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Thyroid cancer by J. Shah
1. The International Federation
of Head and Neck Oncologic Societies
Current Concepts in Head and Neck Surgery and Oncology 2012
Thyroid Cancer
Treatment of the Primary
Jatin P. Shah
2. Thyroid Cancer
Issues
• Incidence • Risk Group
• Pathology Stratification
• Exploiting Biology • Selection of Therapy
• Practice Patterns • Follow up
• Prognostic • Future Directions
Factors • Summary
2012
3. Thyroid Cancer – Incidence & Mortality
1974 to 2012
Thousands
6 USA Overall
0 56460
34
32
30
28
26
24
22 Women
20
18 43210
16
14 Men
12
10 13250
8
6 Mortality
4
2 1780
0
1974 1978 1982 1986 1990 1994 1998 2002 2006 2010 2012
2012 Overall Incidence Incidence in Women
Incidence in Men Mortality
4. Trends in Incidence of
Thyroid Cancer and Papillary Tumors
by Size in the United States
2012
Davies, L. et al. JAMA 2006;295:2164-2167
5. Differentiated Cancer of the
Thyroid Gland
A Biologically Unique Neoplasm
• Multifocal microscopic foci of
carcinoma are common (60 – 80%)
• Micrometastases to regional
lymph nodes are common (>50%)
2012
Its clinical significance ???
6. Pathology
Cancer of the Thyroid
Papillary Medullary
~65% ~10%
Follicular Anaplastic
(Hurthle cell)
~20% ~5%
2012
7. Pathology
Cancer of the Thyroid
Papillary
Thyroid Tall Cell, Poorly
Follicular Insular, differentiated Anaplastic
Cell etc
Follicular
Good Bad Ugly
2012
~85% ~15% <2%
8. Contemporary Thinking of
Pathology of Thyroid Cancer
• Nearly 80% are Papillary Carcinomas
• Pure Follicular Carcinomas are rare
• Approximately 12-15% are
Poorly Differentiated Carcinomas
• Approximately 5-7 % are
Medullary Carcinomas
• Less than 2% are
2012
Anaplastic Carcinomas
9. Prognosis in Thyroid Cancer
WDTC Great majority after initial treatment Cured
A small proportion (~10%) will develop local/regional
recurrence without negative impact on survival
Mortality is exceedingly rare (<2%)
2012
10. Prognosis in Thyroid Cancer
A very small proportion will undergo
progression to
aggressive variants
PTC Tall Cell Poorly Diff Anaplastic
Mortality
2012
12. Exploiting Biology
for Management
PTC Tall Cell Poorly Diff Anaplastic
Glucose metabolism
PET Scan
Cell division
Differentiation
Iodine avidity
2012
RAI Scan
13. Prognosis in Thyroid Cancer
Genomic Instability
PTC Tall Cell Poorly Diff Anaplastic
Size, ETE, DM, Mortality
2012
14. Differentiated Cancer of the Thyroid Gland
Treatment Paradigm
Total or near total thyroidectomy
Radioiodine ablation If we
follow
Radioiodine therapy this
practice
Follow up with TGb and ultrasound
• Majority get excessive treatment
at great cost with little or no benefit
2012
• Some derive benefit
• Some have no impact on prognosis with treatment
15. Differentiated Cancer of the Thyroid Gland
Prognostic Factors
Mayo Lahey Mayo Karolinska MSKCC
AGES AMES MACIS DAMES GAMES
Age Age Metastases DNA Grade
Grade Metastases Age Age Age
Completeness Metastases Metastases
Of resection
Extension Extension Invasion Extension Extension
Size Size Size Size Size
2012
17. Differentiated Carcinoma Risk Groups
of the Thyroid Gland
Risk Groups Prognostic
Factors Low Intermediate High
Factor High Low
Age >45 <45 Age <45 >45 <45 >45
Gender Male Female
Size >4 cm <4 cm
Extent ETE No ETE Gender Female Male
Grade High Low Size < 4 cms. > 4 cms.
Distant Mets Present Absent Extent Intraglandular Extraglandular
2012
Grade Low High
Dist. Mets. Absent Present
21. Selection of Therapy
Be Aggressive at Extremes of Age
• Children (< 16 yrs). Total Thyroidectomy
and RAI therapy
• Older patients (> 60 yrs). Appropriate Aggressive
Surgery followed by RAI and/or RT
Adults
Low risk
High risk tumor in
Unifocal intraglandular
all age groups
tumor
in all age groups
Total
Lobectomy Thyroidectomy
Aggressive surgery
2012
24. Total Thyroidectomy
• Diffuse bilobar tumor
• Bilateral nodules regardless of the
size of primary
• Major extrathyroid extension
• Massive bilateral nodal metastases
• Distant metastases
• History of radiation exposure
2012
25. Extrathyroid Extension
from Differentiated Cancer of the
Thyroid Gland
Minor: • Strap muscles
T3 • Soft tissues
Major: • Trachea
T4A • Larynx
• Esophagus
2012 • Recurrent laryngeal nerve
26. Differentiated Carcinoma of the Thyroid
SURVIVAL: Extrathyroid Extension
100
90 No ETE 94%
80
70 ETE 74%
60
%
50
40
P < 0.01
30
20
No Extrathyroid Extension n =1608
10 Extrathyroid Extension n = 202
0
0 5 10 15 20
2012
Time (Years)
27. Differentiated Carcinoma of the Thyroid
ETE and Recurrence
16
14 13.4 P<0.01
12
10 9.4
% 8 No ETE
6 ETE
4 3.2
2.5
1.8
2
0.2
0
Local Regional Distant
2012
28. Thyroid Carcinoma with Extrathyroid Extension
Young Patients with Complete Excision
Survival
1.0
.9
.8
p=0.46
.7
.6
.5 p=0.005
.4
.3
.2 <=45, ETE, Complete excision
.1 <=45, No ETE
<=45, ETE, Incomplete excision
2012
60 120 180 240 300 360
Time (months)
29. Surgery
for
Extrathyroid
Extension
Principles
•
All
gross
tumor
should
be
removed
•
Preserve
func=oning
structures
•
Preserve
vital
structures
•
Balance
between
tumor
control
and
best
func=onal
results
•
Use
adjuvant
treatments
-‐
RAI,
and/or
RT
2012
31. Extrathyroid
Extension
Recurrent
Laryngeal
Nerve
•
Unilateral
vs
bilateral
•
Preop
vocal
cord
palsy
•
Evaluate
both
lobes
of
thyroid
•
Make
every
effort
to
preserve
func=oning
RLN
•
Look
on
the
other
side
before
sacrificing
func=oning
RLN
•
Nerve
graM
-‐
Reinnerva=on
2012
•
Laryngoplasty
34. Surgery for Extrathyroid Extension
Trachea
• Shaving tumor off the trachea
• Partial/window resection and reconstruction
• Sleeve resection with primary anastomosis
• Resection of trachea with cricoid
2012
38. Extrathyroid
Extension
Esophagus
•
Excision
of
muscular
wall
•
Par=al
esophagectomy
•
Esophagectomy
with
or
without
laryngectomy
•
Gastric
pull-‐up
or
jejunal
free
flap
2012
39. Differentiated Thyroid Cancer 1930-1985
Differentiated Thyroid Cancer 1930-1985
SURVIVAL: Risk Groups
SURVIVAL: Risk Groups
1 99%
p < 0.001 88%
0.8 93%
85%
p < 0.001
0.6 72%
57%
0.4
0.2 Low n=403 Med-<45 n=159
Med->45 n=244 High n=232
0
0 2 4 6 8 10 12 14 16 18 20
TIME (years)
MSKCC-1038 pts. (DOD)
MSKCC-1038 pts. (DOD)
2012
40. Thyroid Cancer
Summary
• Rising incidence of favorable low risk cancers
• Appreciation of pathology and exploiting biology to
deliver cost effective treatment
• Significance of prognostic factors and
risk group stratification
• Discretion in selection of surgical treatment
• Discretion in use of adjuvant therapy and follow up
2012 • Research in molecular biology and new therapies
