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Thyroid Cancer
Well differentiated and poorly differentiated
Endemic Goiter
No longer a problem in the US and the developed world Still a serious health concern in parts of the world with iodine deficiency including mountainous areas or areas with high rainfall/flooding
Kaplan, E. et al. Thyroid Disease Manager Surgery of the Thyroid Gland Chapter 21, May 99
Thyroid Carcinoma
Incidence
Thyroid carcinoma occurs relatively infrequently compared to the common occurrence of benign thyroid disease Thyroid cancers account for only 0.74% of cancers among men, and 2.3% of cancers in women in the US The annual rate has increased nearly 50% since 1973 to approximately 18 000 cases
Kim N, et al. Otolaryngol Clin North Am. 2003;36:17-33. Braverman LE, Utiger RD, eds. Werner & Ingbars The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000. Castro MR, et al. Endocr Pract. 2003;9:128-136.
Thyroid Ultrasonography
Thyroid Ultrasonography
Thyroid Ultrasonography
Certain features may suggest greater risk of cancer:
Irregular or poorly defined borders of nodule Lack of a "halo Hypo-echogenicity Evidence of microcalcifications Increased blood flow Growth and interval change on serial ultrasounds
RAI imaging
Formerly had been used extensively in the initial work up of nodular thyroid disease
FNA is now considered the gold standard
RAI imaging
The problem:
Although hot nodules are usually never cancer, only 5% of all nodules are hyperfunctioning The remaining 90-95% that are warm or cold could be cancer and thus require FNA
RAI imaging
Circumstances where RAI imaging may be useful and indicated:
Suppressed TSH (more likely to have a autonomously functioning nodule) Multiple nodules, none dominant Other
Thyroid FNA
Now considered the most cost effective and sensitive/specific diagnostic test of thyroid nodules
The use of US has expanded the role of FNA in evaluating nodules and improved the validity of the results
Thyroid FNA
Benign: 70 -75 %
Malignant: Up to 5%
Suspicious: About 10% Nondiagnostic: About 10 - 20%
Thyroid FNA
Limitations
False negatives: (< 5% of FNA) more likely in large (>4cm) or small (<1cm) nodules Suspicious FNA (Follicular and Hurhtle cell neoplasm): cannot distinguish benign vs malignant of hypercellular nodules by FNA alone, ALWAYS require surgical pathology for dx (up to 10 30% of these will be CA) Non-diagnostic results: NEVER consider equivalent to benign, up to 10% of ND FNA will contain CA on resection
Malignant:
Surgery and RAI ablation
Suspicious FNA
About 10% of all FNA results CANNOT distinguish benign vs malignant of hypercellular nodules (follicular/Hurthle cell) by FNA alone ALWAYS require surgical resection for dx Up to 10 30% of these will be malignant
Non-diagnostic FNA
About 15% of all FNA results NEVER consider equivalent to benign FNA Up to 10% of ND FNA will contain CA on resection Be very cautious of a pathology report: consistent with benign colloid nodule; if limited/no follicular epithelial cells noted, then this is a ND FNA rather than benign
Thyroid Carcinoma
Kim N, et al. Otolaryngol Clin North Am. 2003;36:17-33. Thyroid Disease Manager Web site. Available at: http://www.thyroidmanager.org. Accessed December 10, 2003. Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463.
50
100
150
200
250
Cancer facts and figures. American Cancer Society Web site. Available at: http://www.cancer.org/downloads/ STT/CAFF2003PWSecured.pdf. Accessed December 10, 2003.
Anaplastic: develops from existing papillary or follicular cancers; aggressive, usually fatal
Lymphoma: develops from lymphocytes; uncommon
Detailed guide: thyroid cancer. American Cancer Society Web site. Available at: http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=43. Accessed December 10, 2003.
Usually stays in the thyroid gland, but can spread to the bones, lungs, and central nervous system
Usually does not spread to the lymph nodes
Thyroid gland disorders. Beers MH, Fletcher AJ, Jones TV, et al, eds. Merck Manual of Medical Information Home Edition. 2nd ed. Whitehouse Station, NJ: Merck & Co., Inc.; 2003. Braverman LE, Utiger RD, eds. Werner & Ingbars The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000. Thyroid Disease Manager Web site. Available at: http://www.thyroidmanager.org. Accessed December 10, 2003.
Tumors >3 cm have a much higher Hebra A, et al. Solitary thyroid nodule. eMedicine Web site. Available at: mortality http://www.emedicine.com/ped/topic2120.htm. rate Accessed December 10, 2003.
Thyroid gland disorders. Beers MH, Fletcher AJ, Jones TV, et al, eds. Merck Manual of Medical Information Home Edition. 2nd ed. Whitehouse Station, NJ: Merck & Co., Inc.; 2003. DeGroot LJ, et al. J Clin Endocrinol Metab. 1990;71:414-424. Kloos RT, Mazzaferri E. Thyroid carcinoma. In: Cooper DS, ed. Medical Management of Thyroid Disease. Monticello, NY:Marcel Dekker, Inc.: 2001;239-241.
Aytug S, et al. Hrthle cell carcinoma. eMedicine Web site. Available at: http://www.emedicine.com/med/topic1045.htm. Accessed December 10, 2003. Kloos RT, Mazzaferri E. Thyroid carcinoma. In: Cooper DS, ed. Medical Management of Thyroid Disease. Monticello, NY: Marcel Dekker, Inc.: 2001:239-241.
Braverman LE, Utiger RD, eds. Werner & Ingbars The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000.
Braverman LE, Utiger RD, eds. Werner & Ingbars The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000. Sherman SI. Lancet. 2003;361:501-511. Types of thyroid cancer. Virginia Masen Medical Center Web site. Available at: http://www.vmmc.org/dbCancer/sec180604.htm. Accessed December 10, 2003.
Braverman LE, Utiger RD, eds. Werner & Ingbars The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000. Cabanillas F. Thyroid lymphoma. eMedicine Web site. Available at: http://www.emedicine.com/med/topic2271.htm. Accessed December 10, 2003.
Thyroid Disease Manager Web site. Available at: http://www.thyroidmanager.org. Accessed December 10, 2003. Braverman LE, Utiger RD, eds. Werner & Ingbars The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000. Ansell SM, et al. Semin Oncol. 1999;26:316-323.
Anaplastic 1%
40
Cumulative, %
N=1355
Medical uses during childhood in the 1950s Current medical uses in cancer therapy Nuclear accidents
Ron E, et al. Radiat Res. 1995;141:259-277. Tuttle RM, et al. Semin Nucl Med. 2000;30:133-140.
Usually sporadic Approximately 5% of patients have other family members with thyroid cancer
Rare genetic syndromes in which thyroid cancer is associated with other benign and malignant
Alsanea O, et al. Curr Opin Oncol. 2001;13:44-51.
Mixture of Features
Shaha AR, et al. Acta Otolaryngol. 2002;122:343-347. Shaha AR. Cancer Control. 2000;7:240-245.
Low Risk
Surgery
Lobectomy Isthmusectomy
Surgery
Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463. Cohen EG, et al. Otolaryngol Clin North Am. 2003;36:129-157.
RAI Ablation
Suppression Therapy
Cohen EG, et al. Otolaryngol Clin North Am. 2003;36:129-157. Mazzaferri EL, et al. J Clin Endocrinol Metab. 2003;88:1433-1441. Sherman SI. Lancet. 2003;361:501-511. Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463. Mazzaferri EL, et al. Endocr Relat Cancer. 2002;9(4):227-247.
1 Year
Whole body scan Stimulated Tg Suppressed Tg assay TSH assay T4 assay Neck examination
Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463. Cohen EG, et al. Otolaryngol Clin North Am. 2003;36:129-157.
+ Thyroid T4
Thyroid T4
Braverman LE, Utiger RD, eds. Werner & Ingbars The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000. Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463. Sherman SI. Lancet. 2003;361:501-511.
Low Normal
0.5 to 1 Very lowrisk patients Long-term survivors
Most patients Persistent or with no Patients recurrent disease evidence of High-risk patients disease
Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463. Sherman SI. Lancet. 2003;361:501-511. Braverman LE, Utiger RD, eds. Werner & Ingbars The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000.
Follow-up
Surgery and radioactive iodine LT4 suppressive therapy Physical examination Radioactive iodine scans Serum Tg TSH and T