1. HEAD AND NECK CASE CONFERENCE (PAPILARY THYROID CARCINOMA)
Philippine Academy for Head and Neck Surgery, Inc. – Medical Center Manila
June 10, PM

2. General Data
R.M.
51 y/o
Female

3. Chief Complaint
Anterior neck mass

4. History November, 2011
Notable mass at the left anterior neck approximately 2x3x3 cm
Physical Examination:
(+) 3X2X2 cm cervical lymphadenopathy, post- auricular area
(+) 2x3x2 cm left anterior neck mass, firm, moves with deglutition

5. What would be your diagnostic work-ups ?
How do you do it in your institution or practice?

6. 10/26/11 Result Normal Value TSH 0.324 0.35-5.50 uIU/ml FT3 2.52
pg/ml
FT4
1.09
ng/dl

7. Ultrasound of the neck 10/26/11
The right thyroid lobe is normal in size and measures x 1.69 x 1.89 cm. While the left thyroid lobe is slightly enlarged and measures 5.60 x 2.14 x 2.20cm
There are lobulated hypoechoic lesions in both thyroid lobes with location and sizes:
Right:
Mid portion (2 nodules) = 0.36 x 0.35 x 0.33 cm and 1.42 x x 0.93 cm
Left
Upper to mid portion with numerous punctate calcification in the margins
A solitary enlarged hypoechoic lymph node with thickened cortex and intact fatty hilum is noted in the left lateral neck measuring 1.87 x 1.73 x 1.0 cm

8. Ultrasound of the neck 10/26/11
Impression;
Normal sized right thyroid lobe and enlarged left lobe with solid nodules. The lesion in the left lobe is vascular with calcifications.
Reactive left cervical adenopathy.

9. FNAB cytology Report 11/2/2011
Organ for aspiration biopsy: left thyroid and left cervical lateral node
Cytologic Diagnosis:
Cell findings are consistent with a papillary carcinoma of the thyroid, left, with metastasis to the left lateral neck area.
Cytologic Description:
Aspirate smears from all slides (4) appear similar and show clusters of atypical thyrocytes forming papillary patterns, there is modest colloid in the background.
There are also histiocytes present.
The nuclei shows grooves and inclusions.

10. How do you interpret fnac /fnab results/
Methesda scoring /nomenclature for fnab?

11. Impression? Stage?
Plan of Management?

12. THYROID CARCINOMA STAGING
Primary tumor (T) Tx
Primary tumor cannot be assessed T0
No evidence of primary tumor T1
Tumor 2cm or less in greatest dimension limited to the thyroid
T1a
Tumor 1cm or less limited to the thyroid
T1b
Tumor more than 1cm but not more than 2cm in greatest dimension, limited to the thyroid T2
Tumor more than 2cm but not more than 4cm in greatest dimension, limited to the thyroid T3
Tumor more than 4cm in greatest dimension, limited to the thyroid or any tumor with extrathyroidal extension (eg. extension to sternothyroid or perithyroid soft tissues)
T4a
Moderate advanced disease
Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, trachea, larynx, esophagus or recurrent laryngeal nerve
T4b
Very advanced disease
Tumor invades prevertebral fascia or encases common carotid artery or mediastinal vessel
all anaplastic carcinomas are considered T4 tumor
American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010)

13. THYROID CARCINOMA STAGING
Regional lymph nodes (N)
Regional lymph nodes are the central compartment, lateral cervical and upper mediastinal nodes. Nx
Regional lymph nodes cannot be assessed N0
No regional lymph node metastasis N1
Regional lymph node metastasis
N1a
Metastasis to level VI (pretracheal, paratracheal, prelaryngeal/Delphian lymph nodes)
N1b
Metastasis to unilateral, bilateral or contralateral cervical (levels I, II, III, IV, V) or retropharyngeal or superior mediastinal lymph nodes (level VII)
American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010)

14. THYROID CARCINOMA STAGING
Distant metastasis (M) M0
No distant metastasis M1
Distant metastasis
American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010)

15. THYROID CARCINOMA STAGING
American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010)

17. Operation November 8, 2011
Total thyroidectomy with modified radical neck dissection Type III, left

18. Is there still a controversy between total and subtotal thyroidectomy
Is there still a controversy between total and subtotal thyroidectomy? In this case?
Role of central neck dissection?
Types of neck dissection? Comprehensive or selective?

19. Record of Operation November 8, 2011
Findings:
Thyroid gland enlarged
Right lobe 4x3x2 cm with solitary nodule 1 cm in diameter
Left lobe 5x3.5x3 with 2 nodules
#1 located at superior pole – 3x3x3cm
#2 located at inferior pole -1x1x1 cm
(+) enlarged cervical nodes/ jugular chain of nodes, left ~5 in number: 2 were dark-colored - 2x2x2 cm in greatest dimensions, other 3 were light-colored

21. Record of Operation November 8, 2011
Post-op Diagnosis:
S/P Total Thyroidectomy, Modified Radical Neck Dissection Type III for Papillary Thyroid Carcinoma Stage IVA (sT2N1bM0)

22. Final Histopath November 8, 2011
Papillary carcinoma, left and right lobes of the thyroid (2.3 cm, left lobe, and two foci in the right lobe, 0.2 cm and 0.4 cm)
Background of focal lymphocytic thyroiditis
Surgical lines of thyroidectomy are negative for tumor.
Positive for tumor metastasis to 9/18 left cervical LN

23. 11/28/11 Result Normal Value TSH 55.00 0.35-5.50 uIU/ml Thyroglobulin
89.47ng/mL
< 1ng/mL

24. Whole body I-131 Scintigraphy Dec. 17, 2011
S/P RAI therapy (12/13/11)
Whole body scans were obtained 4 days after administration of a 100 mci oral therapeutic dose of I-131.
There are foci of dense tracer activity in the right and left thyroid beds representing uptake of the therapy dose by functioning residual thyroid tissues. These measured 1.2x1.2 cms and 1.6x1.6 cms, respectively.
Faint, ill-defined tracer localization is seen in the inferior thyroid bed likewise denoting residual functioning thyroid.
Physiologic tracer accumulation noted in the nasopharynx, salivary glands, gastrointestinal tract and urinary bladder.
No functioning metastasis appreciated.

25. Whole body I-131 Scintigraphy Dec. 17, 2011
Interpretation: Functioning thyroid tissue remnants limited to the anterior area.

28. What are the controversies in thyroid scanning ?
How do you give RAI? What are the doses?

29. 2/13/12 Levothyroxine 100mg OD Result Normal Value TSH 12.89
uIU/ml
FT4
8.78
ng/dl TG
19.44ng/mL
< 1ng/mL

30. 3/14/12 Levothyroxine 100mg OD Result Normal Value TSH 0.124
uIU/ml TG
5.61ng/mL
< 1ng/mL

31. 4/13/12 Levothyroxine 100mg OD Result Normal Value TSH 0.101
uIU/ml TG
4.8
< 1ng/mL

32. Role of TSH suppression? How do you follow up?
Serum TSH
Serum thyroglobulin
Neck ultrasound
Prognosis?

33. 7 months post-operative
No palpable neck mass
Persistently low TSH and elevated TG
Ultrasound of the neck was requested

34. Ultrasound 6/26/12
Scan over the post-cervical bed shows subcentimeter hypoechoic nodular foci in the lower anterior and left para-tracheal region measuring 0.34 to cm. lateral to the said nodule is a 1.19 cm lymph node at level V.
Subcentimeter lymph nodes with fatty hylum are demonstrated in both submandibular, submental and right jugular chain with sizes ranging from cm.
The submandibular and parotid glands are intact.
Impression
S/P Total thyroidectomy from known papillary thyroid carcinoma with subcentimeter nodules in the lower anterior and left lateral neck and a slightly enlarged left cervical lymph nodes likely tumor recurrence. Unremarkable submandibular and parotid glands.

35. Will you do fnab?

36. 6/27/12 Levothyroxine 100mg OD Result Normal Value TSH 0.04
uIU/ml

37. Whole body I-131 scintigraphy Oct 8, 2012
S/P RAI therapy (10/03/12)
Whole body scans were obtained 5 days after administration of 150 mCi oral therapeutic dose of I 131
There are confluent foci of ill-defined tracer activity in the thyroid beds representing uptake of the therapy dose by functioning residual thyroid tissues aggregate measurements were approximately 3 x 6 cms.
Physiologic tracer accumulation noted on the nasopharynx, salivary glands, GIT, and urinary bladder
No functioning metastasis is seen

38. Whole body I-131 scintigraphy Oct 8, 2012
Interpretation: Functioning thyroid tissue remnants limited to the thyroid bed.

41. 12/10/12 Levothyroxine 150g (mon- sat, 1/2 on Sunday) Result
Normal Value
TSH
0.037
uIU/ml TG
5.25
< 1ng/mL

42. Record of Operation 4/26/13
Pre-operative diagnosis: Recurrent papillary thyroid cancer; S/p Total thyroidectomy with modified radical neck dissection Type III, left
S/P RAI 12/13/11 and 10/03/12

43. Record of Operation 4/26/13
Operation: Central node dissection

44. Record of Operation 4/26/13
Findings: multiple adhesions between strap muscle, trachea and surrounding areas, #1 enlarged LN ~ 1cm at Left paratracheal area, multiple persistent LN on central area 0.3-1cm in diameter adherent to the trachea

45. Record of Operation 4/26/13 Recurrent Papillary Thyroid Carcinoma
S/P Total Thyroidectomy for Papillary Thyroid Carcinoma (Nov 8, 2011) Stage IVA (pT2N1bM0)
S/P RAIA 100 mCi (Dec 17, 2011)
S/P RAIA 150 mCi (Oct 8, 2012)

46. Final Histopath 4/26/13
Specimen: Central and left peritracheal lymph nodes
Fibro-adipose tissue, showing papillary carcinoma (0.3cm) and suture granuloma
26/29 Lymph nodes positive for metastatic papillary carcinoma, parathyroid gland (one focus), Thymus gland (fragments)

47. Papers on recurrent papillary thyroid cancer
Another RAI after several RAI sessions?

48. STAGE AND SURVIVAL FOR THYROID CANCER
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for , All Races, Both Sexes
Stage at Diagnosis
Stage Distribution (%)
5-year Relative Survival (%)
Localized (confined to primary site) 68
99.8
Regional (spread to regional lymph nodes) 25
96.9
Distant (cancer has metastasized) 5
56.4
Unknown (unstaged) 2
87.6
based on NCI’s SEER Cancer Statistics Review

49. DIVISION OF LYMPH NODES BY LEVELS ( AMERICAN HEAD & NECK SOCIETY – 1991 )

50. Modified Radical Neck Dissection
Removes
Nodal groups I-V
Preserves
SCM, IJV, XI (any combination)
Classified according to which structures are preserved

51. Modified Radical Neck Dissection
MRND Type I (preserves SAN)
Indications:
Clinically N+
SAN not involved by tumor

52. Modified Radical Neck Dissection
MRND Type II (preserves SAN and IJV)
Indications:
Intraoperative tumor found adherent to the SCM, but not IJV and SAN
Rarely planned

53. Modified Radical Neck Dissection
MRND Type III (preserves SAN, IJV and SCM)
Indications:
SAN, IJV, & SCM not involved by tumor

54. Selective Neck Dissection
Remove high risk lymph node groups based on tumor site.
Supraomohyoid
Levels I-III
Lateral
Levels II-IV
Anterolateral
Levels I-IV

55. Selective Neck Dissection
Posterolateral
Levels II-V
Postauricular nodes
Suboccipital nodes
Anterior compartment
Level VI

56. Initial Diagnostic Tests
PGH (2008)
PCS-PSGS-PAHNSI (2008)
For all thyroid nodules:
Serum TSH
determination
Thyroid ultrasound
FNAB
Serum TSH and/or thyroid hormones
Thyroid UTZ for:
High risk patients (family hx of thyroid CA, previous
dx of MEN2, childhood cervical irradiation)
Suspicious nodule for CA in the background of
multinodular goiter
With adenopathy suggestive of malignant lesion
Evaluation of nodular goiter
Scintigraphy – limited to pxs w/ subnormal
serum TSH
FNAC – recommended for dx of benign &
malignant lesions
PET scan w/ 18F-FDG – for detection of
thyroid CA in inconclusive cytologic
nodular dx of thyroid nodules

57. Extent of Surgery PGH (2008) PCS-PSGS-PAHNSI (2008)
Total or near total thyroidectomy for thyroid nodule proven malignant by FNAB with size >1 cm.
Lobectomy
for lesions <1 cm, isolated intrathyroidal well-differentiated carcinomas with absent cervical nodal metastases.
Near total or Total Thyroidectomy
for WDTC
Total or near-total thyroidectomy
for multinodular goiter.
Lobectomy w/ isthmusectomy for solitary benign thyroid nodule

58. Frozen Section PGH (2008) PCS-PSGS-PAHNSI (2008)
For non-diagnostic preoperative FNAB
Limited utility in diagnosing thyroid malignancies if the FNAB result show follicular neoplasm, inadequate or suspicious aspirate.

59. Lymph Node Dissection PGH (2008) PCS-PSGS-PAHNSI (2008)
Appropriate node dissection shall be performed.
No mention.

60. Role of Radioactive Iodine Ablation
PGH (2008)
PCS-PSGS-PAHNSI (2008)
Lesion size >1 cm
Multifocal disease
Nodal metastases
Involved resection margins Extrathyroidal or vascular
invasion
Aggressive histologies.
Beneficial for decreasing locoregional recurrence and distant metastasis.

61. TSH Suppresion Therapy
PGH (2008)
PCS-PSGS-PAHNSI (2008)
Maintenance of TSH at 0.1 to 0.5 mU/L for patients at risk for complications from thyroid hormone suppressive therapy, in absence of contraindications.
Thyroid hormone suppression will significantly reduce recurrence and thyroid cancer-specific mortality rates.

62. External Beam Radiotherapy
PGH (2008)
PCS-PSGS-PAHNSI (2008)
Pts with unresectable gross cervical disease, painful bone metastases, metastatic lesions likely to result in fracture, neurological or compressive symptoms not amenable to surgery, painful pleural-based lesions, and recurrent hemoptysis.
Indicated as part of the treatment of WDTC when there is gross residual tumor or invasion of adjacent structures, and does not concentrate RAI.

63. Role of Chemotherapy PGH (2008) PCS-PSGS-PAHNSI (2008)
May be considered in patients who have surgically unresectable disease and unresponsive to RAI or external beam radiation.
May also be offered to patients who are not amenable to external beam radiation therapy.
Role of chemotherapy is unclear in recurrent and metastatic WDTC.

64. Role of Post operative Thyroglobulin Assay
PGH (2008)
PCS-PSGS-PAHNSI (2008)
TSH stimulated serum thyroglobulin should be measured every 6-12 months.
The most important initial test to monitor patients for residual or recurrent WDTC.

65. Role of Post operative Serum TSH
PGH (2008)
PCS-PSGS-PAHNSI (2008)
Maintained at 0.1 to 0.5 mU/L unless with contraindications
W/ persistent disease: serum TSH
Should be maintained below 0.1mU/L indefinitely in the absence of specific contraindications.
W/ clinically disease free but presented w/ high risk disease, consideration should be given to maintaining TSH suppressive therapy to achiee serum TSH levels of 0.1 to 0.5 mU/L for 5 to 10 yrs.
Free of disease, especially those at low risk for recurrence, TSH may be kept w/in normal range (0.3 – 2 mU/L)
Serum TSH should be monitored every 6 months to 12 months in the 1st yr and then yearly thereafter

66. Post operative Role of Cervical UTZ
PGH (2008)
PCS-PSGS-PAHNSI (2008)
Evaluation of the thyroid bed, central and lateral node compartments should be performed at 6 to 12 months postoperatively, then annually for at least 3 to 5 years for high risk patients.
Recommended for postoperative surveillance to detect recurrence in the thyroid bed and cervical nodes.

67. Role of Post operative Whole Body Scan
PGH (2008)
PCS-PSGS-PAHNSI (2008)
Done after RAI
Limited usefulness and is NOT necessary in
low risk patients who are clinically free of
residual tumor w/ undetectable serum Tg
and has negative neck ultrasound
NOT necessary if the Tg is elevated and
ultrasound of the neck is positive, since
therapeutic options (surgery or RAI
ablation) are already warranted.

68. Metastatic Work-up PGH (2008) PCS-PSGS-PAHNSI (2008) No mention.
Locoregional:
Preoperative neck ultrasound is
recommended to detect
locoregional metastasis for
WDTC.
Routine use of CT and PET is NOT
recommended.
Distant:
CXR, HRCT and FDG-PET are NOT
routinely recommended to
detect distant metastasis.