thyroid cancer dr. awad alqahtani md,msc.frcsc(g.surgery)frcsc(surgical oncology) laparoscopic and...
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Thyroid Thyroid CancerCancer
Dr. Awad Alqahtani Md,MSc.FRCSC(G.Surgery)FRCSC(Surgical Oncology)
Laparoscopic and Bariatric Surgery
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OutlinesOutlines• Anatomy and Blood Supply• Epidemiology• Causes and Risk Factors• Classification• Clinical Presentation• Diagnosis• Management
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EpidemiologyEpidemiology• Commonest endocrine malignancy
o 1% of all malignancieso 0.5-1 per 100000
• Good prognosis• Extent of treatment is hotly debated
o No randomized trials
• Annual Incidence is 3.7 per 100,000• Sex Ratio is 3:1 (Female:Male)• Can occur at any age group
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Causes and Risk Causes and Risk FactorsFactors
• Genetics:o Abnormal RET oncogene may cause MTC.o MEN 2A, 2B Syndrome.
• Family History:o Hx of goiters increase risk for Papillary Ca.o Gardner’s Syndrome and FAP increase risk for Papillary Ca.
• Radiation Exposure:o Radiation therapy to Head or Neck.o Exposure to Radioactive Iodine during childhood, or other radioactive
substances (Chernobyl) ↑ risk for particularly Papillary carcinoma.
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Causes and Risk Causes and Risk FactorsFactors
• Chronic Iodine deficiency ↑ risk for Follicular carcinoma.
• Gender:o Female > Males.
• Age:o More common at young adults.o MTC usually diagnosed after 60.
• Race:o White race > Black race.
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Thyroid Neoplasm
Benign Malignant
Secondary
Primary
Follicular Cells
Parafollicular Cells
Lymphoid Cells
LymphomaMedullary
Differentiated Undifferentiated
AnaplasticFollicularPapillary
Hurthle Cell
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PresentationPresentation• Solitary or Multiple thyroid nodules• Neck Nodes• Hoarse voice of recent onset• Mediastinal adenopathy• Bone or lung metastasis
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Important HistoryImportant History• Radiation to neck / chest• MEN syndrome
o Family historyo Diarrhoeao Adrenal tumour
• Recent change in a pre-existing goitreo Size change/nodularityo Vocal cord palsy
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EvaluationEvaluation
• Thyroid profile• Serum Thyroglobulin• Serum Calcitonin• Thyroid scan
o Hot/warm/cold nodule 20% malignant
• Serum Ca++
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DiagnosisDiagnosis• Laboratory:
o TSHo T3, T4o Serum Thyroglobulino Serum Thyroid Antibodieso FNA
• Imagingo U/So C.To MRIo Scintigraphy
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LaboratoryLaboratory• Most patients are Euthyroid.• Hyperfunctioning nodule 1% chance of
malignancy.• Serum Tg cannot differentiate between benign
and Malignant nodules• Tg is used for:
o F/U after total thyroidectomyo Serial F/U for non-operative treatment
• Serum Calcitonin patients with MTC, or with family hx of MTC (MEN2)
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FNA CytologyFNA Cytology• Single most important test.• U/S guidance improve the sensitivity.• Accuracy ranges from 70 – 95%.• Nodules• FNAC cannot differentiate between Benign and
Malignant Follicular Neoplasia
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ImagingImaging
• U/S is the investigation of choice.• C.T Regional and distant metastases• MRI Limited role in the diagnosis
Useful in detecting cervical LN metastases• Scintigraphy (I-123)
• Characterizing funtioning nodules• Staging of follicular and papillary Ca
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Prognostic IndicatorsPrognostic Indicators• AGES score:
• Age• Hisological Grade• Extrathyroidal invasion• Metastasis
• MACIS score (post-operative):• Distant Metastasis• Age• Completeness of original surgical resection• Extrathyroidal Invasion• Size of original lesion
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ManagementManagement• Medical
o Radioactive Iodine ablation therapy.o Chemotherapy (Adriamycin, Cisplatin).o Post-operative Thyroid hormone.
• Replacement therapy.• Suppression of TSH release. (↓ recurrence)
• Surgical• Treatment of choice.• Extent of resection is still controversial.
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Thyroid SurgeriesThyroid Surgeries• Relates to the management of contralateral lobe.
• Types Ipsilateral lobectomy Subtotal Thyroidectomy Near-total Thyroidectomy Total Thyroidectomy
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Papillary CarcinomaPapillary CarcinomaMost common Thyroid carcinoma (80%)Related to radiation exposure in I-sufficient areas.Female:male ratio is 2:1Mean age of presentation is 30 to 40 yrs.Slow growing painless mass. Euthyroid-status.LN metastases is common, may be the presenting
symptom (Lateral Aberrant Thyroid).Distant metastases is uncommon at initial
presentation. Develop in 20% of cases. (Lungs, liver,
bones,brain)
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Papillary CarcinomaPapillary Carcinoma• FNA biopsy is diagnostic.
• Treatment• Ipsilateral Lobectomy + Isthmusectomy (No LN
metastasis)• Near-total or Total Thyroidectomy + Modified-radical
or Functional neck dissection (+ve LN metastasis).• Prophylactic LN dissection is unnecessary.
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Follicular CarcinomaFollicular Carcinoma• Account for 10% of all thyroid cancers.• More common in I-deficient areas.• Female:male ratio is 3:1• Mean age at presentation is 50 yrs.• Solitary thyroid nodule, rapid increase in size and
long-standing goiter.• Cervical LN metastasis is uncommon at
presentation (5%), distant metastasis may be present.
• Hyperfunctioning < 1%. (S&S of Thyrotoxicosis)
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Follicular CarcinomaFollicular Carcinoma• FNA biopsy cannot differentiate between benign
and malignant follicular tumors.• Pre-operative diagnosis of malignancy is difficult
unless there is distant metastasis.• Large follicular tumor > 4 cm in old individual CA.
• Treatment:• Thyroid Lobectomy (at least 80% are benign
adenomas)• Total-Thyroidectomy in older individual with tumor >
4cm (50% chance of malignancy).• Prophylactic nodal dissection is unnecessary.
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Post-operative Post-operative ManagementManagement
• Thyroid hormoneo Replacement therapyo Suppression of TSH release
• At 0.1 μU/L in Low-risk group• < 0.1 μU/L in High-risk group
• Thyroglobulin measuremento At 6-months interval then annually when disease-freeo < 2ng/mL in total or near-total + Hormoneso < 5ng/mL in hypothyroid patients.o Level > 2ng/mL = Recurrence/Persistent thyroid tissue
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Post-operative Post-operative ManagementManagement
• Radioiodine Therapy:o Controversial (No prospective RCTs).o Long-term cohort studies by Mazzaferri and Jhiang and DeGroot:
• Small improvement in survival rate and less recurrence when RAI is used, even with Low-risk group.
o RAI is less sensitive than Tg in detecting metastatic disease.o I-131 detect and treat 75% of metastatic differentiated thyroid tumors.
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Medullary CarcinomaMedullary Carcinoma• 5% of all thyroid malignancies.• Arise from Parafollicular cells, concentrated in
superolateral aspect of thyroid lobes.• Most cases are sporadic, 25% are inherited
(Germline mutation in RET oncogene).• Female:Male ratio is 1.5:1• Most patients present between 50 and 60 yrs.• Neck mass + palpable cervical LN (15-20%).• Local pain or aching is common.
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Medullary CarcinomaMedullary Carcinoma• MTC secrets a range of compounds:
o Calcitonin, CEA, CGRP, PG A2 and F2α, Seritonin.o May develop flushing and diarrhoea, Cushing’s syndome (ectopic ACTH).
• Diagnosiso Hx and P/E (Family hx of similar tumors).o ↑ Serum Calcitonin, ↑ CEAo FNAC
• Screen patient for:o RET point mutation.o Coexisting Pheochromocytoma (24-hour urinary level of VMA,
catecholamine, metanephrine).o Hyperparathyroidism (Serum calcium).
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Medullary CarcinomaMedullary Carcinoma• Treatment:
o > 50% are bilateral, ↑ Multicentricity.o Total Thyroidectomy + :
• Bilateral central node dissection as routine (No LN involvement)
• Bilateral Modified-Radical Neck dissection (palpable LN)• Ipsilateral Prophylactic nodal dissection in tumor size >
1.5cm.o External Beam radiation for unresectable residual or recurrent tumor.o No effective Chemotherapy.
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Medullary CarcinomaMedullary Carcinoma• Prophylactic Thyroidectomy in RET mutation
detectiono Before age of 6 yrs for MEN2Ao Before age of 1 yr for MEN2B
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Anaplastic CarcinomaAnaplastic Carcinoma• 1% of all thyroid malignancies.• Women > Men.• Majority present at 7th - 8th decade of life.• Long-standing neck mass, rapidly enlarging in
size.• May be painful, with dyphonia, dyspnea,
dysphagia.• LN are usually involved at presentation.• ± Distant metastasis.
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Anaplastic CarcinomaAnaplastic Carcinoma• FNAC is diagnostic.• Treatment:
o Most aggressive thyroid tumor.o Total Thyroidectomy if resectable.o Adjuvant Chemotherapy + Radiotherapy slightly improve long-term
survival.
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Other TypesOther Types• Thyroid Lymphoma:
o 1% of all Thyroid Ca.o Most are Non-Hodgkin B-cell
Lymphoma.o Underlying chronic lymphocytic
thyroiditis.o FNAC is diagnostic.o Combined Chemotherapy
(CHOP) + Radiotherapy.
• Hurthle-Cell Carcinoma:o 3% of all Thyroid Ca.o Subtype of Follicular Ca.o More multicenteric and bilateral
(30%).o FNAC is not conclusive.o Lobectomy + isthmusectomy
(unilateral)o Total Thyroidectomy (bilateral)
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PrognosisPrognosisTumor Prognosis
Papillary Ca.74-93% long-term
survival rate
Follicular Ca.43-94% long-term
survival rate
Hurthle Cell Ca.20% mortality rate at 10
years
Medullary Ca.80% 10-year survival rate45% with LN involvement
Anaplastic TumorMedian survival of 4 to 5
months at time of diagnosis