Download Risk stratification method for thyroid cancer

RISK STRATIFICATION METHOD
FOR THYROID CANCER
Sunarto Reksoprawiro
Division of Head & Neck Surgery, Department of Surgery
Faculty of Medicine-Airlangga University/ Dr. Soetomo Hospital
Surabaya, Indonesia
INTRODUCTION
THYROID CANCER
 Incidence : 1.2 to 2.6 per 100,000 (men) and
2.0 to 3.8 per 100,000 (women)
 >90% of tumors are differentiated thyroid
cancer
 Some prognostic scoring systems do not
differ between PTC and FTC
 PTC accounts for at least 70% of all DTC
 10% of patients would eventually die of the
disease and an even greater proportion would
face the morbidity of recurrences.
 A number of studies have identified various
clinicopathologic predictors for PTC and
devised risk-group stratification or staging
systems
 Age, gender, histological type, tumour size
and extrathyroidal invasion have been found
previously to be associated with a poor
clinical outcome
 The prognostic impact of regional lymph
node metastases is still a controversial issue
 Distant metastases is a recognized factor for
a poor prognosis
• There are conflicting thoughts over different
aspects of treatment of differentiated thyroid
cancer
• The lack of consensus stems due to the
absence of concrete data from randomized
controlled trials
• Surgery with or without radio-iodine therapy
forms the mainstay of treatment of
differentiated thyroid cancers
STAGING SYSTEMS
 Many scoring or staging systems have been
developed during the last two decades
 The most commonly used staging
classifications are AMES , AGES , MACIS ,
EORTC , and UICC-TNM
STAGING SYSTEMS
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European Organization for Research and Treatment of Cancer (EORTC)
Mayo Clinic (Age, Grade, Extent, Size or AGES)
Lahey Clinic (Age, Metastases, Extent, Size or AMES)
University of Chicago (Clinical Class)
Karolinska Hospital and Institute (DNA ploidy, Age, Metastases, Extent, Size or
DAMES)
Mayo Clinic (Metastases, Age, Complete resection, Invasion, Size or MACIS)
University of Bergen (Sex, Age, Grade or SAG)
Ohio State University (OSU)
Noguchi Thyroid Clinic (Noguchi)
Memorial Sloan Kettering (Grade, Age, Metastases, Extent, Size or GAMES)
University of Munster (Munster)
National Thyroid Cancer Treatment Cooperative Study (NTCTCS)
University of Alabama and M.D. Anderson (UAB &MDA)
Virgen de la Arrixaca University at Murcia (Murcia)
AJCC/UICC 6th edition TNM (TNM)
Cancer Institute Hospital in Tokyo (CIH)
Ankara Oncology Training and Research Hospital in Turkey (Ankara)
Degroot
• There was no difference in the abilities of the
top five classifications (AGES, TNM, EORTC,
MACIS and AMES) to predict the prognosis
for patients with differentiated thyroid
carcinoma, and no statistically significant
superiority of any system over the TNM
classification was found
• Brierley JD, Panzarella T, Tsang RW, Gospodarowicz
MK & O’Sullivan B. A comparison of different
staging systems predictability of patient outcome.
Cancer 1997;79:2414–2423.
 There is no difference in tumor-specific
survival between PTC and FTC when
accounting for the presence of metastases,
age, tumour size, and the presence of
extrathyroidal invasion
 Verburg A, Mäder U, Luster M & Reiners C. Primary
tumor diameter as a risk factor for advanced disease
features of differentiated thyroid carcinoma. Clin
Endocrinol 2009;71: 291–297
 Age at presentation is a well-established
strong prognostic factor for differentiated
thyroid carcinoma
 Cady B & Rossi R. An expanded view of risk-group
definition in differentiated thyroid carcinoma.
Surgery 1988;104 :947–953.
 Gender proved to be of prognostic value for
disease-free survival, which was shorter for
males than for females
 Jukkola A, Bloigu R, Ebeling T & Salmela P.
Prognostic factors in differentiated thyroid
carcinomas and their implications for current
staging classifications. Endocrine-Related Cancer
2004;11:571–579
 Tumor extension beyond the thyroid capsule
(pT4) is described as being one of the
strongest prognostic factors in DTC,
therefore resulting in its use in most staging
systems
 Lerch H, Schober O, Kuwert T & Saur HB. Survival of
differentiated thyroid carcinoma studied in 500
patients. J Clin Oncol 1997;15:2067–2075.
• In some, but not all, studies, local lymph node
involvement has been associated with an increased
risk of tumour recurrence and also with DTC-related
mortality
• Mazzaferri EL & Young EL. Papillarythyroid carcinoma: a 10
year follow-up report of the impact of therapy in 576 patients.
Am J Med 1981;70:511–51
• In patients > 45 years of age, involvement of cervical
lymph nodes was associated with a poorer prognosis
in PTC and FTC patients
• Passler C, Scheuba C, Prager G, Kaczirek K, Kaserer K, Zettinig
G, and Niederle B. Prognostic factors of papillary and follicular
thyroid cancer: difference in an iodine-replate endemic goiter
region. Endocrine-Related Cancer 2004;11:131-139
 The diameter of the primary tumour is a
determinant (independent predictor) for
outcome in differentiated thyroid cancer.
However, the delineation between low-risk
and high-risk tumour size is unsettled.
 Mazzaferri & Kloos
 Machens et al.
 Verburg et al.
: 4 cm
: 2 cm
: 1 cm
Table 1. Risk of Death From Thyroid Cancer (Tuttle et al)
Very Low risk
Low Risk
Intermediate Risk
High Risk
Age at diagnosis
< 45 years
< 45 years
Young patients (< 45 years)
Classic PTC > 4 cm
Or vascular invasion
Or extrathyroidal extension
Or worrisome histology of
any size‡
> 45 years
Primary tumor size
< 1 cm
1–4 cm
Older patients (> 45 years)
Classic PTC < 4 cm
Or extrathyroidal extension
Or worrisome histology
< 1–2 cm confi ned to the
thyroid‡
> 4 cm classic PTC
Histology
Classic PTC, confined Classic PTC, confined to Histology in conjunction Worrisome histology
to the thyroid gland*
the thyroid gland*
with age as above
> 1–2 cm‡
Completeness
resection
of Complete resection
Lymph
node None apparent
involvement
Distant metastasis
None apparent
Complete resection
Complete resection
Incomplete
resection
tumor
Present or absent†
Present or absent†
Present or absent†
None apparent
None apparent
Present
REVISION SURGERY
Pathology review
USG neck
Evidence of lobectomy + isthmectomy or large thyroid remnant
Unfavorable histology
Multifocal disease
Positive margin
Age > 50 years
Male sex
Nodule > 4 cm
Nodule metastasis
Completion thyroidectomy
Low risk group (using presurgery criteria)
observe
If USG insignificant thyroid remnant
RI scan
Significant uptake >15%
Completion thyroidectomy
Low uptake <15%%
RI ablation
Frequency of thyroid carcinoma
Dr.Soetomo Hospital Surabaya (2007-2011)
N= 284 cases
Fig.1. Sex distribution
n = 284
Fig.2. Sex and age distribution
n = 284
Fig.3. Metastases
n = 284
Prognostic Factors
 AMES
Low risk
 Age
 Metastases
 Extension
 Size
: < 40 yrs (male); < 50 yrs (female)
: None
: No extrathyroid extension
: < 4 cm
Fig.4. Risk stratification
n = 284
Fig.5. Treatment
n = 284
Fig.6. Surgical treatment
n = 221
Fig.7. Surgical complication
0.51%
0.51%
0.51%
0.51%
0.51%
n = 195
Fig.8. Completion thyroidectomy
n= 57
Fig.9. Histopathology
n = 284
Fig.10. Mortality in hospital
n = 284
SUMMARY
 A number of risk-group stratification have been
found useful at stratifying patients with
differentiated thyroid carcinoma into risk groups
 Significant risk factors were age, primary tumor
size, histology, grade, local tumor extension,
completeness of resection, and distant
metastasis.
 Aggressive surgical resection was recommended
for all gross disease in high risk and intermediate
risk patients. The standard treatment for high
risk patients are total thyroidectomy followed by
I131 ablation and TSH suppression with thyroxin.
 Well-differentiated thyroid cancer in low risk
patients has a favorable outcome and can be
safely treated with unilateral thyroidectomy
alone.
 Postoperatively, the patient’s operative and
pathology records should be studied to re-assess the
risk-group of the patients.
 Appropriate selection of surgical and adjuvant
treatment should therefore be used based on
prognostic factors and risk group stratification.
Thank you