Management guideline for patients with differentiated thyroid cancer. Teeraporn Ratanaanekchai ENT, KKU 17 October 2007

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1 Management guideline for patients with differentiated thyroid Teeraporn Ratanaanekchai ENT, KKU 17 October 2007

2 Incidence (Srinagarind Hospital, 2005, both sex) Site (all) cases % 1. Liver Lung Cervix Breast Lymph node Hemotopoietic Thyroid gland Ovary Nasopharynx Corpus

3 Incidence (Srinagarind Hospital, 2005, female) Site (all) cases % 1. Liver Cervix Breast Lung Thyroid gland Ovary Corpus Lymph node Hematopoietic Colon

4 Incidence (Srinagarind Hospital, , both sex) Site (head and neck) cases % 1. Oral cavity Nasopharynx Thyroid gland Larynx Oropharynx

5 Incidence (Srinagarind Hospital, , female) Site (head and neck) cases % 1. Oral cavity Thyroid gland Nasopharynx Oropharynx Nose and paranasal sinus

6 Incidence (Srinagarind Hospital, , male) Site (head and neck) cases % 1. Nasopharynx Oral cavity Larynx Oropharynx Thyroid gland

7 Trends of thyroid number 7

8 Age (Srinagarind Hospital, ) Site age male female total 1. HP Larynx OC OP Nose NP Salivary Thyroid

9 Cell types of thyroid Well differentiated thyroid Papillary carcinoma Follicular carcinoma Anaplastic carcinoma Medullary carcinoma Lymphoma Squamous cell carcinoma 9

10 Prognostic factors AGES AMES GAMES MACIS DAMES AJCC Age > 40 y M > 40 y > 45 y > 40 y M > 40 y > 45 y F > 50 y F > 50 y Size > 3 cm > 5 cm > 4 cm / > 5 cm 2/4 cm Extrathy. invasion / / / / / / Metas - / / / / / Etc. Histo. grade - Histo. grade Completeness of resection DNA ploidy Neck node 10

11 Diagnosis History* Physical examination* Fine needle aspiration biopsy* Ultrasonography Thyroid scan Thyroid function test CT scan or MRI 11

12 Clinical presentation Thyroid mass Neck node enlargement Local invasion Hoarseness Stridor Dysphagia/globus Hemoptysis Distant metastasis 12

13 Diagnosis The most common clinical presentation of thyroid is thyroid mass. Thyroid mass mostly is NOT malignancy. Predictive evidence??? 13

14 Diagnosis Strong evidences Neck node enlargement Local invasion Vocal cord paralysis Stridor Dysphagia Hemoptysis Skin invasion Distant metastasis 14

15 Diagnosis Weak evidences Age Sex Family history > 3 cm. Rapid enlargement History of irradiation Solid nodule Cold nodule Failure to thyroid suppression 15

16 Ultrasonography Diagnosis Solid vs cystic vs mixed Solid 15-20% malignancy Cystic less than 5% malignancy Detect lymph node Ultrasound-guide FNA Detect malignancy??? 16

17 Thyroid scan Diagnosis Cold nodule 15-20% Hot nodule FNA??? Malignancy rare (< 5%) High false positive 17

18 Diagnosis Fine needle aspiration biopsy Benign Malignant Papillary carcinoma Follicular carcinoma Anaplastic carcinoma Suspicious Follicular cell carcinoma Hurthle cell carcinoma inadequate 18

19 Diagnosis Fine needle aspiration biopsy High sensitivity & specificity Cost-effectveness Safe Limitation: follicular neoplasm 19

20 Standard treatment: Treatment Total thyroidectomy with I-131 ablation New trend: High risk group Low risk group 20

21 Treatment High risk patient Female > 45 years Male High risk tumor Size Papillary CA > 1.5 cm Follicular CA > 1 cm Incomplete resection Extrathyroid spreading Local or distant metastasis High grade histopathology 21

22 Treatment Low risk pt. High risk pt. Low risk tumor High risk tumor Low risk group Intermediate risk group Intermediate risk group High risk group 22

23 Treatment Low risk pt. High risk pt. Low risk tumor High risk tumor Lobectomy Total thyroidectomy Lobectomy? Total thyroidectomy 23

24 Treatment Indication for thyroid lobectomy Papillary carcinoma and Single and < cm and No vascular or capsular invasion 24

25 Treatment (%) Low risk Intermedi ated risk High risk 5 y SR y SR

26 Treatment Total thyroidectomy Multicentricity (30-70%) Recurrence in the opposite lobe (5-15%) High incidence of mortality in patient with local recurrence High incidence of complication in reoperative thyroid surgery Minimal complication of total thyroidectomy in experienced hands 26

27 Treatment Advantage of thyroid lobectomy High survival rate in low risk group Decrease risk of complications Vocal cord paralysis Unilateral hoarseness Bilateral upper airway obstruction Hypoparathyroidism hypocalcemia 27

28 Treatment Disadvantage of thyroid lobectomy Unable to detect recurrent and distant metastasis by thyroglobulin level and I-131 total body scan Unable to use I-131 ablation as adjuvant therapy 28

29 Treatment Post-op thyroid lobectomy Need thyroid suppression therapy Need carefully follow up by physical examination or ultrasonography to detect recurrence 29

30 Treatment Neck management N 0 not need elective neck treatment Central neck dissection N+ node picking neck dissection Selective neck dissection Modified radical neck dissection 30

31 Summary Thyroid mass FNA Benign Suspicious Malignancy Observation +/- suppression Rx Total thyroidectomy Fail Lobectomy Success Benign Malignancy Benign Malignancy Completion thyroidectomy I-131 Rx 31

32 Summary Thyroid mass FNA Benign Suspicious Malignancy Observation +/- suppression Rx Total thyroidectomy Fail Lobectomy Success Benign Malignancy Benign Malignancy Completion thyroidectomy I-131 Rx 32

33 Summary Thyroid mass FNA Benign Suspicious Malignancy Observation +/- suppression Rx Total thyroidectomy Fail Lobectomy Success Benign Malignancy Benign Malignancy Completion thyroidectomy I-131 Rx Suppression Rx 33

34 Summary Thyroid mass FNA Benign Suspicious Malignancy Observation +/- suppression Rx Total thyroidectomy Fail Lobectomy Success Benign Malignancy Benign Malignancy Completion thyroidectomy I-131 Rx Suppression Rx 34

35 Summary Thyroid mass FNA Benign Suspicious Malignancy Observation +/- suppression Rx Total thyroidectomy Fail Lobectomy Success Benign Malignancy Benign Malignancy Completion thyroidectomy I-131 Rx Suppression Rx 35

36 I-131 ablation 36

37 Age (Sloan, 1954) Prognostic factors Age,sex,histo,size,matas (EORTC, 1979) Age,grade,extent,size (AGES, Hay, 1987) Grade,age,metas,extent,size (GAMES, Shah, 1996) Metas,age,completeness of resection,invasion,size (MACIS, Hay, 1993) TNM system (UICC, 1992) 37

38 Prognostic factors AGES (Mayo clinic, 1987) Age > 40 Grade (histological) > I Extrathyroid extension Size > 3 cm 38

39 Prognostic factors AGES (Mayo clinic, 1987) Prog. score = 0.05 x age (in years if > 40) + 1 (if grade is 2) or + 3 (if grade is 3 or 4) + 1 (for extrathyroid extension) or +3 (for distant metastasis) x tumor size (in cm) 39

40 Prognostic factors AGES (Mayo clinic, 1987) Group PS mortality (%) I < II III IV

41 Prognostic factors AMES (Lahey clinic, 1988) Age > 40 for male or > 50 for female Metastasis Extrathyroid extension Size > 5 cm 41

42 Prognostic factors AMES (Lahey clinic, 1988) AMES factors rec mor 40 y-sur (%) Present Absent

43 GAMES (Memorial Sloan Kettering Cancer Center, 1992) Grade (histological) > II Age > 45 Metastasis Extension beyond the thyroid capsule Size > 4 cm Prognostic factors 43

44 Prognostic factors GAMES (Memorial Sloan Kettering Cancer Center, 1992) High risk patient Age > 45 male High risk tumor Grade (histological) > II Metastasis Extension beyond the thyroid capsule Size > 4 cm 44

45 Prognostic factors GAMES (Memorial Sloan Kettering Cancer Center, 1992) Low risk tumor High risk tumor Low risk pt. Low risk Intermediate risk High risk pt. Intermediate risk High risk 45

46 Prognostic factors GAMES (Memorial Sloan Kettering Cancer Center, 1992) Low risk tumor High risk tumor Low risk pt. Lobectomy Total thyroidectomy High risk pt. Lobectomy? Total thyroidectomy 46

47 Prognostic factors GAMES (Memorial Sloan Kettering Cancer Center, 1992) Patient long-term survival (%) Low risk 99 Intermediate 85 High risk 57 47

48 Prognostic factors MACIS (Mayo clinic, 1993) Metastasis Age > 40 Completeness of resection Extrathyroid invasion Size 48

49 Prognostic factors MACIS (Mayo clinic, 1993) PS = 0 (if no metastasis) or + 3 (if metastasis present) (if age is < 40) or x age (if age 40+) + 1 (if incomplete resection) + 1 (if extrathyroid invasion) x tumor size (in cm) 49

50 Prognostic factors MACIS (Mayo clinic, 1993) Group PS mortality (%) I < 6 1 II III IV

51 Prognostic factors DAMES (Karolinska institute, 1992) DNA ploidy Age > 40 for male or > 50 for female Metastasis Extension beyond the thyroid capsule Size > 5 cm 51

52 Prognostic factors DAMES (Karolinska institute, 1992) Ploidy AMES DAMES rec or DM Euploid + low risk = low risk 8 Euploid + high risk = interm. risk 55 Aneuploid + high risk = high risk

53 Prognostic factors AJCC staging T 1 < 2 cm T cm T 3 > 4 cm T 4 extrathyroid extension N 0 / N 1a (level VI) /N 1b M 0 / M 1 53

54 Age < 45 years Prognostic factors Stage I any T any N M 0 Stage IIany T any N M 1 Age > 45 years * T 1 T 2 T 3 T 4 N 0 I II III IV N 1a III III III IV N 1b IV IV IV IV M+ IV 54

55 AJCC Prognostic factors Age > 45 years Size > 4 cm Extrathyroid extension Lymph node metastasis Distant metastasis 55

56 I Histological grade minimal pleomorphism, encapsulated and circumscribed tumor II some cellular pleomorphism, often with intraglandular invasion III dedifferentiated and pleomorphic tumor, often with extracapsular invasion 56

4/22/2010. Hakan Korkmaz, MD Assoc. Prof. of Otolaryngology Ankara Dıșkapı Training Hospital-Turkey.

4/22/2010. Hakan Korkmaz, MD Assoc. Prof. of Otolaryngology Ankara Dıșkapı Training Hospital-Turkey. Management of Differentiated Thyroid Cancer: Head Neck Surgeon Perspective Hakan Korkmaz, MD Assoc. Prof. of Otolaryngology Ankara Dıșkapı Training Hospital-Turkey Thyroid gland Small endocrine gland: