Beruflich Dokumente
Kultur Dokumente
1
Thyroid Cancer
Clinically uncommon
(60 per million per year)
Pathologically common
(up to 15 % in the U.S.A.)
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Thyroid Cancer Management
Preoperative Diagnosis Thyroid Cancer
Peroperative Diagnosis Thyroid Cancer
Postoperative Diagnosis Thyroid Cancer
Medullary Thyroid Cancer
Anaplastic Thyroid Cancer
Cervical Lymph Nodes
Pediatric Thyroid Cancers
Completion Thyroidectomy
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Preoperative Diagnosis
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Preoperative Diagnosis
Examine for ectopic thyroid tissue
Indirect or fiberoptic laryngoscopy
• vocal cord mobility
• evaluate airway
• preoperative documentation of any unrelated abnormalities
Systematic palpation of the neck
• Metastatic adenopathy commonly found:
in the central compartment (level VI)
along middle and lower portion of the jugular vein
(regions III and IV)
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Blood Tests
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Imaging Modalities for Thyroid Cancer
Radioiodine
US
CT
MRI
PET
Others
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Thyroid Ultrasound
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Thyroid Ultrasound
Suspicious Nodules 0.8- 1.5 cm
• Hypoechoic lesion plus one of the following :
Microcalcifications
Irregular border
Central vascularity
9
Longitudinal scan of a papillary thyroid cancer, showing an
irregularly shaped nodule that has hypoechogenic
heterogeneous internal echo and calcifications (arrows).
10
A, Longitudinal scan and B, transverse scan of a metastatic lymph node from
papillary thyroid cancer. The lymph node is echogenic, with a longitudinal –
transverse ratio of 1.3. 11
Thyroid Ultrasound
Disadvantages:
Unable to reliably diagnose true cystic lesions
Cannot accurately distinguish benign from
malignant nodules
Follicular Lesions ??
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Fine-Needle Aspiration
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Fine-Needle Aspiration
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FNA Results of Thyroid Nodule
Pathologic results are categorized as:
• positive
• negative
• indeterminate
Hossein and Goellner (1993) use four categories.
They pooled data from seven series and came up with
the following rates:
• benign 69%
• suspicious 10%
• malignant 4%
• nondiagnostic 17%
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FNA Results of Thyroid Nodule
Limitations
• skill of the aspirator
• expertise of the cytologist
• difficulty in distinguishing some benign cellular
adenomas from their malignant counterparts
(follicular and Hurthle cell)
False negative results = 1%-6%
(Mazzeferri, 1993)
False positive results = 3%-6%
(Rojeski, 1985, Mazzeferri, 1993, Hall, 1989)
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Malignant FNA
Papillary carcinoma
Medullary carcinoma
Anaplastic carcinoma
Thyroid lymphoma
Metastatic carcinoma
Follicular carcinoma?
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Thyroid Cancer Classification
Papillary carcinoma Medullary Carcinoma
• Follicular variant Miscellaneous
• Tall cell • Sarcoma
• Diffuse sclerosing • Lymphoma
• • Squamous cell carcinoma
Encapsulated
• Mucoepidermoid
Follicular carcinoma carcinoma
• Overtly invasive • Clear cell tumors
• Minimally invasive • Pasma cell tumors
Hurthle cell carcinoma • Metastatic
• Direct extention
Anaplastic carcinoma
• Kidney
• Giant cell • Colon
• Small cell • Melanoma
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Papillary Carcinoma
60%-80% of all thyroid cancers
(Geopfert, 1998, Merino, 1991)
Histologic subtypes
• Follicular variant
• Tall cell
• Columnar cell
• Diffuse sclerosing
• Encapsulated
Prognosis is 80% survival at 10 years
(Goldman, 1996)
Females > Males
Mean age of 35 years
(Mazzaferri, 1994)
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Incidentaloma/Micrometastatic
Disease
Microcarcinomas - a manifestation of papillary
carcinoma
• Definition - papillary carcinoms smaller than 1.0 cm
• Most are found incidentally at autopsy
• Autopsy reports indicate that these may be present in up
to 35% of the population (Mazzaferri, 1993)
• Usually clinically silent
• Most agree that the morbidity and mortality from
microcarcinoma is minimal and near that of the normal
population
• One study showed a 1.3% mortality rate (Hay, 1990)
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Incidentaloma/Micrometastatic
Disease
Lesions detected by imaging or found after surgery
for unrelated indication
Thyroid nodules common in population (4-10% have
palpable nodules any given time)
Female/male incidence 6.4 / 1.6%
12% detected by palpation vs. 45% by imaging
Lesions less than 1 cm-observe
Lesions 1-2cm “gray zone”
Lesions > 2cm are NOT INCIDENTAL
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Incidentaloma/Micrometastatic
Disease
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Papillary Thyroid Cancer
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Incidentaloma/Micrometastatic
Disease and PTC
Pathology
• Gross
- vary considerably in size
- often multi-focal
- unencapsulated but often have a pseudocapsule
• Histology
- closely packed papillae with little colloid
- psammoma bodies
- nuclei are oval or elongated, pale staining with
ground glass appearanc
- Orphan Annie cells
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Papillary Carcinoma
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Follicular Carcinoma
Current Classification New classification
• Minimally invasive Minimally invasive
(gross encapsulation) (capsule only)
angioinvasive grossly
encapsulated
Widely invasive Widely invasive
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Follicular Neoplasms
Resection of lobe/isthmus with careful examination for gross
invasion or nodal disease
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Hurthle Cell Carcinoma
Variant of follicular carcinoma
First described by Askanazy
• “Large, polygonal, eosinophilic thyroid follicular cells with
abundant granular cytoplasm and numerous mitochondria”
(Goldman, 1996)
Definition (Hurthle cell neoplasm) - an encapsulated
group of follicular cells with at least a 75% Hurthle cell
component
Carcinoma requires evidence of vascular and
capsular invasion
4%-10% of all thyroid malignancies (Sessions, 1993)
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Hurthle Cell Carcinoma
Women > Men
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Management Hurthle Cell
Carcinoma
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Prognosis DTC
Based on age, sex, and findings at the time of
surgery (Geopfert, 1998)
Several prognostic schemes represented by
acronyms have been developed by different
groups:
• AMES (Lahey Clinic, Burlington, MA)
• GAMES (Memorial Sloan-Kettering Cancer Center,
New York, NT)
• AGES (Mayo Clinic, Rochester, MN)
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Thyroid Carcinoma Classification
Papillary, Follicular and Medullary Carcinoma
• T1 - ≤ 2cm intrathyroidal
• T2 - > 2 to 4 cm intrathyroidal
• T3 - > 4 cm or minimal extension
• T4a – subcutaneous, larynx, trachea, esophagus, recurrent
laryngeal nerve
• T4b – prevertebral fascia, mediastinal vessels, carotid artery
Anaplastic/ undifferantiated Carcinoma
• T4a – tumor limited to thyroid
• T4b – tumor beyond thyroid capsule
All types
• N1a - Level VI N1b – other regional
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Staging for Differentiated Thyroid
Cancer
In differentiated thyroid carcinoma, several classification and staging
systems have been introduced. However no consensus has emerged
favoring any one method over another
34
University of Chicago system – An easy to remember
staging system for papillary carcinoma is the
Clinical Class scheme proposed by De Groot colleague
the University of Chicago
35
National Thyroid Cancer Treatment
Cooperative Study (NTCTCS)
The NTCTCS created a staging approach that was applied prospectively
to
a registry of patients drawn from 14 cooperating institutions . Clinical-
pathologic staging was based upon:
• patient age at diagnosis
• tumor histology
• tumor size
• intrathyroidal multifocality
• extraglandular invasion
• metastases
• tumor differentiation
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Prognosis DTC
Low risk group
- men younger than 40 years and women younger than
50 years regardless of histologic typ
- recurrence rate -11%
- death rate - 4%
Intermediate risk group
- men older than 40 years and women older than 50 years
who have papillary carcinoma
- recurrence rate - 29%
- death rate - 21%
High risk group
- men older than 40 years and women older than 50 years
who have follicular carcinoma
- recurrence rate - 40%
- death rate - 36%
(Cady and Rossi, 1988 37
Medullary Thyroid Carcinoma
10% of all thyroid malignancies
1000 new cases in the U.S. each year
Arises from the parafollicular cell or C-cells of the
thyroid gland
• derivatives of neural crest cells of the branchial arches
• secrete calcitonin which plays a role in calcium
metabolism
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Medullary Thyroid Carcinoma
Tumor of C- cells
75 % sporadic
25% hereditary
Do not concentrate iodine
Produce calcitonin
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Medullary Thyroid Carcinoma
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Medullary Thyroid Carcinoma
Sporadic MTC:
• 70%-80% of all MTCs (Colson, 1993, Marzano, 1995)
• Mean age of 50 years (Russell, 1983)
• 75% 15 year survival (Alexander, 1991)
• Unilateral and Unifocal (70%)
• Slightly more aggressive than FMTC and MEN IIa
• 74% have extrathyroid involvement at presentation
(Russell, 1983)
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Medullary Thyroid Carcinoma
Familial MTC:
• Autosomal dominant transmission
• Not associated with any other endocrinopathies
• Mean age of 43
• Multifocal and bilateral
• Has the best prognosis of all types of MTC
• 100% 15 year survival
(Farndon, 1986)
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Medullary Thyroid Carcinoma
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Medullary Thyroid Carcinoma
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Medullary Thyroid Carcinoma
Diagnosis
Labs:
1) basal and pentagastrin stimulated serum calcitonin
levels (>300 pg/ml)
2) serum calcium
3) 24 hour urinary catecholamines
(metanephrines, VMA, nor-metanephrines)
4) carcinoembryonic antigen (CEA)
Fine-needle aspiration
Genetic testing of all first degree relatives
• RET proto-oncogene
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Medullary Thyroid Carcinoma
(Management)
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Medullary Thyroid Carcinoma
(Management)
Postoperative management
disease surveillance
• serial calcitonin and CEA
2 weeks postop
3/month for one year, then…
Twice a year
If calcitonin rises
metastatic work-up
surgical excision
if metastases - external beam radiation
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Anaplastic Carcinoma of the Thyroid
48
Anaplastic Carcinoma
(Management)
Most have extensive extrathyroidal
involvement at the time of diagnosis
• surgery is limited to biopsy and tracheostomy
Current standard of care is:
• maximum surgical debulking, possible
• adjuvant radiotherapy and chemotherapy
(Jereb and Sweeney, 1996)
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Management
Surgery is the definitive management of thyroid cancer,
excluding most cases of ATC and lymphoma
Types of operations:
• lobectomy with isthmusectomy
- minimal operation required for a potentially malignant thyroid nodule
• total thyroidectomy
- removal of all thyroid tissue
- preservation of the parathyroid glands
• subtotal thyroidectomy
- anything less than a total thyroidectomy
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Management Papillary and Follicular
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Arguments for Total Thyroidectomy
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Indications for Total
Thyroidectomy
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Papillary/Differentiated Carcinoma
Node Dissection:
Up to 80% of patients found to have asymptomatic positive
nodes during series of prophylactic neck dissections 1,2
Clinically significant disease only develops in less than 10% of
patients with microscopic lymph node metastases 1,3,4
Central node dissection should be carried out if central nodes
are enlarged and positive by frozen section
Ipsilateral modified neck dissection has been shown to reduce
regional recurrence without improving survival if enlarged
cervical node is positive by preop FNA or intraoperative frozen5
1 Am J Surg 122:464-471,1971
2 World J Surg 18:359-367,1994.
3 Surg Clin North Am 67:251-261,1987.
4 Cancer 26:1053-1060, 1970
5 Textbook of Endocrine Surgery, WB Saunders, 1997, p90. 55
Node Dissection
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LYMPHATIC DRAINAGE
Superior
Lateral
Lateral
Posterior Inferior
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Lateral Group 58
Central Group
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Incision
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Outline of modified Mac Fee incision
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Indications of Lymph Node Dissection
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Central Lymph Node Dissection:
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Lateral Lymph Node Dissection
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Complications of Surgery
Hypocalcemia -devascularization of parathyroid
• about 5%, which resolves in 80% of these cases in about 12
months
Bleeding
• wound hematomas
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Standard Initial Treatment
Total
Thyroidectomy
Remove the
thyroid with Radioactive Iodine
all cancerous Treatment
tissue
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Pediatric Papillary Carcinoma
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Pediatric Papillary Carcinoma
Age Female to Male Ratio
5–9 1:6
10-14 1:1
15-19 5 : 2 (peak incidence)
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Completion Thyroidectomy
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Total thyroidectomy is the treatment of
choice for virtually all patients with
thyroid cancer when it can be done
safely. No study documents that lesser
operations have better results than total
thyroidectomy, whereas numerous
studies suggest that patients treated by
total thyroidectomy have fewer
recurrences and better survival.
Orlo H. Clark
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