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Surgical approach for thyroid cancer Surgical approach for thyroid cancer

Surgical approach for thyroid cancer - PowerPoint Presentation

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Surgical approach for thyroid cancer - PPT Presentation

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

cancer thyroid cell carcinoma thyroid cancer carcinoma cell years men papillary follicular age mtc management thyroidectomy nodule total hurthle

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Slide1

Surgical approach for thyroid cancer

Nidal

Younes

MBBSc

Professor of endocrine Surgery

Jordan University Hospital

Slide2

Thyroid 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

Slide3

Thyroid 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

Slide4

Thyroid 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).

Slide5

Cramer

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 

Slide6

 World Age-

Standardised

Incidence Rates, World Regions, 2008 Estimates

Slide7

Thyroid 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

Slide8

Risk 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

Slide9

History

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

Slide10

History

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

Slide11

Inherited 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

Slide12

Radiation 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

Slide13

Chernobyl disaster

Slide14

Children of Chernobyl

Slide15

 

Fukushima

 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

)

 

Slide16

Children of

Fukushima

Slide17

Slide18

Endocr

Rev. 2010 October; 31(5): 756–773

.

Slide19

Slide20

Investigation of thyroid Nodules

محمد مختار جمعة

محمد مختار جمعة

Slide21

Diagnostic 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

Slide22

Evaluation 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

Slide23

Evaluation of the Thyroid Nodule(Radioimaging)

Radioimaging usually not used in initial work-up of a thyroid nodule

Chest radiograph

Computed tomography

Magnetic resonance imaging

Slide24

Thyroid 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

Slide25

Slide26

Thyroid 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

Slide27

Papillary thyroid cytology

Extensive nuclear inclusions or nuclear grooves, papillary formations, no colloid

Slide28

MTC 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.

Slide29

FNAB Results

Benign

Observe and repeat FNAC 1 year

Malignant

Surgery

Suspecious

Diagnostic

hemithyroidectomy

Inadequate

Repeat FNA with or without U/S

guidence

Slide30

Classification 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

Slide31

The frequency of thyroid cancer

Ref: American Cancer Society (2010), National Cancer Institute (2010)

Slide32

Papillary thyroid carcinoma

Slide33

Papillary

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

Slide34

Papillary 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%

Slide35

Papillary 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

Slide36

Follicular 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)

Slide37

Follicular 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

Slide38

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)

Slide39

Hurthle 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

Slide40

Prognosis 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)

Slide41

Prognosis

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)

Slide42

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%

Slide43

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

Slide44

Medullary

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

)

Slide45

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)

Slide46

Medullary 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)

Slide47

Medullary 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

Slide48

Anaplastic 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)

Slide49

Anaplastic 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

Slide50

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

Near

thyroidectomy

- anything less than a total

thyroidectomy

Slide51

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

Slide52

Management -

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

Slide53

Management (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

Slide54

Management 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

Slide55

Management 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)

Slide56

Medullary 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

Slide57

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)

Slide58

Thank You