THYROID CANCER

Dr Martin Borg
THYROID CANCER
ANATOMY
 THYROID CANCER
Epidemiology
Rare (<1%)
0.5-10/105
Most common endocrine malignancy (90%)
Most common cause of death of EM
High survival rates
 THYROID CANCER
Pathology
1. Follicular cell origin (FCDC)
2. Parafollicular (C cells) – medullary
FCDC
1. Papillary (and follicular variant – FVPTC) (most)
2. Follicular
3. Oxyphilic (Hurthle cell)
4. Anaplastic
 THYROID CANCER
Controversies
No PRCT
1. Extent of primary surgical resection
2. Need for regional LND
3. Extent of regional LND
4. Role of postoperative RAI ablation
5. Dose of RAI ablation
6. Degree of suppression of TSH
7. Role of postoperative EBRT
 THYROID CANCER
Diagnosis
History/examination (MEN, MTC FH)
Ultrasound-guided FNAB of clinical or
radiologically detected mass
Thyroid/Neck ultrasound
Serum Ca2+
CT scan neck/superior mediastinum/chest
ENT exam (vocal cords)
TG
(WBBS)
THYROID CANCER
INVESTIGATIVE
PROCEDURES
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RADIONUCLIDE IMAGING
 THYROID
CANCER
I-123 SCAN
SHOWING
COLD SPOT
THYROID CANCER
STAGING CT SCAN
MEDIASTINAL LN 2’
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TNM Staging System (UICC)
Postop Papillary/Follicular Medullary Anaplastic
Stage <45 yr ≥45 yr Any age Any age
I M0 T1 T1 -
II M1 T2 T2 -
III - T3 T3 -
T1-3 N1a T1-3 N1a
IV - T1-3 N1b T1-3 N1b Any
T4 T4
M1 M1
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
PTC – Classification
1. Minimal PTC
(a) T <1 cm
(b) no capsule invasion
(c) no 2’ (bone, lung)
(d) no LVI
MR 0.1%
RR 5%
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
PTC – Classification
High-risk PTC/FTC
1. AMES (age, 2’, T extent/size)
2. AGES (age, grade, T extent/size)
3. TNM (T, LN, 2’)
4. EORTC
5. MACIS (2’, age, resectibility, invasion, T)
6. Histology (Hurthle cell, tall cell, columnar variants)
Other
1. Delay in treatment
2. LVI – especially FTC
3. High grade (PTC/FTC)
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Surgery
1. Total ipsilateral thyroid lobectomy
Minimal PTC or min invasive FTC ± limited cap inv
2. Near total thyroidectomy
High-risk PTC
Bilateral cancer/nodules (papillary not follicular)
Preservation of parathyroid glands (relative RR)
Risks (<2%): (1) HPT
(2) recurrent laryngeal nerve injury
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Surgery
Advantages of NTT
1. PTC often multifocal
2. Lymphatic spread throughout gland
3. Facilitates ablative RAI
4. Facilitates detection of residual and distant
tumour
5. Facilitates treatment of residual and distant
tumour
6. TG more sensitive tumour marker
7. ↓RR and ↑DFS
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Well Differentiated Thyroid Carcinoma
Treatment
Surgery
LND
Risk at Δ in older adults (ipsilateral)
1. PTC: 40%
2. FTC: 10%
3. Hurthle: 25%
Extensive LN 2’ suggestive of follicular
variant of PTC
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Surgery
LND
Significance
1. PTC: ↓LRR not ↑OS
2. FTC: worse prognosis (uncommon)
3. Medullary: ↓LRR and ↑OS
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Surgery
LND
Procedure
1. T > 15 mm: en bloc central cervical LND
2. Limited LN + (extra thyroid) or palpable LN:
functional Cx/M LND (unilateral)
3. Extensive LN + (extra thyroid): radical Cx/M LND
(unilateral or bilateral, ± thymectomy)
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
1. TSH suppression
T4 commenced after ablative RAI
150-200 mcg/day (2mcg/kg)
Serum levels (a) HR: < 0.1 μIU/mL
(b) LR: 0.1 – 0.4μIU/mL
No proven OS benefit/ ↓LR
Monitor cardiac function in elderly
Risks: accelerated bone turnover, OP, AF
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
2. RAI
i. Ablative RAI
All patients after TT/NTT, except
a) Young, female patients with occult
solitary papillary carcinoma < 15mm
b) Partial thyroidectomy
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
2. RAI
i. Ablative RAI
 Rationale
a) ablate residual thyroid tissue and adjacent
microscopic CA
b) TG assay more specific
c) ↓ 2’ CA
d) ↑ TSH increases RAI uptake
e) Radionuclide scans more sensitive for tumour
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
2. RAI
i. Ablative RAI
 CI
a) Patient refusal
b) Poor performance status
c) Uncooperative patient
d) Intractable urinary incontinence
e) Pregnancy
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
2. RAI
i. Ablative RAI
Preparation
1) 6/52 postop
2) TG before RAI
3) Low iodine diet for 2/52
4) Pregnancy test and contraceptives
5) No replacement T3/4
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
2. RAI
i. Ablative RAI
Procedure
1) 75-150 mCi (2,775-5,550 MBq) – controversial
2) Admit for 1-2 days (physicist check)
3) Urinary catheter if female (ovarian dose – 0.3
cGy/mCi)
4) NSAID/paracetamol or steroids for pain
5) Post-op precautions (in ward and at home)
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POSTOP MANAGEMENT
FLOW DIAGRAM
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 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
2. RAI
ii. Therapeutic RAI
150-200 mCi (5500-7000MBq)
Max 1500-2000 mCi (avoid > 1000 mCi)
Min 6/12 between RAI doses
Reduce dose if multiple lung 2’ (80 mCi retained
dose)
Flare response, xerostomia, AML/bladder/breast, BM
suppression, azospermia, menopause
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
2. RAI
ii. Therapeutic RAI
Indications
a) Iodine avid recurrent disease
b) 2’
Dexamethasone
a) cerebral, intra-orbital or intra-spinal 2’
b) Stridor
Reduce dose (80 mCi retained dose) if multiple
lung 2’
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RAI FOR LUNG METATSASES
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
3. EBRT
50.4 Gy @ 1.8 Gy/# in 28#
5-20 Gy boost to residual disease
Total dose limited by SC, other structures
Large AP field with small AP or PA
mediastinal field
6-10 MV photons
INDICATIONS
FOR
EBRT
RADICAL
RT
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
3. EBRT
Target Volume
1) Thyroid and tumour/bed if
i. macroscopic residual, and
ii. N-ve
2) JD, Submandibular, IJ, Sp Accessory, SCF, Sup
Med (to carina) if
i. Residual or extensive N +, or
ii. Non-iodine avid disease
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RADICAL EBRT
THYROID
CANCER
RADICAL
EBRT
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Well Differentiated Thyroid Carcinoma
Follow-up
1. TG if N- TG antibodies
i. Post-op
ii. @ 4/12
iii. 6/12ly x 2years
iv. Annually
2. RAI
i. Rising TG - restaging
ii. Recurrent/metastatic disease – avidity
iii. Surveillance if + TG AB
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Follow-up
3. Radiological tests
CT neck/chest
MRI
U/S
WBBS
PET
4. Thyroid function tests
ensure adequate suppression of TSH
5. Recombinant thyrotopin
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Persistent or Recurrent Disease
1. Restage (CT, RAI)
2. Maximal resection (LND, excision of LR)
3. Whole body iodine scan (diagnostic, test
avidity)
4. Therapeutic RAI
5. EBRT
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Metastases
Incurable but several years’ survival
possible
Management varies with
1. Patient factors
2. Tumour factors (number and site/s of
recurrence, local complications)
3. Iodine avidity
4. Prior treatment and its outcomes
 THYROID CANCER
Well Differentiated Thyroid Carcinoma
Metastases
Surgery
1. Selected long-bone 2’ at risk of fracture
2. Isolated and solitary brain 2’
3. SC compression
4. Isolated lung 2’
5. Rapid progression of 1 pulmonary 2’
RT
Palliative doses for symptom control or to
prevent complications
 THYROID CANCER
MEDULLARY CARCINOMA
6-8% of thyroid cancers
75% sporadic
25% hereditary
Neuroectodermal parafollicular C cells
Independent of TSH
Elevated serum calcitonin (level corresponds
with stage)
FH and MEN screen (esp. pheochromocytoma)
Calcium deposits on U/S
Stage (CT/MRI/octreotide)
neck LN, bone, lung, liver
 THYROID CANCER
MEDULLARY CARCINOMA
Management
Surgery
1. TT
2. Central compartment LND
3. Ipsilateral LND
Calcitonin 8-12/52 postop
EBRT
CT (DTIC + 5-FU)
 THYROID CANCER
MEDULLARY CARCINOMA
Prognostic Features
1. T size
2. Preop calcitonin
3. Advanced age
4. Extrathyroid extension
5. LN 2’ in mediastinum
6. ENE
7. Incomplete excision
8. Histopathologic features
9. Type of syndrome in hereditary MTC
MEDULLARY THYROID
CANCER
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ANAPLASTIC THYROID CARCINOMA
1.6% of thyroid cancers
5th-6th decades
Rapidly expanding mass (> 5cm in 80%)
Short history and multiple local symptoms
ETE, LN 2’, VC palsy in 50% at Δ
2’ common (LN, lung)
Management controversial – almost 0% OS
Radical EBRT + CT (Adriamycin) if good PF