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thyroid cancer

THYROID CANCER ANATOMY. THYROID CANCER. EpidemiologyRare (<1%)0.5-10/105 Most common endocrine malignancy (90%)Most common cause of death of EMHigh survival rates. THYROID CANCER. PathologyFollicular cell origin (FCDC)Parafollicular (C cells)

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thyroid cancer

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    1. THYROID CANCER Dr Martin Borg

    2. THYROID CANCERANATOMY

    3. THYROID CANCER Epidemiology Rare (<1%) 0.5-10/105 Most common endocrine malignancy (90%) Most common cause of death of EM High survival rates

    4. THYROID CANCER Pathology Follicular cell origin (FCDC) Parafollicular (C cells) – medullary FCDC Papillary (and follicular variant – FVPTC) (most) Follicular Oxyphilic (Hurthle cell) Anaplastic

    5. THYROID CANCER Controversies No PRCT Extent of primary surgical resection Need for regional LND Extent of regional LND Role of postoperative RAI ablation Dose of RAI ablation Degree of suppression of TSH Role of postoperative EBRT

    6. THYROID CANCER Diagnosis History/examination (MEN, MTC FH) Ultrasound-guided FNAB of clinical or radiologically detected mass Thyroid/Neck ultrasound Serum Ca2+ CT scan neck/superior mediastinum/chest ENT exam (vocal cords) TG (WBBS)

    9. THYROID CANCERI-123 SCANSHOWING COLD SPOT

    10. THYROID CANCER STAGING CT SCANMEDIASTINAL LN 2’

    12. THYROID CANCER

    13. THYROID CANCERWell Differentiated Thyroid Carcinoma PTC – Classification Minimal PTC (a) T <1 cm (b) no capsule invasion (c) no 2’ (bone, lung) (d) no LVI MR 0.1% RR 5%

    14. THYROID CANCERWell Differentiated Thyroid Carcinoma PTC – Classification High-risk PTC/FTC AMES (age, 2’, T extent/size) AGES (age, grade, T extent/size) TNM (T, LN, 2’) EORTC MACIS (2’, age, resectibility, invasion, T) Histology (Hurthle cell, tall cell, columnar variants) Other Delay in treatment LVI – especially FTC High grade (PTC/FTC)

    15. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Surgery Total ipsilateral thyroid lobectomy Minimal PTC or min invasive FTC ± limited cap inv Near total thyroidectomy High-risk PTC Bilateral cancer/nodules (papillary not follicular) Preservation of parathyroid glands (relative RR) Risks (<2%): (1) HPT (2) recurrent laryngeal nerve injury

    16. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Surgery Advantages of NTT PTC often multifocal Lymphatic spread throughout gland Facilitates ablative RAI Facilitates detection of residual and distant tumour Facilitates treatment of residual and distant tumour TG more sensitive tumour marker ?RR and ?DFS

    17. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Surgery LND Risk at ? in older adults (ipsilateral) PTC: 40% FTC: 10% Hurthle: 25% Extensive LN 2’ suggestive of follicular variant of PTC

    18. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Surgery LND Significance PTC: ?LRR not ?OS FTC: worse prognosis (uncommon) Medullary: ?LRR and ?OS

    19. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Surgery LND Procedure T > 15 mm: en bloc central cervical LND Limited LN + (extra thyroid) or palpable LN: functional Cx/M LND (unilateral) Extensive LN + (extra thyroid): radical Cx/M LND (unilateral or bilateral, ± thymectomy)

    20. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Adjuvant Therapy TSH suppression T4 commenced after ablative RAI 150-200 mcg/day (2mcg/kg) Serum levels (a) HR: < 0.1 µIU/mL (b) LR: 0.1 – 0.4µIU/mL No proven OS benefit/ ?LR Monitor cardiac function in elderly Risks: accelerated bone turnover, OP, AF

    21. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Adjuvant Therapy RAI Ablative RAI All patients after TT/NTT, except Young, female patients with occult solitary papillary carcinoma < 15mm Partial thyroidectomy

    22. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Adjuvant Therapy RAI Ablative RAI Rationale ablate residual thyroid tissue and adjacent microscopic CA TG assay more specific ? 2’ CA ? TSH increases RAI uptake Radionuclide scans more sensitive for tumour

    23. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Adjuvant Therapy RAI Ablative RAI CI Patient refusal Poor performance status Uncooperative patient Intractable urinary incontinence Pregnancy

    24. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Adjuvant Therapy RAI Ablative RAI Preparation 6/52 postop TG before RAI Low iodine diet for 2/52 Pregnancy test and contraceptives No replacement T3/4

    25. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Adjuvant Therapy RAI Ablative RAI Procedure 75-150 mCi (2,775-5,550 MBq) – controversial Admit for 1-2 days (physicist check) Urinary catheter if female (ovarian dose – 0.3 cGy/mCi) NSAID/paracetamol or steroids for pain Post-op precautions (in ward and at home)

    27. THYROID CANCER

    28. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Adjuvant Therapy RAI 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 retained dose) Flare response, xerostomia, AML/bladder/breast, BM suppression, azospermia, menopause

    29. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Adjuvant Therapy RAI Therapeutic RAI Indications Iodine avid recurrent disease 2’ Dexamethasone cerebral, intra-orbital or intra-spinal 2’ Stridor Reduce dose (80 mCi retained dose) if multiple lung 2’

    30. THYROID CANCERRAI FOR LUNG METATSASES

    31. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Adjuvant Therapy 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

    33. THYROID CANCERWell Differentiated Thyroid Carcinoma Treatment Adjuvant Therapy EBRT Target Volume Thyroid and tumour/bed if macroscopic residual, and N-ve JD, Submandibular, IJ, Sp Accessory, SCF, Sup Med (to carina) if Residual or extensive N +, or Non-iodine avid disease

    34. THYROID CANCERRADICAL EBRT

    35. THYROID CANCERRADICAL EBRT

    36. THYROID CANCERWell Differentiated Thyroid Carcinoma Follow-up TG if N- TG antibodies Post-op @ 4/12 6/12ly x 2years Annually RAI Rising TG - restaging Recurrent/metastatic disease – avidity Surveillance if + TG AB

    37. THYROID CANCERWell Differentiated Thyroid Carcinoma Follow-up Radiological tests CT neck/chest MRI U/S WBBS PET Thyroid function tests ensure adequate suppression of TSH Recombinant thyrotopin

    38. THYROID CANCERWell Differentiated Thyroid Carcinoma Persistent or Recurrent Disease Restage (CT, RAI) Maximal resection (LND, excision of LR) Whole body iodine scan (diagnostic, test avidity) Therapeutic RAI EBRT

    39. THYROID CANCERWell Differentiated Thyroid Carcinoma Metastases Incurable but several years’ survival possible Management varies with Patient factors Tumour factors (number and site/s of recurrence, local complications) Iodine avidity Prior treatment and its outcomes

    40. THYROID CANCERWell Differentiated Thyroid Carcinoma Metastases Surgery Selected long-bone 2’ at risk of fracture Isolated and solitary brain 2’ SC compression Isolated lung 2’ Rapid progression of 1 pulmonary 2’ RT Palliative doses for symptom control or to prevent complications

    41. THYROID CANCERMEDULLARY CARCINOMA 6-8% of thyroid cancers 75% sporadic 25% hereditary Neuroectodermal parafollicular C cells Independent of TSH Elevated serum calcitonin (level corresponds with stage) FH and MEN screen (esp. pheochromocytoma) Calcium deposits on U/S Stage (CT/MRI/octreotide) neck LN, bone, lung, liver

    42. THYROID CANCERMEDULLARY CARCINOMA Management Surgery TT Central compartment LND Ipsilateral LND Calcitonin 8-12/52 postop EBRT CT (DTIC + 5-FU)

    43. THYROID CANCERMEDULLARY CARCINOMA Prognostic Features T size Preop calcitonin Advanced age Extrathyroid extension LN 2’ in mediastinum ENE Incomplete excision Histopathologic features Type of syndrome in hereditary MTC

    45. THYROID CANCERANAPLASTIC THYROID CARCINOMA 1.6% of thyroid cancers 5th-6th decades Rapidly expanding mass (> 5cm in 80%) Short history and multiple local symptoms ETE, LN 2’, VC palsy in 50% at ? 2’ common (LN, lung) Management controversial – almost 0% OS Radical EBRT + CT (Adriamycin) if good PF

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