Surgical Management of Surgical Management of Differentiated Thyroid Cancer Differentiated Thyroid Cancer Vanderbilt University Surgical Grand Rounds Carmen C Solórzano, MD, FACS Associate Professor Endocrine and Surgical Oncology Vanderbilt University Nashville, TN May 7, 2010 May 7, 2010
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Surgical Management of Differentiated Thyroid Cancer · 2016-11-21 · • A non-palpable thyroid nodule was found in the contralateral lobe in 38%Æ56% were malignant (vs. 14% if
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Surgical Management of Surgical Management of Differentiated Thyroid CancerDifferentiated Thyroid Cancer
Vanderbilt UniversitySurgical Grand Rounds
Carmen C Solórzano, MD, FACSAssociate Professor
Endocrine and Surgical OncologyVanderbilt University
Trends in Incidence of Thyroid Cancer (1973-2002) and Papillary Tumours by Size (1988-2002) in the USA (SEER)
Davies, L. et al. JAMA 2006;295:2164-2167
Thyroid cancer has the fastest rising Thyroid cancer has the fastest rising incidence of all major cancers in the USA incidence of all major cancers in the USA
>350% since 1950>350% since 1950
Thyroid Cancer Incidence and Mortality1973-2002
0.45 deaths per 100,000 in 20030.45 deaths per 100,000 in 2003
Increasing Incidence: Why?
• Radiation• Iodine excess/deficient states• Reproductive/hormonal factors• Early detection of subclinical disease
…but the incidence has increased across all tumor sizes
•• Risk factors and molecular Risk factors and molecular mechanisms/markersmechanisms/markers
•• Natural history, patterns of failure and Natural history, patterns of failure and pretreatment staging pretreatment staging
•• Surgical treatmentSurgical treatment
•• Rationale for adjuvant therapyRationale for adjuvant therapy
OutlineOutline
The “Thyroid Nodule”
• Prevalence- 5% of US population (15 million)• 50% if thyroid examined by Ultrasonography
Thyroid carcinoma is uncommon:Lifetime risk of thyroid cancer
0.83% women and 0.33% men
Horner- SEER review 1975-2006
ATA guidelines 2009
Thyroid CancerRisk factors- Environmental
• Exposure to radiation is the only established environmental risk factor
1-Medical sources2-Acute environmental exposure:
nuclear fallout, weapons
1 100 thyroid cancer cases in 1,000,000Nagataki Thyroid 2002
Few patients with these syndromes develop thyroid cancer
Thyroid CancerMolecular mechanisms/markers:•• Activation of Activation of BRAF BRAF --(PTC)(PTC)•• Rearrangements of Rearrangements of RET/PTC RET/PTC --(radiation (radiation
exposure and younger pts)exposure and younger pts)•• Activation of Activation of RASRAS-- (FVPTC)(FVPTC)•• Rearrangement of PAX8/PPARRearrangement of PAX8/PPARˠɣ
Presenting Features • 30 and 50 yrs of age (mean 45 yrs) • Female predominance: 60% to 80% • Primary tumors: 1 to 4 cm• 28% multi-focal• Extra-thyroidal invasion of adjacent soft
tissues: about 15%• 30-40% may have lymphadenopathy at
presentation• 2% distant metastases
Generally indolent tumor with low metastatic Generally indolent tumor with low metastatic potentialpotential
Recurrence 30%Recurrence 30% (loco(loco--regional or distant regional or distant metsmets) )
Death in approximately 8%: pulmonary Death in approximately 8%: pulmonary metsmets and/or airway obstructionand/or airway obstruction
Overall 10 year survival: Overall 10 year survival: Papillary 93%Papillary 93% Follicular 85% Follicular 85% HurthleHurthle 76%76%
Natural history and patterns of Natural history and patterns of treatment failuretreatment failure
HundahlHundahl Cancer 1998Cancer 1998
Many Staging ClassificationsThe most predictive prognostic factors:
AgeExtent of tumorPresence of distant metastasisHistology- variants
52,173 patients; 83% total thyroidectomyFor all tumors >1cm, and for tumors 1-2 cm, total thyroidectomy associated with improved survivalReinforces the current common practice
• 134 patients total thyroid, central and lateral neck dissection
• The ipsilateral lateral compartment involved as often as the central (lat 29% vs. central 32%); re-ops (lat 21% vs. central 37%)
• The ipsilateral central compartment most common site for LN mets
• Patients who have central lymph node mets have at least a 70% chance of ipsilateral lateral LN involvement Marchens, Surgery 2009; 145;175-81
Marchens WJS 2002;26:22-8
Lymph Node Metastases in PTCLymph Node Metastases in PTC
• Cervical LN metastases are quite common 20-50%
• Micro-metastases -present in 90%• Lymph node metastases in PTC
significantly correlate with persistence and recurrence of PTC
• Lymph node metastases and their effect on mortality remains controversial
Lymph Node Metastases in PTCLymph Node Metastases in PTC
• Making evidence based recommendations for the treatment of LN metastases is challenging– Studies are retrospective– Indolent disease– Heterogeneity of literature (use of
ultrasound, terminology, prophylactic vs. therapeutic… etc)
The argument against prophylactic (elective) LN dissection
of the central compartment• Lymph node metastases have no
impact on cause specific mortality or recurrence
• More radical surgery greater morbidity (hypoparathyroidism and permanent nerve injury)…
The argument in favor of prophylactic (elective) LN dissection
of the central compartment• Even experienced surgeons can not tell
if lymph nodes are affected• May reduce recurrence/persistence• May improve survival • Re-operations in the central neck are
morbidNoguchi Arch Surg 1998;133:276
White W J Surg 2007; 31:895Sywak, Surgery 2006
Tisell et al. WJS 20:854-859, 1996Zaydfudim et al. Surgery 144: 1070, 2008
Historical Perspective• 1950’s –Frazell, Foote Jr, Crile Jr- ? the need
for radical and then prophylactic neck dissections
• 1970’s- Shiro Noguchi- 90% of PTC patients already have lymph node micromets- ? the need for routine dissections- unless gross disease, >40 yo or >1.5 cm
• 1977- Ernest Mazzaferri- neck dissections do not influence recurrence or survival- extent of thyroidectomy and RAI treatment does
Historical Perspective Cont…• 1980-90’s-The great debates
Hay/Cady/Shaha about Total thyroid vs. lesser…no mention of neck dissections
• 2000’s-Ultrasound and Thyroglobulin- The goal posts have changed position!
HAVE WE EVOLVED OR, HAVE WE MERELY COME FULL CIRCLE?
Zeiger JSO 2010
Extent of Central LN Dissection The New Paradigm!
R27R27……Prophylactic central compartment Prophylactic central compartment neck dissection (ipsilateral or bilateral) may neck dissection (ipsilateral or bilateral) may be performed in patients with PTC with be performed in patients with PTC with clinically uninvolved central neck lymph clinically uninvolved central neck lymph nodes, especially for advanced primary nodes, especially for advanced primary tumors (T3 or T4)tumors (T3 or T4)……
American Thyroid Association: American Thyroid Association: Thyroid Cancer GuidelinesThyroid Cancer Guidelines--R27 R27 Thyroid Thyroid 20092009
Recommendation R27 should be interpreted in light of available expertise
““Prophylactic central neck dissection can be Prophylactic central neck dissection can be considered but is not required in all casesconsidered but is not required in all cases””
National Cancer Center Network-Guidelines 2010
Extent of Central LN Dissection The New Paradigm!
Extent of LN Dissection The punch line!
• Obvious gross lymph node disease in the central compartment should be removed with a therapeutic central LN dissection
• Level VI central neck dissection can be achieved with low morbidity**
• Prophylactic (elective) central dissection? controversial
Gemsenjager JACS 197:182-190, 2003Tisell et al. WJS 20:854-859, 1996** in experienced hands** in experienced hands
Extent of LN Dissection The punch line continued!
• Lateral LN disease when evident clinically, on ultrasound or at the time of surgery should be treated with a functional compartment directed dissection (levels II-V)
• The level VI (central) lymph nodes should also be dissected
• NO BERRY PICKING Tisell et al. WJS 20:854-859, 1996
Musacchio Am Surg. 2003;69(3):191-196
Central and lateral neck dissectionCentral and lateral neck dissection
•• Risk factors and molecular mechanisms Risk factors and molecular mechanisms of tumor developmentof tumor development
•• Natural history/patterns of failure Natural history/patterns of failure
•• Pretreatment staging Pretreatment staging
•• Surgical treatmentSurgical treatment
•• Rationale for adjuvant therapyRationale for adjuvant therapy
OutlineOutline
• Extent of the initial surgical procedureThyroid remnantAdequate lymph node removal
JonklaasJonklaas Thyroid 2006Thyroid 2006Outcomes of patients with DTC following therapyOutcomes of patients with DTC following therapy
TSH suppression
• For high risk patients- YES <0.1 mIU/L• For low risk patients- NO• Moderate suppression for intermediate
risk• Duration?
ConclusionsConclusions
Surgeons play a key role in the Surgeons play a key role in the management of thyroid cancermanagement of thyroid cancer
•• Staging, performing or completing Staging, performing or completing adequate thyroid cancer removaladequate thyroid cancer removal
•• Member of the multidisciplinary team Member of the multidisciplinary team –– Help with surveillance and removal of Help with surveillance and removal of recurrent diseaserecurrent disease
THANK YOUTHANK YOU
Ann Ann SurgSurg 2007200752,173 patients in NCDB52,173 patients in NCDB
For his work on the physiology, pathology, For his work on the physiology, pathology, and surgery of the thyroid glandand surgery of the thyroid gland
Emile Theodor KocherEmile Theodor Kocher
Nobel Prize 1909Nobel Prize 1909
Resident performing endocrine surgeryResident performing endocrine surgery
High incidence of cervical LN High incidence of cervical LN metsmets at diagnosisat diagnosis
ACS ACS CoCCoC patient care evaluation study patient care evaluation study 55835583 cases of cases of thyroid cancerthyroid cancer--
Extent of lymph node dissectionExtent of lymph node dissectionA current controversy!A current controversy!
Type % No LN evaluated
% <1cm
Papillary 54 27Follicular 77 6Hurthle 71 3
Medullary 40 11
HundahlHundahl, Cancer 2000; 89:202, Cancer 2000; 89:202--217217
DFS following RAI: U of Chicago
0
20
40
60
80
100
120
5 10 15 20 25 30 35
RAI no RAI
DeGroot, JCEM 1990;71:414N = approx. 200
Surgeryalone
RAI
U of C stage I and II (intrathyroidal or N1) with T > 1cm
% D
isea
se F
ree
(DFS
)
years
DFS following TSH suppression
0
20
40
60
80
100
120
0 5 10 15
TSH <0.1 TSH>1.0
Pujol, JCEM 1996;81:4318.Stage of disease variable
years
% D
isea
se F
ree
TSH suppression as a determinant of recurrence: 70% papillary
TSH < 0.1 (N=18)
TSH > 1.0 (N=15)
Treating Thyroid Cancer…Start with the end in mind!!!
Non-palpable contra-lateral nodule found by SUS
N=27(38%)
Non-palpable contra-lateral nodule found by SUS
N=27(38%)
No contra-lateral nodule found by SUSN=32
No contra-lateral nodule found by SUSN=32
Total thyroidectomy
N=25
Total thyroidectomy
N=25
Thyroid lobectomy
N=2
Thyroid lobectomy
N=2
14/25 (56%)cancer in
contralaterallobe nodule
14/25 (56%)cancer in
contralaterallobe nodule
Total thyroidectomy
N=28
Total thyroidectomy
N=28
Thyroid lobectomy
N=4
Thyroid lobectomy
N=4
4/28 (14%)cancer in
contralateral lobe
4/28 (14%)cancer in
contralateral lobe
72 patients with thyroid cancer SUS evaluation of contra-lateral lobe72 patients with thyroid cancer SUS evaluation of contra-lateral lobe
SUS identified nonSUS identified non--palpable lymph node metastasis in 24%palpable lymph node metastasis in 24%
Evaluation of Lymph Nodes and the Contralateral Lobe by SUS
Historical Perspective
…“The general lack of a great body of material for prolonged follow-up studies emphasizes the need for extreme caution in making all-inclusive pronouncements of a prognostic nature about a form of cancer in which the most noteworthy attribute is extreme chronicity”…
FrazellFrazell and and FooteFoote Cancer 1958;11:895Cancer 1958;11:895Memorial Center for Cancer and Allied Memorial Center for Cancer and Allied DzDz--NYNY