Saravanan Papillary CA Thyroid

8/2/2019 Saravanan Papillary CA Thyroid

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Most common type

Makes up about 80% of allthyroid carcinomas

Females outnumber males 3:1

Highest incidence in women inmidlife

.


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Unencapsulated tumor nodule with ill-definedmargins

Tumor typically firm and solid

May present as nodal enlargement Commonly metastasizes to neck and mediastinal

lymph nodes

40% to 60% in adults and 90% in children


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PTC Classification

1. Minimal PTC

(a) T


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PTC Classification High-risk PTC/FTC

1. AMES (age, 2, T extent/size)2. AGES (age, grade, T extent/size)3. TNM (T, LN, 2)4. EORTC5. MACIS (2, age, resectibility, invasion, T)

6. Histology (Hurthle cell, tall cell, columnar variants) Other1. Delay in treatment2. LVI especially FTC

3. High grade (PTC/FTC)


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Rationale for total thyroidectomy 1) 30%-87.5% of papillary carcinomas involve opposite

lobe

2) 7%-10% develop recurrence in the contralateral lobe

3) Lower recurrence rates, some studies showincreased survival

4) Facilitates earlier detection and tx for recurrent ormetastatic carcinoma with iodine

5) Residual WDTC has the potential to dedifferentiateto ATC


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Indications for total thyroidectomy

1) Patients older than 40 years with papillary orfollicular carcinoma

2) Anyone with a thyroid nodule with a history ofirradiation

3) Patients with bilateral disease


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Managing lymphatic involvement pericapsular and tracheoesophageal nodes should be

dissected and removed in all patients undergoingthyroidectomy for malignancy

Overt nodal involvement requires exploration ofmediastinal and lateral neck

if any cervical nodes are clinically palpable oridentified by MR or CT imaging as being suspicious aneck dissection should be done (Goldman, 1996)

Prophylactic neck dissections are not done(Gluckman)


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THYROID CANCER

Well Differentiated Thyroid Carcinoma

Treatment Surgery

1. Total ipsilateral thyroid lobectomy

Minimal PTC or min invasive FTC limited cap inv2. Near total thyroidectomy

High-risk PTC

Bilateral cancer/nodules (papillary not follicular)Preservation of parathyroid glands (relative RR)

Risks (


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THYROID CANCER


Treatment Surgery Advantages of NTT1. PTC often multifocal2. Lymphatic spread throughout gland3. Facilitates ablative RAI4. Facilitates detection of residual and distant

tumour

5. Facilitates treatment of residual and distanttumour6. TG more sensitive tumour marker7. RR


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THYROID CANCER


Treatment Surgery

LND Risk at in older adults (ipsilateral)

1. PTC: 40%

2. FTC: 10%

3. Hurthle: 25% Extensive LN 2 suggestive of follicular variant of PTC


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THYROID CANCER


Treatment

Surgery

LND Significance1. PTC: LRR not OS

2. FTC: worse prognosis (uncommon)3. Medullary: LRR and OS


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THYROID CANCER


Treatment

Surgery

LND

Procedure1. T > 15 mm: en bloc central cervical LND

2. Limited LN + (extra thyroid) or palpable LN:functional Cx/M LND (unilateral)

3. Extensive LN + (extra thyroid): radical Cx/M LND

(unilateral or bilateral,

thymectomy)


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THYROID CANCER


Treatment Adjuvant Therapy1. TSH suppression

T4 commenced after ablative RAI

150-200 mcg/day (2mcg/kg)

Serum levels (a) HR: < 0.1 IU/mL

(b) LR: 0.1 0.4IU/mL

No proven OS benefit/ LRMonitor cardiac function in elderly

Risks: accelerated bone turnover, OP, AF


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THYROID CANCER


Treatment

Adjuvant Therapy

2. RAI

i. Ablative RAIAll patients after TT/NTT, except

a) Young, female patients with occult solitarypapillary carcinoma < 15mm

b) Partial thyroidectomy


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THYROID CANCER


Treatment

Adjuvant Therapy2. RAI

i. Ablative RAI Rationalea) ablate residual thyroid tissue and adjacent

microscopic CA

b) TG assay more specificc) 2 CAd) TSH increases RAI uptakee) Radionuclide scans more sensitive for tumour


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THYROID CANCER


Treatment

Adjuvant Therapy

2. RAI

i. Ablative RAI CIa) Patient refusal

b) Poor performance statusc) Uncooperative patientd) Intractable urinary incontinencee) Pregnancy


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THYROID CANCER


Treatment

Adjuvant Therapy

2. RAI

i. Ablative RAI

Preparation1) 6/52 postop

2) TG before RAI3) Low iodine diet for 2/52

4) Pregnancy test and contraceptives

5) No replacement T3/4


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THYROID CANCER


Treatment

Adjuvant Therapy2. RAI

i. Ablative RAI Procedure1) 75-150 mCi (2,775-5,550 MBq) controversial2) Admit for 1-2 days (physicist check)

3) Urinary catheter if female (ovarian dose 0.3cGy/mCi)4) NSAID/paracetamol or steroids for pain5) Post-op precautions (in ward and at home)


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THYROID CANCER

POSTOP MANAGEMENTFLOW DIAGRAM


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THYROID CANCER


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THYROID CANCER


Treatment Adjuvant Therapy

2. RAI

ii. Therapeutic RAI 150-200 mCi (5500-7000MBq)

Max 1500-2000 mCi (avoid > 1000 mCi)

Min 6/12 between RAI doses

Reduce dose if multiple lung 2 (80 mCi retaineddose)

Flare response, xerostomia, AML/bladder/breast, BM

suppression, azospermia, menopause


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THYROID CANCER


Treatment Adjuvant Therapy2. RAIii. Therapeutic RAI

Indicationsa) Iodine avid recurrent diseaseb) 2 Dexamethasone

a) cerebral, intra-orbital or intra-spinal 2b) Stridor Reduce dose (80 mCi retained dose) if multiple

lung 2


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THYROID CANCER


Treatment

Adjuvant Therapy

3. EBRT 50.4 Gy @ 1.8 Gy/# in 28# 5-20 Gy boost to residual disease

Total dose limited by SC, other structures

Large AP field with small AP or PA mediastinal field

6-10 MV photons


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INDICATIONSFOR

EBRTRADICAL

RT


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THYROID CANCER


Treatment Adjuvant Therapy3. EBRT

Target Volume1) Thyroid and tumour/bed ifi. macroscopic residual, andii. N-ve

2) JD, Submandibular, IJ, Sp Accessory, SCF, Sup Med(to carina) ifi. Residual or extensive N +, orii. Non-iodine avid disease


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THYROID CANCER


Follow-up

1. TG if N- TG antibodiesi. Post-op

ii. @ 4/12iii. 6/12ly x 2yearsiv. Annually

2. RAIi. Rising TG - restagingii. Recurrent/metastatic disease avidityiii. Surveillance if + TG AB

THYROID CANCER


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THYROID CANCER


Follow-up3. Radiological tests CT neck/chest

MRI U/S

WBBS

PET

4. Thyroid function testsensure adequate suppression of TSH

5. Recombinant thyrotopin


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THYROID CANCER


If Persistent or Recurrent Disease

1. Restage (CT, RAI)

2. Maximal resection (LND, excision of LR)3. Whole body iodine scan (diagnostic, test avidity)

4. Therapeutic RAI

5. EBRT


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THYROID CANCER


Metastases Incurable but several years survival possible

Management varies with1. Patient factors2. Tumour factors (number and site/s of recurrence, local

complications)

3. Iodine avidity

4. Prior treatment and its outcomes

THYROID CANCER


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THYROID CANCER


Metastases when to prefer Surgery

1. Selected long-bone 2 at risk of fracture

2. Isolated and solitary brain 2

3. SC compression

4. Isolated lung 2

5. Rapid progression of 1 pulmonary 2

RTPalliative doses for symptom control or to preventcomplications


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Saravanan Papillary CA Thyroid