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Thyroid cancer by J. Shah

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Thyroid  cancer by  J. Shah Thyroid cancer by J. Shah Presentation Transcript

  • The International Federation of Head and Neck Oncologic SocietiesCurrent Concepts in Head and Neck Surgery and Oncology 2012 Thyroid CancerTreatment of the Primary Jatin P. Shah
  • Thyroid Cancer Issues •  Incidence •  Risk Group •  Pathology Stratification •  Exploiting Biology •  Selection of Therapy •  Practice Patterns •  Follow up •  Prognostic •  Future Directions Factors •  Summary2012
  • Thyroid Cancer – Incidence & Mortality 1974 to 2012Thousands 6 USA Overall0 5646034323028262422 Women2018 432101614 Men1210 13250 8 6 Mortality 4 2 1780 0 1974 1978 1982 1986 1990 1994 1998 2002 2006 2010 2012 2012 Overall Incidence Incidence in Women Incidence in Men Mortality
  • Trends in Incidence ofThyroid Cancer and Papillary Tumors by Size in the United States2012 Davies, L. et al. JAMA 2006;295:2164-2167
  • Differentiated Cancer of the Thyroid Gland A Biologically Unique Neoplasm •  Multifocal microscopic foci of carcinoma are common (60 – 80%) •  Micrometastases to regional lymph nodes are common (>50%)2012 Its clinical significance ???
  • Pathology Cancer of the Thyroid Papillary Medullary ~65% ~10% Follicular Anaplastic (Hurthle cell) ~20% ~5%2012
  • Pathology Cancer of the Thyroid Papillary Thyroid Tall Cell, PoorlyFollicular Insular, differentiated Anaplastic Cell etc Follicular Good Bad Ugly2012 ~85% ~15% <2%
  • Contemporary Thinking of Pathology of Thyroid Cancer •  Nearly 80% are Papillary Carcinomas •  Pure Follicular Carcinomas are rare •  Approximately 12-15% are Poorly Differentiated Carcinomas •  Approximately 5-7 % are Medullary Carcinomas •  Less than 2% are2012 Anaplastic Carcinomas
  • Prognosis in Thyroid CancerWDTC Great majority after initial treatment CuredA small proportion (~10%) will develop local/regional recurrence without negative impact on survival Mortality is exceedingly rare (<2%)2012
  • Prognosis in Thyroid Cancer A very small proportion will undergo progression to aggressive variantsPTC Tall Cell Poorly Diff Anaplastic Mortality2012
  • Exploiting Biology for ManagementPTC Tall Cell Poorly Diff Anaplastic Thyroglobulin & TTF Differentiation2012
  • Exploiting Biology for ManagementPTC Tall Cell Poorly Diff Anaplastic Glucose metabolism PET Scan Cell division Differentiation Iodine avidity2012 RAI Scan
  • Prognosis in Thyroid Cancer Genomic InstabilityPTC Tall Cell Poorly Diff Anaplastic Size, ETE, DM, Mortality2012
  • Differentiated Cancer of the Thyroid Gland Treatment Paradigm Total or near total thyroidectomy Radioiodine ablation If we follow Radioiodine therapy this practice Follow up with TGb and ultrasound •  Majority get excessive treatment at great cost with little or no benefit 2012 •  Some derive benefit •  Some have no impact on prognosis with treatment
  • Differentiated Cancer of the Thyroid Gland Prognostic FactorsMayo Lahey Mayo Karolinska MSKCCAGES AMES MACIS DAMES GAMESAge Age Metastases DNA GradeGrade Metastases Age Age Age Completeness Metastases Metastases Of resectionExtension Extension Invasion Extension ExtensionSize Size Size Size Size 2012
  • 2012
  • Differentiated Carcinoma Risk Groups of the Thyroid Gland Risk Groups Prognostic Factors Low Intermediate High Factor High LowAge >45 <45 Age <45 >45 <45 >45Gender Male FemaleSize >4 cm <4 cmExtent ETE No ETE Gender Female MaleGrade High Low Size < 4 cms. > 4 cms.Distant Mets Present Absent Extent Intraglandular Extraglandular 2012 Grade Low High Dist. Mets. Absent Present
  • 2012
  • 2012
  • 2012
  • Selection of Therapy Be Aggressive at Extremes of Age•  Children (< 16 yrs). Total Thyroidectomy and RAI therapy•  Older patients (> 60 yrs). Appropriate Aggressive Surgery followed by RAI and/or RT Adults Low risk High risk tumor inUnifocal intraglandular all age groups tumor in all age groups Total Lobectomy Thyroidectomy Aggressive surgery2012
  • Lobectomy  2012
  • Total  Thyroidectomy  2012
  • Total Thyroidectomy •  Diffuse bilobar tumor •  Bilateral nodules regardless of the size of primary •  Major extrathyroid extension •  Massive bilateral nodal metastases •  Distant metastases •  History of radiation exposure2012
  • Extrathyroid Extension from Differentiated Cancer of the Thyroid Gland Minor: •  Strap muscles T3 •  Soft tissues Major: •  Trachea T4A •  Larynx •  Esophagus2012 •  Recurrent laryngeal nerve
  • Differentiated Carcinoma of the Thyroid SURVIVAL: Extrathyroid Extension 100 90 No ETE 94% 80 70 ETE 74% 60 % 50 40 P < 0.01 30 20 No Extrathyroid Extension n =1608 10 Extrathyroid Extension n = 202 0 0 5 10 15 202012 Time (Years)
  • Differentiated Carcinoma of the Thyroid ETE and Recurrence 16 14 13.4 P<0.01 12 10 9.4 % 8 No ETE 6 ETE 4 3.2 2.5 1.8 2 0.2 0 Local Regional Distant2012
  • Thyroid Carcinoma with Extrathyroid Extension Young Patients with Complete ExcisionSurvival 1.0 .9 .8 p=0.46 .7 .6 .5 p=0.005 .4 .3 .2 <=45, ETE, Complete excision .1 <=45, No ETE <=45, ETE, Incomplete excision 2012 60 120 180 240 300 360 Time (months)
  • Surgery  for  Extrathyroid  Extension   Principles   •     All  gross  tumor  should  be  removed   •     Preserve  func=oning  structures   •     Preserve  vital  structures   •     Balance  between  tumor  control  and  best          func=onal  results   •     Use  adjuvant  treatments  -­‐  RAI,  and/or  RT  2012
  • Invasion  of  Recurrent  Laryngeal  Nerve  2012
  • Extrathyroid  Extension   Recurrent  Laryngeal  Nerve   •     Unilateral  vs  bilateral   •     Preop  vocal  cord  palsy   •     Evaluate  both  lobes  of  thyroid   •     Make  every  effort  to  preserve  func=oning  RLN   •     Look  on  the  other  side  before  sacrificing        func=oning  RLN   •     Nerve  graM  -­‐  Reinnerva=on  2012 •     Laryngoplasty  
  • Invasion of Trachea2012
  • Invasion  of  Trachea  2012
  • Surgery for Extrathyroid Extension Trachea •  Shaving tumor off the trachea •  Partial/window resection and reconstruction •  Sleeve resection with primary anastomosis •  Resection of trachea with cricoid2012
  • Invasion  of  Larynx  2012
  • Extrathyroid  Extension   Larynx   •     Peel  the  tumor  off  larynx   •     Par=al  laryngectomy  of  framework   •     Anterolateral  par=al  laryngectomy   •     Total  laryngectomy  -­‐  rare   •     Laryngopharyngectomy  -­‐  rare  2012
  • Invasion  of  Pharynx  -­‐  Esophagus  2012
  • Extrathyroid  Extension   Esophagus   •     Excision  of  muscular  wall   •     Par=al  esophagectomy   •     Esophagectomy  with  or  without  laryngectomy   •     Gastric  pull-­‐up  or  jejunal  free  flap  2012
  • Differentiated Thyroid Cancer 1930-1985 Differentiated Thyroid Cancer 1930-1985 SURVIVAL: Risk Groups SURVIVAL: Risk Groups 1 99% p < 0.001 88%0.8 93% 85% p < 0.0010.6 72% 57%0.40.2 Low n=403 Med-<45 n=159 Med->45 n=244 High n=232 0 0 2 4 6 8 10 12 14 16 18 20 TIME (years)MSKCC-1038 pts. (DOD)MSKCC-1038 pts. (DOD) 2012
  • Thyroid Cancer Summary •  Rising incidence of favorable low risk cancers •  Appreciation of pathology and exploiting biology to deliver cost effective treatment •  Significance of prognostic factors and risk group stratification •  Discretion in selection of surgical treatment •  Discretion in use of adjuvant therapy and follow up2012 •  Research in molecular biology and new therapies