Download Role of Post operative Serum TSH

HEAD AND NECK CASE
CONFERENCE
(PAPILARY THYROID CARCINOMA)
Philippine Academy for Head and Neck Surgery, Inc. –
Medical Center Manila
June 10, 2013 12 PM
General Data
• R.M.
• 51 y/o
• Female
Chief Complaint
• Anterior neck mass
History
November, 2011
• Notable mass at the left anterior neck
approximately 2x3x3 cm
• Physical Examination:
▫ (+) 3X2X2 cm cervical lymphadenopathy, postauricular area
▫ (+) 2x3x2 cm left anterior neck mass, firm, moves
with deglutition
• What would be your diagnostic work-ups ?
• How do you do it in your institution or practice?
10/26/11
Result
Normal Value
TSH
0.324
FT3
2.52
0.35-5.50
uIU/ml
1.68-3.54 pg/ml
FT4
1.09
0.71-1.85 ng/dl
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
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.
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.
How do you interpret fnac /fnab
results/
• Methesda scoring /nomenclature for fnab?
• Impression? Stage?
• Plan of Management?
THYROID CARCINOMA STAGING
Primary tumor (T)
Tx
Primary tumor cannot be assessed
T0
No evidence of primary tumor
T1
Tumor 2cm or less in greatest dimension limited to the thyroid
T1a
Tumor 1cm or less limited to the thyroid
T1b
Tumor more than 1cm but not more than 2cm in greatest dimension, limited to the thyroid
T2
Tumor more than 2cm but not more than 4cm in greatest dimension, limited to the thyroid
T3
Tumor more than 4cm in greatest dimension, limited to the thyroid or any tumor with
extrathyroidal extension (eg. extension to sternothyroid or perithyroid soft tissues)
T4a
Moderate advanced disease
Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues,
trachea, larynx, esophagus or recurrent laryngeal nerve
T4b
Very advanced disease
Tumor invades prevertebral fascia or encases common carotid artery or mediastinal vessel
 all anaplastic carcinomas are considered T4 tumor
American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition
THYROID CARCINOMA STAGING
Regional lymph nodes (N)
Regional lymph nodes are the central compartment, lateral cervical and upper
mediastinal nodes.
Nx
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Regional lymph node metastasis
N1a
Metastasis to level VI (pretracheal, paratracheal,
prelaryngeal/Delphian lymph nodes)
N1b
Metastasis 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
THYROID CARCINOMA STAGING
Distant metastasis (M)
M0
No distant metastasis
M1
Distant metastasis
American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition
THYROID CARCINOMA STAGING
American Joint Committee on Cancer (AJCC) Staging Manual, 7th edition
Operation
November 8, 2011
• Total thyroidectomy with modified radical neck
dissection Type III, left
• 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?
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
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)
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
11/28/11
Result
Normal Value
TSH
55.00
Thyroglobulin
89.47ng/mL
0.35-5.50
uIU/ml
< 1ng/mL
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.
Whole body I-131 Scintigraphy
Dec. 17, 2011
• Interpretation: Functioning thyroid
tissue remnants limited to the anterior
area.
• What are the controversies in thyroid scanning ?
• How do you give RAI? What are the doses?
2/13/12
Result
Normal Value
TSH
12.89
FT4
8.78
0.35-5.50
uIU/ml
0.71-1.85 ng/dl
TG
19.44ng/mL
< 1ng/mL
• Levothyroxine 100mg OD
3/14/12
Result
Normal Value
TSH
0.124
TG
5.61ng/mL
0.35-5.50
uIU/ml
< 1ng/mL
• Levothyroxine 100mg OD
4/13/12
Result
Normal Value
TSH
0.101
TG
4.8
0.35-5.50
uIU/ml
< 1ng/mL
• Levothyroxine 100mg OD
• Role of TSH suppression?
• How do you follow up?
▫ Serum TSH
▫ Serum thyroglobulin
▫ Neck ultrasound
• Prognosis?
7 months post-operative
• No palpable neck mass
• Persistently low TSH and elevated TG
• Ultrasound of the neck was requested
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 -0.85 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 0.19-0.74 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.
• Will you do fnab?
6/27/12
TSH
Result
Normal Value
0.04
0.35-5.50
uIU/ml
• Levothyroxine 100mg OD
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
Whole body I-131 scintigraphy
Oct 8, 2012
• Interpretation: Functioning thyroid
tissue remnants limited to the thyroid
bed.
12/10/12
Result
Normal Value
TSH
0.037
TG
5.25
0.35-5.50
uIU/ml
< 1ng/mL
• Levothyroxine 150g (mon- sat, 1/2 on Sunday)
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
Record of Operation 4/26/13
• Operation: Central node dissection
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
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)
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)
Papers on recurrent papillary thyroid
cancer
• Another RAI after several RAI sessions?
STAGE AND SURVIVAL FOR THYROID CANCER
Stage Distribution and 5-year Relative Survival by Stage at Diagnosis for
2001-2007, All Races, Both Sexes
Stage
Distribution (%)
5-year
Relative Survival (%)
Localized (confined to
primary site)
68
99.8
Regional (spread to
regional lymph nodes)
25
96.9
Distant (cancer has
metastasized)
5
56.4
Unknown (unstaged)
2
87.6
Stage at Diagnosis
• based on NCI’s SEER Cancer Statistics
DIVISION OF LYMPH NODES BY LEVELS
( AMERICAN HEAD & NECK SOCIETY – 1991 )
Modified Radical Neck Dissection
• Removes
▫ Nodal groups I-V
• Preserves
▫ SCM, IJV, XI (any
combination)
• Classified according to
which structures are
preserved
Modified Radical Neck Dissection
MRND Type I (preserves SAN)
• Indications:
▫ Clinically N+
▫ SAN not involved by tumor
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
Modified Radical Neck Dissection
MRND Type III
(preserves SAN, IJV and
SCM)
• Indications:
▫ SAN, IJV, & SCM not
involved by tumor
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
Selective Neck Dissection
Posterolateral
Levels II-V
Postauricular nodes
Suboccipital nodes
Anterior
compartment
Level VI
Initial Diagnostic Tests
PGH (2008)
For all thyroid nodules:
Serum TSH
determination
Thyroid ultrasound
FNAB
PCS-PSGS-PAHNSI (2008)
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
Extent of Surgery
PGH (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.
PCS-PSGS-PAHNSI (2008)
Near total or Total Thyroidectomy
for WDTC
Total or near-total thyroidectomy
for multinodular goiter.
Lobectomy w/ isthmusectomy for solitary
benign thyroid nodule
Frozen Section
PGH (2008)
For non-diagnostic preoperative
FNAB
PCS-PSGS-PAHNSI (2008)
Limited utility in diagnosing thyroid
malignancies if the FNAB result show
follicular neoplasm, inadequate or
suspicious aspirate.
Lymph Node Dissection
PGH (2008)
Appropriate node dissection shall
be performed.
PCS-PSGS-PAHNSI (2008)
No mention.
Role of Radioactive Iodine Ablation
PGH (2008)
Lesion size >1 cm
Multifocal disease
Nodal metastases
Involved resection margins
Extrathyroidal or vascular
invasion
Aggressive histologies.
PCS-PSGS-PAHNSI (2008)
Beneficial for decreasing locoregional
recurrence and distant metastasis.
TSH 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.
External Beam Radiotherapy
PGH (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.
PCS-PSGS-PAHNSI (2008)
Indicated as part of the treatment of
WDTC when there is gross residual tumor
or invasion of adjacent structures, and
does not concentrate RAI.
Role of Chemotherapy
PGH (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.
PCS-PSGS-PAHNSI (2008)
Role of chemotherapy is unclear in
recurrent and metastatic WDTC.
Role of Post operative Thyroglobulin Assay
PGH (2008)
TSH stimulated serum
thyroglobulin should be measured
every 6-12 months.
PCS-PSGS-PAHNSI (2008)
The most important initial test to monitor
patients for residual or recurrent WDTC.
Role of Post operative Serum TSH
PGH (2008)
Maintained at 0.1 to 0.5
mU/L unless with
contraindications
PCS-PSGS-PAHNSI (2008)
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 1st yr and then
yearly thereafter
Post operative Role of Cervical UTZ
PGH (2008)
PCS-PSGS-PAHNSI (2008)
Evaluation of the thyroid bed, central Recommended for postoperative
and lateral node compartments
surveillance to detect recurrence in the
should be performed at 6 to 12 months thyroid bed and cervical nodes.
postoperatively, then annually for at
least 3 to 5 years for high risk patients.
Role of Post operative Whole Body Scan
PGH (2008)
Done after RAI
PCS-PSGS-PAHNSI (2008)
Limited 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.
Metastatic Work-up
PGH (2008)
No mention.
PCS-PSGS-PAHNSI (2008)
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.