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What Operation for Thyroid Cancer

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What Operation for Thyroid Cancer What Operation for Thyroid Cancer Presentation Transcript

  • 12 th G. Rainey Williams Surgical Symposium What Operation for Thyroid Cancer? Ronald Squires, MD FACS Associate Professor of Surgery Sections of General and Transplant Surgery University of Oklahoma Health Science Center
  • TOTAL THYROIDECTOMY
  • Questions?
  • Introduction
    • First reports of thyroidectomy from School of Salerno in Italy in 1170
    • Johann Dieffenbach of Berlin in 1848 stated that thyroidectomy was “one of the most thankless and most perilous undertakings” in surgery
    • Outcomes were so poor that the French Academy of Medicine banned its practice in 1850
    • Billroth performed 59 thyroidectomies from 1861-1867 with a 40% mortality—a later series from 1877-1881 reported 16 thyroidectomies with 100% survival
    • Theodore Kocher won the Nobel prize in medicine in 1909 for his contributions to thyroid surgery including many of the techniques still used by modern day thyroid surgeons
    • Halsted first to advocate and popularize subtotal thyroidectomy to preserve parathyroids and protect recurrent laryngeal nerves
  • Thyroid Cancers
    • Differentiated cancers
      • Papillary carcinoma
      • Mixed papillary/follicular carcinoma
      • Follicular carcinoma
      • H ü rthle cell
    • Medullary carcinoma
    • Anaplastic carcinoma
    • Lymphoma of thyroid
  • Thyroid Cancers
    • Differentiated cancers
      • Papillary carcinoma
      • Mixed papillary/follicular carcinoma
      • Follicular carcinoma
      • H ü rthle cell
    • Medullary carcinoma
  • Thyroid Nodule Workup
    • 50% of population over 50 years have an US detectable thyroid nodule
    • Prevalence of nonpalpable clinically significant (1-1.5cm) nodes is 2-3%
    • 90% of all nodules reflect benign disease
    • Of the 10% of malignant nodules, 75% are papillary and 15% are follicular
  • Thyroid Nodule Workup
    • Check TSH level
      • If high, begin thyroid replacement until euthyroid
      • If low, nuclear scan to check for hyperfunctioning nodule (very rarely malignant)
    • FNA with or without US guidance when euthyroid
    • Nodules greater than 1cm in two dimensions are clinically significant
    • 16% of patients with palpable nodules will have no nodule visible by US and the vast majority will be diagnosed with Hashimoto’s thyroiditis
    • In multinodular goiter, masses > 1cm should be biopsied (5-13% risk of cancer in these larger lesions)
  • Thyroid Nodule Workup
    • FNA results should be limited
      • Benign goiter
      • Malignancy
      • Follicular neoplasm
      • Nondiagnostic sample
    • Diagnostic accuracy
      • Sensitivity > 92%
      • Specificity 91-98%
  • Thyroid Nodule Workup
    • Benign diagnosis
      • Reultrasound in 6 months
        • If same or smaller, follow yearly
        • If larger, (15% increase in size in two dimensions) then repeat FNA
    • Indeterminate diagnosis
      • Repeat FNA in 3 months or consider using US guidance if not previously used
    • Follicular cytology (80% benign disease)
      • Thyroid scan (if “hot” nodule in euthyroid patient then observe)
      • All cold nodules and hot nodules in hyperthyroid patients should be removed
  • The Science
    • All recommendations are based on retrospective series or multivariate analysis
    • Mathematical models are also utilized to extrapolate data to existing populations
    • The incidence of thyroid carcinoma is 11,000 cases per year in the US with 1,100 deaths
    • Given the good overall survival, a prospective study would need at least 12,000 patients followed for a minimum of 20 years to distinguish subtle therapeutic differences
  • Arguments for Total Thyroidectomy
    • Radioactive iodine may be used to detect and treat residual normal thyroid tissue and local or distant metastases
    • Serum thyroglobulin level is a more sensitive marker for persistent or recurrent disease when all normal thyroid tissue is removed
    • In up to 85% of papillary cancer, microscopic foci are present in the contralateral lobe. Total thyroidectomy removes these possible sites of recurrence
    • Recurrence develops in 7% of contralateral lobes (1/3 die)
    • Risk (though very low [1%]) of dedifferentiation into anaplastic thyroid cancer is reduced
    • Survival is improved if papillary cancer greater than 1.5cm or follicular greater than 1cm
    • Need for reoperative surgery associated with higher risk is lower
  • Arguments against total thyroidectomy
    • Total thyroidectomy may be associated with higher complication rate than lobectomy
    • 50% of recurrences can be controlled with surgery
    • Fewer than 5% of recurrences occur in the thyroid bed
    • Tumor multicentricity has little clinical significance
    • Prognosis of low risk patients (age, grade, extent, size) is excellent regardless of extent of resection
  • Complications
    • Hypoparathyroidism should occur in less than 2% of patients
    • Recurrent laryngeal nerve injury in virgin neck less than 0.5% of patients
    • Superior laryngeal nerve injury in virgin neck less than 2% of patients
  • Papillary Carcinoma Algorithm for Treatment of Possible PTC
  • Papillary Carcinoma
    • If FNA is suspicious for papillary ca but not diagnostic then incidence is 54% cancer
    • Presence of microcalcifications on FNA suggestive of papillary ca (36% sensitivity, 93% specificity, 76% accuracy)
    • Pts with confirmed or highly suspicious intraoperative finding should receive total or near total thyroidectomy (< 3 gm remnant)
    • Prophylactic node dissection not indicated
  • Papillary/Differentiated Carcinoma
    • Up to 80% of patients found to have asymptomatic positive nodes during series of prophylactic neck dissections 1,2
    • Clinically significant disease only develops in less than 10% of patients with microscopic lymph node metastases 1,3,4
    • Central node dissection should be carried out if central nodes are enlarged and positive by frozen section
    • Ipsilateral modified neck dissection has been shown to reduce regional recurrence without improving survival if enlarged cervical node is positive by preop FNA or intraoperative frozen 5
    Node Dissection: 1 Am J Surg 122:464-471,1971 2 World J Surg 18:359-367,1994. 3 Surg Clin North Am 67:251-261,1987. 4 Cancer 26:1053-1060, 1970 5 Textbook of Endocrine Surgery, WB Saunders, 1997, p90.
  • Follicular Neoplasms
    • 14-29% are invasive cancer
    • Frozen section analysis can be misleading
    • Hallmarks of cancer are capsular or vascular invasion
    • Follicular CA more likely hematogenous spread
    • Worse prognosis associated with increased age and stage at diagnosis compared to papillary
    • >4cm nodule is 50-60% likely invasive disease
  • Follicular Neoplasms
    • Resection of lobe/isthmus with careful examination for gross invasion or nodal disease
    • Await final pathology of lobe/isthmus and if positive, return to OR for completion lobectomy
    • Subsequent I 131 treatment, TSH suppression and monitoring of thyroglobulin (<2 µ g/l)
  • H ü rthle Cell Neoplasms
    • More aggressive than other differentiated thyroid carcinomas (higher mets/lower survival rates)
    • Decreased affinity for I 131
    • Need to differentiate from benign/malignant
    • Cancer in 13-35% of H ü rthle cell FNAs
    • 65% of tumors > 4cm are malignant
    • If malignant, needs total thyroidectomy and I 131 with thyroglobulin assays
    • Mets may be more sensitive to I 131 than primary
  • Medullary Carcinoma
    • Presents as either an inherited syndrome (20%) or as an incidental event
    • More aggressive than the differentiated thyroid cancers
    • Does not respond to I 131
    • Multicentric in 20% of sporadic cases and in almost all of inherited cases
    • Much more likely to invade lateral lymph basins
    • Need baseline CEA and calcitonin levels
  • Medullary Carcinoma
    • Familial cases positive for RET proto-oncogene mutation
    • If positive family history, then genetic testing
    • If MEN IIA or FMTC then total thyroidectomy and central lymph node dissection between ages of 5-6 years
    • If MEN IIB then total thyroidectomy and central node dissection ages 6mos - 3 years
    • SURGERY IS ONLY EFFECTIVE THERAPY
  • Medullary Carcinoma
    • If persistent elevated CEA or calcitonin, CT scan for residual disease (50% of pts)
    • Aggressive neck dissection advocated by many if persistent disease
    • Consider laparotomy for possible liver mets
    • Prolonged survival with significant symptoms not uncommon with widely metastatic disease
  • Medullary Carcinoma
  • Incidentaloma/Micrometastatic Disease
    • Lesions detected by imaging or found after surgery for unrelated indication
    • Thyroid nodules common in population (4-10% have palpable nodules any given time)
    • Female/male incidence 6.4 / 1.6%
    • 12% detected by palpation vs. 45% by imaging
    • Lesions less than 1 cm-observe
    • Lesions 1-2cm “gray zone”
    • Lesions > 2cm are NOT INCIDENTAL
  • Incidentaloma/Micrometastatic Disease
    • Consider suspicious features:
      • Increased vascularity
      • Irregular margin
      • Central microcalcification
      • Cervical adenopathy
  • Incidentaloma/Micrometastatic Disease
  • Local Invasion of the Neck Tracheal resection repaired primarily
  • Local Invasion of the Neck Crycoid invasion with local muscle flap reconstruction
  • Local Invasion of the Neck Vertical hemilaryngectomy
  • Local Invasion of the Neck Circumferential tracheal resection with primary anastomosis
  • Summary
    • Total thyroidectomy is surgery of choice for differentiated cancer as well as medullary carcinoma of thyroid
    • Consider subtotal (less than 2gms residual tissue) if less experienced or hazardous operative environment
    • No therapeutic advantage for total thyroidectomy in setting of papillary microcarcinoma
  • Questions