Thyroid Disease


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Thyroid Disease

  1. 1. Thyroid Cancer May 10, 2006
  2. 2. Thyroid Cancer <ul><li>Accounts for 1.5% of all cancers in the US </li></ul><ul><li>Most common endocrine malignancy (95%) </li></ul><ul><li>22,000 cases per year and estimated 500 – 1000 patients die annually </li></ul><ul><li>90% of thyroid cancer cases have favorable prognosis </li></ul>
  3. 3. Classification & Incidence of Thyroid Cancer <ul><li>Follicular cell origin </li></ul><ul><li>Differentiated </li></ul><ul><ul><li>Papillary 80% </li></ul></ul><ul><ul><li>Follicular 10% </li></ul></ul><ul><ul><li>Hurthle cell 3-5% </li></ul></ul><ul><li>Undifferentiated </li></ul><ul><ul><li>Anaplastic 1-2% </li></ul></ul><ul><li>Parafollicular cell origin </li></ul><ul><li> – Medullary 5% </li></ul>
  4. 4. Papillary Carcinoma <ul><li>Accounts for 90% radiation induced cancer </li></ul><ul><li>Classified as microcarcinoma, intrathyroidal, and extrathyroidal </li></ul><ul><ul><li>Histologic variants: tall-cell, clear-cell, columnar, diffuse sclerosing </li></ul></ul><ul><li>Multicentric in 30-50% of tumors </li></ul><ul><li>Spreads via lymphatics with propensity for mid- and lower-anterior cervical chain (Level VI) </li></ul><ul><li>20-50% patients have involvement of cervical LN </li></ul>
  5. 5. Follicular Carcinoma <ul><li>Only 10% of thyroid cancers in developed countries, although more prevalent in regions with iodine deficiency </li></ul><ul><li>Diagnosis depends on demonstration of vascular or capsular invasion </li></ul><ul><li>Classified as minimally or widely invasive </li></ul><ul><ul><li>Vascular invasion tends to have a more aggressive course than capsular invasion </li></ul></ul><ul><li>Uncommon to have multicentric disease </li></ul><ul><li>Hematogenous spread </li></ul>
  6. 6. Follicular Carcinoma <ul><li>Where does follicular carcinoma tend to metastasize? </li></ul><ul><li>Bone </li></ul><ul><li>Lung </li></ul>
  7. 7. Hurthle Cell Carcinoma <ul><li>High propensity to spread to cervical lymph nodes and high incidence of distant metastasis </li></ul><ul><li>Less than 10% of Hurthle cell carcinomas take up radioiodine </li></ul><ul><li>High tumor recurrence rate </li></ul><ul><li>High mortality rate – 30% mortality at 10 years </li></ul>
  8. 8. Anaplastic Carcinoma <ul><li>Increasingly rare </li></ul><ul><li>Arise within differentiated cancers </li></ul><ul><li>Pts > 60 years old with rapidly expanding neck mass </li></ul><ul><li>Local invasion very common at time of dx (FNA) </li></ul><ul><li>Surgery plays limited role given advanced stage at dx </li></ul><ul><li>Radiation and chemotherapy have not demonstrated any significant improvement in survival </li></ul><ul><li>Median survival ~ 4 - 6 months </li></ul>
  9. 9. Medullary Thyroid Carcinoma <ul><li>Originates from the parafollicular C cells </li></ul><ul><li>Elevation in calcitonin and CEA (50%) </li></ul><ul><li>80% have sporadic MTC (unifocal), remainder have genetic component </li></ul><ul><li>75% patients have LN metastasis at time of dx, 20% distant mets </li></ul>
  10. 10. Medullary Thyroid Carcinoma <ul><li>MEN IIA  </li></ul><ul><ul><li>MTC (100%), pheo (40%), hyperparathyroidism (35%) </li></ul></ul><ul><ul><li>AD inheritance </li></ul></ul><ul><ul><li>Missense mutation of extracellular cysteine of RET </li></ul></ul><ul><ul><li>Surgery recommended before 6 years of age </li></ul></ul><ul><li>MEN IIB  </li></ul><ul><ul><li>MTC (100%), pheo (50%), mucosal ganglioneuromas (100%), marfanoid habitus </li></ul></ul><ul><ul><li>AD inheritance </li></ul></ul><ul><ul><li>Missense mutation of tyrosine kinase domain of RET </li></ul></ul><ul><ul><li>Surgery recommended in infancy </li></ul></ul><ul><li>Familial MTC </li></ul>
  11. 11. Lymphoma of the Thyroid <ul><li>Usually non-Hodgkin’s B cell type </li></ul><ul><li>Pts with Hashimoto’s thyroiditis have 70-80 fold increase risk </li></ul><ul><li>Typically women > 70yo present with enlarging neck mass </li></ul><ul><li>FNA > 80% accuracy </li></ul><ul><li>Treatment includes XRT and chemotherapy </li></ul><ul><li>5 year survival rates 50-70% </li></ul>
  12. 12. 45 year old female presents to your office with a thyroid nodule. What questions will you ask her?
  13. 13. History <ul><li>Characteristics of nodule </li></ul><ul><li>Is the patient symptomatic? </li></ul><ul><ul><li>Hyperthyroid/Hypothyroid </li></ul></ul><ul><ul><li>Compressive sxs </li></ul></ul><ul><li>Family history  MEN endocrinopathies </li></ul><ul><li>Radiation exposure </li></ul>
  14. 14. 45 year old female with thyroid nodule <ul><li>Characteristics of nodule  found incidentally by PCP </li></ul><ul><li>Is the patient symptomatic?  No </li></ul><ul><ul><li>Hyperthyroid/Hypothyroid </li></ul></ul><ul><ul><li>Compressive sxs </li></ul></ul><ul><li>Family history  None </li></ul><ul><li>Radiation exposure  None </li></ul>
  15. 15. Physical Exam <ul><li>Size </li></ul><ul><li>Consistency of nodule, multiple or solitary </li></ul><ul><li>Fixed or mobile </li></ul><ul><li>Presence of cervical LAD </li></ul>
  16. 16. Physical Exam <ul><li>Solitary nodule </li></ul><ul><li>Mobile, not obviously adherent to adjacent structures </li></ul><ul><li>No cervical LAD </li></ul><ul><li>Normal voice </li></ul><ul><li>Otherwise well appearing </li></ul>
  17. 17. Evaluating a thyroid nodule <ul><li>Thyroid nodules are common, but less than 10% are malignant </li></ul><ul><li>History and PE </li></ul><ul><li>TSH level should be obtained during initial evaluation </li></ul><ul><ul><li>If low, radioisotope study </li></ul></ul><ul><ul><li>If normal or high, then proceed to ultrasound </li></ul></ul>
  18. 18. Evaluating a thyroid nodule <ul><li>What is the risk of a “hot” nodule on radioiodine scan being malignant? </li></ul><ul><li>Less than 1% </li></ul><ul><li>What about a “cold” nodule? </li></ul><ul><li>15% – 20% </li></ul>
  19. 19. Evaluating a thyroid nodule <ul><li>Radioisotope studies may also be useful: </li></ul><ul><ul><li>FNA reports “suspicious for follicular neoplasm” or “indeterminate” </li></ul></ul><ul><ul><li>Detecting neck metastasis </li></ul></ul>
  20. 20. Evaluating a thyroid nodule <ul><li>What information will an ultrasound provide? </li></ul><ul><ul><li>Number of nodules </li></ul></ul><ul><ul><li>Location and size of nodules </li></ul></ul><ul><ul><li>Cystic versus solid </li></ul></ul>
  21. 21. Evaluating a thyroid nodule <ul><li>Which of the following are concerning findings on ultrasound? </li></ul><ul><ul><li>Halo sign </li></ul></ul><ul><ul><li>Hypoechogenic </li></ul></ul><ul><ul><li>Calcifications </li></ul></ul><ul><ul><li>< 1cm </li></ul></ul>
  22. 22. Evaluating a thyroid nodule <ul><li>Which of the following are concerning findings on ultrasound? </li></ul><ul><ul><li>Halo sign </li></ul></ul><ul><ul><li>Hypoechogenic </li></ul></ul><ul><ul><li>Calcifications </li></ul></ul><ul><ul><li>< 1cm </li></ul></ul>
  23. 23. Evaluating a thyroid nodule <ul><li>FNA is the most reliable and cost efficient way to determine malignant from benign lesion </li></ul><ul><li>4 categories: </li></ul><ul><ul><li>Malignant, benign, suspicious, indeterminate </li></ul></ul><ul><li>Limitation of FNA: </li></ul><ul><ul><li>Cannot distinguish benign follicular or Hurthle cell adenoma from malignancy – based upon presence or absence of capsular or vascular invasion </li></ul></ul><ul><li>False negative rate < 5% </li></ul>
  24. 24. 45 year old female with thyroid nodule <ul><li>TSH level was normal </li></ul><ul><li>Underwent an ultrasound-guided FNA of the nodule, pathology revealed papillary carcinoma in a nodule measuring 2.5cm </li></ul>
  25. 25. Management of Papillary Carcinoma <ul><li>What surgical procedure would you offer her? </li></ul><ul><li>Near-total or total thyroidectomy is recommended if: </li></ul><ul><ul><li>Tumor > 1-1.5cm </li></ul></ul><ul><ul><li>Contralateral nodules </li></ul></ul><ul><ul><li>Local or regional metastasis </li></ul></ul><ul><ul><li>+ FHx in 1 st degree relative </li></ul></ul><ul><ul><li>+ history of radiation exposure </li></ul></ul><ul><ul><li>Age >45 yo </li></ul></ul><ul><li>Increased extent of surgery lowers recurrence rates and has improved survival in high-risk patients </li></ul>
  26. 26. Management of Papillary Cancer <ul><li>When is lobectomy an acceptable surgical procedure for FNA proven papillary cancer? </li></ul><ul><li>According to the American Thyroid Association Guidelines Taskforce, lobectomy with isthmusectomy may be sufficient treatment for microcarcinoma (  1cm), low-risk patients, intrathyroidal cancer without involvement of cervical LN </li></ul>
  27. 27. Management of Papillary Cancer <ul><li>Will you plan on performing a lymph node dissection? </li></ul><ul><li>A central compartment (Level VI) neck dissection should be considered </li></ul><ul><li>If nodal disease is evident clinically then a more extensive cervical lymphadenectomy should be performed </li></ul><ul><li>LN sampling not recommended </li></ul>
  28. 28. Surgical Anatomy: Lymphatics
  29. 29. Surgical Anatomy: Lymphatics <ul><li>What are the LNs located superior to the thryoid gland in the midline called? </li></ul><ul><li>Delphian nodes </li></ul>
  30. 30. 45 year old female with papillary carcinoma <ul><li>Patient opted to have a total thyroidectomy and surgical specimen demonstrated unifocal disease with capsular invasion and negative LN. Does she have a favorable or unfavorable prognosis? </li></ul>
  31. 31. Prognostic Risk Classification for Patients with Well-Differentiated Thyroid Cancer (AMES or AGES) <ul><li>Low Risk High Risk </li></ul><ul><li>Age <40 years >40 years </li></ul><ul><li>Sex Female Male </li></ul><ul><li>Extent No local extension, Capsular invasion, extra- </li></ul><ul><li>intrathyroid, no caps thyroidal extension </li></ul><ul><li>invasion </li></ul><ul><li>Metastasis None Regional/distant </li></ul><ul><li>Size <2 cm >4 cm </li></ul><ul><li>Grade Well diff Poorly diff </li></ul>
  32. 32. Management of Papillary Cancer <ul><li>What further treatment is recommended? </li></ul><ul><li>TSH suppression therapy </li></ul><ul><li>Radioiodine ablation therapy </li></ul>
  33. 33. 45 year old female with papillary carcinoma <ul><li>She wants to know what her long-term survival is. What will you tell her? </li></ul><ul><li>~ 90% at 10 years for papillary carcinoma </li></ul>
  34. 34. 45 year old female with thyroid nodule <ul><li>TSH level was normal </li></ul><ul><li>Underwent an ultrasound-guided FNA of the nodule, pathology suspicious for a follicular neoplasm </li></ul><ul><li>What is the risk that this is malignant? </li></ul><ul><li>Approximately 20% </li></ul><ul><li>What surgical procedure will you offer her? </li></ul>
  35. 35. Management of FNA suspicious for follicular neoplasm <ul><li>Lobectomy would be a reasonable surgical procedure, particularly in low-risk patient who prefers limited surgical intervention </li></ul><ul><li>Near-total or total thyroidectomy still recommended for high-risk patient and/or large tumor size </li></ul>
  36. 36. Management of FNA suspicious for follicular neoplasm <ul><li>Intra-operative frozen sections can be helpful in this scenario? True or false </li></ul><ul><li>False </li></ul>
  37. 37. 45 year old female with thyroid nodule <ul><li>You performed a lobectomy and the final pathology reveals Hurthle cell carcinoma </li></ul><ul><li>What further treatment do you recommend? </li></ul><ul><li>Completion thyroidectomy with central compartment LN dissection </li></ul><ul><li>TSH suppression therapy </li></ul>
  38. 38. Post-operative radioiodine remnant ablation <ul><li>To whom should it be offered? </li></ul><ul><li>Stages III and IV disease </li></ul><ul><li>Stage II disease in pts under age 45 </li></ul><ul><li>Selected pts with Stage I </li></ul><ul><ul><li>Multifocal disease </li></ul></ul><ul><ul><li>Nodal metastasis </li></ul></ul><ul><ul><li>Extrathyroidal extension </li></ul></ul><ul><ul><li>Vascular invasion </li></ul></ul><ul><ul><li>Aggressive histology </li></ul></ul>
  39. 39. TMN Classification for differentiated thyroid cancer <ul><li>T1  2cm </li></ul><ul><li>T2 2-4cm </li></ul><ul><li>T3 >4cm, limited to thyroid </li></ul><ul><li>T4a Any size, invasion of SQ, trachea, esophagus, RLN </li></ul><ul><li>T4b Any size invasion of prevertebral fascia or encasing carotid/mediastinal vessels </li></ul><ul><li>N0 no nodes </li></ul><ul><li>N1a Level VI </li></ul><ul><li>N1b All other levels </li></ul><ul><li>Stages </li></ul><ul><li>Stage I T1, N0, M0 </li></ul><ul><li>Stage II T2, N0, M0 </li></ul><ul><li>Stage III T3, N0, M0 </li></ul><ul><li> T1-3, N1a, M0 </li></ul><ul><li>Stage IVA T4a, N0, M0 </li></ul><ul><li> T4a, N1a, M0 </li></ul><ul><li> T1-3, N1b, M0 </li></ul><ul><li>Stage IVB T4b, any N, M0 </li></ul><ul><li>Stage IVC Any T and N, M1 </li></ul>
  40. 40. 45 year old female with thyroid nodule <ul><li>She asks what her overall 10 year survival will be with her diagnosis of Hurthle cell carcinoma? </li></ul><ul><li>~70% </li></ul><ul><li>What if she had follicular carcinoma? </li></ul><ul><li>~70% </li></ul>
  41. 41. Recommendations for follow-up (differentiated cancers) <ul><li>Thyroid cancer recurs in 20-40% patients, most commonly within the first 2 years </li></ul><ul><li>Thyroglobulin used as tumor marker checked every 6-12 months </li></ul><ul><li>Whole body scan may be useful in intermediate and high-risk patients 6-12 months after ablation </li></ul><ul><li>Ultrasound should be done 6-12 months after surgery, then annually for the next 3-5 years </li></ul>
  42. 42. Management of recurrent and metastatic disease <ul><li>Surgery mainstay of treatment for locoregional disease  radioiodine  radiation </li></ul><ul><li>Metastatic disease treated with radioiodine </li></ul><ul><ul><li>Older patients with bony mets are less likely to respond to radioiodine and have poor prognosis </li></ul></ul><ul><ul><li>Pulm mets more radio responsive than bone mets </li></ul></ul>
  43. 43. 55 year old male presents to your office with MTC on FNA <ul><li>Palpable thyroid nodule and cervical LN </li></ul><ul><li>Diarrhea and flushing </li></ul><ul><li>No FHx of MEN endocrinopathies </li></ul><ul><li>Calcitonin elevated, FNA reveals MTC </li></ul><ul><li>Any further tests that you should order? </li></ul><ul><li>Genetic testing </li></ul><ul><li>CT scan to see extent of disease </li></ul>
  44. 44. 55 year old male presents to your office with MTC on FNA <ul><li>What surgical procedure will you recommend to him? </li></ul><ul><li>Total thyroidectomy with LN dissection in Level VI and LN sampling in lateral regions (frozen sectioning intra-operatively) </li></ul>
  45. 45. 55 year old male presents to your office with MTC on FNA <ul><li>What do you want to check for before bringing him into the operating room? </li></ul><ul><li>Presence of a pheochromocytoma </li></ul>
  46. 46. 55 year old male presents to your office with MTC on FNA <ul><li>How would you handle the parathyroid glands? </li></ul><ul><li>Some recommend performing a total parathyroidectomy with autotransplantation in either the forearm or SCM </li></ul>
  47. 47. 55 year old male presents to your office with MTC on FNA <ul><li>Further treatment remains controversial but includes radiation therapy and chemotherapy </li></ul><ul><li>Surveillance using calcitonin levels </li></ul>
  48. 48. Surgical Anatomy: Vasculature
  49. 49. Surgical Anatomy: Vasculature and nerves
  50. 50. Surgical Anatomy <ul><li>What is the consequence of injurying the external branch of the superior laryngeal nerve? </li></ul><ul><li>Injury results in paralysis of the cricothyroid muscle </li></ul>
  51. 51. Surgical Anatomy: Anatomical variations of the Right RLN
  52. 52. Surgical Anatomy <ul><li>What is the result of an injury to the recurrent laryngeal nerve? </li></ul><ul><ul><li>Ipsilateral paralysis </li></ul></ul><ul><ul><li>Contralateral paralysis </li></ul></ul>
  53. 53. Surgical Anatomy <ul><li>What is the result of an injury to the recurrent laryngeal nerve? </li></ul><ul><ul><li>Ipsilateral paralysis </li></ul></ul><ul><ul><li>Contralateral paralysis </li></ul></ul>
  54. 54. Surgical Anatomy <ul><li>What would you do if the tumor involved the RLN? </li></ul><ul><li>If vocal cord is paralyzed pre-operatively, then consider resecting the RLN along with specimen </li></ul><ul><li>If no vocal cord paralysis, dissect tumor off nerve </li></ul>
  55. 55. Surgical Anatomy: The Parathyroids
  56. 56. Surgical Anatomy: The Parathyroids <ul><li>What are your options if the blood supply to the parathyroids has been compromised? </li></ul><ul><li>Implantation within the sternocleidomastoid muscle or forearm muscle for easy access </li></ul>