Integrating Guidelines, Experience, and Clinical Judgment in the Management of Thyroid Cancer AACE Annual Meeting May 5, 2016

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Hubert Gilmore
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1 Integrating Guidelines, Experience, and Clinical Judgment in the Management of Thyroid Cancer AACE Annual Meeting May 5, 2016 Bryan Haugen, M.D. Julie Ann Sosa, M.D. Mike Tuttle, M.D. Peter A. Singer, M.D.

2 ATA Thyroid Nodule and Cancer Guidelines 1996 Singer, P et al, 7 pages; 21 references 2009 Cooper, D et al, 47 pages; 437 refs 2015 Haugen, B et al, 133 pages, 1078 refs!!

3 Thyroid Cancer Papers Published During my fellowship 991 The last two years (2015, 16) 6,696 (~8X) So far in ,241 Total number in Pubmed 66,293!

4 Thyroid Cancer Papers Published By Our Panel Bryan Haugen 74 ( 3 in 2017) Julia Ann Sosa 121 (9 so far this year) Mike Tuttle 236 (11 thru April seriously?)

5 60 Year Old Woman With Thyroid Cancer In 2005 underwent total thyroidectomy and right modified neck dissection. Notes indicate stage lll T1b N1 M0. She then received 126 mci 131 I, and 6 months later 138 mci 131 I. WBS negative after each Rx. Any utility in giving 2 nd dose? 2008 later recurrence/persistence and underwent surgery, followed by XRT. Spotty follow up until mid 2012 and Tg reported as undetectable. 8/2013 ultrasound, chest XR negative, and 11/2013 WBS reported as negative. Tg still neg.

6 CT Neck: 08/29/2008

7 60 Year Old Woman With Thyroid Cancer Sept 2014 CT chest revealed sub cm nodules and 2.9 cm central pulmonary lesion within the lingula, with +/- pressure on inferior segmental bronchus. Bx of lingular lesion=ptc. PET scan revealed multiple hypermetabolic pulmonary lesions. What now? More 131 I Surgery of 2.9 cm lesion XRT Or, refer to USC?!

8 60 Year Old Woman With Thyroid Cancer She was seen at USC 2/2015, and other than long standing hoarseness (RLN) felt well, without pulmonary symptoms. Outside CT reviewed and no significant pressure on bronchus. Tg 0.2/Ab neg. Now what?

9 60 Year Old Woman With Thyroid Cancer Singer s Guideline if you don t know what you re doing, don t do it. I didn t do anything, since she was stable, but: CT repeated 3/2015 (6 months after OSH) multiple nodules, with 2.9 cm lingular lesion unchanged. I left her alone. 9/2015 CT showed lingular lesion increased from 2.9 to 3.5 cm, with minimal obstruction. Mild increase in size of other lesions. PET basically stable. Surgery? XRT TKI?

10 CT Chest 03/06/2015

11 CT Chest 03/06/2015

12 CT Chest 10/06/2015

13 PET/CT fusion image: 11/11/2015

14 60 Year Old Woman With Thyroid Cancer 10/2015 surgeon said not amenable to resection 10/2015 radiation oncology consult and patient Rx d with SBRT, 50 Gy in 10 Gy fractions. 3/2016 CT lingular lesion decreased to 2.8 cm, but some others slightly increasing. She feels ok. 7/2016 rad onc CT lingular lesion 1.8 cm, but increased consolidation of lingula, likely due to XRT. To follow up with CT in 3 months.

15 CT Chest: 03/04/2016

16 CT Chest: 07/08/2016

17 60 Year Old Woman With Thyroid Cancer 10/2016 admitted to OSH with SOB and pneumonia. CT showed increased consolidation left infrahilar region, central lingula, and LLL. Also invades left paracardiac mediastinum and hemidiaphragm. In other words, things are worse. Tg at OSH 0.9! What s the significance of tumor not producing Tg? Now what? Should we have done something different earlier?

18 60 Year Old Woman With Thyroid Cancer 12/2016 bone scan at OSH=left acetabular lytic lesion and erosion of right posterior medial rib and 2.6 x 1.6 cm soft tissue mass abutting the rib. and CT shows increasing size of pulmonary mets. Patient now having significant pleural type pain. Now what? Oncology consult at OSH to begin TKI

19 Case 34 year old woman with thyroid Ca History: C.C. at ~ 21 +/- years old underwent thyroidectomy for papillary thyroid cancer. She was then treated with 131 I which revealed diffuse pulmonary mets. Patient referred to me at in 2007, at 25 years of age; by then had received a total of ~550 mci of 131 I, and continued to have diffuse pulmonary mets on post-rx scan. When seen by me, she felt perfectly well, with no pulmonary symptoms. Her exam was negative. She was taking L-T mg/d. Labs: Tg

20 Case 34 year old woman with thyroid Ca U/S Jan 2008 with B/L nodes, largest on right 1.1 cm. Follow? FNA? Surgery?

21 Ultrasound 1/2008

22 Ultrasound, 10/2008

23 Case 34 year old woman with thyroid Ca Underwent bilat neck dissection Jan, 2009, with 4/20 positive nodes on left, largest 1.1 cm with ENE; 2/36 nodes positive on right, with largest 1.9 cm. Now what? Follow? More 131 I?

24 Case 34 year old woman with thyroid Ca C.C was followed by me over the next 6-7 years, at 6 month intervals, and had yearly chest CT scans, which for revealed gradual increase in # of micromets. She felt well, without pulmonary symptoms. PFT s were done, most recent 2014, and were normal.

25 Case 34 year old woman with thyroid Ca Jan 2015 by now had converted from C.C. to C.H. and considered pregnancy. CT without contrast revealed gradual increase in # of pulmonary micro mets and a few slightly > 1 cm. Jan 2015 WBS confirmed persistent pulmonary mets, with increased activity in bases. Serum Tg 1125; TgAb 1.0 essentially stable past 18 months. What do you recommend re pregnancy? Go ahead and no further Rx and follow as usual Rx with 131 I and then pregnant Get pregnant, and consider 131 I after pregnancy

26 WBS 1/2015

27 CT Chest 1/2015

28 Case 34 year old woman with thyroid Ca Aug 2015 C.H. became pregnant. Dec 2015 Tg 1125; TgAb 1.0 December 2014 Tg 1170 with TgAb 1.1, so seemed stable. March 2016 seen for follow up and was becoming SOB. Exam WNL. Assumption was related to 3 rd trimester of pregnancy. Tg 2100/TgAb 0.7 May 2016 admitted to outside hospital in respiratory distress, and emergency C-section (38 weeks) 4 # 11 oz w/o fetal distress. Emergency CTPA negative for PE. PO2 50 %. 100 % 02 at 40 L/min required to keep 02 sat ~90 %

29 Ultrasound 1/2008

30 Case 2 34 year old woman with thyroid ca She was finally discharged 2 ½ weeks later, on 2L 02, and 02 sats dropped to high 80 s with effort. She received 105 mci 131 l two months later

31 WBS post 105 mci 131 I August, 2016

32 Ultrasound--November, 2008

33 Representative Tg/TgAb (all TSH Suppressed) 11/12 955/3.2 12/13 785/1.5 7/14 960/0.6 12/ /1.1 3/ /0.7 (7 mos pregnant) 12/ /0.6

34 Case 34 year old woman with thyroid ca When seen in December, 2016, felt well, albeit still on O2. Tg 1470/0.6 Now what? Did pregnancy cause this?

42 yr old male with h/o Graves disease and prior I 131 treatment presents with hyperthyroidism and undetectable TSH. 2 hr uptake 20%, 24 hr uptake 50%

42 yr old male with h/o Graves disease and prior I 131 treatment presents with hyperthyroidism and undetectable TSH. 2 hr uptake 20%, 24 hr uptake 50% Pinhole images of the neck are acquired in multiple projections, 24hrs after the oral administration of approximately 200 µci of I123. Usually, 24hr uptake value if also calculated (normal 24 hr uptake