Thyroid Cancer The Basics

Outline • Workup / clinical – Euthyroid disease (benign vs. malignant) – FNA

• Thyroid Cancer – Focus mostly on Papillary/Follicular Ca – Preoperative/operative/postoperative management

• Data

Case Presentation • HPI: M is a 30 yo M referred to surgery for a palpable thyroid nodule on physical exam by PCP. No dysphonia, dysphagia, odynophagia, change in voice. No smoking history. Recent cough for a few weeks. No fevers, chills, weight loss. No hx of radiation to neck • Dysphonia is more correlated to malignancy • Radiation key risk factor, a must ask

Case Presentation • PMH: major depressive disorder, sleep apnea – Meds: desipramine, buproprion

• PSH: left shoulder surgery 1996, pilonidal cyst excision 2000 • All: NKDA • FHx: Maternal Aunt – goiter • SHx: no tobacco, social etoh, no drugs • PE: Pertinent only of Right side 3 cm mass • Pertinent Labs: normal TSH

Ultrasonography • Ultrasonography to evaluate • Higher risk findings: hypoechoic, increased vascularity, irregular contours • Typical euthyroid Nodules: – Cystic – usually benign, rare to be pure cystic, usually solid component – Multiple Nodules (multinodular goiter) – find dominant nodule, and high risks nodules for FNA – Solitary Nodule

Cystic • • • • •

Aspiration for cyst (cytology if available) Solid component should be treat as nodule Repeat evaluation 6 weeks Asipiration again, then Lobectomy Surgery

Multinodular Goiter • If 4cm with symptoms – questions need for FNA at all. Acceptable to go to OR. FNA with increased False negative for > 4cm. • Btwn 1 and 4 cm no symptoms do FNA of Dominant and irregular appearing node • If symptoms are present then surgery acceptable w/o FNA

Solitary Nodule • Need FNA – With US is prefered to reduce False negative rate. • Greater than 4cm – acceptable to operate w/o FNA. • 4cm, extrathyroidal extension, mets, lymphatic spread, cell type, radiation • At diagnosis: 25% multi-centric this is key to recall when determining surgical management of lobectomy vs total. – 1/3rd + nodes – Distant mets < 5% (pulm)

Papillary Thyroid Cancer • Surgical Decisions – >1cm – Total Thyroidectomy …. This is when risk of recurrence and mortality increases at 10 years – < 1cm – lobectomy unless, high risk factors, poor f/u expected

• To do or not…. Central node resection? – Guidelines are not clear unless patient has operative findings suggestive or + FNA. – FNA – aggressive variants – Lymphatic spread suggested intraoperative – Just for the hell of it… all cancer cases with one or more risk factors (age >45, larger tumors, extracapsular)

• Lateral Lymphadenectomy – clinical pathologically proven disease only.

Postoperative Management for PTC • Adjuvant RAI for Thyroid remnant ablation – T3, T4, Nodal Disease

• Thyroid Suppression – realize after total thyroidectomy for benign disease you give replacement to normalize TSH, after Cancer you give it to lower TSH as much as possible. • Total Thyroidectomy, with RAI, and good suppression has the lowest recurrence rates.

Follicular Thyroid Cancer • • • • •

10 to 15% of Thyroid malignancies Usually solitary mass compared to PTC Mets spreads via blood not lymph (lung, bone) Prognostic factors - >50y/o, >3.5cm Can’t determine malignancy by FNA b/c? – Capsular invasion – Vascular invasion

Follicular Thyroid Cancer • Requires a tissue diagnosis – Either total or lobectomy

• If lobectomy and path reports shows – Small amount capsular invasion, no vascular – ok to follow with out total – Significant capsular and vascular invasion patient needs completion thyroidectomy. – Central Lymph Node dissection indicated with clinical findings.

• RAI ablation / Thyroid Supression – All but min invasive disease

Hürthle Cell Carcinoma • < than 5% of Thyroid Cancer • Subset of follicular neoplasms • Considered more aggressive – Extrathyroidal extensions and metastases – More nodal disease – RAI uptake is often minimal utility

• Total Thyroidectomy with central node dissection if clinically indicated. • RAI/thyroid suppression

Other Cancers of the Thyroid • • • •

MTC Anaplastic Primary Thyroid Lymphoma Metastatic from distant primary

Early Post Op Management • Total Thyroidectomy – PACU Voice quality, airway – Monitor Hematoma – Hypoparathyroidism – POD 1 iCal, total calcium – Hypocalcemia – symptoms and treatment – Thyroid Hormone Management +/- RAI – T4 suppression

Complications • Wound infection – possible tracheal injury, mediastinitis risk • Neck Hematoma/seroma – postop airway • Nerve injury – blunt vs severed – Blunt injuries usually recover in 3 months.

American Thyroid Association

American Thyroid Association Central Lymph Node Dissection Central Compartment • Superiorly – Hyoid bone • Laterally – carotid arteries • Anteriorly – superficial layer of the deep cervical fascia • Posteriorly – deep layer of the deep cervical fascia • Inferiorly – superior to innominate artery on right, and corresponding axial plane on the left.

Data to Support Consensus Guidelines

•National Cancer Data Base (1985–1998) •52,173 patients with surgery for PTC •Survival estimated by Kaplan-Meier method, compared using log-rank tests •Cox Proportional Hazards modeling stratified by tumor size used to assess impact of surgical extent on outcomes •Results: 43,227 (82.9%) underwent total thyroidectomy, 8946 (17.1%) underwent lobectomy. • For PTC1 cm, lobectomy resulted in higher risk of recurrence and death (P = 0.04, P = 0.009) • 1 to 2 cm lesions were examined separately: lobectomy again resulted in a higher risk of recurrence and death (P = 0.04, P = 0.04). Bilimoria KY et al. Extent of surgery affects survival for papillary thyroid cancer. Ann Surg 2007;246:375-384.

Cumulative Recurrence Rate vs Years of FollowUp by Tumor Size

Bilimoria KY et al. Extent of surgery affects survival for papillary thyroid cancer. Ann Surg 2007;246:375-384.

Cumulative Recurrence Rate vs Years of FollowUp by Extent of Surgery

Bilimoria KY et al. Extent of surgery affects survival for papillary thyroid cancer. Ann Surg 2007;246:375-384.

Cumulative Survival Rate vs Years of Follow-Up by Extent of Surgery

Bilimoria KY et al. Extent of surgery affects survival for papillary thyroid cancer. Ann Surg 2007;246:375-384.