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Tiroide: chi decide quale intervento e per chi?

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Presentazione a cura del Dottor Bellotti Carlo - "Incontri endocrinologici AME LAzio - L'endocrinologia nel SSN: prospettive e nuove problematiche" - Roma 17/12/2018

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Tiroide: chi decide quale intervento e per chi?

  1. 1.  Prof. Carlo Bellotti  Responsabile UOS Chirugia della Tiroide e delle Paratiroidi  Azienda Ospedaliera Sant’Andrea  Facoltà di Medicina e Psicologia  La Sapienza di Roma La Sapienza di Roma di Roma Prof. Carlo Bellotti Responsabile UOS Chirugia della Tiroide e delle Paratiroidi
  2. 2. QUALE INTERVENTO ATTEGGIAMENTO MENO AGGRESSIVO FUNZIONALE MAGGIOR RISPETTO PER LA TIROIDE PSICOLOGICO RIDUZIONE DELL’INCIDENZA DI COMPLICANZE
  3. 3. Obiettivi del trattamento chirugico di DTC The American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer • To remove the primary tumor • To minimize treatment-related morbidity • To permit accurate staging of the disease • To facilitate postoperative treatment with radioactive iodine, where appropriate. • To permit accurate long-term surveillance for disease recurrence • To minimize the risk of disease recurrence and metastatic spread
  4. 4. Indicazioni chirurgiche precedenti The American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer Published in Volume: 19 Issue 11: November 4, 2009 RECOMMENDATION 26 For patients with thyroid cancer >1 cm, the initial surgical procedure should be a near-total or total thyroidectomy unless there are contraindications to this surgery. Thyroid lobectomy alone may be sufficient treatment for small (<1 cm), low-risk, unifocal, intrathyroidal papillary carcinomas in the absence of prior head and neck irradiation or radiologically or clinically involved cervical nodal metastases. Recommendation rating: A RECOMMENDATION 25 Patients with indeterminate nodules who have bilateral nodular disease, or those who prefer to undergo bilateral thyroidectomy to avoid the possibility of requiring a future surgery on the contralateral lobe, should also undergo total or near-total thyroidectomy. Recommendation rating: C
  5. 5. RECOMMENDATION 35 (Strong recommendation, Moderate-quality evidence) (B) For patients with thyroid cancer >1 cm and <4 cm without extrathyroidal extension, and without clinical evidence of any lymph node metastases (cN0), the initial surgical procedure can be either a bilateral procedure (neartotal or total thyroidectomy) or a unilateral procedure. Thyroid lobectomy alone may be sufficient initial treatment for low-risk papillary and follicular carcinomas; however, the treatment team may choose total thyroidectomy to enable RAI therapy or to enhance followup based upon disease features and/or patient preferences. If surgery is chosen for patients with thyroid cancer <1 cm without extrathyroidal extension and cN0, the initial surgical procedure should be a thyroid lobectomy unless there are clear indications to remove the contralateral lobe. Thyroid lobectomy alone is sufficient treatment for small, unifocal, intrathyroidal carcinomas in the absence of prior head and neck radiation, familial thyroid carcinoma, or clinically detectable cervical nodal metastases. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer
  6. 6. Tiroidectomia vs lobectomia
  7. 7. stratified based on the size and number of metastatic lymph nodes, as well as the presence of extranodal extension. Randolph GW1, et al, Tuttle RM; American Thyroid Association Surgical Affairs Committee’s Taskforce on Thyroid Cancer Nodal Surgery Thyroid. 2012 Nov;22(11):1144-52
  8. 8. Perchè fare una tiroidectomia? TIROIDECTOMIA VANTAGGI SVANTAGGI Possibilita di focolai controlaterali (7%) < incidenza dicomplicanze Riduzione dei reinterventi Aumento dei tempi operatori TG come marker di malattia terapia sostitutiva a vita Possibilità di trattamento nucleare Prevenzione di sdifferenziazione di eventuale residuo
  9. 9. Perchè fare una emitiroidectomia? EMITIROIDECTOMIA VANTAGGI SVANTAGGI Minor incidenza di complicanze Possibilità di persistenza della malattia Riduzione tempi operatori No terapia radiometabolica Non indispensabile terapia levotiroxinica Stadiazione! Attento Follow Up Monitoraggio Tgb?
  10. 10. World J Surg. 2007 May;31(5):879-87.
  11. 11. Fattori prognostici del cancro differenziato della tiroide 2015 American Thyroid Association management Guidelines for adult patients whith thyroid nodules and differentiated thyroid cancer
  12. 12. Comparison of the American Joint Committee on Cancer Seventh and Eighth Edition Staging System Differentiated and anaplastic thyroid carcinoma: Major changes in the American Joint Committee on Cancer eighth edition cancer staging manual. Perrier ND1, Brierley JD2, Tuttle RM3.
  13. 13. Major Changes to the American Joint Committee on Cancer TNM Staging of Differentiated Thyroid Cancers in the Eighth Edition Il termine “limited to the thyroid” include anche la minima estensione nel connettivo peritiroideo e la microscopica infiltrazione dei muscoli peritiroidei. La minima estensione extratiroidea (ovvero la minima estensione attraverso la capsula visibile solo all’esame istologico) non viene più considerata come pT3, e non influenza né il T nè lo stadio. Pertanto, la mini-invasione del tessuto adiposo o dei muscoli, nervi o vasi non fa più parte della categoria T3b.! La macroscopica invasione extratiroidea individuata con l’ecografia o durante l’intervento può rientrare nel T3b (muscoli peritiroidei), nel T4a (laringe, trachea, muscoli del collo, esofago, ricorrente), nel T4b (fascia prevertebrale, carotide, vasi mediastinici). Il cut-off anagrafico usato per la stadiazione del carcinoma differenziato nella VII edizione è stato portato da 45 a 55 anni. Per l’assenza di metastasi non serve più la conferma cito-istologica ma basta la negatività radiologica, clinica preoperatoria e clinica intraoperatoria
  14. 14. In caso di CDT ad alto rischio e/o tumori localmente avanzati (T3, T4): Linfadenectomia del compartimento centrale SEMPRE ? Ispezione accurata del compartimento centrale ed eventuale rimozione di linfoadenopatie sospette per esame istologico estemporaneo In caso di positivita’ LINFOADENECTOMIA TERAPEUTICA In caso di CDT ad basso rischio: Linfectomia del compartimento centrale Strategia chirurgica
  15. 15. Ruolo dell’ecografia
  16. 16. decision making consenso informato livello di conoscenza Chi riceve l’informazione Chi da l’informazione
  17. 17. 2015 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer RECOMMENDATION 35 (Strong recommendation, Moderate-quality evidence) (B) For patients with thyroid cancer >1 cm and <4 cm without extrathyroidal extension, and without clinical evidence of any lymph node metastases (cN0), the initial surgical procedure can be either a bilateral procedure (neartotal or total thyroidectomy) or a unilateral procedure. Thyroid lobectomy alone may be sufficient initial treatment for low-risk papillary and follicular carcinomas; however, the treatment team may choose total thyroidectomy to enable RAI therapy or to enhance followup based upon disease features and/or patient preferences. If surgery is chosen for patients with thyroid cancer <1 cm without extrathyroidal extension and cN0, the initial surgical procedure should be a thyroid lobectomy unless there are clear indications to remove the contralateral lobe. Thyroid lobectomy alone is sufficient treatment for small, unifocal, intrathyroidal carcinomas in the absence of prior head and neck radiation, familial thyroid carcinoma, or clinically detectable cervical nodal metastases.
  18. 18. CHI DA L’INFORMAZIONE  NON INGENERARE INCERTEZZA  NON TRASMETTERE CARATTERE D’URGENZA  FORNIRE DATI CONFORTANTI SULLA PROGNOSI  ESSERE COLLEGATI CON CENTRI DI RIFERIMENTO  Informazione sulle complicanze
  19. 19. CONDIVISIONE DELLE PROBLEMATICHE CHIRURGICHE Coplicanze radicalità Risultati
  20. 20. Strategia chirurgica con le nuove tecnologie continuous neuromonitoring
  21. 21. Lobectomia Vs. Tirodectomia  La maggior parte dei nostri pz arriva alla nostra osservazione con PTC di dimensioni comprese tra 0,5 e 1,5cm  E’ il miglioramento della sopravvivenza a distanza il nostro obiettivo piuttosto che la diminuzione di incidenza di ricomparsa di malattia  Quali sono i fattori prognostici validi per la definizione del pz a basso o alto rischio (Braf, Galectina3, multifocalità, dimensioni del tumore, infiltrazione capsulare)  Siamo in grado di abbassare l’incidenza di complicanze
  22. 22. conclusioni • Considerare con attenzione la reale possibilità di eseguire la sola lobectomia per il trattamento del cancro della tiroide a basso rischio (secondo le ultime definizioni) • Istruire il paziente sulla strategia chirurgica al fine di limitare il ricorso ad un eventuale reintervento solo nei casi strettamente necessari • Condividere la decision making ritagliata sul caso clinico con un team multidisciplinare Endocrinologi Patologi Medici nucleari Chirurghi

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