THYCER

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THYCER

  1. 1. THYROID CANCER Dr Martin Borg
  2. 2. THYROID CANCER ANATOMY
  3. 3. THYROID CANCER <ul><li>Epidemiology </li></ul><ul><li>Rare (<1%) </li></ul><ul><li>0.5-10/10 5 </li></ul><ul><li>Most common endocrine malignancy (90%) </li></ul><ul><li>Most common cause of death of EM </li></ul><ul><li>High survival rates </li></ul>
  4. 4. THYROID CANCER <ul><li>Pathology </li></ul><ul><li>Follicular cell origin (FCDC) </li></ul><ul><li>Parafollicular (C cells) – medullary </li></ul><ul><li>FCDC </li></ul><ul><li>Papillary (and follicular variant – FVPTC) (most) </li></ul><ul><li>Follicular </li></ul><ul><li>Oxyphilic (Hurthle cell) </li></ul><ul><li>Anaplastic </li></ul>
  5. 5. THYROID CANCER <ul><li>Controversies </li></ul><ul><li>No PRCT </li></ul><ul><li>Extent of primary surgical resection </li></ul><ul><li>Need for regional LND </li></ul><ul><li>Extent of regional LND </li></ul><ul><li>Role of postoperative RAI ablation </li></ul><ul><li>Dose of RAI ablation </li></ul><ul><li>Degree of suppression of TSH </li></ul><ul><li>Role of postoperative EBRT </li></ul>
  6. 6. THYROID CANCER <ul><li>Diagnosis </li></ul><ul><li>History/examination (MEN, MTC FH) </li></ul><ul><li>Ultrasound-guided FNAB of clinical or radiologically detected mass </li></ul><ul><li>Thyroid/Neck ultrasound </li></ul><ul><li>Serum Ca 2+ </li></ul><ul><li>CT scan neck/superior mediastinum/chest </li></ul><ul><li>ENT exam (vocal cords) </li></ul><ul><li>TG </li></ul><ul><li>(WBBS) </li></ul>
  7. 7. THYROID CANCER INVESTIGATIVE PROCEDURES
  8. 8. THYROID CANCER RADIONUCLIDE IMAGING
  9. 9. THYROID CANCER I-123 SCAN SHOWING COLD SPOT
  10. 10. THYROID CANCER STAGING CT SCAN MEDIASTINAL LN 2’
  11. 12. THYROID CANCER Any T1-3 N1b T4 M1 T1-3 N1b T4 M1 - IV - T3 T1-3 N1a T3 T1-3 N1a - III - T2 T2 M1 II - T1 T1 M0 I Any age Any age ≥ 45 yr <45 yr Stage Anaplastic Medullary Papillary/Follicular Postop TNM Staging System (UICC)
  12. 13. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>PTC – Classification </li></ul><ul><li>Minimal PTC </li></ul><ul><li>(a) T <1 cm </li></ul><ul><li>(b) no capsule invasion </li></ul><ul><li>(c) no 2’ (bone, lung) </li></ul><ul><li>(d) no LVI </li></ul><ul><li>MR 0.1% </li></ul><ul><li>RR 5% </li></ul>
  13. 14. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>PTC – Classification </li></ul><ul><li>High-risk PTC/FTC </li></ul><ul><li>AMES (age, 2’, T extent/size) </li></ul><ul><li>AGES (age, grade, T extent/size) </li></ul><ul><li>TNM (T, LN, 2’) </li></ul><ul><li>EORTC </li></ul><ul><li>MACIS (2’, age, resectibility, invasion, T) </li></ul><ul><li>Histology (Hurthle cell, tall cell, columnar variants) </li></ul><ul><li>Other </li></ul><ul><li>Delay in treatment </li></ul><ul><li>LVI – especially FTC </li></ul><ul><li>High grade (PTC/FTC) </li></ul>
  14. 15. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Surgery </li></ul><ul><li>Total ipsilateral thyroid lobectomy </li></ul><ul><li>Minimal PTC or min invasive FTC ± limited cap inv </li></ul><ul><li>Near total thyroidectomy </li></ul><ul><li>High-risk PTC </li></ul><ul><li>Bilateral cancer/nodules (papillary not follicular) </li></ul><ul><li>Preservation of parathyroid glands (relative RR) </li></ul><ul><li>Risks (<2%): (1) HPT </li></ul><ul><li> (2) recurrent laryngeal nerve injury </li></ul>
  15. 16. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Surgery </li></ul><ul><li>Advantages of NTT </li></ul><ul><li>PTC often multifocal </li></ul><ul><li>Lymphatic spread throughout gland </li></ul><ul><li>Facilitates ablative RAI </li></ul><ul><li>Facilitates detection of residual and distant tumour </li></ul><ul><li>Facilitates treatment of residual and distant tumour </li></ul><ul><li>TG more sensitive tumour marker </li></ul><ul><li>↓ RR and ↑DFS </li></ul>
  16. 17. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Surgery </li></ul><ul><li>LND </li></ul><ul><li>Risk at Δ in older adults (ipsilateral) </li></ul><ul><li>PTC: 40% </li></ul><ul><li>FTC: 10% </li></ul><ul><li>Hurthle: 25% </li></ul><ul><li>Extensive LN 2’ suggestive of follicular variant of PTC </li></ul>
  17. 18. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Surgery </li></ul><ul><li>LND </li></ul><ul><li>Significance </li></ul><ul><li>PTC: ↓LRR not ↑OS </li></ul><ul><li>FTC: worse prognosis (uncommon) </li></ul><ul><li>Medullary: ↓LRR and ↑OS </li></ul>
  18. 19. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Surgery </li></ul><ul><li>LND </li></ul><ul><li>Procedure </li></ul><ul><li>T > 15 mm: en bloc central cervical LND </li></ul><ul><li>Limited LN + (extra thyroid) or palpable LN: functional Cx/M LND (unilateral) </li></ul><ul><li>Extensive LN + (extra thyroid): radical Cx/M LND </li></ul><ul><li>(unilateral or bilateral, ± thymectomy) </li></ul>
  19. 20. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Adjuvant Therapy </li></ul><ul><li>TSH suppression </li></ul><ul><li>T4 commenced after ablative RAI </li></ul><ul><li>150-200 mcg/day (2mcg/kg) </li></ul><ul><li>Serum levels (a) HR: < 0.1 μ IU/mL </li></ul><ul><li> (b) LR: 0.1 – 0.4 μ IU/mL </li></ul><ul><li>No proven OS benefit/ ↓LR </li></ul><ul><li>Monitor cardiac function in elderly </li></ul><ul><li>Risks: accelerated bone turnover, OP, AF </li></ul>
  20. 21. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Adjuvant Therapy </li></ul><ul><li>RAI </li></ul><ul><li>Ablative RAI </li></ul><ul><li>All patients after TT/NTT, except </li></ul><ul><li>Young, female patients with occult solitary papillary carcinoma < 15mm </li></ul><ul><li>Partial thyroidectomy </li></ul>
  21. 22. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Adjuvant Therapy </li></ul><ul><li>RAI </li></ul><ul><li>Ablative RAI </li></ul><ul><li>Rationale </li></ul><ul><li>ablate residual thyroid tissue and adjacent microscopic CA </li></ul><ul><li>TG assay more specific </li></ul><ul><li>↓ 2’ CA </li></ul><ul><li>↑ TSH increases RAI uptake </li></ul><ul><li>Radionuclide scans more sensitive for tumour </li></ul>
  22. 23. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Adjuvant Therapy </li></ul><ul><li>RAI </li></ul><ul><li>Ablative RAI </li></ul><ul><li>CI </li></ul><ul><li>Patient refusal </li></ul><ul><li>Poor performance status </li></ul><ul><li>Uncooperative patient </li></ul><ul><li>Intractable urinary incontinence </li></ul><ul><li>Pregnancy </li></ul>
  23. 24. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Adjuvant Therapy </li></ul><ul><li>RAI </li></ul><ul><li>Ablative RAI </li></ul><ul><li>Preparation </li></ul><ul><li>6/52 postop </li></ul><ul><li>TG before RAI </li></ul><ul><li>Low iodine diet for 2/52 </li></ul><ul><li>Pregnancy test and contraceptives </li></ul><ul><li>No replacement T3/4 </li></ul>
  24. 25. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Adjuvant Therapy </li></ul><ul><li>RAI </li></ul><ul><li>Ablative RAI </li></ul><ul><li>Procedure </li></ul><ul><li>75-150 mCi (2,775-5,550 MBq) – controversial </li></ul><ul><li>Admit for 1-2 days (physicist check) </li></ul><ul><li>Urinary catheter if female (ovarian dose – 0.3 cGy/mCi) </li></ul><ul><li>NSAID/paracetamol or steroids for pain </li></ul><ul><li>Post-op precautions (in ward and at home) </li></ul>
  25. 26. THYROID CANCER POSTOP MANAGEMENT FLOW DIAGRAM
  26. 27. THYROID CANCER
  27. 28. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Adjuvant Therapy </li></ul><ul><li>RAI </li></ul><ul><li>Therapeutic RAI </li></ul><ul><li>150-200 mCi (5500-7000MBq) </li></ul><ul><li>Max 1500-2000 mCi (avoid > 1000 mCi) </li></ul><ul><li>Min 6/12 between RAI doses </li></ul><ul><li>Reduce dose if multiple lung 2’ (80 mCi retained dose) </li></ul><ul><li>Flare response, xerostomia, AML/bladder/breast, BM suppression, azospermia, menopause </li></ul>
  28. 29. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Adjuvant Therapy </li></ul><ul><li>RAI </li></ul><ul><li>Therapeutic RAI </li></ul><ul><li>Indications </li></ul><ul><li>Iodine avid recurrent disease </li></ul><ul><li>2’ </li></ul><ul><li>Dexamethasone </li></ul><ul><li>cerebral, intra-orbital or intra-spinal 2’ </li></ul><ul><li>Stridor </li></ul><ul><li>Reduce dose (80 mCi retained dose) if multiple lung 2’ </li></ul>
  29. 30. THYROID CANCER RAI FOR LUNG METATSASES
  30. 31. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Adjuvant Therapy </li></ul><ul><li>EBRT </li></ul><ul><li>50.4 Gy @ 1.8 Gy/# in 28# </li></ul><ul><li>5-20 Gy boost to residual disease </li></ul><ul><li>Total dose limited by SC, other structures </li></ul><ul><li>Large AP field with small AP or PA mediastinal field </li></ul><ul><li>6-10 MV photons </li></ul>
  31. 32. INDICATIONS FOR EBRT RADICAL RT
  32. 33. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Treatment </li></ul><ul><li>Adjuvant Therapy </li></ul><ul><li>EBRT </li></ul><ul><li>Target Volume </li></ul><ul><li>Thyroid and tumour/bed if </li></ul><ul><li>macroscopic residual, and </li></ul><ul><li>N-ve </li></ul><ul><li>JD, Submandibular, IJ, Sp Accessory, SCF, Sup Med (to carina) if </li></ul><ul><li>Residual or extensive N +, or </li></ul><ul><li>Non-iodine avid disease </li></ul>
  33. 34. THYROID CANCER RADICAL EBRT
  34. 35. THYROID CANCER RADICAL EBRT
  35. 36. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Follow-up </li></ul><ul><li>TG if N- TG antibodies </li></ul><ul><li>Post-op </li></ul><ul><li>@ 4/12 </li></ul><ul><li>6/12ly x 2years </li></ul><ul><li>Annually </li></ul><ul><li>RAI </li></ul><ul><li>Rising TG - restaging </li></ul><ul><li>Recurrent/metastatic disease – avidity </li></ul><ul><li>Surveillance if + TG AB </li></ul>
  36. 37. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Follow-up </li></ul><ul><li>Radiological tests </li></ul><ul><li>CT neck/chest </li></ul><ul><li>MRI </li></ul><ul><li>U/S </li></ul><ul><li>WBBS </li></ul><ul><li>PET </li></ul><ul><li>Thyroid function tests </li></ul><ul><li>ensure adequate suppression of TSH </li></ul><ul><li>Recombinant thyrotopin </li></ul>
  37. 38. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Persistent or Recurrent Disease </li></ul><ul><li>Restage (CT, RAI) </li></ul><ul><li>Maximal resection (LND, excision of LR) </li></ul><ul><li>Whole body iodine scan (diagnostic, test avidity) </li></ul><ul><li>Therapeutic RAI </li></ul><ul><li>EBRT </li></ul>
  38. 39. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Metastases </li></ul><ul><li>Incurable but several years’ survival possible </li></ul><ul><li>Management varies with </li></ul><ul><li>Patient factors </li></ul><ul><li>Tumour factors (number and site/s of recurrence, local complications) </li></ul><ul><li>Iodine avidity </li></ul><ul><li>Prior treatment and its outcomes </li></ul>
  39. 40. THYROID CANCER Well Differentiated Thyroid Carcinoma <ul><li>Metastases </li></ul><ul><li>Surgery </li></ul><ul><li>Selected long-bone 2’ at risk of fracture </li></ul><ul><li>Isolated and solitary brain 2’ </li></ul><ul><li>SC compression </li></ul><ul><li>Isolated lung 2’ </li></ul><ul><li>Rapid progression of 1 pulmonary 2’ </li></ul><ul><li>RT </li></ul><ul><li>Palliative doses for symptom control or to prevent complications </li></ul>
  40. 41. THYROID CANCER MEDULLARY CARCINOMA <ul><li>6-8% of thyroid cancers </li></ul><ul><li>75% sporadic </li></ul><ul><li>25% hereditary </li></ul><ul><li>Neuroectodermal parafollicular C cells </li></ul><ul><li>Independent of TSH </li></ul><ul><li>Elevated serum calcitonin (level corresponds with stage) </li></ul><ul><li>FH and MEN screen (esp. pheochromocytoma) </li></ul><ul><li>Calcium deposits on U/S </li></ul><ul><li>Stage (CT/MRI/octreotide) </li></ul><ul><li>neck LN, bone, lung, liver </li></ul>
  41. 42. THYROID CANCER MEDULLARY CARCINOMA <ul><li>Management </li></ul><ul><li>Surgery </li></ul><ul><li>TT </li></ul><ul><li>Central compartment LND </li></ul><ul><li>Ipsilateral LND </li></ul><ul><li>Calcitonin 8-12/52 postop </li></ul><ul><li>EBRT </li></ul><ul><li>CT (DTIC + 5-FU) </li></ul>
  42. 43. THYROID CANCER MEDULLARY CARCINOMA <ul><li>Prognostic Features </li></ul><ul><li>T size </li></ul><ul><li>Preop calcitonin </li></ul><ul><li>Advanced age </li></ul><ul><li>Extrathyroid extension </li></ul><ul><li>LN 2’ in mediastinum </li></ul><ul><li>ENE </li></ul><ul><li>Incomplete excision </li></ul><ul><li>Histopathologic features </li></ul><ul><li>Type of syndrome in hereditary MTC </li></ul>
  43. 44. MEDULLARY THYROID CANCER
  44. 45. THYROID CANCER ANAPLASTIC THYROID CARCINOMA <ul><li>1.6% of thyroid cancers </li></ul><ul><li>5 th -6 th decades </li></ul><ul><li>Rapidly expanding mass (> 5cm in 80%) </li></ul><ul><li>Short history and multiple local symptoms </li></ul><ul><li>ETE, LN 2’, VC palsy in 50% at Δ </li></ul><ul><li>2’ common (LN, lung) </li></ul><ul><li>Management controversial – almost 0% OS </li></ul><ul><li>Radical EBRT + CT (Adriamycin) if good PF </li></ul>

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