’s syndrome)

Klasifikasi

Klasifikasi Carcinoma of Thyroid

klasifikasi_karsinoma_tyroid.png

klasifikasi_ca_thyroid.png

klasifikasi_ca_thyroid2.png

Klasifikasi Karsinoma Tiroid menurut WHO:

  1. Tumor epitel maligna
    1. Karsinoma folikulare
    2. Karsinoma papilare
    3. Campuran karsinoma folikulare-papilare
    4. Karsinoma anaplastik ( undifferentiated )
    5. Karsinoma sel skuamosa
    6. Karsinoma Tiroid medulare
  2. Tumor non-epitel maligna
    1. Fibrosarkoma
    2. Lain-lain
  3. Tumor maligna lainnya
    1. Sarkoma
    2. Limfoma maligna
    3. Haemangiothelioma maligna
    4. Teratoma maligna
  4. Tumor sekunder dan unclassified tumors

Mc Kenzie membedakan kanker tiroid atas 4 tipe yaitu :

  1. karsinoma papilare
    • 60%-80% of all thyroid cancers (Geopfert, 1998, Merino, 1991), Most common form of thyroid cancer.
    • Histologic subtypes
      • Follicular variant
      • Tall cell
      • Columnar cell
      • Diffuse sclerosing
      • Encapsulated
    • Prognosis is 80% survival at 10 years (Goldman, 1996)
    • Females > Males
    • Mean age of 35 years (Mazzaferri, 1994)
    • Lymph node involvement is common
      • Major route of metastasis is lymphatic
      • Clinically undetectable lymph node involvement does not worsen prognosis (Harwood, 1978)
  2. karsinoma folikulare
    1. 20% of all thyroid malignancies
    2. Women > Men (2:1 - 4:1) (Davis, 1992, De Souza, 1993)
    3. Mean age of 39 years (Mazzaferri, 1994)
    4. Prognosis - 60% survive to 10 years (Geopfert, 1994)
    5. Metastasis
      1. angioinvasion and hematogenous spread
      2. 15% present with distant metastases to bone and lung
    6. Lymphatic involvement is seen in 13% (Goldman, 1996)
  3. karsinoma medulare
    1. 10% of all thyroid malignancies
    2. 1000 new cases in the U.S. each year
    3. Arises from the parafollicular cell or C-cells of the thyroid gland
      1. derivatives of neural crest cells of the branchial arches
      2. secrete calcitonin which plays a role in calcium metabolism
  4. karsinoma anaplastik.
    • Highly lethal form of thyroid cancer
    • Median survival <8 months (Jereb, 1975, Junor, 1992)
    • 1%-10% of all thyroid cancers (Leeper, 1985, LiVolsi, 1987)
    • Affects the elderly (30% of thyroid cancers in patients >70 years) (Sou, 1996)
    • Mean age of 60 years (Junor, 1992)
    • 53% have previous benign thyroid disease (Demeter, 1991)
    • 47% have previous history of WDTC (Demeter, 1991)

Patogenesis

//Gambar Patogenesis//

Patofisiologi

//Gambar Patofisiologi//

Diagnosis

Anamne
  • Biasanya, satu-satunya gejala yang diduga sebagai keganasan adalah adanya massa tiroid teraba yang tidak nyeri atau kelenjar getah bening yang membesar.
  • Terkadang, pasien datang dengan gejala dan tanda-tanda yang perlu diwaspadai untuk kemungkinan kondisi ganas.

Gejala dan tanda tersebut misalnya:

  • suara serak (akibat penekanan n. Laryngeus rekuren)
  • nyeri lokal
  • Disfagia
  • sesak napas
  • Hemoptisis
  • nodul atau massa pada leher tidak nyeri yang cepat membesar
  • Stridor
  • Pembengkakan tanpa nyeri pada regio tiroid
Pemeriksaan Fisik
  • Benjolan di leher
  • teraba asimetris 
  • ikut gerakan menelan
Differential Diagnosis
  1.  
Pemeriksaan Penunjang

PA : 

  1. Papilare : 
    • Gross finding : Solid, firm, grayish white lobulated lesion with sclerotic center.
    • micro finding : 
      • Based on characteristic architecture & cytological feature.
      • Papillae formed by a central fibrovascular stalk & covered by neoplastic epithelial cells.
      • Psammoma bodies in the papillary stalk, fibrous stroma or between tumor cells.
      • Nuclear features:
        • Round to slight oval shape.
        • Pale, clear, empty or ground glass appearance (Orphan Annie): empty of nucleus with irregular thickened inner aspect of nuclear membrane.
        • Pseudo-inclusion: deep cytoplasmic invagination and result in nuclear acidophilic, inclusion-like round structures, sharply outlined and eccentric, with a crescent shaped rim of compressed chromatin on the side.
        • Grooves: coffee-bean like.

Thyroid function studies are generally normal. Thyroid-stimulating hormone (TSH), T4, and serum thyroglobulin levels should be obtained before thyroidectomy in patients with confirmed thyroid carcinoma.

Serum thyroglobulin levels can be useful postoperatively to monitor recurrence of thyroid carcinoma.

Increased plasma calcitonin assay in patients with medullary carcinoma (tumors produce thyrocalcitonin).

Pendekatan Diagnosis karsinoma anaplastik.
  1. Labs :
    1. basal and pentagastrin stimulated serum calcitonin levels (>300 pg/ml)
    2. serum calcium
    3. 24 hour urinary catecholamines (metanephrines, VMA, nor-metanephrines)
    4. carcinoembryonic antigen (CEA)
  2. Fine-needle aspiration
  3. Genetic testing of all first degree relatives

PA Thyroid Cancer

PA_kanker_thyroid.png

Tatalaksana

Prinsip

 

Non-Farmakoterapi  
Farmakoterapi

 

Tatalaksana Lain

 

Respon Terapi  

 //Gambar Guideline//

Prognosis

Prognosis

  • Quo Ad vitam : 
  • Quo Ad functionam : 
  • Quo Ad sanationam : 

Sumber

 

 

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