09 01 05 Entgr Management Of Well Differentiated Thyroid Cancer

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