controversies in the management of differentiated thyroid carcinoma dimyati achmad department of...
TRANSCRIPT
Controversies in the Management of Differentiated Thyroid Carcinoma
Dimyati AchmadDepartment of Surgery, Faculty of Medicine Padjadjaran University/
Hasan Sadikin Hospital, Bandung Indonesia
Introduction
• Thyroid carcinoma is the most frequent malignancy of the endocrine system
• The incidence has increased sharply in three decades
• Almost 90% of thyroid carcinoma are well-differentiated thyroid carcinoma
Differentiated Thyroid Carcinoma (DTC)
• Is categorized into:– Papillary thyroid carcinoma (85%)– Folliculare thyroid carcinoma (10%)– Hurtle cell carcinoma (3%)
• Slow growing tumor• Good prognosis
LOW RISK HIGH RISK
AMES
Age Males < 41 y, female < 51 y Males > 40 y, female > 50 y
Metastases No distant metastases Distant metastases
Extent Intrathyroidal papillary or follicular with minor capsule invasion
Extrathyroidal papillary or follicular with major invasion
Size < 5 cm > 5 cm
Definition A: Any low-risk age group without metastasesB: High-risk age without metastases and with low-risk extent and size
A: Any patient with metastasesB: High-risk age with either high-risk extent and size
Debated Issue Includes :
• The extent of primary surgical resection and / or need for the extent of regional lymph node dissection
• The role of post operative radio iodine remnant ablation
• The role of B-RAF mutation in management of papillary thyroid carcinoma
Until today, the managementof DTC are still in controversy
The Extent of Primary Surgical Resection
Based on high risk and low risk criteria from prognostic scoring system, the controversial issue especially, in the management of low risk case.
Some group of surgeons performed only thyroid lobectomy, whether performed total thyroidectomy.
The Guidelines of American Thyroid Association 2009:
• Thyroid cancer > 1 cm → recommended to perform total / near total thyroidectomy.
• Thyroid cancer < 1 cm, is a low risk, unifocal intrathyroidal papillary carcinoma and in the absence of prior head and neck irradiation → recommended to perform only thyroid lobectomy.
Neck Dissection
Central – compartment (level VI) neck dissection
should included in total thyroidectomy, especially:
• Patients with clinically present central or
lateral neck lymph node enlargement.
• Advanced primary tumors.
Lateral neck compartement (level II-V) lymph node dissection:
Should be perfomed for patients with lateral cervical lymph node enlargement which is prove have metastatic by histopathological examination.
The Role of Post OperativeRadio Iodine Remnant Ablation
The goals of the treatment are
to destroy any residual thyroid tissue
to prevent locoregional recurrence
and to facilitate surveillance
with whole-body iodine scans
and/or adjusment thyroglobulin value.
Major Factors Impacting Decision Makingin Radioiodine Remnant Ablation
Expected benefit
Factors Description
Decreasedrisk ofdeath
Decreasedrisk of
reccurence
May facilitate initial staging and follow up
RAI ablation usually
recommended
Strengthof
evidence
T1 1 cm or less, intrathyroidal or microscopic multifocal No No Yes No E
1-2 cm, intrathyroidal No Conflicting dataa Yes Selective usea I
T2 > 2-4 cm intrathyroidal No Conflicting dataa Yes Selective usea C
T3 > 4 cm
< 45 years old No Conflicting dataa Yes Yes B
> 45 years old Yes Yes Yes Yes B
Any size, any age, minimal extrathyroidal extension No Inadequate dataa Yes Selective usea I
T4 Any size with gross extrathyroidal extension Yes Yes Yes Yes B
Nx,N0 No metastatic nodes document No No Yes No I
N1 < 45 years old No Conflicting dataa Yes Selective usea C
> 45 years old Conflicting data Conflicting dataa Yes Selective usea C
M1 Distant metastasis present Yes Yes Yes Yes A
• Gross extrathyroidal extension and distant metastasis present → radioiodine ablation is usually recommended
• In low risk case no recommended for radioiodine ablation
The Role of B-RAF Mutationin the Management of
Papillary Thyroid Carcinoma
HGF
Met
Mutant B-RAF Protein
MEK
ERK
C-METECM
ERKB-RAF
Mutation
C-JUNC-FOS
HYPOXIA
HIF-1α
HIF-1α-1β
VEGFVE6F-C
VEGFVEGF-C
Proliferation ↑Extrathyroidal Invasion
Lymph nodemetastases
RET
RAS
RAF
• The recent explosion of knowledge regarding the molecular and cellular pathogenesis of cancer has led to the development of range of targeted therapies
• Efficacy has already been demonstrated for several agents including Sorafenib as tyrosine kinase inhibitor
HGF
Met
Mutant B-RAF Protein
MEK
ERK
C-METECM
ERKB-RAF
Mutation
C-JUNC-FOS
HYPOXIA
HIF-1α
HIF-1α-1β
VEGFVE6F-C
VEGFVEGF-C
Proliferation Extrathyroidal Invasion
SORAFENIB
X
Some of the researchers are recommended to undergo sorafenib utilization
But, there is no guideline of management papillary thyroid carcinoma, describe the role of tyrosine kinase inhibitor
The management of differentiated thyroid carcinoma remains controversial
The choice for management of differentiated thyroid carcinoma:Total thyroidectomy, radioiodine ablation and thyroxine suppresion therapy.
Conclusion
• Lateral neck compartement lymph node dissection should be perfomed for patients with lateral cervical lymph node enlargement which is prove have metastatic by histopathological examination.
• In papillary thyroid carcinoma with B-RAF mutation are recommended to undergo Sorafenib utilization as Tyrosine Kinase Inhibitor (TKI).
THANK YOU