Transcript PowerPoint 簡報 - Introduction

JHSGR
Management of Papillary
Ca Thyroid
Chris Cheng Tsz Ling
Princess Margaret Hospital
Introduction
 Thyroid carcinoma has the fastest rising incidence
of all major cancers, ↑4% per year
 Papillary thyroid carcinoma(PTC) is the most
common type of differentiated thyroid carcinoma,
incidence x 2 throughout 25 years
 Excellent prognosis, 10-year cancer specific
survival rate >90%
 Locoregional recurrence (LRR) is a major cause of
disease morbidity
Grubbs EG, Rich TA, Li G, et al. Recent advances in thyroid cancer. Curr Probl Surg 2008;45:156 –250
Cancer incidence and mortality in Hong Kong 1983–2008: Hong Kong Cancer Registry, Hong Kong
Agenda
 The optimal extent of surgery
 Prophylactic central neck LN dissection
 Rationale for use of adjuvant radioactive
iodine (RAI) remnant ablation
Thyroidectomy
Total/Near total Thyroidectomy
Vs Lobectomy
 Total thyroidectomy (n=43227) Vs Lobectomy (n=8946)
 ≥ 1cm CA thyroid, Lobectomy was associated with
 15% higher risk of recurrence (p=0.04)
 31% higher risk of death (p=0.009)
 < 1cm CA thyroid, no difference in recurrence or survival
 Bilimoria et al. Extent of surgery affects survival for papillary thyroid cancer.
Ann Surg 2007 Sep;246(3):375-81
 American Thyroid Association recommendation:
 Lobectomy: for <1cm, low risk, unifocal, intrathyroidal papillary
carcinoma without cervical LN or history of head & neck irradiation
 Near-total / Total thyroidectomy: for >1cm
Neck LN Dissection
Neck Dissection
 Therapeutic
- Clinically evident and biopsy proven LN involvement
 Prophylactic
- No clinical evidence of LN
- HOT debate: Prophylactic Central LN dissection(level
VI)
Central neck dissection
(minimum)
- Pre-laryngeal
- Pre-tracheal
- Para-tracheal
Central neck dissection may be extended to:
- Retropharyngeal
- Retroesophageal
- Paralaryngopharyngeal (superior vascular pedicle)
- Superior mediastinal (inferior to innominate artery)
ATA Guideline. Consensus Statement on the Terminology and Classification
of Central Neck Dissection for Thyroid Cancer. Thyroid. Volume 19, Number 11, 2009
Central Neck dissection
 SEER (Surveillance, Epidemiology, and End Results) database
 9904 Papillary thyroid cancer
 Cervical LN met in papillary cancer of Age>45
 Independent risk factor for decreased survival
 The most common site for lymph node metastases and DTC
recurrence is within the central compartment
 Roh JL et al. Total thyroidectomy plus neck dissection in differentiated
papillary thyroid carcinoma patients: pattern of nodal metastasis, morbidity,
recurrence, and postoperative levels of serum parathyroid hormone. Ann
Surg 2007 245:604–610.
 Central neck dissection may convert some patients from cN0 to
pathologic N1a
Central Neck dissection
 Mayo clinic 60-year observation in 900 patients
with <1cm microcarcinoma
 In 450 patients with any form of LN surgery done,
 30% lymph node involvement at initial surgery
 80% recurrence at central LN
Hay ID et al. Papillary thyroid microcarcinoma: a study of 900 cases
observed in a 60-year period. Surgery 2009. 144:980–987.
CND may reduce recurrence
 In 950 Papillary thyroid cancer patients
 Stage I 45%, Stage II 25%, Stage III 22%, Stage IV 6%
 75% LN dissection done (mostly CND only)
 Recurrences
 LN dissection: 6.8%
 No LN dissection: 16.5% (p<0.001)
 Stage I (1%), Stage II (6%), Stage III (6%), Stage IV
(77%)
 No difference in 10-yr / 15-yr survival
 Toniato A et al. Papillary thyroid carcinoma: factors influencing
recurrence and survival. Ann Surg Oncol 2008;15: 1518–1522.
Central Neck Dissection
 Seems Improve survival in comparing observational
studies
Tisell LE et al. Improved survival of patients with papillary
thyroid cancer after surgical microdissection. World J Surg
1996. 20:854–859.
Central Neck Dissection
 Increases the proportion of patients who appear disease
free with unmeasureable Tg levels 6 months after
surgery
 undetectable TG levels
 Total thyroidectomy + CND: 72%
 Total thyroidectomy only: 43% (p<0.001)
 Sywak M et al. Routine ipsilateral level VI lymphadenectomy
reduces postoperative thyroglobulin levels in papillary thyroid
cancer. Surgery 2006. 140:1000–1007
Central neck dissection
increases complications?
Complications of thyroidectomy alone
Vs thyroidectomy + CND
Chrisholm et al. Systematic review and meta-analysis of the adverse effects of
thyroidectomy combined with central neck dissection as compared with
thyroidectomy alone. Laryngoscope 2009 Jun;119(6):1135-9
Complications of thryoidectomy alone
Vs thryoidectomy + CND
Chrisholm et al. Systematic review and meta-analysis of the adverse effects of
thyroidectomy combined with central neck dissection as compared with
Central Neck Dissection
 All existing literatures are cohort studies
 No RCT
 American thyroid association has commented it is NOT
feasible to do an RCT on prophylactic central neck
dissection
 Need to randomize 5840 patients to have enough power to
show a difference in recurrence or complications!
American Thyroid Association Design and Feasibility of a
Prospective Randomized Controlled Trial of Prophylactic Central
Lymph Node Dissection for Papillary Thyroid Carcinoma.
THYROID. Volume 22, Number 3, 2012
American Thyroid Association (ATA)
guideline – Central neck dissection
 Prophylactic central-compartment neck dissection
(ipsilateral or bilateral)
PTC with clinically uninvolved central neck LN,
especially for advanced primary tumors (T3 or T4).
 Recommendation rating: C
 Near-total or total thyroidectomy without prophylactic
central neck dissection
for small (T1 or T2), noninvasive, clinically node-negative PTCs.
 Recommendation rating: C
 These recommendations should be interpreted in light of
available surgical expertise.
Radioactive Iodine
Ablation
Role of post thyroidectomy
RAI
1.Remnant ablation (to facilitate detection
of recurrent disease and initial staging)
2.Adjuvant therapy (to decrease risk of
recurrence and disease specific mortality
by destroying suspected, but unproven
metastatic disease), or
3.RAI therapy (to treat known persistent
disease).
↓ Recurrence and cancer death
in Stage 2/3 disease
Mazzaferri EL, Jhiang SM 1994 Long-term impact of initial surgical and
medical therapy on papillary and follicular thyroid cancer. Am J Med 97:418–
428.
RAI improved survival
 The single most powerful prognostic
indicator
- ↑ increase disease-free interval (p<0.001)
- ↑ increase survival
 Samaan Na et al. The results of various modalities of treatment
of well differentiated thyroid carcinomas: a retrospective review
of 1599 patients. J Clin Endocrinol Metab 1992. 75:714–720.
The National Thyroid Cancer Treatment
Cooperative Study Group (NTCTCSG)
 2936 patients
 median follow-up of 3 years
 Near-total thyroidectomy followed by RAI therapy
and aggressive thyroid hormone suppression
therapy
Improved overall survival of patients with
NTCTCSG stage II-IV disease
No impact of therapy in stage I disease
Jonklaas J et al. Outcomes of patients with differentiated thyroid carcinoma
following initial therapy. Thyroid 2006. 16:1229–1242.
Mayo Clinic experience on MACIS
low risk papillary thyroid cancer
Hay ID, McConahey WM, Goellner JR. Managing patients with papillary thyroid
carcinoma: insights gained from the Mayo Clinic’s experience of treating 2,512
consecutive patients during 1940 through 2000. Trans Am Clin Climatol Assoc
2002.113:241–260
RAI in papillary thyroid microcarcinoma
RAI after thyroidectomy for <1cm
PTM did not reduce recurrence
Hay ID et al. Papillary thyroid microcarcinoma: a study of 900 cases
observed in a 60-year period. Surgery 2009. 144:980–987.
RAI in papillary cancer
 RAI did not show benefit in low risk disease
 Recurrence and survival benefits restricted to:
 >1.5cm
 Residual disease following surgery
ATA guideline on RAI remnant
ablation
ATA guideline on RAI remnant
ablation
 Recommended for T3-4 or M1
 Recommended for selected cases in 1-4cm thyroid cancers
with:
 Lymph node metastases, or
 high risk features
 Age >45, tumor invasion, individual histology, incomplete resection
 Recommendation rating: C
 NOT recommended for patients with:
 unifocal cancer <1 cm without other higher risk features
 Recommendation rating: E
 multifocal cancer when all foci are <1 cm in the absence other
higher risk features
 Recommendation rating: E
Conclusion
 Individualized management according to risk
stratification
 Low Vs High risk
 Total/Near-total Thyroidectomy is standard for >1cm
papillary thyroid cancer
 Prophylactic Central neck dissection is indicated for T3-4
tumors to reduce local recurrence
 For T1-2 tumors, need to balance benefits and
complications
 RAI mainly indicated for T3-4 & M1 disease
Thank you