Tumor Board

1
Tumor Board

• Rummana Aslam, MD
• 10/28/08

2

• AS 37 y/o WF of Russian origin referred for a
  biopsy proven papillary carcinoma in the left
  lobe of the thyroid
• She had h/o hypothyroidism and multinodular
  goiter for last 10 years
• Recently she had ultrasound of thyroid and had a
  FNA
• She has no symptoms of fatigue, heat or cold
  sensation or headaches and no radiation exposure.
  She had irregular periods.

3

• Past Medical and Past surgical history none
  except above
• Medications Levothyroxine 50 micrograms
• No allergies and transfusions
• Social married with one son and is a research
  scientist
• No family history of thyroid cancer. Mother had
  stomach cancer. Father had kidney and panc
  cancer. Maternal grandmother had kidney cancer
• Pertinent physical exam finding moderately
  enlarged thyroid with a prominent nodule below
  the isthmus around 1.5 cms. Nodular thyroid.
  Right post triangle neck 0.5 cm LN palpable. No
  thyroid bruit

4

• Biopsy of left thyroid nodule by FNA papillary
  thyroid carcinoma
• Blood tests normal including T4 and TSH
• Taken to OR last week

5
Extent of Surgical Treatment Total VS Partial
Thyroidectomy

• 1909 Theodor Kocher was awarded Nobel prize for
  his contributions in the fields of pathology,
  physiology and surgery of the thyroid gland
• Almost 100 years ago the discussion on the extent
  of thyroid resections for benign and malignant
  thyroid diseases started and, until now, this
  question has been addressed in many retrospective
  studies, but remains controversial

Weber et al. Current Opinion In Internal Medic.
2006
6
Surgical Treatment of Papillary And Follicular
Thyroid Carcinoma

• For differentiated thyroid carcinoma, guidelines
  composed by dedicated experts in the fields of
  endocrinology and endocrine surgery recommend
• Lobectomy for suspicious thyroid nodules,
  minimally invasive differentiated thyroid
  carcinomas smaller than 1 cm which do not extend
  beyond the thyroid capsule

AACE/AAES medical/surgicalguidelines for clinical
practice management of thyroid carcinoma.
Endocrine Practice.2001
7

• Total or near-total thyroidectomy is the
  preferred operation for high-risk patients with
  PTC and FTC, when the tumor extends beyond the
  thyroid capsule or local or distant metastasis
  are present
• Enlarged lymph nodes in the central and lateral
  compartment of the neck should be removed by
  systematic modified-radical or functional neck
  dissection

8

• Classification of patients into high or low-risk
  groups might be difficult
• Due to lack of prospective randomized trials the
  surgical therapy of DTC remains an ongoing
  controversy

9
Recent Literature

• Extent of Surgery Affects Survival for Papillary
  Thyroid Cancer
• BIlimora et al. Annals of Surgery. 2007
• Objectives
• Whether total thyroidectomy for PTC resulted in
  improved recurrence and long-term survival rates
  for patients with PTC
• Whether a specific tumor size threshold could be
  identified above which total thyroidectomy was
  associated with a decreased risk of recurrence
  and death

10

• Method from the National Cancer database
  (1985-1998) 52,173 patients underwent surgery for
  PTC
• 43,227 underwent total thyroidectomy and 8946
  underwent lobectomy
• Results for PTC lt 1 cm extent of surgery did not
  impact recurrence or survival (p0.24, p0.83)

11

• For tumors gt 1 cm lobectomy resulted in higher
  risk of recurrence and death (p 0.04, p0.04)
• Limitations of the study
• Analysis using administrative databases and
  cancer registeries
• Information on extrathyroidal extension not
  available
• 56.2 of patients were reported to have received
  RAI
• Hospitals were cancer hospitals, a potential
  selection bias

12

• Kim et al. Arch Surg. 2004
• Retrospective study describing significantly
  better survival rates for patients with PTC over
  60 years of age with total thyroidectomy compared
  with lobectomy
• Haigh et al. Arch Surg Oncol. 2005
• Evaluated retrospectively the effect of total and
  partial thyroidectomy by using the NCI database
  on 5432 patients with PTC. Overall survival was
  93 at 5 years and 86 at 10 years 10 year
  survival rate was 89 in the low-risk group and
  73 in the high-risk group
• After a mean follow up of 7.4 years survival of
  patientrs with PTC was not significantly
  influenced by the extent of thyroidectomy

13

• Jukkola et al. Endocrine-related Cancer. 2004
• Found significantly longer recurrence-free
  survival rates for total thyroidectomy in
  patients with papillary and follicular thyroid
  cancer
• Cushing et al. Laryngoscope 2004
• showed a significant effect of total
  thyroidectomy on disease recurrence but not on
  cause-specific mortality rates in differentiated
  thyroid carcinoma

14
Classification of Neck Dissections

• Radical neck dissection Levels I to V dissected,
  including resection of the internal jugular
  vein,sternomastoid muscle and accessory nerve
• Modified neck dissection Levels I to V dissected
  but preserving one or more of the accessory
  nerve, internal jugular vein or sternomastoid
  muscle
• Selective neck dissection Denotes preservation
  of one or more lymph node groups (levels I to V)
  and preservation of the accessory nerve, internal
  jugular vein and the sternomastoid muscle

15
Lymph Node dissection in Differentiated Thyroid
carcinoma

• Lymph node metastasis in PTC are found in 40-60
  of the patients
• FTC lymph node involvement is 15-19
• Systematic lymphadenectomy of the central or
  lateral compartment of the neck is recommended if
  a suspicious node is detected by ultrasound
• A functional lymph node resection (berry
  picking) is less effective and may complicate
  further operations
• Previous studies have failed to show a
  correlation between cervical metastasis and
  survival

16

• Regional Metastasis in Well-Differentiated
  Thyroid Carcinoma Pattern of Spread
• Yanir et al. The Laryngoscope. 2008
• Evaluated the pattern of spread to regional lymph
  nodes metastasis of WDTC in patients with
  clinically positive nodes
• Retrospective chart review. 28 neck dissections
  with a mean follow up of 33.7 months. 24 with
  papillary carcinoma and follicular carcinoma in 3
• All patients underwent a total thyroidectomy and
  SND

17
Results Mean number of nodes in ND specimen
6.7 Predominant site of metastasis level VI -
95 Level III 68 Level IV 57 Level II 54
18

• IS Radical Neck Dissection a Current Option for
  Neck Disease?
• Ferlito et al. The laryngoscope. October 2008
• At present conventional RND (MRND) are no longer
  indicated for elective neck dissection
• The cancers of the head and neck do not involve
  all levels and sublevels of the lateral neck
• SND is being implemented as an oncologically safe
  and effective procedure for multiple N disease
  while limiting morbidity

19

• Urono et al.Surgery today. 2004
• Found prognosis after re-operation for local
  recurrence of PTC was better after an SND
• Thompson et al. World J Surg. 2004
• 21 studies on childhood PTC 1800 cases
• Based on their data, authors recommend total or
  near total thyroidectomy and a SND for children
  with papillary carcinoma

20

• Conclusion
• For differentiated thyroid carcinoma (larger than
  1 cm) total or near-total thyroidectomy and
  central neck dissection might reduce local
  recurrence.
• The influence of these procedures on survival
  rates still remains questionable