What Operation for Thyroid Cancer

1212thth G. Rainey Williams Surgical Symposium G. Rainey Williams Surgical Symposium

What Operation for Thyroid Cancer?What Operation for Thyroid Cancer?

Ronald Squires, MD FACSRonald Squires, MD FACSAssociate Professor of SurgeryAssociate Professor of Surgery

Sections of General and Transplant SurgerySections of General and Transplant Surgery

University of Oklahoma Health Science CenterUniversity of Oklahoma Health Science Center

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TOTAL TOTAL THYROIDECTOMYTHYROIDECTOMY

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Questions?Questions?

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IntroductionIntroduction First reports of thyroidectomy from School of Salerno in Italy in First reports of thyroidectomy from School of Salerno in Italy in

11701170 Johann Dieffenbach of Berlin in 1848 stated that thyroidectomy Johann Dieffenbach of Berlin in 1848 stated that thyroidectomy

was “one of the most thankless and most perilous undertakings” was “one of the most thankless and most perilous undertakings” in surgeryin surgery

Outcomes were so poor that the French Academy of Medicine Outcomes were so poor that the French Academy of Medicine banned its practice in 1850banned its practice in 1850

Billroth performed 59 thyroidectomies from 1861-1867 with a Billroth performed 59 thyroidectomies from 1861-1867 with a 40% mortality—a later series from 1877-1881 reported 16 40% mortality—a later series from 1877-1881 reported 16 thyroidectomies with 100% survivalthyroidectomies with 100% survival

Theodore Kocher won the Nobel prize in medicine in 1909 for Theodore Kocher won the Nobel prize in medicine in 1909 for his contributions to thyroid surgery including many of the his contributions to thyroid surgery including many of the techniques still used by modern day thyroid surgeonstechniques still used by modern day thyroid surgeons

Halsted first to advocate and popularize subtotal thyroidectomy Halsted first to advocate and popularize subtotal thyroidectomy to preserve parathyroids and protect recurrent laryngeal nervesto preserve parathyroids and protect recurrent laryngeal nerves

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Thyroid CancersThyroid Cancers

Differentiated cancersDifferentiated cancers• Papillary carcinomaPapillary carcinoma• Mixed papillary/follicular carcinomaMixed papillary/follicular carcinoma• Follicular carcinomaFollicular carcinoma• HHüürthle cellrthle cell

Medullary carcinomaMedullary carcinoma Anaplastic carcinomaAnaplastic carcinoma Lymphoma of thyroidLymphoma of thyroid

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Thyroid CancersThyroid Cancers

Differentiated cancersDifferentiated cancers• Papillary carcinomaPapillary carcinoma• Mixed papillary/follicular carcinomaMixed papillary/follicular carcinoma• Follicular carcinomaFollicular carcinoma• HHüürthle cellrthle cell

Medullary carcinomaMedullary carcinoma

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Thyroid Nodule WorkupThyroid Nodule Workup

50% of population over 50 years have an US 50% of population over 50 years have an US detectable thyroid noduledetectable thyroid nodule

Prevalence of nonpalpable clinically Prevalence of nonpalpable clinically significant (1-1.5cm) nodes is 2-3%significant (1-1.5cm) nodes is 2-3%

90% of all nodules reflect benign disease90% of all nodules reflect benign disease Of the 10% of malignant nodules, 75% are Of the 10% of malignant nodules, 75% are

papillary and 15% are follicularpapillary and 15% are follicular

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Check TSH levelCheck TSH level• If high, begin thyroid replacement until euthyroidIf high, begin thyroid replacement until euthyroid• If low, nuclear scan to check for hyperfunctioning nodule If low, nuclear scan to check for hyperfunctioning nodule

(very rarely malignant)(very rarely malignant) FNA with or without US guidance when euthyroidFNA with or without US guidance when euthyroid Nodules greater than 1cm in two dimensions are Nodules greater than 1cm in two dimensions are

clinically significantclinically significant 16% of patients with palpable nodules will have no 16% of patients with palpable nodules will have no

nodule visible by US and the vast majority will be nodule visible by US and the vast majority will be diagnosed with Hashimoto’s thyroiditisdiagnosed with Hashimoto’s thyroiditis

In multinodular goiter, masses > 1cm should be In multinodular goiter, masses > 1cm should be biopsied (5-13% risk of cancer in these larger lesions)biopsied (5-13% risk of cancer in these larger lesions)

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FNA results should be limitedFNA results should be limited• Benign goiterBenign goiter• MalignancyMalignancy• Follicular neoplasmFollicular neoplasm• Nondiagnostic sampleNondiagnostic sample

Diagnostic accuracyDiagnostic accuracy• Sensitivity > 92%Sensitivity > 92%• Specificity 91-98%Specificity 91-98%

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Benign diagnosisBenign diagnosis• Reultrasound in 6 monthsReultrasound in 6 months

– If same or smaller, follow yearlyIf same or smaller, follow yearly– If larger, (15% increase in size in two dimensions) then If larger, (15% increase in size in two dimensions) then

repeat FNArepeat FNA Indeterminate diagnosisIndeterminate diagnosis

• Repeat FNA in 3 months or consider using US guidance if Repeat FNA in 3 months or consider using US guidance if not previously usednot previously used

Follicular cytology (80% benign disease)Follicular cytology (80% benign disease)• Thyroid scan (if “hot” nodule in euthyroid patient then Thyroid scan (if “hot” nodule in euthyroid patient then

observe)observe)• All cold nodules and hot nodules in hyperthyroid patients All cold nodules and hot nodules in hyperthyroid patients

should be removedshould be removed

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The ScienceThe Science

All recommendations are based on retrospective All recommendations are based on retrospective series or multivariate analysisseries or multivariate analysis

Mathematical models are also utilized to extrapolate Mathematical models are also utilized to extrapolate data to existing populationsdata to existing populations

The incidence of thyroid carcinoma is 11,000 cases The incidence of thyroid carcinoma is 11,000 cases per year in the US with 1,100 deathsper year in the US with 1,100 deaths

Given the good overall survival, a prospective study Given the good overall survival, a prospective study would need at least 12,000 patients followed for a would need at least 12,000 patients followed for a minimum of 20 years to distinguish subtle therapeutic minimum of 20 years to distinguish subtle therapeutic differencesdifferences

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Arguments for Total ThyroidectomyArguments for Total Thyroidectomy

Radioactive iodine may be used to detect and treat residual Radioactive iodine may be used to detect and treat residual normal thyroid tissue and local or distant metastasesnormal thyroid tissue and local or distant metastases

Serum thyroglobulin level is a more sensitive marker for Serum thyroglobulin level is a more sensitive marker for persistent or recurrent disease when all normal thyroid tissue is persistent or recurrent disease when all normal thyroid tissue is removedremoved

In up to 85% of papillary cancer, microscopic foci are present in In up to 85% of papillary cancer, microscopic foci are present in the contralateral lobe. Total thyroidectomy removes these the contralateral lobe. Total thyroidectomy removes these possible sites of recurrencepossible sites of recurrence

Recurrence develops in 7% of contralateral lobes (1/3 die)Recurrence develops in 7% of contralateral lobes (1/3 die) Risk (though very low [1%]) of dedifferentiation into anaplastic Risk (though very low [1%]) of dedifferentiation into anaplastic

thyroid cancer is reduced thyroid cancer is reduced Survival is improved if papillary cancer greater than 1.5cm or Survival is improved if papillary cancer greater than 1.5cm or

follicular greater than 1cmfollicular greater than 1cm Need for reoperative surgery associated with higher risk is lowerNeed for reoperative surgery associated with higher risk is lower

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Arguments against total thyroidectomyArguments against total thyroidectomy

Total thyroidectomy may be associated with higher Total thyroidectomy may be associated with higher complication rate than lobectomycomplication rate than lobectomy

50% of recurrences can be controlled with surgery50% of recurrences can be controlled with surgery Fewer than 5% of recurrences occur in the thyroid Fewer than 5% of recurrences occur in the thyroid

bedbed Tumor multicentricity has little clinical significanceTumor multicentricity has little clinical significance Prognosis of low risk patients (age, grade, extent, Prognosis of low risk patients (age, grade, extent,

size) is excellent regardless of extent of resectionsize) is excellent regardless of extent of resection

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ComplicationsComplications

Hypoparathyroidism should occur in less than 2% of patientsHypoparathyroidism should occur in less than 2% of patients Recurrent laryngeal nerve injury in virgin neck less than 0.5% of Recurrent laryngeal nerve injury in virgin neck less than 0.5% of

patientspatients Superior laryngeal nerve injury in virgin neck less than 2% of Superior laryngeal nerve injury in virgin neck less than 2% of

patientspatients

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Papillary CarcinomaPapillary Carcinoma

Algorithm for Treatment of Possible PTCAlgorithm for Treatment of Possible PTC

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Papillary CarcinomaPapillary Carcinoma

If FNA is suspicious for papillary ca but not If FNA is suspicious for papillary ca but not diagnostic then incidence is 54% cancerdiagnostic then incidence is 54% cancer

Presence of microcalcifications on FNA Presence of microcalcifications on FNA suggestive of papillary ca (36% sensitivity, suggestive of papillary ca (36% sensitivity, 93% specificity, 76% accuracy)93% specificity, 76% accuracy)

Pts with confirmed or highly suspicious Pts with confirmed or highly suspicious intraoperative finding should receive total or intraoperative finding should receive total or near total thyroidectomy (< 3 gm remnant)near total thyroidectomy (< 3 gm remnant)

Prophylactic node dissection not indicatedProphylactic node dissection not indicated

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Papillary/Differentiated CarcinomaPapillary/Differentiated Carcinoma

Up to 80% of patients found to have asymptomatic positive Up to 80% of patients found to have asymptomatic positive nodes during series of prophylactic neck dissections nodes during series of prophylactic neck dissections 1,21,2

Clinically significant disease only develops in less than 10% of Clinically significant disease only develops in less than 10% of patients with microscopic lymph node metastases patients with microscopic lymph node metastases 1,3,41,3,4

Central node dissection should be carried out if central nodes are Central node dissection should be carried out if central nodes are enlarged and positive by frozen sectionenlarged and positive by frozen section

Ipsilateral modified neck dissection has been shown to reduce Ipsilateral modified neck dissection has been shown to reduce regional recurrence without improving survival if enlarged cervical regional recurrence without improving survival if enlarged cervical node is positive by preop FNA or intraoperative frozennode is positive by preop FNA or intraoperative frozen55

Node Dissection:Node Dissection:

11 Am J Surg 122:464-471,1971 Am J Surg 122:464-471,19712 2 World J Surg 18:359-367,1994.World J Surg 18:359-367,1994.33 Surg Clin North Am 67:251-261,1987. Surg Clin North Am 67:251-261,1987.44 Cancer 26:1053-1060, 1970 Cancer 26:1053-1060, 197055 Textbook of Endocrine Surgery, WB Saunders, 1997, p90. Textbook of Endocrine Surgery, WB Saunders, 1997, p90.

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Follicular NeoplasmsFollicular Neoplasms

14-29% are invasive cancer14-29% are invasive cancer Frozen section analysis can be misleadingFrozen section analysis can be misleading Hallmarks of cancer are capsular or vascular invasionHallmarks of cancer are capsular or vascular invasion Follicular CA more likely hematogenous spreadFollicular CA more likely hematogenous spread Worse prognosis associated with increased age and Worse prognosis associated with increased age and

stage at diagnosis compared to papillarystage at diagnosis compared to papillary >4cm nodule is 50-60% likely invasive disease>4cm nodule is 50-60% likely invasive disease

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Follicular NeoplasmsFollicular Neoplasms

Resection of lobe/isthmus with careful Resection of lobe/isthmus with careful examination for gross invasion or nodal examination for gross invasion or nodal diseasedisease

Await final pathology of lobe/isthmus and if Await final pathology of lobe/isthmus and if positive, return to OR for completion positive, return to OR for completion lobectomylobectomy

Subsequent ISubsequent I131131 treatment, TSH suppression treatment, TSH suppression and monitoring of thyroglobulin (<2and monitoring of thyroglobulin (<2µµg/l)g/l)

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HHüürthle Cell Neoplasmsrthle Cell Neoplasms

More aggressive than other differentiated thyroid More aggressive than other differentiated thyroid carcinomas (higher mets/lower survival rates)carcinomas (higher mets/lower survival rates)

Decreased affinity for IDecreased affinity for I131131

Need to differentiate from benign/malignantNeed to differentiate from benign/malignant Cancer in 13-35% of HCancer in 13-35% of Hüürthle cell FNAsrthle cell FNAs 65% of tumors > 4cm are malignant65% of tumors > 4cm are malignant If malignant, needs total thyroidectomy and IIf malignant, needs total thyroidectomy and I131131 with with

thyroglobulin assaysthyroglobulin assays Mets may be more sensitive to IMets may be more sensitive to I131 131 than primarythan primary

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Medullary CarcinomaMedullary Carcinoma

Presents as either an inherited syndrome (20%) or as Presents as either an inherited syndrome (20%) or as an incidental eventan incidental event

More aggressive than the differentiated thyroid More aggressive than the differentiated thyroid cancerscancers

Does not respond to IDoes not respond to I131131

Multicentric in 20% of sporadic cases and in almost all Multicentric in 20% of sporadic cases and in almost all of inherited casesof inherited cases

Much more likely to invade lateral lymph basinsMuch more likely to invade lateral lymph basins Need baseline CEA and calcitonin levelsNeed baseline CEA and calcitonin levels

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Familial cases positive for Familial cases positive for RETRET proto- proto-oncogene mutationoncogene mutation

If positive family history, then genetic testingIf positive family history, then genetic testing If MEN IIA or FMTC then total thyroidectomy If MEN IIA or FMTC then total thyroidectomy

and central lymph node dissection between and central lymph node dissection between ages of 5-6 yearsages of 5-6 years

If MEN IIB then total thyroidectomy and If MEN IIB then total thyroidectomy and central node dissection ages 6mos - 3 yearscentral node dissection ages 6mos - 3 years

SURGERY IS ONLY EFFECTIVE THERAPYSURGERY IS ONLY EFFECTIVE THERAPY

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If persistent elevated CEA or calcitonin, CT If persistent elevated CEA or calcitonin, CT scan for residual disease (50% of pts)scan for residual disease (50% of pts)

Aggressive neck dissection advocated by Aggressive neck dissection advocated by many if persistent diseasemany if persistent disease

Consider laparotomy for possible liver metsConsider laparotomy for possible liver mets Prolonged survival with significant symptoms Prolonged survival with significant symptoms

not uncommon with widely metastatic diseasenot uncommon with widely metastatic disease

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Incidentaloma/Micrometastatic DiseaseIncidentaloma/Micrometastatic Disease

Lesions detected by imaging or found after Lesions detected by imaging or found after surgery for unrelated indicationsurgery for unrelated indication

Thyroid nodules common in population (4-Thyroid nodules common in population (4-10% have palpable nodules any given time)10% have palpable nodules any given time)

Female/male incidence 6.4 / 1.6%Female/male incidence 6.4 / 1.6% 12% detected by palpation vs. 45% by 12% detected by palpation vs. 45% by

imagingimaging Lesions less than 1 cm-observeLesions less than 1 cm-observe Lesions 1-2cm “gray zone”Lesions 1-2cm “gray zone” Lesions > 2cm are NOT INCIDENTALLesions > 2cm are NOT INCIDENTAL

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Consider suspicious features:Consider suspicious features:• Increased vascularityIncreased vascularity• Irregular marginIrregular margin• Central microcalcificationCentral microcalcification• Cervical adenopathyCervical adenopathy

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Local Invasion of the NeckLocal Invasion of the Neck

Tracheal resection repaired primarilyTracheal resection repaired primarily

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Crycoid invasion with local muscle flap reconstructionCrycoid invasion with local muscle flap reconstruction

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Vertical hemilaryngectomyVertical hemilaryngectomy

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Circumferential tracheal resection with primary anastomosisCircumferential tracheal resection with primary anastomosis

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SummarySummary

Total thyroidectomy is surgery of choice for Total thyroidectomy is surgery of choice for differentiated cancer as well as medullary differentiated cancer as well as medullary carcinoma of thyroidcarcinoma of thyroid

Consider subtotal (less than 2gms residual Consider subtotal (less than 2gms residual tissue) if less experienced or hazardous tissue) if less experienced or hazardous operative environmentoperative environment

No therapeutic advantage for total No therapeutic advantage for total thyroidectomy in setting of papillary thyroidectomy in setting of papillary microcarcinoma microcarcinoma

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QuestionsQuestions

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What Operation for Thyroid Cancer