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HEAD AND NECK CASE CONFERENCE (PAPILARY THYROID CARCINOMA) Philippine Academy for Head and Neck Surgery, Inc. – Medical Center Manila June 10, 2013 12.

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Presentation on theme: "HEAD AND NECK CASE CONFERENCE (PAPILARY THYROID CARCINOMA) Philippine Academy for Head and Neck Surgery, Inc. – Medical Center Manila June 10, 2013 12."— Presentation transcript:

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 ResultNormal Value TSH uIU/ml FT pg/ml FT ng/dl

7 Ultrasound of the neck 10/26/11 The right thyroid lobe is normal in size and measures 4.98 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 0.76 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 American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010) THYROID CARCINOMA STAGING Primary tumor (T) TxPrimary tumor cannot be assessed T0No evidence of primary tumor T1Tumor 2cm or less in greatest dimension limited to the thyroid T1aTumor 1cm or less limited to the thyroid T1bTumor more than 1cm but not more than 2cm in greatest dimension, limited to the thyroid T2Tumor more than 2cm but not more than 4cm in greatest dimension, limited to the thyroid T3Tumor more than 4cm in greatest dimension, limited to the thyroid or any tumor with extrathyroidal extension (eg. extension to sternothyroid or perithyroid soft tissues) T4aModerate advanced disease Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, trachea, larynx, esophagus or recurrent laryngeal nerve T4bVery advanced disease Tumor invades prevertebral fascia or encases common carotid artery or mediastinal vessel  all anaplastic carcinomas are considered T4 tumor

13 American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010) THYROID CARCINOMA STAGING Regional lymph nodes (N) Regional lymph nodes are the central compartment, lateral cervical and upper mediastinal nodes. NxRegional lymph nodes cannot be assessed N0No regional lymph node metastasis N1Regional lymph node metastasis N1aMetastasis to level VI (pretracheal, paratracheal, prelaryngeal/Delphian lymph nodes) N1bMetastasis to unilateral, bilateral or contralateral cervical (levels I, II, III, IV, V) or retropharyngeal or superior mediastinal lymph nodes (level VII)

14 American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010) THYROID CARCINOMA STAGING Distant metastasis (M) M0No distant metastasis M1Distant metastasis

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

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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? 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

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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 ResultNormal Value TSH uIU/ml Thyroglobulin89.47ng/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.

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

29 2/13/12 Levothyroxine 100mg OD ResultNormal Value TSH uIU/ml FT ng/dl TG19.44ng/mL< 1ng/mL

30 3/14/12 Levothyroxine 100mg OD ResultNormal Value TSH uIU/ml TG5.61ng/mL< 1ng/mL

31 4/13/12 Levothyroxine 100mg OD ResultNormal Value TSH uIU/ml TG4.8< 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 ResultNormal Value TSH 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.

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41 12/10/12 Levothyroxine 150g (mon- sat, 1/2 on Sunday) ResultNormal Value TSH uIU/ml TG5.25< 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 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) Regional (spread to regional lymph nodes) Distant (cancer has metastasized) Unknown (unstaged)287.6 STAGE AND SURVIVAL FOR THYROID CANCER based on NCI’s SEER Cancer Statistics Review

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

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

51 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 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 Initial Diagnostic Tests

57 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 Extent of Surgery

58 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. Frozen Section

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

60 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. Role of Radioactive Iodine Ablation

61 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. TSH Suppresion Therapy

62 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. External Beam Radiotherapy

63 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. Role of Chemotherapy

64 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. Role of Post operative Thyroglobulin Assay

65 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 1 st yr and then yearly thereafter Role of Post operative Serum TSH

66 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. Post operative Role of Cervical UTZ

67 PGH (2008)PCS-PSGS-PAHNSI (2008) Done after RAILimited 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. Role of Post operative Whole Body Scan

68 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. Metastatic Work-up


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