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

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Management of Differentiated Thyroid Cancer: Head Neck Surgeon Perspective

of Otolaryngology Ankara Dıșkapı Training Hospital-Turkey Thyroid gland Small

absence, life goes on without any morbidity It can host the most aggressive and

1 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: gr Very important t physiological i l functions In its absence, life goes on without any morbidity It can host the most aggressive and the best prognostic cancers of human body Its surgery may lead to very significant morbidity (dyspnea, hoarseness, hypocalcemia, death) 1

2 Thyroid Nodules Prevalence Palpabl 3-7% (women 64% 6.4%, men 1.5%) 15%) USG 50% 5% of nodules can be malignant To determine the malignant nodules accurately would increase the cure rates of thyroid cancer Thyroid cancers Differentiated thyroid follicular cancer (epithelial) Papillary cancer 75-80% Follicular cancer 5-10% Hurthle cell cancer 5% Medullary thyroid cancer 5-10% (neuroendocrine/parafollicular C cells) Poorly differentiated cancer 1% Anaplastic cancer 1% Lymphoma <1% Rare cancers and metastasis 2

3 The goals of initial treatment of differentiated thyroid cancers (ATA 2006) To remove the primary tumor, its extracapsular extensions, involved lymph nodes To minimize disease and treatment related morbidity To permit accurate staging of the disease To facilitate postoperative radioactive ablation when appropriate To permit accurate long-term surveillance for disease recurrence (USG, thyroglobulin, whole body scan) To minimize the risk of local recurrance and metastatic spread (RI ablation,tsh supr, ekst.radyot. ) TNM staging (2002 AJC) pt1 : <1cm tumor pt2: >1-4cm tumor pt3: >4cm tumor pt4a: extrathyroidal extension (soft tissue, larynx, trachea, esophagous, RLN) pt4b: invasion to prevertebral fascia, carotid artery, mediastinal vessels N0: No lymph node N1a: central lymph nodes(para and pretracheal, upper mediastinal) N1b: Bilateral, ipsilateral, contralateral cervical and mediastinal lymph nodes M0: No distant metastasis M1: Distant metastasis 3

4 TNM staging (AJCC 2002) age <45 age >45 Stage I All pt, All N, M0 pt1, N0, M0 Stage II All pt,all N, M1 pt2, N0, M0 Stage III pt3, N0, M0 pt1/2/3, N1a, M0 Stage IVA pt4a, N0/1a,M0 pt1/2/3, N1b,M0 pt4a,n1b,m0 Stage IVB T4b, All N, M0 Stage IVC All pt, All N, M1 Clinical Prognostic factors age>45, size>4cm Age Grade Extension Size (Mayo) Age Metastasis Extension Size (Lahey) Age Metastasis Completeness of resection İnvasion Size Low risk patients 75-80% of all patients 4

5 Patient management Diagnosis Surgery Adjuvant thearpy (radiaoactive ablation, TSH supression) Follow up Diagnosis Symptoms/ physical examination (not specific) Imaging-Ultrasound* FNA cytology* Scintigraphy Laboratory 5

6 Imaging: USG is gold standart Imaging High resolution Ultrasonography** : if hypoechogenic nodules with Microcalcifications Irregular borders and extranodular extension Peripheral vascularity CT and MRI is not routine and indicated d if Extrathyroidal extension Retrosternal extension Palpable lymph nodes Fine Needle Aspiration Cytology (FNAC) Benign: 1-2% malignant follow up Non-diagnostic: repeat FNA /5-10% malignancy if repeated biopsy non diagnostici surgery Suspicious or indeterminate Follicular or Hurthle cell neoplazm: 10-20% malignancy surgery Suspicious for malignancy :20% malignancy-papillary cancer surgery Atypical cells repeat biopsy vs follow up Malignant: 95% malignant surgery 6

7 Nodules: risk of malignancy The malignancy risk of multinodular goiter is similar to single nodule Ultrasonographic characteristics of the nodule should determine the need for FNA Not always the largest nodule has the risk of malignancy Sonographic findings are superior to nodule size with respect to malignancy Scintigraphy Thyroid scans has almost no role in the diagnosis of malignancy It is not indicated as routine If the cytology is nondiagnostic or indeterminant and TSH is low: DO THYROİD SCAN Very little chance of malignancy in warm or hot nodules 7

8 Laboratory TSH, free T 4, free T 3 are indicated to rule out hypo or hyper thyroidism Thyroglobulin (Tg) Shows presence of thyroid tissue, does not show malignancy / the level is correlated with the size of nodule Anti-thyroglobulin (Ab-Tg) is important along with Tg levels in the postop follow up Calcitonin indicated to differentiate medullary cancer (1/ nodules) Surgery is the only treatment Total thyroidectomy Near total thyroidectomy (<1 gr tissue left) Subtotal thyroidectomy (>1 gr tissue left): is contraindicated in thyroid cancers Total lobectomy: diagnostic/ should be followed by completion thyroidectomy if the pathology reports cancer 8

9 Completion thyroidectomy (when the pathologic examination is cancer after the diagnostic total lobectomy) For patients who need total or near-total thyroidectomy Low risk, micropapillary cancer with negative nodes may not be needed The goals of thyroid surgery To obtain diagnosis in non-diagnostic or suspicious (indeterminant) cytology Complete eradication of thyroid cancer and normal thyroid tissue Staging Preparation for radioactive ablation 9

10 Surgery: Neck dissection Therapeutic neck dissection: standart if lymph node positive with palpation and imaging (level II, III, IV, VI) Always compartmental, NEVER BERRY PICKING Elective neck dissection: Not for follicular ca./usg is the choice of imaging for lymph nodes High risk patients: central neck dissection (levelvi) Papillary cancer Hurthle cell cancer Low risk patients: age<45, tumor< 1cm, female, Not standart Elective neck dissection Bilateral central neck dissection improves regional control and survival (contrary to previous reports) Micrometastasis may be missed by USG plus retrosternal region is difficult to examine by USG routine elective central dissection Level II, III and IV dissection is not indicated if lymph nodes are negative by USG 10

11 Radioactive Ablation: Adjuvant Treatment High risk cancers: standart Low risk cancers: The goals of this treatment are to destroy residual thyroid tissue, to prevent recurrence and to facilitate long-term surveillance with whole-body iodine scans and/or stimulated thyroglobulin measurements (ATA 2006) Radioactiveiodine ablation A number of large, retrospective studies show a significant reduction in the rates of disease recurrence and cause-specific mortality. However, other similar studies show no such benefit, at least among the majority of patients with papillary thyroid carcinoma, who are at the lowest risk for mortality (<1.5 cm, young age)(ata 2006) 11

12 Radioiodine ablation is recommended for patients stages III and IV disease all patients with stage II disease younger than age 45 years (M1) and most patients with stage II disease 45 years or older, selected patients with stage I disease, (multifocal disease, nodal metastases, extrathyroidal or vascular invasion, and/or more aggressive histologies) Supression of TSH Supraphysiological dose of LT4 treatment For high risk patients TSH should be <0.01 Low risk patients TSH A recent meta-analysis supported the efficacy of TSH suppression therapy in preventing major adverse clinical events 12

13 External beam radiation Infrequently used >45 y, residual disease, unresectable disease, gross extrathyroidal extension and invasion Chemotherapy: almost no advantage Follow up Ultrasound Scanning (Thyroid vs whole body) Thyroglobulin (should be below <2 ng) 13

14 Conclusion Differentiated thyroid cancer is very curable disease USG and cytology are gold standart for diagnosis Only treatment is thyroidectomy Adjuvant treatment, with radioactive ablation and TSH supression, in high risk patients is very important USG, Thyroglubulin, Whole body scan are very helpful in follow-up 14

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

Management guideline for patients with differentiated thyroid Teeraporn Ratanaanekchai ENT, KKU 17 October 2007 Incidence (Srinagarind Hospital, 2005, both sex) Site (all) cases % 1. Liver 1178 27 2. Lung