2. GOAL of treatment
Remove primary tumor with clinically significant LN
Minimise treatment related morbidity
Accurately stage the disease
Facilitate post op RAI therapy if needed
Minimise risk of recurrence and metastasis
3. TREATMENT MODALITIES
Primary treatment- SURGERY
Others- a) RAI therapy
b) TSH suppression
c) EBRT
d) Systemic CT if required
e) Targeted therpay i.e. Tyrosine kinase
inhibitor ( SORAFENIB)
4. SURGERIES
Total thyroidectomy- removal of both thyroid lobes
along with isthmus
Near total thyroidectomy –removal of both lobes+
isthmus with 1gm or 1cm tissue on 1 or both sides
Subtotal thyroidectomy-both lobes + isthmus with 4-
8gm of tissue left at lower pole
Hemithyroidectomy- removal of isthmus +1 lobe
Completion thyroidectomy
5. SURGERY FOR DTC
If size< 1cm- microcarcinoma
+ no LN
no extrathyroidal spread
no h/o radiation exposure
Surgery is not required but to be followed up and
active survellience to be done – first 6 monthly, then
yearly
If size increases by 3mm or LN mets detected-
becomes an indication for surgery.
6. DTC =1-4cm
Lobectomy if no high risk features
If > 4cm or presence of high risk features- go for
total thyroidectomy and post op RAI therapy
7. TREATMENT OF PTC
Total or near total thyroidectomy with MRND
Suppresive dose of L-thyroxine ( 0.3 mg OD)
( for TSH to be <0.1mIU/L)
This dose can cause osteoporosis, so calcium and
vitamin D supplementation is required.
8. TREATMENT OF FTC
Total thyroidectomy with LN dissection
As FNAC is inconclusive , hemithyroidectomy done
histology comes out to be follicular carcinoma
go for Completion thyroidectomy
9. Guidelines for completion thyroidectomy
Within 3 days or after 3 months
Should be performed if :
a)the management recommendation would have
been total or near total thyroidectomy if pathology
was known preop.
b) RAI therapy is planned post op.
10. Follow up for FTC
By radioisotope scan at regular intervals
If it detects remnant disease- radioablation dose of
I131 given scan repeated after 8 days.
Thyroglobulin estimation ( once in 3-6 months)
N= 3-40ng/ml , > 50ng means recurrence or mets
if secondaries detected – therapeutic dose of I131
given orally, thyroxine to be stopped 6 weeks prior to
it.
11. LYMPH NODE DISSECTION
Central LN
+clinically or on
USG
Therapeutic LN
dissection
Negative
clinically and on
USG
Check intraop ,if
+
Therapeutic LN
dissection
Negative but pt
is high risk
Tu>4cm
Extrathy spread
Lateral LN +
Therapeutic LN
dissecttion
13. TREATMENT OF MTC
SURGERY- completely cured by complete resection
of 1° tumor + local or regional mets
TOTAL thyroidectomy
+ prophylactic level VI LN dissection,if
a) usg shows lateral LN +
b)S. cal> 200
c) tumor > 1.5cm
14. Sporadic MTC- within 1 lobe
Familial MTC – upper halves of both lobes
MEN 2A- prophylactic total thyroidectomy before
5 years of age
MEN 2B- prophylactic total thyroidectomy before
1 year of age
If MTC diagnosed in a patient who underwent less than near
total thyroidectomy, then
completion thyroidectomy + LN dissection, except
if MTC is sporadic or unifocal
no C-cell hyperplasia
normal S. Calcitonin
normal USG neck
negative surgical margins
15. If neck LN + a) CECT chest+ abd
OR ( liver mets)
S. Cal > 500pg/mL b) MRI( bone mets)
Patient with extensive locoregional disease – EBRT
Unresectable disease- TK inhibitors- Vandetanib
Cabozanitib
