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Mesa RedondaManejo del Cancer de
TiroidesRicard Simo FRCS (ORL-HNS) PhD
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Panelistas
Profesor Javier GavilanHospital de la PazUniversida Autonoma de Madrid
Dr Ricard MesiaInstitut Catalad’OncologiaBadalona
Dr Joan VergesHospital Germans TriesBarcelona
Dr Jaume Puig de DouEndocrinoHospital del MarBarcelona
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Objetivos
• Comite de Tumores de cancer de tiroides• Discutir diferentes escenarios de cancer de tiroides• Resaltar controversias en el manejo del cancer de tiroides• Discutir aspectos referentes a la evaluacion, manejo quirugico,
manejo no quirurgico, estratificacion del riesgo, seguimiento y terapias adyuvantes
• Estimular a la audiencia para la participacion
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Thyroid Clinical Case 1
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Clinical Summary
• 79 years old referred by HM at GSTT• PC: Malignant Melanoma right foot treated with WSE• and right inguinal dissection • June 2010 – PET CT Uptake Left thyroid lobe - SUV 9• Thyroid status: Euthyroid• FNAC: Thy 3a Bethesda III• PMH: Osteoporosis and OA• FH: None significant• ECoG PS: 2• Smokes: None smoker• Alcohol: Socially• SH: JW, retired WHO PA and lives alone
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PET-CT
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Clinical Findings
• 2x2 cm left STN irregular and hard
• C and r N0
• cMx
• U5 on USS
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Proposed Treatment
• Diagnostic? • left thyroid lobectomy and level VI exploration
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Histopathological Findings and Further Treatment
• pT2 -2.5 x 2.5 encapsulated PTCa – No aggressive features
• N0 0/4 Lymph nodes
• ? Any further treatment
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Thyroid Clinical Case 2
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Clinical Summary
• 39 years old referred by Endocrinology• PC: Left STN increasing in size since 2001• Thyroid status: Euthyroid• FNAC: Initially Thy 3 f Bethesda 4 and review by central MDM Thy 3f• PMH: Anaemia• FH: Mother and sister with hypothyroidism• ECoG PS: 0• Smokes: Non-smoker• Alcohol: 14 units / week• SH: TV producer, lives with husband and 2 children
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Clinical Findings
• cT2 3x2 cm left thyroid nodule with irregular capsule
• cN0
• cMx
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USS Findings
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Proposed Treatment
• Diagnostic L Thyroid Lobectomy!!!!!!
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Histopathology
• 2cm papillary thyroid carcinoma with 3 mm satellite micropapillary• Pre-cricoid lymph node – metastatic micropapillary carcinoma
• What next?
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Clinical Case 3
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Clinical Summary
• 31 years old house wife referred by AFO at GSTT• PC: 10 years history of midline neck mass at the • level of hyoid bone clinically compatible with a thyroglossal duct cyst• Thyroid status: Euthyroid• FNAC: Thy 3f Bethesda 4• USS and MRI scan: Microcalcification and 2 nodules right thyroid lobe• PMH: Allergic rhinitis and depression• FH: None significant• ECoG PS: 0• Smokes: Non-smoker• Alcohol: Rare• SH: Lives alone with 4 children
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Clinical Findings
• cT2 3x3 cm thyroglossal duct solid mass
• cN0
• cMx
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USS Findings
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MRI Scan Findings
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Proposed Treatment
• Patient not keen on surgery and she things that she is pregnant
• What next?
• What metabolic changes pregnancy may have on the thyroid?
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Surgery
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Histopathology
• 4 x 4 cm thyroglossal duct cyst completely replaced by PTC and abutting the capsule
• What next?
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Clinical Case 4
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Clinical Summary 4
• 64 years old driver• Increasing history of SOBOE• CXR – Upper mediastinal shadow• USS guided FNAC – Thy 3f – Bethesda 4
• Upgraded to Thy 4 Bethesda 5 – Any other investigations?• Cross Sectional Imaging?
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Case 4
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Intraoperative Findings
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Postoperative findings
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Histopathology
• Histology: Conventional T4 N1b R1????? Follicular variant Papillary Thyroid Carcinoma
• What next?
• RIA Dose?
• PORT? Dose?
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Clinical Case 5
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Clinical Summary 5
• 27 years old project manager• T2N0M0 PTCa treated with Total Thyroidectomy and RIA• Raising thyroglobulin both non-stimulated and stimulated• USS guided FNAC – Recurrence right thyroid bed• Revision surgery – Fat• Would like a second opinion
• How we should investigate her? CT, MRI, PET
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Preoperative Mapping“Strategic Mapping Plan”• Done with USS by Radiologist or Surgeon• Mark the site and indicate depth - Intraoperative USS
Scharpf et al Head & Neck 2016
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Targeted Approach – How?
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Clinical Case 6
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Clinical Summary
• 57 years old nurse from Malaisya.• Short history of thyroid mass, with SOBOE• PMH: Mitral valve prolapse and CVA• ECoG: 1• Smoking: Non-smoker• Alcohol: 14 units a week• SH: Lives with husband• Fibreoptic laryngoscopy shows left vocal cord palsy
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Clinical Findings
• cT4
• cN0
• cMx
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Investigations?
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Clinical Findings - Panendoscopy
• cT4
• cN0
• cMx
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Surgical Resection – Approach
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Surgical Resection – Mediastinal Exploration
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Surgical Excision – Tracheal Resection
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Tracheal Reconstruction
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Histopathological Specimen
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Management Plan• Histopathology: Poorly differentiated thyroidCarcinoma: – 25% well differentiated
– 50% Tall cell variant
• Advice on adjuvant therapy?
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Clinical Case 7
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Clinical Summary
• 34 years old originally from Lebanon who works in finance• 3/12 history of thyroid mass increasing in size causing
pain and associated with B symptoms• USS FNAC/CNB: PDTCa with neck metastases• Anaemia and raised WCC, ESR and LDH – Seen Paul Fields• PMH: None• ECoG: 0• Smoking: Non-smoker• Alcohol: 14 units a week• SH: Lives with family
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Clinical Findings October 2018
• cT4
• cN1b
• cMx
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Clinical Findings November 2018
• cT4
• cN1b
• cMx
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Management Plan
• Review Histopathology and recent CT scans
• PET-CT
• Discuss further management in view of recent changes in the skin and rapid tumour progression
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Current Treatment
• Vendetanib 24 mg daily• Thyroxine 125 micrograms daily• Ferrous Fumarate• Daily dressings
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Clinical Progress – December 2018
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Clinical Progress – January 2019
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Management Plan
• What next?
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Thank you