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4.treatment & follow up of thyroid malignancy
1) The document discusses the treatment and follow-up of thyroid swelling and thyroid cancer. It outlines surgical and medical management strategies for different types of thyroid nodules, cancers, and postoperative care. 2) Types of thyroid cancer discussed include papillary, follicular, medullary, and anaplastic carcinoma. Treatment options covered are surgery, radioiodine therapy, chemotherapy, and external beam radiation. 3) Follow-up care involves monitoring of thyroid function tests, tumor markers, and imaging to detect recurrence and provide additional treatment if needed. Lifelong thyroid hormone suppression is also recommended in many cases.
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Presentation on thyroid swelling treatment by Sayan Banerjee from Malda Medical College.
Illustration of lymph node levels in the neck relevant to thyroid cases.
Overview of FNAC results for thyroid nodules, emphasizing malignant, benign, and indeterminate diagnostics.
Management of toxic multinodular goitre focusing on surgery options and pre-op preparations.
Details on the treatment of toxic adenoma with surgical options based on nodule size and function.
Pre-surgical management of hyperthyroid patients, emphasizing euthyroid state and other preparations.
Summary of various surgical operations relevant to thyroid conditions.
Criteria for unilateral thyroid lobectomy based on cyst characteristics and recurrence risks.
Different surgical treatments for papillary thyroid carcinoma based on risk level and tumor characteristics.
Advantages and reasons for choosing total thyroidectomy vs. lobectomy in low-risk patients.
NCCN guidelines for total thyroidectomy, highlighting various risk factors and patient profiles.
Recommendation against prophylactic lateral neck node dissection in papillary thyroid carcinoma.
Management protocol for residual disease after thyroid surgery, including imaging and treatment.
Findings linking total thyroidectomy to improved survival rates, with factors affecting outcomes.
Interventions for metastatic disease involving CNS and bone with approaches to palliation.
Surgical treatment options for suspected follicular carcinoma and criteria for intervention.
Guidelines for managing Hurthle cell carcinoma with surgery and radioiodine treatment recommendations.
Post-operative management strategies including RAI, EBRT, and chemotherapy.
Indications and procedures for RAI in differentiated thyroid cancer, detailing follow-up requirements.
Detailed steps involved in RAI treatment and post-treatment imaging strategies.
Introduction of Sorafenib for differentiated thyroid cancer refractory to RAI.
Thyroid suppression post-surgery aiming to reduce recurrence rates.
EBRT applications for unresectable or locally invasive thyroid cancer.
Limitations of chemotherapy in thyroid cancer and role of doxorubicin as a sensitizer.
Surgical approach for medullary thyroid carcinoma with emphasis on lymph node dissection.
Advances in therapies for medullary thyroid carcinoma including inhibitors and ablation techniques.
Approaches for managing hypercalcemia related to thyroid conditions and cancer.
Recommendations for assessing and managing family members of patients with medullary thyroid cancer.
Treatment options for anaplastic carcinoma focusing on surgical and chemoradiotherapy.
Core treatment protocols for lymphomas involving chemotherapy and potential surgery.
Thyroglobulin levels as a marker for tumor recurrence post-thyroidectomy.
Guidelines for follow-up imaging in thyroid cancer patients based on risk categories.
Routine monitoring of calcitonin and CEA levels post-operatively for recurrence evaluation.
Approaches for managing both localized and non-localized recurrence in thyroid malignancies.
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4.treatment & follow up of thyroid malignancy
- 1. TREATMENT & FOLLOW-UPOF A CASE OF THYROID SWELLING SAYAN BANERJEE 8TH SEMESTER MALDA MEDICAL COLLEGE
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- 4. Toxic Multinodular Goitre •Elderly, long standing MNG • Mainly cardiac • NO EXTRATHYROIDAL FEATURES • ↓TSH; ↑FT4,FT3 • RAIU : internodular tissue hot • Tx: Make euthyroid → Thyroidectomy (STT, Hartley Dunhill, TT) RAI (I131): Elderly, Poor risk patients
- 5. Toxic Adenoma (Plummer’sdisease) • Single nodule • Young, longstanding nodule, sudden growth and hyper-function • RAIU: Hot nodule • Small nodule: ATT, RAI • Large nodule/ Young patients: Lobectomy
- 6. Surgery in aHyperthyroid Patient • Make patient euthyroid prior to surgery→ • Continue ATT upto morning of surgery • Lugol’s Iodine or SSKI: 3 drops BD starting 10 days prior • Inhibits release of hormone, ↓vascularity • Propranolol
- 7. Operations on theThyroid
- 8. Unilateral thyroid lobectomyis recommended: 1. Cyst persist after 3 attempts for aspiration 2. Cyst >4cm 3. Complex cyst with solid and cystic components higher chances of malignancy (15 %)
- 9. Papillary thyroid carcinoma TYPETREATMENT HIGH RISK or BILATERAL Total or near total thyroidectomy Minimal papillary carcinoma in thyroid specimen Unilateral thyroid lobectomy and isthmusectomy Large, Locally aggressive/ metastatic tumours Total thyroidectomy with excision of adjacent involved structures if necessary and appropriate nodal surgery followed by radioablation with long term TSH suppression Modified Radical neck dissection type III is done in case of biopsy-proven lymph node metastases
- 10. Low risk groups Pointsin favour of total thyroidectomy Point in favour of lobectomy Enables the use of RAI to detect and treat residual thyroid tissue/mets Lobectomy has less complication rate Makes serum Tg level more sensitive for recurrent or persistent disease Recurrence in remaining tissue is unsual (5%) and mostly curable by surgery Removes contralateral occult cancer as sites of recurrence ( 85% bilateral) Tumour multicetricity has little prognostic significance Reduces recurrence risk and improved survival Prognosis is comparable to total thyroidectomy Decreases the 1 % risk of progression to anaplastic cancer Reduces rate of re-operation and complication Generally total or near total thyroidectomy is recomended in low risk groups provided complication rates are low <2 %
- 11. Indication of totalthyroidectomy NCCN guidelines If any present If all present (thyroidectomy/lobectomy) Age <15y or >45y Age 15 – 45 y Radiation history No radiation history Known distant mets No distant mets Bilateral nodularity No nodularity Extrathyroidal invasion No extrathyroidal invasion Tumour > 4cm Tumour <4 cm Cervical lymph node mets No cervical lymph nodes mets Aggressive variant No aggressive variant
- 12. • Prophylactic lateralneck node dissection is NOT recommended in PTC • Cancer doesn’t metastasize systemically from lymph nodes • Micrometastasis can be ablated by RAI therapy
- 13. Residual disease Postoperatively • TSH + Tg and antithyroglobulin antibodies • 2 to 12 weeks post operatively • Total body RAI imaging • Suspected or proven RAIEBRT • Adequate RAI uptake Radioiodine treatment and post treatment I131 imaging • If no imaging performed EBRT • In all these cases suppress TSH with Levothyroxine.
- 14. •Total thyroidectomy resultedin improved survival over other techniques •Poorer outcomes were associated with age, stage T3/T4 disease, positive nodes, and tumour size
- 15. Metastatic disease • CNS Neurosurgical resection and/or image guided EBRT • BONE Surgical palliation (weight bearing extremities and/or RAI treatment and/or EBRT) • bisphosphonate or denosumab therapy • Embolization of metastatic deposits • Other than CNS surgical resection and/or EBRT of selected mets and/or radioiodine • Best supportive care
- 16. Follicular carcinoma • Follicularlesion on FNAB thyroid lobectomy (80 % are benign adenomas) • Thyroid cancer Total thyroidectomy is recommended in → • Older patients • Lesion >4cm ( cancer risk is higher- 50 %) • Intraoperative frozen section examination if • Evidence of vascular or capsular invasion • Adjacent lymphadenopathy is present • Thyroid specimen follicular carcinoma total thyroidectomy • Nodal metastasis therapeutic neck dissection Prophylactic nodal dissection is unwarranted as nodal involvement is infrequent
- 17. Hurthle cell carcinoma •Unilateral Hurthle cell adenomas lobectomy + isthmusectomy • Invasive (on definitive paraffin section histology) total thyroidectomy + central neck node removal • Modified radical neck dissection if lateral nodes are palpable & identified by USG • TSH suppression • Although RAI scanning and ablation usually are ineffective, they probably should be considered to ablate any residual normal thyroid tissue and occasionally ablate tumors because there is no other good therapy. Retinoic acid and PPAR-γ agonists have shown some benefit in these tumors in vitro; but needs further research
- 18. Post operative managementof Differentiated Thyroid Cancer 1. Radioiodine scanning and ablation 2. External beam radiotherapy (EBRT) 3. Chemotherapy
- 19. 1.Radioiodine scanning andablation • RAI ablation is recommended in • All patients with stage 3 and 4 disease • All Patients with stage 2 disease <45 years • Most patients ≥ 45 years with stage 2 disease • Stage 1 disease with • Aggressive histology • Nodal metastases • Multifocal disease • Extrathyroidal or vascular invasion • More senstive than X-ray/ CT in detecting metastatic disease • Less senstive than Tg level except in Hurthle cell tumors • 4-6 weeks after thyroidectomy, hypothyroid can be induced by discontinuing replacement (T4 for 4 weeks or T3 for 2 weeks) to obtain high serum TSH levels.
- 20. 1.Radioiodine scanning andablation (CONTD….) • A diagnostic dose of 131I or 123I is given initially. • Whole-body scanning is performed to detect any tissue taking up radioiodine. • If any normal thyroid remnant or metastatic disease is detected, a therapeutic dose of 131I is administered to ablate the tissue. • Post-treatment scanning should also be performed because it may reveal metastatic disease not otherwise noted. • If a treatment dose of 131I is required, diagnostic thyroid scanning is repeated after 6 months after initial treatment, • If the diagnostic scan Positive additional therapeutic dose is given. Process is repeated until the diagnostic scan is negative Role of recombinant human TSH • Thyrogen stimulation avoids the discomfort of patients having to discontinue thyroid replacement • T4 stopped 1 day before TSH stimulation
- 21. Recent advances Sorafenib* (Nexavar)was approved in November 2013 for differentiated thyroid cancer (DTC) that is refractory to radioactive iodine treatment. *Sorafenib is a small molecular inhibitor of several tyrosine protein kinases
- 22. Thyroid suppression • Usedafter thyroidectomy and radioablation • Reduces tumoural growth and recurrence rates • Suppressive dose is 0.3 mg OD lifelong • TSH levels should be < 0.1 mU/L
- 23. 2. External beamradiotherapy • Used in unresectable, locally invasive or recurrent disease • In bone mets to decrease • Risk of fractures • Bone pain
- 24. 3. Chemotherapy • Generallyhas no role • Doxorubicin is used as radiation sensitizer in patients undergoing external beam radiation
- 25. Medullary thyroid carcinoma •If pheochromocytoma present operated first • Total thyroidectomy is the treatment of choice with bilateral central neck node dissection • Palpable cervical lymph nodes modified radical neck dissection • Tumour >1 cm ipsilateral Prophylactic modified radical neck dissection • If +ive than contralateral node dissection is done • If unresectable • Tumor debulking to reduce symptoms • External beam radiation
- 26. Medullary thyroid carcinoma Recentadvances Tyrosine kinase inhibitors Imitanib Zactima (reduces calcitonin and CEA levels Anti CEA monoclonal antibody Labetuzumab Laparoscopic Radiofrequency ablation For Liver mets >1.5 cm (palliative)
- 27. • If patientis hypercalcemic at thyroidectomy • Only enlarged parathyroid gland is removed • RET mutation carrier total thyoroidectomy • MEN2A before 6 years • MEN2B before 1 year • Central neck node dissection • Avoided in calcitonin negative and normal USG exam • Done prophylactically in calcitonin positive and if USG suggests cancer • Maintenance dose of L-thyroxine
- 28. • All familymembers of patients with MTC should be evaluated with serum calcitonin (genetic evaluation can also be done ) and if it is high they should undergo prophylatic thyroidectomy ......
- 29. Anaplastic carcinoma • Ifresectable • Adjuant chemoradiotherapy • Adriamycin is used for chemo. • Tracheostomy and isthemectomy to relieve airway obstruction in unresectable cases
- 30. Lymphomas • Mainstay Chemotherapy • CHOP ( Cyclophosphamide, Doxorubicin, vincristine, and prednisolone) • Radiotherapy may also be given • Thyroidectomy and nodal resection to alleviate airway obstruction
- 32. Differentiated Thyroid Carcinoma Thyroglobulinlevels Thyroglobulin is a useful marker of tumor recurrence because well- differentiated thyroid cancers synthesize thyroglobulin • After total thyroidectomy levels should be • <2 ng/ml if taking t4 • <5ng/ml if hypothyroid • Levels >2ng/ml suggest metastatic or persistant normal tissue. (>95%) • Tg and Tg antibodies measuresd initially 6 months interval then annualy if disease free.
- 33. Follow up imaging •In low risk and –ive TSH stimulated Tg and cervical USG routine whole bodyscan is not recommended after first post operative scan • After remnant ablation routine whole body scan after 6 to 12 months is recommended Cervical USG • To evaluate thyroid bed and lymph node 6 to 12 months post thyroidectomy then annually for 4 to 5 years FDG PET SCAN • If RAI and USG normal but Tg remain elevated
- 34. Medullary thyroid carcinoma •Annual measurements of calcitonin and CEA levels. • Regular USG , CT , MRI if required • FGD PET scans • Superior to other radionuclide based studies
- 35. Management of recurrence •Localized • Surgical excision • Non localized • 131 I radioablation • External beam radiotherapy