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develop a papillary thyroid carcinoma Papillary carcinoma can sometimes undergo a late anaplastic transformation into an aggressive carcinoma Generally speaking, papillary carcinoma is the least aggressive thyroid malignancy However, the tumor spreads via lymphatics within the thyroid, becoming multifocal in 60% of patients and involving both lobes in 30% of patients About 80% of patients have microscopic metastases to cervical lymph nodes; palpable lymph node involvement is present in 15% of adults and 60% of youths Unlike other forms of cancer, patients with papillary thyroid carcinoma who have palpable lymph node metastases do not have a particularly increased mortality rate; however, their risk of local recurrence is increased Occult metastases to the lung occur in 10 15% of differentiated thyroid cancer; such lung metastases may be first noted on the whole-body scan following 131I therapy About 70% of small lung metastases resolve following 131I therapy; however, larger pulmonary metastases have only a 10% remission rate Microscopic micropapillary carcinoma (invisible even on thyroid ultrasound) is a variant of normal, being found in 24% of thyroidectomies performed for benign thyroid disease when 2-mm sections were carefully examined It thus appears that the overwhelming majority of these microscopic foci never become clinically significant The surgical pathology report of such a tiny papillary carcinoma that is otherwise benign does not justify aggressive follow-up or treatment because a cancer diagnosis is unwarranted and harmful All that may be required is yearly follow-up with palpation of the neck and mild TSH suppression by thyroxine Follicular thyroid carcinoma results from certain gene mutations or translocations Aberrant DNA methylation, activation of the ras oncogene, and mutations of the MEN1 gene can result in benign follicular adenomas Loss of function of PPARg or the 3P tumor suppressor gene can lead to follicular carcinoma, and additional loss of the p53 tumor suppressor gene can produce anaplastic carcinoma Follicular thyroid carcinoma and adenomas develop in patients with Cowden s disease, a rare autosomal dominant familial syndrome caused by loss of a tumor suppressor gene; such patients tend to have macrocephaly, multiple hamartomas, early-onset breast cancer, intestinal polyps, facial papules, and other skin and mucosal lesions Follicular and H rthle cell carcinoma accounts for about 14% of thyroid malignancies and is generally more aggressive than papillary carcinoma Rarely, some follicular carcinomas secrete enough T4 to cause thyrotoxicosis if the tumor load becomes significant Metastases commonly are found in neck nodes, bone, and lungs Most follicular thyroid carcinomas avidly absorb iodine, making possible diagnostic scanning and treatment with 131I after total thyroidectomy Certain follicular histopathologic features are associated with a high risk of metastasis and recurrence: poorly differentiated and H rthle cell (oncocytic) variants The latter variants do not take up RAI Medullary thyroid carcinoma is often caused by an activating mutation of the ret oncogene on chromosome 10 Mutation analysis of the ret oncogene s exons 10, 11, 13, and 14 detects 95% of the mutations causing MEN 2A and 90% of the mutations causing familial medullary thyroid carci-.

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noma Patients with MEN 2B have activating mutations in exon 16 of the ret oncogene These germline mutations can be detected by DNA analysis of peripheral WBCs, allowing identification of gene carriers within the family When a family with MEN 2A or familial medullary thyroid carcinoma does not have an identifiable ret oncogene mutation, gene carriers may still be identified using family linkage analysis Somatic mutations of the ret oncogene can be identified in the tumors of 30% of patients with sporadic (nonfamilial) medullary thyroid carcinoma (See Multiple Endocrine Neoplasia) Medullary thyroid carcinoma represents about 3% of thyroid cancers About one-third of cases are sporadic, onethird are familial, and one-third are associated with MEN type 2 Therefore, discovery of a medullary thyroid carcinoma makes genetic analysis mandatory, as noted above If a gene defect is discovered, related family members must have genetic screening for that specific gene defect Even when no gene defect is detectable, family members should have regular thyroid surveillance Medullary thyroid carcinoma arises from parafollicular thyroid cells that can secrete calcitonin, prostaglandins, serotonin, ACTH, corticotropin-releasing hormone (CRH), and other peptides These peptides can cause symptoms and can be used as tumor markers Early local metastases are usually present, usually to adjacent muscle and trachea as well as to local and mediastinal lymph nodes Eventually, late metastases may appear in the bones, lungs, adrenals, or liver Metastases to the neck may be detected by ultrasound Metastases are best detected using 18 FDG-PET whole-body scanning Medullary thyroid carcinoma does not concentrate iodine Anaplastic thyroid carcinoma is caused by certain gene mutations, including inactivating mutations of the p53 tumor suppressor gene, as described above for papillary and follicular thyroid carcinomas Anaplastic thyroid carcinoma represents about 2% of thyroid cancers It usually presents in an older patient as a rapidly enlarging mass in a multinodular goiter It is the most aggressive thyroid carcinoma and metastasizes early to surrounding nodes and distant sites Local pressure symptoms include dysphagia or vocal cord paralysis This tumor does not concentrate iodine Other thyroid malignancies together represent about 3% of thyroid cancers Lymphoma of the thyroid is more common in older women It usually presents as a rapidly enlarging, painful mass arising out of a multinodular or diffuse goiter affected by autoimmune thyroiditis, with which it may be confused microscopically About 20% of cases have concomitant hypothyroidism Thyroid lymphomas are most commonly B cell lymphomas (50%) or mucosa-associated lymphoid tissue (MALT; 23%); other types include follicular, small lymphocytic, and Burkitt s lymphoma and Hodgkin s disease Thyroidectomy is rarely required Metastatic cancers may sometimes involve the thyroid, particularly bronchogenic, breast, and renal carcinomas and malignant melanoma.

Thyroid carcinoma usually presents as a palpable, firm, nontender nodule in the thyroid Most thyroid carcinomas are

Functions | Account Assignment/Costing | Revenue Account Determination | Check Master Data Relevant for Account Assignment | Customers: Account Assignment Groups Again, to re-create new entries, you can copy the existing standard and rename the entry using a two-character alphanumeric key with a short description These account assignment keys are useful in grouping account determination For example, the business may want domestic sales revenue to be posted into account X, while international sales revenue may have to be posted into account Y, differentiated by account assignment group

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