Transcript NCCN - Management of Thyroid Carcinoma -2001

Update in the Management of
Thyroid Neoplasms
David R. Byrd, MD
Department of Surgery
University of Washington
NCCN - National Comprehensive
Cancer Network
• yearly update from the NCI-designated
comprehensive cancer centers (FHCRC -> FHCRC + UWMC)
• Consensus guidelines from the NCCN
membership institutions
• not focussed on the practice of the
community cancer practitioner
NCCN - Management of
Thyroid Carcinoma -2001
Thyroid Nodule - History
Local Sxs
Risk factors
Function
Thyroid nodules
• 6-10% adult U.S. population
– 5% are malignant
• FNA best initial test - 96% PPV
• U/S good to follow or document MNG
• thyroid scan good if symptoms of hyper- or
hypothyroidism or if indeterminate
cytology/multinodular goiter
• suppression most successful when TSH high
FNA Results of Thyroid Nodule
Benign --> F/U 6-12 months
cyst --> F/U 6-12 months
FNA
indeterminate --> repeat FNA, I123 scan
if same results
follicular neoplasm --> I123 scan or surgery
suspicious --> surgery
carcinoma --> surgery
Results of
123
I
scan
“hot” --> check TFTs
I123 scan
“euthyroid” --> rarely CA, F/U only
“cold”* (still takes up some iodine,
though less than normal gland)
*NOTE: 1. Nearly all cancers are “cold”
2. However, only about 10-15%
of “cold” nodules are cancer
Thyroid Carcinoma
©National Comprehensive Cancer Network
- Nodule Evaluation
Thyroid Carcinoma
- Nodule Evaluation
©National Comprehensive Cancer Network
Pathology of Thyroid Cancer
• differentiated thyroid cancer (DTC):
– papillary - commonly spreads to nodes (40-50%),
excellent prognosis
– mixed - papillary and follicular - acts like papillary,
excellent prognosis
– follicular - slightly worse than papillary, can spread
to bone, less to nodes (15%); Hurthle cell Ca is
variant
• medullary - sporadic vs. familial (MEN 2A),
total thyroidectomy is treatment
• anaplastic - aggressive and fatal, surgical role is
biopsy only
Thyroid Carcinoma
- Papillary Carcinoma
©National Comprehensive Cancer Network
Rationale for Total
Thyroidectomy for DTC
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improved effectiveness for I131 ablation
lowers dose needed forI131 ablation
allows f/u w/ thyroglobulin levels
decreased recurrence
improved survival in high risk pts.
decreased risk of pulmonary mets and
dedifferentiated CA
Rationale Against Total
Thyroidectomy for DTC
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increased RLN injury and hypoparathyroidism
contralateral disease not clinically relevant
survival nearly equivalent for low risk patients
I131 ablation not necessary for most patients
thyroglobulin levels not necessary for most
patients
Thyroidectomy for DTC Technique
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know the anatomy
protect RLN
preserve all parathyroids
know when to reassess or quit
Thyroid Carcinoma
- Papillary Carcinoma
©National Comprehensive Cancer Network
Lymphadenectomy for
Papillary or Mixed Thyroid CA
parathyroid
RLN
Thyroid Carcinoma - Papillary Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma
- Papillary Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma
- Papillary Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma
©National Comprehensive Cancer Network
- Papillary Carcinoma
Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network
Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network
? Residual Thyroid Cancer
• 25 y/o woman with papillary thyroid
cancer
– Capsular penetration
– Lymph nodes not sampled
• Dx and Post-Rx (200 mCi) I-131 scans
show thyroid remnant only
– TG off TSH = 110 ng/dL
• Dx I-131 scan 1 year later negative
– TG off TSH is still 100 ng/dL
Thyroid Cancer
Post therapy (10/98)
Tc-99m
markers
2055870
I-131
window
Thyroid Cancer
Diagnostic Scan (7/99)
Tc-99m
markers
2055870
I-131
window
? Residual Thyroid Cancer:
FDG PET Scan 8/99
L Cervical
Lymph
Nodes
20558
70
? Central
Lymph
Nodes
Case 1
• 60F undergoes L thyroid lobectomy for a
solitary nodule w/ follicular cells on
FNAC.
• Final path shows 2cm follicular adenoma
and incidental 5mm papillary thyroid CA
• ?further management
Case 1 - issues
Result: the 2 cm nodule is benign and the 0.5cm nodule
is an incidental carcinoma of minimal significance
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? Completion thyroidectomy --> NO
? Radioactive iodine therapy --> NO
? Thyroid suppression --> +/? F/u -6 month intervals with H & P
Case 2
• 40M w/ solitary 1.5cm L thyroid nodule
on exam
• h/o neck irradiation for enlarged thymus
as child
• ?further management
Case 2 - Issues
This is a setting of higher risk of cancer - male, solitary
lesion, and equivocal hx of neck irradiation:
minimal operation is thyroid lobectomy + isthmusectomy,
proceed to total or subtotal thyroidectomy if bilateral nodules
and/or if carcinoma found
frozen section is notoriously unable to definitively call
carcinoma - therefore permanent pathology usually
necessary to confirm carcinoma