Tumor Board

1. Tumor Board Rummana Aslam, MD 10/28/08

2. AS 37 y/o WF of Russian origin referred for a biopsy proven papillary carcinoma in the left lobe of the thyroid • She had h/o hypothyroidism and multinodular goiter for last 10 years • Recently she had ultrasound of thyroid and had a FNA • She has no symptoms of fatigue, heat or cold sensation or headaches and no radiation exposure. She had irregular periods.

3. Past Medical and Past surgical history: none except above • Medications: Levothyroxine 50 micrograms • No allergies and transfusions • Social: married with one son and is a research scientist • No family history of thyroid cancer. Mother had stomach cancer. Father had kidney and panc cancer. Maternal grandmother had kidney cancer • Pertinent physical exam finding: moderately enlarged thyroid with a prominent nodule below the isthmus around 1.5 cms. Nodular thyroid. Right post triangle neck 0.5 cm LN palpable. No thyroid bruit

4. Biopsy of left thyroid nodule by FNA : papillary thyroid carcinoma • Blood tests normal including T4 and TSH • Taken to OR last week

5. Extent of Surgical Treatment: Total VS Partial Thyroidectomy • 1909 Theodor Kocher was awarded Nobel prize for his contributions in the fields of pathology, physiology and surgery of the thyroid gland • Almost 100 years ago the discussion on the extent of thyroid resections for benign and malignant thyroid diseases started and, until now, this question has been addressed in many retrospective studies, but remains controversial Weber et al. Current Opinion In Internal Medic. 2006

6. Surgical Treatment of Papillary And Follicular Thyroid Carcinoma • For differentiated thyroid carcinoma, guidelines composed by dedicated experts in the fields of endocrinology and endocrine surgery recommend • Lobectomy for suspicious thyroid nodules, minimally invasive differentiated thyroid carcinomas smaller than 1 cm which do not extend beyond the thyroid capsule AACE/AAES medical/surgicalguidelines for clinical practice: management of thyroid carcinoma. Endocrine Practice.2001

7. Total or near-total thyroidectomy is the preferred operation for high-risk patients with PTC and FTC, when the tumor extends beyond the thyroid capsule or local or distant metastasis are present • Enlarged lymph nodes in the central and lateral compartment of the neck should be removed by systematic modified-radical or functional neck dissection

8. Classification of patients into high or low-risk groups might be difficult • Due to lack of prospective randomized trials the surgical therapy of DTC remains an ongoing controversy

9. Recent Literature • Extent of Surgery Affects Survival for Papillary Thyroid Cancer • BIlimora et al. Annals of Surgery. 2007 • Objectives • Whether total thyroidectomy for PTC resulted in improved recurrence and long-term survival rates for patients with PTC • Whether a specific tumor size threshold could be identified above which total thyroidectomy was associated with a decreased risk of recurrence and death

10. Method: from the National Cancer database (1985-1998) 52,173 patients underwent surgery for PTC • 43,227 underwent total thyroidectomy and 8946 underwent lobectomy • Results: for PTC < 1 cm extent of surgery did not impact recurrence or survival (p=0.24, p=0.83)

11. For tumors > 1 cm lobectomy resulted in higher risk of recurrence and death (p= 0.04, p=0.04) • Limitations of the study • Analysis using administrative databases and cancer registeries • Information on extrathyroidal extension not available • 56.2% of patients were reported to have received RAI • Hospitals were cancer hospitals, a potential selection bias

12. Kim et al. Arch Surg. 2004 • Retrospective study describing significantly better survival rates for patients with PTC over 60 years of age with total thyroidectomy compared with lobectomy • Haigh et al. Arch Surg Oncol. 2005 • Evaluated retrospectively the effect of total and partial thyroidectomy by using the NCI database on 5432 patients with PTC. Overall survival was 93% at 5 years and 86% at 10 years; 10 year survival rate was 89% in the low-risk group and 73% in the high-risk group • After a mean follow up of 7.4 years survival of patientrs with PTC was not significantly influenced by the extent of thyroidectomy

13. Jukkola et al. Endocrine-related Cancer. 2004 • Found significantly longer recurrence-free survival rates for total thyroidectomy in patients with papillary and follicular thyroid cancer • Cushing et al. Laryngoscope 2004 • showed a significant effect of total thyroidectomy on disease recurrence but not on cause-specific mortality rates in differentiated thyroid carcinoma

14. Classification of Neck Dissections Radical neck dissection: Levels I to V dissected,including resection of the internal jugularvein,sternomastoid muscle and accessory nerve Modified neck dissection: Levels I to Vdissected but preserving one or more of theaccessory nerve, internal jugular vein orsternomastoid muscle Selective neck dissection: Denotes preservationof one or more lymph node groups (levels I toV) and preservation of the accessory nerve,internal jugular vein and the sternomastoidmuscle

15. Lymph Node dissection in Differentiated Thyroid carcinoma • Lymph node metastasis in PTC are found in 40-60% of the patients • FTC lymph node involvement is 15-19% • Systematic lymphadenectomy of the central or lateral compartment of the neck is recommended if a suspicious node is detected by ultrasound • A functional lymph node resection (‘berry picking’) is less effective and may complicate further operations • Previous studies have failed to show a correlation between cervical metastasis and survival

16. Regional Metastasis in Well-Differentiated Thyroid Carcinoma: Pattern of Spread • Yanir et al. The Laryngoscope. 2008 • Evaluated the pattern of spread to regional lymph nodes metastasis of WDTC in patients with clinically positive nodes • Retrospective chart review. 28 neck dissections with a mean follow up of 33.7 months. 24 with papillary carcinoma and follicular carcinoma in 3 • All patients underwent a total thyroidectomy and SND

17. Results: Mean number of nodes in ND specimen 6.7 Predominant site of metastasis level VI - 95% Level III – 68% Level IV – 57% Level II – 54%

18. IS Radical Neck Dissection a Current Option for Neck Disease? • Ferlito et al. The laryngoscope. October 2008 • At present conventional RND (MRND) are no longer indicated for elective neck dissection • The cancers of the head and neck do not involve all levels and sublevels of the lateral neck • SND is being implemented as an oncologically safe and effective procedure for multiple N+ disease while limiting morbidity

19. Urono et al.Surgery today. 2004 • Found prognosis after re-operation for local recurrence of PTC was better after an SND • Thompson et al. World J Surg. 2004 • 21 studies on childhood PTC 1800 cases • Based on their data, authors recommend total or near total thyroidectomy and a SND for children with papillary carcinoma

20. Conclusion: • For differentiated thyroid carcinoma (larger than 1 cm) total or near-total thyroidectomy and central neck dissection might reduce local recurrence. • The influence of these procedures on survival rates still remains questionable