Chapters Transcript Video Thyroid Cancer Hi, my name is Vishal Gupta, my assistant professor and staff physician at Roswell Park Comprehensive Cancer Center. The topic of today's talk is direct cancer. The target audience for this talk is primary care physicians. Now this talk is divided into various objectives and we will review the epidemiology and history of thyroid cancer, how the prevalence of this disease has changed over the years. We'll talk about ultrasound findings and indication for the biopsy, preoperative consideration and decision making about the surgical management of these patients. So about 50% of individuals over 50 years of age will have thyroid nodules somehow looks like both. High. You know, there's a two loaves one on each side connected by isthmus. Uh The nodules are mostly benign. We do see thyroid cancer in about 8% of this nodule and 4% of the nodules and women will have the tired cancer, but the vast majority of them are benign. Now. Over the years, the incidents or rejection rate of thyroid nodules has changed. Uh and so does the incidence of thyroid cancer. As you can see. Uh nowadays we find a thyroid cancer 2-3 times more common. Then it was found in 75 and this is this is mostly because of the increased detection of these nodules. The mortality rate has remained stable. Uh as you can see in the slide. Uh there are about 3700 new cases of thyroid cancer detected in 2009 and for this year it's it is somewhere close to 43,000 cases. The median age of diagnosis is 51. Again, like I mentioned, we were finding more cases of thyroid cancer because of increased detection. Uh, as in previous years, from 88 to 89 about 25% of these tired cases had the, the size of tumor was less than a centimeter in size. But nowadays because of increased detection, we have 39% of these new cases less than a centimeter in size. There have been studies done, which has looked at the prevalence of thyroid cancer in general population. And these are the autopsy studies that showed about 11% of people who died of unrelated causes will have thyroid cancer, which was, which was not the cause of cancer cause of the death. Now, broadly speaking, thyroid cancer can be divided into different types, differentiated types includes popularity, follicular and hurdle cell. Then there are imaginary and and a plastic. In a study of 63,000 people, about 90% had popularity cancer. 4.5% had follicular cancer, 1.8% in hurdle sell 1.6 my jewelry and then anna plastic was least common Differentiated thyroid cancer in particular have excellent prognosis with 10 year survival over 90%. No, we talked about increased detection and some of this pertains to imaging. Nowadays, a lot of central utilizing various imaging modalities for for reasons unrelated to thyroid. Give an example of his pet scan. Pet scan is commonly utilized for screening and staging of various cancer. In a study of 45,000 pet scan, about 500 people were found to have Pat avid, Taranov. Pat avid means it laid up on the pet scan. And once biopsy, about 36% of them had a thyroid cancer. So these were diagnosed incidentally because of a scan. So for perhaps getting particular about one third of the technology, you can have thyroid cancer. Now the malignant nodules are known to have certain features and these features are based on ultrasound findings. So when we're looking at ultrasound, we want to look for features like if they're solid hyperlink OIC taller than wide irregular margins or micro calcifications. Typically ultrasound reports will tell us all these findings. Now, once we have those findings, we look at their various guidelines like american association guidelines and tied IT system which can be utilized to guide us further. So area guidelines starts with suspected technological evaluation using sonogram and then based on the level of suspicion, we either watch them or go for biopsy. Tyrek system is another system which looked at five different features in tara nodule, assigned them points and then these points are added to guide us along the diagnostic letter. Both systems are highly reliable and can be utilized for management of nodules coming to the protest. A classification soba tester classification is a system to report fine needle aspiration cytology and and so that everyone is speaking in the common language it divides uh fine needle aspiration report into because the one to protest a six But Chester one basically means that there is not enough tissue to make a diagnostic assessment. And typically people end up requiring repeat biopsy. But this is too is uh considered as negative, which means very low risk of malignancy. And people can be followed with ultrasound surgery only if there's symptoms like large started nodule causing compressive symptoms, difficulty in breathing, difficulty in swallowing or cosmetically unpleasant appearance. But as the three and 4 are undetermined date or There are gray areas, uh both of them does carry risk of malignancy 6-8% from 3, 10 to 40%. But again, these risk categories are the risk is not high enough to warrant surgery and it's not low enough to just ignore them. So, you know, so what we can do for them and well, there are various molecular tests that we can utilize to further uh characterize this nodule and find out the chances of malignancy. So is one of those molecular tests it looks for mutations in DNA and RNA. And assign a risk category uh has a very high sensitivity of 94%. Which is sensitivity means ruling out. So it has very high sensitivity and specificity for for distinguishing benign thyroid nodule from malignant. A former. I see another test which is RNA based test also have a very high negative value, positive, predictive value, not that good. So mostly users rule out test which means if the test is negative we can say with high reliability that there is no cancer. The third test I want to talk about is theragenics and Jaromir. This is a combination of two tests. So Taro Gion next test looks for mutations panel which looks again mutations which are known to be present in thyroid cancer. If those if none if no mutations are found then we do the second test cara miA tests which look at micro RNA and they are known to have abnormal expression in thyroid cancer. Again very high sensitivity specificity as well as negative predictive value. Now so this is the diagnostic work up or management algorithm as taken from the N. C. C. And guidelines for protester three and four. Again that there is a risk of malignancy but not high enough to go for surgery typically and also not low enough to just ignore them. So these are the gray area and we need we want more answers before uh uh before good doing anything. So typically those answers schemes in different ways. You do molecule testing and if the test is benign you can just watch them. Uh It's possible that molecular diagnostic is also not informative enough. And then we look at the again go back to the basics and look at the symptom Atala ji look at the ultrasound findings and have a 1 to 1 discussion with the patient and discuss various options. Of course if it's malignant then most of the time we recommend surgical management. Either it's low back me where we remove half of the thyroid or total thyroidectomy where we remove the entire land. But that's the five usually means that there is a high suspicion for tired cancer and usually typically warrant surgical management. Uh Having said that it depends on the size of the nodule which is positive. So if the nodule is less than or equal to a centimeter in size, with ultrasound showing no other concerning findings, then in certain scenario it is possible to do active surveillance with ultrasound which means ultrasound every so often. Just to make sure that nodule is not increasing in size. Typically this patient do end up going forward back to me which is removal of half of the third gland and and sending it for further testing nodule which are created a sentiment in size. Also require staging work up just like ultrasound just to make sure there's no other lymph nodes. Cities scanning M. R. I. R. Know typically indicated only if there is suspicion of advanced disease like presence of lymph nodes or vocal cords are paralyzed. Also, again, vocal cord needs to be looked at before surgery just to look at how they are functioning and if there's any problem after the surgery, you can you can watch for the recovery and if there's any nodules present in the neck based on ultrasound or ct findings. Typically we require a biopsy of this to rule out malignancy. Once these are done, then comes the decision making whether to remove the whole thyroid gland or remove half of it. So for the thyroid nodule which are between 1 to 4 centimeter in size. With no other high risk feature as mentioned above, it is reasonable to go for lumpectomy. Total thyroidectomy can also be done Half of nodules which are over four centimeters in size and have high risk feature like known distant mats, the extension of the tumor outside the thyroid present of lymph nodes in the neck. High risk pathology like poorly differentiated history of radiation or presence of modularity on both sides. They require total thyroidectomy with possible removal of lymph nodes because of six also pretends or indicate the presence of thyroid cancer and work up from diagnostic to decision making is similar to five, which is divided between again or sent over a centimeter in size or less than equal to send in between size and going forward. So again, coming back to candidates patients who are candidates for for hemi, thyroidectomy, lumpectomy. We never want to remove just a nodule. A lot of people ask, can you just remove the we never remove just the knowledge that you have to remove half of the half of the thyroid gland to to remove the entire tumor in its entirety and avoid spillage of the tumor into the neck. So for low back to me or me. Uh the ideal candidates are patients with tumors lesson four centimeter in size, no extension beyond thyroid, no lymph nodes and no distant mats monograph or ultrasound will also tell us presence of any nodules on the other side. And if they are suspicious or not, for total thyroidectomy, the tumor which are four sentiment in size which are extending outside the thyroid gland has presence of metastatic lymph nodes and other high risk features like high grade pathology, vascular invasion or known or confirmed disease. On the other side they require total thyroidectomy. No. What's done after tired surgery? Do people ask you to need any additional treatment? And that depends upon the pathology? Okay, so the additional treatment is given in a way of something called radioactive iodine, radioactive iodine is radioactive iodine. I sort of 1 31 which is given as a pill. This is a targeted radiation treatment for thyroid cancers. Uh the cancer cells and tired cells usually pick up the iodine that's like food for them and once they pick up they get exposed to radiation which kills any residual tissue in the body. So typically if the patient has classical paper titled cancer now public cancer is the most common. It has different variants. So classic one which is less than a two centimeter in size limited to third land Is either one area is present or multiple area but less than you could do one cm in size and no other features like no no no detectable anti anti global antibodies. Post operative and similarly global level less than one and negative post operative ultrasound. This is too much to remember. But the just of this slide is that in low risk patients typically they don't require really active iodine. Now then comes again the gray area. There is always a great area. So these are dis electively recommended. Okay. And based on discussion between clinician and the patient reviewing the risk and benefit of radioactive iodine so selectively recommended will be presence of an anti third globally, antibodies are between 2 to 4 centimeters in size. High risk histology, lymphatic invasion, vascular invasion, lymph node, mats multiple areas which are positive positive margins and presence of terrible which is unstinting lated reactive iron line is typically recommended when there is presence of high risk features like humor is extending ourselves. A thyroid, large sized tumor postoperative, stimulate global in greater than 10 nanograms per M. O. Now globally is a protein which is found in the blood and usually made by the thyroid cells. So we watch for this protein as a marker for presence of thyroid tissue in the body Morris the amount present more is the likelihood there is some result. President the party. So that's what we're talking about is a marker of presence of thyroid tissue in the party And presents Bulky or or greater than five positively influence is also an indication for radioactive iodine. Now, what are reactive? So really after radioactive iodine patients are referred to the endocrinologist who manages the current medication. So we typically patient with thyroid cancer, require uh thyroid suppressive doses, which means that we give enough of thyroid medication so that if there's any resulting tissue present, the high dose will suppress the growth of the of those tissues. Um These are some of the references I used. Uh please feel free to contact us if you have any. If you need any further information. Thank you very. Created by
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