Thyroid Cancer

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Slide 1 :

Thyroid Cancer May 10, 2006

Slide 2 :

Thyroid Cancer Accounts for 1.5% of all cancers in the US Most common endocrine malignancy (95%) 22,000 cases per year and estimated 500 – 1000 patients die annually 90% of thyroid cancer cases have favorable prognosis

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Classification & Incidence of Thyroid Cancer Follicular cell origin Differentiated Papillary 80% Follicular 10% Hurthle cell 3-5% Undifferentiated Anaplastic 1-2% Parafollicular cell origin – Medullary 5%

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Papillary Carcinoma Accounts for 90% radiation induced cancer Classified as microcarcinoma, intrathyroidal, and extrathyroidal Histologic variants: tall-cell, clear-cell, columnar, diffuse sclerosing Multicentric in 30-50% of tumors Spreads via lymphatics with propensity for mid- and lower-anterior cervical chain (Level VI) 20-50% patients have involvement of cervical LN

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Follicular Carcinoma Only 10% of thyroid cancers in developed countries, although more prevalent in regions with iodine deficiency Diagnosis depends on demonstration of vascular or capsular invasion Classified as minimally or widely invasive Vascular invasion tends to have a more aggressive course than capsular invasion Uncommon to have multicentric disease Hematogenous spread

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Follicular Carcinoma Where does follicular carcinoma tend to metastasize? Bone Lung

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Hurthle Cell Carcinoma High propensity to spread to cervical lymph nodes and high incidence of distant metastasis Less than 10% of Hurthle cell carcinomas take up radioiodine High tumor recurrence rate High mortality rate – 30% mortality at 10 years

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Anaplastic Carcinoma Increasingly rare Arise within differentiated cancers Pts > 60 years old with rapidly expanding neck mass Local invasion very common at time of dx (FNA) Surgery plays limited role given advanced stage at dx Radiation and chemotherapy have not demonstrated any significant improvement in survival Median survival ~ 4 - 6 months

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Medullary Thyroid Carcinoma Originates from the parafollicular C cells Elevation in calcitonin and CEA (50%) 80% have sporadic MTC (unifocal), remainder have genetic component 75% patients have LN metastasis at time of dx, 20% distant mets

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Medullary Thyroid Carcinoma MEN IIA ? MTC (100%), pheo (40%), hyperparathyroidism (35%) AD inheritance Missense mutation of extracellular cysteine of RET Surgery recommended before 6 years of age MEN IIB ? MTC (100%), pheo (50%), mucosal ganglioneuromas (100%), marfanoid habitus AD inheritance Missense mutation of tyrosine kinase domain of RET Surgery recommended in infancy Familial MTC

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Lymphoma of the Thyroid Usually non-Hodgkin’s B cell type Pts with Hashimoto’s thyroiditis have 70-80 fold increase risk Typically women > 70yo present with enlarging neck mass FNA > 80% accuracy Treatment includes XRT and chemotherapy 5 year survival rates 50-70%

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45 year old female presents to your office with a thyroid nodule. What questions will you ask her?

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History Characteristics of nodule Is the patient symptomatic? Hyperthyroid/Hypothyroid Compressive sxs Family history ? MEN endocrinopathies Radiation exposure

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45 year old female with thyroid nodule Characteristics of nodule ? found incidentally by PCP Is the patient symptomatic? ? No Hyperthyroid/Hypothyroid Compressive sxs Family history ? None Radiation exposure ? None

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Physical Exam Size Consistency of nodule, multiple or solitary Fixed or mobile Presence of cervical LAD

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Physical Exam Solitary nodule Mobile, not obviously adherent to adjacent structures No cervical LAD Normal voice Otherwise well appearing

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Evaluating a thyroid nodule Thyroid nodules are common, but less than 10% are malignant History and PE TSH level should be obtained during initial evaluation If low, radioisotope study If normal or high, then proceed to ultrasound

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Evaluating a thyroid nodule What is the risk of a “hot” nodule on radioiodine scan being malignant? Less than 1% What about a “cold” nodule? 15% – 20%

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Evaluating a thyroid nodule Radioisotope studies may also be useful: FNA reports “suspicious for follicular neoplasm” or “indeterminate” Detecting neck metastasis

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Evaluating a thyroid nodule What information will an ultrasound provide? Number of nodules Location and size of nodules Cystic versus solid

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Evaluating a thyroid nodule Which of the following are concerning findings on ultrasound? Halo sign Hypoechogenic Calcifications < 1cm

Slide 22 :

Evaluating a thyroid nodule Which of the following are concerning findings on ultrasound? Halo sign Hypoechogenic Calcifications < 1cm

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Evaluating a thyroid nodule FNA is the most reliable and cost efficient way to determine malignant from benign lesion 4 categories: Malignant, benign, suspicious, indeterminate Limitation of FNA: Cannot distinguish benign follicular or Hurthle cell adenoma from malignancy – based upon presence or absence of capsular or vascular invasion False negative rate < 5%

Slide 24 :

45 year old female with thyroid nodule TSH level was normal Underwent an ultrasound-guided FNA of the nodule, pathology revealed papillary carcinoma in a nodule measuring 2.5cm

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Management of Papillary Carcinoma What surgical procedure would you offer her? Near-total or total thyroidectomy is recommended if: Tumor > 1-1.5cm Contralateral nodules Local or regional metastasis + FHx in 1st degree relative + history of radiation exposure Age >45 yo Increased extent of surgery lowers recurrence rates and has improved survival in high-risk patients

Slide 26 :

Management of Papillary Cancer When is lobectomy an acceptable surgical procedure for FNA proven papillary cancer? 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

Slide 27 :

Management of Papillary Cancer Will you plan on performing a lymph node dissection? A central compartment (Level VI) neck dissection should be considered If nodal disease is evident clinically then a more extensive cervical lymphadenectomy should be performed LN sampling not recommended

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Surgical Anatomy:Lymphatics

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Surgical Anatomy:Lymphatics What are the LNs located superior to the thryoid gland in the midline called? Delphian nodes

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45 year old female with papillary carcinoma 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?

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Prognostic Risk Classification for Patients with Well-Differentiated Thyroid Cancer (AMES or AGES) Low Risk High Risk Age <40 years >40 years Sex Female Male Extent No local extension, Capsular invasion, extra- intrathyroid, no caps thyroidal extension invasion Metastasis None Regional/distant Size <2 cm >4 cm Grade Well diff Poorly diff

Slide 32 :

Management of Papillary Cancer What further treatment is recommended? TSH suppression therapy Radioiodine ablation therapy

Slide 33 :

45 year old female with papillary carcinoma She wants to know what her long-term survival is. What will you tell her? ~ 90% at 10 years for papillary carcinoma

Slide 34 :

45 year old female with thyroid nodule TSH level was normal Underwent an ultrasound-guided FNA of the nodule, pathology suspicious for a follicular neoplasm What is the risk that this is malignant? Approximately 20% What surgical procedure will you offer her?

Slide 35 :

Management of FNA suspicious for follicular neoplasm Lobectomy would be a reasonable surgical procedure, particularly in low-risk patient who prefers limited surgical intervention Near-total or total thyroidectomy still recommended for high-risk patient and/or large tumor size

Slide 36 :

Management of FNA suspicious for follicular neoplasm Intra-operative frozen sections can be helpful in this scenario? True or false False

Slide 37 :

45 year old female with thyroid nodule You performed a lobectomy and the final pathology reveals Hurthle cell carcinoma What further treatment do you recommend? Completion thyroidectomy with central compartment LN dissection TSH suppression therapy

Slide 38 :

Post-operative radioiodine remnant ablation To whom should it be offered? Stages III and IV disease Stage II disease in pts under age 45 Selected pts with Stage I Multifocal disease Nodal metastasis Extrathyroidal extension Vascular invasion Aggressive histology

Slide 39 :

TMN Classification for differentiated thyroid cancer T1 ? 2cm T2 2-4cm T3 >4cm, limited to thyroid T4a Any size, invasion of SQ, trachea, esophagus, RLN T4b Any size invasion of prevertebral fascia or encasing carotid/mediastinal vessels N0 no nodes N1a Level VI N1b All other levels Stages Stage I T1, N0, M0 Stage II T2, N0, M0 Stage III T3, N0, M0 T1-3, N1a, M0 Stage IVA T4a, N0, M0 T4a, N1a, M0 T1-3, N1b, M0 Stage IVB T4b, any N, M0 Stage IVC Any T and N, M1

Slide 40 :

45 year old female with thyroid nodule She asks what her overall 10 year survival will be with her diagnosis of Hurthle cell carcinoma? ~70% What if she had follicular carcinoma? ~70%

Slide 41 :

Recommendations for follow-up(differentiated cancers) Thyroid cancer recurs in 20-40% patients, most commonly within the first 2 years Thyroglobulin used as tumor marker checked every 6-12 months Whole body scan may be useful in intermediate and high-risk patients 6-12 months after ablation Ultrasound should be done 6-12 months after surgery, then annually for the next 3-5 years

Slide 42 :

Management of recurrent and metastatic disease Surgery mainstay of treatment for locoregional disease ? radioiodine ? radiation Metastatic disease treated with radioiodine Older patients with bony mets are less likely to respond to radioiodine and have poor prognosis Pulm mets more radio responsive than bone mets

Slide 43 :

55 year old male presents to your office with MTC on FNA Palpable thyroid nodule and cervical LN Diarrhea and flushing No FHx of MEN endocrinopathies Calcitonin elevated, FNA reveals MTC Any further tests that you should order? Genetic testing CT scan to see extent of disease

Slide 44 :

55 year old male presents to your office with MTC on FNA What surgical procedure will you recommend to him? Total thyroidectomy with LN dissection in Level VI and LN sampling in lateral regions (frozen sectioning intra-operatively)

Slide 45 :

55 year old male presents to your office with MTC on FNA What do you want to check for before bringing him into the operating room? Presence of a pheochromocytoma

Slide 46 :

55 year old male presents to your office with MTC on FNA How would you handle the parathyroid glands? Some recommend performing a total parathyroidectomy with autotransplantation in either the forearm or SCM

Slide 47 :

55 year old male presents to your office with MTC on FNA Further treatment remains controversial but includes radiation therapy and chemotherapy Surveillance using calcitonin levels

Slide 48 :

Surgical Anatomy:Vasculature

Slide 49 :

Surgical Anatomy:Vasculature and nerves

Slide 50 :

Surgical Anatomy What is the consequence of injurying the external branch of the superior laryngeal nerve? Injury results in paralysis of the cricothyroid muscle

Slide 51 :

Surgical Anatomy:Anatomical variations of the Right RLN

Slide 52 :

Surgical Anatomy What is the result of an injury to the recurrent laryngeal nerve? Ipsilateral paralysis Contralateral paralysis

Slide 53 :

Surgical Anatomy What is the result of an injury to the recurrent laryngeal nerve? Ipsilateral paralysis Contralateral paralysis

Slide 54 :

Surgical Anatomy What would you do if the tumor involved the RLN? If vocal cord is paralyzed pre-operatively, then consider resecting the RLN along with specimen If no vocal cord paralysis, dissect tumor off nerve

Slide 55 :

Surgical Anatomy:The Parathyroids

Slide 56 :

Surgical Anatomy:The Parathyroids What are your options if the blood supply to the parathyroids has been compromised? Implantation within the sternocleidomastoid muscle or forearm muscle for easy access

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Hyperthyroid/Hypothyroid; Compressive sxs. Family MEN endocrinopathies; Radiation exposure. 45 yea more Hyperthyroid/Hypothyroid; Compressive sxs. Family MEN endocrinopathies; Radiation exposure. 45 year old female withàhistory thyroid nodule ... less
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