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http://www.unisanet.unisa.edu.au/Resources/100074/Radiation%20Therapy/THYROID%20CANCER.ppt

http://www.unisanet.unisa.edu.au/Resources/100074/Radiation%20Therapy/THYROID%20CANCER.ppt

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THYCER THYCER Presentation Transcript

  • 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%
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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)
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • Treatment
    • Surgery
    • LND
    • Significance
    • PTC: ↓LRR not ↑OS
    • FTC: worse prognosis (uncommon)
    • Medullary: ↓LRR and ↑OS
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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)
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • Treatment
    • Adjuvant Therapy
    • RAI
    • Ablative RAI
    • All patients after TT/NTT, except
    • Young, female patients with occult solitary papillary carcinoma < 15mm
    • Partial thyroidectomy
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • Treatment
    • Adjuvant Therapy
    • RAI
    • Ablative RAI
    • CI
    • Patient refusal
    • Poor performance status
    • Uncooperative patient
    • Intractable urinary incontinence
    • Pregnancy
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER RADICAL EBRT
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • Follow-up
    • Radiological tests
    • CT neck/chest
    • MRI
    • U/S
    • WBBS
    • PET
    • Thyroid function tests
    • ensure adequate suppression of TSH
    • Recombinant thyrotopin
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • Persistent or Recurrent Disease
    • Restage (CT, RAI)
    • Maximal resection (LND, excision of LR)
    • Whole body iodine scan (diagnostic, test avidity)
    • Therapeutic RAI
    • EBRT
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER Well Differentiated Thyroid Carcinoma
    • 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
  • THYROID CANCER MEDULLARY CARCINOMA
    • Management
    • Surgery
    • TT
    • Central compartment LND
    • Ipsilateral LND
    • Calcitonin 8-12/52 postop
    • EBRT
    • CT (DTIC + 5-FU)
  • THYROID CANCER MEDULLARY CARCINOMA
    • 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