THYCER

THYROID CANCER Dr Martin Borg

THYROID CANCER ANATOMY

THYROID CANCER
Epidemiology
Rare (<1%)
0.5-10/10 5
Most common endocrine malignancy (90%)
Most common cause of death of EM
High survival rates

THYROID CANCER
Pathology
Follicular cell origin (FCDC)
Parafollicular (C cells) – medullary
FCDC
Papillary (and follicular variant – FVPTC) (most)
Follicular
Oxyphilic (Hurthle cell)
Anaplastic

THYROID CANCER
Controversies
No PRCT
Extent of primary surgical resection
Need for regional LND
Extent of regional LND
Role of postoperative RAI ablation
Dose of RAI ablation
Degree of suppression of TSH
Role of postoperative EBRT

THYROID CANCER
Diagnosis
History/examination (MEN, MTC FH)
Ultrasound-guided FNAB of clinical or radiologically detected mass
Thyroid/Neck ultrasound
Serum Ca 2+
CT scan neck/superior mediastinum/chest
ENT exam (vocal cords)
TG
(WBBS)

THYROID CANCER INVESTIGATIVE PROCEDURES

THYROID CANCER RADIONUCLIDE IMAGING

THYROID CANCER I-123 SCAN SHOWING COLD SPOT

THYROID CANCER STAGING CT SCAN MEDIASTINAL LN 2’

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)

THYROID CANCER Well Differentiated Thyroid Carcinoma
PTC – Classification
Minimal PTC
(a) T <1 cm
(b) no capsule invasion
(c) no 2’ (bone, lung)
(d) no LVI
MR 0.1%
RR 5%

PTC – Classification
High-risk PTC/FTC
AMES (age, 2’, T extent/size)
AGES (age, grade, T extent/size)
TNM (T, LN, 2’)
EORTC
MACIS (2’, age, resectibility, invasion, T)
Histology (Hurthle cell, tall cell, columnar variants)
Other
Delay in treatment
LVI – especially FTC
High grade (PTC/FTC)

Treatment
Surgery
Total ipsilateral thyroid lobectomy
Minimal PTC or min invasive FTC ± limited cap inv
Near total thyroidectomy
High-risk PTC
Bilateral cancer/nodules (papillary not follicular)
Preservation of parathyroid glands (relative RR)
Risks (<2%): (1) HPT
(2) recurrent laryngeal nerve injury

Treatment
Surgery
Advantages of NTT
PTC often multifocal
Lymphatic spread throughout gland
Facilitates ablative RAI
Facilitates detection of residual and distant tumour
Facilitates treatment of residual and distant tumour
TG more sensitive tumour marker
↓ RR and ↑DFS

Treatment
Surgery
LND
Risk at Δ in older adults (ipsilateral)
PTC: 40%
FTC: 10%
Hurthle: 25%
Extensive LN 2’ suggestive of follicular variant of PTC

Treatment
Surgery
LND
Significance
PTC: ↓LRR not ↑OS
FTC: worse prognosis (uncommon)
Medullary: ↓LRR and ↑OS

Treatment
Surgery
LND
Procedure
T > 15 mm: en bloc central cervical LND
Limited LN + (extra thyroid) or palpable LN: functional Cx/M LND (unilateral)
Extensive LN + (extra thyroid): radical Cx/M LND
(unilateral or bilateral, ± thymectomy)

Treatment
Adjuvant Therapy
TSH suppression
T4 commenced after ablative RAI
150-200 mcg/day (2mcg/kg)
Serum levels (a) HR: < 0.1 μ IU/mL
(b) LR: 0.1 – 0.4 μ IU/mL
No proven OS benefit/ ↓LR
Monitor cardiac function in elderly
Risks: accelerated bone turnover, OP, AF

Treatment
Adjuvant Therapy
RAI
Ablative RAI
All patients after TT/NTT, except
Young, female patients with occult solitary papillary carcinoma < 15mm
Partial thyroidectomy

Treatment
Adjuvant Therapy
RAI
Ablative RAI
Rationale
ablate residual thyroid tissue and adjacent microscopic CA
TG assay more specific
↓ 2’ CA
↑ TSH increases RAI uptake
Radionuclide scans more sensitive for tumour

Treatment
Adjuvant Therapy
RAI
Ablative RAI
CI
Patient refusal
Poor performance status
Uncooperative patient
Intractable urinary incontinence
Pregnancy

Treatment
Adjuvant Therapy
RAI
Ablative RAI
Preparation
6/52 postop
TG before RAI
Low iodine diet for 2/52
Pregnancy test and contraceptives
No replacement T3/4

Treatment
Adjuvant Therapy
RAI
Ablative RAI
Procedure
75-150 mCi (2,775-5,550 MBq) – controversial
Admit for 1-2 days (physicist check)
Urinary catheter if female (ovarian dose – 0.3 cGy/mCi)
NSAID/paracetamol or steroids for pain
Post-op precautions (in ward and at home)

THYROID CANCER POSTOP MANAGEMENT FLOW DIAGRAM

THYROID CANCER

Treatment
Adjuvant Therapy
RAI
Therapeutic RAI
150-200 mCi (5500-7000MBq)
Max 1500-2000 mCi (avoid > 1000 mCi)
Min 6/12 between RAI doses
Reduce dose if multiple lung 2’ (80 mCi retained dose)
Flare response, xerostomia, AML/bladder/breast, BM suppression, azospermia, menopause

Treatment
Adjuvant Therapy
RAI
Therapeutic RAI
Indications
Iodine avid recurrent disease
2’
Dexamethasone
cerebral, intra-orbital or intra-spinal 2’
Stridor
Reduce dose (80 mCi retained dose) if multiple lung 2’

THYROID CANCER RAI FOR LUNG METATSASES

Treatment
Adjuvant Therapy
EBRT
50.4 Gy @ 1.8 Gy/# in 28#
5-20 Gy boost to residual disease
Total dose limited by SC, other structures
Large AP field with small AP or PA mediastinal field
6-10 MV photons

INDICATIONS FOR EBRT RADICAL RT

Treatment
Adjuvant Therapy
EBRT
Target Volume
Thyroid and tumour/bed if
macroscopic residual, and
N-ve
JD, Submandibular, IJ, Sp Accessory, SCF, Sup Med (to carina) if
Residual or extensive N +, or
Non-iodine avid disease

THYROID CANCER RADICAL EBRT

Follow-up
TG if N- TG antibodies
Post-op
@ 4/12
6/12ly x 2years
Annually
RAI
Rising TG - restaging
Recurrent/metastatic disease – avidity
Surveillance if + TG AB

Follow-up
Radiological tests
CT neck/chest
MRI
U/S
WBBS
PET
Thyroid function tests
ensure adequate suppression of TSH
Recombinant thyrotopin

Persistent or Recurrent Disease
Restage (CT, RAI)
Maximal resection (LND, excision of LR)
Whole body iodine scan (diagnostic, test avidity)
Therapeutic RAI
EBRT

Metastases
Incurable but several years’ survival possible
Management varies with
Patient factors
Tumour factors (number and site/s of recurrence, local complications)
Iodine avidity
Prior treatment and its outcomes

Metastases
Surgery
Selected long-bone 2’ at risk of fracture
Isolated and solitary brain 2’
SC compression
Isolated lung 2’
Rapid progression of 1 pulmonary 2’
RT
Palliative doses for symptom control or to prevent complications

THYROID CANCER MEDULLARY CARCINOMA
6-8% of thyroid cancers
75% sporadic
25% hereditary
Neuroectodermal parafollicular C cells
Independent of TSH
Elevated serum calcitonin (level corresponds with stage)
FH and MEN screen (esp. pheochromocytoma)
Calcium deposits on U/S
Stage (CT/MRI/octreotide)
neck LN, bone, lung, liver

Management
Surgery
TT
Central compartment LND
Ipsilateral LND
Calcitonin 8-12/52 postop
EBRT
CT (DTIC + 5-FU)

Prognostic Features
T size
Preop calcitonin
Advanced age
Extrathyroid extension
LN 2’ in mediastinum
ENE
Incomplete excision
Histopathologic features
Type of syndrome in hereditary MTC

MEDULLARY THYROID CANCER

THYROID CANCER ANAPLASTIC THYROID CARCINOMA
1.6% of thyroid cancers
5 th -6 th decades
Rapidly expanding mass (> 5cm in 80%)
Short history and multiple local symptoms
ETE, LN 2’, VC palsy in 50% at Δ
2’ common (LN, lung)
Management controversial – almost 0% OS
Radical EBRT + CT (Adriamycin) if good PF

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THYCER

by Flavio Guzmán on Dec 05, 2009

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THYCER — Presentation Transcript