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Update in the Management of Thyroid Neoplasms. David R. Byrd, MD Department of Surgery University of Washington. NCCN - National Comprehensive Cancer Network. yearly update from the NCI-designated comprehensive cancer centers (FHCRC --> FHCRC + UWMC)

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slide1

Update in the Management of Thyroid Neoplasms

David R. Byrd, MD

Department of Surgery

University of Washington

nccn national comprehensive cancer network
NCCN - National Comprehensive Cancer Network
  • yearly update from the NCI-designated comprehensive cancer centers (FHCRC --> FHCRC + UWMC)
  • Consensus guidelines from the NCCN membership institutions
  • not focussed on the practice of the community cancer practitioner
thyroid nodule history
Thyroid Nodule - History

Local Sxs

Risk factors

Function

slide5

Thyroid nodules

  • 6-10% adult U.S. population
    • 5% are malignant
  • FNA best initial test - 96% PPV
  • U/S good to follow or document MNG
  • thyroid scan good if symptoms of hyper- or hypothyroidism or if indeterminate cytology/multinodular goiter
  • suppression most successful when TSH high
fna results of thyroid nodule
FNA Results of Thyroid Nodule

Benign --> F/U 6-12 months

cyst --> F/U 6-12 months

indeterminate --> repeat FNA, I123 scan

if same results

follicular neoplasm --> I123 scan or surgery

suspicious --> surgery

carcinoma --> surgery

FNA

results of i 123 scan
Results of I123 scan

“hot” --> check TFTs

“euthyroid” --> rarely CA, F/U only

“cold”* (still takes up some iodine,

though less than normal gland)

I123 scan

*NOTE: 1. Nearly all cancers are “cold”

2. However, only about 10-15%

of “cold” nodules are cancer

thyroid carcinoma nodule evaluation
Thyroid Carcinoma - Nodule Evaluation

©National Comprehensive Cancer Network

thyroid carcinoma nodule evaluation1
Thyroid Carcinoma - Nodule Evaluation

©National Comprehensive Cancer Network

pathology of thyroid cancer
Pathology of Thyroid Cancer
  • differentiated thyroid cancer (DTC):
    • papillary - commonly spreads to nodes (40-50%), excellent prognosis
    • mixed - papillary and follicular - acts like papillary, excellent prognosis
    • follicular - slightly worse than papillary, can spread to bone, less to nodes (15%); Hurthle cell Ca is variant
  • medullary - sporadic vs. familial (MEN 2A), total thyroidectomy is treatment
  • anaplastic - aggressive and fatal, surgical role is biopsy only
thyroid carcinoma papillary carcinoma
Thyroid Carcinoma - Papillary Carcinoma

©National Comprehensive Cancer Network

rationale for total thyroidectomy for dtc
Rationale for Total Thyroidectomy for DTC
  • improved effectiveness for I131 ablation
  • lowers dose needed forI131 ablation
  • allows f/u w/ thyroglobulin levels
  • decreased recurrence
  • improved survival in high risk pts.
  • decreased risk of pulmonary mets and dedifferentiated CA
rationale against total thyroidectomy for dtc
Rationale Against Total Thyroidectomy for DTC
  • increased RLN injury and hypoparathyroidism
  • contralateral disease not clinically relevant
  • survival nearly equivalent for low risk patients
  • I131 ablation not necessary for most patients
  • thyroglobulin levels not necessary for most patients
thyroidectomy for dtc technique
Thyroidectomy for DTC - Technique
  • know the anatomy
  • protect RLN
  • preserve all parathyroids
  • know when to reassess or quit
thyroid carcinoma papillary carcinoma1
Thyroid Carcinoma - Papillary Carcinoma

©National Comprehensive Cancer Network

slide18

Thyroid Carcinoma -Papillary Carcinoma

©National Comprehensive Cancer Network

slide19

Thyroid Carcinoma - Papillary Carcinoma

©National Comprehensive Cancer Network

slide20

Thyroid Carcinoma - Papillary Carcinoma

©National Comprehensive Cancer Network

slide21

Thyroid Carcinoma - Papillary Carcinoma

©National Comprehensive Cancer Network

slide22

Thyroid Carcinoma - Follicular Carcinoma

©National Comprehensive Cancer Network

slide23

Thyroid Carcinoma - Follicular Carcinoma

©National Comprehensive Cancer Network

slide24

Thyroid Carcinoma - Follicular Carcinoma

©National Comprehensive Cancer Network

slide25

Thyroid Carcinoma - Follicular Carcinoma

©National Comprehensive Cancer Network

slide26

Thyroid Carcinoma - Follicular Carcinoma

©National Comprehensive Cancer Network

residual thyroid cancer
? Residual Thyroid Cancer
  • 25 y/o woman with papillary thyroid cancer
    • Capsular penetration
    • Lymph nodes not sampled
  • Dx and Post-Rx (200 mCi) I-131 scans show thyroid remnant only
    • TG off TSH = 110 ng/dL
  • Dx I-131 scan 1 year later negative
    • TG off TSH is still 100 ng/dL
slide28

Thyroid Cancer

Post therapy (10/98)

I-131

window

Tc-99m

markers

2055870

slide29

Thyroid Cancer

Diagnostic Scan (7/99)

I-131

window

Tc-99m

markers

2055870

slide30

? Residual Thyroid Cancer:

FDG PET Scan 8/99

L Cervical Lymph Nodes

? Central Lymph Nodes

2055870

case 1
60F undergoes L thyroid lobectomy for a solitary nodule w/ follicular cells on FNAC.

Final path shows 2cm follicular adenoma and incidental 5mm papillary thyroid CA

?further management

Case 1
case 1 issues
? Completion thyroidectomy --> NO

? Radioactive iodine therapy --> NO

? Thyroid suppression --> +/-

? F/u -6 month intervals with H & P

Case 1 - issues

Result: the 2 cm nodule is benign and the 0.5cm nodule

is an incidental carcinoma of minimal significance

case 2
40M w/ solitary 1.5cm L thyroid nodule on exam

h/o neck irradiation for enlarged thymus as child

?further management

Case 2
case 2 issues
Case 2 - Issues

This is a setting of higher risk of cancer - male, solitary

lesion, and equivocal hx of neck irradiation:

minimal operation is thyroid lobectomy + isthmusectomy,

proceed to total or subtotal thyroidectomy if bilateral nodules

and/or if carcinoma found

frozen section is notoriously unable to definitively call

carcinoma - therefore permanent pathology usually

necessary to confirm carcinoma