1 / 37

Thyroid Cancer 2005

Thyroid Cancer 2005. Nancy Fuller, M.D. University of Wisconsin-Madison. 52 yo woman in good health; presented with back pain of a musculoskeletal nature.

bobby
Télécharger la présentation

Thyroid Cancer 2005

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Thyroid Cancer 2005 Nancy Fuller, M.D. University of Wisconsin-Madison

  2. 52 yo woman in good health; presented with back pain of a musculoskeletal nature. Exam of neck: palpable right sided thyroid nodule approx 2x3 cm; gland otherwise not enlarged and no other nodules or lymphadenopathy. Ultrasound: solid nodule; uptake scan: no excess uptake in nodule TFTs: normal A FNA was performed. DX: Hurthle cell neoplasia

  3. 2. 64 yo woman with hyperlipidemia; presented for a preventive health exam with no complaints. Neck exam: 4x2 cm right sided thyroid nodule, gland otherwise normal, no lymphadenopathy. Ultrasound-solid nodule, uptake scan no excess uptake in nodule. TFTs A FNA was performed. DX: Hurthle cell neoplasia

  4. 3. 28 yo woman presented after having a thyroid nodule found incidentally on a carotid ultrasound being performed as a normal control for a study. Exam: 2x2 cm right sided thyroid nodule, gland otherwise normal, no lymphadenopathy. TFTs normal Dedicated ultrasound: solid nodule; FNA performed that day because of availability of pathology support DX: Papillary thyroid carcinoma

  5. Learning objectives: • To learn about the epidemiology, types, behaviors, treatment and prognosis of thyroid cancer. • No financial disclosures

  6. Epidemiology • Thyroid nodules: very common • Clinically detectable thyroid carcinoma: rare: <1% of all cancers • Female to male ratio- 2.5:1 • Median age at dx: 45-50

  7. Overall incidence is rising: • In 1935: 1.3/100,000 women, .2/100,000 men • By 1991: 5.8/100,000 women, 2.5/100,000 men • Incidence has continued to rise in past 10 years: most rapid rate of increase in all tracked cancers

  8. Reason for rise? • Neck irradiation: used between 1910 and 1960 • Better diagnosis? BUT: only rise is in papillary type; if better diagnosis was reason, would expect rise in all types

  9. Algorithm for the Cost-Effective Evaluation and Treatment of a Clinically Detectable Solitary Thyroid Nodule Hegedus, L. N Engl J Med 2004;351:1764-1771

  10. Thyroid cancer: epithelial types Differentiated: Papillary: 70-75 % of all thyroid cancers Follicular: 15-25% Undifferentiated: Anaplastic: 2-5%

  11. Thyroid cancer: non epithelial Medullary thyroid cancer • Sporadic • Familial • MEN-2A and B Others: lymphoma, mets from breast, colon, renal and melanoma

  12. Papillary thyroid carcinoma Pathogenesis: 1. Activation of tyrosine kinase receptors by rearrangement or gene amplification • Results in a chimeric gene • Occurs either by radiation or sporadic 2. Point mutations in BRAF gene • 10X increased risk of thyroid cancer in relatives of thyroid cancer patients: suggests a genetic link

  13. PTC Presentation: • Solitary nodule most common • Pathology: typically unencapsulated; may be cystic Papillae: 1 or 2 layers of tumor surrounding fibrovascular core Follicles and colloid are typically absent

  14. PTC • Psommoma bodies: scarred remnants of tumor papillae that have infarcted • Present in half of papillary thyroid carcinomas

  15. PTC Growth and behavior: minor to major • Microcarcinoma: occult papillary carcinoma, with tumor <1cm • Found in up to 50% of glands at autopsy (rarer in children) • Incidental finding of no clinical importance

  16. PTC • Other end of spectrum: aggressive metastasis through interthyroidal lymphatic channels to form multifocal tumors • Involves regional lymph nodes • At diagnosis: clinically detectable nodes more common in children (50%) than adults • 2-10% distant mets at dx: 2/3 pulmonary, 1/4 skeletal; also brain, kidneys, liver, adrenals

  17. PTC Prognosis • Most patients do not die of their disease • 80-95% 10 year survival rates • Patients between 20-45: best long term survival • Patients older than 45 with lymph node recurrences are most likely to die from PTC

  18. PTC • Prognosis is poorer in patients with large tumors: one large series showed cancer related mortality of 6%/2-3.9cm, 16%/4-6.9cm and 50%7 cm and above • Several variants have a worse prognosis: tall cell variant=1% of PTC; more aggressive and invasive

  19. Survival Rate among 1701 Patients with Papillary or Follicular Carcinoma and No Distant Metastases at the Time of Diagnosis Schlumberger, M. J. N Engl J Med 1998;338:297-306

  20. Follicular thyroid carcinoma • Characterized by follicular differentiation and encapsulation • Invasion of the capsule and blood vessels is the main determinant between adenomas and carcinoma • 2 main forms: minimally invasive and widely invasive • Multicentricity and lymph node involvement are less frequent than in PTC

  21. FTC • Minimally invasive FTC behaves more like PTC • Widely invasive behaves more like anaplastic thyroid carcinoma • Hurthle Cell variant:more aggressive • FTC is more likely than PTC to be nonresponsive to I 131.

  22. Anaplastic thyroid carcinoma • Undifferentiated tumor of thyroid follicular epithelium • Very aggressive, with a disease specific mortality approaching 100% • 2/1,000,000 annual incidence • Typical patient is older than differentiated carcinoma, mean age 65 • <10% under 50 • 60-70% women

  23. ATC • 20% of ATC: history of differentiated thyroid carcinoma, most papillary • 10% of Hurthle cell carcinoma: has anaplastic tumor within • Up to 1/2 of ATC: history of multinodular goiter

  24. ATC • Presentation: • Nearly all present with a thyroid mass • Regional or distant spread is present 90% of the time at dx • Lungs, bones, brain most common mets • Rapidly enlarging tumor; often causes compression symptoms like dyspnea, dysphagia, hoarseness • Constitutional symptoms like fatigue, anorexia, wt loss

  25. ATC • 50% have palpable nodes at dx • Dx: made by FNA, then CT neck and mediastinum, CXR • Prognostic factors: tumor size <6 cm=25% 2 yr survival >6cm=3-15% 2 yr survival Others: older age, male sex, dyspnea at presentation • No effective treatment for advanced or metastatic ATC: uniformly fatal, with median survival 3-7 mo

  26. Treatment of differentiated thyroid carcinoma • Surgery: goal is to remove all tumor tissue from neck • Total or near total thyroidectomy because of risk of multicentricity • Removal of local nodes in PTC, only palpable nodes in FTC because of lower rate of lymph node involvement

  27. Treatment • I 131: given post op: destroys any remaining normal thyroid tissue, and may destroy occult microcarcinomas • Increases sensitivity of subsequent 1 131 total body scans • 4-6 wks after surgery a total body scan off thyroid replacement with low dose 1 131; if any uptake, a treatment dose is given (2 mCi vs. 30-100 mCi) • Radiation: only if surgical excision is impossible and tissue doesn’t take up I 131

  28. Followup Goals of followup: • Maintain adequate thyroxine treatment • Detect persistent or recurrent cancer • Recurrences usually occur early but may occur later so follow up for life

  29. Thyroxine treatment goals: initial serum thyrotropin level 0.1 or less, serum free T3 normal • Check U/S of thyroid area and nodal areas • Serum thyroglobulin levels: TG produced by follicular cells-should not be detectable after total ablation; presence signifies persistent or recurrent disease • 80% of patients with TG >40 have detectable foci or I 131 uptake

  30. I 131 scanning: needs to be done after withdrawal of thyroxine tx, with TSH >30 needed • Scanning is done 3 days after I 131 given • Low risk patients with no I 131 uptake after 1 year: TSH maintained at low but detectable level (0.1-0.5)

  31. Local or regional mets: occur in 5-20% • Excision/I 131 tx/ Radiation tx if no I 131 uptake • Distant mets: If I 131 uptake, high dose I 131 given + RT

  32. Complications of treatment: • I 131: nausea, sialadenitis common but mild and short duration • Genetic defects: can’t be given to pregnant women • Increased risk of miscarriage in pregnancies within 1 year of tx • Overall relative risk of a second type of cancer only if high cumulative dose of I 131 and/or radiation

  33. Medullary thyroid cancer • Much less common than epithelial thyroid cancers • Involves abnormalities of parafollicular C-cells • Most cases are sporadic

  34. MTC • MEN 2 A: autosomal dominant disorder characterized by MTC, pheochromocytoma, and primary parathyroid hyperplasia • MEN 2 B: same inheritance; MTC + pheochromocytoma. Occurs at a younger age; more aggressive. • Familial MTC: like MEN 2 A but no other associated abnormalities

  35. MTC • Female to male ratio=1:1 • MEN 2 A and familiar MTC: peak in index cases in 3rd decade • MEN 2 B: children and teens most common age of presentation. • Basal serum calcitonin: usually correlates with tumor mass and is almost always high with palpable tumor

  36. MTC • MTC in MEN 2 B: more aggressive • Early onset • Surgery often not curative • Death from MTC: 50% of MEN 2 B, 10 % MEN 2 A

  37. Cases: recap and current status

More Related