papillary thyroid carcinoma ppt

DR TARIQUE AHMED MAKAREGISTRAR ENT

Management of Complicated Papillary Thyroid Carcinoma

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CASE I PRESENTATION


Patient Profile

Name XYZ

Age 70 years

Gender Male

Residence Chakwal

Date of admission 15.04.13

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Present History

Known Hypothyroidism/ goitre- 1 year

Rapid increase in neck swelling- 2 months

Difficulty in breathing - 2 weeks

No hoarseness No dysphagia

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History- cont’d…

Past history Known case of DM, HypertensionHad been op for Fr femur 2 yrs ago

Personal history

Poor socioeconomic class, smoker

Family history

Not positive for thyroid diseases 6

General Physical Examination

Vital signs

Pulse : 84/min

BP : 135/90mmHg

R/ R : 19/min

Temp : 98.4°F

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General Physical Examination

Pallor Jaundice Negative Cyanosis Lymph nodes Not palpable Clubbing Koilonychia Negative Oedema

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Systemic Examination

Cardiovascular system

Respiratory system

Gastrointestinal system

Central nervous system

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NAD

ENT Examination

Neck

Massive multinodular swelling

Inferior extent could not be assessed

Moved on swallowing

Normothermic, non tender

Mobile overlying skin

No bruit10

ENT Examination

ThroatNAD

IDL & fibreoptic laryngoscopy

Normal laryngeal structures

No mass or lesion seen

Both vocal cords normal &

mobile11

ENT Examination

Ear

Nose NAD

Oral cavity

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Provisional Diagnosis

MULTI-NODULAR GOITER

WITH TRACHEAL COMPRESSION

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Shift to ENT care

Nurse in propped up position

Observation & continuous monitoring

of vitals & SpO2

Immediate management

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Thyroid profile - WNL

FNAC

Thyroid Scan

CT scan Neck

Carotid Doppler USG

Investigations

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FNAC

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Thyroid Scan

CT Scan

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Enlarged thyroid gland with multiple nodules displacing the vessels (with normal flow)

Carotid Doppler USG

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Final Diagnosis

MNG WITH SUSPICION OF MALIGNANCY

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Management Plan

TOTAL THYROIDECTOMY

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Pre Op Investigations

Blood complete picture Urine RE Serum urea & electrolytes PT, PTTK LFTs Blood Glucose levels ECG , 2-D echo X-Ray Chest

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Within normal limits

Pre Op Work Up

Counseling

Informed written consent

Pre-anesthesia assessment ASA-IV

02 Units RCC arranged

NPO over night

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OPERATIVE STEPS

Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Post OP Management

Nursed in ITC

Inj Ceftriaxone 1g I/V 12 hourly (ATD)

Inj Coamoxiclav 1.2g I/V 8 hourly (ATD)

Inj Ketorolac 30mg I/V 08 hourly

Inj Dexamethasone 8 mg I/V 08 hourly

Inj Ca Gluconate 10 mg I/V 08 hourly

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Post OP Management

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7th Post op day

- Shifted to ward

10th Post op day

- Fibreoptic laryngoscopy

- Decannulation

14th Post op day

- Grillo’s sutures removed

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CASE II PRESENTATION


Patient Profile

Name XYZ

Age 23 years

Gender Male

Profession Serving

DOA 23.01.2013

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Case Summary

Painless swelling on Rt side neck

Metastatic Papillary Thyroid Ca on FNAC

Nodule Rt lobe thyroid & Rt Metastatic lymph

nodes Level III, V on CT

Near Total Thyroidectomy with ‘Berry picking’

Cervical Nodes (Rt) 44

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Case Summary cont’d…

Thyroid Scan

Completion thyroidectomy

Post-op Complications

- Hoarseness & dyspnea on

exertion

IDL/ Fibreoptic Laryngoscopy

- Both Vocal Cords immobile,

paramedian46


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Whole Body Scan

Management Plan

COMPLETION THYROIDECTOMY &RIGHT RADICAL NECK DISSECTION

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Management

Pre-op work up Counselling

Details of the nature and severity of the disease

Treatment options available Specific risk of surgery and GA

Informed written consent Pre-anesthesia assessment: ASA-I 02 Units RCC arranged

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OPERATIVE STEPS

Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Operative Steps

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Post OP Management

Nursed in Surgical ITC

Inj Ceftriaxone 1g I/V 12 hourly (ATD)

Inj Coamoxiclav 1.2g I/V 8 hourly (ATD)

Inj Ketorolac 30mg I/V 08 hourly

Inj Dexamethasone 8 mg I/V 08 hourly

Inj Ca Gluconate 10 mg I/V 08 hourly

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Post OP Management

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2nd Post operative day

- Fibreoptic laryngoscopy

3rd Post operative day

- Shifted to Surg HDU

5th Post op day

- Shifted to ward

14TH Post op day

- Stitches removed

- Thyroid profile

Follow Up

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LITERATURE REVIEW


Case Summary

Commonest thyroid tumour 80%* Age incidence 20-50 years Male : Female 1 : 3 Multifocal 80%† Spread by lymphatics Local invasion 10-20% 10 year survival 93%

* Murray D. The thyroid gland, in: Kovacs L, Asa SL (eds). Functional endocrine pathology. Oxford: Blackwell. Science, 1998: 295-369† Baloch ZW, LivoIsi VA. Pathology of thyroid gland. In: LivoIsi VA, Asa SL (eds). Endocrine pathology. Philadelphia, PA: Churchill Livingstone, 2002: 61-101

Papillary Thyroid Carcinoma

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Etiology / Risk Factors

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Prolonged stimulation by TSH*

Persistent solitary thyroid nodule

Radiation exposure

Familial & Genetic factors

- Gardner’s Syndrome

* Williams ED, Abrosimov A, Bogdanova T et al. Thyroid carcinoma after Chernobyl latent period, morphology and aggressiveness. British Journal of Cancer 2004; 90: 2219-24

Case SummaryClassification

62* Hedinger C, ed. Histological Typing of Thyroid Tumours. 2nd ed. Berlin: Springer-Verlag; 1988


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Papillary carcinoma i. Papillary microcarcinomaii. Encapsulated variantiii. Follicular variantiv. Diffuse sclerosing variantv. Oxyphilic(Hurthe) cell type

Case Summary Solitary nodule

Prominent nodule in MNG

Palpable Cervical Lymph Nodes 30% *

Hoarseness

Difficulty in breathing 3-5%

Difficulty in swallowing

*Wang TS, Dubner S, Sznyter LA, Heller KS. Incidence of metastatic well-differentiated thyroid cancer in cervical lymph nodes. Archives of Otolaryngology - Head and Neck Surgery 2004; 130: 110-13

Clinical Presentation

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Case Summary

Examination of Neck Firm, solitary or dominant nodule in MNG Movement of swelling on swallowing Mobility Consistency Extent Cervical lymph nodes

Examination of Pharynx & Larynx IDL/ Fibreoptic endoscopy

- Vocal cord paralysis/ compression of airway

Physical Examination

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Case Summary

FNAC

Thy 1 – inadequate for diagnosis

Thy 2 – benign disease

Thy 3 – suspicious for neoplasia

Thy 4 – suspicious for malignancy

Thy 5 – positive for malignancy

Investigations

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Case Summary

Serum Thyroid Profile

T3, T4 Euthyroid

↑ TSH Malignancy*

↑ Thyroglobulin Recurrence

* Boelaert K, Horacek J, Holder RL et al. Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules, investigated by fine-needle aspiration. Journal of Clinical Endocrinology and Metabolism 2006; 91:4295-301

Investigations cont’d…

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Case Summary USG Neck*

Nodularity, size, consistency, cacifications

Disease in contralateral lobe Cervical lymph nodes US guided FNAC

Colour Flow Doppler Sonography

Type III flow (Intranodular/central)

* Appetecchia M, Solivetti FM. The association of colour flow Doppler sonography and conventional ultrasonography improves the diagnosis of thyroid carcinoma. Hormone Research 2006; 66: 249-56


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Case Summary Thyroid Isotope Scan

Iodine-123 or Iodine-131

Technetium-99m

Show nodules greater than 5 mm

Cold nodules may be malignant

Hot or warm nodules are unlikely to be

malignant

Mehahna H, Jain A, Morton RP et al. Investigating the thyroid nodule. British Medical Journal 2009; 338: 733


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Case Summary

CT MRI Neck & Thorax

Local invasion

Retrosternal extension

Som PM, Brandwein M, Lidov M et al. The varied presentations of papillary thyroid carcinoma cervical nodal disease: CT and MR findings. AJNR. American Journal of Neuroradiology 1994;-15: 1123-8


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Case SummaryPrognostic Factors

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Lundgren CI, Hall P, Dickman PW. Zedenius J. Clinically significant prognostic factors for differentiated thyroid carcinoma: a population-based, nested case-control study. Cancer 2006; 106: 524-3

Case Summary

TNM Staging

72Edge SB, Byrd DR, Carducci M et al. AJCC cancer staging manual, 7th edn. New York: Springer, 2009

Case Summary

Staging

73Edge SB, Byrd DR, Carducci M et al. AJCC cancer staging manual, 7th edn. New York: Springer, 2009


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Minimal or Micro carcinoma < 1 cm

Intrathyroidal > 1 cm

Extrathyroidal Beyond capsule/ Lymph

node metastasis

Case Summary

Surgery is the mainstay of treatment*

Radio-ablation of thyroid remnant

Thyroxine suppression

External beam radiation

Treatment

75*Mazzaferri EL, Kloos RT. Clinical review 128: Current approaches to primary therapy for papillary and follicular thyroid cancer. Journal of Clinical Endocrinology and Metabolism 2001; 86: 1447-63.

Case SummarySurgical Treatment

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*Head and Neck Cancer:Multidisciplinary Management Guidelines 2011British Association of Head and Neck Oncologists, British Association of Endocrine and Thyroid Surgeons, British Association of Otolaryngology– Head and Neck Surgery

*

Case Summary Extent of Surgery for cervical lymph nodes

Selective nodal excision (Not recommended)*- Berry/ Cherry picking

Anterior/ Central (Level VI) Neck Dissection

Lateral/ Selective or Modified Radical Neck† Dissection (Level III, II, IV, I, V)

Surgical Treatment

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*Scheumann GF, Gimm 0, Wegener G ef al. Prognostic significance and surgical management of locoregional lymph node metastases in papillary thyroid cancer. World Journal of Surgery 2009; 18: 559-67†Pingpank JFJr, Sasson AR, Hanlon AL et.al. Tumor above the spinal accessory nerve in papillary thyroid cancer that involves lateral neck nodes: a common occurrence. Archives of Otolaryngology - Head and Neck Surgery 2002; 128: 1275-8.

Case Summary

Post Op TSH suppression by exogenous thyroxine*

TSH levels of < 0.1 mU/L in high risk and between 0.1-0.5mU/L in low risk patients

TSH suppression is discontinued 2-4 weeks before radio ablation

TSH Suppression Therapy

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*Cooper DS, Specker B, Ho M et al. Thyrotropin suppression and disease progression in patients with differentiated thyroid cancer: results from the National Thyroid Cancer Treatment Cooperative Registry. Thyroid 1998; 8:737-44

Radioiodine is used for ablation of normal thyroid*

tissue & to treat residual thyroid tumour

Pre therapy whole body diagnostic scan

Therapeutic doses of 100-200 mCi

Not recommended in low risk group†

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Radio Ablation

*Sawka AM, Thephamongkhol K, Brouwers M et al. Clinical review 170: A systematic review and metaanalysis of the effectiveness of radioactive iodine remnant ablation for well-differentiated thyroid cancer. Journal of Clinical Endocrinology and Metabolism 2004; 89: 3668-76†British Thyroid Association and Royal College of Physicians. Guidelines for management of thyroid cancer, 2007. Available from www.british-thyroidassociation.org

EBRT along with Doxirubicin improves local control

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External Beam RT & Chemotherapy

British Thyroid Association and Royal College of Physicians. Guidelines for management of thyroid cancer, 2007. Available from www.british-thyroidassociation.org

Case Summary 30% recurrence*

Regular TSH levels

Serial Thyroglobulin levels†

Diagnostic Radio iodine scans

US Neck

FDG-PET Scans

Follow up/ Monitoring

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*Mazzaferri EL, Kloos RT. Clinical review 128: Current approaches to primary therapy for papillary and follicular thyroid cancer. Journal of Clinical Endocrinology and Metabolism 2001; 86: 1447-63† Mazzaferri EL Empirically treating high serum thyroglobulin levels. Journal of Nuclear Medicine 2005; 46: 1079-88.

Case Summary

DATA ANALYSIS

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Case Summary

13

5

2

3 2

n = 25

PapillaryFollicularAnaplasticLymphomaundifferentiated

Data Analysis

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Data Analysis

Papillary Follicular Anaplastic Undifferentiated0

10

20

30

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50

60

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CMH DataJPMC DataUK Data

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Conclusion

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Thyroid cancer is relatively rare , one of the

most curable cancers

Surgery is the treatment of choice

Complications to be kept minimal

Low recurrences to be ensured

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DEPARTMENT OF ENT, HEAD AND NECK SURGERY

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papillary thyroid carcinoma ppt

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