01 Visión Del Cáncer de Tiroides - Piura 2015

Instituto Nacional de Enfermedades Neoplásicas
F
T VISIÓN DEL CÁNCER
| DE TIROIDES
V
Dr. Fernando Torres Vega

Departamento de Cabeza y Cuello
Visión del cáncer de tiroides

1 Incidencia
Incidencia de
de cáncer
cáncer de
de tiroides
tiroides
2 Tendencias
F
T 3 Cambios anatomopatológicos
V
4 Grupos de riesgo
5 Comportamiento biológico
6 Tratamiento

Incidencia en cáncer de tiroides
Increasing Incidence of Thyroid Cancer

in the United States, 1973-2002
Louise Davies, MD, MS, H.Gilbert Welch, MD, MPH
Context Increasing cancer incidence is typically interpreted as an increase in the true occurrence of disease but may also
F reflect changing pathological criteria or increased diagnostic scrutiny. Changes in the diagnostic approach to thyroid nodules
may have
resulted in an increase in the apparent incidence of thyroid cancer.
T Objective To examine trends in thyroid cancer incidence, histology, size distribution, and mortality in the United States.
Methods Retrospective cohort evaluation of patients with thyroid cancer, 1973-2002, using the Surveillance, Epidemiology,
V and End Results (SEER) program and data on thyroid cancer mortality from the National Vital Statistics System.
Main Outcome Measures Thyroid cancer incidence, histology, size distribution, and mortality.
Results The incidence of thyroid cancer increased from 3.6 per 100 000 in 1973 to 8.7 per 100 000 in 2002—a 2.4-fold
increase (95% confidence interval [CI], 2.2-2.6; P.001 for trend). There was no significant change in the incidence of the less
common
histological types: follicular, medullary, and anaplastic (P.20 for trend). Virtually the entire increase is attributable to an
increase in incidence of papillary thyroid cancer, which increased from 2.7 to 7.7 per 100 000—a 2.9-fold increase (95% CI,
2.6-3.2; P.001 for trend). Between 1988 (the first year SEER collected data on tumor size) and 2002, 49% (95% CI, 47%-51%)
of the increase consisted of cancers measuring 1 cm or smaller; 87% (95% CI, 85%-89%) consisted of cancers measuring 2 cm
or smaller. Mortality from thyroid cancer was stable between 1973 and 2002 (approximately 0.5 deaths per 100 000).
Conclusions The increasing incidence of thyroid cancer in the United States is predominantly due to the increased detection of
small papillary cancers. These trends, combined with the known existence of a substantial reservoir of subclinical cancer and
stable overall mortality, suggest that increasing incidence reflects increased detection of subclinical disease, not an increase in
the true occurrence of thyroid cancer.
Increasing Incidence of Thyroid Cancer in the United States, 1973-2002

Visión del cáncer de tiroides JAMA. 2006;295:2164-2167
Incidencia en cáncer de tiroides

reflect changing pathological criteria or increased diagnostic scrutiny. Changes in the diagnostic approach to thyroid nodules
F may have
9
resulted in an increase in8the apparent incidence of thyroid cancer.
Tasa de incidencia por 100,000 Incidencia
T Objective To examine trends in thyroid cancer incidence, histology, size distribution, and mortality in the United States.
7
and End Results (SEER)6program and data on thyroid cancer mortality from the National Vital Statistics System.
V Main Outcome Measures Thyroid cancer incidence, histology, size distribution, and mortality.
5
increase (95% confidence 4 interval [CI], 2.2-2.6; P.001 for trend). There was no significant change in the incidence of the less
common
3
increase in incidence of papillary
2 thyroid cancer, which increased from 2.7 to 7.7 per 100 000—a 2.9-fold increase (95% CI,
Mortalidad
of the increase consisted 1of cancers measuring 1 cm or smaller; 87% (95% CI, 85%-89%) consisted of cancers measuring 2 cm
or smaller. Mortality from0 thyroid cancer was stable between 1973 and 2002 (approximately 0.5 deaths per 100 000).
Conclusions The increasing1973incidence
1976 of1979thyroid1982
cancer in the United
1985 1988States
1991is predominantly
1994 1997due2000 to the increased detection of
small papillary cancers. These trends, combined with the known existence
Años of a substantial reservoir of subclinical cancer and
the true occurrence of thyroid cancer.

Incidencia en cáncer de tiroides: Tipo histológico

F may have
Todos los
resulted in an increase9 in the apparent incidence cáncercancer.
of thyroid de tiroides Todos
T Objective To examine8 trends in thyroid cancer incidence, histology, size distribution, and mortality in the United States.
Papilar
Tasa de incidencia por 100,000
7
and End Results (SEER) program and data on thyroid cancer mortality from the National Vital Statistics System.
V Main Outcome Measures 6 Thyroid cancer incidence, histology, size distribution, and mortality.
5 interval [CI], 2.2-2.6; P.001 for trend). There was no significant change in the incidence of the less
increase (95% confidence
common 4
increase in incidence 3of papillary thyroid cancer, which increased from 2.7 to 7.7 per 100 000—a 2.9-fold increase (95% CI,
2.6-3.2; P.001 for trend).
2 Between 1988 (the first year SEER collected data on tumor size) and 2002, 49% (95% CI, 47%-51%)
of the increase consisted of cancers measuring 1 cm or smaller; 87% (95% CI, 85%-89%) consisted of cancers measuring 2 cm
or smaller. Mortality from
1 thyroid cancer was stable between 1973 and 2002 (approximatelyFolicular 0.5 deaths per 100 000).
Conclusions The increasing incidence of thyroid cancer in the United States is predominantly due to the increased
Pobremente detection of
diferenciado
0
small papillary cancers.
1973 These
1976trends,
1979combined with the
1982 1985 1988known
1991existence
1994 of a substantial
1997 2000 reservoir of subclinical cancer and
the true occurrence of thyroid cancer. Años

Incidencia en cáncer de tiroides en mujeres
Italia
20 USA
F Australia
T 15
Edad
Hong Kong
V 10
Nueva Zelanda
5 Reino Unido
0
1975 1985 1995 2005
Años
Visión del cáncer de tiroides Incidence of thyroid cancer in women over

LMcLeod et. Al. Lancet 2013
Incidencia según tamaño tumoral: Cáncer papilar

F may have
resulted in an increase in the Tamaño tumoral
4.0 apparent incidence of thyroid cancer.
T Objective To examine trends in thyroid cancer incidence, papilar
Cáncer histology,desize
tiroides
distribution, and mortality in the United States.
3.5 evaluation of patients with thyroid cancer, 1973-2002, using the0Surveillance,
– 1.0 cm Epidemiology,
Tasa de incidencia por 100,000
Methods Retrospective cohort

and End Results (SEER) program and data on thyroid cancer mortality from the National Vital Statistics System.
V Main Outcome Measures
Results The incidence of2.5
3.0
Thyroid cancer incidence, histology, size distribution, and mortality.
thyroid cancer increased from 3.6 per 100 000 in 1973 to 8.7 per 100 000 in 2002—a 2.4-fold
increase (95% confidence interval [CI], 2.2-2.6; P.001 for trend). There was no significant change in the incidence of the less
1.1 – 2.0 cm
common 2.0
histological types: follicular, medullary, and anaplastic (P.20 for trend). Virtually the entire increase
2.1 – 5.0iscm
attributable to an
1.5
increase in incidence of papillary thyroid cancer, which increased from 2.7 to 7.7 per 100 000—a 2.9-fold increase (95% CI,
1.0cancers measuring 1 cm or smaller; 87% (95% CI, 85%-89%) consisted of cancers measuring 2 cm
of the increase consisted of
or smaller. Mortality from0.5
thyroid cancer was stable between 1973 and 2002 (approximately 0.5 deaths per 100 000).
> 5.0 cm
Conclusions The increasing incidence of thyroid cancer in the United States is predominantly due to the increased detection of
small papillary cancers. These0 trends, combined with the known existence of a substantial reservoir of subclinical cancer and
1988 that 1990
stable overall mortality, suggest increasing1992 1994
incidence reflects1996
increased1998 2000
detection 2002 disease, not an increase in
of subclinical
the true occurrence of thyroid cancer. Años

Cáncer de tiroides INEN 1990-2010
1600
Ca. de Piel
1400
Ca. de Tiroides
1200
1000
F 800
Ca. de Cavidad Oral
600
T
400
V 200
Ca. de Orofaringe
0
1990 - 1995 1996 - 2000 2001 - 2005 2006 - 2010
CANCER DE PIEL CANCER DE TIROIDES Y PARATIROIDES CANCER DE CAVIDAD ORAL
CANCER DE FOSA NASAL Y SPN TUMORES ORBITARIOS CANCER DE LARINGE Y TRAQUEA
CANCER DE HIPOFARINGE Y ESOFAGO CANCER DE OROFARINGE CANCER DE GLANDULAS SALIVALES
CANCER DE NASOFARINGE SARCOMA DE PARTES BLANDAS LINFOMA PRIMARIO CERVICAL
SARCOMAS ÓSEOS/CARTILAGINOSOS
Data Departamento de Cabeza y cuello

Visión del cáncer de tiroides Instituto Nacional de Enfermedades Neoplásicas
Prevalencia de cáncer de tiroides: 1985
Occult Papillary Carcinoma of the Thyroid

A “Normal” Finding in Finland. A Systematic Autopsy Study
H. Ruben Harach, MD,* Kaarle O. Franssila, MD, And Veli-Matti Wasenius. BA
F The thyroids from 101 consecutive autopsies from Finland were subserially sectioned at 2- to 3-mm intervals. From
36 thyroids, 52 foci of occult papillary carcinoma (OPC) were found, giving a prevalence rate of 35.6%. the highest
reported rate in the world. The rate was higher, although not significantly, in males (43.3%) than in females (27.1%),
T but it did not correlate to the age of the patients. Twentysix glands contained one tumor focus and ten glands
contained two to five tumor foci. Only a minority of the smallest tumors can be detected with the method used. The
V probable number of OPCs over 0.15 mm in diameter was calculated to be about 300 in this material. The tumor
diameter varied from 0.15 mm to 14.0 mm, with 67% of tumors under 1.0 mm. The smallest tumors were usually
circumscribed and were composed almost solely of follicles. Larger tumors had more papillary structures and were
often invasive. Fibrosis and, in the largest OPCs, lymphocytic reaction were seen around the invasive islands. All
tumors were positively stained for thyroglobulin and all but one of the tumors stained positively for epidermal keratin.
OPC appears to arise from follicular cells of normal follicles. Apparently the great majority of the tumors remain
small and circumscribed and even from those few tumors that grow larger and become invasive OPCs only a minimal
proportion will ever become a clinical carcinoma. According to the study, OPC can be regarded as a normal finding
which should not be treated when incidentally found. In order to avoid unnecessary operations it is suggested that
incidentally found small OPCs (less than 5 mm in diameter) were called occult papillary tumor instead of carcinoma.
Occult Papilary carcinoma of Thyroid

Visión del cáncer de tiroides Cancer 56:531 -538, 1985
Prevalencia de cáncer de tiroides: 1985
Occult Papillary Carcinoma of the Thyroid

A “Normal” Finding in Finland. A Systematic Autopsy Study
H. Ruben Harach, MD,* Kaarle O. Franssila, MD, And Veli-Matti Wasenius. BA
F Prevalencia de Cáncer de tiroides

The thyroids from 101 consecutive autopsies from Finland were subserially sectioned at 2- to 3-mm intervals. From
36 thyroids, 52 foci of occult papillary carcinoma (OPC) were found, giving a prevalence rate of 35.6%. the highest
reported rate in the world. The rate was higher, although not significantly, in males (43.3%) than in females (27.1%),
T but it did not correlate to the age of the patients. Twentysix glands contained one tumor focus and ten glands
contained two to five tumor foci. Only a minority of the smallest tumors can be detected with the method used. The
26 casos
V probable number of OPCs over 0.15 mm in diameter was calculated to be about 300 in this material. The tumor
diameter varied from 0.15 mm to 14.0 mm, with 67% of tumors under 1.0 mm. The 1 Focotumors
smallest de cáncer
were usually
circumscribed and were composed almost solely of follicles.Ca. Larger tumors had more papillary structures and were
Tiroides
101 Fibrosis and, in the
often invasive. Cortes
largestde
OPCs, lymphocytic reaction were seen around the invasive islands. All
tumors were positively stained for thyroglobulin
36 casos
Autopsias 2-3 mm and all but one of the tumors stained positively for epidermal keratin.
OPC appears to arise from follicular cells of normal follicles. 35.6%
Apparently the great majority of the tumors remain
10 casos
small and circumscribed and even from those few tumors that grow larger and become invasive OPCs only a minimal
proportion will ever become a clinical carcinoma. According to the study, OPC can be regardedEntreas 2a normal
y 5 finding
which should not be treated when incidentally found. In order to avoid unnecessary operations it is
focos de cáncersuggested that
incidentally found small OPCs (less than 5 mm in diameter) were called occult papillary tumor instead of carcinoma.
Occult Papilary carcinoma of Thyroid

Visión del cáncer de tiroides Cancer 56:531 -538, 1985
Hallazgos Ecográficos
• Bordes mal definidos.

• Calcificaciones densas
F intra-glándulares.
T
• Micro-calcificaciones.
V
• Vascularización
central.
• Nódulo sólido.

Nódulos tiroideos: Resultados de la biopsia aspiración
F
T
V Benigno (80%) Maligno (≤ 10%) Sospechoso/ Indeterminado (5-20%) No diagnóstico (≤ 10%)
Medular Papilar Folicular hurthle

5 – 50%
≥ 95%
Riesgo de
Sensibilidad
cáncer
Tiroidectomía terapéutica Tiroidectomía diagnóstica

1 Incidencia de cáncer de tiroides
2 Tendencias
Tendencias
F
V
4 Grupos de riesgo
6 Tratamiento

Cambios en las tendencias de cáncer bien diferenciado
Changing Trends in Well Differentiated Thyroid

Carcinoma Over Eight Decades
Iain J Nixon, MD, Ian Ganly, MD, PhD Frank L. Palmer, BA, monica Whitcher, BA, Ronny Ghossein, MD,
Snehal G Patel, MD, Michael Tutle,MD, Ashok Shaha,MD, Jatin Shah,MD
Introduction: The incidence of well differentiated thyroid cancer (WDTC) is rising in the USA. The objective of this
F study is to present the changes in incidence, presentation, management and outcomes of WDTC within our institution
over the past 8 decades.
T Methods: 2797 patients managed between 1932-2005 at Memorial Sloan Kettering Cancer Center were identified from
our institucional database.
Results: There has been an increase in the number of patients managed per decade. Although the median age was 45
V years, patients managed post-1985 were more likely to be over 45 years (53% versus 44%, p<0.001). The percentage of
womann increased from 68% to 72% (p=0.026), and the percentage of papillary carcinomas also increased, from 78% to
92%, p<0.001. An increase in early stage tumor was observed with pT1 lesions increasing from 19% to 48%. Patients
in the latter cohort were less likely to have thyroid lobectomy (29%. versus 72%, p<0.001). There was a significant
change in the use of RRA, with 8% of the early versus 44% of the latter group receiving post-operative RRA (p<0.001).
Since the introduction of risk group stratification disease specific survival (DSS) has not changed significantly. With a
median follow up of 90 months, 10 year DSS rates were below 90% in the cohort managed prior to the 1970s, which
rose to >95% thereafter (p<0.001).
Conclusions: Older poatients with earlier stage disease present an increasing workload for surgical oncologists.
Excellent outcomes remain unchanged despite increasingly aggressive surgical and medical management.
Iain J Nixon, MD
Visión del cáncer de tiroides Int. J Surg.2012; 10(10): 618-23
Cambios en las tendencias de cáncer bien diferenciado
Changing Trends in Well Differentiated Thyroid

Carcinoma Over Eight Decades
Iain J Nixon, MD, Ian Ganly, MD, PhD Frank L. Palmer, BA, monica Whitcher, BA, Ronny Ghossein, MD,
Snehal G Patel, MD, Michael Tutle,MD, Ashok Shaha,MD, Jatin Shah,MD
Introduction: The n =incidence

987 of well differentiated thyroid cancern(WDTC) = 1810is rising in the USA. The objective of this
F study is to present
1932the- 1987
n=2797
changes in incidence, presentation, management
1986 -and
2005 outcomes of WDTC within our institution
over the past 8 decades.
T Methods: 2797 patients managed between 1932-2005 at Memorial Sloan Kettering Cancer Center were identified from
44%
our institucional database. <45 años 53% P <0.001
Results: There has been an increase in the number of patients managed per decade. Although the median age was 45
V years, patients managed post-1985 were more likely to be over 45 years (53% versus 44%, p<0.001). The percentage of
Mujeres
womann increased68% from 68% to 72% (p=0.026), and the percentage of 72%
papillary carcinomasPalso
0.026
increased, from 78% to
92%, p<0.001. An increase in early stage tumor was observed with pT1 lesions increasing from 19% to 48%. Patients
in the latter cohort were less likely to have thyroid lobectomy (29%. versus 72%, p<0.001). There was a significant
78%
change in the use of RRA, with 8% of Cáncer papilar
the early versus 44% of the latter92% P< 0.001 RRA (p<0.001).
group receiving post-operative
Since the introduction of risk group stratification disease specific survival (DSS) has not changed significantly. With a
median follow up of 90 months, 10 year DSS rates were below 90% in the cohort managed prior to the 1970s, which
19%(p<0.001).
rose to >95% thereafter P T1 48%
Conclusions: Older poatients with earlier stage disease present an increasing workload for surgical oncologists.
Excellent outcomes remain unchanged despite increasingly aggressive surgical and medicalPmanagement.
72% Hemi-tiroidectomía 29% <0.001
Iain J Nixon, MD
Visión del cáncer de tiroides Int. J Surg.2012; 10(10): 618-23
2 Tendencias
F
T 3 Cambios
Cambios anatomopatológicos
anatomopatológicos
V
4 Grupos de riesgo
6 Tratamiento

Variante folicular del carcinoma papilar
Papillary carcinoma of the thyroid. A discussion of its several

morphologic expressions, with particular emphasis on the
follicular variant.
Rosaí J, Zampi G, Carcangiu ML.
F
Abstract
T
Papillary carcinoma of the thyroid has been classically defined on the basis of the presence and even the
V predominance of papillary formations within the tumor. Changes in this traditional concept have evolved along
two separate but related lines. The first is the realization that well-differentiated tumors having a papillary
component, however minimal, will exhibit the behavior of papillary carcinoma even in the presence of extensive
areas with a sclerosing, solid, or follicular pattern of growth. The second is an increased reliance on cytologic
criteria (particularly the ground-glass nucleus) rather than architectural features for the identification of papillary
carcinoma. Through the use of these criteria in association with various clinical features, evidence is put forward in
support of the concept of a follicular variant of papillary carcinoma, i.e., a tumor type in which papillae are nil or
absent but which still belongs by cell type and clinicopathologic behavior to the group of papillary carcinomas.

Visión del cáncer de tiroides Am J Surg Pathol. 1983 Dec;7(8):809-17
Variante folicular del carcinoma papilar
Papillary carcinoma of the thyroid. A discussion of its several

morphologic expressions, with particular emphasis on the
follicular variant.
F
Abstract Bien Indiferenciado
T
Papillary carcinoma of the diferenciado (Anaplásico)
thyroid has been classically defined on the basis of the presence and even the
V predominance of papillary formations within the tumor. Changes in this traditional concept have evolved along
two separate but related lines. The first is the realization that well-differentiated tumors having a papillary
areas with a sclerosing, solid,

Ca. Papilar Ca.orFolicular
-
component, however minimal, will exhibit the behavior of papillary carcinoma even in the presence of extensive
follicular pattern of Ca.
growth.
Mixto The second is an increased reliance on cytologic
criteria (particularly the ground-glass nucleus) rather than architectural features for the identification of papillary
carcinoma. Through the use of these criteria in association with various clinical features, evidence is put forward in
support of the concept of a follicular variant of papillary carcinoma, i.e., a tumor type in which papillae are nil or
absent but which still belongs by cell type and clinicopathologic behavior to the group of papillary carcinomas.

Visión del cáncer de tiroides Am J Surg Pathol. 1983 Dec;7(8):809-17
Carcinoma poco diferenciado
Poorly differentiated thyroid carcinoma:

an incubating entity
Peter M. Sadow and William C. Faquin
F Estimates for 2012 reveal thyroid cancer as the fifth most expected
malignancy in American women. Although thyroid cancer is not
infrequently diagnosed, it rarely bests its host. We understand a
T great deal about well-differentiated thyroid cancers, including
Pobremente diferenciado
carcinomas of the thyrocyteBien and parafollicular c-cells. We have Indiferenciado
V identified a number of mutations and gene rearrangements
responsible for familial diferenciado
Carcinoma Insular
(Anaplásico)
and sporadic tumors. We have postulated Poco diferenciado
about mechanisms of spread and are able to predict biological
behaviors of particular cancer types. However, gray zones remain,
and as physicians and scientists, we are never comfortable with
these gray zones, as they potentially contain magical epitopes for
disease eradication and serve as peskyCa.
Ca. Papilar reminders
Folicularthat medicine is
not an exact science. In thyroid cancer, poorly differentiated thyroid
carcinomas (PDTC) represent the bridge between more well
differentiated malignancies of thyrocytes and the undifferentiated
(anaplastic) thyroid carcinomas. Six years ago in Turin, a group of
expert surgical pathologists set the stage for refining the diagnosis
of PDTC, as introduced by the WHO in 2004, rather than it serving
as a diagnosis for those entities which had “high grade features” but
did not fit neatly into one of the other defined categories. The Peter M. Sadow and William C. Faquin
conundrum that now exists is the incubation period between the June 2012 | Volume 3 | Article 77 | 1
Variantes de carcinoma papilar
Overexpression of p53 in tall cell variants of

papillary thyroid carcinoma †
MD Anders Rüter, MD John Dreifus, MD M. Jones, MD Ronald Nishiyama, MD, PhD Sten Lennquist
F Background. The tall cell variant (TCV) is a clinically aggressive subtype of papillary thyroid cancer. The aim of this study
was to discover the prevalence of mutant forms of p53 protein in this subtype and relate it to clinical outcome.
T Methods. Eighteen patients with TCV and a control group with common papillary cancers, matched for age and gender, were
studied. The p53 mutations were identified by means of immunohistochemical staining. Data reviewed were overall survival,
V recurrence, TNM stage, and p53 positivity.
Results. p53 mutations occurred in 11 (61%) patients with TCV compared with two (11%) in control group (p=0.05). In the
TCV group two patients died of the disease (11%) and eight (44%) had local recurrences or distant metastases compared with
none in the control group. All deaths and 70% of the recurrences occurred in patients with stage III or IV disease. p53
positivity did not correlate with any reduction in survival (7% compared with 9%) but with increased rate of local (23%
compared with 4%) and distant (23% compared with 13%) recurrences.
Conclusions. TCV was associated with a significantly higher rate of p53 positivity than common papillary carcinoma. The
stage of the disease seemed to be a better prognostic indicator than p53 positivity for overall survival.
MD Anders Rüter, MD, PhD Sten Lennquist

Visión del cáncer de tiroides Surgery Volume 120, Issue 6, December 1996, Pages 1046–1050
Variantes de carcinoma papilar
Overexpression of p53 in tall cell variants of

papillary thyroid carcinoma †
MD Anders Rüter, MD John Dreifus, MD M. Jones, MD Ronald Nishiyama, MD, PhD Sten Lennquist
Bien Pobremente Indiferenciado
F Background. The tall cell variant (TCV) is a clinically aggressive subtype of papillary thyroid cancer. The aim of this study
Background. The talldiferenciado
was to discover the prevalence of mutant forms of p53 proteindiferenciado
in this subtype and relate it to clinical(Anaplásico)
cell variant (TCV) is a clinically aggressive subtype of papillary thyroid cancer. The aim of this study
outcome.
was to discover the prevalence of mutant forms of p53 protein in this subtype and relate it to clinical outcome.
T Methods. Eighteen patients with TCV and a control group with common papillary cancers, matched for age and gender, were
Methods. Eighteen patients with TCV and a control group with common papillary cancers, matched for age and gender, were
studied. The p53 mutations were identified by means of immunohistochemical staining. Data reviewed were overall survival,
V studied. The p53 mutations were identified by means of immunohistochemical staining. Data reviewed were overall survival,
recurrence, TNM
Ca.
recurrence,
stage, and p53 positivity.
Papilar
TNM Ca. Folicular
stage, and p53 positivity.
Clásicotwo patients died of the
TCV group Células de (11%)
disease Hurtle and eight (44%) had local recurrences or distant metastases compared with
TCV group two patients died of the disease (11%) and eight (44%) had local recurrences or distant metastases compared with
none inMicrocarcinoma
the control group. All deaths and 70% of the recurrences occurred in patients with stage III or IV disease. p53
none in the control group. All deaths and 70% of the recurrences occurred in patients with stage III or IV disease. p53
Variante
positivity folicular
did not correlate with any reduction in survival (7% compared with 9%) but with increased rate of local (23%
positivity did not correlate with any reduction in survival (7% compared with 9%) but with increased rate of local (23%
Células
compared withcolumnares
4%) and distant (23% compared with 13%) recurrences.
compared with 4%) and distant (23% compared with 13%) recurrences.
Difuso esclerosante
Sólido oTCV
Conclusions.
Conclusions. trabecular
TCV
was associated with a significantly higher rate of p53 positivity than common papillary carcinoma. The
was associated with a significantly higher rate of p53 positivity than common papillary carcinoma. The
Células
stage of altas
the disease seemed to be a better prognostic indicator than p53 positivity for overall survival.
stage of the disease seemed to be a better prognostic indicator than p53 positivity for overall survival.
MD Anders Rüter, MD, PhD Sten Lennquist

Visión del cáncer de tiroides Surgery Volume 120, Issue 6, December 1996, Pages 1046–1050
Variantes agresivas de carcinoma papilar
Tall cell variant: An aggressive form of papillary

thyroid carcinoma
STEPHEN PRENDIVILLE, MD, KENNETH D. BURMAN, MD, MATTHEW D. RINGEL, MD, BARRY M.
SHMOOKLER, MD, ZIAD E. DEEB, MD, KATHERINE WOLFE, MD, NORIO AZUMI, MD, LEONARD
WARTOFSKY, MD, ROY B. SESSIONS, MD
F
T Abstract
Twenty-four cases of the tall cell variant (TCV), a subset of papillary thyroid carcinoma, were identified in a
V group of 624 patients with thyroid cancer. All pathology specimens were reviewed, and each patient’s
carcinoma was categorized according to characteristics on presentation, local recurrence, distant metastases,
follow-up, and tumor-related mortality. The TCV group was compared with a historical control group
(Mazzaferri and Jhiang: 1355 patients). The TCV group had a statistically higher percentage of stage 3 and 4
carcinoma, extrathyroidal invasion, and tumor size less than 1.5 cm than the control group. There was no
statistical relationship between age greater than 50 years and stage in the TCV group. No relationship could be
found between TCV histology and recurrence or mortality. These findings, combined with those of studies that
link stage on presentation to poor outcomes, have led to our conclusion that TCV is an aggressive malignancy
warranting appropriate treatment and close follow-up. (Otolaryngol Head Neck Surg 2000;122:352-7.)
STEPHEN PRENDIVILLE, MD, ROY B. SESSIONS, MD

Visión del cáncer de tiroides Otolaryngology - Head and Neck Surgery
Volume 122, Issue 3, March 2000, Pages 352–357
Variantes agresivas de carcinoma papilar
Tall cell variant: An aggressive form of papillary

thyroid carcinoma
STEPHEN PRENDIVILLE, MD, KENNETH D. BURMAN, MD, MATTHEW D. RINGEL, MD, BARRY M.
SHMOOKLER, MD, ZIAD E. DEEB, MD, KATHERINE WOLFE, MD, NORIO AZUMI, MD, LEONARD
WARTOFSKY, MD,Bien
ROY B. SESSIONS, MD Pobremente Indiferenciado
F diferenciado diferenciado (anaplásico)
T Abstract
Twenty-four cases of the tall cell variant (TCV), a subset of papillary thyroid carcinoma, were identified in a
V group of 624 patients with
Ca. Papilar Ca. thyroid
Folicular cancer. All pathology specimens were reviewed, and each patient’s
carcinoma was categorized according to characteristics on presentation, local recurrence, distant metastases,
follow-up, and tumor-related mortality. The TCV group was compared with a historical control group
Clásico Células de Hurtle
(Mazzaferri
Microcarcinomaand Jhiang: 1355 patients). The TCV group had a statistically higher percentage of stage 3 and 4
carcinoma, extrathyroidal invasion, and tumor size less than 1.5 cm than the control group. There was no
Variante folicular
statistical relationship
Células columnares between age greater than 50 years and stage in the TCV group. No relationship could be
found Variante and
between TCV histology
Difuso esclerosante mas recurrence
agresiva or mortality. These findings, combined with those of studies that
Sólidostage
link o trabecular
on presentation to poor outcomes, have led to our conclusion that TCV is an aggressive malignancy
Células altas
warranting appropriate treatment and close follow-up. (Otolaryngol Head Neck Surg 2000;122:352-7.)
STEPHEN PRENDIVILLE, MD, ROY B. SESSIONS, MD

Visión del cáncer de tiroides Otolaryngology - Head and Neck Surgery
Volume 122, Issue 3, March 2000, Pages 352–357
2 Tendencias
F
V
4 Grupos
Grupos de
de riesgo
riesgo
6 Tratamiento

Factores de riesgo
Long-term impact of initial surgical and medical

therapy on papillary and follicular thyroid cancer
Ernest L. Mazzaferri, MD, FACP, Sissy M. Jhiang, PhD
Abstract
Purpose: To determine the long-term impact of medical and surgical treatment of well differentiated papillary and follicular thyroid cancer.
Methods: Patients with papillary and follicular cancer (n = 1,355) treated either in U.S. Air Force or Ohio State University hospitals over the past 40
F years were prospectively followed by questionnaire or personal examination to determine treatment outcomes. Outcomes were analyzed by Kaplan-
Meier survival curves and Cox proportional-hazard regression model.
Results: Median follow-up was 15.7 years; 42% (568) of the patients were followed for 20 years and 14% (185) for 30 years. After 30 years, the survival
T rate was 76%, the recurrence rate was 30%, and the cancer death rate was 8%. Recurrences were most frequent at the extremes of age (<20 and >59
years). Cancer mortality rates were lowest in patients younger than 40 years and increased with each subsequent decade of life. Thirty-year cancer
mortality rates were greatest in follicular cancer patients, who were more likely to have adverse prognostic factors: older age, larger tumors, more
V mediastinal node involvement, and distant metastases. When patients with distant metasteses at diagnosis were excluded, follicular and papillary cancer
mortality rates were similar (10% versus 6%, P not significant [NS]). In a Cox regression model that excluded patients who presented with distant
metastases, the likelihood of cancer death was (1) increased by age ≥40 years, tumor size ≥1.5 cm, local tumor invasion, regional lymph-node
metastases, and delay in therapy ≥12 months; (2) reduced by female sex, surgery more extensive than lobectomy, and 131I plus thyroid hormone
therapy; and (3) unaffected by tumor histologic type. Following 131I therapy given only to ablate normal thyroid gland remnants, the recurrence rate
was less than one third the rate after thyroid hormone therapy alone (P <0.001). No patient treated in this way with 131I has died of thyroid cancer. Low
131I doses (29 to 50 mCi) were as effective as high doses (51 to 200 mCi) in controlling tumor recurrence (7% versus 9%, P = NS). Following 131I
therapy, whether given for thyroid remnant ablation or cancer therapy, recurrence and the likelihood of cancer death were reduced by at least half,
despite the existence of more adverse prognostic factors in patients given 131I. At 30 years, the cumulative cancer mortality rate following 131I
therapy, regardless of the reason for its use, was one third that in patients not so treated (P = 0.03).
Conclusion: Over the long term, for tumors ≥1.5 cm that are not initially metastatic to distant sites, near-total thyroidectomy followed by 131I plus
thyroid hormone therapy confers a distinct outcome advantage. This therapy reduces tumor recurrence and mortality sufficiently to offset the augmented
risks incurred by delayed therapy, age ≥40 at the time of diagnosis, and tumors that are much larger than 1.5 cm, multicentric, locally invasive, or
regionally metastatic.
The American Journal of Medicine

Visión del cáncer de tiroides Volume 97, Issue 5, Pages 418–428, November 1994
Long-term impact of initial surgical and medical
therapy on papillary and follicular thyroid cancer
Ernest L. Mazzaferri, MD, FACP, Sissy M. Jhiang, PhD
Abstract
Purpose: To determine the long-term impact of medical and surgical treatment of well differentiated papillary and follicular thyroid cancer.
Methods: Patients with papillary and follicular cancer (n = 1,355) treated either in U.S. Air Force or Ohio State University hospitals over the past 40
F years were prospectively followed by questionnaire or personal examination to determine treatment outcomes. Outcomes were analyzed by Kaplan-
Meier survival curves and Cox proportional-hazard regression model.
Results: Median follow-up was 15.7 years; 42% (568) of the patients were followed for 20 years and 14% (185) for 30 years. After 30 years, the survival
T rate was 76%, the recurrence rate was 30%, and the cancer death rate was 8%. Recurrences were most frequent at the extremes of age (<20 and >59
years). Cancer mortality rates were lowest in patients younger than 40 years and increased with each subsequent decade of life. Thirty-year cancer
mortality rates were greatest in follicular cancer patients, who were more likely to have adverse prognostic factors: older age, larger tumors, more
V mediastinal node involvement, and distant metastases. When patients with distant metasteses at diagnosis were excluded, follicular and papillary cancer
mortality rates were similar (10% versus 6%, P not significant [NS]). In a Cox regression model that excluded patients who presented with distant
metastases, the likelihood of cancer death was (1) increased by age ≥40 years, tumor size ≥1.5 cm, local tumor invasion, regional lymph-node
metastases, and delay in therapy ≥12 months; (2) reduced by female sex, surgery more extensive than lobectomy, and 131I plus thyroid hormone
therapy; and (3) unaffected by tumor histologic type. Following 131I therapy given only to ablate normal thyroid gland remnants, the recurrence rate
was less than one third the rate after thyroid hormone therapy alone (P <0.001). No patient treated in this way with 131I has died of thyroid cancer. Low
131I doses (29 to 50 mCi) were as effective as high doses (51 to 200 mCi) in controlling tumor recurrence (7% versus 9%, P = NS). Following 131I
therapy, whether given for thyroid remnant ablation or cancer therapy, recurrence and the likelihood of cancer death were reduced by at least half,
despite the existence of more adverse prognostic factors in patients given 131I. At 30 years, the cumulative cancer mortality rate following 131I
therapy, regardless of the reason for its use, was one third that in patients not so treated (P = 0.03).
Conclusion: Over the long term, for tumors ≥1.5 cm that are not initially metastatic to distant sites, near-total thyroidectomy followed by 131I plus
thyroid hormone therapy confers a distinct outcome advantage. This therapy reduces tumor recurrence and mortality sufficiently to offset the augmented
Dr. Ernest L. Mazzaferri
risks incurred by delayed therapy, age ≥40 at the time of diagnosis, and tumors that are much larger than 1.5 cm, multicentric, locally invasive, or
regionally metastatic.
The American Journal of Medicine

Visión del cáncer de tiroides Volume 97, Issue 5, Pages 418–428, November 1994
Factores de Riesgo
Mayo Lahey Mayo Karolinska MSKCC

AGES AMES MACIS AMES GAMES
Edad Edad Edad Edad Edad
F
T Grado Metástasis Metástasis DNA Grado
V Resección
Metástasis Metástasis
completa
Extensión Extensión Invasión Extensión Extensión
Tamaño Tamaño Tamaño Tamaño Tamaño

Grupos de Riesgo
Alto Riesgo
< 45 años. > 45 años.
F < 4 cm. > 4 cm.
T Intraglandular. Extensión
Bajo Riesgo
Extraglandular.
V
Sin metástasis a Metástasis a
distancia. distancia.
Intermedio
Evolución de los grupos de riesgo
Riesgo
1. Evaluación prede muertedel riesgo
operatoria
F
T
Bajo Intermedio Alto
V

Factores para la evaluación de riesgo (ATA 2009)
5
Medicina
Nuclear
F 4
1 • Examen físico.
• Parálisis de cuerdas vocales.
T Laboratorio
Pre
operatorio • Imágenes.
Evaluación
V de riesgo
3 2
Hallazgos
Patología
operatorios

1
Pre
operatorio
F 5 2
• Extensión extratiroidea.
• Compromiso estructuras del
T Medicina
Nuclear
Hallazgos
Operatorios
cuello.
Evaluación • Resección completa del tumor.
V de riesgo
4 3
Laboratorio Patología

2
Hallazgos
operatorios
F 1 3
• Subtipo histológico.
• Invasión vascular.
T Pre operatorio Patología • Invasión extratiroidea.
Evaluación • Características moleculares.
V de riesgo
5 4
Medicina
Laboratorio
Nuclear

3
Patología
F 2 4 • Niveles post operatorios

T Hallazgos
operatorios Laboratorio de tiroglobulina
Evaluación
V de riesgo
1 5
Medicina
Pre operatorio
Nuclear

4
Laboratorio
F 3
5 • Rastreo con “Yodo 131”
T Patología
Medicina
Nuclear
• PET CT
Evaluación
V de riesgo
2 1
Hallazgos
Pre operatorio
operatorios

Bajo Riesgo
1. Evaluación pre de muerte del riesgo Alto
operatoria
Intermedio
2. Evaluación post operatoria del riesgo

Riesgo de recurrencia (ATA 2009)
F
T Bajo Intermedio Alto
• Sin enfermedad local ni a distancia. • Invasión microscópica peri-tiroidea. • Invasión macroscópica.
V • Enf. macroscópica 100% resecada. • Metástasis cervical. • Resección incompleta.
• Sin invasión a Bajo
partes blandas. Intermedio
• Rastreo (+) fuera del lecho tiroideo. Alto
• Metástasis a distancia.
• Histología no agresiva, sin invasión • Histología agresiva o invasión • Incongruencia en la tiroglobulina.
vascular. vascular.
• Rastreo (-) fuera del lecho tiroideo.

Bajo Riesgo
1. Evaluación pre de muerte del riesgo Alto
operatoria
Intermedio
Bajo 2. Riesgo de recurrencia

Evaluación post (ATA del
operatoria
Intermedio 2009)
riesgoAlto
3. Evaluación de riesgo según respuesta al tratamiento
F Riesgo dinámico: Basado en la respuesta
T
V Respuesta Excelente Respuesta Aceptable Respuesta Incompleta
• Tiroglobulina: < 1ng/ml • Tiroglobulina: < 1ng/ml ≥1

• Tiroglobulina:
Identificar a los pacientes
Bajonegativa.
• Ecografía cervical estimuladaque
≥ 1 y tienen
Intermedio ≤ 10ng/ml. mal pronóstico.
estimuladaAlto
≥ 10ng/ml.
• Rastreo negativo • Ecografía cervical: Ganglios <1cm. • Incremento en los niveles de Tg.
• Rastreo con cambios no • Rastreo sospechoso o positivo.
específicos.

Riesgo dinámico:
Predictor de riesgo de recurrencia o persistencia
Estimating Risk of Recurrence in Differentiated Thyroid Cancer After
Total Thyroidectomy and Radioactive Iodine Remnant Ablation: Using
Response to Therapy Variables to Modify the Initial Risk Estimates
Predicted by the New American Thyroid Association Staging System
R. Michael Tuttle,1 Hernan Tala,1 Jatin Shah,2 Rebecca Leboeuf,1 Ronald Ghossein,3
Mithat Gonen,4 Matvey Brokhin,1 Gal Omry,1 James A. Fagin,1 and Ashok Shaha2
F
T Background: A risk-adapted approach to management of thyroid cancer requires risk estimates that change over time based on response to therapy and
the course of the disease. The objective of this study was to validate the American Thyroid Association (ATA) risk of recurrence staging system and
determine if an assessment of response to therapy during the first 2 years of follow-up can modify these initial risk estimates.
V Methods: This retrospective review identified 588 adult follicular cell-derived thyroid cancer patients followed for a median of 7 years (range 1–15
years) after total thyroidectomy and radioactive iodine remnant ablation.
Patients were stratified according to ATA risk categories (low, intermediate, or high) as part of initial staging.
Clinical data obtained during the first 2 years of follow-up (suppressed thyroglobulin [Tg], stimulated Tg, and imaging studies) were used to re-stage
each patient based on response to initial therapy (excellent, acceptable, or incomplete). Clinical outcomes predicted by initial ATA risk categories were
compared with revised risk estimates obtained after response to therapy variables were used to modify the initial ATA risk estimates.
Results: Persistent structural disease or recurrence was identified in 3% of the low-risk, 21% of the intermediaterisk, and 68% of the high-risk patients
( p<0.001). Re-stratification during the first 2 years of follow-up reduced the likelihood of finding persistent structural disease or recurrence to 2% in
low-risk, 2% in intermediate-risk, and 14% in high-risk patients, demonstrating an excellent response to therapy (stimulated Tg<1 ng/mL without
structural evidence of disease). Conversely, an incomplete response to initial therapy (suppressed Tg > 1 ng/mL, stimulated Tg > 10 ng/mL, rising Tg
values, or structural disease identification within the first 2 years of follow-up) increased the likelihood of persistent structural disease or recurrence to
13% in low-risk, 41% in intermediate-risk, and 79% in high-risk patients.
Conclusions: Our data confirm that the newly proposed ATA recurrence staging system effectively predicts the risk of recurrence and persistent disease.
Further, these initial ATA risk estimates can be significantly refined based on the assessment of response to initial therapy, thereby providing a dynamic
risk assessment that can be used to more effectively tailor ongoing follow-up recommendations.
THYROID
Visión del cáncer de tiroides Volume 20, Number 12, 2010
Riesgo dinámico:
Predictor de riesgo de recurrencia o persistencia
Estimating Risk of Recurrence in Differentiated Thyroid Cancer After
Total Thyroidectomy and Radioactive Iodine Remnant Ablation: Using
Response to Therapy Variables to Modify the Initial Risk Estimates
Predicted by the New American Thyroid Association Staging System
R. Michael Tuttle,1 Hernan Tala,1 Jatin Shah,2 Rebecca Leboeuf,1 Ronald Ghossein,3
Mithat Gonen,4 Matvey Brokhin,1 Gal Omry,1 James A. Fagin,1 and Ashok Shaha2
F
T Background: A risk-adapted approach to management of thyroid cancer requires risk estimates that change over time based on response to therapy and
the course of the disease. The objective of this study was to validate the American Thyroid Association (ATA) risk of recurrence staging system and
determine if an assessment of response to therapy during the first 2 years of follow-up can modify these initial risk estimates.
Re-estratificación a losfollowed
2 años
V Methods: This retrospective review identified 588 adult follicular cell-derived
years) after total thyroidectomy and radioactive iodine remnant ablation.
thyroid cancer patients
Riesgo dinámico
Patients were stratified according to ATA risk categories (low, intermediate, or high) as part of initial staging.
for a median of 7 years (range 1–15
Clinical data obtained during the first 2 years of follow-up (suppressed thyroglobulin [Tg], stimulated Tg, and imaging studies) were used to re-stage
ATA - 2009 Excelente Incompleta
n=471 acceptable, or incomplete). Clinical outcomes predicted by initial ATA risk categories were
each patient based on response to initial therapy (excellent,
compared with revised risk estimates obtained after response to therapy variables were used to modify the initial ATA risk estimates.
Results: Persistent structural disease or recurrence was identified in 3% of the low-risk, 21% of the intermediaterisk, and 68% of the high-risk patients
Bajo riesgo 3% 2%
( p<0.001). Re-stratification during the first 2 years of follow-up reduced the likelihood of finding persistent
13%
•• Tg•• structural
Tg Tg
Tg estimulada
suprimida
estimulada
suprimida <1
>> 11 ng/,l
disease ngi/ml
<1recurrence
ng/,l
or ngi/ml to 2% in
low-risk, 2% in intermediate-risk, and 14% in high-risk patients, demonstrating an excellent response••toTg •
Tg• Sin
Sin evidencia
estimulada
therapy (stimulated
evidencia
estimulada de
>> 10deng/ml
10Tg<1 ng/mL without
ng/ml
Riesgo intermedio 2% 41%
structural evidence of disease). Conversely, an incomplete response to initial therapy (suppressed Tg > 1 ng/mL, stimulated Tg > 10 ng/mL, rising Tg
18% enfermedad
• persistent
values, or structural disease identification within the first 2 years of follow-up) increased the likelihood of• Incremento
enfermedad
Incremento de
structural
estructural.
de valores
disease de
estructural.
valores Tg
derecurrence
or Tg to
13% in low-risk, 41% in intermediate-risk, and 79% in high-risk patients. •• Enfermedad estructutal.
Enfermedad estructutal.
Alto Riesgo 66% 14% 79%
Conclusions: Our data confirm that the newly proposed ATA recurrence staging system effectively predicts the risk of recurrence and persistent disease.
Further, these initial ATA risk estimates can be significantly refined based on the assessment of response to initial therapy, thereby providing a dynamic
risk assessment that can be used to more effectively tailor ongoing follow-up recommendations.
THYROID
Visión del cáncer de tiroides Volume 20, Number 12, 2010
Cambios en el riesgo y el estadío por el compromiso ganglionar
The prognostic significance of nodal metastases from papillary thyroid

carcinoma can be stratified based on the size and number of metastatic
lymph nodes, as well as the presence of extranodal extension.
Randolph GW, Duh QY, Heller KS , LiVolsi VA, Mandel SJ , Steward DL , Tufano RP , Tuttle RM ;
F American Thyroid Association Surgical Affairs Committee’s Taskforce on Thyroid Cancer Nodal Surgery.
Abstract AJCC
T Ultrasound and prophylactic dissections have facilitated identification of small-
pN+
AJCCvolume cervical lymph node (LN) metastases in patients with
A T Ado not stratify risk based on size orECnumber
papillary thyroid carcinoma (PTC). Since most staging systems IVa of LN metastases, even a single-
microscopic LN metastasis can upstage a patient with low-risk papillary
Microcarcinoma EC III Enfermedad
pN+thyroid microcarcinoma (PMC) toLateral
an intermediate risk of recurrence
V in the American Thyroid Association (ATA) system and to an increased
Riesgo intermedio de risk
Enfermedadof death in the
CentralAmerican Joint Committee on Cancer (AJCC)
staging system (stage III if the metastatic node is in the central neck or stage IVA if the microscopic LN metastasis is identified in the lateral
Microcarcinoma
neck). Such microscopic upstaging recurrencia
may lead to potentially unnecessary or additional treatments and follow-up studies. The goal of this review
Bajo riesgo
is to determine if the literature supports the concept that specific characteristics (clinically apparent size, number, and extranodal extension) of
LN metastases can be used to stratify the risk of recurrence in PTC.
CONCLUSION: Our previous paradigm assigned the same magnitude of risk for all patients with N1 disease. However, small-volume
subclinical microscopic N1 disease clearly conveys a much smaller risk of recurrence than large-volume, macroscopic clinically apparent loco-
regional metastases. Armed with this information, clinicians will be better able to tailor initial treatment and follow-up recommendations.
Implications of N1 stratification for PTC into small-volume microscopic disease versus clinically apparent macroscopic disease importantly
relate to issues of prophylactic neck dissection utility, need for pathologic nodal size description, and suggest potential modifications to the
AJCC TNM (tumor, nodal disease, and distant metastasis) and ATA risk recurrence staging systems
Randolph GW, Duh QY, Heller KS , LiVolsi VA, Mandel SJ , Steward DL , Tufano RP , Tuttle RM
Visión del cáncer de tiroides Thyroid. 2012 Nov;22(11):1144-52. doi: 10.1089/thy.2012.0043. Epub 2012 Oct 19.
Cambios en el riesgo y el estadío por el compromiso ganglionar
The prognostic significance of nodal metastases from papillary thyroid

carcinoma can be stratified based on the size and number of metastatic
lymph nodes, as well as the presence of extranodal extension.
Randolph GW, Duh QY, Heller KS , LiVolsi VA, Mandel SJ , Steward DL , Tufano RP , Tuttle RM ;
F American Thyroid Association Surgical Affairs Committee’s Taskforce on Thyroid Cancer Nodal Surgery.
Abstract
T Ultrasound and prophylactic dissections have facilitated identification of small- volume cervical lymph node (LN) metastases in patients with
papillary thyroid carcinoma (PTC). Since most staging systems do not stratify risk based on size or number of LN metastases, even a single-
microscopic LN metastasis can upstage a patient with low-risk papillary thyroid microcarcinoma (PMC) to an intermediate risk of recurrence
V in the American Thyroid Association (ATA) system and to an increased risk of death in the American Joint Committee on Cancer (AJCC)
El aumento en estadío clínico por enfermedad
staging system (stage III if the metastatic node is in the central neck or stage IVA if the microscopic LN metastasis is identified in the lateral
neck). Such microscopic upstaging may lead to potentially unnecessary or additional treatments and follow-up studies. The goal of this review
microscópica puede llevar a
is to determine if the literature supports the concept that specific characteristics (clinically apparent size, number, and extranodal extension) of
LN metastases can be used to stratify the risk of recurrence in PTC.
estudios y tratamientos innecesarios
CONCLUSION: Our previous paradigm assigned the same magnitude of risk for all patients with N1 disease. However, small-volume
subclinical microscopic N1 disease clearly conveys a much smaller risk of recurrence than large-volume, macroscopic clinically apparent loco-
regional metastases. Armed with this information, clinicians will be better able to tailor initial treatment and follow-up recommendations.
Implications of N1 stratification for PTC into small-volume microscopic disease versus clinically apparent macroscopic disease importantly
relate to issues of prophylactic neck dissection utility, need for pathologic nodal size description, and suggest potential modifications to the
AJCC TNM (tumor, nodal disease, and distant metastasis) and ATA risk recurrence staging systems
Randolph GW, Duh QY, Heller KS , LiVolsi VA, Mandel SJ , Steward DL , Tufano RP , Tuttle RM
Visión del cáncer de tiroides Thyroid. 2012 Nov;22(11):1144-52. doi: 10.1089/thy.2012.0043. Epub 2012 Oct 19.
Observación en pacientes con microcarcinoma
Patient Age Is Significantly Related to the Progression of

Papillary Microcarcinoma of the Thyroid Under Observation
Yasuhiro Ito, Akira Miyauchi, Minoru Kihara, Takuya Higashiyama, Kaoru Kobayashi, and Akihiro Miya
F Background: We showed previously that subclinical low-risk papillary thyroid microcarcinoma (PTMC) could be observed without immediate
surgery. Patient age is an important prognostic factor of clinical papillary thyroid carcinoma (PTC). In this study, we investigated how patient
T Microcarcinomas papilares subclínicos
age influences the observation of low-risk PTMC.
Methods: Between 1993 and 2011, 1235 patients with low-risk PTMC chose observation without immediate surgery. They were followed
periodically with ultrasound examinations. These patients were enrolled in this study. We divided them into three subsets based on age at the
V beginning of observation: young (<40 years), middle-aged (40–59 years), and old patients ( ‡ 60 years). Observation periods ranged from 18 to
227 months (average 75 months).
< 40 años
Results: We set three parameters for the evaluation of PTMC progression: (i) size enlargement, (ii) novel appearance of lymph-node
metastasis, and (iii) progression to clinical disease (tumor size reaching 12mm or larger, or novel appearance of nodal metastasis). The
proportion of patients with1235
PTMC progression was lowest in the old patients and highest in the young patients. On multivariate analysis, young
age was anPacientes
independent predictor of PTMC progression. However,
Observación
de bajo riesgo 40 –none
59ofañosthe 1235 patients showed distant metastasis or died of PTC during
observation. Although only 51 patients (4%) underwent thyrotropin (TSH) suppression based 1 aon19 añospreference, the PTMC of all
physician
1993
patients enrolled in this TSH -suppression
2011 study, except one, were clinically stable. To date, 191 patients underwent surgery for various reasons
after observation. None showed recurrence except for one in the residual thyroid, and none died of PTC after surgery.
Conclusions: Old patients with subclinical low-risk PTMC may be the best candidates for observation. Although PTMC in young patients may
≥ 60 años
be more progressive than in older patients, it might not be too late to perform surgery after subclinical PTMC has progressed to clinical
disease, regardless of patient age.
THYROID Volume 24, Number 1, 2014

Visión del cáncer de tiroides ª Mary Ann Liebert, Inc.
DOI: 10.1089/thy.2013.0367

T age influences the observation of low-risk PTMC. Criterios de Exclusión
Results: We set three parameters for the evaluation of PTMC progression: (i) size enlargement, (ii) novel appearance of lymph-node
• Localización
metastasis, and (iii) progression adyacente
to clinical disease al nervio
(tumor size reaching 12mmo orla larger,
tráquea.
or novel appearance of nodal metastasis). The
•
proportion of patients with PTMC progression was lowest in the old patients and highest
Signos de infiltración al nervio laríngeo o la tráquea. in the young patients. On multivariate analysis, young
age was an independent predictor of PTMC progression. However, none of the 1235 patients showed distant metastasis or died of PTC during
observation. Although only• 51Biopsia aspiración
patients (4%) underwent de lesión(TSH)
thyrotropin de alto grado.
suppression based on physician preference, the PTMC of all
patients enrolled in this TSH suppression study, except one, were clinically stable. To date, 191 patients underwent surgery for various reasons
• Enfermedad metastásica.
after observation. None showed recurrence except for one in the residual thyroid, and none died of PTC after surgery.

DOI: 10.1089/thy.2013.0367

T age influences the observation of low-risk PTMC.
Conclusiones
Results: We set three •parameters
Ninguno
for the de los pacientes
evaluation del estudio
of PTMC progression: (i) sizemostró
enlargement, (ii) novel appearance of lymph-node
metastasis, and (iii) progression to clinical disease (tumor size reaching 12mm or larger, or novel appearance of nodal metastasis). The
enfermedad a distancia o murió por cáncer.
proportion of patients with PTMC progression was lowest in the old patients and highest in the young patients. On multivariate analysis, young
age was an independent •predictor
Losofpacientes mayores
PTMC progression. However,de 60of años
none the 1235son losshowed
patients mejores
distant metastasis or died of PTC during
observation. Although only 51 patients (4%) underwent thyrotropin (TSH) suppression based on physician preference, the PTMC of all
candidatos a la observación.
patients enrolled in this TSH suppression study, except one, were clinically stable. To date, 191 patients underwent surgery for various reasons
after observation. None • showedEnrecurrence
la actualidad solo
except for one in the191 (15%)
residual thyroid,han sidodiedoperados
and none of PTC after surgery.
por diferentes razones.

DOI: 10.1089/thy.2013.0367
2 Tendencias
F
V
4 Grupos de riesgo
5 Comportamiento
Comportamiento biológico
biológico
6 Tratamiento

Cáncer de tiroides: Progresión biológica
Genome – Wide Appraisal of Thyroid Cancer Progression

Volkert B. Wreesmann, Ronald A, Ghossein, Snehal G. Patel, Charles P. Harris, Erick A. Schnaser, Ashok R. Shaha, R.
Michael Tuttle, Jatin P. Shah, Palivarthi H. Rao, Bhuvanesh Singh
Abstract
Several lines of evidence suggest that follicular cell derived thyroid cancers represent a continuum of disease that progresses
F from the highly curable well differentiated thyroid cancers to the universally fatal anaplastic cancers. However, the genetic
mechanisms underling thyroid cancer progression remain ill defined. W compared the molecular – cytogenetic profiles
T derived from comparative genomic hybridization (CGH) analysis of major histological variants of thyroid cancer to define
genetic variables associated with progression. Overall, a sequential increase in chromosomal complexity was observed from
V well differentiated papillary thyroid cancer to poorly differentiated and anaplastic carcinomas, both in terms of the presence
of CGH detectable abnormalities (p=0.003) and the median number of abnormalities per case (p<0.001). The presence of
multiple abnormalities common to all thyroid cancer variants, including gains of 5 p 15, 5 q 11-13, 19 p, and q and loss of 8p,
suggests that these tumors are derived from a common genetic pathway. Gains of 1 p34-36, 6 p 21, 9q34, 17q25, and 20q
losses of 1p11 p 31, 2q32-33, 4q11-13, 6q21 and 13q21-31 may represent secondary evens in progression, as they were only
detected in poorly differentiate4d and anaplastic carcinomas. Finally, recurrent gains at 3p13-14 and 11q13, and loss of 5q11-
31 were unique to anaplastic carcinomas, suggesting they may be markers for anaplastic transformation. Our data suggest that
the development of chromosomal instability underlies the progression to more aggressive phenotypes of thyroid cancer and
sheds light on the possible genomic aberrations that may be selected for during this process.
Molecular-Cytogenetic Characaterization of Head and Neck Cancer

Visión del cáncer de tiroides Volkert B Wreesmann, MD. Bhuvanesh Singh, MD. Chapter 15 - 2004

Papilar
Abstract Evidencia 2
Several lines of evidence suggest that follicular cell derived thyroid cancers represent a continuum
Evidencia 1 of disease that progresses from
F the highly curable well differentiated thyroid cancers to the universally fatal anaplastic cancers. However, the genetic mechanisms
Células • Muchos pacientes con cáncer bien diferenciado
underling thyroid cancer progression remain ill defined. W compared the molecular – cytogenetic profiles derived from comparative
hybridization (CGH) analysis of major •histological
En los cortes Pobremente
of thyroidde patología devariables
las associated
piezaswith
T genomic
foliculares desarrollan
Células variants
altas. múltiples recurrencias.
cancer to define genetic
diferenciado
Anaplásico
progression. Overall, a sequential increase in chromosomal complexity was observed from well differentiated papillary thyroid
tiroideas operatorias de tumores bien diferenciados se
V cancer to poorly differentiated and anaplastic carcinomas, both in terms of the presence of CGH detectable abnormalities (p=0.003)
• En
puede
and the median number of abnormalities per case (p<0.001).
la secuencia
encontrar
The
patológica
presence of áreas
multiple poco
sediferenciadas.
puede
abnormalities
ver que hay
common to all thyroid cancer
variants, including gains of 5 p 15, 5 q 11-13, 19 p,progresión metaplásica
and q and loss of 8p, suggests thatythese
desdiferenciación.
tumors are derived from a common
genetic pathway. Gains of 1 p34-36, 6 p 21, 9q34, 17q25, and 20q losses of 1p11 p 31, 2q32-33, 4q11-13, 6q21 and 13q21-31 may
represent secondary evens Folicular
in progression, as they were only detected in poorly differentiate4d and anaplastic carcinomas. Finally,
recurrent gains at 3p13-14 and 11q13, and loss of 5q11-31 were unique to anaplastic carcinomas, suggesting they may be markers
for anaplastic transformation. Our data suggest that the development of chromosomal instability underlies the progression to more
aggressive phenotypes of thyroid cancer and sheds light on the possible genomic aberrations that may be selected for during this
process. 80% 15% 2%
Bueno Malo Muy Malo


Papilar
Abstract
Several lines of evidence suggest that follicular cell derived thyroid cancers represent a continuum of disease that progresses from
F the highly curable well differentiated thyroid cancers
Células 10%
La gran mayoría después Curación
to the universally fatal anaplastic cancers. However, the genetic mechanisms
underling del tratamiento
thyroid cancer progression remain ill defined. W compared the molecular – inicial
cytogenetic profiles
Pobremente derived from comparative
(Mortalidad < 2%)
T genomic hybridization
foliculares (CGH) analysis of major histological variants
Células altas. of thyroid
progression. Overall, a sequential increase in chromosomal complexity was observed
cancer to
diferenciado
define genetic variables associated with
Anaplásico
from well differentiated papillary thyroid
tiroideas
V cancer to poorly differentiated and anaplastic carcinomas, both in terms of the presence of CGH detectable abnormalities (p=0.003)
and the median number of abnormalities per case (p<0.001). The presence of multiple abnormalities common to all thyroid cancer
variants, including gains of 5 p 15, 5 q 11-13, 19 p, and q and loss of 8p, suggests that these tumors are derived from a common
Desarrollará recurrencia local y/o regional, sin
in progression, as they were onlyun impacto
detected negativo
in poorly en la sobrevida.
differentiate4d and anaplastic carcinomas. Finally,
process. 80% 15% 2%
Bueno Malo Muy Malo


Papilar
• Enfermedad yodo-refractaria.
Abstract
Several lines progresión
• Rápida of evidence suggest that follicular cell derived thyroid cancers represent a continuum of disease that progresses from
y recurrencias.
F the highly curable well differentiated thyroid cancers to the universally fatal anaplastic cancers. However, the genetic mechanisms
• Metástasis
Células
underling thyroid ganglionar.
cancer progression remain ill defined. W compared the molecular – cytogenetic profiles derived from comparative
Pobremente
T genomic hybridization
foliculares
• Extensión (CGH) analysis of major histological
extra-tiroidea.
variants of thyroid cancer to define genetic variables
Células altas.
diferenciado
associated with
Anaplásico
progression. Overall, a sequential increase in chromosomal complexity was observed from well differentiated papillary thyroid
tiroideas
V • Estadíos
cancer to poorly differentiated and anaplastic carcinomas, both in terms of the presence of CGH detectable abnormalities (p=0.003)
avanzados.
and the median number of abnormalities per case (p<0.001). The presence of multiple abnormalities common to all thyroid cancer
• Fallas
variants, del tratamiento.
including gains of 5 p 15, 5 q 11-13, 19 p, and q and loss of 8p, suggests that these tumors are derived from a common
in progression, as they were only detected in poorly differentiate4d and anaplastic carcinomas. Finally,
process. 80% 15% 2%
Bueno Malo Muy Malo

Progresión biológica: Alteraciones genéticas
Ca. Papilar Cáncer Pobremente

Oculto Papilar diferenciado
BRAF
RAS
NTRK
p53
RET/PTC
MET
F myc
T RAS
PAX8-PPAR
Célula PTEN
Adenoma PAXS-PPAR
Cáncer p53
Cáncer
V tiroidea
normal
fos
folicular Papilar anaplásico
RAS
p53
Myc
fos
Adenoma Ca. de células
células Hurtle de Hurtle
Shibru, et al. Curr Opin Oncol 2008

Biología y traducción clínica
Inestabilidad genómica
Anaplásico
F Pobremente
Células Altas. diferenciado
Mayor tamaño
T Cáncer Extensión extratiroidea
V Papilar Metástasis a distancia
Mortalidad elevada

Biología y traducción funcional
Metabolismo de la glucosa en PET Scan
F Carcinoma División
Papilar celular
T Células Altas
Pobremente
V Diferenciación
Diferenciado
Anaplásico
Captación de yodo radioactivo

Tiroglobulina
TTF1

2 Tendencias
F
V
4 Grupos de riesgo
6 Tratamiento
Tratamiento

Cáncer de tiroides
Tratamiento quirúrgico
F
T
V Enfermedad Enfermedad Enfermedad
local central regional

¿ Por que tiroidectomía total ?
Extent of Surgery Affects Survival for

Papillary Thyroid Cancer
Karl Y. Bilimoria, MD,*† David J. Bentrem, MD,* Clifford Y. Ko, MD, MS, MSHS,†‡ Andrew K. Stewart,
MA,† David P. Winchester, MD,†§ Mark S. Talamonti, MD,* and Cord Sturgeon, MD, MS*
F Background: The extent of surgery for papillary thyroid cancers (PTC) remains controversial. Consensus guidelines have
T recommended total thyroidectomy for PTC ≥1 cm; however, no study has supported this recommendation based on a survival
advantage. The objective of this study was to examine whether the extent of surgery affects outcomes for PTC and to
determine whether a size threshold could be identified above which total thyroidectomy is associated with improved
V outcomes.
Methods: From the National Cancer Data Base (1985–1998), 52,173 patients underwent surgery for PTC. Survival was
estimated by the Kaplan-Meier method and compared using log-rank tests. Cox Proportional Hazards modeling stratified by
tumor size was used to assess the impact of surgical extent on outcomes and to identify a tumor size threshold above which
total thyroidectomy is associated with an improvement in recurrence and long-term survival rates.
Results: Of the 52,173 patients, 43,227 (82.9%) underwent total thyroidectomy, and 8946 (17.1%) underwent lobectomy. For
PTC < 1 cm extent of surgery did not impact recurrence or survival (P=0.24, P = 0.83). For tumors ≥1 cm, lobectomy resulted
in higher risk of recurrence and death (P = 0.04, P = 0.009). To minimize the influence of larger tumors, 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).
Conclusions: The results of this study demonstrate that total thyroidectomy results in lower recurrence rates and improved
survival for PTC ≥1.0 cm compared with lobectomy. This is the first study to demonstrate that total thyroidectomy for PTC ≥
1.0 cm improves outcomes.
Karl Y. Bilimoria, MD
Visión del cáncer de tiroides Annals of Surgery •
Volume 246, Number 3, September 2007
¿ Por que tiroidectomía total ?
Extent of Surgery Affects Survival for

Papillary Thyroid Cancer
Karl Y. Bilimoria, MD,*† David J. Bentrem, MD,* Clifford Y. Ko, MD, MS, MSHS,†‡ Andrew K. Stewart,
MA,† David P. Winchester, MD,†§ Mark S. Talamonti, MD,* and Cord Sturgeon, MD, MS*
F Background: The extent of surgery for papillary thyroid cancers (PTC) remains controversial. Consensus guidelines have
T recommended total thyroidectomy for PTC ≥1 cm; however, no study has supported this recommendation based on a survival
advantage. The objective of this study was to examine
43,227 (83%) whether the extent of surgery affects outcomes for PTC and to
Tiroidectomía
determine whether a size threshold could be identified above which total thyroidectomy istotal associated with improved
V outcomes.
Tiroidectomía Total
CONCLUSIÓN P:
P:0.009
0.24
Methods: From the National Cancer Data Base (1985–1998), 52,173 patients underwent surgery for PTC. Survival was
52,173de este estudio demuestran que la TIROIDECTOMÍA TOTAL
estimated by the Kaplan-Meier method and compared using log-rank tests. Cox Proportional Hazards modeling stratified by
Los resultados Mayor a
tumor size was used to assess the impact of surgical extent on outcomes and ≤ 1tocm
identify a tumor size threshold above which
casos 1 cmsurvival rates.
total thyroidectomy is associated with an improvement in recurrence and long-term
tiene bajos rangos de recurrencia y mejor sobrevida en comparación a la
Results: Of 1985 - 1998
the 52,173 patients, 43,227 (82.9%) underwent total thyroidectomy, and 8946 (17.1%) underwent lobectomy. For
PTC < 1 cm extent of surgery did not impact recurrence or survival (P=0.24, P = 0.83). For tumors ≥1 cm, lobectomy resulted
Hemitiroidectomía
in higher risk of recurrence and death (P = 0.04,
8,946P =(17%)
0.009). To minimize the influence of larger tumors, 1 to 2 cm lesions were
Hemitiroidectomía para tumores mayores a 1cm
examined separately: lobectomy again resulted
P: 0.04
0.83
in a higher risk of recurrence and death (P=0.04, P=0.04).
Lobectomía
Conclusions: The results of this study demonstrate that total thyroidectomy results in lower recurrence rates and improved
survival for PTC ≥1.0 cm compared with lobectomy. This is the first study to demonstrate that total thyroidectomy for PTC ≥
1.0 cm improves outcomes.
Karl Y. Bilimoria, MD
Visión del cáncer de tiroides Annals of Surgery •
Volume 246, Number 3, September 2007
Disección central: Unilateral-Bilateral (2009)
F
T
V
THYROID. Volume 19, Number 11, 2009

Visión del cáncer de tiroides Mary Ann Liebert, Inc. DOI:10.1089/thy.2009,0159
Disección central: Unilateral-Bilateral (2009)
F
T
V
Nivel VI
1. Délfico.
2. Pre traqueal.
3. Paratraqueal ó recurrencial.
THYROID. Volume 19, Number 11, 2009

Visión del cáncer de tiroides Mary Ann Liebert, Inc. DOI:10.1089/thy.2009,0159
Patrones de diseminación cervical
• Piel parte anterior

de la cara.
• Mucosa nasal. retroauricular
• Seno maxilar.
• Cavidad oral.
F • Región parotídea.
• Mitad anterior cuero IB
IIB Sub
occipital
IA • Región retroauricular
T cabelludo. IIA • ½ post cuero cabelludo
• Región sub occipital
V • Nasofaringe
III • Orofaringe (base de lengua)
VA
• Laringe
• Hipofaringe
• Esófago
IV VB
• Tiroides
Visión del cáncer de tiroides Pathways for cervical metastasis in malignant neoplasms of the head and neck region. Yuan Wang, Thomas J. Ow, Jeffrey N. Myers
Article first published online: 18 AUG 2011Clinical Anatomy Special Issue: Special Issue on Head and Neck
Disecciones de cuello
Disección Radical Clásica
F DRM DRC Selectiva

T
V Tipo I SHI
Tipo II Lateral Ca. De Tiroides

Grupos: II, III, IV, Vb
DRM: Funcional Tipo III Posterior

Grupos II al V

Disección lateral: Consenso ATA (2012)
F
T
V
IIb
IIa
III
Vb
IV
THYROID Mary Ann Liebert, Inc.

Visión del cáncer de tiroides DOI: 10.1089/thy.2011.0312 . Volume 22, Number 5, 2012
Cáncer de tiroides: Guías de manejo ATA (2009)
F
T
V |
RECOMENDACIÓN 28
La disección lateral de cuello se debe realizar en los
pacientes con metástasis cervical demostrada por biopsia.
Tipo B (Evidencia razonable)


Visión del cáncer de tiroides © Mary Ann Liebert, Inc.
DOI: 10.1089=thy.2009.0110
Conclusiones
F
T LaLaenfermedad
metástasis clínica
microscópica
tiene
un impacto
central ysignificativo
lateral
V en la
nosobrevida
afectan los
y laresultados
recurrencia.
El rol
El de
rolladedisección
la disección
TERAPÉUTICA
ELECTIVA es
esta
incierto
definido
Iain J. Nixon a, Ashok R. Shaha Head and Neck Service, MSKCC, New York, USA
Visión del cáncer de tiroides Oral Oncology 49 (2013) 671–675 Available online 9 April 2013
Conclusiones
F Magnitud de la metástasis Impacto

Micrometástasis (histología) Ninguno
T Micrometástasis (ecografía) Ninguno
V Ganglios pequeños intraoperatorios
metastásicos
Ninguno
Macrometástasis > Recurrencia local

y a distancia.
• Todos recurren.
Metástasis grosera • Afecta la sobrevida en
mayores de edad.
Iain J. Nixon a, Ashok R. Shaha Head and Neck Service, MSKCC, New York, USA
Visión del cáncer de tiroides Oral Oncology 49 (2013) 671–675 Available online 9 April 2013
Conclusiones
F
Ganglio sospechoso Conducta
T
< 8 mm por ecografía Control periódico
V Evidencia de progresión Biopsia aspiración
Biopsia aspiración (+) Cirugía
La decisión debe ser tomada de mutuo acuerdo

entre el paciente y el cirujano
Visión del cáncer de tiroides Iain J. Nixon a, Ashok R. Shaha Head and Neck Service, MSKCC, New York, USA
Oral Oncology 49 (2013) 671–675 Available online 9 April 2013
Conclusiones
F
T Tratamiento racional del cuello
V Los cirujanos deben minimizar las
complicaciones e incrementar los
resultados oncológicos y funcionales.
Visión del cáncer de tiroides Iain J. Nixon a, Ashok R. Shaha Head and Neck Service, MSKCC, New York, USA
Oral Oncology 49 (2013) 671–675 Available online 9 April 2013
Individualizar el tratamiento
F
T Un Una Un
V paciente enfermedad tratamiento
Ashok Shaha
Visión del cáncer de tiroides MSKCC New York
F
T
V Gracias…

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Instituto Nacional de Enfermedades Neoplásicas

Dr. Fernando Torres Vega

Visión del cáncer de tiroides

Visión del cáncer de tiroides

Increasing Incidence of Thyroid Cancer

Increasing Incidence of Thyroid Cancer in the United States, 1973-2002

Increasing Incidence of Thyroid Cancer

Increasing Incidence of Thyroid Cancer in the United States, 1973-2002

Increasing Incidence of Thyroid Cancer

Increasing Incidence of Thyroid Cancer in the United States, 1973-2002

Visión del cáncer de tiroides Incidence of thyroid cancer in women over

Increasing Incidence of Thyroid Cancer

Methods Retrospective cohort

Increasing Incidence of Thyroid Cancer in the United States, 1973-2002

Data Departamento de Cabeza y cuello

Occult Papillary Carcinoma of the Thyroid

Occult Papilary carcinoma of Thyroid

Occult Papillary Carcinoma of the Thyroid

F Prevalencia de Cáncer de tiroides

Occult Papilary carcinoma of Thyroid

• Bordes mal definidos.

Visión del cáncer de tiroides

Medular Papilar Folicular hurthle

Visión del cáncer de tiroides

Visión del cáncer de tiroides

Changing Trends in Well Differentiated Thyroid

Changing Trends in Well Differentiated Thyroid

Introduction: The n =incidence

Visión del cáncer de tiroides

Papillary carcinoma of the thyroid. A discussion of its several

Rosaí J, Zampi G, Carcangiu ML.

Papillary carcinoma of the thyroid. A discussion of its several

areas with a sclerosing, solid,

Rosaí J, Zampi G, Carcangiu ML.

Poorly differentiated thyroid carcinoma:

Overexpression of p53 in tall cell variants of

MD Anders Rüter, MD, PhD Sten Lennquist

Overexpression of p53 in tall cell variants of

MD Anders Rüter, MD, PhD Sten Lennquist

Tall cell variant: An aggressive form of papillary

STEPHEN PRENDIVILLE, MD, ROY B. SESSIONS, MD

Tall cell variant: An aggressive form of papillary

STEPHEN PRENDIVILLE, MD, ROY B. SESSIONS, MD

Visión del cáncer de tiroides

Long-term impact of initial surgical and medical

The American Journal of Medicine

The American Journal of Medicine

Mayo Lahey Mayo Karolinska MSKCC

Tamaño Tamaño Tamaño Tamaño Tamaño

Visión del cáncer de tiroides

Visión del cáncer de tiroides

Visión del cáncer de tiroides

Visión del cáncer de tiroides

Visión del cáncer de tiroides

F 2 4 • Niveles post operatorios

Visión del cáncer de tiroides

Visión del cáncer de tiroides

2. Evaluación post operatoria del riesgo

Visión del cáncer de tiroides

Bajo 2. Riesgo de recurrencia

• Tiroglobulina: < 1ng/ml • Tiroglobulina: < 1ng/ml ≥1

Visión del cáncer de tiroides

The prognostic significance of nodal metastases from papillary thyroid