09 01 05 Entgr Management Of Well Differentiated Thyroid Cancer


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09 01 05 Entgr Management Of Well Differentiated Thyroid Cancer

  1. 1. Management of Well Differentiated Thyroid Cancer Vivek Ramarathnam, M.D. SIU- Otolaryngology Grand Rounds 9/1/2005
  2. 2. Thyroid Nodules <ul><li>Between 4-7% of individuals in US have palpable thyroid nodules </li></ul><ul><li>More common in women </li></ul><ul><li>Increase in frequency with age </li></ul><ul><li>Fewer than 10% of solitary nodules are malignant </li></ul><ul><li>- Papillary (75%) </li></ul><ul><li>- Follicular (15%) </li></ul>
  3. 3. Thyroid Carcinoma <ul><li>1.5% of all newly diagnosed cancers </li></ul><ul><li>Number increasing over last 25 years; </li></ul><ul><li>4.8 to 8.0 cases per 100,000 </li></ul><ul><li>Female predominance (11.7 female to 4.2 male cases/100,000 </li></ul><ul><li>Death rate 0.5 cases per 100,000 </li></ul>
  4. 4. Nodules and Carcinoma Rates <ul><li>Rates of carcinoma in a single nodule: 5-17% </li></ul><ul><li>Rates of carcinoma in multinodular patients: 5-13% </li></ul>
  5. 5. Risk Factors for Malignancy <ul><li>Prior irradiation </li></ul><ul><li>Family history </li></ul><ul><li>Male sex </li></ul><ul><li>Nodules in individuals <15, >45 </li></ul><ul><li>Symptoms of invasiveness: development of hoarseness, progressive dyshagia, or dyspnea </li></ul>
  6. 6. Physical Examination <ul><li>Pulse rate, Blood Pressure </li></ul><ul><li>Neck Lymphadenopathy </li></ul><ul><li>Deviation of Trachea </li></ul><ul><li>Palpation of Thyroid gland </li></ul><ul><li>(Size, consistency, mobility, presence or absence of tenderness, multinodularity) </li></ul><ul><li>Attention of thyroid mass to surrounding anatomy </li></ul>
  7. 7. Preoperative Evaluation <ul><li>Individuals with symptoms potentially of invasive carcinoma- dysphonia, dysphagia, or stridor </li></ul><ul><li>Flexible laryngoscopy </li></ul><ul><li>MRI allows soft tissue evaluation (cervical esophageal invasion) </li></ul><ul><li>CT, readily available, iodinated contrast used can delay the use of RAI postoperatively 4-6 weeks </li></ul><ul><li>Selected patients, panendoscopy </li></ul>
  8. 8. Thyroid Picture
  9. 9. Thyroid Anatomy <ul><li>Arteries- Paired arteries, superior, inferior arteries </li></ul><ul><li>Venous drainage- parallels arterial drainage, superior thyroid veins drain into internal jugular vein, inferior thyroid veins to brachiocephalics </li></ul><ul><li>Lymphatics- intraglandular lymphatic network, paratracheal, upper, mid, and lower jugular nodes </li></ul>
  10. 10. Thyroid Hormone Physiology <ul><li>Growth- hormones work in bone formation </li></ul><ul><li>CNS- brain maturation </li></ul><ul><li>Basal metabolic rate </li></ul><ul><li>Cardiovascular and respiratory systems </li></ul><ul><li>Metabolic effects </li></ul>
  11. 11. Thyroid Histology
  12. 12. Thyroid Hormone Regulation <ul><li>TSH stimulates both </li></ul><ul><li>iodine uptake and its organification </li></ul>
  13. 13. Management steps with a Thyroid Nodule <ul><li>TSH level </li></ul><ul><li>- 95% of all nodules are hypofunctional (cold) </li></ul><ul><li>If TSH normal, obtain a ultrasound and perform FNA </li></ul><ul><li>- if firm and palpable FNA can be performed without image guidance </li></ul>
  14. 14. Ultrasound Imaging and Nodules <ul><li>US reports thyroid size and appearance, 3D description of specific nodules, presence of paratracheal nodes, and evidence of invasive qualities. </li></ul><ul><li>Useful in individuals undergoing FNA and have difficult lesions to palpate. </li></ul><ul><li>Also beneficial in complex cysts, and nodules with questionable multinodularity </li></ul>
  15. 15. Management steps with a Thyroid Nodule <ul><li>If TSH high, treat with thyroid hormone replacement and FNA when patient is euthyroid </li></ul><ul><li>TSH level low; may have hyperfunctioning nodule and should be evaluated with thyroid scan. Low likelihood of malignancy </li></ul>
  16. 16. Evaluation of solitary nodule <ul><li>FNA (fine needle aspiration) </li></ul><ul><li>4 types of interpretations: </li></ul><ul><li>1) Benign </li></ul><ul><li>2) Malignant </li></ul><ul><li>3) Suspicious for follicular or Hurthle cell tumor </li></ul><ul><li>4) Insufficient for diagnosis </li></ul>
  17. 17. Overview of Nodule workup
  18. 18. Case Presentation <ul><li>22 female referred for enlarging thyroid mass Right lobe of thyroid. Last year 2.8 cm and now 3.4 cm in greatest diameter. Complex mass described per US report. Otherwise asymptomatic. Mother- hyperthyroid. Medications: Effexor XR, Ortho patch </li></ul><ul><li>FNA- Cellular follicular lesion </li></ul>
  19. 19. Papillary Carcinoma
  20. 20. Follicular Carcinoma
  21. 21. Fine needle aspiration <ul><li>Procedure requires skill by operator, as well as by cytopathologist </li></ul><ul><li>Even in skilled hands, approximately 10% of biopsy findings nondiagnostic </li></ul><ul><li>Sensitivity 92%, Specificity- 91-97.5% </li></ul>
  22. 22. Findings on FNA <ul><li>Benign finding- Followed serially by US </li></ul><ul><li>If nodule has increased in size ~15%, repeat FNA should be performed </li></ul><ul><li>Follicular neoplasm- 80% of these nodules are benign, 20% represent thyroid carcinoma </li></ul><ul><li>Papillary carcinoma- accuracy of FNA approaches 100% </li></ul>
  23. 23. Fine needle aspiration <ul><li>Suspicious for follicular or Hurthle cell tumor </li></ul><ul><li>Diagnosis of follicular of Hurthle cell tumor from follicular carcinoma or Hurthle cell carcinoma requires presence or absence of capsular or vascular invasion seen on histologic examination of surgical specimens </li></ul><ul><li>Follicular and Hurthle cell tumors diagnosed by FNA have malignancy rate of 10-20% </li></ul>
  24. 24. Case Presentation <ul><li>Pt underwent Right lobectomy with isthmusectomy </li></ul><ul><li>Frozen section- Follicular neoplasm </li></ul><ul><li>Final pathology- Follicular adenoma </li></ul>
  25. 25. Management of FNA results <ul><li>Follicular neoplasm </li></ul><ul><li>- Thyroid lobectomy, allow histiopathologic diagnosis to dictate need for total </li></ul><ul><li>- Serial US, TSH suppression, repeat FNA </li></ul><ul><li>- Plan for lobectomy with frozen section, if reveals follicular variant of papillary, perform total </li></ul><ul><li>- Perform total thyroidectomy </li></ul>
  26. 26. Staging
  27. 27. Staging
  28. 28. 5 year survival rates 47.1% 45.3% Stage 4 79.4% 95.8% Stage 3 100% 100% Stage 2 100% 100% Stage 1 Follicular Cancer Papillary Cancer
  29. 29. Risk Analysis <ul><li>AGES (age, grade, extent, size) </li></ul><ul><li>AMES (age, metastases (distant), extent, size) </li></ul><ul><li>MACIS (metastasis, patient age, completeness of resection, local invasion, and tumor size) </li></ul>
  30. 30. AGES <ul><li>Hay ID, et al. 61 st American Thyroid Association Annual Meeting 1986 </li></ul>Papillary CA N= 860 Age= 0.5 x age Grade2 = 1 Grade3-4 =3 Extrathyroidal=1 E(distant)= 3 Size= 0.2 x cm
  31. 31. Hay ID, et al.
  32. 32. Surgical Management <ul><li>Wein, RO, Weber RS, Contemporary Management of Differentiated Thyroid Carcinoma. Otolaryngol Clin N Am 2005 </li></ul><ul><li>“ Surgery therapy for the majority of well-differentiated thyroid carcinomas should be tailored to the eradication of macroscopic disease while preserving the patient’s capacity for functional speech and swallowing and parathyroid preservation.” </li></ul>
  33. 33. Lobectomy vs. Total Thyroidectomy <ul><li>Shaha AR, Shah JP, Loree TR Ann Surg Oncol 1997 </li></ul><ul><li>Low risk patients need selective treatment </li></ul><ul><li>Retrospective review of 1038 patients, 465 patients in low risk group, 403 patients papillary and 62 patients follicular </li></ul><ul><li>Median follow-up 20 years. No statistical difference in overall failure rate or local recurrence rate between lobectomy vs. total thyroidectomy </li></ul>
  34. 34. Reasons for Total Thyroidectomy <ul><li>Hay ID et al. Surgery 1987 </li></ul><ul><li>Removes not only the primary tumor but also microscopic contralateral disease ~80% </li></ul><ul><li>Prevents local recurrence (5-24%) or anaplastic (<1%) transformation in the contralateral lobe </li></ul><ul><li>Decreased need for 2 nd operation with increased risk </li></ul><ul><li>Thyroglobulin surveillance for recurrence </li></ul><ul><li>Radioactive iodine scanning/therapy </li></ul>
  35. 35. Complications of Total Thyroidectomy <ul><li>Hypoparathyroidism ~ 10% </li></ul><ul><li>Recurrent laryngeal nerve paralysis ~1% </li></ul>
  36. 36. Sites of Invasive Spread <ul><li>McCaffrey, TV et al. Mayo Clinic, 50-year experience. Head Neck 1994 </li></ul>30% Other structures 12% Larynx 53% Strap musculature 47% Recurrent laryngeal nerve 21% Esophagus 37% Trachea
  37. 37. Surgical Considerations <ul><li>Tracheal involvement </li></ul><ul><li>- Window and sleeve resections </li></ul><ul><li>- Larger defects, sternocleidomastoid and pectoralis major myoperiosteal flaps over T-tubes </li></ul><ul><li>- Tracheal resection with re-anastomosis </li></ul>
  38. 38. Esophageal Invasion <ul><li>Tends to invade only the outer muscular layers </li></ul><ul><li>Limited resection without intraluminal entry is posssible </li></ul><ul><li>When intraluminal invasion encountered, primary closure vs. free tissue transfer for larger resections </li></ul>
  39. 39. Recurrent laryngeal nerve <ul><li>Falk SA, McCaffrey TV. Otolaryngol Head Neck Surg 1995 </li></ul><ul><li>Retrospectively compared patients and noted that complete resection of tumor and nerve sacrifice offered no survival benefit over potentially incomplete resection of tumor and nerve preservation </li></ul>
  40. 40. Laryngeal Involvement <ul><li>Vertical partial laryngectomy, unilateral disease </li></ul><ul><li>Supracricoid partial laryngectomy, extensive anterior invasion </li></ul><ul><li>Total laryngectomy, extensive laryngeal spread </li></ul>
  41. 41. Regional metastasis <ul><li>Intraglandular lymphatics </li></ul><ul><li>First nodal drainage paralaryngeal, paratracheal, prelaryngeal nodes VI </li></ul><ul><li>Second level of drainage II, III, IV, V </li></ul><ul><li>Elective neck dissection in setting of papillary CA will detect occult spread in 50% of patients; reported no added benefit on survival </li></ul>
  42. 42. Regional metastasis <ul><li>Radiologic imaging for regional spread include US, CT, and MRI </li></ul><ul><li>US- most accurate when combined with FNA, Serial tests can evaluate changes in nodal size </li></ul><ul><li>Imaging criteria for CT/MRI: recurrent disease, clinical lymph node metastases, vocal cord paralysis, fixation of mass to adjacent structures, symptoms of upper aerodigestive involvement </li></ul><ul><li>Type of neck dissection dictated by extent of disease </li></ul>
  43. 43. Neck dissection <ul><li>Ferlito A., Pellitteri PK, Robbins KT et al. Review article. Acta Otolaryngol 2002 </li></ul><ul><li>Selective dissection for extension of tumor noted, direct involvement of non-lymphatic structures </li></ul><ul><li>In high risk patients (male >45, with large 4cm cancer) recommend ipsilateral paratracheal node dissection given highest risk of containing metastases </li></ul><ul><li>Low risk, palpate region if no enlarged lymph nodes, elective neck dissection not carried out </li></ul>
  44. 44. Postoperative treatment <ul><li>Radioactive iodine ablation decreases the local recurrence and mortality rates in patients with stage 2 and stage 3 well-differentiated thyroid carcinoma </li></ul><ul><li>Use of postoperative RAI and thyroid hormone supression has been advocated for patients with tumors > 1.5 cm </li></ul>
  45. 45. Long term potential complications of Thyrotropin (TSH) Suppression <ul><li>Increased bone loss, particularly in postmenopausal women </li></ul><ul><li>Hyperthyroidism </li></ul><ul><li>Cardiac hypertrophy </li></ul><ul><li>Cardiac arrythmias </li></ul>
  46. 46. Radioactive Iodine Side Effects <ul><li>Radiation thyroiditis (when large remnant present), sialoadenitis, taste dysfunction, nausea </li></ul>
  47. 47. Postoperative Treatments <ul><li>Thyroglobulin levels in the absence of normal </li></ul><ul><li>thyroid tissue, is a sensitive and specific marker for the presence of thyroid cancer </li></ul><ul><li>Ideally this assay should be performed when the thyrotropin (TSH) level is elevated </li></ul><ul><li>Recombinant human TSH </li></ul><ul><li>Ongoing clinical surveillance </li></ul>
  48. 48. Postoperative followup Woodrum DT, Gauger PG Journal of Surgical Oncology 2005
  49. 49. Other Therapies <ul><li>Not first line therapy, external beam radiation may have a role in treatment of non-RAI avid tumors, gross residual tumor, or unresectable disease </li></ul><ul><li>Also clinical trials involving gene therapy and tumor redifferentiation research </li></ul>
  50. 50. Conclusions <ul><li>Strategy for Thyroid Nodules </li></ul><ul><li>Understanding prognosis- low, intermediate, high risk </li></ul><ul><li>Total Thyroidectomy and Radioiodine Ablation for High Risk </li></ul><ul><li>In the future, have more effective screening and therapies </li></ul>