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  • Rimini,5-8novembre2015

    Rimini,5-8novembre2015

    PaciniF,PapiniE,BellantoneR,SalvatoriM&Frasolda@A

    CarcinomaDifferenziatoTiroideoLelineeguidanellareal-life

  • Rimini,5-8novembre2015

    Aisensidellart.3.3sulconfliOodiinteressi,pag17delRegolamentoApplica@voStato-Regionidel5/11/2009,dichiarochenegliul@mi2anninonhoavutorilevan@rappor@direTdifinanziamentoconsoggeTportatoridiinteressicommercialiincamposanitario.

    Conflitti di interesse

  • Rimini,5-8novembre2015

    Emanuela, age 51 Shop manager in fashion outlet - No children Clinical history: thoracic trauma after car

    accident 15 years ago Currently asymptomatic Thyroid US exam during a medical check up.

    Clinicalcase1.

  • Rimini,5-8novembre2015

    Clinicalcase1:EmanuelaRimini,5-8novembre2015

  • Rimini,5-8novembre2015

    US Report

    Normal Thyroid size

    Left thyroid lobe: in the upper third, small (7.5 mm )

    hypoechoic nodule with slightly irregular margins

    Right thyroid lobe: no nodules - homogeneous gland

    tissue

    No enlarged neck lymph nodes.

  • Rimini,5-8novembre2015

    Clinical and Lab data

    Thyroid nodule is not clinically evident, neither at palpation nor at inspection

    No thyroid disease in Emanuelas family

    TSH: 2.3 U/ml

    US-guided FNA is performed

  • Rimini,5-8novembre2015

    FNA report

    Solid aggregates of thyroid epithelial cells. Focal nuclear dysmetria and occasional nuclear grooves

    Tir5

  • Rimini,5-8novembre2015

    Surgery or

    Wait-and-see strategy?

    Question 1.

  • Rimini,5-8novembre2015

    FNA evidence of thyroid malignancy

    If a cytology result is diagnostic for primary thyroid malignancy, surgery is generally recommended.

    An active surveillance management approach can be considered as an alternative to immediate surgery in patients with very low risk tumors

    (Strong recommendation, Moderate-quality evidence)

  • Rimini,5-8novembre2015

    Question 1 Surgical treatment or a wait-and-see strategy?

    [D3] Active surveillance of DTC primary tumors

    Ito, Miyauchi et al. 2010; Sugitani, Toda et al. 2010

    have provided compelling data that an active surveillance

    management approach to papillary microcarcinoma is a

    safe and effective alternative to immediate surgical

    These data have led to Recommendation 8E that

    FNA is not required for suspicious thyroid nodules < 1 cm

    without other high risk features and Recommendation

    12A which allow for active surveillance of primary

    tumors provided they could be classified as very low risk

    tumors.

  • Rimini,5-8novembre2015

    n 340 patients

  • Rimini,5-8novembre2015

    If surgery, total thyroidectomy (+ CND?) or lobectomy?

    Question 2.

  • Rimini,5-8novembre2015

    Operative approach for differentiated thyroid cancer

    If surgery is chosen for patients with thyroid cancer

  • Rimini,5-8novembre2015

    Operative approach for differentiated thyroid cancer

    Thyroid lobectomy alone is sufficient treatment for small, unifocal, intrathyroidal carcinomas in the absence of prior head and neck irradiation, familial thyroid carcinoma, or clinically detectable cervical nodal metastases. (Strong Recommendation, Moderate-quality evidence)

  • Rimini,5-8novembre2015

    Question 2: what kind of surgery

    In properly selected patients, clinical outcomes are very similar following unilateral or bilateral thyroid surgery. More selective approach to RAI ablation. The presence of the remaining lobe of the gland may obviate the life-long need for

    exogenous thyroid hormone therapy. Reliance on neck ultrasonography and serial serum Tg measurements. Evidence: Bilimoria et al: 52,173 PTC (National Cancer Data Base 43,227 total

    thyroidectomy, 8,946 lobectomy), similar 10 year overall survival (98.4% vs 97.1%) and 10 year recurrence rate (7.7% vs 9.8%).

    Haigh et al: 5,432 PTCs (SEER data based 4,612 total thyroidectomy and 820 lobectomy): no difference in 10 year overall survival.

    Barney et al SEER database: 23,605 DTC (12, 598 total thyroidectomy, 3,266 lobectomy): no difference in 10 year cause specific survival (96.8% vs 98.6).

    Mendelsohn et al: 22,724 PTC (16,760 total thyroidectomy, 5,964 lobectomy): no difference in disease specific survival.

  • Rimini,5-8novembre2015

    And the other Guidelines?

    Question 1. & 2.

  • Rimini,5-8novembre2015

  • Rimini,5-8novembre2015

    Lobectomy may be considered when all the following are present: Age 15 45 yrs No prior irradiation No distant metastasis No cervical node metastasis No extrathyroidal extension Tumor < 4 cm in diameter No aggressive variant

  • Rimini,5-8novembre2015

    Management of papillary microcarcinoma

    Thyroid lobectomy is recommended for patients with a unifocal microPTC and no other risk factors.

    British Thyroid Association Guidelines for the Management of Thyroid Cancer

  • Rimini,5-8novembre2015

    Management of papillary microcarcinoma

    Total thyroidectomy is recommended for patients with:

    - microPTC and familial non-medullary thyroid cancer

    - multifocal microPTC involving both lobes.

    British Thyroid Association Guidelines for the Management of Thyroid Cancer

  • Rimini,5-8novembre2015

    Management of papillary microcarcinoma

    For all other patients with microPTC, recommendation for type of surgery should be based on consideration of risk factors and Personalised Decision Making is recommended.

    British Thyroid Association Guidelines for the Management of Thyroid Cancer

  • Rimini,5-8novembre2015

    What is the Experts Opinion?

    Question 1. & 2.

  • Rimini,5-8novembre2015

    Danica, age 33, born in Romania, Italy since 2007

    Tenderness and discomfort in her neck and

    appearance of a lump on the right side

    No familial thyroid disease - no irradiation

    TSH 1.45 mU/ml

    Referred by her GP for thyroid US exam.

    Clinicalcase2:Danica

  • Rimini,5-8novembre2015

    Clinicalcase2:DanicaRimini,5-8novembre2015

  • Rimini,5-8novembre2015

    Clinicalcase2:DanicaRimini,5-8novembre2015

  • Rimini,5-8novembre2015

    US Report

    Normal Thyroid size. Mildly inhomogeneous tissue

    Right thyroid lobe: large (29 x 17 x 21 mm)

    hysoechoic solid nodule, slightly irregular but well

    defined margins. Peri- and intra-nodular

    vascularization.

    Left thyroid lobe: no nodules

    No evidence of enlarged neck lymph nodes.

  • Rimini,5-8novembre2015

    FNA Report

    Follicular and microfollicular aggregates of thyrocytes with mild anysocariosis. Scarce colloid. Follicular neoplasm .

    TIR3B (SIAPEC) - Thy-3f (BTA)

  • Rimini,5-8novembre2015

    Case 2- Surgical treatment

    Danica undergoes right lobectomy

    Histologic Report: Papillary thyroid cancer, follicular variant, 28 mm diameter. Minimal infiltration of the thyroid capsule without clear extension into soft tissues Surgical margins free of disease. No vascular invasion pT2 pNx R0

    TSH: 4.7 uU/ml

  • Rimini,5-8novembre2015

    Completion thyroidectomy?

    Question n.3

  • Rimini,5-8novembre2015

    Completion thyroidectomy

    Completion thyroidectomy should be offered to those patients for whom a bilateral thyroidectomy would have been recommended had the diagnosis been available before the initial surgery.

    Therapeutic central neck lymph node dissection should be included if the lymph nodes are clinically involved.

    (Strong Recommendation, Moderate-quality evidence)

  • Rimini,5-8novembre2015

    For patients with thyroid cancer >1 cm and

  • Rimini,5-8novembre2015

    Thyroid lobectomy alone may be sufficient initial treatment for low risk papillary and follicular carcinomas; however, the treatment team may choose total thyroidectomy to enable RAI therapy or to enhance follow-up based upon disease features and/or patient preferences.

    (Strong Recommendation, Moderate-quality evidence)

    Surgery for FNA evidence of thyroid malignancy

  • Rimini,5-8novembre2015

    Question 3: completion thyroidectomy

    This case has the features of a low risk intrathyroidal tumor.

    Such PTCs can be managed with either lobectomy or total thyroidectomy.

    Thus, a completion thyroidectomy is not required.

  • Rimini,5-8novembre2015

    And the other Guidelines?

    Question 3

  • Rimini,5-8novembre2015

  • Rimini,5-8novembre2015

    Observe without completion thyroidectomy if all the following are present: Tumor < 1 cm in diameter No cervical node metastasis No contralateral lesion Complete surgical resection

  • Rimini,5-8novembre2015

    Therapeutic surgery for thyroid cancer

    Total thyroidectomy is recommended for patients with tumours greater than 4 cm in diameter, or tumours of any size in association with any of the following characteristics: multifocal disease, bilateral disease, extra-thyroidal spread (pT3 and pT4a), familial disease, and those with clinically or radiologically involved nodes and/or

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