1. Dr. Varun Goel
MEDICAL ONCOLOGIST
RAJIV GANDHI CANCER INSTITUTE, DELHI
2. Introduction
The most common endocrine malignancy
95% of all endocrine cancers
accounts for ~3% of all cancers
Female to Male Ratio 3:1
sixth most frequently diagnosed cancer in women
continued increased incidence with an estimated
48,020 new cancer cases in 2011.
six deaths per 1 million people occur annually.
3. based on pathology can be divided into three general
subtypes
differentiated (papillary, follicular, and Hürthle cell),
more than 90% of thyroid cancers
medullary, and
anaplastic thyroid cancers
The prognosis is excellent for most patients with
thyroid cancer
overall survival rate of 85% at 10 years.
Most effectively treated by thyroidectomy and use of
radioactive iodine.
Despite low mortality rates,
local recurrence occurs in up to 20% of patients, and
distant metastases in approximately 10% at 10 years.
4. History
Symptoms
The most common presentation painless mass in
the region of the thyroid gland (Goldman, 1996).
Symptoms consistent with malignancy
Pain
dysphagia
Stridor
hemoptysis
rapid enlargement
hoarseness
5. Important History
Radiation to neck / chest
MEN syndrome
Family history
Diarrhoea
Adrenal tumour
6. History (continued...)
Risk factors
Thyroid exposure to irradiation
low or high dose external irradiation
(40-50 Gy [4000-5000 rad])
especially in childhood for:
large thymus, enlarged tonsils, cervical adenitis, sinusitis, and
malignancies
30%-50% chance of a thyroid nodule to be malignant
(Goldman, 1996)
7. History (continued...)
Risk factors (continued…)
Age and Sex
Benign nodules occur most frequently in women 20-40
years (Campbell, 1989)
5%-10% of these are malignant (Campbell, 1989)
Men have a higher risk of a nodule being malignant
Belfiore and co-workers found that:
the odds of cancer in men quadrupled by the age of 64
a thyroid nodule in a man older than 70 years had a 50% chance
of being malignant
8. History (continued…)
Family History
family member with medullary thyroid carcinoma
family member with other endocrine abnormalities
(parathyroid, adrenals)
familial polyposis (Gardner’s syndrome)
10. Evaluation of the thyroid Nodule
Physical Exam
Blood Tests
Ultrasonography
CT Scan
PET Scan
Radioisotope Scanning
FNAC
11. Physical Exam
Examination of the thyroid nodule:
consistency - hard vs. soft
size
Multinodular vs. solitary nodule
multi nodular - 3% chance of malignancy (Goldman, 1996)
solitary nodule - 5%-12% chance of malignancy
(Goldman, 1996)
Mobility with swallowing
Mobility with respect to surrounding tissues
Well circumscribed vs. ill defined borders
13. Ultrasonography
Advantages
Sensitive for identifying lesions in the thyroid (2-3mm)
90% accuracy in categorizing nodules as
solid, cystic, or mixed (Rojeski, 1985)
Best method of determining the volume of a nodule
(Rojeski, 1985)
Can detect the presence of lymph node enlargement
and calcifications
Noninvasive and inexpensive
15. CT Scan
Not commonly needed
Better when suspecting mediastinal disease
PET Scan
FNAC
Accurate for PTC and MTC
Cannot diagnose FTC
16. Radioisotope Scanning
Prior to FNA, was the initial diagnostic procedure of
choice
Performed with: technetium 99m pertechnetate or
radioactive iodine
Technetium 99m pertechnetate
cost-effective
readily available
short half-life
trapped but not organified by the thyroid - cannot determine
functionality of a nodule
17. Radioisotope Scanning (Continued…)
Radioactive iodine
radioactive iodine (I-131, I-125, I-123)
is trapped and organified
can determine functionality of a
thyroid nodule
19. Limitations of Radionuclide Scan
Cold nodules usually benign...
but could be cancer
Hot nodules never cancer…
and revealed by low TSH
20. Radioisotope Scanning (continued...)
Limitations
Not as sensitive or specific as FNA in
distinguishing benign from malignant nodule
90%-95% of thyroid nodules are hypofunctioning, with 10%-20%
being malignant (Geopfert, 1994, Sessions, 1993)
Campbell and Pillsbury (1989) performed a meta-analysis of 10
studies
17% of cold nodules, 13% of warm or cool nodules, and 4% of hot
nodules to be malignant
21. Fine-Needle Aspiration
Currently considered to be the best first-line diagnostic
procedure in the evaluation of the thyroid nodule:
Advantages:
Safe
Cost-effective
Minimally invasive
Leads to better selection of patients for surgery than any other
test (Rojeski, 1985)
22. Fine-Needle
Aspiration (continued…)
FNA halved the number of patients requiring
thyroidectomy (Mazzaferri, 1993)
FNA has double the yield of cancer in those who do
undergo thyroidectomy (Mazzaferri, 1993)
23. Fine-Needle Aspiration (continued…)
Limitations
skill of the aspirator
Sampling error in lesions <1cm, >4cm, multinodular lesions, and
hemorrhagic lesions
Error can be diminished using ultrasound guidance
expertise of the cytologist
difficulty in distinguishing some benign cellular
adenomas from their malignant counterparts (follicular
and Hurthle cell)
False negative results = 1%-6% (Mazzeferri, 1993)
False positive results = 3%-6%
(Rojeski, 1985, Mazzeferri, 1993, Hall, 1989)
25. Thyroid Cancer Type Mutation Prevalence, %
Papillary
BRAF[V600E] 45
BRAF copy gain 3
RET/PTC 20
RAS 10
PI3KCA 3
PI3KCA copy gain 12
PTEN 2
Follicular
BRAF copy gain 35
RAS 45
PAX8-PPARγ 35
PTEN < 10
PI3KCA < 10
PI3KCA copy gain 12
Medullary
RET (familial) > 95
RET (sporadic) 50
26.
27.
28. In last 30 years, it has become clear that thyroid
cancers are associated with genetic mutations that
lead to aberrant intracellular signaling
inhibition of intracellular signaling cascades including
MAPK and PI3K pathways may be effective in the
treatment .
Ahmed 2011; Hong 2011; Carr 2010; Robinson 2010; Lam
2010; Sherman 2008;Gupta-Abramson 2008
30. WDTC - Papillary
Carcinoma
Pathology
Gross - vary considerably in size
- often multi-focal
- unencapsulated but often have a
pseudocapsule
Histology - closely packed papillae with
little colloid
- psammoma bodies
- nuclei are oval or elongated,
pale staining with
ground glass appearanc -
Orphan Annie cells
31. WDTC - Follicular Carcinoma
Pathology
Gross - encapsulated, solitary
Histology - very well-differentiated
(distinction between follicular
adenoma and carcinomaid
difficult)
- Definitive diagnosis -
evidence of vascular and
capsular invasion
FNA and frozen section cannot
accurately distinquish between benign
and malignant lesions
32. CEA Synaptophysin Chromogranin
Calcitonin Thyroglobulin
S03-12297
33. 72 yr old female, 2 week history enlarging thyroid mass
2-3 day history of hoarseness and stridor
FNA: poorly differentiated thyroid cancer
Thyroglobulin neg
Spindle cells Giant cells
PTC
Anaplastic
34. WDTC - PROGNOSIS
Prognostic schemes:
AMES (Lahey Clinic, Burlington, MA)
GAMES (Memorial Sloan-Kettering Cancer Center, NY)
AGES (Mayo Clinic, Rochester, MN)
GAMES scoring (PAPILLARY & FOLLICULAR CANCER)
G - Grade
A - Age of patient when tumor discovered
M - Metastases of the tumor (other than Neck LN)
E - Extent of primary tumor
S - Size of tumor (>5 cm)
The patient is then placed into a high or low risk category
35. WDTC - Prognosis (Continued…)
1) Low risk group - men younger than 40 years and
women younger than 50 years regardless
of histologic type
- recurrence rate -11%
- death rate - 4%
(Cady and Rossi, 1988)
36. WDTC - Prognosis (Continued…)
1) Intermediate risk group - Men older than 40 years and
women older than 50 years
who have papillary carcinoma
- recurrence rate - 29%
- death rate - 21%
2) High risk group - Men older than 40 years and women
older than 50 years who have follicular
carcinoma
- recurrence rate - 40%
- death rate - 36%
37. AJCC :Classification of Thyroid Cancer
Primary
tumor
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Tumor < 2 cm confined to the thyroid
T2 Tumor >2 cm and <4 cm confined to the thyroid
T3 Tumor >4 cm confined to the thyroid
or Tumor of any size with minimal extrathyroid extension
T4a Tumor of any size with extrathyroid extension to subcutaneous
soft tissues, larynx, trachea, esophagus, or recurrent laryngeal
nerve
or Intrathyroidal anaplastic carcinoma- resectable
T4b Tumor invading prevertebral fascia/encasing carotid artery or
mediastinal vessels or Extrathyroidal anaplastic carcinoma -
unresectable
38. Regional LN(N) (central compartment, lateral
cervical, and upper mediastinal)
NX Regional lymph nodes cannot be
assessed
N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
N1a Metastasis to level VI (pretracheal or
paratracheal, and prelaryngeal)
N1b Metastasis to unilateral, bilateral, or
contralateral cervical(Levels I, II, III, IV or
V) or superior mediastinal lymph nodes
(Level VII )
39. Distant
metastasis
(M)
MX Distant metastasis
cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
41. AJCC/UICC StagingThyroid Cancer
Papillary/Follicular
Stage Age < 45 yrs Age > 45 yrs
I Any T, any N, M0 <2 cm, intrathyroidal, N0, M0
II Any T, Any N, M1 2- 4cm, intrathyroidal, N0, M0
III Minimal ETE, or > 4cm, N0, M0
or T1-3, N1a, M0
IV Any T, Any N, Gross ETE, or M1
Hürthle cell carcinoma is considered a follicular carcinoma. All anaplastic
carcinomas are stage IV.
42. staging of thyroid cancer is the only one in
oncology that takes patient age at diagnosis into
account.
age is the most important prognostic variable for
mortality
a large proportion of thyroid cancers (primarily
PTC) occur in women under the age of 45.
As a group these are highly sensitive to RAI;
thus, even with metastatic disease can be cured with
RAI following surgery.
As the age of diagnosis increases, the mortality rate
increases as well, most sharply after the age of 60 years.
43.
44. Overall, the differentiated thyroid cancers are
associated with a good prognosis and 10-year
survival rates are
93% for papillary
85% for follicular and
76% for Hürthle cell carcinomas, respectively.
45. Initial Management
Surgery is the definitive management of
thyroid cancer, excluding most cases of ATC
and lymphoma
Types of operations:
lobectomy with isthmusectomy –
minimal operation required for a potentially malignant
thyroid nodule
total thyroidectomy - removal of all thyroid tissue
preservation of the contralateral parathyroid glands
subtotal thyroidectomy
anything less than a total thyroidectomy
46. Management (WDTC) - Papillary and
Follicular
Subtotal vs. total thyroidectomy
47. (continued…)
Rationale for total thyroidectomy
1) 30%-87.5% of papillary carcinomas involve opposite
lobe (Hirabayashi, 1961, Russell, 1983)
2) 7%-10% develop recurrence in the contralateral lobe
(Soh, 1996)
3) Residual WDTC has the potential to dedifferentiate to
ATC
48. (Continued…)
Rationale for subtotal thyroidectomy
1) Lower incidence of complications
Hypoparathyroidism (1%-29%) (Schroder, 1993)
Recurrent laryngeal nerve injury (1%-2%) (Schroder, 1993)
Superior laryngeal nerve injury
2) Long term prognosis is not improved by total
thyroidectomy (Grant, 1988)
49. (continued)
Indications for total thyroidectomy
1) Patients older than 40 years with papillary or
follicular carcinoma
2) Anyone with a thyroid nodule with a history of
irradiation
3) Patients with bilateral disease
50. (continued)
Managing lymphatic involvement
pericapsular and tracheoesophageal nodes should be
dissected and removed in all patients undergoing
thyroidectomy
Overt nodal involvement requires exploration of
mediastinal and lateral neck
If any cervical nodes are clinically palpable or identified
by MR or CT imaging as being suspicious a neck
dissection should be done (Goldman, 1996)
Prophylactic neck dissections are not done (Gluckman)
51. Management (WDTC) - Papillary and Follicular
(continued)
Postoperative therapy/follow-up
Radioactive iodine (administration)
Scan at 4-6 weeks postop
repeat scan at 6-12 months after ablation
repeat scan at 1 year then...
every 2 years thereafter
52. Management (WDTC) - Papillary and Follicular
(continued)
Postoperative therapy/follow-up
Thyroglobulin (TG) (Gluckman)
measure serum levels every 6 months
Level >30 ng/ml are abnormal
Thyroid hormone suppression
(control TSH dependent cancer) (Goldman, 1996)
should be done in –
1) all total thyroidectomy patients
2) all patients who have had
radioactive ablation of any remaining thyroid tissue
53. neck ultrasound should be performed 6 and 12 months
after surgery, and then annually for 3 to 5 years,
depending on the patients risk for recurrence and Tg
status.
CT and PET scans has been increasingly used in the
surveillance of patients with iodine-negative,
differentiated thyroid carcinoma.
54. (WDTC) - Hurthle Cell Carcinoma
Variant of follicular carcinoma
Lymphatic spread seen in 30% of patients (Goldman,
1996)
Distant metastases to bone and lung is seen in 15% at
the time of presentation
Total thyroidectomy is recommended because:
1) Lesions are often Multifocal
2) They are more aggressive than WDTCs
3) Most do not concentrate iodine
56. Medullary Thyroid Carcinoma
10%
Arises from the parafollicular cell or C-cells of the thyroid
gland
derivatives of neural crest cells of the branchial arches
secrete calcitonin which plays a role in calcium metabolism
Developes in 4 clinical settings:
Sporadic MTC (SMTC)
Familial MTC (FMTC)
Multiple endocrine neoplasia IIa (MEN IIa)
Multiple endocrine neoplasia IIb (MEN IIb)
57. Medullary Thyroid Carcinoma
(continued…)
Sporadic MTC:
70%-80% of all MTCs
Mean age of 50 years
Unilateral and Unifocal (70%)
Slightly more aggressive than FMTC and MEN IIa
Familial MTC:
Autosomal dominant transmission
Not associated with any other endocrinopathies
Mean age of 43
Multifocal and bilateral
Has the best prognosis of all types of MTC
100% 15 year survival
58. Medullary Thyroid Carcinoma
(continued…)
MEN IIa (Sipple’s Syndrome):
MTC, Pheochromocytoma, parathyroid hyperplasia
Autosomal dominant transmission
Mean age of 27
100% develop MTC
85%-90% survival at 15 years
MEN IIb (Wermer’s Syndrome):
Pheochromocytoma, multiple mucosal neuromas, marfanoid
body habitus
90% develop MTC by the age of 20
Most aggressive type of MTC
15 year survival is <40%-50%
59. Medullary Thyroid Carcinoma
(continued…)
Diagnosis
Labs: 1) basal and pentagastrin stimulated serum
calcitonin levels (>300 pg/ml)
2) serum calcium
3) 24 hour urinary catecholamines
(metanephrines, VMA, nor-
metanephrines)
4) carcinoembryonic antigen (CEA)
Fine-needle aspiration
Genetic testing of all first degree relatives
RET proto-oncogene
60. Medullary Thyroid Carcinoma
(Management)
Recommended surgical management
total thyroidectomy
central lymph node dissection
lateral jugular sampling
if suspicious nodes - modified radical neck dissection
If patient has MEN syndrome
remove pheochromocytoma before thyroid surgery
61. Medullary Thyroid Carcinoma
(Management)
Postoperative management
disease surveillance
serial calcitonin and CEA
2 weeks postop
3/month for one year, then…
biannually
If calcitonin rises
metastatic work-up
surgical excision
if metastases - external beam radiation
62. Anaplastic Carcinoma of the Thyroid
Highly lethal form of thyroid cancer
Median survival <8 months
1%-10% of all thyroid cancers
Affects the elderly (30% of thyroid cancers in
patients >70 years)
Mean age of 60 years
53% have previous benign thyroid disease
47% have previous history of WDTC
63. Anaplastic Carcinoma of the Thyroid
Pathology
Classified as large cell or small cell
Large cell is more common and has a worse prognosis
Histology - sheets of very poorly differentiated cells
little cytoplasm
numerous mitoses
necrosis
extrathyroidal invasion
64. Anaplastic Carcinoma
(Management)
Most have extensive extrathyroidal
involvement at the time of diagnosis
surgery is limited to biopsy and tracheostomy
Current standard of care is:
maximum surgical debulking, possible
adjuvant radiotherapy and chemotherapy
65. Recurrent DTC
85% of patients with DTC :disease-free after initial
treatment
10–15% : recurrent disease
Most recurrences occur within the first five years after
initial treatment
5%: distant metastases
lungs (50%), bones (25%), lungs and bones (20%) ,
10-year-survival rates ranging from 25% to 42%
66. Treatment methods
Surgery (when feasible)
Radioiodine treatment in presence of radioiodine
uptake in tumor foci
Other local treatments (dependent on location and
extent of disease): external radiation beam
treatment, embolisation, radiofrequency
New treatment methods, eg, molecularly targeted
treatments,
67. Selection of patients with
metastases for treatment
Candidates for radioiodine treatment
Younger age
Well differentiated tumour
High radioiodine uptake
Small metastases
Location in lungs
Low uptake of fluorodeoxyglucose
Loss of RAI uptake is often associated with the increased uptake
of PET scanning.
Repeated radioiodine treatment (response rate:
85%, with 96% of complete responses seen with a
cumulative activity <600 mCi)
68. Advanced Disease
when recurrent or metastatic lesions either
no longer take up radioactive iodine (RAI) or
have grown in the setting of recent treatment
with RAI (RAI-refractory), or
if the recommended lifetime dose of RAI
(600 mCi) has been exceeded.
survival drops to an average of 2.5-3.5
years.[Robbins 2006
69. Very few treatment options.
Cytotoxic chemotherapy
The experience with chemotherapy is limited
benefits have been marginal.
70. Among 49 patients with metastatic differentiated thyroid
carcinoma treated with five chemotherapy protocols,
a combination of doxorubicin, etoposide, 5-fluorouracil and
cyclophosphamide;
elliptinium acetate;
doxorubicin;
cisplatin;
and the combination of doxorubicin and cisplatin.
only two (3%) patients had objective responses.
(Droz et al, 1990)
In a review of published series, 38% of patients had a
response defined as a reduction in tumor mass to
doxorubicin.
three most widely applied cytostatics are adriamycin,
bleomycin and cis-platinum, and it seems that adriamycin
monotherapy, is superior to all other therapies, even
combinations
(Ahuja and Ernst, 1987)
71. Doxorubicin, approved by the U.S FDA for use in
advanced thyroid cancer in the 1970s
Tumor response rates with doxorubicin, range
between 0% and 22% and are short-lived and
without survival benefit .
72. Administration of doxorubicin with cisplatin
has been equally disappointing.
Randomized phase II study - ECOG
Cisplatin/Doxorubicin vs. Doxorubicin
Cisplatin/Doxorubicin Arm (43 patients)
CR 5; PR 5; SD 13
Doxorubicin (41 patients)
CR 0; PR 7; SD 9
Shimaoka K, et al: Cancer 56:2155-2160, 1985
Combination chemotherapy is not clearly superior to
doxorubicin therapy alone.
(Mazzaferri, 1993)
73. The role of external beam radiation therapy
(EBRT) to control cervical disease in patients with
progressive DTC is not well-defined.
Progress in the knowledge of genetic alterations in
thyroid cancer cells is rapidly offering several
opportunities to develop new drugs directed to
specific targets
74. Targets in cell signalling and angiogenesis
Papillary carcinomas :
80% :mutations of genes of mitogen-
activated protein kinase (MAPK)
pathway.
5–30%: RET/PTC rearrangements
10%: RAS mutations
40%: BRAF mutations
Follicular carcinomas:
20–35% : RAS mutations
30% :PAX8/PPARɣ rearrangements
Medullary Thyroid Cancer
RET
Anaplastic Thyroid Cancer
p53, Vascular Structures
75. Drugs currently proposed for
molecular therapy include:
(a) monoclonal antibodies;
(b) kinase inhibitors;
(c) anti-angiogenetic drugs;
(d) proteasome inhibitors;
(e) retinoic acid and PPAR-c ligands;
(f) radionuclide therapy;
(g) epigenetic drugs (deacetylase inhibitors and demethylating
agents).
The results of several phase II trials using molecular
drugs look promising.
None of the treated patients, however, had CR, and only
a minority of them had a PR.
76. Several tyrosine kinase inhibitors have shown
activity
majority (motesanib, sunitinib, sorafenib,
and pazopanib) target the mitogen-activated
protein kinase and antiangiogenic pathways.
[Ahmed 2011; Hong 2011; Carr 2010; Robinson 2010;Lam 2010]
79. VANDETANIB
Vandetanib is a tyrosine kinase inhibitor
activity against RET, VEGFR and endothelial growth
factor receptor pathways.
Vandetanib was approved by FDA in 2011 for use in
patients with unresectable metastatic medullary
thyroid cancer on the basis of a phase III clinical trial
(N = 331).
• [Wells 2011]
80. Once-Daily Vandetanib 300mg or Placebo.
significantly prolonged PFS
(median 30.5 months vs 19.3 months;
ORR 45% Versus 13%
No difference in OS
Wells SA Jr, J Clin Oncol. 2010
associated with a higher incidence of QT
prolongation
Elevated rates of hypertension and diarrhea
also observed.
Hinweis der Redaktion
Thyroid Cancer TypeMutationPrevalence, %PapillaryBRAF[V600E]45 BRAF copy gain3 RET/PTC20 RAS10 PI3KCA3 PI3KCA copy gain12 PTEN2FollicularBRAF copy gain35 RAS45 PAX8-PPARγ35 PTEN< 10 PI3KCA< 10 PI3KCA copy gain12Medullary RET (familial)> 95 RET (sporadic)50