CH62 Management of

Differentiated Thyroid Cancer

Presenter PGY 許懷朔

2023/07/26
Introduction
• Differentiated Thyroid Cancer (DTC) prognosis:
1.Stage I – III 10-year survival rate over 98%
2.Stage IV drops dramatically
• Poor prognosis :
(1) Gross local invasion,
(2) Distant metastases,
(3) Older than 45

Perros, P., Boelaert, K., Colley, S., Evans, C., Evans, R. M., Gerrard Ba, G., ... & Williams, G. R. (2014). Guidelines for the management of thyroid
cancer. Clinical endocrinology, 81, 1-122.
Introduction
• Differentiated Thyroid Cancer (DTC) prognosis:
1.Stage I – III 10-year survival rate over 98%
2.Stage IV drops dramatically
• Poor prognosis :
(1) Gross local invasion,
(2) Distant metastases,
(3) Older than 45

Perros, P., Boelaert, K., Colley, S., Evans, C., Evans, R. M., Gerrard Ba, G., ... & Williams, G. R. (2014). Guidelines for the management of thyroid
cancer. Clinical endocrinology, 81, 1-122.
Denaro, Nerina, et al. "The tumor microenvironment and the estrogen loop in thyroid cancer." Cancers 15.9 (2023): 2458.
Investigations
• Diagnosis:
(1)High-resolution ultrasound scan (USS)
(2)Fine needle aspiration cytology (FNA)

• Further investigation: CT or MRI

(1)Tumor size
(2)Other structures invasion : Trachea, Esophagus
(3)Nodal metastases / distant meta
• Contrast CT → Ablative radioiodine ↓ within 2 months
(Clearance of Iodine < 4 weeks)
Investigations
 Investigations

FNA results

Diagnostic
procedure
 Investigations

FNA results

Diagnostic
procedure
 Investigations

FNA results

Diagnostic
procedure
 Investigations

FNA results

Diagnostic
procedure
 Investigations

Preoperative or
Intraoperative

FNA results Decision-making

criteria
Diagnostic
procedure
TNM classification of thyroid cancer
TNM classification of thyroid cancer
Treatment
• Extent of Thyroidectomy
• Treatment of Papillary Thyroid Microcarcinoma
• Neck dissection
• Radioiodine Ablation
• External Beam Radiotherapy
Treatment : Extent of Thyroidectomy
• Total thyroidectomy :
1.Tumor > 4cm
2.Multifocal disease
3.Bilateral disease
4.Extrathyroidal spread
5.Confirmed nodal or distant metastases
Treatment : Extent of Thyroidectomy
• Total thyroidectomy :
1.Tumor > 4cm
2.Multifocal disease
3.Bilateral disease
4.Extrathyroidal spread
5.Confirmed nodal or distant metastases

• Additional factors for bilateral surgery:

1.Radiation exposure or Aged (>55 years)
2.Familial DTC history or Adverse histopathological features
3.Difficulties with follow-up
Treatment : Extent of Thyroidectomy
• Total thyroidectomy :
1.Tumor > 4cm
2.Multifocal disease
3.Bilateral disease
4.Extrathyroidal spread
5.Confirmed nodal or distant metastases

• Additional factors for bilateral surgery:

1.Radiation exposure or Aged (>55 years)
2.Familial DTC history or Adverse histopathological features
3.Difficulties with follow-up
Treatment : Extent of Thyroidectomy
• Total thyroidectomy :
1.Tumor > 4cm
2.Multifocal disease
3.Bilateral disease
4.Extrathyroidal spread
5.Confirmed nodal or distant metastases

• Additional factors for bilateral surgery:

• For low-risk PTC (<4cm):
1.Radiation exposure or Aged (>55 years) Difference between Total or
2.Familial DTC history or Adverse histopathological features
3.Difficulties with follow-up Limited surgery is small.
Treatment : Extent of Thyroidectomy
• Recurrent laryngeal nerve (RLN) :
→Preserve if it was functioning preoperatively
→Small amount of disease is left
→No survival benefit for nerve sacrifice
Treatment : Extent of Thyroidectomy
• Recurrent laryngeal nerve (RLN) :
→Preserve if it was functioning preoperatively
Treatment : Extent of Thyroidectomy
• Recurrent laryngeal nerve (RLN) :
→Preserve if it was functioning preoperatively
→Small amount of disease is left
Treatment : Extent of Thyroidectomy
• Recurrent laryngeal nerve (RLN) :
→Preserve if it was functioning preoperatively
→Small amount of disease is left
→No survival benefit for nerve sacrifice Acceptable !
Treatment : Extent of Thyroidectomy
• Recurrent laryngeal nerve (RLN) :
→Preserve if it was functioning preoperatively
→Small amount of disease is left
→No survival benefit for nerve sacrifice Acceptable !

• Partial tracheal or esophageal resection :

→CT/MRI preoperatively to assess
→Aim to achieve microscopic clearance
→Residual leads to decrease in survival
Treatment : Extent of Thyroidectomy
• Recurrent laryngeal nerve (RLN) :
→Preserve if it was functioning preoperatively
→Small amount of disease is left
→No survival benefit for nerve sacrifice Acceptable !

• Partial tracheal or esophageal resection :

→CT/MRI preoperatively to assess
→Aim to achieve microscopic clearance
→Residual leads to decrease in survival
[Cardiothoracic surgeon]
Treatment : Papillary Thyroid Microcarcinoma

• Papillary Thyroid Microcarcinoma (PTMC) :

1.tumor < 1cm
2.Excellent prognosis, almost no mortality
3.Two types:
(1)Incidentally found postoperatively by histological evaluation
(2)Preoperatively by radiological investigation or symptomatic
Treatment : Papillary Thyroid Microcarcinoma

• Papillary Thyroid Microcarcinoma (PTMC) :

1.tumor < 1cm
2.Excellent prognosis, almost no mortality
3.Two types:
(1)Incidentally found postoperatively by histological evaluation
(2)Preoperatively by radiological investigation or symptomatic
• Incidentally found :
1.Hemithyroidectomy,
2.Annual follow-up,
3.Risk of hypothyroidism
Treatment : Papillary Thyroid Microcarcinoma

• Papillary Thyroid Microcarcinoma (PTMC) :

1.tumor < 1cm
2.Excellent prognosis, almost no mortality
3.Two types:
(1)Incidentally found postoperatively by histological evaluation
(2)Preoperatively by radiological investigation or symptomatic
• Incidentally found : • Radiologically found :
1.Hemithyroidectomy, 1.Higher risk
2.Annual follow-up, 2.follow up for 5 years
3.Risk of hypothyroidism 3.As low-risk DTC
Treatment : Neck dissection

• Prophylactic lateral neck dissection → No benefit.

Treatment : Neck dissection

• Prophylactic lateral neck dissection → No benefit.

Treatment : Neck dissection

• Prophylactic lateral neck dissection → No benefit.

• Central neck dissection → unclear, conflicting
→ May have additional complication or ↑morbidity
→ May have benefit in tumor > 4cm or extrathyroidal extension
Treatment : Neck dissection

• Prophylactic lateral neck dissection → No benefit.

• Central neck dissection → unclear, conflicting
→ May have additional complication or ↑morbidity
→ May have benefit in tumor > 4cm or extrathyroidal extension

Perros, P., Boelaert, K., Colley, S., Evans, C., Evans, R. M., Gerrard Ba, G., ... & Williams, G. R. (2014). Guidelines for the management of thyroid
cancer. Clinical endocrinology, 81, 1-122.
Treatment : Neck dissection

• Prophylactic lateral neck dissection → No benefit.

• Central neck dissection → unclear, conflicting
→ May have additional complication or ↑morbidity
→ May have benefit in tumor > 4cm or extrathyroidal extension

Perros, P., Boelaert, K., Colley, S., Evans, C., Evans, R. M., Gerrard Ba, G., ... & Williams, G. R. (2014). Guidelines for the management of thyroid
cancer. Clinical endocrinology, 81, 1-122.
Treatment : Neck dissection

• Prophylactic lateral neck dissection → No benefit.

• Central neck dissection → unclear, conflicting
→ May have additional complication or ↑morbidity
→ May have benefit in tumor > 4cm or extrathyroidal extension
• Prophylactic central neck dissection:
→no benefit for low risk patient
(tumor < 4cm, classical PTC, no extrathyroidal extension)
Treatment : Neck dissection

• Prophylactic lateral neck dissection → No benefit.

• Central neck dissection → unclear, conflicting
→ May have additional complication or ↑morbidity
→ May have benefit in tumor > 4cm or extrathyroidal extension
• Prophylactic central neck dissection:
→no benefit for low risk patient
(tumor < 4cm, classical PTC, no extrathyroidal extension)
Treatment : Radioiodine Ablation
• Total thyroidectomy is required
→Hemithyroidectomy should undergo complete thyroidectomy.
Treatment : Radioiodine Ablation
• Total thyroidectomy is required
→Hemithyroidectomy should undergo complete thyroidectomy.
• Positive effects:
1.Improved survival
2.Reduced recurrence
3.Better monitoring with thyroglobulin
Treatment : Radioiodine Ablation
• Total thyroidectomy is required
→Hemithyroidectomy should undergo complete thyroidectomy.
• Positive effects:
1.Improved survival
2.Reduced recurrence
3.Better monitoring with thyroglobulin

• Negative effects:
1.Isolation ward
2.Avoid contact with people for 2-4 weeks
3.No pregnancy, no breast feeding
Treatment : Radioiodine Ablation
• Total thyroidectomy is required
→Hemithyroidectomy should undergo complete thyroidectomy.
• Positive effects:
1.Improved survival
2.Reduced recurrence
3.Better monitoring with thyroglobulin

• Negative effects:
1.Isolation ward
2.Avoid contact with people for 2-4 weeks
3.No pregnancy, no breast feeding
Treatment : Radioiodine Ablation
• Total thyroidectomy is required
→Hemithyroidectomy should undergo complete thyroidectomy.
• Positive effects:
1.Improved survival
2.Reduced recurrence
3.Better monitoring with thyroglobulin

• Negative effects:
1.Isolation ward
2.Avoid contact with people for 2-4 weeks
3.No pregnancy, no breast feeding
Treatment : Radioiodine Ablation
• Total thyroidectomy is required
→Hemithyroidectomy should undergo complete thyroidectomy.
• Positive effects:
1.Improved survival
2.Reduced recurrence
3.Better monitoring with thyroglobulin

• Negative effects:
1.Isolation ward
2.Avoid contact with people for 2-4 weeks
3.No pregnancy, no breast feeding
Treatment : Radioiodine Ablation
• Patient indicated:
1.Tumor > 4cm or
2.Gross extrathyroidal spread, distant metastases
Treatment : Radioiodine Ablation
• Patient indicated:
1.Tumor > 4cm or
2.Gross extrathyroidal spread, distant metastases

• Patient not indicated:

1.Unifocal or multifocal tumor < 1cm (papillary or follicular variant)
2.Minimally invasive follicular cancer
3.Angioinvasion or extension outside the thyroid capsule
Treatment : Radioiodine Ablation
• Patient with intermediate features (tumor 1-4cm)

1.Poor prognostic features:

(1)Aggressive histology
(tall cell, poorly differentiated, diffuse sclerosing PTC)
(2)Widely invasive follicular thyroid cancer (FTC)
(3)Multiple involved lymph nodes, large size lymph node
Treatment : Radioiodine Ablation
• Patient with intermediate features (tumor 1-4cm)

1.Poor prognostic features:

(1)Aggressive histology
(tall cell, poorly differentiated, diffuse sclerosing PTC)
(2)Widely invasive follicular thyroid cancer (FTC)
(3)Multiple involved lymph nodes, large size lymph node

2.Difficulty in this group, sparse data.

Treatment : Radioiodine Ablation
Treatment : Radioiodine Ablation

• Dose:
＊ Low dose : 1.1 Mbq
＊ High dose : 3.7 Gbq
＊ Same effectiveness
Treatment : Radioiodine Ablation

• Dose:
＊ Low dose : 1.1 Mbq (fewer side effect)
＊ High dose : 3.7 Gbq
＊ Same effectiveness
Treatment : Radioiodine Ablation

• Dose:
＊ Low dose : 1.1 Mbq (fewer side effect)
＊ High dose : 3.7 Gbq
＊ Same effectiveness
Treatment : External Beam Radiotherapy

• Patient indicated:
1.Gross evidence of local tumor invasion at surgery
2.Residual or recurrent disease that is non-radioiodine avid
→External beam radiotherapy (EBRT)
→Intensity-modulated radiotherapy (IMRT)
Treatment : External Beam Radiotherapy

• Patient indicated:
1.Gross evidence of local tumor invasion at surgery
2.Residual or recurrent disease that is non-radioiodine avid
→External beam radiotherapy (EBRT)
→Intensity-modulated radiotherapy (IMRT)
Treatment : External Beam Radiotherapy

• Patient indicated:
1.Gross evidence of local tumor invasion at surgery
2.Residual or recurrent disease that is non-radioiodine avid
→External beam radiotherapy (EBRT)
→Intensity-modulated radiotherapy (IMRT)
 Investigations

FNA results

Diagnostic
procedure