4History November, 2011Notable mass at the left anterior neck approximately 2x3x3 cmPhysical Examination:(+) 3X2X2 cm cervical lymphadenopathy, post- auricular area(+) 2x3x2 cm left anterior neck mass, firm, moves with deglutition
5What would be your diagnostic work-ups ? How do you do it in your institution or practice?
610/26/11 Result Normal Value TSH 0.324 0.35-5.50 uIU/ml FT3 2.52 pg/mlFT41.09ng/dl
7Ultrasound 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 2.20cmThere 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 cmLeftUpper to mid portion with numerous punctate calcification in the marginsA 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
8Ultrasound 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.
9FNAB cytology Report 11/2/2011 Organ for aspiration biopsy: left thyroid and left cervical lateral nodeCytologic 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.
10How do you interpret fnac /fnab results/ Methesda scoring /nomenclature for fnab?
12THYROID CARCINOMA STAGING Primary tumor (T)TxPrimary tumor cannot be assessedT0No evidence of primary tumorT1Tumor 2cm or less in greatest dimension limited to the thyroidT1aTumor 1cm or less limited to the thyroidT1bTumor more than 1cm but not more than 2cm in greatest dimension, limited to the thyroidT2Tumor more than 2cm but not more than 4cm in greatest dimension, limited to the thyroidT3Tumor 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 diseaseTumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, trachea, larynx, esophagus or recurrent laryngeal nerveT4bVery advanced diseaseTumor invades prevertebral fascia or encases common carotid artery or mediastinal vesselall anaplastic carcinomas are considered T4 tumorAmerican Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010)
13THYROID CARCINOMA STAGING Regional lymph nodes (N)Regional lymph nodes are the central compartment, lateral cervical and upper mediastinal nodes.NxRegional lymph nodes cannot be assessedN0No regional lymph node metastasisN1Regional lymph node metastasisN1aMetastasis 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)American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010)
14THYROID CARCINOMA STAGING Distant metastasis (M)M0No distant metastasisM1Distant metastasisAmerican Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010)
15THYROID CARCINOMA STAGING American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition (2010)
17Operation November 8, 2011Total thyroidectomy with modified radical neck dissection Type III, left
18Is 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?
19Record of Operation November 8, 2011 Findings:Thyroid gland enlargedRight lobe 4x3x2 cm with solitary nodule 1 cm in diameterLeft 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
21Record 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)
22Final 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 thyroiditisSurgical lines of thyroidectomy are negative for tumor.Positive for tumor metastasis to 9/18 left cervical LN
2311/28/11 Result Normal Value TSH 55.00 0.35-5.50 uIU/ml Thyroglobulin 89.47ng/mL< 1ng/mL
24Whole 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.
25Whole body I-131 Scintigraphy Dec. 17, 2011 Interpretation: Functioning thyroid tissue remnants limited to the anterior area.
28What are the controversies in thyroid scanning ? How do you give RAI? What are the doses?
292/13/12 Levothyroxine 100mg OD Result Normal Value TSH 12.89 uIU/mlFT48.78ng/dlTG19.44ng/mL< 1ng/mL
303/14/12 Levothyroxine 100mg OD Result Normal Value TSH 0.124 uIU/mlTG5.61ng/mL< 1ng/mL
314/13/12 Levothyroxine 100mg OD Result Normal Value TSH 0.101 uIU/mlTG4.8< 1ng/mL
32Role of TSH suppression? How do you follow up? Serum TSHSerum thyroglobulinNeck ultrasoundPrognosis?
337 months post-operative No palpable neck massPersistently low TSH and elevated TGUltrasound of the neck was requested
34Ultrasound 6/26/12Scan 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.ImpressionS/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.
366/27/12 Levothyroxine 100mg OD Result Normal Value TSH 0.04 uIU/ml
37Whole 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 131There 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 bladderNo functioning metastasis is seen
38Whole body I-131 scintigraphy Oct 8, 2012 Interpretation: Functioning thyroid tissue remnants limited to the thyroid bed.
4112/10/12 Levothyroxine 150g (mon- sat, 1/2 on Sunday) Result Normal ValueTSH0.037uIU/mlTG5.25< 1ng/mL
42Record of Operation 4/26/13Pre-operative diagnosis: Recurrent papillary thyroid cancer; S/p Total thyroidectomy with modified radical neck dissection Type III, leftS/P RAI 12/13/11 and 10/03/12
43Record of Operation 4/26/13Operation: Central node dissection
44Record of Operation 4/26/13Findings: 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
46Final Histopath 4/26/13Specimen: Central and left peritracheal lymph nodesFibro-adipose tissue, showing papillary carcinoma (0.3cm) and suture granuloma26/29 Lymph nodes positive for metastatic papillary carcinoma, parathyroid gland (one focus), Thymus gland (fragments)
47Papers on recurrent papillary thyroid cancer Another RAI after several RAI sessions?
48STAGE AND SURVIVAL FOR THYROID CANCER Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for , All Races, Both SexesStage at DiagnosisStage Distribution (%)5-year Relative Survival (%)Localized (confined to primary site)6899.8Regional (spread to regional lymph nodes)2596.9Distant (cancer has metastasized)556.4Unknown (unstaged)287.6based on NCI’s SEER Cancer Statistics Review
49DIVISION OF LYMPH NODES BY LEVELS ( AMERICAN HEAD & NECK SOCIETY – 1991 )
50Modified Radical Neck Dissection RemovesNodal groups I-VPreservesSCM, IJV, XI (any combination)Classified according to which structures are preserved
51Modified Radical Neck Dissection MRND Type I (preserves SAN)Indications:Clinically N+SAN not involved by tumor
52Modified Radical Neck Dissection MRND Type II (preserves SAN and IJV)Indications:Intraoperative tumor found adherent to the SCM, but not IJV and SANRarely planned
53Modified Radical Neck Dissection MRND Type III (preserves SAN, IJV and SCM)Indications:SAN, IJV, & SCM not involved by tumor
54Selective Neck Dissection Remove high risk lymph node groups based on tumor site.SupraomohyoidLevels I-IIILateralLevels II-IVAnterolateralLevels I-IV
55Selective Neck Dissection PosterolateralLevels II-VPostauricular nodesSuboccipital nodesAnterior compartmentLevel VI
56Initial Diagnostic Tests PGH (2008)PCS-PSGS-PAHNSI (2008)For all thyroid nodules:Serum TSHdeterminationThyroid ultrasoundFNABSerum TSH and/or thyroid hormonesThyroid UTZ for:High risk patients (family hx of thyroid CA, previousdx of MEN2, childhood cervical irradiation)Suspicious nodule for CA in the background ofmultinodular goiterWith adenopathy suggestive of malignant lesionEvaluation of nodular goiterScintigraphy – limited to pxs w/ subnormalserum TSHFNAC – recommended for dx of benign &malignant lesionsPET scan w/ 18F-FDG – for detection ofthyroid CA in inconclusive cytologicnodular dx of thyroid nodules
57Extent of Surgery PGH (2008) PCS-PSGS-PAHNSI (2008) Total or near total thyroidectomy for thyroid nodule proven malignant by FNAB with size >1 cm.Lobectomyfor lesions <1 cm, isolated intrathyroidal well-differentiated carcinomas with absent cervical nodal metastases.Near total or Total Thyroidectomyfor WDTCTotal or near-total thyroidectomyfor multinodular goiter.Lobectomy w/ isthmusectomy for solitary benign thyroid nodule
58Frozen Section PGH (2008) PCS-PSGS-PAHNSI (2008) For non-diagnostic preoperative FNABLimited utility in diagnosing thyroid malignancies if the FNAB result show follicular neoplasm, inadequate or suspicious aspirate.
60Role of Radioactive Iodine Ablation PGH (2008)PCS-PSGS-PAHNSI (2008)Lesion size >1 cmMultifocal diseaseNodal metastasesInvolved resection margins Extrathyroidal or vascularinvasionAggressive histologies.Beneficial for decreasing locoregional recurrence and distant metastasis.
61TSH 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.
62External 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.
63Role 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.
64Role 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.
65Role of Post operative Serum TSH PGH (2008)PCS-PSGS-PAHNSI (2008)Maintained at 0.1 to 0.5 mU/L unless with contraindicationsW/ persistent disease: serum TSHShould 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
66Post 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.
67Role of Post operative Whole Body Scan PGH (2008)PCS-PSGS-PAHNSI (2008)Done after RAILimited usefulness and is NOT necessary inlow risk patients who are clinically free ofresidual tumor w/ undetectable serum Tgand has negative neck ultrasoundNOT necessary if the Tg is elevated andultrasound of the neck is positive, sincetherapeutic options (surgery or RAIablation) are already warranted.
68Metastatic Work-up PGH (2008) PCS-PSGS-PAHNSI (2008) No mention. Locoregional:Preoperative neck ultrasound isrecommended to detectlocoregional metastasis forWDTC.Routine use of CT and PET is NOTrecommended.Distant:CXR, HRCT and FDG-PET are NOTroutinely recommended todetect distant metastasis.