Presentation on theme: "Controversies in the Management of Differentiated Thyroid Carcinoma"— Presentation transcript:
1 Controversies in the Management of Differentiated Thyroid Carcinoma Dimyati AchmadDepartment of Surgery, Faculty of Medicine Padjadjaran University/Hasan Sadikin Hospital, Bandung Indonesia
2 IntroductionThyroid carcinoma is the most frequent malignancy of the endocrine systemThe incidence has increased sharply in three decadesAlmost 90% of thyroid carcinoma are well-differentiated thyroid carcinoma
4 LOW RISK HIGH RISK AMES Age Males < 41 y, female < 51 y MetastasesNo distant metastasesDistant metastasesExtentIntrathyroidal papillary or follicular with minor capsule invasionExtrathyroidal papillary or follicular with major invasionSize< 5 cm> 5 cmDefinitionA: Any low-risk age group without metastasesB: High-risk age without metastases and with low-risk extent and sizeA: Any patient with metastasesB: High-risk age with either high-risk extent and size
5 Debated Issue Includes : Until today, the managementof DTC are still in controversyDebated Issue Includes :The extent of primary surgical resection and / or need for the extent of regional lymph node dissectionThe role of post operative radio iodine remnant ablationThe role of B-RAF mutation in management of papillary thyroid carcinoma
6 The Extent of Primary Surgical Resection Based on high risk and low risk criteria from prognostic scoring system, the controversial issue especially, in the management of low risk case. Some group of surgeons performed only thyroid lobectomy, whether performed total thyroidectomy.
7 The Guidelines of American Thyroid Association 2009: Thyroid cancer > 1 cm → recommended to perform total / near total thyroidectomy.Thyroid cancer < 1 cm, is a low risk, unifocal intrathyroidal papillary carcinoma and in the absence of prior head and neck irradiation → recommended to perform only thyroid lobectomy.
8 Neck DissectionCentral – compartment (level VI) neck dissection should included in total thyroidectomy, especially:Patients with clinically present central or lateral neck lymph node enlargement.Advanced primary tumors.
9 Lateral neck compartement (level II-V) lymph node dissection: Should be perfomed for patients with lateral cervical lymph node enlargement which is prove have metastatic by histopathological examination.
10 The Role of Post Operative Radio Iodine Remnant Ablation
11 The goals of the treatment are to destroy any residual thyroid tissue to prevent locoregional recurrenceand to facilitate surveillancewith whole-body iodine scansand/or adjusment thyroglobulin value.
12 Major Factors Impacting Decision Making in Radioiodine Remnant Ablation Expected benefitFactorsDescriptionDecreasedrisk ofdeathreccurenceMay facilitate initial staging and follow upRAI ablation usually recommendedStrengthofevidenceT11 cm or less, intrathyroidal or microscopic multifocalNoYesE1-2 cm, intrathyroidalConflicting dataaSelective useaIT2> 2-4 cm intrathyroidalCT3> 4 cm< 45 years oldB> 45 years oldAny size, any age, minimal extrathyroidal extensionInadequate dataaT4Any size with gross extrathyroidal extensionNx,N0No metastatic nodes documentN1Conflicting dataM1Distant metastasis presentA
13 Gross extrathyroidal extension and distant metastasis present → radioiodine ablation is usually recommendedIn low risk case no recommended for radioiodine ablation
14 The Role of B-RAF Mutation in the Management of Papillary Thyroid Carcinoma
16 The recent explosion of knowledge regarding the molecular and cellular pathogenesis of cancer has led to the development of range of targeted therapiesEfficacy has already been demonstrated for several agents including Sorafenib as tyrosine kinase inhibitor
18 Some of the researchers are recommended to undergo sorafenib utilization But, there is no guideline of management papillary thyroid carcinoma, describe the role of tyrosine kinase inhibitor
19 ConclusionThe management of differentiated thyroid carcinoma remains controversialThe choice for management of differentiated thyroid carcinoma:Total thyroidectomy, radioiodine ablation and thyroxine suppresion therapy.
20 Lateral neck compartement lymph node dissection should be perfomed for patients with lateral cervical lymph node enlargement which is prove have metastatic by histopathological examination.In papillary thyroid carcinoma with B-RAF mutation are recommended to undergo Sorafenib utilization as Tyrosine Kinase Inhibitor (TKI).