Implementing Guidelines For Thyroid Cancer

10th ASIA and OCEANIA THYROID ASSOCIATION CONGRESS24-27 OCTOBER 2012

MUCHLIS RAMLIProfessor in Surgical Oncology Departement of Surgery University of Indonesia

UNIVERSITY Of INDONESIAAND

CIPTO MANGUNKUSUMO HOSPITAL

The Oldest University Fac. of Medicine

in Indonesia

A part of academic hospital where Dept of Surgery placed

The aim of guidelines

To standardize of services To evaluate of quality of services To plan improvement of services for

increasing the quality. To support of the basic and clinical

research. To support of education process

We need “ a solid working group ” in implementing of guidelines

In implementing of guidelines absolutely need : “same perception and criteria in”

Clinical staging classification Histological report classification Several activities : etc

- Surgical technique or type of surgery- Preparation for thyroid or whole body

scan and others Same fasicilities ( hopefully ) Same competency of the man behind

(education)

There are many guidelines has been published.

Most of famous of cancer institution :› Cancer Centers or Hospital› Cancer Organization› Education

Has a thyroid cancer Guideline Etc : ATA

NCCNESSO

And we have : guideline of ISSO

The incidence of thyroid cancer is rapidly increasing

In USA :› 4% for year for the past 20 years› 2010 : 44.670 newly diagnosed, 1.690 thyroid

cancer death In Indonesia : the ninth of the ten frequent

cancer ( pathological Based 2005)In dr. Cipto Mangunkusumo Teaching Hospital of University of Indonesia.The newly diagnosed as thyroid cancer in 2010-2011 : 199/280 nodule thyroid ( 71,1% )

THYROID CANCER IN DR.CIPTO MANGUNKUSUMO HOSPITAL

• 2010-2011 : 199/280 nodule thyroid ( 71,1% )• 2000-2009 : 262 *thyroid cancer (missing part of data)• 1990-1999 : 361 thyroid cancer among 962 thyroid nodules (38%)• 1996 : 289 thyroid cancer among 832 thyroid nodule (34,7%)• 1990 : 155 thyroid cancer among 842 thyroid nodule (18,36%)• 1985 : 48 thyroid cancer among 324 thyroid nodule ( 14,8%)• 1978 : 64 thyroid cancer among 601 thyroid nodule (10,5%)

It is a tendency increasing of thyroid cancer hospitalized in Dr.CiptoMangunkusumo Hospital

It is estimated that the increasing of thyroid cancer due to :- The development of diagnostic method- Awareness of the patient for seeking health care

* Part of data missing

Guidelines of thyroid cancer

The ISSO guideline had been developed according of situation ( fasicility and condition ) what we have ( 2003 and revised in 2010 )

I. Introduction or backgroundII. Histological classificationIII. Staging classificationIV. Diagnostic procedures :

History and clinical examinationSonography examinationScan thyroidSitology ( FNAB)Histopathology examination ( as Gold Standard diagnostic )

V. Treatment proceduresVI. Follow up

Histological classification according to the Indonesian Pathologist Association Classification ( identic with WHO Classification)

Histological classification of thyroid cancer

Follicular carsinoma Papillary carsinoma

Medullary carsinoma Anaplastic carsinoma

Staging Classification based an UICC/AJCC 2002 Classification

Diagnostic Procedures• History and physical examination• Laboratory finding• Ultrasonography• Thyroid Scan (Tc, Iodine)• FNAB / Cytology• Histopathology gold standard

Optional : CT retrosternal struma MRI PET SCAN

Diagnostic Procedures (cont 1)

• Clinical finding are important• Suspicious malignant nodule if :

- history of prior external irradiation head neck area

- thyroid nodule has grown rapidly

- local compression symptoms or infiltration :• disturbance of swallowing (dysphagia)• difficulty of breathing• difficulty of speaking (hoarseness)

- nodule in man or in patient at extremely of age

- family history of thyroid malignancy (as medullary

type)

- thyroid nodule with cervical lymphadenopathy or

sign of distance metastases• Cervical plain photo : calcification of thyroid nodule

(70% malignancy)• The accuracy of clinical sign and symptoms is 80,9 %

( study in Dr.Cipto Mangunkusumo)

Diagnostic Procedures (cont 2)

ULTRASOUND IMAGES

Diagnostic Procedure (cont 3)

Suspicious malignant :

- poorly defined,irreguler margins

- punctate/micro calcification

- central hipervascularity• Ultrasonography

- to differentiate solid or cystic nodule

(hypoechoic vs normal thyroid tissue )

Thyroid Scan

- to differentiate :

- cold nodule, warm nodule, hot nodule

- soliter or multiple nodule

- 16 – 30 % cold nodule are malignant

- could be used to control after surgery (total thyroidectomy )

- maybe useful in hyperfunctioning adenoma

Fine Needle Aspiration

• FNAB :- diagnostic accuracy 95 %

- sensitivity 80 – 85 % - specificity 90 – 95 % for papillary type ca

- false negatives 5 %- false positive 1 – 3 %

- difficult to differentiate follicular adenoma, follicular carcinoma

and benign follicular lesions • Frozen section

- accuracy 83 %• Gold standard diagnostic : Histopathologic examination

Diagnostic Procedures (cont 4)

Clinical suspicious malignant thyroid nodule

Extreme age : younger than 20 or older than 50.

Previously radiation of the neck or chest in child hold age

Clinical symptoms : dysphagia,hoarseness, disturbance of respiration stridor

Nodule : single,man,rapid growth, hard or firm in consistency, enlargement of regional lymph nodes or distance metastases

TREATMENT PROCEDURES

Management of thyroid nodule and thyroid cancer

If suspected malignant thyroid nodule, it is classified as operable one or inoperable.

Operable one : isthmolobectomy and frozen section should be performed

Five possible result of frozen section examination are :

Benign lesion surgery is completed

Papillary carcinoma Low risk surgery is completed and observation

High risk total thyroidectomy should be performed or surgery should be performed directly (although classified low or high risk one)

Follicular carcinoma total thyroidectomy should be performed

Medullary carcinoma total thyroidectomy should be performed

Anaplastic carsinoma If operable : a total thyroidectomy

should be performed; followed be external beam radiation

If inoperable, just biopsy and followed by external beam radiation .( see the schema)

Thyroid Nodule

Clinical FeaturesMalignant

SuspectBenign Suspect

Inoperable

Operable FNAB

Isthmolobectomy

Incisional Biopsy

Benign Lesion

Malignant susp, Follicular pattern,

Hurthle cell

Benign

Papillary Follicular Medullar Anaplastic TSH Suppression (6 Months)

Low Risk High RiskProgressiv

e, no change

Shrinking

Observation Total Thyroidectomy

DebulkingExternal

radiation/chemotherapy

Schema I

Thyroid Nodule

Clinical FeaturesMalignant

SuspectBenign Suspect

Inoperable OperableObservation

Lobectomy/ Isthmolobectomy

Incisional Biopsy

Benign Lesion

Compression symptoms

TSH Suppression Failed

Cosmetic Reason

Papillary Follicular Medullar Anaplastic

Low Risk High Risk

Operation Finished

Observation

Total Thyroidectomy Debulking

External radiation/chemotherapy

Malignant Lesion

Schema II

American Thyroid Association Guidelines

Thyroid cancer with regional lymph node (s) metastases

Operable one : total thyroidectomy with modified radical neck dissection or classical RND ; depend on extend of invasion.

Inoperable : radiation and chemotherapy (see the schema III)

Inoperable Operable

Accessory Nerve

Infiltration

Internal Jugular Vein infiltration

SCM Infiltration

Infiltration (-)

Radiotherapy, Chemo-

radiotherapy

TT + Functional

RND

TT + Modification

2 RND

TT + Modification

1 RND

TT + Standard

RND

Thyroid Cancer + Regional Metastasis

infiltration

Schema III

For thyroid cancer with distant metastase

Well differentiated carsinoma total thyroidectomy with internal radiation J.131

Poorly differentiated carsinoma chemotherapy ( see schema IV)

Thyroid Cancer + Distant Metastasis

Poorly Differentiated

Well Differentiated

Total Thyroidectomy + Internal Radiation

Chemotherapy Response (-)Response

(+)

Suppression/ Substitution

Therapy

Schema IV

Medicamentous treatment in thyroid cancer : all patient post total thyroidectomy will be given thyroxin hormone with supressive dose

Follow up of thyroid cancer

Well differentiated thyroid cancer

4-6 week after total thyroidectomy, thyroid scan and/or whole body scan should be performed, to detect residual tumor or metastatic lesion and detect of thyroglobulin level as marker of well differentiated thyroid cancer.

Ablation theraphy with J.131 should be given for residual tumor detected (see schema V)

Total Thyroidectomy

Residual Tissue (+)

AblationSupression/ Substitution

Therapy

Internal Radiation

Metastasis (+)

Metastasis (-)

Residual Tissue (-)

Schema V

4 WEEKS SCAN THYROID

CONTROVERSION

6 MONTHWHOLE BODY SCAN

American Thyroid Associationfor ablation

Medullary thyroid carsinoma

Calcetonin level should be examined 3 month after total thyroidectomy with or without central node dissection. If level calcetonin > 10 mg/ml, it mean suspicious recurrence and further examination should be performed (see schema VI)

Observation

CT Scan, MRI, SVC

Locally Residive (+)

Distant Metastasis

Re-excision Operable Inoperable

Excision Paliative

Total Thyroidectomy

Locally Residive (-)

Calcitonin Level > 10ng

Low Calcitonin Level

Schema VI

3 Months Post Operation

Evaluation of implementing of guideline of thyroid cancer in Indonesia will be presented concerning of cases, stage classification : histophatological classification, treatment and others.

Data collected from several center in Indonesia.Medan : Emir T. Pasaribu, et allJakarta : Muchlis Ramli, et allBandung : Dimyati Achmad, et allSemarang : Djoko Handojo, et allDenpasar : Tjakra Wibawa Manuaba, et all

Gender distribution Thyroid Cancer from several centers in Indonesia

( 3 or 5 years)

Medan (2009-2011) Jakarta (2007-2011) Bandung (2005-2009)

Semarang (2007-2011)

Denpasar (2007-Juli2012)

Female 23 394 118 102 178

Male 5 77 30 39 38

25

75

125

175

225

275

325

375

425

475

23

394

118 102

178

5

77

3039

38

valu

e

Fe-male82%

Male18%

Medan (2009-2011)

Female84%

Male16%

Jakarta (2007-2011) Female80%

Male20%

Bandung (2005-2009)

Fe-male72%

Male28%

Semarang (2007-2011)

Female82%

Male18%

Denpasar (2007-Juli2012)

Most cases of thyroid cancer : female

Distribution of Stage thyroid cancerfrom several centers in Indonesia

Medan (2009-2011)

Jakarta (2007-2011)

Bandung (2005-2009)

Semarang (2007-2011)

Denpasar (2007-Juli2012)

0

50

100

150

200

250

9

63

47

2

41

2

146

9

20

66

1

205

37

109

40

7

58 55

1015

9

54

IIIIIIIVNot deffined

Most cases of thyroid cancer : stage II

Distribution of Stage thyroid cancer dr.Cipto Mangunkusumo Hospital

(2007-2011 )

I13%( 63 )

II31%

( 146 )

III44%

( 205 )

IV12%( 58 )

Most cases thyroid cancer in dr. Cipto Mangunkusomo Hospital : stage III

Ca.Pa-piler

Ca. Foliculer

Ca.medulare

Ca.anaplastic

Ca. pa-piler

Varian Foliculer

Ca.Pa-piler

varian Tall cell

Ca. Hurthle

cell

lym-phoma

Atipic cell

ca. musi-nosa

SCC Unclas-sifed

Medan (2009-2011)

14 11 1 2 NaN NaN NaN NaN NaN NaN NaN NaN

Jakarta (2007-2011)

354 22 NaN 3 36 16 6 1 16 5 3 9

Bandung (2005-2009)

93 47 1 6 NaN NaN 1 NaN NaN NaN NaN NaN

Se-marang (2007-2011)

99 34 4 4 NaN NaN NaN NaN NaN NaN NaN NaN

Denpasar (2007-Juli2012)

158 24 NaN 13 2 NaN 5 3 NaN NaN 3 6

25

75

125

175

225

275

325

375 354

223

36

166 1

165 3 9

Histopatologyvalu

e

Distribution of histologic

Distribution of histologic thyroid cancerfrom RSCM (2007-2011)

353 (75% )

22(5%)

36( 8%)16( 3%)

3(1%)

6( 1%)16; 3%

9(2%) 5(1%) 3(1%) 1(0% )

ca. papiler thyroid

ca. folliculer thyroid

ca. papiler varian foliculer

ca.papiler varian tall cell

ca. anaplastic

ca.hurthle cell thyroid

sel atipic

unclassifed thyroid car.

ca. mucinosa thyroid

SCC thyroid

Primary lymphoma of thyroid

Most cases of thyroid cancer : papillary carsinoma type.

Isth-molobectomy

Total Thy-

roidec-tomy

TT +RND

TT + Berry

Picking

Debulc-ing

Com-pletion

Sub TT Near TT

Exci-sion

Tra-cheostomy

No Treat-ment

Medan (2009-2011)

10 15 1 NaN 1 NaN NaN NaN 1 NaN NaN

Jakarta (2007-2011)

68 319 9 4 14 36 14 4 NaN 3 NaN

Bandung (2005-2009)

NaN 107 35 NaN NaN NaN NaN NaN NaN 6 NaN

Se-marang (2007-2011)

NaN 124 14 NaN 3 NaN NaN NaN NaN NaN NaN

Denpasar (2007-Juli2012)

41 153 8 NaN 3 NaN NaN NaN 6 2 24

25

75

125

175

225

275

325

68

319

9 414

36

144 3

Operation of thyroid cancervalu

e

Distribution type of surgery

Distribution type of surgery thyroid cancer from RSCM (2007-2011)

68(14%)

319(68%)

9(2%)

4(1%)

14(3%)

36(8%) 14(3%) 4(1%) 3(0%) Isthmolobectomy

Total Thyroidectomy

Total Thyroidectomy + RND

Total Thyroidectomy +berry Pick-ing

Debulking

Completion

Subtotal Thyroidectomy

Near Total Thyroidectomy

Tracheostomy

Most operation of thyroid cancer : Total Thyroidectomy

Completion in dr. Cipto Mangunkusumo Hospital : 36 ( 8% ) . Because :

1. Refference from another hospital.2. Miss result from frozen section.

Result frozen section in dr.Cipto Mangunkusumo Hospital :

- Sensitivity : 65,5%- Specifity : 86,3%- Acurasi : 70%

And FNAB in dr.Cipto Mangunkusumo Hospital - Sensitivity : 58,2%- Specifity : 88,9%- Acurasi : 63,4%

COMPLICATION

Complication for thyroid cancer 2000-2009 at Cipto Mangunkusumo Hospital

- Nerve injury : 3%- Hipocalcemi : 2%- Bleeding : 0.5%

COMPLICATION

Complication for thyroid cancer - Nerve injury : 3%- Hipocalcemi : 2%- Bleeding : 0.5%

From : Davinson BJ & Burman KD : Cancer of thyroid and parathyroid in “ Head & neck Cancer a multidisciplinary approach “.

Data collected from several center in IndonesiaNo. Criteria Medan Jakarta Bandung Semarang Denpasar

1. Year 2009-2011 2007-2011 2005-2009 2007-2011 2007- Juli 2012

Duration 3 year 5 year 5 year 5 year 5,5 year

2. Gender

Male 5 77 30 39 38

female 23 394 118 102 178

Total 28 471 148 141 216

3. Stage

I 9 63 47 2 41

II 2 146 9 20 66

III 1 205 37 109 40

IV 7 58 55 10 15

Not defined 9 54

4. Type of Histologic

Ca. papiller 14 353 93 99 153

Ca. folicular 11 22 47 34 24

Ca. papiller varian foliculer

36 2

Ca. papiller varian tall cell

16

Data collected from several center in Indonesia (cont 2 )No. Criteria Medan Jakarta Bandung Semarang Denpasar

Ca. medullare 1 1 4

Ca. anaplastic 2 3 6 4 13

Ca. Hurthle cell 6 1 5

Primary lymphoma 1 3

Atipic cell 16

Ca. cystic papiler 1 2

Ca. mucinosa 5

Squamosa cell carsinoma

3 3

unclassified 9 6

5. Type of surgery

Isthmolobectomy 10 68 41

Total Thyroidectomy 15 319 107 124 153

TT + RND 1 9 35 14 8

TT + Berry Picking 4

Debulcing 1 14 3 3

Completion 36

Tracheostomy 3 6 2

excision 1 6

Sub total thyroidectomy 14

Near total thyroidectomy 4

Not surgery 24

The problem in implementing guidelines

1. Registration 2. Facilities3. Controversies in preparation of the patient

for radioiodine diagnostic and treatment4.Patients factors Education Social economic Alternative treatment

( TCM ?, herbal ?)

THANK YOU