update in the management of thyroid neoplasms david r. byrd, md department of surgery university of...
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Update in the Management of Thyroid Neoplasms
David R. Byrd, MD
Department of Surgery
University of Washington
NCCN - National Comprehensive Cancer Network
• yearly update from the NCI-designated comprehensive cancer centers (FHCRC --> FHCRC + UWMC)
• Consensus guidelines from the NCCN membership institutions
• not focussed on the practice of the community cancer practitioner
NCCN - Management of Thyroid Carcinoma -2001
Thyroid Nodule - History
Local Sxs
Risk factors
Function
Thyroid nodules
• 6-10% adult U.S. population– 5% are malignant
• FNA best initial test - 96% PPV
• U/S good to follow or document MNG
• thyroid scan good if symptoms of hyper- or hypothyroidism or if indeterminate cytology/multinodular goiter
• suppression most successful when TSH high
FNA Results of Thyroid Nodule
Benign --> F/U 6-12 months
cyst --> F/U 6-12 months
indeterminate --> repeat FNA, I123 scan if same results
follicular neoplasm --> I123 scan or surgery
suspicious --> surgery
carcinoma --> surgery
FNA
Results of I123 scan
“hot” --> check TFTs
“euthyroid” --> rarely CA, F/U only
“cold”* (still takes up some iodine, though less than normal gland)
*NOTE: 1. Nearly all cancers are “cold” 2. However, only about 10-15%
of “cold” nodules are cancer
I123 scan
Thyroid Carcinoma - Nodule Evaluation
©National Comprehensive Cancer Network
Thyroid Carcinoma - Nodule Evaluation
©National Comprehensive Cancer Network
Pathology of Thyroid Cancer• differentiated thyroid cancer (DTC):
– papillary - commonly spreads to nodes (40-50%), excellent prognosis
– mixed - papillary and follicular - acts like papillary, excellent prognosis
– follicular - slightly worse than papillary, can spread to bone, less to nodes (15%); Hurthle cell Ca is variant
• medullary - sporadic vs. familial (MEN 2A), total thyroidectomy is treatment
• anaplastic - aggressive and fatal, surgical role is biopsy only
Thyroid Carcinoma - Papillary Carcinoma
©National Comprehensive Cancer Network
Rationale for Total Thyroidectomy for DTC
• improved effectiveness for I131 ablation• lowers dose needed forI131 ablation• allows f/u w/ thyroglobulin levels• decreased recurrence• improved survival in high risk pts.
• decreased risk of pulmonary mets and dedifferentiated CA
Rationale Against Total Thyroidectomy for DTC
• increased RLN injury and hypoparathyroidism• contralateral disease not clinically relevant• survival nearly equivalent for low risk patients• I131 ablation not necessary for most patients• thyroglobulin levels not necessary for most
patients
Thyroidectomy for DTC - Technique
• know the anatomy
• protect RLN
• preserve all parathyroids
• know when to reassess or quit
Thyroid Carcinoma - Papillary Carcinoma
©National Comprehensive Cancer Network
Lymphadenectomy for Papillary or Mixed Thyroid CA
RLN
parathyroid
Thyroid Carcinoma - Papillary Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma - Papillary Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma - Papillary Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma - Papillary Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network
? Residual Thyroid Cancer• 25 y/o woman with papillary thyroid cancer
– Capsular penetration– Lymph nodes not sampled
• Dx and Post-Rx (200 mCi) I-131 scans show thyroid remnant only– TG off TSH = 110 ng/dL
• Dx I-131 scan 1 year later negative– TG off TSH is still 100 ng/dL
Thyroid CancerPost therapy (10/98)
2055870
Tc-99m markers
I-131window
Thyroid CancerDiagnostic Scan (7/99)
2055870
Tc-99m markers
I-131window
? Residual Thyroid Cancer:FDG PET Scan 8/99
2055870
L Cervical Lymph Nodes
? Central Lymph Nodes
Case 1
• 60F undergoes L thyroid lobectomy for a solitary nodule w/ follicular cells on FNAC.
• Final path shows 2cm follicular adenoma and incidental 5mm papillary thyroid CA
• ?further management
Case 1 - issues
• ? Completion thyroidectomy --> NO
• ? Radioactive iodine therapy --> NO
• ? Thyroid suppression --> +/-
• ? F/u -6 month intervals with H & P
Result: the 2 cm nodule is benign and the 0.5cm nodule is an incidental carcinoma of minimal significance
Case 2
• 40M w/ solitary 1.5cm L thyroid nodule on exam
• h/o neck irradiation for enlarged thymus as child
• ?further management
Case 2 - Issues
This is a setting of higher risk of cancer - male, solitary lesion, and equivocal hx of neck irradiation:
minimal operation is thyroid lobectomy + isthmusectomy, proceed to total or subtotal thyroidectomy if bilateral nodules and/or if carcinoma found
frozen section is notoriously unable to definitively call carcinoma - therefore permanent pathology usually necessary to confirm carcinoma