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8/7/2019 Thyroid Disease1
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Thyroid Cancer
May 10, 2006
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Thyroid Cancer
� Accounts for 1.5% of all cancers in the US
� Most common endocrine malignancy (95%)� 22,000 cases per year and estimated 500 ±
1000 patients die annually
� 90% of thyroid cancer cases have favorableprognosis
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Classification & Incidence of
Thyroid Cancer Follicular cell origin
� Differentiated
± Papillary 80%± Follicular 10%
± Hurthle cell 3-5%
� Undifferentiated
± Anaplastic 1-2%Parafollicular cell origin
± Medullary 5%
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P apillary Carcinoma
� Accounts for 90% radiation induced cancer
� Classified as microcarcinoma, intrathyroidal, and
extrathyroidal
± Histologic variants: tall-cell, clear-cell, columnar , diffuse
sclerosing
� Multicentric in 30-50% of tumors
� Spreads via lymphatics with propensity for mid- andlower-anterior cervical chain (Level VI)
� 20-50% patients have involvement of cervical LN
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F ollicular Carcinoma
� Only 10% of thyroid cancers in developed countries, although more prevalent in regions with iodinedeficiency
� Diagnosis depends on demonstration of vascular or capsular invasion
� Classified as minimally or widely invasive
± Vascular invasion tends to have a more aggressive course
than capsular invasion� Uncommon to have multicentric disease
� Hematogenous spread
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F ollicular Carcinoma
Where does follicular carcinoma tend to
metastasize?
� Bone
� Lung
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H urthle Cell Carcinoma
� High propensity to spread to cervical lymph
nodes and high incidence of distant metastasis
� Less than 10% of Hurthle cell carcinomas takeup radioiodine
� High tumor recurrence rate
� High mortality rate ± 30% mortality at 10 years
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Anaplastic Carcinoma
� Increasingly rare
� Arise within differentiated cancers
� Pts > 60 years old with rapidly expanding neck mass
� Local invasion very common at time of dx (FNA)
� Surgery plays limited role given advanced stage at dx
� R adiation and chemotherapy have not demonstrated
any significant improvement in survival
� Median survival ~ 4 - 6 months
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M edullary Thyroid Carcinoma
� Originates from the parafollicular C cells
� Elevation in calcitonin and CEA (50%)� 80% have sporadic MTC (unifocal), remainder
have genetic component
� 75% patients have LN metastasis at time of dx, 20% distant mets
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M edullary Thyroid Carcinoma
� MEN IIA ± MTC (100%), pheo (40%), hyperparathyroidism (35%)
± AD inheritance
± Missense mutation of extracellular cysteine of RET
± Surgery recommended before 6 years of age
� MEN IIB ± MTC (100%), pheo (50%), mucosal ganglioneuromas (100%),
marfanoid habitus
± AD inheritance
± Missense mutation of tyrosine kinase domain of RET± Surgery recommended in infancy
� Familial MTC
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Lymphoma of the Thyroid
� Usually non-Hodgkin¶s B cell type
� Pts with Hashimoto¶s thyroiditis have 70-80
fold increase risk � Typically women > 70yo present with
enlarging neck mass
�F
NA > 80% accuracy� Treatment includes XR T and chemotherapy
� 5 year survival rates 50-70%
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45 year old female presents to your office with a
thyroid nodule. What questions will you ask
her?
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H istory
1. Characteristics of nodule
2. Is the patient symptomatic?
1. Hyperthyroid/Hypothyroid2. Compressive sxs
3. Family history MEN endocrinopathies
4. R adiation exposure
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45 year old female with thyroid nodule
1. Characteristics of nodule found
incidentally by PCP
2. Is the patient symptomatic?
No1. Hyperthyroid/Hypothyroid
2. Compressive sxs
3.F
amily history
None4. R adiation exposure None
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P hysical Exam
� Size
� Consistency of nodule, multiple or solitary� Fixed or mobile
� Presence of cervical LAD
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P hysical Exam
� Solitary nodule
� Mobile, not obviously adherent to adjacent
structures� No cervical LAD
� Normal voice
� Otherwise well appearing
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Evaluating a thyroid nodule
� Thyroid nodules are common, but less than
10% are malignant
� History and PE
� TSH level should be obtained during initial
evaluation± If low, radioisotope study
± If normal or high, then proceed to ultrasound
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Evaluating a thyroid nodule
What is the risk of a ³hot´ nodule on radioiodine
scan being malignant?
� Less than 1%
What about a ³cold´ nodule?
� 15% ± 20%
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Evaluating a thyroid nodule
� R adioisotope studies may also be useful:
± FNA reports ³suspicious for follicular neoplasm´or ³indeterminate´
± Detecting neck metastasis
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Evaluating a thyroid nodule
� What information will an ultrasound provide?
± Number of nodules± Location and size of nodules
± Cystic versus solid
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Evaluating a thyroid nodule
� Which of the following are concerning
findings on ultrasound?
± Halo sign
± Hypoechogenic
± Calcifications
± < 1cm
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Evaluating a thyroid nodule
� Which of the following are concerning
findings on ultrasound?
± Halo sign
± Hypoechogenic
± Calcifications
± < 1cm
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Evaluating a thyroid nodule
� FNA is the most reliable and cost efficient wayto determine malignant from benign lesion
� 4 categories:
± Malignant, benign, suspicious, indeterminate
� Limitation of FNA:
± Cannot distinguish benign follicular or Hurthle cell
adenoma from malignancy ± based upon presenceor absence of capsular or vascular invasion
� False negative rate < 5%
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45 year old female with thyroid nodule
� TSH level was normal
� Underwent an ultrasound-guided FNA of the
nodule, pathology revealed papillarycarcinoma in a nodule measuring 2.5cm
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M anagement of P apillary Carcinoma
What surgical procedure would you offer her?
� Near-total or total thyroidectomy is recommended if:
± Tumor > 1-1.5cm
± Contralateral nodules± Local or regional metastasis
± + FHx in 1st degree relative
± + history of radiation exposure
± Age >45 yo� Increased extent of surgery lowers recurrence rates
and has improved survival in high-risk patients
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M anagement of P apillary Cancer
When is lobectomy an acceptable surgicalprocedure for FNA proven papillary cancer?
� According to the American ThyroidAssociation Guidelines Taskforce, lobectomywith isthmusectomy may be sufficient
treatment for microcarcinoma (e
1cm), low-risk patients, intrathyroidal cancer withoutinvolvement of cervical LN
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M anagement of P apillary Cancer
Will you plan on performing a lymph nodedissection?
� A central compartment (Level VI) neck dissection should be considered
� If nodal disease is evident clinically then a
more extensive cervical lymphadenectomyshould be performed
� LN sampling not recommended
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S urgical Anatomy:
Lymphatics
� What are the LNs located superior to the
thryoid gland in the midline called?
� Delphian nodes
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45 year old female with
papillary carcinoma
Patient opted to have a total thyroidectomy and
surgical specimen demonstrated unifocaldisease with capsular invasion and negative
LN. Does she have a favorable or unfavorable
prognosis?
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P rognostic Risk Classification for P atients with
Well-Differentiated Thyroid Cancer
( AM E S or AGE S)Low Risk High Risk
� Age <40 years >40 years
� Sex Female Male
� Extent No local extension, Capsular invasion, extra-
intrathyroid, no caps thyroidal extension
invasion
� Metastasis None
R egional/distant
� Size <2 cm >4 cm
� Grade Well diff Poorly diff
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M anagement of P apillary Cancer
What further treatment is recommended?
� TSH suppression therapy� R adioiodine ablation therapy
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45 year old female with
papillary carcinoma
She wants to know what her long-term survival
is.W
hat will you tell her?
� ~ 90% at 10 years for papillary carcinoma
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45 year old female with thyroid nodule
� TSH level was normal
� Underwent an ultrasound-guided FNA of the
nodule, pathology suspicious for a follicular neoplasm
� What is the risk that this is malignant?
� Approximately 20%
� What surgical procedure will you offer her?
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M anagement of FNA suspicious for
follicular neoplasm
� Lobectomy would be a reasonable surgical
procedure, particularly in low-risk patient whoprefers limited surgical intervention
� Near-total or total thyroidectomy still
recommended for high-risk patient and/or
large tumor size
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M anagement of FNA suspicious for
follicular neoplasm
� Intra-operative frozen sections can be helpful
in this scenario? True or false
� False
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45 year old female with thyroid nodule
� You performed a lobectomy and the final
pathology reveals Hurthle cell carcinoma
� What further treatment do you recommend?
� Completion thyroidectomy with centralcompartment LN dissection
� TSH suppression therapy
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P ost-operative radioiodine
remnant ablation
� To whom should it be offered?
� Stages III and IV disease� Stage II disease in pts under age 45
� Selected pts with Stage I± Multifocal disease
± Nodal metastasis
± Extrathyroidal extension
± Vascular invasion
± Aggressive histology
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T MN Classification for differentiated
thyroid cancer
� T1 e 2cm
� T2 2-4cm
� T3 >4cm, limited to thyroid
� T4a Any size, invasion of SQ, trachea, esophagus, R LN
� T4b Any size invasion of prevertebral fascia or encasingcarotid/mediastinal vessels
� N0 no nodes
� N1a Level VI
� N1b All other levels
Stages
� Stage I T1, N0, M0
� Stage II T2, N0, M0
� Stage III T3, N0, M0T1-3, N1a, M0
� Stage IVA T4a, N0, M0
T4a, N1a, M0
T1-3, N1b, M0
� Stage IVB T4b, any N, M0� Stage IVC Any T and N, M1
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45 year old female with thyroid nodule
She asks what her overall 10 year survival will
be with her diagnosis of Hurthle cell
carcinoma?
� ~70%
W
hat if she had follicular carcinoma?� ~70%
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Recommendations for follow-up
(differentiated cancers)
� Thyroid cancer recurs in 20-40% patients, most
commonly within the first 2 years
� Thyroglobulin used as tumor marker checked every
6-12 months
� Whole body scan may be useful in intermediate and
high-risk patients 6-12 months after ablation� Ultrasound should be done 6-12 months after surgery,
then annually for the next 3-5 years
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M anagement of recurrent and
metastatic disease
� Surgery mainstay of treatment for locoregional
disease
radioiodine
radiation� Metastatic disease treated with radioiodine
± Older patients with bony mets are less likely to
respond to radioiodine and have poor prognosis
± Pulm mets more radio responsive than bone mets
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55 year old male presents to your
office with MTC on FNA
� Palpable thyroid nodule and cervical LN
� Diarrhea and flushing
� No FHx of MEN endocrinopathies
� Calcitonin elevated, FNA reveals MTC
Any further tests that you should order?� Genetic testing
� CT scan to see extent of disease
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55 year old male presents to your
office with MTC on FNA
What surgical procedure will you recommend to
him?� Total thyroidectomy with LN dissection in
Level VI and LN sampling in lateral regions
(frozen sectioning intra-operatively)
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55 year old male presents to your
office with MTC on FNA
What do you want to check for before bringing
him into the operating room?
� Presence of a pheochromocytoma
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55 year old male presents to your
office with MTC on FNA
How would you handle the parathyroid glands?
� Some recommend performing a totalparathyroidectomy with autotransplantation in
either the forearm or SCM
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55 year old male presents to your
office with MTC on FNA
� Further treatment remains controversial but
includes radiation therapy and chemotherapy� Surveillance using calcitonin levels
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Surgical Anatomy:
Vasculature
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Surgical Anatomy:
Vasculature and nerves
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S urgical Anatomy
What is the consequence of injurying the
external branch of the superior laryngealnerve?
� Injury results in paralysis of the cricothyroid
muscle
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Surgical Anatomy:
Anatomical variations of the
R ight R LN
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S urgical Anatomy
What is the result of an injury to the recurrent
laryngeal nerve?
± Ipsilateral paralysis
± Contralateral paralysis
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S urgical Anatomy
What is the result of an injury to the recurrent
laryngeal nerve?
± Ipsilateral paralysis
± Contralateral paralysis
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S urgical Anatomy
What would you do if the tumor involved theR LN?
� If vocal cord is paralyzed pre-operatively, thenconsider resecting the R LN along with
specimen� If no vocal cord paralysis, dissect tumor off
nerve
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S urgical Anatomy:
The P arathyroids
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