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Sisson Symposium
Review Course for Residents and Fellows
Vancouver, BC
The rule of 20: Only 20% of the
people will remember 20% of what
you said 20 minutes after your
lecture.
Shaha’s Aphorisms
Thyroid Literature
Medline
Thyroid disease
Thyroid tumors
Trends in Incidence of Thyroid Cancer and Papillary
Tumors by Size in the United States
136,053
33,554
• New Paper on Thyroid Disease – Every 3 Hours
• New Paper on Thyroid Cancer – Every 8 Hours
Thyroid Google search
Thyroid Cancer Google search
36 million
21 million
Davies, L. et al. JAMA 2006;295:2164-2167.
1
Incidentaloma of the Thyroid
Clinical –
• Routine physical exam
• Obstetrics – Check up
• Pregnancy – Prenatal
Imaging –
• CT
• MRI – Trauma, cervical spine
• Ultrasound – Carotid, breast
PET Scan –
PET Incidentaloma
PET Associated Incidental Neoplasms
(PAIN)
Thyroid Cancer
A Unique Human Neoplasm
• Age is the most important prognostic factor
• No stage III & IV cancers in pts below 45
• Focal vs Diffuse Uptake
• 50% malignancy in patients with focal uptake
• Oncocytic pathology, tall cell or insular tumors
• Multicentricity of thyroid cancer is frequent –
no prognostic impact
Microscopic tumor – “laboratory cancer”
• Nodal metastasis has no impact on outcome
• Impact of extrathyroidal spread
• Grade of the tumor & histologic poorly
differentiated features
Katz/Shaha. J Am Coll Surg 2008
2
Surgical Principles
•
•
•
•
•
Evaluate the risk groups
Evaluate the prognostic factors
Evaluate the extent of disease
Evaluate extrathyroidal extension
Cost effective/Evidence based
management
• Avoid overtreatment and treatment
related surgical & medical complications
Minimally Invasive Surgery
•
•
•
•
•
•
•
•
Nodulectomy
Lobectomy / Isthmusectomy
Subtotal Thyroidectomy
Local anesthesia / regional block
Outpatient Surgery
23 hr discharge
Small incision surgery – 3-5 cm
Endoscopic - Video assisted
Cervical
Chest approach
Submammary
Transaxillary
• Robotic Transaxillary
• Bilateral Axillary Breast Approach (BABA)
• Transoral Thyroidectomy
Transrectal Thyroidectomy
3
Differentiated
Differentiated Thyroid
Thyroid Cancer
Cancer 1930-1985
1930-1985
Differentiated
Differentiated Thyroid
Thyroid Cancer
Cancer 1930-1985
1930-1985
SURVIVAL: Age
1
98%
< 45 yrs.
85%
0.8
70%
0.6
0.4
0
2
4
6
0.2
10
12
14
16
18
20
TIME (years)
0
2
0.8
4
6
8
10
12
14
16
18
20
TIME (years)
34%
94%
MSKCC-1038
MSKCC-1038pts.
pts. (DOD)
(DOD)
12
N0
0
2
4
87%
81%
Hurthle
65%
Papillary
810
Follicular 169
59
Hurthle
0.2
n=545
n=493
p < 0.025
0
6
8
10
12
14
16
18
20
0
2
4
6
8
10
12
14
16
18
20
TIME (years)
TIME (years)
MSKCC-1038
MSKCC-1038 pts.
pts. (DOD)
(DOD)
M0
MSKCC-1038
MSKCC-1038 pts.
pts. (DOD)
(DOD)
Differentiated Cancer of the Thyroid
Risk Group Definitions
14
16
18
M0
TIME (years)
0
20
M1
43%
n=993
n= 45
2
4
Low Risk
8
10
12
14
16
TIME (years)
MSKCC-1038
MSKCC-1038pts.
pts. (DOD)
(DOD)
High Risk
<45
<45
>45
Distant mets
M0
M+
M0
M+
Tumor size
T1/T2
(<4cm)
T3/T4
(>4cm)
T1/T2
(<4cm)
T3/T4
(>4cm)
Histology &
Grade
Papillary
Follicular
Papillary
&/or
high grade
p < 0.001
6
Intermediate Risk
Age (years)
>45
0.2
86%
52%
0.4
M1
10
94%
Papillary
87% Follicular
81%
0.4
N+
6
0.6
p < 0.001
8
0.8
p = n.s.
0.2
n= 86
4
82%
57%
0
2
N0
1
0.6
SURVIVAL:
SURVIVAL: Distant
Distant Metastases
Metastases
0
0
91%
0.6
Differentiated
Differentiated Thyroid
Thyroid Cancer
Cancer 1930-1985
1930-1985
88%
No extension n=952
Extension
0.8
SURVIVAL: Histology
87%
1 1 0.2
N+
n=192
MSKCC-1038
MSKCC-1038 pts.
pts. (DOD)
(DOD)
0.8
T4
1 0
Differentiated
Differentiated Thyroid
Thyroid Cancer
Cancer 1930-1985
1930-1985
0.4
0
SURVIVAL:
SURVIVAL: Extrathyroidal
Extrathyroidal Extension
Extension
95%
T1-3
0.6
59%
91%
> 4 cm
<= 4 cm n=846
> 4 cm
8
0.4
n=476
0
MSKCC-1038
MSKCC-1038 pts.
pts. (DOD)
(DOD)
p < 0.001
< 45 yrs. n=562
> 45 yrs.
72%
SURVIVAL:
SURVIVAL: Nodal
Nodal Status
Status
0.4
p < 0.001
0.2
>45 yrs.
0.6
96%
1 97%
< 4 cm
0.8
Differentiated
Differentiated Thyroid
Thyroid Cancer
Cancer 1930-1985
1930-1985
Differentiated
Differentiated Thyroid
Thyroid Cancer
Cancer 1930-1985
1930-1985
SURVIVAL:
SURVIVAL: Tumor
Tumor Size
Size
Differentiated Thyroid Cancer 1980-1980
SURVIVAL: Lobectomy vs. Total
18
20
Follicular
&/or
high grade
Indications for
Total Thyroidectomy
Low Risk Group
• Grossly palpable disease in both lobes
PROPORTION SURVIVING
1
100%
99%
0.8
• High risk patient with high risk tumor
• Radiated patient
0.6
• Young patient with large nodal metastasis
to facilitate RAI
0.4
Lobectomy n = 276
0.2
Total n = 90
• Patient with distant metastasis likely to
require RAI
0
0
5
10
15
20
TIME (years)
4
Management Guidelines for Patients with Thyroid
Nodules and Differentiated Thyroid Cancer
Let the
punishment fit
the crime.
Estimating Risk of Recurrence
2009 Update
Intermediate Risk
Low Risk
Classic PTC
No local or distant mets
Complete resection
No tumor invasion
No vascular invasion
If given, no RAI uptake
outside TB
Microscopic ETE
Cervical LN mets
Aggressive Histology
Vascular invasion
High Risk
Macroscopic gross ETE
Incomplete tumor resection
Distant Mets
Inappropriate Tg elevation
Increasing Incidence of Total
Thyroidectomy
• Preop U/S showing bilateral nodules
• Preop consultation with Endocrinologist
suggesting total and RAI
• Patients perceive fear of recurrence and paper
confirmation of negative scan
• Thyroglobulin follow up
• Follow up with repeated U/S showing tiny
nodules (Hashimoto’s)
• Dr. Google
Extent of tracheal involvement
5
Management of Neck in Thyroid Cancer
Clinically Negative
Intraoperative Management
Good judgment comes
from experience;
and experience comes
from bad judgment!
• Look for TE groove nodes
• Look for sup mediastinal nodes
• Look for jugular nodes
• If any of these enlarged - do the
respective clearance
• Central compartment clearance
Management of Neck in Thyroid Cancer
Clinically Positive
Intraoperative Management
• “Berry picking” not recommended,
higher incidence of neck recurrence
• Modified neck dissection
• Preserving SCM
IJV
Accessory nerve
Submandibular sal gland (Level I)
• RND - rarely indicated
Elective ND
Radical ND
U/S & U/S FNA
No clinical finding
Rising TGB
No prognostic
implication
Thyroglobulin
follow-up
Only therapeutic ND
Clinical
follow-up
Central compartment ND
6
Continuum of Papillary Thyroid
Cancer
Classic PTC
Patients with multiple positive neck
nodes from papillary ca may have
additional paratracheal, sup
mediastinal, or lateral neck nodes,
and may remain with persistent mild
hyperthyroglobulinemia. We may not
achieve biochemical cure.
Tall Cell Variant
Moderately Differentiated
Poorly Differentiated
Anaplastic
FDG PET Positivity
RAI Avidity
Shaha, 2004
Thyroid Cancer
Thyrogen - Recombinant
TSH
• No need to make patients hypothyroid
MSKCC Experience
• Ease of treating with RAI
RAI
0
• Can be done post-op/follow-up
• Low iodine diet
Levothyroxine Withdrawal
Traditional
thyroid
hormone
withdrawal
(Prior to 1999)
rhTSH
Stimulation
(1999-2000)
4 wks
6 wks
Levothyroxine Suppression
Mon
Tue
Wed
Thur
Fri
7
ADJUSTED CLINICAL OUTCOMES FROM
THYROIDECTOMY
BY SURGEON VOLUME GROUP
A 1-9
cases
Outcomes
Complication rate
Unadjusted (%)
Length of stay
Unadjusted (days)
Surgeon Volume Groups
B10-29 C30-100 D>100
cases
cases
cases
10.1
6.7
6.9
5.9
2.8
2.1
2.2
1.7
Sosa, Udelsman, et al. Ann Surg 1998.
Thyroidectomy
Medical malpractice and the thyroid gland
Lydiatt DD. Head Neck 25:429-431, 2003.
• Jury verdict reviews from 1987-2000 were obtained from a
computerized database
• 30 suits from 9 states occurred
• Plaintiffs were women in 80% of the cases, with a mean
age of 41
• 50% of pts (15 of 30) had a bad outcome, (9 of 30 dead, 4
of 30 with neurologic deficits, 1 blind & 1 alive w/ cancer)
• 30% alleged surgical complications, most RLN injury, and
75% of cancer pts alleged a delay, either through falsely
negative biopsies or no biopsy taken
• Respiratory events occurred in 43% and frequently
resulted in large awards
Technique of Thyroidectomy
RLN Injury
• In the TE groove
(nodal dissection)
• At the crossing of
the inferior thyroid
artery
• Near the ligament of
Berry – small vessels
Traversing: Bipolar cautery
Amelita Galli-Curci
Dissection of the superior thyroid vessels parallel to the vessels on
surface of thyroid & exposure of SLN
Shaha A. J Surg Onc, 1993.
8
Guidelines to Parathyroid
Preservation
• Good exposure, light, hemostasis
• Recognition of parathyroids - color, size, location
• Meticulous dissection
• Identify and protect the blood supply to parathyroids
• Ligate inferior thyroid artery close to thyroid
• Autotransplantation
Thyroid Cancer
20 yr
survival
Good
99%
Lobectomy.
Appropriate surgery
based on extent of
disease.
85%
Total thyroidectomy.
Select extent of
thyroidectomy based
on extent of disease.
RAI in select cases.
Low
Bad
Intermediate
Ugly
57%
High
Treatment
Total thyroidectomy.
RAI.
Ext RT in selected
cases.
Surgeon
Complications
Institutional
philosophy
Endocrinologist
Thyroid ca
patient (Internet)
Nuclear Physician
THE BOSS!
9
Thyroid Cancer
Call: 1-800-ARSHAHA
10