tyroid cancer

8/14/2019 Tyroid cancer

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THYROD CANCERTHYROD CANCERProf.Dr.YUSUF BKEYProf.Dr.YUSUF BKEY


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IntoductionIntoduction Consistent techniques of thyroid surgery dateConsistent techniques of thyroid surgery date

back approximately 100 yearsback approximately 100 years Theodor Kocher of Bern, Switzerland made majorTheodor Kocher of Bern, Switzerland made major

contibutions to thyroid the understanding ofcontibutions to thyroid the understanding ofthyroid disease and thyroid surgerythyroid disease and thyroid surgery

1872 - performed his first thyroidectomy1872 - performed his first thyroidectomy 1901 - had performed 2,000 thyroid procedure1901 - had performed 2,000 thyroid procedure 1901 - overall operative mortality had decreased1901 - overall operative mortality had decreased

from 50% tofrom 50% to 4.5%4.5% 1909 - won the nobel prize for his work1909 - won the nobel prize for his work

(Cady,(Cady,1991, Soh,1996)1991, Soh,1996)


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Statistics of Thyroid CancerStatistics of Thyroid Cancer 1.0%-1.5%1.0%-1.5% of all new cancer cases in the United Statesof all new cancer cases in the United States

(Sessions, 1993, Silverberg, 1989)(Sessions, 1993, Silverberg, 1989) ten fold less than that of lung, breast, or colorectalten fold less than that of lung, breast, or colorectalcancercancer

8,000-14,0008,000-14,000 new cases diagnosed eachnew cases diagnosed eachyear (Sessions,year (Sessions,1993, Geopfert, 1998)1993, Geopfert, 1998)

3%3% of patients who die of other causes have occult thyroidof patients who die of other causes have occult thyroidcancer andcancer and 10%10% have microscopic cancers (Robbins, 1991)have microscopic cancers (Robbins, 1991)

35%35% of thyroid gland at autopsy in some studies haveof thyroid gland at autopsy in some studies havepapillary carcinomas (


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Statistics of Thyroid CancerStatistics of Thyroid Cancer(continued)(continued)

4%-7%4%-7% of adults in North America haveof adults in North America havepalpable thyroid nodulespalpable thyroid nodules (Mazzaferri, 1993,(Mazzaferri, 1993,Vander, 1968)Vander, 1968)

4:14:1 women to menwomen to men (Mazzaferri, 1993)(Mazzaferri, 1993) Overall, fewer thanOverall, fewer than 5%5% of nodules areof nodules are

malignantmalignant (Mazzaferri, 1988)(Mazzaferri, 1988)


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HistoryHistory

SymptomsSymptoms The most common presentation of a thyroidThe most common presentation of a thyroid

nodule, benign or malignant, is a painlessnodule, benign or malignant, is a painlessmass in the region of the thyroid glandmass in the region of the thyroid gland(Goldman, 1996)(Goldman, 1996)..

Symptoms consistent with malignancySymptoms consistent with malignancyPainPain

dysphagiadysphagiaStridorStridorhemoptysishemoptysisrapid enlargementrapid enlargement

hoarsenesshoarseness


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HistoryHistory (continued...)(continued...)

Risk factorsRisk factors((continued)continued)

Age and SexAge and SexBenign nodules occur most frequently inBenign nodules occur most frequently in

women 20-40 yearswomen 20-40 years (Campbell, 1989)(Campbell, 1989)5%-10% of these are malignant5%-10% of these are malignant (Campbell, 1989)(Campbell, 1989)Men have a higher risk of a nodule beingMen have a higher risk of a nodule being

malignantmalignantBelfiore and co-workers found that:Belfiore and co-workers found that:

the odds of cancer in men quadrupled by the age ofthe odds of cancer in men quadrupled by the age of6464

a thyroid nodule in a man older than 70 years hada thyroid nodule in a man older than 70 years had

a 50% chance of being malignanta 50% chance of being malignant


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HistoryHistory (continued)(continued)

Family HistoryFamily History History of family member withHistory of family member with

medullary thyroid carcinomamedullary thyroid carcinoma

History of family member with otherHistory of family member with otherendocrine abnormalities (parathyroid,endocrine abnormalities (parathyroid,adrenals)adrenals)

History of familial polyposisHistory of familial polyposis(Gardners syndrome)(Gardners syndrome)


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Evaluation of the thyroid NoduleEvaluation of the thyroid Nodule((Physical ExamPhysical Exam))

Examination of the thyroid nodule:Examination of the thyroid nodule:consistency - hardconsistency - hard vs.vs. softsoft

size -size - < 4.0 cm< 4.0 cmMultinodularMultinodular vs.vs. solitary nodulesolitary nodule multi nodular -multi nodular - 3%3% chance of malignancychance of malignancy

(Goldman, 1996)(Goldman, 1996)

solitary nodule -solitary nodule - 5%-12%5%-12% chance of malignancychance of malignancy

(Goldman, 1996)(Goldman, 1996)Mobility with swallowingMobility with swallowingMobility with respect to surrounding tissuesMobility with respect to surrounding tissuesWell circumscribedWell circumscribed vs.vs. ill defined bordersill defined borders


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Physical ExamPhysical Exam (continued)(continued) Examine for ectopic thyroid tissueExamine for ectopic thyroid tissue Indirect or fiberoptic laryngoscopyIndirect or fiberoptic laryngoscopy

vocal cord mobilityvocal cord mobilityevaluate airwayevaluate airway

preoperative documentation of any unrelatedpreoperative documentation of any unrelatedabnormalitiesabnormalities

Systematic palpation of the neckSystematic palpation of the neckMetastatic adenopathy commonly found:Metastatic adenopathy commonly found:

in the central compartment (level VI)in the central compartment (level VI) along middle and lower portion of the jugular veinalong middle and lower portion of the jugular vein

(regions III and IV) and(regions III and IV) and Attempt to elicit Chvosteks signAttempt to elicit Chvosteks sign


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Evaluation of the Thyroid NoduleEvaluation of the Thyroid Nodule(Blood Tests)(Blood Tests)

Thyroid function testsThyroid function teststhyroxine (T4)thyroxine (T4)

triiodothyronin (T3)triiodothyronin (T3)thyroid stimulating hormone (TSH)thyroid stimulating hormone (TSH)

Serum CalciumSerum Calcium

Thyroglobulin (TG)Thyroglobulin (TG)CalcitoninCalcitonin


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Solitary Thyroid NoduleSolitary Thyroid Nodule HistoryHistory

Duration, recent enlargement, voice change, H/ODuration, recent enlargement, voice change, H/Ohypo/hyperthyroidism, irradiation, F/H goitre/cancerhypo/hyperthyroidism, irradiation, F/H goitre/cancer

Physical examinationPhysical examination

Dominant nodule, movement on deglutition, cervicalDominant nodule, movement on deglutition, cervicallymph nodes, fixation, hardnesslymph nodes, fixation, hardness

Thyroid function studiesThyroid function studies

Serum TSHSerum TSH

T4 & T3 levelsT4 & T3 levels

Antibody levels; ATA, AMA 1:100Antibody levels; ATA, AMA 1:100

Thyroid imaging; Scanning (99mTc, 123I, 131I)Thyroid imaging; Scanning (99mTc, 123I, 131I)


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Solitary Thyroid NoduleSolitary Thyroid Nodule CXRCXR

UltrasoundUltrasound

Solid/cysticSolid/cystic

MulticentricMulticentric

Lymph node involvementLymph node involvement Ultrasound-assisted FNAUltrasound-assisted FNA

CT/MRI of neckCT/MRI of neck

Mainly for large/recurrent cancersMainly for large/recurrent cancers

Vascular/lymphatic invasionVascular/lymphatic invasion Cervical/mediastinal metastasisCervical/mediastinal metastasis


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Solitary Thyroid NoduleSolitary Thyroid Nodule FNAC (Fine Needle Aspiration Cytology)FNAC (Fine Needle Aspiration Cytology)

Easy, safe, cost effectiveEasy, safe, cost effective

Negative predictive valueNegative predictive value 89%- 98%89%- 98%

False Negative rateFalse Negative rate 6%6%

False Positive rateFalse Positive rate 4%4%

FNAC CytodiagnosisFNAC Cytodiagnosis

BenignBenign Colloid adenoma, thyroiditis, cystColloid adenoma, thyroiditis, cyst

MalignantMalignant Papillary (70%), follicular (15%), medullary (5%-10%),Papillary (70%), follicular (15%), medullary (5%-10%),

anaplastic(3%), lymphoma (3%), metastasis (rare)anaplastic(3%), lymphoma (3%), metastasis (rare)

IndeterminateIndeterminate Microfollicular, Hurthle cell, embryonal neoplasmMicrofollicular, Hurthle cell, embryonal neoplasm


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Solitary Thyroid NoduleSolitary Thyroid Nodule

FNAC ResultFNAC Result

BenignBenign Observe and repeat FNAC 1 yearObserve and repeat FNAC 1 year

MalignantMalignant SurgerySurgery

IndeterminateIndeterminate serum TSH normalserum TSH normal SurgerySurgery

Serum TSH lowSerum TSH low ScintiscanScintiscan

InadequateInadequate Repeat FNARepeat FNA


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Thyroid CancerThyroid Cancer IncidenceIncidence 1%1%

M/F ratioM/F ratio 3:13:1 Risk factorsRisk factors

Radiation exposureRadiation exposure

ExternalExternal Medical treatment for benign conditionsMedical treatment for benign conditions

Medical treatment for malignanciesMedical treatment for malignancies

Environmental exposure- Nuclear weapons or accidentsEnvironmental exposure- Nuclear weapons or accidents

InternalInternal Medical treatment of benign condition with I131Medical treatment of benign condition with I131

Diagnostic tests with I131Diagnostic tests with I131

Environmental- fallout from nuclear weaponsEnvironmental- fallout from nuclear weapons

Other factorsOther factors Diet- Iodine deficiency, goitrogensDiet- Iodine deficiency, goitrogens

Hormonal factors- female gender predominanceHormonal factors- female gender predominance

Benign thyroid diseaseBenign thyroid disease

AlcoholAlcohol


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Classification of Malignant ThyroidClassification of Malignant ThyroidNeoplasmsNeoplasms

Papillary carcinomaPapillary carcinoma Follicular variantFollicular variant Tall cellTall cell Diffuse sclerosingDiffuse sclerosing EncapsulatedEncapsulated

Follicular carcinomaFollicular carcinoma Overtly invasiveOvertly invasiveMinimally invasiveMinimally invasive

Hurthle cellHurthle cell carcinomacarcinoma AnaplasticAnaplastic carcinomacarcinoma

Giant cellGiant cell Small cellSmall cell

Medullary CarcinomaMedullary Carcinoma MiscellaneousMiscellaneous

SarcomaSarcoma LymphomaLymphoma

Squamous cellSquamous cellcarcinomacarcinoma

MucoepidermoidMucoepidermoidcarcinomacarcinoma

Clear cell tumorsClear cell tumors Pasma cell tumorsPasma cell tumorsMetastaticMetastatic

Direct extentionDirect extention

KidneyKidney

ColonColon MelanomaMelanoma


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Thyroid CancerThyroid Cancer

PathologyPathology

Papillary carcinoma;Papillary carcinoma; 60-70% of all cases60-70% of all cases

MultifocalMultifocal

Nonencapsulated, but circumscribedNonencapsulated, but circumscribed Lymphatic spreadLymphatic spread

80% 10 year survival80% 10 year survival Follicular carcinomaFollicular carcinoma

15-20% of thyroid cancers15-20% of thyroid cancers

Usually encapsulatedUsually encapsulated 60% 10 year survival60% 10 year survival


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Well-Differentiated Thyroid CarcinomasWell-Differentiated Thyroid Carcinomas(WDTC) - Papillary, Follicular, and Hurthle(WDTC) - Papillary, Follicular, and Hurthle CCellell

Pathogenesis - unknownPathogenesis - unknown Papillary has been associated with the RETPapillary has been associated with the RET

proto-oncogene but no definitive link hasproto-oncogene but no definitive link hasbeen provenbeen proven (Geopfert, 1998)(Geopfert, 1998)

Certain clinical factors increase theCertain clinical factors increase thelikelihood of developing thyroid cancerlikelihood of developing thyroid cancer

Irradiation -Irradiation - papillary carcinomapapillary carcinoma

Prolonged elevation of TSH (iodine deficiency) -Prolonged elevation of TSH (iodine deficiency) -follicular carcinomafollicular carcinoma (Goldman, 1996)(Goldman, 1996)

relationship not seen with papillary carcinomarelationship not seen with papillary carcinoma

mechanism is not knownmechanism is not known


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WDTC - Papillary CarcinomaWDTC - Papillary Carcinoma

60%-80% of all thyroid cancers60%-80% of all thyroid cancers(Geopfert, 1998, Merino, 1991)(Geopfert, 1998, Merino, 1991)Histologic subtypesHistologic subtypes

Follicular variantFollicular variant

Tall cellTall cellColumnar cellColumnar cellDiffuse sclerosingDiffuse sclerosingEncapsulatedEncapsulated

Prognosis is 80% survival at 10 yearsPrognosis is 80% survival at 10 years(Goldman, 1996)(Goldman, 1996)

Females > MalesFemales > MalesMean age of 35 yearsMean age of 35 years (Mazzaferri, 1994)(Mazzaferri, 1994)


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WDTC - Papillary CarcinomaWDTC - Papillary Carcinoma(continued)(continued)

Lymph node involvement is commonLymph node involvement is commonMajor route ofMajor route ofmetastasis is lymphaticmetastasis is lymphatic46%-90% of patients have lymph node46%-90% of patients have lymph nodeinvolvementinvolvement

(Goepfert, 1998, Scheumann, 1984, De Jong, 1993)(Goepfert, 1998, Scheumann, 1984, De Jong, 1993)

Clinically undetectable lymph nodeClinically undetectable lymph nodeinvolvement does not worsen prognosisinvolvement does not worsen prognosis(Harwood, 1978)(Harwood, 1978)


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WDTC - Papillary CarcinomaWDTC - Papillary Carcinoma(Continued)(Continued)

Microcarcinomas - a manifestation ofMicrocarcinomas - a manifestation ofpapillarypapillary carcinomacarcinoma

Definition - papillary carcinoms smaller than 1.0 cmDefinition - papillary carcinoms smaller than 1.0 cm

Most are found incidentally at autopsyMost are found incidentally at autopsyAutopsy reports indicate that these may be presentAutopsy reports indicate that these may be present

in up to 35% of the population (Mazzaferri, 1993)in up to 35% of the population (Mazzaferri, 1993)Usually clinically silentUsually clinically silent

Most agree that the morbidity and mortality fromMost agree that the morbidity and mortality frommicrocarcinoma is minimal and near that of themicrocarcinoma is minimal and near that of thenormal populationnormal population

One study showed a 1.3% mortality rate (Hay, 1990)One study showed a 1.3% mortality rate (Hay, 1990)


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WDTC - Papillary CarcinomaWDTC - Papillary Carcinoma(continued)(continued)

PathologyPathologyGross - vary considerably in sizeGross - vary considerably in size

-- oftenoften multi-focalmulti-focal-- unencapsulated but often have a pseudocapsuleunencapsulated but often have a pseudocapsuleHistology - closely packed papillae with littleHistology - closely packed papillae with little

colloidcolloid

--psammoma bodiespsammoma bodies- nuclei are oval or elongated, pale staining withnuclei are oval or elongated, pale staining with

ground glass appearancground glass appearancee

-- Orphan Annie cellsOrphan Annie cells

WDTC F lli l C i


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WDTC - Follicular CarcinomaWDTC - Follicular Carcinoma

20% of all thyroid malignancies20% of all thyroid malignanciesWomen > Men (2:1 - 4:1)Women > Men (2:1 - 4:1) (Davis, 1992, De(Davis, 1992, DeSouza, 1993)Souza, 1993)

Mean age of 39 yearsMean age of 39 years (Mazzaferri, 1994)(Mazzaferri, 1994) Prognosis - 60% survive to 10 yearsPrognosis - 60% survive to 10 years

(Geopfert, 1994)(Geopfert, 1994)

Metastasis - angioinvasion andMetastasis - angioinvasion and

hematogenoushematogenous spreadspread15% present with distant metastases to bone15% present with distant metastases to bone

and lungand lung

Lymphatic involvement is seen in 13%Lymphatic involvement is seen in 13%(Goldman, 1996)(Goldman, 1996)


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WDTC - Follicular CarcinomaWDTC - Follicular Carcinoma(Continued)(Continued)

PathologyPathologyGross - encapsulated, solitaryGross - encapsulated, solitary

Histology - very well-differentiated (distinctionHistology - very well-differentiated (distinctionbetweenbetween follicularfollicularadenoma and carcinomaidadenoma and carcinomaiddifficult)difficult)

- Definitive diagnosis - evidence- Definitive diagnosis - evidence

ofofvascularvascular and capsularand capsularinvasioninvasion

FNA and frozen section cannot accuratelyFNA and frozen section cannot accuratelydistinquishdistinquish between benign andbetween benign andmalignant lesionsmalignant lesions

WDTC H thl C ll C i


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WDTC - Hurthle Cell CarcinomaWDTC - Hurthle Cell Carcinoma

Variant of follicular carcinomaVariant of follicular carcinoma First described by AskanazyFirst described by AskanazyLarge, polygonal, eosinophilic thyroid follicularLarge, polygonal, eosinophilic thyroid follicular

cells with abundant granular cytoplasm andcells with abundant granular cytoplasm and

numerous mitochondrianumerous mitochondria(Goldman, 1996)(Goldman, 1996) Definition (Hurthle cell neoplasm) - anDefinition (Hurthle cell neoplasm) - an

encapsulated group of follicular cells with atencapsulated group of follicular cells with atleast a 75% Hurthle cell componentleast a 75% Hurthle cell component

Carcinoma requires evidence of vascular andCarcinoma requires evidence of vascular andcapsular invasioncapsular invasion

4%-10% of all thyroid malignancies4%-10% of all thyroid malignancies(Sessions,(Sessions,1993)1993)


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WDTC - Hurthle Cell CarcinomaWDTC - Hurthle Cell Carcinoma(Continued)(Continued)

Women > MenWomen > Men Lymphatic spread seen in 30% ofLymphatic spread seen in 30% of

patientspatients (Goldman, 1996)(Goldman, 1996)Distant metastases to bone and lungDistant metastases to bone and lung

is seen in 15% at the time ofis seen in 15% at the time of

presentationpresentation


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WDTC - PrognosisWDTC - PrognosisBased on age, sex, and findings at theBased on age, sex, and findings at the

time of surgerytime of surgery (Geopfert, 1998)(Geopfert, 1998)Several prognostic schemesSeveral prognostic schemes

represented by acronyms have beenrepresented by acronyms have beendeveloped by different groups:developed by different groups:

AMESAMES (Lahey Clinic, Burlington, MA)(Lahey Clinic, Burlington, MA)

GAMESGAMES (Memorial Sloan-Kettering Cancer(Memorial Sloan-Kettering CancerCenter, New York, NT)Center, New York, NT)

AGESAGES (Mayo Clinic, Rochester, MN)(Mayo Clinic, Rochester, MN)


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WDTC - PrognosisWDTC - Prognosis (Continued)(Continued)

Depending on variables, patients areDepending on variables, patients arecategorized in to one of the followingcategorized in to one of the followingthree groups:three groups:

1)1) Low risk groupLowrisk group - men younger than 40- men younger than 40yearsyears andand women younger than 50 yearswomen younger than 50 yearsregardless of histologic typeregardless of histologic type

-- recurrence raterecurrence rate -11%-11%

-- death ratedeath rate - 4%- 4%

(Cady and Rossi, 1988)(Cady and Rossi, 1988)


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WDTC - PrognosisWDTC - Prognosis (Continued)(Continued)

1)1)Intermediate risk groupIntermediate risk group

- Men older than 40 years and women older than- Men older than 40 years and women older than

50 years50 years who have papillary carcinomawho have papillary carcinoma

-- recurrence raterecurrence rate - 29%- 29%-- death ratedeath rate - 21%- 21%2)2) High risk groupHigh risk group- Men older than 40 years and women older thanMen older than 40 years and women older than

50 years who have follicular carcinoma50 years who have follicular carcinoma-- recurrence raterecurrence rate - 40%- 40%

-- death ratedeath rate - 36%- 36%


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Medullary Thyroid CarcinomaMedullary Thyroid Carcinoma

10% of all thyroid malignancies10% of all thyroid malignancies 1000 new cases in the U.S. each year1000 new cases in the U.S. each yearArises from the parafollicular cell orArises from the parafollicular cell or

C-cells of the thyroid glandC-cells of the thyroid glandderivatives of neural crest cells of the branchialderivatives of neural crest cells of the branchial

archesarchessecrete calcitonin which plays a role in calciumsecrete calcitonin which plays a role in calcium

metabolismmetabolism


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Medullary Thyroid CarcinomaMedullary Thyroid Carcinoma(Continued)(Continued)

Developes in 4 clinical settings:Developes in 4 clinical settings:Sporadic MTC (SMTC)Sporadic MTC (SMTC)Familial MTC (FMTC)Familial MTC (FMTC)Multiple endocrine neoplasia IIaMultiple endocrine neoplasia IIa

(MEN IIa)(MEN IIa)Multiple endocrine neoplasia IIbMultiple endocrine neoplasia IIb(MEN IIb)(MEN IIb)


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Medullary Thyroid CarcinomaMedullary Thyroid Carcinoma(continued)(continued)

Sporadic MTC:Sporadic MTC:

70%-80% of all MTCs70%-80% of all MTCs(Colson, 1993, Marzano, 1995)(Colson, 1993, Marzano, 1995)Mean age of 50 years (Russell, 1983)Mean age of 50 years (Russell, 1983) 75% 15 year survival (Alexander, 1991)75% 15 year survival (Alexander, 1991) Unilateral and Unifocal (70%)Unilateral and Unifocal (70%) Slightly more aggressive than FMTC and MEN IIaSlightly more aggressive than FMTC and MEN IIa 74% have extrathyroid involvement at presentation74% have extrathyroid involvement at presentation

(Russell, 1983)(Russell, 1983)


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Medullary Thyroid CarcinomaMedullary Thyroid Carcinoma(continued)(continued)

Multiple endocrine neoplasia IIbMultiple endocrine neoplasia IIb

(Wermers Syndrome, MEN III,(Wermers Syndrome, MEN III,

mucosal syndrome):mucosal syndrome):

Pheochromocytoma, multiple mucosalPheochromocytoma, multiple mucosalneuromas, marfanoid body habitusneuromas, marfanoid body habitus

90% develop MTC by the age of 2090% develop MTC by the age of 20Most aggressive type of MTCMost aggressive type of MTC15 year survival is


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Thyroid CancerThyroid Cancer Hurthle cell neoplasmHurthle cell neoplasm

5% of thyroid cancers5% of thyroid cancers

Variant of follicular cancerVariant of follicular cancer

Lymph node spread slightly higher than follicular cancerLymph node spread slightly higher than follicular cancer

Lees avidity for 131ILees avidity for 131I Medullary cancerMedullary cancer

Parafollicular C cellsParafollicular C cells

Autosomal dominance inheritance in 20%Autosomal dominance inheritance in 20%

Unilateral involvement in sporadic, bilaterality in familialUnilateral involvement in sporadic, bilaterality in familialformsforms

Calcitonin secretionCalcitonin secretion

Metastasis both by lymphatic and blood streamMetastasis both by lymphatic and blood stream

10 year survival 90% in localised disease, 70% with10 year survival 90% in localised disease, 70% withcervical mets, 20% with distant metscervical mets, 20% with distant mets


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Anaplastic Carcinoma of the ThyroidAnaplastic Carcinoma of the Thyroid

Highly lethal form of thyroid cancerHighly lethal form of thyroid cancer Median survival 70 years) (Sou, 1996)(Sou, 1996)

Mean age of 60 yearsMean age of 60 years (Junor, 1992)(Junor, 1992) 53% have previous benign thyroid disease53% have previous benign thyroid disease(Demeter, 1991)(Demeter, 1991)

47% have previous history of WDTC47% have previous history of WDTC(Demeter, 1991)(Demeter, 1991)


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Anaplastic Carcinoma of the ThyroidAnaplastic Carcinoma of the Thyroid

PathologyPathology

Classified as large cell or small cellClassified as large cell or small cellLarge cell is more common and has a worseLarge cell is more common and has a worse

prognosisprognosis

Histology - sheets of very poorlyHistology - sheets of very poorlydifferentiated cellsdifferentiated cells little cytoplasmlittle cytoplasm numerousnumerousmitosesmitoses necrosisnecrosis extrathyroidal invasionextrathyroidal invasion


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ManagementManagement

Surgery is the definitive management of thyroidSurgery is the definitive management of thyroidcancer, excluding most cases of ATC and lymphomacancer, excluding most cases of ATC and lymphoma Types of operations:Types of operations:

** lobectomy with isthmusectomylobectomy with isthmusectomy- minimal operation required for a potentiallyminimal operation required for a potentially

malignant thyroid nodulemalignant thyroid nodule** total thyroidectomytotal thyroidectomy removal of all thyroid tissueremoval of all thyroid tissue- preservation of the contralateral parathyroidpreservation of the contralateral parathyroid

glandsglands** subtotal thyroidectomysubtotal thyroidectomy-- anything less than a total thyroidectomyanything less than a total thyroidectomy


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M t (WDTC) P ill dM t (WDTC) P ill d


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Management (WDTC)- Papillary andManagement (WDTC)- Papillary and

FollicularFollicular(continued)(continued)

Rationale for total thyroidectomyRationale for total thyroidectomy1) 30%-87.5% of papillary carcinomas involve1) 30%-87.5% of papillary carcinomas involve

opposite lobeopposite lobe (Hirabayashi, 1961, Russell, 1983)(Hirabayashi, 1961, Russell, 1983)

2) 7%-10% develop recurrence in the2) 7%-10% develop recurrence in thecontralateral lobecontralateral lobe (Soh, 1996)(Soh, 1996)3) Lower recurrence rates, some studies show3) Lower recurrence rates, some studies show

increasedincreased survivalsurvival (Mazzaferri, 1991)(Mazzaferri, 1991)

4) Facilitates earlier detection and tx for4) Facilitates earlier detection and tx forrecurrent orrecurrent or metastatic carcinoma with iodinemetastatic carcinoma with iodine(Soh, 1996)(Soh, 1996)

5) Residual WDTC has the potential to5) Residual WDTC has the potential todedifferentiate to ATCdedifferentiate to ATC


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Thyroid cancerThyroid cancer

Anaplastic cancerAnaplastic cancer UndifferentiatedUndifferentiated

Rapidly growing, often inoperableRapidly growing, often inoperable

Invade locally, metastasize both locally and distantlyInvade locally, metastasize both locally and distantly

Mean survival 6 monthsMean survival 6 months

5 year survival rate 7%5 year survival rate 7% LymphomaLymphoma

Rare, rapidly enlarging tumourRare, rapidly enlarging tumour

Primary or secondaryPrimary or secondary

Seventh decade, 6:1 F/M ratioSeventh decade, 6:1 F/M ratio 5 year survival rate 75-80%, when confined to thyroid5 year survival rate 75-80%, when confined to thyroid


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Thyroid cancerThyroid cancer Staging and PrognosisStaging and Prognosis

AGES and AMES scoring systemsAGES and AMES scoring systems AA Age of patientAge of patient

GG Tumour GradeTumour Grade

MM Distant metastasisDistant metastasis

EE Extent of tumourExtent of tumour

SS Size of tumourSize of tumour Both scoring systems have identified 2 distinctBoth scoring systems have identified 2 distinct

subgroups;subgroups; Low-risk groupLow-risk group; Men 40years or younger, women 50 or; Men 40years or younger, women 50 or

younger, without distant metastasis (bone & lungs)younger, without distant metastasis (bone & lungs)

Older patients with intrathyroid follicullar/papillaryOlder patients with intrathyroid follicullar/papillarycarcinoma, with minor capsular involvement with tumourscarcinoma, with minor capsular involvement with tumours< 5cms in diameter< 5cms in diameter

High risk groupHigh risk group; All patients with distant metastasis; All patients with distant metastasis

All older patients with extrathyroid papillary/follicularAll older patients with extrathyroid papillary/follicular

carcinoma & tumours >5 cms regardless of extent ofcarcinoma & tumours >5 cms regardless of extent ofdiseasedisease


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Thyroid cancerThyroid cancer

Adjuvant therapyAdjuvant therapy

TSH suppressionTSH suppression

Post operative radioactive Iodine ablationPost operative radioactive Iodine ablation

External beam radiotherapyExternal beam radiotherapy

SurveillanceSurveillance

Serum thyroglobulin levelsSerum thyroglobulin levels

CXR or CT scanCXR or CT scan

Repeat 131I if positiveRepeat 131I if positive

tyroid cancer

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