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Management of Well Differentiated Thyroid Cancer,Vivek Ramarathnam, M.D. SIU- Otolaryngology Grand Rounds 9/1/2005,Thyroid Nodules,Between 4-7% of individuals in US have palpable thyroid nodules More common in women Increase in frequency with age Fewer than 10% of solitary nodules are malignant - Papillary (75%) - Follicular (15%),Thyroid Carcinoma,1.5% of all newly diagnosed cancers Number increasing over last 25 years; 4.8 to 8.0 cases per 100,000 Female predominance (11.7 female to 4.2 male cases/100,000 Death rate 0.5 cases per 100,000,Nodules and Carcinoma Rates,Rates of carcinoma in a single nodule: 5-17% Rates of carcinoma in multinodular patients: 5-13%,Risk Factors for Malignancy,Prior irradiation Family history Male sex Nodules in individuals 45 Symptoms of invasiveness: development of hoarseness, progressive dyshagia, or dyspnea,Physical Examination,Pulse rate, Blood Pressure Neck Lymphadenopathy Deviation of Trachea Palpation of Thyroid gland (Size, consistency, mobility, presence or absence of tenderness, multinodularity) Attention of thyroid mass to surrounding anatomy,Preoperative Evaluation,Individuals with symptoms potentially of invasive carcinoma- dysphonia, dysphagia, or stridor Flexible laryngoscopy MRI allows soft tissue evaluation (cervical esophageal invasion) CT, readily available, iodinated contrast used can delay the use of RAI postoperatively 4-6 weeks Selected patients, panendoscopy,Thyroid Picture,Thyroid Anatomy,Arteries- Paired arteries, superior, inferior arteries Venous drainage- parallels arterial drainage, superior thyroid veins drain into internal jugular vein, inferior thyroid veins to brachiocephalics Lymphatics- intraglandular lymphatic network, paratracheal, upper, mid, and lower jugular nodes,Thyroid Hormone Physiology,Growth- hormones work in bone formation CNS- brain maturation Basal metabolic rate Cardiovascular and respiratory systems Metabolic effects,Thyroid Histology,Thyroid Hormone Regulation,TSH stimulates both iodine uptake and its organification,Management steps with a Thyroid Nodule,TSH level - 95% of all nodules are hypofunctional (cold) If TSH normal, obtain a ultrasound and perform FNA - if firm and palpable FNA can be performed without image guidance,Ultrasound Imaging and Nodules,US reports thyroid size and appearance, 3D description of specific nodules, presence of paratracheal nodes, and evidence of invasive qualities. Useful in individuals undergoing FNA and have difficult lesions to palpate. Also beneficial in complex cysts, and nodules with questionable multinodularity,Management steps with a Thyroid Nodule,If TSH high, treat with thyroid hormone replacement and FNA when patient is euthyroid TSH level low; may have hyperfunctioning nodule and should be evaluated with thyroid scan. Low likelihood of malignancy,Evaluation of solitary nodule,FNA (fine needle aspiration) 4 types of interpretations: 1) Benign 2) Malignant 3) Suspicious for follicular or Hurthle cell tumor 4) Insufficient for diagnosis,Overview of Nodule workup,Case Presentation,22 female referred for enlarging thyroid mass Right lobe of thyroid. Last year 2.8 cm and now 3.4 cm in greatest diameter. Complex mass described per US report. Otherwise asymptomatic. Mother- hyperthyroid. Medications: Effexor XR, Ortho patch FNA- Cellular follicular lesion,Papillary Carcinoma,Follicular Carcinoma,Fine needle aspiration,Procedure requires skill by operator, as well as by cytopathologist Even in skilled hands, approximately 10% of biopsy findings nondiagnostic Sensitivity 92%, Specificity- 91-97.5%,Findings on FNA,Benign finding- Followed serially by US If nodule has increased in size 15%, repeat FNA should be performed Follicular neoplasm- 80% of these nodules are benign, 20% represent thyroid carcinoma Papillary carcinoma- accuracy of FNA approaches 100%,Fine needle aspiration,Suspicious for follicular or Hurthle cell tumor Diagnosis of follicular of Hurthle cell tumor from follicular carcinoma or Hurthle cell carcinoma requires presence or absence of capsular or vascular invasion seen on histologic examination of surgical specimens Follicular and Hurthle cell tumors diagnosed by FNA have malignancy rate of 10-20%,Case Presentation,Pt underwent Right lobectomy with isthmusectomy Frozen section- Follicular neoplasm Final pathology- Follicular adenoma,Management of FNA results,Follicular neoplasm - Thyroid lobectomy, allow histiopathologic diagnosis to dictate need for total - Serial US, TSH suppression, repeat FNA - Plan for lobectomy with frozen section, if reveals follicular variant of papillary, perform total - Perform total thyroidectomy,Staging,Staging,5 year survival rates,Risk Analysis,AGES (age, grade, extent, size) AMES (age, metastases (distant), extent, size) MACIS (metastasis, patient age, completeness of resection, local invasion, and tumor size),AGES,Hay ID, et al. 61st American Thyroid Association Annual Meeting 1986,Papillary CA N= 860 Age= 0.5 x age Grade2 = 1 Grade3-4 =3 Extrathyroidal=1 E(distant)= 3 Size= 0.2 x cm,Hay ID, et al.,Surgical Management,Wein, RO, Weber RS, Contemporary Management of Differentiated Thyroid Carcinoma. Otolaryngol Clin N Am 2005 “ Surgery therapy for the majority of well-differentiated thyroid carcinomas should be tailored to the eradication of macroscopic disease while preserving the patients capacity for functional speech and swallowing and parathyroid preservation.”,Lobectomy vs. Total Thyroidectomy,Shaha AR, Shah JP, Loree TR Ann Surg Oncol 1997 Low risk patients need selective treatment Retrospective review of 1038 patients, 465 patients in low risk group, 403 patients papillary and 62 patients follicular Median follow-up 20 years. No statistical difference in overall failure rate or local recurrence rate between lobectomy vs. total thyroidectomy,Reasons for Total Thyroidectomy,Hay ID et al. Surgery 1987 Removes not only the primary tumor but also microscopic contralateral disease 80% Prevents local recurrence (5-24%) or anaplastic (1%) transformation in the contralateral lobe Decreased need for 2nd operation with increased risk Thyroglobulin surveillance for recurrence Radioactive iodine scanning/therapy,Complications of Total Thyroidectomy,Hypoparathyroidism 10% Recurrent laryngeal nerve paralysis 1%,Sites of Invasive Spread,McCaffrey, TV et al. Mayo Clinic, 50-year experience. Head Neck 1994,Surgical Considerations,Tracheal involvement - Window and sleeve resections - Larger defects, sternocleidomastoid and pectoralis major myoperiosteal flaps over T-tubes - Tracheal resection with re-anastomosis,Esophageal Invasion,Tends to invade only the outer muscular layers Limited resection without intraluminal entry is posssible When intraluminal invasion encountered, primary closure vs. free tissue transfer for larger resections,Recurrent laryngeal nerve,Falk SA, McCaffrey TV. Otolaryngol Head Neck Surg 1995 Retrospectively compared patients and noted that complete resection of tumor and nerve sacrifice offered no survival benefit over potentially incomplete resection of tumor and nerve preservation,Laryngeal Involvement,Vertical partial laryngectomy, unilateral disease Supracricoid partial laryngectomy, extensive anterior invasion Total laryngectomy, extensive laryngeal spread,Regional metastasis,Intraglandular lymphatics First nodal drainage paralaryngeal, paratracheal, prelaryngeal nodes VI Second level of drainage II, III, IV, V Elective neck dissection in setting of papillary CA will detect occult spread in 50% of patients; reported no added benefit on survival,Regional metastasis,Radiologic imaging for regional spread include US, CT, and MRI US- most accurate when combined with FNA, Serial tests can evaluate changes in nodal size Imaging criteria for CT/MRI: recurrent disease, clinical lymph node metastases, vocal cord paralysis, fixation of mass to adjacent structures, symptoms of upper aerodigestive involvement Type of neck dissection dictated by extent of disease,Neck dissection,Ferlito A., Pellitteri PK, Robbins KT et al. Review article. Acta Otolaryngol 2002 Selective dissection for extension of tumor noted, direct involvement of non-lymphatic structures In high risk patients (male 45, with large 4cm cancer) recommend ipsilateral paratracheal node dissection given highest risk of containing metastases Low risk, palpate region if no enlarged lymph nodes, elective neck dissection not carried out,Postoperative treatment,Radioactive iodine ablation decreases the local recurrence and mortality rates in patients with stage 2 and stage 3 well-differentiated thyroid carcinoma Use of postoperative RAI and thyroid hormone supression has been advocated for patients with tumors 1.5 cm,Long term potential complications of Thyrotropin (TSH) Suppression,Increased bone loss, particularly in postmenopausal women Hyperthyroidism Cardiac h