HEAD AND NECK CASE CONFERENCE (PAPILARY THYROID CARCINOMA)

Philippine Academy for Head and Neck Surgery, Inc. – Medical Center Manila

June 10, 2013 12 PM

General Data•R.M.•51 y/o•Female

Chief Complaint•Anterior neck mass

History November, 2011•Notable mass at the left anterior neck

approximately 2x3x3 cm

•Physical Examination:▫(+) 3X2X2 cm cervical lymphadenopathy,

post-auricular area▫(+) 2x3x2 cm left anterior neck mass, firm,

moves with deglutition

•What would be your diagnostic work-ups ?

•How do you do it in your institution or practice?

10/26/11

Result Normal Value

TSH 0.324 0.35-5.50 uIU/ml

FT3 2.52 1.68-3.54 pg/ml

FT4 1.09 0.71-1.85 ng/dl

Ultrasound of the neck10/26/11• The right thyroid lobe is normal in size and measures 4.98

x 1.69 x 1.89 cm. While the left thyroid lobe is slightly enlarged and measures 5.60 x 2.14 x 2.20cm

• There are lobulated hypoechoic lesions in both thyroid lobes with location and sizes:▫ Right:

Mid portion (2 nodules) = 0.36 x 0.35 x 0.33 cm and 1.42 x 0.76 x 0.93 cm

▫ Left Upper to mid portion with numerous punctate calcification in

the margins• A solitary enlarged hypoechoic lymph node with thickened

cortex and intact fatty hilum is noted in the left lateral neck measuring 1.87 x 1.73 x 1.0 cm

Ultrasound of the neck10/26/11•Impression;

▫Normal sized right thyroid lobe and enlarged left lobe with solid nodules. The lesion in the left lobe is vascular with calcifications.

▫Reactive left cervical adenopathy.

FNAB cytology Report11/2/2011• Organ for aspiration biopsy: left thyroid and left

cervical lateral node• Cytologic Diagnosis:

▫Cell findings are consistent with a papillary carcinoma of the thyroid, left, with metastasis to the left lateral neck area.

• Cytologic Description:▫Aspirate smears from all slides (4) appear similar and

show clusters of atypical thyrocytes forming papillary patterns, there is modest colloid in the background.

▫There are also histiocytes present. ▫The nuclei shows grooves and inclusions.

How do you interpret fnac /fnab results/

•Methesda scoring /nomenclature for fnab?

•Impression? Stage?

•Plan of Management?

American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010)

THYROID CARCINOMA STAGINGPrimary tumor (T)

Tx Primary tumor cannot be assessed

T0 No evidence of primary tumor

T1 Tumor 2cm or less in greatest dimension limited to the thyroid

T1a Tumor 1cm or less limited to the thyroid

T1b Tumor more than 1cm but not more than 2cm in greatest dimension, limited to the thyroid

T2 Tumor more than 2cm but not more than 4cm in greatest dimension, limited to the thyroid

T3 Tumor more than 4cm in greatest dimension, limited to the thyroid or any tumor with extrathyroidal extension (eg. extension to sternothyroid or perithyroid soft tissues)

T4a Moderate advanced diseaseTumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, trachea, larynx, esophagus or recurrent laryngeal nerve

T4b Very advanced diseaseTumor invades prevertebral fascia or encases common carotid artery or mediastinal vessel all anaplastic carcinomas are considered T4 tumor

American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010)

THYROID CARCINOMA STAGING

Regional lymph nodes (N)

Regional lymph nodes are the central compartment, lateral cervical and upper mediastinal nodes.Nx Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Regional lymph node metastasis

N1a Metastasis to level VI (pretracheal, paratracheal, prelaryngeal/Delphian lymph nodes)

N1b Metastasis to unilateral, bilateral or contralateral cervical (levels I, II, III, IV, V) or retropharyngeal or superior mediastinal lymph nodes (level VII)

American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010)

THYROID CARCINOMA STAGING

Distant metastasis (M)

M0 No distant metastasis

M1 Distant metastasis

THYROID CARCINOMA STAGING

American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010)

OperationNovember 8, 2011•Total thyroidectomy with modified radical

neck dissection Type III, left

•Is there still a controversy between total and subtotal thyroidectomy? In this case?

•Role of central neck dissection?

•Types of neck dissection? Comprehensive or selective?

Record of OperationNovember 8, 2011•Findings:

▫Thyroid gland enlarged▫Right lobe 4x3x2 cm with solitary nodule 1 cm

in diameter▫Left lobe 5x3.5x3 with 2 nodules

#1 located at superior pole – 3x3x3cm #2 located at inferior pole -1x1x1 cm

▫(+) enlarged cervical nodes/ jugular chain of nodes, left ~5 in number: 2 were dark-colored -2x2x2 cm in greatest dimensions, other 3 were light-colored

Record of OperationNovember 8, 2011•Post-op Diagnosis:

S/P Total Thyroidectomy, Modified Radical Neck Dissection Type III for Papillary Thyroid Carcinoma Stage IVA (sT2N1bM0)

Final Histopath November 8, 2011•Papillary carcinoma, left and right lobes

of the thyroid (2.3 cm, left lobe, and two foci in the right lobe, 0.2 cm and 0.4 cm)

•Background of focal lymphocytic thyroiditis

•Surgical lines of thyroidectomy are negative for tumor.

•Positive for tumor metastasis to 9/18 left cervical LN

11/28/11Result Normal Value

TSH 55.00 0.35-5.50 uIU/ml

Thyroglobulin 89.47ng/mL < 1ng/mL

Whole body I-131 ScintigraphyDec. 17, 2011• S/P RAI therapy (12/13/11)

▫ Whole body scans were obtained 4 days after administration of a 100 mci oral therapeutic dose of I-131.

▫ There are foci of dense tracer activity in the right and left thyroid beds representing uptake of the therapy dose by functioning residual thyroid tissues. These measured 1.2x1.2 cms and 1.6x1.6 cms, respectively.

▫ Faint, ill-defined tracer localization is seen in the inferior thyroid bed likewise denoting residual functioning thyroid.

▫ Physiologic tracer accumulation noted in the nasopharynx, salivary glands, gastrointestinal tract and urinary bladder.

▫ No functioning metastasis appreciated.

Whole body I-131 ScintigraphyDec. 17, 2011•Interpretation: Functioning thyroid

tissue remnants limited to the anterior area.

•What are the controversies in thyroid scanning ?

•How do you give RAI? What are the doses?

2/13/12

•Levothyroxine 100mg OD

Result Normal ValueTSH 12.89 0.35-5.50

uIU/mlFT4 8.78 0.71-1.85

ng/dlTG 19.44ng/mL < 1ng/mL

3/14/12

•Levothyroxine 100mg OD

Result Normal ValueTSH 0.124 0.35-5.50

uIU/mlTG 5.61ng/mL < 1ng/mL

4/13/12

•Levothyroxine 100mg OD

Result Normal ValueTSH 0.101 0.35-5.50

uIU/mlTG 4.8 < 1ng/mL

•Role of TSH suppression?

•How do you follow up?▫Serum TSH▫Serum thyroglobulin▫Neck ultrasound

•Prognosis?

7 months post-operative•No palpable neck mass •Persistently low TSH and elevated TG•Ultrasound of the neck was requested

Ultrasound 6/26/12• Scan over the post-cervical bed shows subcentimeter

hypoechoic nodular foci in the lower anterior and left para-tracheal region measuring 0.34 to -0.85 cm. lateral to the said nodule is a 1.19 cm lymph node at level V.

• Subcentimeter lymph nodes with fatty hylum are demonstrated in both submandibular, submental and right jugular chain with sizes ranging from 0.19-0.74 cm.

• The submandibular and parotid glands are intact.• Impression

▫ S/P Total thyroidectomy from known papillary thyroid carcinoma with subcentimeter nodules in the lower anterior and left lateral neck and a slightly enlarged left cervical lymph nodes likely tumor recurrence. Unremarkable submandibular and parotid glands.

•Will you do fnab?

6/27/12

•Levothyroxine 100mg OD

Result Normal ValueTSH 0.04 0.35-5.50

uIU/ml

Whole body I-131 scintigraphy Oct 8, 2012• S/P RAI therapy (10/03/12)

▫Whole body scans were obtained 5 days after administration of 150 mCi oral therapeutic dose of I 131

▫There are confluent foci of ill-defined tracer activity in the thyroid beds representing uptake of the therapy dose by functioning residual thyroid tissues aggregate measurements were approximately 3 x 6 cms.

▫Physiologic tracer accumulation noted on the nasopharynx, salivary glands, GIT, and urinary bladder

▫No functioning metastasis is seen

Whole body I-131 scintigraphy Oct 8, 2012

•Interpretation: Functioning thyroid tissue remnants limited to the thyroid bed.

12/10/12

•Levothyroxine 150g (mon- sat, 1/2 on Sunday)

Result Normal ValueTSH 0.037 0.35-5.50

uIU/mlTG 5.25 < 1ng/mL

Record of Operation 4/26/13•Pre-operative diagnosis: Recurrent

papillary thyroid cancer; S/p Total thyroidectomy with modified radical neck dissection Type III, left

•S/P RAI 12/13/11 and 10/03/12

Record of Operation 4/26/13•Operation: Central node dissection

Record of Operation 4/26/13•Findings: multiple adhesions between

strap muscle, trachea and surrounding areas, #1 enlarged LN ~ 1cm at Left paratracheal area, multiple persistent LN on central area 0.3-1cm in diameter adherent to the trachea

Record of Operation 4/26/13 Recurrent Papillary Thyroid Carcinoma

S/P Total Thyroidectomy for Papillary Thyroid Carcinoma (Nov 8, 2011) Stage IVA (pT2N1bM0)

S/P RAIA 100 mCi (Dec 17, 2011) S/P RAIA 150 mCi (Oct 8, 2012)

Final Histopath 4/26/13•Specimen: Central and left peritracheal

lymph nodes▫Fibro-adipose tissue, showing papillary

carcinoma (0.3cm) and suture granuloma▫26/29 Lymph nodes positive for metastatic

papillary carcinoma, parathyroid gland (one focus), Thymus gland (fragments)

Papers on recurrent papillary thyroid cancer•Another RAI after several RAI sessions?

Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for 2001-2007, All Races, Both Sexes

Stage at Diagnosis Stage Distribution (%)

5-year Relative Survival (%)

Localized (confined to primary site) 68 99.8

Regional (spread to regional lymph nodes) 25 96.9

Distant (cancer has metastasized) 5 56.4

Unknown (unstaged) 2 87.6

STAGE AND SURVIVAL FOR THYROID CANCER

• based on NCI’s SEER Cancer Statistics Review

DIVISION OF LYMPH NODES BY LEVELS ( AMERICAN HEAD & NECK SOCIETY – 1991 )

•Removes▫Nodal groups I-V

•Preserves▫SCM, IJV, XI (any

combination)

•Classified according to which structures are preserved

Modified Radical Neck Dissection

Modified Radical Neck DissectionMRND Type I (preserves SAN)

•Indications:▫Clinically N+▫SAN not involved by tumor

Modified Radical Neck DissectionMRND Type II

(preserves SAN and IJV)

•Indications:▫Intraoperative tumor

found adherent to the SCM, but not IJV and SAN

▫Rarely planned

Modified Radical Neck DissectionMRND Type III

(preserves SAN, IJV and SCM)

•Indications:▫SAN, IJV, & SCM not

involved by tumor

Selective Neck Dissection•Remove high risk lymph node groups

based on tumor site.

SupraomohyoidLevels I-III

LateralLevels II-IV

Anterolateral

Levels I-IV

Selective Neck Dissection

PosterolateralLevels II-V

Postauricular nodesSuboccipital nodes

Anterior compartment

Level VI

PGH (2008) PCS-PSGS-PAHNSI (2008)For all thyroid nodules: Serum TSH determination Thyroid ultrasound FNAB

Serum TSH and/or thyroid hormones Thyroid UTZ for: High risk patients (family hx of thyroid CA,

previous dx of MEN2, childhood cervical irradiation) Suspicious nodule for CA in the background of multinodular goiter With adenopathy suggestive of malignant lesion Evaluation of nodular goiter

Scintigraphy – limited to pxs w/ subnormal serum TSH

FNAC – recommended for dx of benign & malignant lesions

PET scan w/ 18F-FDG – for detection of thyroid CA in inconclusive cytologic nodular dx of thyroid nodules

Initial Diagnostic Tests

PGH (2008) PCS-PSGS-PAHNSI (2008)Total or near total thyroidectomy for thyroid nodule proven malignant by FNAB with size >1 cm.

Lobectomy for lesions <1 cm, isolated intrathyroidal well-differentiated carcinomas with absent cervical nodal metastases.

Near total or Total Thyroidectomy for WDTC

Total or near-total thyroidectomy for multinodular goiter.

Lobectomy w/ isthmusectomy for solitary benign thyroid nodule

Extent of Surgery

PGH (2008) PCS-PSGS-PAHNSI (2008)For non-diagnostic preoperative FNAB

Limited utility in diagnosing thyroid malignancies if the FNAB result show follicular neoplasm, inadequate or suspicious aspirate.

Frozen Section

PGH (2008) PCS-PSGS-PAHNSI (2008)Appropriate node dissection shall be performed.

No mention.

Lymph Node Dissection

PGH (2008) PCS-PSGS-PAHNSI (2008)Lesion size >1 cmMultifocal diseaseNodal metastasesInvolved resection margins Extrathyroidal or vascular invasionAggressive histologies.

Beneficial for decreasing locoregional recurrence and distant metastasis.

Role of Radioactive Iodine Ablation

PGH (2008) PCS-PSGS-PAHNSI (2008)Maintenance of TSH at 0.1 to 0.5 mU/L for patients at risk for complications from thyroid hormone suppressive therapy, in absence of contraindications.

Thyroid hormone suppression will significantly reduce recurrence and thyroid cancer-specific mortality rates.

TSH Suppresion Therapy

PGH (2008) PCS-PSGS-PAHNSI (2008)Pts with unresectable gross cervical disease, painful bone metastases, metastatic lesions likely to result in fracture, neurological or compressive symptoms not amenable to surgery, painful pleural-based lesions, and recurrent hemoptysis.

Indicated as part of the treatment of WDTC when there is gross residual tumor or invasion of adjacent structures, and does not concentrate RAI.

External Beam Radiotherapy

PGH (2008) PCS-PSGS-PAHNSI (2008)May be considered in patients who have surgically unresectable disease and unresponsive to RAI or external beam radiation.

May also be offered to patients who are not amenable to external beam radiation therapy.

Role of chemotherapy is unclear in recurrent and metastatic WDTC.

Role of Chemotherapy

PGH (2008) PCS-PSGS-PAHNSI (2008)TSH stimulated serum thyroglobulin should be measured every 6-12 months.

The most important initial test to monitor patients for residual or recurrent WDTC.

Role of Post operative Thyroglobulin Assay

PGH (2008) PCS-PSGS-PAHNSI (2008)Maintained at 0.1 to 0.5 mU/L unless with contraindications

W/ persistent disease: serum TSHShould be maintained below 0.1mU/L indefinitely in the absence of specific contraindications.

W/ clinically disease free but presented w/ high risk disease, consideration should be given to maintaining TSH suppressive therapy to achiee serum TSH levels of 0.1 to 0.5 mU/L for 5 to 10 yrs.

Free of disease, especially those at low risk for recurrence, TSH may be kept w/in normal range (0.3 – 2 mU/L)

Serum TSH should be monitored every 6 months to 12 months in the 1st yr and then yearly thereafter

Role of Post operative Serum TSH

PGH (2008) PCS-PSGS-PAHNSI (2008)Evaluation of the thyroid bed, central and lateral node compartments should be performed at 6 to 12 months postoperatively, then annually for at least 3 to 5 years for high risk patients.

Recommended for postoperative surveillance to detect recurrence in the thyroid bed and cervical nodes.

Post operative Role of Cervical UTZ

PGH (2008) PCS-PSGS-PAHNSI (2008)Done after RAI Limited usefulness and is NOT necessary in

low risk patients who are clinically free of residual tumor w/ undetectable serum Tg and has negative neck ultrasound

NOT necessary if the Tg is elevated and ultrasound of the neck is positive, since therapeutic options (surgery or RAI ablation) are already warranted.

Role of Post operative Whole Body Scan

PGH (2008) PCS-PSGS-PAHNSI (2008)

No mention. Locoregional: Preoperative neck ultrasound is recommended to detect locoregional metastasis for WDTC. Routine use of CT and PET is NOT recommended.

Distant: CXR, HRCT and FDG-PET are NOT routinely recommended to detect distant metastasis.

Metastatic Work-up