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Most common type
Makes up about 80% of allthyroid carcinomas
Females outnumber males 3:1
Highest incidence in women inmidlife
.
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Unencapsulated tumor nodule with ill-definedmargins
Tumor typically firm and solid
May present as nodal enlargement Commonly metastasizes to neck and mediastinal
lymph nodes
40% to 60% in adults and 90% in children
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PTC Classification
1. Minimal PTC
(a) T
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PTC Classification High-risk PTC/FTC
1. AMES (age, 2, T extent/size)2. AGES (age, grade, T extent/size)3. TNM (T, LN, 2)4. EORTC5. MACIS (2, age, resectibility, invasion, T)
6. Histology (Hurthle cell, tall cell, columnar variants) Other1. Delay in treatment2. LVI especially FTC
3. High grade (PTC/FTC)
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Rationale for total thyroidectomy 1) 30%-87.5% of papillary carcinomas involve opposite
lobe
2) 7%-10% develop recurrence in the contralateral lobe
3) Lower recurrence rates, some studies showincreased survival
4) Facilitates earlier detection and tx for recurrent ormetastatic carcinoma with iodine
5) Residual WDTC has the potential to dedifferentiateto ATC
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Indications for total thyroidectomy
1) Patients older than 40 years with papillary orfollicular carcinoma
2) Anyone with a thyroid nodule with a history ofirradiation
3) Patients with bilateral disease
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Managing lymphatic involvement pericapsular and tracheoesophageal nodes should be
dissected and removed in all patients undergoingthyroidectomy for malignancy
Overt nodal involvement requires exploration ofmediastinal and lateral neck
if any cervical nodes are clinically palpable oridentified by MR or CT imaging as being suspicious aneck dissection should be done (Goldman, 1996)
Prophylactic neck dissections are not done(Gluckman)
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment Surgery
1. Total ipsilateral thyroid lobectomy
Minimal PTC or min invasive FTC limited cap inv2. Near total thyroidectomy
High-risk PTC
Bilateral cancer/nodules (papillary not follicular)Preservation of parathyroid glands (relative RR)
Risks (
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment Surgery Advantages of NTT1. PTC often multifocal2. Lymphatic spread throughout gland3. Facilitates ablative RAI4. Facilitates detection of residual and distant
tumour
5. Facilitates treatment of residual and distanttumour6. TG more sensitive tumour marker7. RR
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment Surgery
LND Risk at in older adults (ipsilateral)
1. PTC: 40%
2. FTC: 10%
3. Hurthle: 25% Extensive LN 2 suggestive of follicular variant of PTC
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Surgery
LND Significance1. PTC: LRR not OS
2. FTC: worse prognosis (uncommon)3. Medullary: LRR and OS
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Surgery
LND
Procedure1. T > 15 mm: en bloc central cervical LND
2. Limited LN + (extra thyroid) or palpable LN:functional Cx/M LND (unilateral)
3. Extensive LN + (extra thyroid): radical Cx/M LND
(unilateral or bilateral,
thymectomy)
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment Adjuvant Therapy1. TSH suppression
T4 commenced after ablative RAI
150-200 mcg/day (2mcg/kg)
Serum levels (a) HR: < 0.1 IU/mL
(b) LR: 0.1 0.4IU/mL
No proven OS benefit/ LRMonitor cardiac function in elderly
Risks: accelerated bone turnover, OP, AF
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
2. RAI
i. Ablative RAIAll patients after TT/NTT, except
a) Young, female patients with occult solitarypapillary carcinoma < 15mm
b) Partial thyroidectomy
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy2. RAI
i. Ablative RAI Rationalea) ablate residual thyroid tissue and adjacent
microscopic CA
b) TG assay more specificc) 2 CAd) TSH increases RAI uptakee) Radionuclide scans more sensitive for tumour
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
2. RAI
i. Ablative RAI CIa) Patient refusal
b) Poor performance statusc) Uncooperative patientd) Intractable urinary incontinencee) Pregnancy
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
2. RAI
i. Ablative RAI
Preparation1) 6/52 postop
2) TG before RAI3) Low iodine diet for 2/52
4) Pregnancy test and contraceptives
5) No replacement T3/4
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy2. RAI
i. Ablative RAI Procedure1) 75-150 mCi (2,775-5,550 MBq) controversial2) Admit for 1-2 days (physicist check)
3) Urinary catheter if female (ovarian dose 0.3cGy/mCi)4) NSAID/paracetamol or steroids for pain5) Post-op precautions (in ward and at home)
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THYROID CANCER
POSTOP MANAGEMENTFLOW DIAGRAM
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THYROID CANCER
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment Adjuvant Therapy
2. RAI
ii. Therapeutic RAI 150-200 mCi (5500-7000MBq)
Max 1500-2000 mCi (avoid > 1000 mCi)
Min 6/12 between RAI doses
Reduce dose if multiple lung 2 (80 mCi retaineddose)
Flare response, xerostomia, AML/bladder/breast, BM
suppression, azospermia, menopause
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment Adjuvant Therapy2. RAIii. Therapeutic RAI
Indicationsa) Iodine avid recurrent diseaseb) 2 Dexamethasone
a) cerebral, intra-orbital or intra-spinal 2b) Stridor Reduce dose (80 mCi retained dose) if multiple
lung 2
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment
Adjuvant Therapy
3. EBRT 50.4 Gy @ 1.8 Gy/# in 28# 5-20 Gy boost to residual disease
Total dose limited by SC, other structures
Large AP field with small AP or PA mediastinal field
6-10 MV photons
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INDICATIONSFOR
EBRTRADICAL
RT
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Treatment Adjuvant Therapy3. EBRT
Target Volume1) Thyroid and tumour/bed ifi. macroscopic residual, andii. N-ve
2) JD, Submandibular, IJ, Sp Accessory, SCF, Sup Med(to carina) ifi. Residual or extensive N +, orii. Non-iodine avid disease
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Follow-up
1. TG if N- TG antibodiesi. Post-op
ii. @ 4/12iii. 6/12ly x 2yearsiv. Annually
2. RAIi. Rising TG - restagingii. Recurrent/metastatic disease avidityiii. Surveillance if + TG AB
THYROID CANCER
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Follow-up3. Radiological tests CT neck/chest
MRI U/S
WBBS
PET
4. Thyroid function testsensure adequate suppression of TSH
5. Recombinant thyrotopin
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
If Persistent or Recurrent Disease
1. Restage (CT, RAI)
2. Maximal resection (LND, excision of LR)3. Whole body iodine scan (diagnostic, test avidity)
4. Therapeutic RAI
5. EBRT
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Metastases Incurable but several years survival possible
Management varies with1. Patient factors2. Tumour factors (number and site/s of recurrence, local
complications)
3. Iodine avidity
4. Prior treatment and its outcomes
THYROID CANCER
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THYROID CANCER
Well Differentiated Thyroid Carcinoma
Metastases when to prefer Surgery
1. Selected long-bone 2 at risk of fracture
2. Isolated and solitary brain 2
3. SC compression
4. Isolated lung 2
5. Rapid progression of 1 pulmonary 2
RTPalliative doses for symptom control or to preventcomplications
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