Locally advanced papillary thyroid cancer

Transcription

1 Locally advanced papillary thyroid cancer Educational Session 12 th October 2015 Presenters: Smith JA, Carr-Boyd E Supervisors: Palme CE, Elliott M, Navin N, Gupta R

2 Content Case report Imaging Primary Therapy Surgery Pathology Adjuvant Therapy

3 Case report 56y female patient Persistent left lower neck mass Voice and Airway NAD Swallowing NAD No family history MTC/PTC No radiation exposure Obesity, Hypertension, OSAS Investigations?

4 FNAC Bethesda 6 USS suspicious mass 6cm?extra-thyroidal What investigations? Treatment options? Total Thyroidectomy Fixed to trachea and larynx How to proceed? How to decide intraoperatively? Case Report

5 Case report Right hemithyroidectomy performed Open biopsy left thyroid Procedure abandoned

6 Normal thyroid histology

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8 Histology incisional biopsy

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11 Intranuclear cytoplasmic inclusions Nuclear grooves

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13 Case report Patient offered ERBT 5/52 course Sorafanib 3/12 course Then offered resection?laryngectomy Sought second opinion Comments?

14 ERBT in PTC? Treatment as primary modality Palliative setting only Addressing specific symptom with no possibility of cure Treatment of DTC as adjuvant therapy High risk of loco regional recurrence Gross local invasion Recurrence in non-iodine concentrating disease where surgery is impractical Metastasis in inaccessible places (palliative) Brain Spine Bone Perros P, Boelaert K, Colley S, Evans C, Evans RM, Gerrard BA G, et al. Guidelines for the management of thyroid cancer. Clin Endocrinol (Oxf) Jul 1;81:1 122.

15 Sorafanib in PTC? Small molecular therapy (TKinase inhib) Inhibits angiogenesis (RET, KIT, VEGFR1-3, PDGFR-B) Improves DFS not DSS (phase III RCT) FDA licensed for RAI resistant DTC The principal indication for targeted treatments is progressive, symptomatic disease, refractory to conventional treatments (4, D). Targeted therapies should only be administered in the setting of cancer units that have experience in monitoring and managing adverse effects of targeted therapies (4,D) Consideration should therefore be given to entry into clinical Brose studies M, Nutting (4,D) C, Jarzab B, et al. Sorafenib in locally advanced or metastatic patients with radioactive iodine refractory differentiated thyroid cancer: The phase III DECISION trial. J Clin Oncol 2013:31

16 Case report Firm?fixed mass left lower neck No palpable nodes No voice airway issue Received ERBT and sorafanib Comments? Investigations?

17 CT

18 CT/MRI Carotid abutted not obviously encased Pre-vertebral muscles not obviously invaded No luminal tracheal/laryngeal invasion Oesophagus not clearly involved MRI higher sensitivity/specificity Wang J, Takashima S, Matsushita T, Takayama F, Kobayashi T, Kadoya M. Esophageal invasion by thyroid carcinomas: prediction using magnetic resonance imaging. J Comput Assist Tomogr Feb;27(1):18 25.

19 FDG-PET

20 Role of PET-CT in PCT? Detection of recurrent disease in patients with rising Tg Identification of resectable disease Detection for suspected metastasis RAI uptake inversely proportional to SUV May serve as a prognostic marker (marker of dedifferentiation) Perros P, Boelaert K, Colley S, Evans C, Evans RM, Gerrard BA G, et al. Guidelines for the management of thyroid cancer. Clin Endocrinol (Oxf) Jul 1;81:1 122.

21 Treatment options? Principles? Resection Challenges Reconstruction Options? How do we prepare How to consent the patient?

22 What we did Completion thyroidectomy Major vessels peeled off tumour IJV and CC preserved RLN sacrificed Neck dissection Access to retro-pharyngeal nodes Tracheal shave Positive margin frozen sections Window resection tracheal Further tracheal resection Fascio-cutaneous infra-clavicular pedicled flap De-epitheliased Sutured around tracheostomy

23 Intra-operative: Ablation

24 Specimen

25 Intra-operative: Reconstruction

26 Intra-operative: Reconstruction

27 Diagnosis Left lobe - Papillary thyroid carcinoma Extrathyroidal extension LVI No evidence of anaplastic transformation BRAFV600E + Thyroglobulin + Right lobe - NEOM

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30 Low power sclerosis, tumour islands

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46 Variants with aggressive behaviour PTC with transformation to anaplastic carcinoma Diffuse sclerosing variant (lymph node and lung metastasis more common) Tall cell variant Columnar cell variant Solid variant (found in children with hx radiation exposure; vascular invasion and extra-thyroidal extension occur in 1/3) PTC with prominent hobnail-features (50% mortality from metastases) PTC with focal insular component (potentially more aggressive than conventional PTC)

47 Variants of papillary carcinoma Follicular variant (most common) Macrofollicular variant (diagnostically difficult) Cribriform morular variant (need to check for FAP) Oncocytic variant Clear cell variant (diagnostically difficult at metastatic site) Papillary microcarcinoma (<1cm, often incidental, multifocal) PTC with fasciitis-like stroma

48 Prognosis papillary thyroid carcinoma Stage I 97.1% II 92.8% III 82% IV 41.4% 5-Year Relative Survival Rate

49 Case report: Post operative recovery Covering tracheostomy through defect Neck drains NG feeding Requiring significant PEEP to maintain sats

50 Summary so far ypt4a ypn1b M0 PTC no atypical features Completely excised Adjuvant therapy?

51 Radio active iodine treatment

52 Adjuvant therapy? I 131 ERBT Chemotherapy Small molecular therapy