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Difficult thyroid cancer cases. Ampica Mangklabruks MD 10 May 2012. Case 1 : A 50 year-old -man. Diagnosed as papillary thyroid carcinoma since yr 2000

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difficult thyroid cancer cases

Difficult thyroid cancer cases

AmpicaMangklabruks MD

10 May 2012

case 1 a 50 year old man
Case 1 : A 50 year-old -man
  • Diagnosed as papillary thyroid carcinoma since yr 2000
  • Near total thyroidectomy in yr 2000, cervical Lymph node positive for metastasis . (with surgical complications: Hypoparathyroidism and TVC paralysis)
  • Received radioactive iodine complete ablation
  • Bilateral lung metastasis was detected by WBS in yr 2005
  • Plain Chest film- negative
  • CT chest : not done
pulmonary metastases 1
Pulmonary metastases (1)

Key criteria for theraputic decision

  • Size of metastatic lesion
    • Macronodular detected by chest x-ray
    • Micronodular detected by chest CT
    • lesions can not detect by CT (only WBS positive)
  • Avidity of RAI
  • Stability of metastatic lesion
  • Pulmonary fibrosis from radiation pneumonitis (rare)
pulmonary metastases 2
Pulmonary metastases (2)
  • Pulmonary micrometastases treated with RAI (Recgr A) highest rate of complete remission
  • May use empiric dose (100-200mCi) or dosimetry
  • Macronodular met  use RAI if iodine avid (continue if benefit can be demonstatedie size reduction, Tg decreased ) but complete remission is not common.
  • Non-RAI –avid pulmonary metastases :
    • Micronodular : RAI and post treatment scan
    • Macronodular : RAI usually no benefit, consider chemotherapy , Tyrosine Kinase Inhibitor ,palliative treatment
case 1
Case 1
  • He received RAI, 150 mCi each times , for 6-7 times (every 6-12 months)
  • total dose of I131 = 1000 millicurie
  • In June 2010: WBS still show residual bilat lung metastasis
  • Thyroglobulin= 18.6, anti TG= 269
dose and methods of administering i131 for locoregional or metastatic disease
Dose and methods of administering I131 for locoregional or metastatic disease
  • The optimal therapeutic dose is uncertain and controversial
    • Three approach
      • Empiric fixed dose
      • Therapy determined by body and blood dosimetry (upper limit)
      • Quantitative tumor dosimetry
    • No study to compare the outcom available
    • Dosimetry usually reserved for pt with distant metastasis, renal insufficiency
long term complications of rai
Long term complications of RAI
  • Salivary gland damage, dental caries, nasolacrimal duct obstruction.
  • Secondary malignancies and leukemia ( increased risk at accumulative dose 500-600 mCi)
case 11
Case 1
  • Internal dosimetry : rapid washout
  • Received lithium carbonate (300) , monitoring blood level (blood level after receiving 900mg/d =0.82 (0.6-1.2 mmol/L)
  • Repeat dosimetry : delayed wash out
  • Total dose of RAI not exceed safty dose at lung and marrow.
  • Repeat I131 150 millicurie with lithium (Feb 2011)
lithium and thyroid cancer
Lithium and thyroid cancer
  • Action : inhibit thyroid hormone release without impairing iodine uptake

Enhance I131 retention in normal thyroid and tumor cell

  • Koong SS et al : lithium can increase estimate I131 radiation dose in metastatic tumor by 2 fold (tumor which rapidly clear iodine)
  • Liu YY et al can not demonstrate clinical benefit (12 pt)
  • ATA recommendation : Data insufficient to recommend lithium therapy ( rating I)
slide11

Case 1

  • Post treatment scan : good uptake at both lung
  • Follow up WBS september2011 : complete I131 ablation
  • Thyroglobulin level
case 2 a 49 year old woman
Case 2: a 49-year-old woman
  • A history of thyroid nodule for 30 years, getting bigger last 5 years.
  • I yr ago: Rt shoulder pain , mass found at scalp. Difficulty in breathing. No hoarseness, no difficulty in swallowing.
  • Physical Exam: thyroid nodule 10 cm diameter, scalp nodule 5 cm, swelling mass Rt upper arm.
  • FNA at scalp : Metastasis follicular carcinoma
  • FNA thyroid nodule: Follicular neoplasm
slide15
Rthumerus :Plain film : osteolytic lesion Rt proximal humerus, Impending pathological fracture
ct results
CT results
  • Lt Thyroid mass 6.6x8.1x10.8cms.Rightward displacement of trachea and esophagus. Posterior displacement of carotid artery.Part of mass can not be separates from trachea, esophagus, and carotid artery.
  • Skull metas right high parietal bone.
  • Bone scan; multiple bone met at skull, rthumerous, ipsilateral distal clavicle, rt scapula and Lt pubic bone
treatment of bone metastases
Treatment of bone metastases
  • Key criteria for therapeutic decision:
    • Presence of or risk of pathologic fracture, particularly in weight bearing structure
    • Risk of neurological compromise from vertebral lesions
    • Presence of pain
    • Avidity of RAI uptake
    • Potential significant marrow exposure from radiation (RAI- avid pelvic metastases)
treatment of bone metastases1
Treatment of bone metastases
  • Complete surgical resection for isolate lesion
  • RAI therapy improve survival (but rarely curative)
  • External radiation for lesion with severe pain, fracture, neurological complication external radiation and glucocorticoid.
  • Others such as intra-arterial embolization, radiofrequency ablation, periodic pamidronate or zoledronate infusion.etc
how to manage this patient
How to manage this patient??
  • RAI ?? : Need thyroidectomy first
  • Thyroidectomy?? Possible??
  • Palliative??
  • Rthumerous : Intralesional curette and prophylactic fixation