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Update in the Management of Thyroid Neoplasms

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)

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Update in the Management of Thyroid Neoplasms

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  1. Update in the Management of Thyroid Neoplasms David R. Byrd, MD Department of Surgery University of Washington

  2. 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

  3. NCCN - Management of Thyroid Carcinoma -2001

  4. Thyroid Nodule - History Local Sxs Risk factors Function

  5. 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

  6. 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

  7. Results of I123 scan “hot” --> check TFTs “euthyroid” --> rarely CA, F/U only “cold”* (still takes up some iodine, though less than normal gland) I123 scan *NOTE: 1. Nearly all cancers are “cold” 2. However, only about 10-15% of “cold” nodules are cancer

  8. Thyroid Carcinoma - Nodule Evaluation ©National Comprehensive Cancer Network

  9. Thyroid Carcinoma - Nodule Evaluation ©National Comprehensive Cancer Network

  10. 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

  11. Thyroid Carcinoma - Papillary Carcinoma ©National Comprehensive Cancer Network

  12. 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

  13. 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

  14. Thyroidectomy for DTC - Technique • know the anatomy • protect RLN • preserve all parathyroids • know when to reassess or quit

  15. Thyroid Carcinoma - Papillary Carcinoma ©National Comprehensive Cancer Network

  16. Lymphadenectomy for Papillary or Mixed Thyroid CA parathyroid RLN

  17. Thyroid Carcinoma -Papillary Carcinoma ©National Comprehensive Cancer Network

  18. Thyroid Carcinoma - Papillary Carcinoma ©National Comprehensive Cancer Network

  19. Thyroid Carcinoma - Papillary Carcinoma ©National Comprehensive Cancer Network

  20. Thyroid Carcinoma - Papillary Carcinoma ©National Comprehensive Cancer Network

  21. Thyroid Carcinoma - Follicular Carcinoma ©National Comprehensive Cancer Network

  22. Thyroid Carcinoma - Follicular Carcinoma ©National Comprehensive Cancer Network

  23. Thyroid Carcinoma - Follicular Carcinoma ©National Comprehensive Cancer Network

  24. Thyroid Carcinoma - Follicular Carcinoma ©National Comprehensive Cancer Network

  25. Thyroid Carcinoma - Follicular Carcinoma ©National Comprehensive Cancer Network

  26. ? 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

  27. Thyroid Cancer Post therapy (10/98) I-131 window Tc-99m markers 2055870

  28. Thyroid Cancer Diagnostic Scan (7/99) I-131 window Tc-99m markers 2055870

  29. ? Residual Thyroid Cancer: FDG PET Scan 8/99 L Cervical Lymph Nodes ? Central Lymph Nodes 2055870

  30. 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

  31. ? Completion thyroidectomy --> NO ? Radioactive iodine therapy --> NO ? Thyroid suppression --> +/- ? F/u -6 month intervals with H & P Case 1 - issues Result: the 2 cm nodule is benign and the 0.5cm nodule is an incidental carcinoma of minimal significance

  32. 40M w/ solitary 1.5cm L thyroid nodule on exam h/o neck irradiation for enlarged thymus as child ?further management Case 2

  33. 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

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