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Controversies in the Management of Differentiated Thyroid Carcinoma Dimyati Achmad Department of Surgery, Faculty of Medicine Padjadjaran University/ Hasan.

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Presentation on theme: "Controversies in the Management of Differentiated Thyroid Carcinoma Dimyati Achmad Department of Surgery, Faculty of Medicine Padjadjaran University/ Hasan."— Presentation transcript:

1 Controversies in the Management of Differentiated Thyroid Carcinoma Dimyati Achmad Department of Surgery, Faculty of Medicine Padjadjaran University/ Hasan Sadikin Hospital, Bandung Indonesia

2 Introduction Thyroid carcinoma is the most frequent malignancy of the endocrine system The incidence has increased sharply in three decades Almost 90% of thyroid carcinoma are well- differentiated thyroid carcinoma

3 Differentiated Thyroid Carcinoma (DTC) Is categorized into: – Papillary thyroid carcinoma (85%) – Folliculare thyroid carcinoma (10%) – Hurtle cell carcinoma (3%) Slow growing tumor Good prognosis

4 LOW RISKHIGH RISK AMES AgeMales < 41 y, female < 51 yMales > 40 y, female > 50 y MetastasesNo distant metastasesDistant metastases ExtentIntrathyroidal papillary or follicular with minor capsule invasion Extrathyroidal papillary or follicular with major invasion Size< 5 cm> 5 cm DefinitionA: Any low-risk age group without metastases B: High-risk age without metastases and with low-risk extent and size A: Any patient with metastases B: High-risk age with either high- risk extent and size

5 Debated Issue Includes : The extent of primary surgical resection and / or need for the extent of regional lymph node dissection The role of post operative radio iodine remnant ablation The role of B-RAF mutation in management of papillary thyroid carcinoma Until today, the management of DTC are still in controversy

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 Dissection Central – 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 recurrence and to facilitate surveillance with whole-body iodine scans and/or adjusment thyroglobulin value.

12 Major Factors Impacting Decision Making in Radioiodine Remnant Ablation Expected benefit FactorsDescription Decreased risk of death Decreased risk of reccurence May facilitate initial staging and follow up RAI ablation usually recommended Strength of evidence T1 1 cm or less, intrathyroidal or microscopic multifocal No YesNoE 1-2 cm, intrathyroidalNoConflicting data a YesSelective use a I T2> 2-4 cm intrathyroidalNoConflicting data a YesSelective use a C T3> 4 cm < 45 years oldNoConflicting data a Yes B > 45 years oldYes B Any size, any age, minimal extrathyroidal extension NoInadequate data a YesSelective use a I T4 Any size with gross extrathyroidal extension Yes B Nx,N0No metastatic nodes documentNo YesNoI N1 < 45 years oldNoConflicting data a YesSelective use a C > 45 years oldConflicting dataConflicting data a YesSelective use a C M1Distant metastasis presentYes A

13 Gross extrathyroidal extension and distant metastasis present radioiodine ablation is usually recommended In low risk case no recommended for radioiodine ablation

14 The Role of B-RAF Mutation in the Management of Papillary Thyroid Carcinoma

15 HGF Met Mutant B-RAF Protein MEK ERK C-MET ECM ERK B-RAF Mutation C-JUN C-FOS HYPOXIA HIF-1α HIF-1α-1β VEGF VE6F-C VEGF VEGF-C Proliferation Extrathyroidal Invasion Lymph node metastases RET RAS RAF

16 The recent explosion of knowledge regarding the molecular and cellular pathogenesis of cancer has led to the development of range of targeted therapies Efficacy has already been demonstrated for several agents including Sorafenib as tyrosine kinase inhibitor

17 HGF Met Mutant B-RAF Protein MEK ERK C-MET ECM ERK B-RAF Mutation C-JUN C-FOS HYPOXIA HIF-1α HIF-1α-1β VEGF VE6F-C VEGF VEGF-C Proliferation Extrathyroidal Invasion SORAFENIB X

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 The management of differentiated thyroid carcinoma remains controversial The choice for management of differentiated thyroid carcinoma: Total thyroidectomy, radioiodine ablation and thyroxine suppresion therapy. Conclusion

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).

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