Differentiated Thyroid

Cancer

Presenter: Dr Aakriti Athavale

Moderated by : Gp Capt (Dr) PK Sahu
Scope
• Introduction
• Classification of DTC
• Diagnostic Evaluation
• Prognosis, Staging and Risk Stratification
• Surgical management
• Radioiodine Remnant Ablation
• Follow up and Dynamic Risk Stratification post-treatement
• DTC in Pregnancy
• DTC in Paediatric population
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Introduction
• Thyroid follicular cells
• 90% of all thyroid malignancy*
• Female> Male
• Older age group
• Family history

*Hedinger C, Williams ED, Sobin LH. Histological typing of thyroid tumours: WHO international classification of tumours,
4th edn. Berlin: Springer-Verlag, 1998.

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Classification of DTC

Papillary Follicular
Follicular variant pf
PTC Minimally Widely
Invasive Invasive
Non
Encapsulated
encapsulated

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Diagnostic Evaluation
• Ultrasound of Neck

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Approach to Patient
ATA Nodule
• Ultrasound of Neck sonographic features
and risk of
malignancy

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Diagnostic Evaluation
• Ultrasound in DTC

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Diagnostic Evaluation
• Thyroid Function Tests
• No role of Tg – initial evaluation

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Diagnostic Evaluation
• Cytology
• Sensitivity- 80-93.5%, Specificity- 56-94%
• FNAC – cytological features in papillary carcinoma*
Orphan Annie nuclei
Psammoma bodies

• Diagnosis of follicular carcinoma- only by capsular invasion and vascular

invasion

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Diagnostic Evaluation

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Diagnostic Evaluation
• Imaging
• Preoperative cross-sectional imaging studies(CT, MRI) with IV contrast
-recommended for advanced disease
• invasive primary tumor
• clinically apparent multiple bulky lymph node

• Molecular markers- Improves diagnostic accuracy

• BRAF, RAS, RET/PTC, Pax8-PPARa, Galectin-3

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Diagnostic Evaluation
• Incidentalomas
• Routine use of FDG-PET

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Prognosis, Staging and Risk Stratification
• Risk Factors
• PatientLow
factors-
risk Age< 45years- better prognosis
Moderate risk High risk
Gender- males-
No symptoms/ signs Age <20poorer
yrs, >60 yrs Rapid growth
• Tumour factors- Histology- H/oPTC-radiotherapy
better prognosisFirm
thannodule
FTC,with fixation
Family history of thyroid
Size, cancer
Extra-thyroidal invasion,
Recurrence rate- 2% Compressive symptoms
Recurrence rate- 40%
Male gender (dysphagia, dyspnea,
Lymph node metastases
Mortality- 0.1% Mortality- 45%
hoarseness)
Nodule > 4 cms Cervical lymphadenoathy

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Prognosis, Staging and Risk Stratification
• Staging Systems
• EORTC- Male, histology, T-stage, distant metastases
• AGES(Mayo Clinic)- Age, Gender, Extrathyroidal invasion, Tumour size
• AMES(Lahey)- Age, Metastases, Extrathyroidal invasion, Tumour size
• MACIS- Metastases, Age, Completeness of surgical resection, Invasion,Size

No advantage over TNM

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Prognosis, Staging and Risk Stratification
• TNM Staging of DTC

*AJCC Cancer Staging Manual, Eight Edition

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Prognosis, Staging and Risk Stratification
• TNM Staging of DTC

*AJCC Cancer Staging Manual, Eight Edition

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Prognosis, Staging and Risk Stratification

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Goals of Treatment
• Removal of primary tumour with LN metastases
• Minimise risk of recurrence/ metastatic spread
• Facilitate postoperative treatment with RAI
• Accurate staging and risk stratification
• Long term surviellance for disease recurrence
• Minimal treatment related morbidity

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 Surgery
• Controversy regarding extent of thyroidectomy
• Recommendation for:
1-4cm-Hemithyroidectomy
Total thyroidectomy favourableTotal Thyroidectomy
All DTC< 1cm in size , without ETS All high risk patients
Improved recurrence and survival rates
No distant metastases Nodule>4cm
Age <15years or >45years
Radiation history
Known distant metastases
Clinically involved Cervical node
Unfavourable histology- Tall cell
variant, columnar cell, diffuse
sclerosing, poorly differentiated
First-degree family history of DTC

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 Neck Dissection in DTC
• Incidence of L.n metastases-
• Papillary Ca- 50%
• Follicular Ca- 10%
• Hurthle cell variant- 25%

No role for berry picking

• Therapeutic central compartment clearance – node positive
• Lateral compartment- if involved

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 Neck Dissection in DTC
• Prophylactic Level VI dissection
• Large PTC (T3/T4) – prophylactic central compt. Clearance
• T1/T2 non-invasive, clinically node negative PTC
FTC Close intraoperative
inspection

• Bulky nodal metastases- Poor prognosis

Higher incidence of distant metastasis
Regional recurrence

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 Radioiodine Remnant Ablation
• Goals of postoperative RRA
• Remnant ablation- early detection of recurrence
• Adjuvant therapy- residual disease- after surgery
• RIA therapy – Treatment of known residual/recurrent / metastatic disease

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Radioiodine Remnant Ablation
• Recommended –
• Known distant metastases
• Gross extra thyroidal extension
• Primary > 4cm
• If primary 1-4cm, high risk factors
• High risk histology-
• Tall cell
• Columnar
• Insular
• Solid
• Poorly differentiated
• Intrathyroidal vascular invasion
• Multifocal disease
• Hurthle cell cancer

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Radioiodine Remnant Ablation
• For distant metastases-
• Mainstay
• Lungs, Spine, Appendicular bones- most common
• Bone metastases- resistant to RI

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Radioiodine Remnant Ablation
• Preparation for RRA
• Aim- TSH <30mU/ml
• Thyroid Hormone Withdrawl- Stopping LT4 and switching to LT3 – 2-4weeks

Complete withdrawal of LT3 for 2weeks

• Use of rhTSH

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Radioiodine Remnant Ablation
• Method of administration of RI
• Empiric dose: 100-300mCi
• Tailored dose according to dosimetry
• To enhance uptake of RI
• Low iodine diet
• Li- 10mg/kg/day for 07days  Serum Li- 0.8-1.2mmol/L
• Retinoic acid- 1.2mg/kg/day
• Histone deacetylate inhibitors
• Demethylating agents

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Radioiodine Remnant Ablation
• Early adverse effects of RRA and I-131 therapy
• Dyguesia
• Nausea
• Neck discomfort and swelling
• Radiation cystitis, gastritis
• Late effects
• Xerostomia
• Sialadenitis and Lacrimal gland dysfunction
• Increased risk of Leukemia- in pts receiving > 18.5GBq and with use of EBRT
• Radiation fibrosis- in pts with pulmonary metastases

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Radioiodine Remnant Ablation
• Aftercare
• Radiation protection advice- Children, pregnant
• If rhTSH given prior to I-131- continue thyroxine
• Post-ablation scan(2-10days)
• SPECT-CT to localise uptake accurately
• Small risk of spontaneous abortion upto 1year post RRA/I-131-therapy

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Radioiodine Remnant Ablation
• Assessment of RRA success
• Stimulated or Serum Thyroglobulin and Neck USG – 9-12months from RRA
• rhTSH(0.9mg for 2days) –for stimulated Tg- to be measured on day 5 after
first administration

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Follow up
• Thyroglobulin
• USG neck
• Cross sectional imaging
• TSH assessment

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Follow up

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Long Term and Advanced Cancer
Management
• Factors associated with locoregional recurrence:
• Macroscopic extra-thyroid extension
• Multiple/ large volume nodal metastasis
• Locally invasive disease
• Aggressive histological types (insular/tall cell)
• Advanced age
• Tg doubling time

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Long Term and Advanced Cancer
Management

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Long Term and Advanced Cancer
Management
• Assessment
• Serum Thyroglobulin
• Ultrasound
• Imaging
• Diagnostic RAI scans
• FDG – PET sacns
• CT and MRI

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Long Term and Advanced Cancer
Management
• Thyroglobulin measurement
• High risk : 6 – 12 months
• Intermediate risk : 12 – 24 months
• Low risk : 12 – 24 months

• TSH – 12 monthly
• Neck ultrasound
• Thyroid bed + level VI nodes : 6 – 12 months
• > 8 – 10 mm – biopsy, Tg
• <8 -10 mm – FNAC if needed
• Low risk , low Tg – clinical follow up
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Long Term and Advanced Cancer
Management
• Neck ultrasound
• Thyroid bed + level VI nodes : 6 – 12 months
• > 8 – 10 mm – FNAC, Tg
• <8mm – FNAC if needed
• Low risk , low Tg – clinical follow up

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Long Term and Advanced Cancer
Management
• Whole body RAI scan
• High risk : 6 – 12 months after RAI scan
(123 I or low activity 131 I)
• Low/ intermediate risk : clinical follow up
- 1St post treatment scan – negative

• SPECT CT preferred over planar imaging

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Long Term and Advanced Cancer
Management
• Empiric RAI therapy • FDG PET scan
18

• High risk, Tg >10 ng/mL, RAI

• Directed therapy imaging –ve
• Stereoactic radiation / thermal • Initial staging of poorly DTC,
ablation invasive Ca
• Prior to initiation of systemic • Prognostic tool in metastasis
treatment • Post treatment
• Cross sectional imaging
• Neck, upper chest
• CT chest
• Others – MRI brain, skeletal survey,
abdomen
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DTC in Pregnancy
• Prevalence of thyroid nodule in pregnancy- 3-21%
• Radioiodine scans, RRA, I-131 therapy- contraindicated (also in lactating
mother)
• If FNAC- Thy3a/Thy3f (or) suspicious of papillary thyroid cancer

No rapid growth Rapid nodular growth &/or L.N metastases

surgery can be deferred till after delivery Thyroidectomy – safe in 2 nd trimester

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 DTC in Paediatrics
• Rare in children
• Risk- Exposure to radiotherapy to head and neck
• PTC in ≤15years- more aggressive, Lymph node involvement
Total thyroidectomy with Central compt. Clearance
• TSH suppression- recommended
• Follow up with serum Tg- lifelong

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Conclusion
• Differentiated thyroid carcinomas have an excellent prognosis

• Surgical treatment – mainstay

• Dynamic risk stratification – guide follow up and further management

• Recurrent DTC – multidisciplinary team management

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References
• BR Haugen et al. 2015 American Thyroid Association management
guidelines for adult patients with thyroid nodules and differentiated
thyroid cancer.
• Evidence based management of cancers in India. Guidelines for Head
and neck cancers. Tata Memorial Centre
• Scott- Brown’s Otorhinolaryngology, Head and Neck Surgery, 8th
edition.

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