Nidal Younes MBBSc Professor of endocrine Surgery Jordan University Hospital Thyroid cancer It is the most common endocrine cancer Thyroid cancer is the fastest increasing cancer in both men and women ID: 779286
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Slide1
Surgical approach for thyroid cancer
Nidal
Younes
MBBSc
Professor of endocrine Surgery
Jordan University Hospital
Slide2Thyroid cancer
It is the most common endocrine cancer
Thyroid cancer is the fastest increasing cancer in both men and women.
Thyroid cancer is one of the few cancers that has increased in incidence rates over recent years. It occurs in all age groups from children through seniors.
The American Cancer Society estimates that there was about 60,220 new cases of thyroid cancer in the U.S. in 2013. About 1,850 people (1,040 women and 810 men) will die of thyroid cancer in 2013.
Present as a lump in the neck
Slide3Thyroid cancer is unique cancer!
From the slowest to the fastest growing tumor in the body!!
Papillary to
anaplastic
Lymph node metastasis in PTC does not influence the prognosis!!
Thyroid tissue is sensitive to all kinds of radiation
Slide4Thyroid cancer trend world wide
Gradual increase of thyroid cancer is noticed in the US 1973
ــ
2002
87 % of the increase was due the diagnosis of small papillary cancer
increased diagnostic scrutiny has caused an apparent increase in incidence of cancer rather than a real increase (Davies,
et al.,
2006).
Slide5Cramer
et al
Surgery 148, Issue 6
, December 2010, Pages 1147–1153 Analysis of the rising incidence of thyroid cancer using the Surveillance, Epidemiology and End Results national cancer data registry
Slide6World Age-
Standardised
Incidence Rates, World Regions, 2008 Estimates
Slide7Thyroid ca in the Arab world
Thyroid cancer ranked 2nd among females in all the GCC countries except in Bahrain ( 3
rd
).
The ASR in these countries ranged from 5 per 100 000 in Saudi Arabia to 15 per 100 000 in Qatar.
Worldwide, the highest incidence rates have been reported from Hawaii, Iceland, Israel and Los Angeles
Incidence of cancer in Gulf Cooperation Council countries, 1998–2001 N. Al-
Hamdan
et al
,
La Revue de Santé de la
Méditerranée
orientale
, Vol. 15, N° 3, 2009
Slide8Risk Factors for thyroid cancer
Familial
MTC
PTC
Radiation exposure
External
Medical treatment for benign conditions
Medical treatment for malignancies
Environmental exposure- Nuclear weapons or accidents
Internal
Medical treatment of benign condition with I131
Diagnostic tests with I131
Other factors
Diet- Iodine deficiency,
goitrogens
Extremes of age
Slide9History
Age and Sex
Benign nodules occur most frequently in women 20-40 years
(Campbell, 1989)
5%-10% of these are malignant
(Campbell, 1989)
Men have a higher risk of a nodule being malignant
Belfiore
and co-workers found that:
the odds of cancer in men quadrupled by the age of 64
a thyroid nodule in a man older than 70 years had a 50% chance of being malignant
Slide10History
Symptoms
The most common presentation of a thyroid nodule, benign or malignant, is a painless mass in the region of the thyroid gland
(Goldman, 1996)
.
Symptoms consistent with malignancyPain
dysphagia
Stridor
hemoptysis
rapid enlargement
hoarseness
Slide11Inherited thyroid cancer
PTC (familial polyposis, Gardner’s)
MTC ( 25%)
Familial non MEN MTC
MEA syndromes
Type -1Type -2 all have MTCRET proto-oncogene mutation
Useful in young children
Removal of the thyroid before cancer begins
Slide12Radiation induced thyroid cancer
Duffy
Bj
, Fitzgerald
Pj
. Cancer of the thyroid in children: A report of 28 cases. J Clin
Endocrinol
Metab
1950;
10
: 1296-1308
Jablon
S.,
Tachikawa
K.,
Belsky
Jl
, Steer A.. Cancer in Japanese exposed as children to atomic bombs.
Lancet
1971;
i
: 927-932
Fibrikant Ji. Health effects of the nuclear accident at Three Mile Island. Health Physics 1981; 40: 151-161
Slide13Chernobyl disaster
Slide14Children of Chernobyl
Slide15Fukushima
Daiichi
nuclear disaster
11 March 2011
October 2013,
Prime Minister Naoto Kan
in
The Huffington Post
said that if the worst-case scenario had realized, the evacuation of 50 million people within a 250-kilometer radius of Fukushima had needed
!!!!!! (
shinzo
Abi
)
Children of
Fukushima
Slide17Slide18Endocr
Rev. 2010 October; 31(5): 756–773
.
Slide19Slide20Investigation of thyroid Nodules
محمد مختار جمعة
محمد مختار جمعة
Slide21Diagnostic guidelinesATA 2009
Measure serum TSH in the initial evaluation of a patient with a thyroid nodule. If the serum TSH is subnormal, a radionuclide thyroid scan should be performed using either technetium 99mTc pertechnetate or 123I. Recommendation rating: A
Thyroid sonography should be performed in all patients with known or suspected thyroid nodules. Recommendation rating: A
FNA is the procedure of choice in the evaluation of thyroid nodules. Recommendation rating: A
US guidance for FNA is recommended for those nodules that are nonpalpable, predominantly cystic, or located posteriorly in the thyroid lobe. Recommendation rating: B
Slide22Evaluation of the Thyroid Nodule(Blood Tests)
Thyroid function tests
thyroxine
(T4)
triiodothyronin
(T3)thyroid stimulating hormone (TSH)
Serum
Calcium
in MTC
Calcitonin
in MTC
Thyroglobulin
(TG)
in the follow up PTC, FTC
Slide23Evaluation of the Thyroid Nodule(Radioimaging)
Radioimaging usually not used in initial work-up of a thyroid nodule
Chest radiograph
Computed tomography
Magnetic resonance imaging
Slide24Thyroid Nodule Ultrasonography
Advantages
Most sensitive procedure or identifying lesions in the thyroid (2-3mm)
90% accuracy in categorizing nodules as solid, cystic, or mixed
(
Rojeski
, 1985
)
Can detect the presence of lymph node enlargement and calcifications
Noninvasive and inexpensive
Slide25Slide26Thyroid Nodule
FNAC (Fine Needle Aspiration Cytology)
Easy, safe, cost effective
Negative predictive value 89%- 98%
False Negative rate 6%
False Positive rate 4%
FNAC Cytodiagnosis
Benign
Colloid adenoma, thyroiditis, cyst
Malignant
Papillary (70%), follicular (15%), medullary (5%-10%), anaplastic(3%), lymphoma (3%), mets
Indeterminate
Microfollicular, Hurthle cell, embryonal neoplasm
Slide27Papillary thyroid cytology
Extensive nuclear inclusions or nuclear grooves, papillary formations, no colloid
Slide28MTC cytology
plasmacytoid
cells of variable sizes. The cells had eccentric nuclei with coarse chromatin and abundant
amphophilic
cytoplasm, clumps of
amyloid
-like amorphous, glassy,
eosinophilic
material.
Slide29FNAB Results
Benign
Observe and repeat FNAC 1 year
Malignant
Surgery
Suspecious
Diagnostic
hemithyroidectomy
Inadequate
Repeat FNA with or without U/S
guidence
Slide30Classification of Malignant Thyroid Neoplasms
Papillary carcinoma
Follicular variant
Tall cell
Diffuse sclerosing
Encapsulated
Follicular carcinoma
Overtly invasive
Minimally invasive
Hurthle cell carcinoma
Anaplastic carcinoma
Giant cell
Small cell
Medullary Carcinoma
Miscellaneous
Sarcoma
Lymphoma
Squamous cell carcinoma
Mucoepidermoid carcinoma
Clear cell tumors
Pasma cell tumors
Metastatic
Direct extention
Kidney
Colon
Melanoma
Slide31The frequency of thyroid cancer
Ref: American Cancer Society (2010), National Cancer Institute (2010)
Slide32Papillary thyroid carcinoma
Slide33Papillary
Carcinoma
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
Slide34Papillary thyroid carcinoma
Occult/micro PTC (OPTC)
(a) T <1 cm
(b) no capsule invasion
(c) no 2’ (bone, lung)
(d) no LVI
MR 0.1%
RR 5%
Slide35Papillary Thyroid cancer
Staging and Prognosis
AGES and AMES scoring systems
A Age of patient
G Tumour Grade
M Distant metastasis
E Extent of tumour
S Size of tumour
Both scoring systems have identified 2 distinct subgroups;
Low-risk group
;
Men 40years or younger, women 50 or younger, without distant metastasis (bone & lungs)
High –risk group
; All patients with distant metastasis
All older patients with
extrathyroid
papillary/follicular carcinoma & tumours >5
cms
regardless of extent of disease
Slide36Follicular Carcinoma
20% of all thyroid malignancies
Women > Men (2:1 - 4:1)
(Davis, 1992, De Souza, 1993)
Mean age of 39 years
(Mazzaferri, 1994)Prognosis - 60% survive to 10 years
(Geopfert, 1994)
Metastasis - angioinvasion and hematogenous spread
15% present with distant metastases to bone and lung
Lymphatic involvement is seen in 13%
(Goldman, 1996)
Slide37Follicular Carcinoma
Pathology
Gross - encapsulated, solitary
Histology - very well-differentiated (distinction between follicular adenoma and carcinomaid difficult)
- Definitive diagnosis - evidence of
vascular and capsular invasion
FNA and frozen section cannot accurately distinquish between benign and malignant lesions
Slide38Hurthle 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)
Slide39Hurthle Cell Carcinoma
Women > Men
Lymphatic spread seen in 30% of patients
(Goldman, 1996)
Distant metastases to bone and lung is seen in 15% at the time of presentation
Slide40Prognosis of thyroid cancer
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)
Slide41Prognosis
Depending on variables, patients are categorized in to one of the following three groups:
1)
Low risk group
- men younger than 40 years and women younger than 50 years regardless of histologic type
-
recurrence rate
-11%
-
death rate
- 4%
(Cady and Rossi, 1988)
Prognosis
1)
Intermediate risk group
- Men older than 40 years and women older than 50 years
who
have papillary carcinoma
-
recurrence rate
- 29%
-
death rate
- 21%
2)
High risk group
- Men older than 40 years and women older than 50 years who have follicular carcinoma
-
recurrence rate
- 40%
-
death rate
- 36%
Slide43Medullary 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
Slide44Medullary
Thyroid Carcinoma
Developes
in 4 clinical settings:
Sporadic MTC (SMTC)
Familial MTC (FMTC)
Multiple endocrine
neoplasia
IIa
(MEN
IIa
)
Multiple endocrine
neoplasia
IIb
(MEN
IIb
)
Slide45Medullary
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)
Slide46Medullary Thyroid Carcinoma (Continued…)
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)
Slide47Medullary Thyroid Carcinoma (continued…)
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
Slide48Anaplastic Carcinoma of the Thyroid
Highly lethal form of thyroid cancer
Median survival <8 months
(Jereb, 1975, Junor, 1992)
1%-10% of all thyroid cancers
(Leeper, 1985, LiVolsi, 1987)
Affects the elderly (30% of thyroid cancers in patients >70 years)
(Sou, 1996)
Mean age of 60 years
(Junor, 1992)
53% have previous benign thyroid disease
(Demeter, 1991)
47% have previous history of WDTC
(Demeter, 1991)
Slide49Anaplastic Carcinoma of the Thyroid
Pathology
Classified as large cell or small cell
Large cell is more common and has a worse prognosis
Histology - sheets of very poorly differentiated cells
little cytoplasm numerous mitoses
necrosis
extrathyroidal invasion
Slide50Management
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
Near
thyroidectomy
- anything less than a total
thyroidectomy
Treatment of Thyroid cancer
Papillary cancer
< 1 cm
Lobectomy
&
isthmusectomy> 1 cm Near/Total thyroidectomy
Follicular cancer Near/
Total
thyroidectomy
Hurthle
Near/Total
thyroidectomy
Medullary
Near/
Total
thyroidectomy
& central neck dissection
Slide52Management -
Papillary and Follicular
Postoperative therapy/follow-up
Radioactive iodine (administration)
Scan at 4-6 weeks postop
repeat scan at 6-12 months after ablation
repeat scan at 1 year then...
every 2 years thereafter
Slide53Management (WDTC) - Papillary and Follicular (continued)
Postoperative therapy/follow-up
Thyroglobulin
(TG)
(
Gluckman)
measure serum levels every 6 months
Level >30
ng
/ml are
abnormal
Thyroid
hormone suppression (control TSH dependent cancer) (Goldman, 1996)
should be done in - 1) all total
thyroidectomy
patients
2) all patients who have had radioactive ablation of any remaining thyroid tissue
Slide54Management of
Hurthle
Cell Carcinoma
Total thyroidectomy is recommended because:
1) Lesions are often Multifocal
2) They are more aggressive than WDTCs
3) Most do not concentrate iodine
Slide55Management of
Hurthle
Cell Carcinoma
Postoperative management
Thyroid suppressionMeasure serum thyroglobulin every 6 months
Postoperative radioactive iodine is usually not effective (10% concentrate iodine)
(Clark, 1994)
Slide56Medullary Thyroid Carcinoma (Management)
Recommended surgical management
total thyroidectomy
central lymph node dissection
lateral jugular sampling
if suspicious nodes - modified radical neck dissectionIf patient has MEN syndrome remove pheochromocytoma before thyroid surgery
Slide57Anaplastic 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)
Slide58Thank You