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UNIVERSITY Of INDONESIA AND CIPTO MANGUNKUSUMO HOSPITAL The Oldest University Fac. of Medicine in Indonesia A part of academic hospital where Dept of.

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Presentation on theme: "UNIVERSITY Of INDONESIA AND CIPTO MANGUNKUSUMO HOSPITAL The Oldest University Fac. of Medicine in Indonesia A part of academic hospital where Dept of."— Presentation transcript:

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2 UNIVERSITY Of INDONESIA AND CIPTO MANGUNKUSUMO HOSPITAL The Oldest University Fac. of Medicine in Indonesia A part of academic hospital where Dept of Surgery placed

3 To standardize of services To evaluate of quality of services To plan improvement of services for increasing the quality. To support of the basic and clinical research. To support of education process We need a solid working group in implementing of guidelines

4 Clinical staging classification Histological report classification Several activities : etc - Surgical technique or type of surgery - Preparation for thyroid or whole body scan and others Same fasicilities ( hopefully ) Same competency of the man behind (education)

5 Most of famous of cancer institution : Cancer Centers or Hospital Cancer Organization Education Has a thyroid cancer Guideline Etc : ATA NCCN ESSO And we have : guideline of ISSO

6 In USA : 4% for year for the past 20 years 2010 : newly diagnosed, thyroid cancer death In Indonesia : the ninth of the ten frequent cancer ( pathological Based 2005) In dr. Cipto Mangunkusumo Teaching Hospital of University of Indonesia. The newly diagnosed as thyroid cancer in : 199/280 nodule thyroid ( 71,1% )

7 THYROID CANCER IN DR.CIPTO MANGUNKUSUMO HOSPITAL : 199/280 nodule thyroid ( 71,1% ) : 262 *thyroid cancer (missing part of data) : 361 thyroid cancer among 962 thyroid nodules (38%) 1996 : 289 thyroid cancer among 832 thyroid nodule (34,7%) 1990 : 155 thyroid cancer among 842 thyroid nodule (18,36%) 1985 : 48 thyroid cancer among 324 thyroid nodule ( 14,8%) 1978 : 64 thyroid cancer among 601 thyroid nodule (10,5%) It is a tendency increasing of thyroid cancer hospitalized in Dr.Cipto Mangunkusumo Hospital It is estimated that the increasing of thyroid cancer due to : - The development of diagnostic method - Awareness of the patient for seeking health care * Part of data missing

8 Guidelines of thyroid cancer The ISSO guideline had been developed according of situation ( fasicility and condition ) what we have ( 2003 and revised in 2010 ) I. Introduction or background II. Histological classification III. Staging classification IV. Diagnostic procedures : History and clinical examination Sonography examination Scan thyroid Sitology ( FNAB) Histopathology examination ( as Gold Standard diagnostic ) V. Treatment procedures VI. Follow up

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10 Follicular carsinoma Papillary carsinoma Medullary carsinoma Anaplastic carsinoma

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12 Diagnostic Procedures History and physical examination History and physical examination Laboratory finding Laboratory finding Ultrasonography Ultrasonography Thyroid Scan (Tc, Iodine) Thyroid Scan (Tc, Iodine) FNAB / Cytology FNAB / Cytology Histopathology gold standard Histopathology gold standard Optional : CT retrosternal struma MRI MRI PET SCAN PET SCAN

13 Diagnostic Procedures (cont 1) Diagnostic Procedures (cont 1) Clinical finding are important Clinical finding are important Suspicious malignant nodule if : Suspicious malignant nodule if : - history of prior external irradiation head neck area - thyroid nodule has grown rapidly - local compression symptoms or infiltration : disturbance of swallowing (dysphagia) disturbance of swallowing (dysphagia) difficulty of breathing difficulty of breathing difficulty of speaking (hoarseness) difficulty of speaking (hoarseness)

14 - nodule in man or in patient at extremely of age - family history of thyroid malignancy (as medullary type) type) - thyroid nodule with cervical lymphadenopathy or sign of distance metastases sign of distance metastases Cervical plain photo : calcification of thyroid nodule (malignancy) Cervical plain photo : calcification of thyroid nodule (70% malignancy) The accuracy of clinical sign and symptoms is The accuracy of clinical sign and symptoms is 80,9 % ( study in Dr.Cipto Mangunkusumo) ( study in Dr.Cipto Mangunkusumo) Diagnostic Procedures (cont 2) Diagnostic Procedures (cont 2)

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16 Diagnostic Procedure (cont 3) Diagnostic Procedure (cont 3) Suspicious malignant : - poorly defined,irreguler margins - punctate/micro calcification - central hipervascularity Ultrasonography Ultrasonography - to differentiate solid or cystic nodule (hypoechoic vs normal thyroid tissue ) (hypoechoic vs normal thyroid tissue )

17 Thyroid Scan - to differentiate : - cold nodule, warm nodule, hot nodule - soliter or multiple nodule - cold nodule are malignant - 16 – 30 % cold nodule are malignant - could be used to control after surgery (total thyroidectomy ) - maybe useful in hyperfunctioning adenoma

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19 Fine Needle Aspiration

20 FNAB : FNAB : - diagnostic accuracy 95 % - sensitivity 80 – 85 % - sensitivity 80 – 85 % - specificity 90 – 95 % for papillary type ca - specificity 90 – 95 % for papillary type ca - false negatives 5 % - false positive 1 – 3 % - difficult to differentiate follicular adenoma, follicular carcinoma - difficult to differentiate follicular adenoma, follicular carcinoma and benign follicular lesions and benign follicular lesions Frozen section Frozen section - accuracy 83 % Gold standard diagnostic : Histopathologic examination Gold standard diagnostic : Histopathologic examination Diagnostic Procedures (cont 4) Diagnostic Procedures (cont 4)

21 Extreme age : younger than 20 or older than 50. Previously radiation of the neck or chest in child hold age Clinical symptoms : dysphagia,hoarseness, disturbance of respiration stridor Nodule : single,man,rapid growth, hard or firm in consistency, enlargement of regional lymph nodes or distance metastases

22 TREATMENT PROCEDURES

23 If suspected malignant thyroid nodule, it is classified as operable one or inoperable. Operable one : isthmolobectomy and frozen section should be performed Five possible result of frozen section examination are :

24 Benign lesion surgery is completed Papillary carcinoma Low risk surgery is completed and observation High risk total thyroidectomy should be performed or surgery should be performed directly (although classified low or high risk one) Follicular carcinoma total thyroidectomy should be performed Medullary carcinoma total thyroidectomy should be performed

25 Anaplastic carsinoma If operable : a total thyroidectomy should be performed; followed be external beam radiation If inoperable, just biopsy and followed by external beam radiation.( see the schema)

26 Thyroid Nodule Clinical Features Malignant Suspect Benign Suspect Inoperable Operable FNAB Isthmolobectomy Incisional Biopsy Benign Lesion Malignant susp, Follicular pattern, Hurthle cell Benign PapillaryFollicularMedullarAnaplastic TSH Suppression (6 Months) Low Risk High Risk Progressive, no change Shrinking Observation Total Thyroidectomy Debulking External radiation/chemotherap y Schema I

27 Thyroid Nodule Clinical Features Malignant Suspect Benign Suspect Inoperable Operable Observation Lobectomy/ Isthmolobectomy Incisional Biopsy Benign Lesion Compression symptoms TSH Suppression Failed Cosmetic Reason PapillaryFollicularMedullar Anaplastic Low Risk High Risk Operation Finished Observation Total Thyroidectomy Debulking External radiation/chemotherapy Malignant Lesion Schema II

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29 Operable one : total thyroidectomy with modified radical neck dissection or classical RND ; depend on extend of invasion. Inoperable : radiation and chemotherapy (see the schema III)

30 Inoperable Operable Accessory Nerve Infiltration Internal Jugular Vein infiltration SCM Infiltration Infiltration (-) Radiotherapy, Chemo- radiotherapy TT + Functional RND TT + Modification 2 RND TT + Modification 1 RND TT + Standard RND Thyroid Cancer + Regional Metastasis infiltration Schema III

31 For thyroid cancer with distant metastase Well differentiated carsinoma total thyroidectomy with internal radiation J.131 Poorly differentiated carsinoma chemotherapy ( see schema IV)

32 Thyroid Cancer + Distant Metastasis Poorly Differentiated Well Differentiated Total Thyroidectomy + Internal Radiation Chemotherapy Response (-)Response (+) Suppression/ Substitution Therapy Schema IV

33 Medicamentous treatment in thyroid cancer : all patient post total thyroidectomy will be given thyroxin hormone with supressive dose

34 Follow up of thyroid cancer

35 4-6 week after total thyroidectomy, thyroid scan and/or whole body scan should be performed, to detect residual tumor or metastatic lesion and detect of thyroglobulin level as marker of well differentiated thyroid cancer. Ablation theraphy with J.131 should be given for residual tumor detected (see schema V)

36 Total Thyroidectomy Residual Tissue (+) Ablation Supression/ Substitution Therapy Internal Radiation Metastasis (+) Metastasis (-) Residual Tissue (-) Schema V 4 WEEKS SCAN THYROID CONTROVERSION 6 MONTH WHOLE BODY SCAN

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38 Calcetonin level should be examined 3 month after total thyroidectomy with or without central node dissection. If level calcetonin > 10 mg/ml, it mean suspicious recurrence and further examination should be performed (see schema VI)

39 Observation CT Scan, MRI, SVC Locally Residive (+) Distant Metastasis Re-excision OperableInoperable Excision Paliative Total Thyroidectomy Locally Residive (-) Calcitonin Level > 10ng Low Calcitonin Level Schema VI 3 Months Post Operation

40 Evaluation of implementing of guideline of thyroid cancer in Indonesia will be presented concerning of cases, stage classification : histophatological classification, treatment and others. Data collected from several center in Indonesia. Medan : Emir T. Pasaribu, et all Jakarta : Muchlis Ramli, et all Bandung : Dimyati Achmad, et all Semarang : Djoko Handojo, et all Denpasar : Tjakra Wibawa Manuaba, et all

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42 Most cases of thyroid cancer : female

43 Most cases of thyroid cancer : stage II

44 Most cases thyroid cancer in dr. Cipto Mangunkusomo Hospital : stage III

45 Distribution of histologic

46 Most cases of thyroid cancer : papillary carsinoma type.

47 Distribution type of surgery

48 Most operation of thyroid cancer : Total Thyroidectomy

49 Completion in dr. Cipto Mangunkusumo Hospital : 36 ( 8% ). Because : 1. Refference from another hospital. 2. Miss result from frozen section. Result frozen section in dr.Cipto Mangunkusumo Hospital : - Sensitivity : 65,5% - Specifity : 86,3% - Acurasi : 70% And FNAB in dr.Cipto Mangunkusumo Hospital - Sensitivity : 58,2% - Specifity : 88,9% - Acurasi : 63,4%

50 COMPLICATION Complication for thyroid cancer at Cipto Mangunkusumo Hospital - Nerve injury : 3% - Hipocalcemi : 2% - Bleeding : 0.5%

51 COMPLICATION Complication for thyroid cancer - Nerve injury : 3% - Hipocalcemi : 2% - Bleeding : 0.5% From : Davinson BJ & Burman KD : Cancer of thyroid and parathyroid in Head & neck Cancer a multidisciplinary approach.

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53 No.CriteriaMedanJakartaBandungSemarangDenpasar 1.Year Juli 2012 Duration3 year5 year 5,5 year 2.Gender Male female Total Stage I II III IV Not defined954 4.Type of Histologic Ca. papiller Ca. folicular Ca. papiller varian foliculer362 Ca. papiller varian tall cell16

54 No.CriteriaMedanJakartaBandungSemarangDenpasar Ca. medullare 114 Ca. anaplastic Ca. Hurthle cell 615 Primary lymphoma 13 Atipic cell 16 Ca. cystic papiler 12 Ca. mucinosa 5 Squamosa cell carsinoma 33 unclassified 96 5.Type of surgery Isthmolobectomy Total Thyroidectomy TT + RND TT + Berry Picking4 Debulcing11433 Completion36 Tracheostomy362 excision16 Sub total thyroidectomy14 Near total thyroidectomy4 Not surgery24

55 1. Registration 2. Facilities 3. Controversies in preparation of the patient for radioiodine diagnostic and treatment 4.Patients factors Education Social economic Alternative treatment ( TCM ?, herbal ? )

56 THANK YOU


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