10/24/2008. Surgery for Well-differentiated Thyroid Carcinoma- The Primary

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1 Surgery for Well-differentiated Thyroid Carcinoma- The Primary Head and Neck Endocrine Surgery Department of Otolaryngology-Head and Neck Surgery, UCSF October 24-25, 2008 Robert A. Sofferman, MD Professor of Surgery Chairman Emeritus Division of Otolaryngology University of Vermont School of Medicine Outline Histology and Natural History Prognosis Controversies Technical Issues Cases General Concepts follicular cell derived from primitive foregut parafollicular cell(c cell) derived from neural crest and produces calcitonin follicular epithelial cells- well differentiated and undifferentiated 1

2 Thyroid Cancer papillary follicular ( Hurthle cell also known as Askanazy or oxyphil ) medullary anaplastic differentiated tumors % thyroid carcinomas Papillary Carcinoma most common mainly in young patients best prognosis multifocal not encapsulated invade regional lymphatics- lymphadenopathy subgroup locally invasive distant mets to lungs common 2

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4 Follicular Carcinoma solitary encapsulated invades veins bone and lungs when metastasizes neck nodes uncommon, except in presence of extensive capsular invasion or recurrent tumor spreads through blood stream 4

5 Follicular carcinoma with vascular invasion in capsule Follicular carcinoma with tumor cells in blood vessel 5

6 Capsular Invasion autopsy 138 patients without clinical thyroid disease 86 had focal capsular defects where thyroid follicles found in perithyroidal areolar tissue or strap muscles Komorowski RA, Hanson GA, Occult thyroid pathology in the young adult: an autopsy study of 138 patients without thyroid disease. Hum Pathol 1988: 19:689. 6

7 Occult Papillary Carcinoma Significance of Occult Disease new WHO Histologic Classification of Thyroid Tumors (1989) change term to papillary microcarcinoma from former occult papillary carcinoma for lesions < 1 cm to insure identification of smallest tumor, slides per gland. In one case, 1375 sections required to find a.3 x.6 occult ca associated with a presenting cervical metastatic node Occult Thyroid Carcinoma % in one American autopsy series Nishiyama RH et al.the prevalence of small papillary thyroid carcinomas in 100 consecutive necrrpsies in an American population. In EdGroot L, Frohman LA, Kaplan EL et al., eds. Radiation-associated associated thyroid carcinoma. New York: Grune and Stratton, 1976;123. autopsy series of young patients( years) without clinical thyroid disease - 4% incidence occult ca. Average size.2mm Occult Papillary Carcinoma unsuspected microfoci of occult papillary ca in 90% of uninvolved contralateral lobe when obvious unilateral papillary carcinoma 7

8 Natural History Papillary Carcinoma Iodine Deficiency in iodine sufficient areas, 85-90% cancers are papillary and most in low risk category in iodine deficient areas, only 60% of cancers are papillary and ratio of high/low risk patients is higher Natural History of Differentiated Thyroid Carcinoma series of 859 patients with papillary ca and 40 year follow-up Prognosis 6.5% mortality death related to age>50, male sex, >4cm tumor size, tumor grade, initial extent of disease, absence of Hashimoto McConahey WM, Hay ID, Woolner LB, et al. Papillary thyroid cancer treated at the Mayo Clinic, :initial manifestations, pathologic findings, therapy, and outcome. Mayo Clin Proc 1986;61:978 8

9 Prognosis in Greek means toward knowing Differentiated Thyroid Carcinoma Largest Series with Long Term Follow-up Mayo Clinic, Lahey Clinic, University of Michigan Low Risk no distant metastasis men under 40, women under 50 older patients with intrathyroidal papillary or minor capsular invasion by follicular ca primary cancers < 5cm Differentiated Thyroid Carcinoma High Risk all patients with distant metastasis older patients with extrathyroidal papillary or major capsular invasion by follicular ca primary tumor > 5cm Age first reported by William McDermott,Jr at MGH in 1954 in 190 patients the older the patient is, the poorer the outcome of treatment; the younger the patient is, the better the prognosis 9

10 Age mortality of thyroid cancer very much higher in patients over 40 years of age peak incidence between 40 and 50 years of age, younger than most other organs children- more neck nodes initially, less extrathyroidal invasion at primary site, more distant metastasis, more frequent recurrence of nodal disease Biochemical Phenotyping Hamming( Netherlands)- ploidy only significant prognostic factor for overall survival, second only to age Hamming JL, Schelfhout LJDM, Cornelisse CJ. Prognostic value of nuclear DNA content in papillary and follicular thyroid cancer. World J Surg 1988;12:503 Prognostic Scoring Systems late 1970s-early 1980s AGES(Mayo Clinc)- Age, Grade, Extent, Size AMES(Lahey Clinic)- Age, Metastasis, Extent, Size MACIS( Metastasis, Age, Completeness of Surgery, Invasion, Size) 84% fall into low risk group 1% 20 year death rate only 11% of low risk or young patients with incomplete removal died if followed > 15 years >90% of older or high risk patients died if incomplete resection 10

11 MACIS Scoring-Hay et al. Predicting outcome in papillary thyroid carcinoma: Development of a reliable prognostic scoring system in a cohort of 1779 patients surgically treated at one institution during 1940 through Surgery 1993;114: if age < 39 years.08 x age if age > 40 years.3 x tumor size in cm +1 if incompletely resected +1 if locally invasive +3 if distant metastases MACIS Scoring 20 year survival < 6= 99% = 89% = 56% 8 and above= 24% Controversies Controversies in the Management of Differentiated Thyroid Carcinoma hemi vs total thyroidectomy airway involvement adjunctive therapy 11

12 Hemi vs. Total Thyroidectomy Hemi vs Total Thyroidectomy low risk patients- mortality rate 1% at 20 years high risk patients- mortality rate 40% survival rate excellent and not affected by bilateral surgery in low risk patient Advantages of Hemithyroidectomy no risk of hypoparathyroidism no risk of bilateral vocal cord paralysis patients remain euthyroid and may not need TSH suppression in small tumors Hemithyroidectomy and Opposite Lobe Russell et al. - 88% of cases intrathyroidal lymphatics allow spread throughout the gland but actual tumor recurrence in opposite lobe is low (average 7%) 12

13 Disadvantages of Hemithyroidectomy cannot use thyroglobulin for follow-up RaI cannot be used to detect distant metastases Myth of Utility of Subtotal Thyroidectomy - Orlo Clark RLNs have already been identified parathyroids have already been separated from the thyroid gland eliminates need to give an ablative dose RaI to thyroid remnant allows post op I131 scan and ablative treatment thyroglobulin assay for follow-up removes intrathyroidal lymphatic issues decreases small risk of differentiated ca becoming poorly differentiated Invasion of the Airway 13

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17 Laryngotracheal Invasion by Differentiated Thyroid Carcinoma Retrospective review 292 patients at Mayo Clinic Well-differentiated papillary ca invading the trachea, larynx, RLN, esophagus, strap muscles categorized into 3 groups- complete removal, shave excision with likely microscopic tumor remaining, incomplete gross resection Czaja JM and McCaffrey TV. The surgical management of laryngotracheal invasion by well-differentiated papillary thyroid carcinoma. Arh Otol Head Neck Surg 123: , 490, Resection of Involved Airway Structures shave and post op RT or RaI have high local recurrence rate and seldom successful Grillo HC et al. Resectional management of thyroid carcinoma invading the airway. Ann Thorac Surg 54:3-10, 1992 shave resection and post op RT or RaI failed to control disease in 12 of 16 patients Park CS et al. Cartilage shaving procedure for the control of tracheal cartilage invasion by thyroid carcinoma. Head Neck 15: , 291, Technical Considerations tracheal window- repair with strap or SCM, periosteal flap partial laryngectomy- up to 30% of cricoid may be safely removed tracheal resection and primary anastomosis- 5 to 6 cm of trachea limit of resection Management of Thyroid Carcinoma Invading the Aerodigestive Tract 28 patients well-differentiated, 13 poorly differentiated all patients with incomplete resection had local recurrence no recurrences in well-differentiated ca after complete resection- all received RaI mCi Bayles SW et al. Management of thyroid carcinoma invading the aerodigestive tract. Laryngoscope 108: , 1407,

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25 Case 58 yo female involved in MVA and air-bag deployment Serious hemorrhage from anterior chest wall mass 25

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