1. Update in the Management of Thyroid Neoplasms University of Washington
David R. Byrd, MD
Department of Surgery
University of Washington

2. NCCN - National Comprehensive Cancer Network
yearly update from the NCI-designated comprehensive cancer centers (FHCRC --> FHCRC + UWMC)
Consensus guidelines from the NCCN membership institutions
not focussed on the practice of the community cancer practitioner

3. NCCN - Management of Thyroid Carcinoma -2001

4. Thyroid Nodule - History
Local Sxs
Risk factors
Function

5. Thyroid nodules 6-10% adult U.S. population
5% are malignant
FNA best initial test - 96% PPV
U/S good to follow or document MNG
thyroid scan good if symptoms of hyper- or hypothyroidism or if indeterminate cytology/multinodular goiter
suppression most successful when TSH high

6. FNA Results of Thyroid Nodule
Benign --> F/U 6-12 months
cyst --> F/U 6-12 months
indeterminate --> repeat FNA, I123 scan
if same results
follicular neoplasm --> I123 scan or surgery
suspicious --> surgery
carcinoma --> surgery
FNA

7. Results of I123 scan “hot” --> check TFTs
“euthyroid” --> rarely CA, F/U only
“cold”* (still takes up some iodine,
though less than normal gland)
I123 scan
*NOTE: 1. Nearly all cancers are “cold”
2. However, only about 10-15%
of “cold” nodules are cancer

8. Thyroid Carcinoma - Nodule Evaluation
©National Comprehensive Cancer Network

9. Thyroid Carcinoma - Nodule Evaluation
©National Comprehensive Cancer Network

10. Pathology of Thyroid Cancer
differentiated thyroid cancer (DTC):
papillary - commonly spreads to nodes (40-50%), excellent prognosis
mixed - papillary and follicular - acts like papillary, excellent prognosis
follicular - slightly worse than papillary, can spread to bone, less to nodes (15%); Hurthle cell Ca is variant
medullary - sporadic vs. familial (MEN 2A), total thyroidectomy is treatment
anaplastic - aggressive and fatal, surgical role is biopsy only

11. Thyroid Carcinoma - Papillary Carcinoma
©National Comprehensive Cancer Network

12. Rationale for Total Thyroidectomy for DTC
improved effectiveness for I131 ablation
lowers dose needed forI131 ablation
allows f/u w/ thyroglobulin levels
decreased recurrence
improved survival in high risk pts.
decreased risk of pulmonary mets and dedifferentiated CA

13. Rationale Against Total Thyroidectomy for DTC
increased RLN injury and hypoparathyroidism
contralateral disease not clinically relevant
survival nearly equivalent for low risk patients
I131 ablation not necessary for most patients
thyroglobulin levels not necessary for most patients

14. Thyroidectomy for DTC - Technique
know the anatomy
protect RLN
preserve all parathyroids
know when to reassess or quit

16. Thyroid Carcinoma - Papillary Carcinoma
©National Comprehensive Cancer Network

17. Lymphadenectomy for Papillary or Mixed Thyroid CA
parathyroid
RLN

18. Thyroid Carcinoma - Papillary Carcinoma
©National Comprehensive Cancer Network

19. Thyroid Carcinoma - Papillary Carcinoma
©National Comprehensive Cancer Network

20. Thyroid Carcinoma - Papillary Carcinoma
©National Comprehensive Cancer Network

21. Thyroid Carcinoma - Papillary Carcinoma
©National Comprehensive Cancer Network

22. Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network

23. Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network

24. Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network

25. Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network

26. Thyroid Carcinoma - Follicular Carcinoma
©National Comprehensive Cancer Network

27. ? Residual Thyroid Cancer
25 y/o woman with papillary thyroid cancer
Capsular penetration
Lymph nodes not sampled
Dx and Post-Rx (200 mCi) I-131 scans show thyroid remnant only
TG off TSH = 110 ng/dL
Dx I-131 scan 1 year later negative
TG off TSH is still 100 ng/dL

28. Thyroid Cancer Post therapy (10/98)
window
Tc-99m
markers

29. Thyroid Cancer Diagnostic Scan (7/99)
window
Tc-99m
markers

30. ? Residual Thyroid Cancer:
FDG PET Scan 8/99
L Cervical Lymph Nodes
? Central Lymph Nodes

31. Case 1
60F undergoes L thyroid lobectomy for a solitary nodule w/ follicular cells on FNAC.
Final path shows 2cm follicular adenoma and incidental 5mm papillary thyroid CA
?further management

32. Case 1 - issues ? Completion thyroidectomy --> NO
Result: the 2 cm nodule is benign and the 0.5cm nodule
is an incidental carcinoma of minimal significance
? Completion thyroidectomy --> NO
? Radioactive iodine therapy --> NO
? Thyroid suppression --> +/-
? F/u -6 month intervals with H & P

33. Case 2 40M w/ solitary 1.5cm L thyroid nodule on exam
h/o neck irradiation for enlarged thymus as child
?further management

34. Case 2 - Issues
This is a setting of higher risk of cancer - male, solitary
lesion, and equivocal hx of neck irradiation:
minimal operation is thyroid lobectomy + isthmusectomy,
proceed to total or subtotal thyroidectomy if bilateral nodules
and/or if carcinoma found
frozen section is notoriously unable to definitively call
carcinoma - therefore permanent pathology usually
necessary to confirm carcinoma