thyroid cancer


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thyroid cancer

  1. 1. Thyroid Cancer <br />Col N Kannan<br />Sr Adv Surgery & Surgical Oncology<br />Army Hospital (R&R)<br />New Delhi<br />
  2. 2. Thyroid Cancer<br />Commonest endocrine malignancy<br />1% of all malignancies<br />0.5-1 per 100000<br />Good prognosis<br />Extent of treatment is hotly debated<br />No randomized trials<br />
  3. 3. Thyroid cancer<br />1.5% of all cancer<br />Papillary carcinoma(75-85% of cases)<br />Activation of receptor tyrosine kinases (RET/PTC, TRK, MET) ->Produce chimeric proteins with tyrosine kinase activity<br />Follicular carcinoma(10-20%)<br />Medullary carcinoma(5%)<br />Anaplastic carcinoma(<5%)<br />
  4. 4. Classification<br />Differentiated Thyroid Cancer<br />Papillary Cancer (PTC) and its variants<br />Follicular Cancer (FTC)<br />Hurthle cell cancer<br />Anaplastic Cancer<br />MedullarycancerM<br />
  5. 5. Presentation<br />Solitary or Multiple thyroid nodules<br />Neck Nodes<br />Hoarse voice of recent onset<br />Mediastinaladenopathy<br />Bone or lung metastasis<br />
  6. 6. Important History<br />Radiation to neck / chest<br />MEN syndrome<br />Family history<br />Diarrhoea<br />Adrenal tumour<br />Recent change in a pre-existing goitre<br />Size change/nodularity<br />Vocal cord palsy<br />
  7. 7. Evaluation<br />Clinical<br />Single nodule<br />Age<20 and >70, males<br />Hard or fixed<br />Unilateral/bilateral nodules<br />Nodes<br />IDL for cord palsy <br />
  8. 8. Evaluation<br />USG neck<br />Solid or cystic<br />Hypoechoic lesions<br />Irregular lesions<br />Microcalcifications<br />Vascularity on doppler<br />Pick up asymptomatic nodules<br />
  9. 9. Evaluation<br />Thyroid profile<br />Serum Thyroglobulin<br />Serum Calcitonin<br />Thyroid scan<br />Hot/warm/cold nodule 20% malignant<br />Serum Ca++<br />
  10. 10. Evaluation<br />CT Scan<br />Not commonly needed<br />Better when suspecting mediastinal disease<br />PET Scan<br />FNAC<br />Accurate for PTC and MTC<br />Cannot diagnose FTC<br />
  11. 11. Treatment<br />Total Thyroidectomy with <br />Central Neck Dissection<br />RAI scan and sos Ablation<br />Suppressive dose of thyroxine<br />
  12. 12. Surgery<br />Total thyroidectomy<br />Lower LRR<br />Can use RAI for residual disease<br />Serum Tg a useful post op monitoring marker<br />Approx 2% risk to RLN and parathyroids<br />Hemithyroidectomy<br />No difference in OS<br />Avoids risk of hypoparathyroidsm<br />No need for replacement therapy and risks associated<br />
  13. 13. Risk stratification<br />Risk Grading<br />AGES, AMES, MACIS, TNM<br />Histology<br />Tall cell, Columnar, Hurthle cell<br />Metastasis<br />Tumour grade<br />LVSI especially for FTC<br />
  14. 14. Nodal disease<br />No effect on OS<br />Increased risk of LRR<br />Ipsilateral nodal disease <br />40% with PTC<br />10% with FTC<br />25% with Hurthle cell ca<br />
  15. 15. Surgery for Nodes<br />Central neck dissection<br />Ipsilateral/bilateral for all<br />Selective neck dissection<br />For minimal disease (ipsilateral)<br />Comprehensive neck dissection<br />For gross disease in nodes<br />Include superior mediastinal nodes<br />
  16. 16. Radioiodine treatment<br />All patients who have undergone TT/ significant residue<br />Targeted therapy<br />Ablates tumour and adjacent tissue<br />Dose 75-150mCi, max dose 1500mCi<br />Not indicated in <br />Micropapillary ca, <15mm lesion in young females<br />Lobectomy as treatment<br />Complications: Xerostomia, menopause, azzospermia, flare phenomenon, BM suppression, AML<br />
  17. 17. Post treatment<br />TSH suppression <br />0.1micro IU/ml in high risk disease<br />Thyroxine in doses 150-200mcg per day<br />No proven benefit of OS or reduction of LRR<br />Risks of osteoporosis, AF, cardiac risk in elderly needs management<br />
  18. 18. Role of EBRT<br />Indications<br />Non iodine avid disease<br />Mediastinal bulky nodes<br />Bone metastasis<br />Brain metastasis<br />Locally inoperable massive disease<br />SVCO<br />
  19. 19. Newer therapies<br />Targetted therapy<br />Aimed at BRAF Kinase and MAPK pathway<br />COX 2 inhibitors<br />Antiangiogenic therapy<br />Anti EGFR therapy<br />
  20. 20. Follow Up<br />Review adequacy of replacement T3/T4<br />USG neck, CXR for recurrence<br />RAI scans 6 monthly till 2 scans are normal<br />Serum Tg levels in TT patients (<2ng/ml when anti Tg levels are not elevated)<br />Imaging as directed by findings<br />
  21. 21. Prognosis DTC<br />85% of patients with DTC :disease-free after initial treatment <br />10–15% : recurrent disease <br />5%: distant metastases <br />Distant metastases :lungs (50%), bones (25%), lungs and bones (20%) ,10-year-survival rates ranging from 25% to 42%<br />Overall 20yr survival 95%<br />
  22. 22. Anaplastic Cancer<br /><ul><li>1.6% of thyroid cancers
  23. 23. 5th-6th decades
  24. 24. Rapidly expanding mass (> 5cm in 80%)
  25. 25. Short history and multiple local symptoms
  26. 26. ETE, LN 2’, VC palsy in 50% at Δ
  27. 27. Mets common (LN, lung)
  28. 28. Management controversial – almost 0% OS
  29. 29. Rarely resectable
  30. 30. Radical EBRT + CT (Adriamycin) if good PF</li></li></ul><li>MEDULLARY CARCINOMA<br />6-8% of thyroid cancers<br />75% sporadic , 25% hereditary (MEN screening)<br />Neuroectodermalparafollicular C cells<br />Elevated serum calcitonin (level corresponds with stage)<br />CEA is elevated <br />Calcium deposits on U/S<br />Staging: CT/MRI/octreotide, for neck LN, bone, lung, liver lesions<br />
  31. 31. MEDULLARY CARCINOMA<br />Prognostic Features<br />T size<br />High Preopcalcitonin s/o high tumour load<br />Advanced age<br />Extrathyroid extension<br />LN in mediastinum<br />Perinodal invasion<br />Incomplete excision<br />Histopathologic features<br />Type of syndrome in hereditary MTC<br />
  32. 32. MEDULLARY CARCINOMA<br />TT<br />Central compartment LND<br />Ipsilateral LND /biateral neck and mediastinal dissection<br />RT to neck and mediastinum when there is a high nodal load<br />
  33. 33. Medullary Cancer<br />Follow up<br />Imaging<br />Calcitonin and CEA levels<br />Asymptomatic hypercalcitoninemeia with no apparent disease on imaging needs to be followed up<br />
  34. 34. Questions<br />