Potassium Iodide KI Prophylaxis

Excess iodine supply downregulates NIS on the surface of thyroid cells, thus inhibiting the uptake of iodine (stable or radioactive) into the gland. In addition, excess iodide administration competes with radioactive iodine, diluting the amount available for uptake into the gland. In the case of radioiodine release from a nuclear incident, the uptake of radioactive iodine from inhalation or ingestion of contaminated foods may be blocked for at least 24 hours if 30-200 mg of KI is administered...

Obtaining Cytological Histological Diagnosis

Fine-needle aspiration sampling (FNA) for cytological diagnosis is a standard procedure for palpable nodules. Traditionally this is performed by inserting a green needle on a syringe into the palpated nodule. It is safe and accurate for most head and neck masses 14,15 . Ultrasound is now increasingly being used to position the needle more accurately by selecting a particular part of the nodule, for example the solid component of the wall in a mainly cystic nodule 16,17 or into impalpable...

DNA Mutation Analysis

About 25 of medullary thyroid carcinomas are hereditary, and it is important to recognize the heritable form because of the risk of other tumors in the patient and in the family. Lack of family history does not exclude heritable medullary thyroid cancer the disease may not be apparent in relatives because of skipped generations or an isolated case may be the start of a new family. Consequently, every case of medullary thyroid carcinoma should be offered genetic testing to look for genomic...

TgAb Interference

TgAb interference with serum Tg measurement is undoubtedly the most serious technical problem that currently compromises the use of serum Tg as a tumor marker for patients with DTC. The magnitude of the problem is evident from the high prevalence of TgAb detected in DTC patients ( 20 ) 10,23,24 . It has been recognized for more than thirty years that endogenous TgAb has the potential to interfere with Tg measurements made by either by IMA or RIA methodology 10,23,25,26 . When TgAb is present,...

Prevalence of Psychological Distress

For most people a diagnosis of cancer is a distressing life event. For many, the initial reaction is that they have been given a death sentence. In fact the majority of patients diagnosed with cancer will adjust psychologically, cope with subsequent treatment, and adapt their lives appropriately. Nevertheless, a substantial minority of patients will experience clinical levels of psychological distress that merit some level of professional intervention. Estimates of the prevalence of...

Serum Tg Concentrations During TSH Suppression and after TSH Stimulation

TSH-stimulated serum Tg concentrations, which typically rise > 10-fold above basal (THST) levels 16 , increase about twofold higher in response to THW than they do with rhTSH 16 . Although the exact Tg cutoff level varies with the assay being used, a TSH-stimulated serum Tg level > 2 mg L 1,28 after rhTSH administration or during endogenous TSH elevation (THW) is suspicious of tumor in a patient who has undergone total thyroidec-tomy and thyroid remnant ablation 1,5,11 . This is a much more...

Thyroid Cancer and the Endocrinologist

The long-term outcome of treatment for papillary and follicular thyroid cancer is generally good the overall 10-year survival for adult patients with differentiated thyroid carcinoma is 80-90 . However, local or regional recurrences develop in up to 30 of patients, distant metastases in up to 20 , and 8-10 of patients die of their disease 1,2 . Thyroid cancer patients thus require a very long-term follow-up. Adequacy of surgical treatment and 131I ablation apparently have an important influence...

Production of Recombinant Human TSH rhTSH

TSH is a pituitary heterodimeric glycoprotein composed of an a-subunit common to gonadotropins and a hormone-specific-b-subunit. Once the b-subunit of the human TSH gene had been cloned, the encoded protein could be over-expressed in a cell system, by transfection with the human a- and b-subunits of complementary or genomic DNA. With this technique, high quantities of highly purified rhTSH with biological properties similar to native TSH can be obtained. In vitro studies have shown that rhTSH...

Hrthle Cell Cancer

The H rthle cell variant of follicular thyroid cancer is characterized by oxyphilic follicular cells. They are more aggressive than follicular carcinomas and metastasize more frequently. Unlike standard follicular cancers, only 10 of H rthle cell cancers take up iodine and this fact, together with their aggressive behavior, results in a 20-year survival of 65 compared with 81 for follicular cancers. Imaging H rthle cell cancers has been attempted with a variety of radiopharmaceuti-cals. Yen et...

Ultrasound Color Doppler Imaging and FDGPET

High resolution ultrasound (US) is a powerful tool for the description and detection of micronodules of the thyroid and, when com bined with FNAB, is a potential means to distinguish benign from malignant lesions. Thus, US contributes significantly to the management of clinical problems but, its very power is revealing a high rate of previously undetected thyroid nodules. Having discovered an impalpable nodule or multiple nodules of very small size by US for whatever indication, what is the...

References

Flower MA, al-Saadi D, Harmer CL, McCready VR, Ott RJ. Dose response study on thyrotoxic patients undergoing positron emission tomography and radioiodine therapy. Eur J Nucl Med 1994 21 531-536. 2. Cox PH, Belfer AJ, Van der Pompe WB. Thallium 201 uptake in tumours, a possible complication in heart scintigraphy. Br J Radiol 1976 49 767-768. 3. Hisada K, Tonami N, Miyamae T, et al. Clinical evaluation of tumour imaging with 201-Tl chloride. Radiology 1978 129 497-500. 4. Ohta H, Yamamoto K, Endo...

Definition of MDT

The most practical definition suggested by the Manual of Cancer Services Standards UK, published in July 2004, is given below. This is best answered from the patient's point of view. If you were a patient, who would you consider to be your MDT Primarily it is that group of people of different health care disciplines, which meets together at a given time (whether physically in one place, or by video or tele-conferencing) to discuss a given patient and who are each able to contribute...

Well Differentiated Thyroid Carcinoma

The prognosis for pediatric patients with WDTC is better than for adults with same disease stage. The survival of children and adolescents until 1970 was approximately 82 at 20 years 106 , but in four series published in the late 1980s, survival rates of more than 95 at 15-20 years were reported 86,107-109 . The presence of distant metastases does not necessarily portend a poor prognosis. In a series of young patients who presented with distant metastases (reported in 1988 from the Mayo...

When to Refer and How Urgently

In the UK the presence of any of the following is an indication for urgent referral 13 . The clinical information should be faxed to secondary care within 24 hours of the decision to refer so that the patient can be seen within 2 weeks 1. Thyroid lump - newly presenting or increasing in size. 2. Thyroid lump in a patient with a family history of thyroid cancer. 3. Thyroid lump in a patient with a history of previous neck irradiation. 4. Thyroid lump in very young (usually < 10 years) or very...

Years After Initial Therapy

Figure 20.2 Recurrence rates of differentiated thyroid cancer over time. (Drawn from the data of Mazzaferri and Kloos 14 .) during THST, any alteration in the serum Tg level usually reflects a change in tumor mass 16,17 . Still, an undetectable basal (THST) Tg level, using current commercial assays, is not a reliable criterion to exclude tumor in patients who have been treated with total thyroidectomy and 131I 17 . This requires TSH stimulation. The magnitude of rise in serum Tg levels in...

Classification of Tumor Status after Initial Therapy

Patients are classified as being free of disease after total or near-total thyroidectomy and 131I remnant ablation when all of the following criteria are fulfilled Complete resection of identifiable tumor. No uptake outside the thyroid bed on the posttherapy whole body 131I scan. Negative neck ultrasound examination. Undetectable serum Tg levels (< 1 mg L) during both thyroid hormone suppression of TSH and TSH stimulation. TSH stimulation of Tg can be achieved either by administering...

Treatment of Disseminated Disease

Several studies have indicated that ATC is relatively resistant to chemotherapy. No response was observed in distant metastases in our recent study 36 , or in another study employing doxorubicin (60mg m2), cisplatin (90mg m2), and local radiation 24 . The use of a more aggressive cytostatic regimen in a multimodal approach is therefore not justified, except possibly in younger subjects performing well upon termination of local therapy. Such a strategy would not compromise the completion of the...

Chemotherapy

Experience with chemotherapy in DTC is limited by the rarity of tumors not controlled by surgery, radioiodine, or external beam radiotherapy. However, a minority of patients who do not respond to conventional therapy may survive with minimal symptoms. Because presently available drugs are of limited benefit and cause significant morbidity our practice is to reserve chemotherapy for patients with progressive and symptomatic disease that fails to concentrate radioiodine 114 . Doxorubicin...

Radionuclide Imaging

Nuclear medicine diagnostic investigations for the investigation of thyroid cancer require appropriate equipment, trained authorized staff, and a supply of appropriate radiopharma-ceuticals. A gamma camera with tomographic capabilities is essential if high quality studies with appropriate sensitivity are to be achieved. Studies for small volume recurrent disease will be nondiagnostic if only planar views are obtained. High resolution, low, medium and high energy collimators will be required if...

Palliative Care

Palliative care is not necessary in the vast majority of patients with differentiated thyroid cancer because they are cured. However, in a very small proportion of patients with recurrent end-stage disease (and in patients with anaplastic thyroid cancer) palliative care will be necessary. The GP should work with a palliative care consultant, in conjunction with the MDT. Symptoms of stridor and fear of choking are very distressing and can be alleviated by pharmacological means, palliative...

Endocrine Surgery Fellowship Training

Although most surgeons in the USA who perform endocrine operations do so in the context of a broad general surgery practice, many believe that additional training in endocrine surgery is required for those who will serve as experts in the field. Endocrine surgery fellowships of variable duration add clinical, operative, and research experiences onto the standard surgical residency training. The duration and curriculum for such programs have not been formally established. Current fellowships in...

Objectives and Stages of Followup

After initial treatment, the follow-up of patients with DTC has two objectives (1) to discover at the earliest possible time persistent or recurrent disease, allowing for treatment that may extend survival 1,7 , and (2) to ensure that the patient receives the lowest effective L-T4 dose, that is one that provides no more TSH suppression than necessary 8,9 . Monitoring patients with DTC comprises four stages (1) evaluation at the time of radioiodine ablation of thyroid remnants (2) 3-month...

Genetic Risk Assessment

After ascertaining the proband's perception on their personal risk, it is important to give some objective estimate of risk, based on the family history. There are considerable epidemiological data available to give a quantitative risk estimate, based on the pedigree analysis. The advantage of such data is that they are applicable to the majority of individuals referred to the clinic and have either a negligible or modestly increased risk of cancer over the general population. Some estimates of...

Role of the Clinical Psychologist in Thyroid Cancer

It is apparent that patients undergoing treatment and surveillance for thyroid cancer may be experiencing much greater levels of psycholog ical distress than healthcare staff have generally anticipated, based on a relatively good prognosis. A significant minority of people with any type of cancer experience clinical levels of distress at some point in their cancer journey and it may well be that those with thyroid cancer experience higher levels of distress than some other subgroups. Therefore...

Nerve Injury

There are several nerves that are at risk during the performance of a neck dissection (Table 13.11). The accessory nerve should be identified early on as part of the neck dissection. Probably the best way to find it is at Erb's point, which is one centimeter above where the greater auricular nerve winds round the posterior border of the sternomastoid. Once identified,it can be isolated with a sloop, and the dissection proceeds caudal to the nerve. In a certain proportion of cases, the main...

Nodular Goiter

This disease develops as the result of absolute or relative deficiency of iodine intake. Goiter is defined as endemic in areas where more than 10 of the population is affected and sporadic when the incidence is less than that. Endemic goiter occurs in areas of iodine deficiency. Increased requirement for thyroid hormones, individual dietary insufficiency of iodine, ingestion of goitrogens, and subclinical levels of dyshormonogenesis may be important in the pathogenesis of the sporadic form. The...

Follicular Variant of Papillary Carcinoma

This is the next commonest variant to the classic variant of papillary carcinoma. It is characterized by follicular architecture, but the cells lining the follicles have the cytological features of papillary carcinoma. Where a mixed pattern of classic papillary and follicular architecture is present, the tumor should be classified as a classic variant. Most of these tumors are not encapsulated or have a poorly formed capsule. Prominent fibrous bands may extend between the tumor cells. The...

Patterns of Spread

The thyroid gland contains a dense network of intrathyroidal lymphatics which surround the thyroid follicles and facilitate direct communication across the isthmus between the two lobes of the gland. This explains the multifocal-ity of papillary thyroid cancer and forms one of the rationales for total thyroidectomy. This intrathyroidal lymphatic network then joins collecting and draining lymphatic trunks within the subcapsular region of the gland that run alongside the extensive vascular...

Benign Nodules

Hot nodules causing hyperthyroidism may be treated with radioidine, which usually restores euthyroidism and causes reduction of the size of the nodule over several months 48 . Good results are also reported with percutaneous ethanol injection in centers with experience in this 49 . Benign thyroid nodules in euthyroid patients do not require treatment unless they are symptomatic. Treatment may be considered if patients are concerned about the cosmetic effect of the nodule or if the nodule is...

Psychological Aspects of Thyroid Cancer

Thyroid cancer is a relatively rare disease, with an incidence of 3.1 per 100000 per year 11 . Differentiated thyroid cancer, accounting for the majority of cases, is curable in 90 of patients given appropriate treatment 12 . On this basis many patients are told that thyroid cancer is a good cancer to have. However, medullary carcinoma, accounting for 4 of cases, has a 10-year survival rate of 75 . Undifferentiated, or anaplastic, carcinomas account for only 2 of cases, but carry a very poor...

Effects on Male Fertility

Sperm production in males is maintained by production of FSH by the pituitary and regulated by a negative feedback mechanism by inhibin produced by the seminiferous tubules within the testes. Androgen production is maintained by pituitary production of LH, also controlled by a negative feedback mechanism by production of testosterone by the testicular Leydig cells. Fertility in men is assessed by semen analysis with assessment of sperm concentration, motility, and percentage of abnormal forms....

Maintenance of Surgical Decision Making

Integral to surgical success and often entwined in the volume-outcome relationship is the ability of the surgeon to use clinical information, diagnostic study results, and professional judgment to determine treatment recommendations. How the operative approach and treatment guidelines should be modified for each individual patient are challenging aspects of endocrine surgery that are taught in residency, refined in fellowship and remain a dynamic challenge in clinical practice. As the optimal...

Prevalence of Thyroid Cancer in the Population

There are about 300000 patients in the USA 3 and 200000 in Europe 184 living with thyroid cancer. Virtually all require lifelong follow-up, which until recently, was done mainly with serum Tg determinations obtained during T4 suppression of TSH and 131I DxWBS performed after thyroid hormone withdrawal. More recently, follow-up has become more complex, and is substantially more accurate. Older antithyroglobulin antibody assays did not detect low levels of anti-Tg antibody 184 , which...

The Role of the SN in Symptom Control and Rehabilitation

Resent research suggests that patient support should be in the form of early rehabilitation programs and should be provided by the MDT. This should be delivered in a holistic way, ideally during the first year after diagnosis. It should include counseling with a psychotherapeutic approach to improve mental health, emotional functioning, and social competence 8 . Growing research also suggests that psychotherapy, especially group psychotherapy, can reduce psychological distress and in some cases...

Incidence Rates

An estimated 122803 cases of thyroid cancer occurred around the world in the year 2000, causing an estimated 8570 deaths 1 . Yet thyroid cancer is relatively uncommon, striking only about 1.18 people per 100000 persons worldwide,with a somewhat higher incidence in Europe and North America 1 . Thyroid cancer accounted for only about 1.6 of all new cancer cases in the USA during 2003 2 , but it strikes at all ages. Its incidence rate in women is about threefold that in men, peaking in midlife in...

Insufficient TSH Stimulation of 131I Uptake

After thyroidectomy, 131I uptake by thyroid remnants and metastases is increased by high serum TSH levels. To maximize the therapeutic effect of 131I, one must closely adhere to a protocol that ensures serum TSH reaches levels of at least 30 mIU L. This may be done by administering oral T3 (liothyronine, Cytomel) alone for 4 weeks then withdrawing it for 2 weeks, after which the patient is hypothyroid and the serum TSH usually is about 70 mIU L, but it ranges from just over 30 to nearly 300mIU...

Pain

Most cancer patients fear pain yet in general 25 of patients with cancer have no pain 1 and 33 have three or more pains 2 . Approximately 15 of pains encountered in cancer patients 2 are not due to malignancy. Patients with recurrent and or metastatic thyroid cancer more commonly suffer pain due to local tumor progression, bone metastases, and nerve compression or infiltration. The key to successful pain management is accurate diagnosis of the cause appropriate analgesia including disease...

Long Term Serial Tg Monitoring

A diagnosis of DTC is often made in the third or fourth decade of life. Since recurrences can occur decades after thyroidectomy patients require life-long monitoring for recurrence with clinical examinations, selected imaging, and serial serum Tg and TgAb measurements 62,63 . Historically, a negative diagnostic RAI whole-body scan has been used as the gold standard for the absence of disease 60,64-66 . With the increasing use of imaging modalities such as ultrasound, CT, MRI, and PET, it is now...

Complications of Radioiodine Treatment

Radioiodine therapy is well tolerated and usually lacks serious complications. Patients may experience nausea and vomiting, especially during the first 24 hours after administration prophylactic use of metoclopramide 10mg 30 minutes prior to 131I is therefore recommended 90 . Radiation thyroiditis may occur within the first week and last for several days after ablation of a large remnant this is characterized by local discomfort, pain on swallowing, neck swelling, and even transient...

Thyroid Cancer from the Perspective of a Patient

In October 1997, following a bit of a cold, I noticed a tiny lump, about the size of a pea, in the middle of my throat. That night I rang Professor Newman-Taylor, who had been such a help in the past, and told him about my discovery. He asked me some questions did it move up and down when I swallowed He then said he thought it was my thyroid and asked me to keep him informed when I had seen my GP. The next morning our vet Charlie Schreiber was at our racing yard blood testing some horses, so I...

Papillary Microcarcinoma

This is a term that should be applied only to papillary carcinomas measuring < 10 mm in maximum dimension found incidentally in a thyroid examined for other reasons. They are found in about 30 of thyroids sampled by step section at autopsy and in up to 24 of thyroids removed for other reasons. Most are probably of no clinical significance. The debate continues therefore as to how to deal with these lesions. Many would advise that, if there is no evidence of disease in the other lobe, they are...

Etiology

The nature of the apparent geographic disparities in the prevalence of PMCT remains to be defined. Purely technical matters such as the stringency of the histological criteria used to diagnose cancer, or the thickness of histological sections do not adequately explain the differences. Dietary iodine, exposure to radiation, the association of PMCT with Graves' disease, and genetic influences have all been explored. Iodine deficiency remains a worldwide problem, especially in Africa, Europe, and...

Histology

The parafollicular C cells represent about 1 of all thyroid cells and are located at the basal layer of the follicle (Figure 21.9). At variance with thyroid follicular cells, which derive from endo-derm, C cells originate from the neural crest and migrate to the final location along with the ulti-mobranchial body, during embryonic development 110,111 . Although C cells have several features that differentiate them from follicular epithelium, there is evidence to suggest the possible origin of...

Sarcoma

Primary sarcomas of the thyroid gland are extremely rare. They have mesenchymal (stromal) features and can resemble undifferen-tiated tumors, rendering differentiation from anaplastic carcinoma difficult. Previous case reports have described sarcomas when in fact these tumors were spindle cell variants of anaplastic carcinoma. This is of little practical significance, as the natural history and response to treatment remain similar. Most malignant thyroid tumors with a sarcoma-like appearance...

External Beam Radiotherapy

The value of external beam radiotherapy (EBRT) in the management of differentiated thyroid cancer remains controversial because published data are conflicting. In many reports, results are presented with no distinction between prophylactic (adjuvant) postoperative EBRT and treatment of microscopic or macroscopic residual disease. Due to the rarity of the disease and its long natural history there are no prospective randomized controlled trials. EBRT does not prevent simultaneous administration...

Thyroid Cancer Conclusion

Nuclear medicine imaging continues to have an established role in the management of patients with papillary and follicular thyroid cancers, with 131I scanning remaining the routine imaging technique for localizing remnant and recurrent disease. The development of recombinant human TSH offers increased flexibility for imaging and treatment, whilst reducing the side effects of thyroxine withdrawal. The newer radionuclide imaging techniques remain underutilized, despite good evidence for their...

The Structure and Function of the Thyroid Cancer MDT in the UK the NICE Guidance

The National Institute of Clinical Excellence published an improvement in outcomes guidance for head and neck cancer in November 2004. This is a most comprehensive assessment of the service and will provide detailed and definitive advice about service configuration and commissioning of cancer services for thyroid cancer as well. The following is a summary. For the details the reader is advised to consult the manual 20 or the website -www.nice.org.uk. The responsibility of the thyroid MDT would...

Gene Carrier Treatment

Once a gene carrier has been diagnosed by genetic analysis, the therapeutic strategy should be defined according to the guidelines for the diagnosis and treatment of multiple endocrine neoplasia 29 , which take into account the different biological behavior of the medullary thyroid carcinoma in the three forms of multiple endocrine neoplasia. In MEN2B total thy-roidectomy should be performed as soon as possible, even under 2 years of age if the diagnosis is available. In MEN2A, total...

The Objectives of MDT

The key objective is to provide each individual patient with the best possible management decisions currently available. Again the definition of this as mentioned in the MCS is as follows To ensure that designated specialists work effectively together in teams such that decisions regarding all aspects of diagnosis, treatment, and care of individual patients and decisions regarding the team's operational policies are multidisciplinary decisions. To ensure that care is given according to...

Radioactive Iodine 131I Therapy Thyroid Remnant Ablation

This is defined as 131I therapy administered to destroy presumably normal residual thyroid tissue. Routine 131I remnant ablation, although questioned by some 116 , is widely used and has appeal for several reasons. First, it may destroy occult microscopic cancer 18,62 . Second, it enables earlier detection of persistent tumor by post 131I treatment whole-body scans (RxWBS) 81 . Third, it greatly facilitates the use of serum Tg measurements during follow-up. Few metastases can be visualized by...

Superficial Lymph Node System Waldeyers External Ring

The lymphatic drainage of head and neck tissue is divided into superficial and deep systems and usually, but not always, the passage of lymph is lateralized and sequential and follows a predefined route from superficial to deep. The superficial nodal system, which drains the superficial tissues, consists of two circles of nodes, one in the head and the other in the neck. In the head, the nodes are situated around the skull base and are known as the occipital, postauricular, parotid or...

Histological Changes Following Preoperative Fine Needle Aspiration Cytology

Alterations in histology caused by preoperative FNA are increasingly recognized by patholo-gists in surgical specimens. Some of these cause problems in diagnosis. Sometimes, a needle track is obvious, with hemorrhage, granulation tissue, and hemosiderin-laden macrophages. Cholesterol crystals may also be present. The cells in the adjacent follicles may show some enlargement and atypia. There may be distortion or disruption of the capsule where the needle has passed through. The capsular changes...

Non Syndromic Familial Nonmedullary Thyroid Cancer

In addition to an association with readily identifiable cancer predisposition syndromes such as FAP, a number of families with non-syndromic clustering of thyroid cancers (primarily PTCs) have been described (Table 22.3). Although on first inspection it might be thought that familial clustering is secondary to ascertainment bias, this is statistically highly unlikely. For example, a nuclear family with two offspring with NMTC (e.g. the family reported by Lote et al. 49 ) would be expected to...

Iodine Contamination

Before 131I treatment is administered, the total body iodine pool should be low and urine iodine levels should be less than 100 mg g of cre-atinine. This requires at least 2 full weeks of a low iodine diet 56 and absolute avoidance of iodine-containing medicines or iodinated radiographic contrast materials that may expand the iodine pool for 3 months or longer, depending upon the contrast material and the patient's age and renal function. The time to excrete the iodine load increases with the...

Thyroid Lymphoma

Primary thyroid non-Hodgkin's lymphoma (NHL) is uncommon, representing 4 of all thyroid cancers 1 . Only 2 of extranodal lymphomas arise within the thyroid. Secondary involvement is more frequent as a manifestation of generalized disease, which occurs in 10 of all lymphomas and leukemias 2 . The mean age at presentation is 60-70 years with a female male predominance of 3 1. Presentation before age 40 is rare. Preexisting Hashimoto's thyroiditis is a significant risk factor 3 and may be the...

Serum Basal and Stimulated Calcitonin

Calcitonin is the most specific and sensitive medullary thyroid tumor marker, both before and after thyroidectomy 2,82,83 . It is a small polypeptide hormone of 32 amino acids normally produced almost exclusively by C cells. The gene encoding for calcitonin is located on chromosome 11p and yields two distinct messenger RNAs (mRNA) by alternative splicing calcitonin and calcitonin gene-related peptide (CGRP) 84,85 . Calcitonin mRNA is found almost exclusively in the thyroid and CGRP mRNA in the...

Hurthle Cell Oncocytic Follicular Tumors

Follicular tumors are defined as Hurthle cell when more than 75 of the tumor cells are oncocytic. Grossly, these are usually single nodules with a deep brown cut surface. They often undergo infarction following FNA, and it has been suggested that this may be related to their microvasculature, which is different from other thyroid tumors. A higher proportion of Hurthle cell tumors are malignant (35 ) than in follicular lesions. A variety of growth patterns is seen in both benign and malignant...

Relapse Rates and the Extent of Initial Thyroid Surgery

Recurrence rates are high with large thyroid gland remnants. Some find that patients treated by lobectomy alone have a 5 to 10 recurrence rate in the opposite thyroid lobe 16,29 and an overall long-term recurrence rate over 30 (versus 1 after total thyroidectomy and 131I therapy 3 ) and the highest frequency (11 ) of subsequent pulmonary metastases 30 . Higher recurrence rates are also observed with cervical lymph node metastases and multicentric tumors, which also provide justification for...

Introduction

Differentiated (papillary and follicular) thyroid carcinoma (DTC) generally is characterized by an indolent course with low morbidity and mortality and is among the most curable cancers 1 . In most cases, initial treatment for DTC is total thyroidectomy, with lymph node dissection in case of papillary thyroid carcinoma. In case of persistent disease or when the TNM (tumor, node, metastasis) or any other scoring system predicts a high risk of recurrence, the surgery may be followed by...

Metastasectomy

Distant metastases develop in 5-23 of patients with DTC and another 1-4 demonstrate distant metastases at presentation 70-72 . Most commonly affected are the lung and bone, with the liver and brain rarely being involved. Despite improved outcome compared with other cancers, at least half of thyroid cancer patients will die of metastatic disease. We have reported overall survival at 5 and 10 years of 63 and 44 73 . Schlumberger et al. reported similar overall figures of 53 and 38 at 5 and 10...

Medullary Carcinoma

Medullary carcinoma (MTC) accounts for 5-10 of thyroid cancer and about one quarter are familial,in the context of multiple endocrine neoplasia type 2A and 2B and familial MTC. Sporadic tumors are usually single, while familial disease is multiple and bilateral and arises on a background of C-cell hyperplasia. A variety of histological patterns can be seen and these are similar in both sporadic and familial disease. The most common is the alveolar and trabecular arrangement. The cells are...

Cosmetic Implications

Patients should be advised about the scar, which will usually be a transverse cervicotomy performed in a skin crease, either with subcuticu-lar absorbable stitches or with metal clips 1 .In most patients the scar will leave a fine line similar to a crease in the neck, but in some cases broadening of the scar and keloid formation can occur. There may be some local reduction in sensation in the upper or lower skin flaps, which will gradually improve over the first 9 months postoperatively, and...

Cancer Predisposition Syndrome Associated Nonmedullary Thyroid Cancer

A number of families have been reported which show clustering of PTC and other NMTCs. Review of these reports suggests that NMTCs can be arbitrarily divided into two groups a syndromic variant, in which NMTC is associated with other cancers in the context of a cancer predisposition syndrome, and a non-syndromic variant, in which NMTC is independent of an accompanying disorder. We first focus on syndromes associated with NMTC. Familial Adenomatous Polyposis Role of APC Familial adenomatous...

Lymph Node Levels

Level I Submental and Submandibular Groups This consists of the submental group of lymph nodes within the triangle bounded by the ante rior belly of digastric and hyoid bone, and the submandibular group of nodes bounded by the posterior belly of digastric and body of the mandible. This consists of the lymph nodes located around the upper third of the internal jugular vein and adjacent spinal accessory nodes extending from the skull base down to the level of the carotid bifurcation where the...

Insular Carcinoma

Insular carcinoma is a form of poorly differentiated tumor arising from follicular cells, with behavior intermediate between differentiated (papillary follicular) and undifferentiated (anaplastic) carcinoma 18 . They usually retain some features of differentiated follicular thyroid cells with ability to produce thyroglobulin and retain radioiodine but display a more aggressive clinical behavior 45,46 . Macroscopic features are of an invasive solid tumor typically greater than 5 cm in diameter...

RET Genetic Analysis

RET mutation analysis represents one of the most useful genetic screening tests in clinical practice. The mutation is inherited as an autosomal dominant trait since the penetrance of RET mutations is near 100 , all gene heterozygous carriers will develop medullary thyroid Figure 21.11 Medullary thyroid carcinoma (MTC) and normal adjacent thyroid tissue (NT). A Immunohistochemistry for calcitonin. B Immunohistochemistry for chromogranin. C Immunohistochemistry for thyroglobulin. Both calcitonin...

How to Break Bad News

While providing patients with the facts about an adverse diagnosis such as thyroid cancer is important, the manner in which the news is conveyed is vital. Poorly conveyed bad news can leave long-lasting adverse psychological consequences 17 . Meticulous attention to detail will minimize the impact of the news. If the patient is coming as an outpatient to receive the diagnosis, they should be advised to have their spouse or a trusted adult come with them to the consultation. Adequate time should...

Nodule Characterization [7

Although US examination of the thyroid is very sensitive it is not very specific for identifying the cause of solid nodules. The appearances of benign and malignant nodules themselves can be similar. Examination of the surrounding structures for additional features of malignancy can be helpful. Local invasion (Figure 26.2) or large lymph nodes within the neck clearly indicate malignancy. The majority of malignant nodules (approximately 90 ) have a lower echo return than the normal thyroid...

Thyroid Papillary Carcinoma In Hla Identical Sibs

In vitro models of thyroid cancer. Cancer Surv 1993 16 115-134. 2. Mulligan LM, Eng C, Healey CS, et al. Specific mutations of the RET proto-oncogene are related to disease phenotype in MEN 2A and FMTC. Nat Genet 1994 6(1) 70-74. 3. Ron E, Kleinerman RA, Boice JD, Jr, LiVolsi VA, Flannery JT, Fraumeni JF, Jr. A population-based case-control study of thyroid cancer. J Natl Cancer Inst 1987 79(1) 1-12. 4. Stoffer SS, Van Dyke DL, Bach JV, Szpunar W, Weiss L. Familial papillary...

Deep System Cervical Lymph Nodes Proper

Subclavian Triangle Nodes

The deeper fascial structures of the head and neck drain either directly into the deep cervical lymph nodes or through the superficial system first and then into the deep system. These superficial nodes have already been described. The deep cervical lymph nodes proper (Figure 13.1) consist of the junctional nodes, the upper, middle, and lower cervical nodal groups which are situated along the internal jugular vein, the spinal accessory group which accompanies the accessory nerve in the...

Papillary and Follicular Thyroid Cancer

The role of imaging in the investigation of patients with suspected thyroid cancer is controversial, reflecting the high incidence of nodules in the normal population and low prevalence of thyroid malignancy. In a patient with a palpable nodule in the thyroid, the simple technique of imaging the thyroid using 99mTc pertechnetate will identify whether the palpable nodule is functioning or nonfunctioning. Thyroid cancer typically appears as a hypofunctioning cold nodule on 99mTc pertechnetate...

Primary Thyroidectomy

An incision is made in a skin crease about 2 cm cephalad to the clavicles. Once a surgeon gains more experience with this procedure, the transverse incision decreases in length from about 8 cm to about 4-5 cm. This generally results in an imperceptible scar, and negates the benefits of endoscopic assisted thyroidectomy, a much more complex and lengthy procedure. Superior and inferior flaps are raised in a subplatysmal plane. These really only need to be done in between the sternocleidomastoid...

List of Contributors

Sir Richard Bayliss, KCVO, MD, FRCP, Nadine R. Caron, MD, MPH, FRCS Department of Surgery, University of British Columbia, Prince George, BC, Canada Orlo H. Clark, MD, FACS Department of Surgery, University of California, San Francisco, UCSF Comprehensive Cancer Center at Mt Zion Hospital, San Francisco, CA, USA Susan E. M. Clarke, MSc, FRCP, FRCR Department of Nuclear Medicine, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK Mary Comiskey, MB BCh, FRCP Northern Centre for Cancer...

Fine Needle Aspiration Cytology

Fine-needle aspiration should be performed on any solitary or dominant nodule more than 10 mm in diameter or in nodules as small as 8 mm with highly suspicious ultrasonographic characteristics. Where the nodule is palpable it can be aspirated under direct palpation in the first instance. In some places in Europe and the USA and in Japan, ultrasound guidance is used for all lesions. However, in view of the additional resource required, many centers would reserve its use for cases where standard...

Therapy

The majority of patients with a tumor size of more than 1cm diameter should have 131I ablation therapy. Pregnancy or breast-feeding must be excluded before radioactive iodine is administered. Reassessment with a whole-body radioiodine scan (after stopping T4 for 4 weeks) is indicated 4-6 months after 131I ablation, although in low risk patients measurement of Tg alone may be adequate. If significant uptake of the tracer is detectable, a further 131I therapy dose should be given and a...

Multidisciplinary Team Organization in Different Countries

The MDT in the USA mostly comprises of endo-crinologists, nuclear medicine specialists who do the nuclear medicine components, patholo-gists who are familiar with these tumors, radiologists who perform the other imaging studies such as positron emission tomography (PET), endocrine and head and neck surgeons, and radiotherapy specialists who get involved with external beam radiotherapy. The primary care practitioners do not get very involved in management, but are key players in the...

Efficacy of 131I Therapy

When the DxWBS and neck ultrasonography are both negative, patients are often empirically treated with 131I, both to locate and to treat persistent tumor 4 . Whether this benefits patients has sparked much controversy 12-15 , mainly because there are few studies with long-term follow-up of such treatment, there are no randomized prospective trials of this treatment, and there are considerable differences in patient cohorts and endpoints among studies of empiric 131I treatment. Still, there is...

Ablation of Residual Normal Thyroid Tissue

In the management of differentiated thyroid cancer (DTC) ablation of thyroid remnants with 131I aims to destroy all residual normal thyroid tissue. Total (or near-total) thyroidectomy will permit this to be achieved with a modest administered activity. Remnant ablation after lobectomy is more difficult and a repeat administration may be required. Ablation of a large remnant may cause radiation thyroiditis with neck pain and swelling. Furthermore thyroid-stimulating hormone (TSH) levels may fail...

General Surgery Residency Training

According to the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee (RRC) for Surgery, a standard general surgery residency program is expected to provide the training to enable its graduates to perform endocrine surgery safely, efficiently, and with appropriate indications, preoperative preparation and postoperative care 4,5 . The majority of surgeons in the USA who perform endocrine operations rely on this level of training. Harness et al. evaluated the...

Follicular Carcinoma

Follicular carcinoma accounts for 5-15 of all thyroid cancers in iodine-sufficient areas. It is more common in women and presents on average about 10 years later than papillary carcinoma. It is usually a single cold nodule. Occasional cases present as distant metastases, particularly in bone. On the basis of the extent of invasion, the tumor is subdivided into two categories - minimally and widely invasive. Minimally invasive tumors are more common. These are diagnosed on the presence of...

Completion Thyroidectomy

Residual tumor is common in the contralateral thyroid lobe but cannot be predicted on the basis of the tumor size in the ipsilateral lobe or the presence of regional lymph node metastases 45 but is more likely if there are multiple tumors in the ipsilateral thyroid lobe and if the serum thyroglobulin level is very high 46 . Completion thyroidectomy should be considered for tumors that have the potential for recurrence because large thyroid remnants are difficult to ablate with 131I 47 and...

Treatment Philosophy

Many patients with differentiated thyroid cancer have metastatic spread within the regional lymph nodes and for the majority, this usually represents occult disease 1-4 . Its frequency is related to histology (more common in papillary thyroid cancer) and to the size of the primary tumor. The chances of having regional lymph node metastases with follicular carcinoma is much lower and occurs in less than 20 of cases 2 . Lymph node metastases in differentiated thyroid cancer are often multiple,...

Misleadingly High Serum Tg Measurements

This is also of importance, especially considering the trend of treating high serum Tg levels with 131I when the DxWBS is negative. Heterophile antibodies (HAB), which are human anti-animal (often anti-mouse) antibodies, may interfere with Tg measurements made by immunometric assays (IMA). Unlike the situation with TgAb, interference caused by HAB tends to artifactually raise serum Tg levels. A recent study 25 of one commonly used automated IMA system found that 3 of 1106 specimens with a serum...

High Serum Tg Levels and Negative Whole Body 131I Imaging

The main consequence of applying sensitive diagnostic tests during follow-up is identifying patients with elevated serum Tg levels and negative 131I imaging studies. This is a complex problem that requires careful evaluation but sometimes identifies patients with early metastatic tumor that is often highly amenable to 131I therapy. This problem is reviewed in depth in Chapter 20. The new management and Phase l First FoIIowup after Surgery Phase l First FoIIowup after Surgery Figure 1.10 The...

Therapeutic Use of rhTSH

As mentioned above, withdrawal of L-T4 sup-pressive therapy in preparation for 131I therapy may expose patients with metastases in critical body structures, such as vertebrae or the brain, to severe complications which are mainly neu- Total thyroidectomy and 131I ablation Undetectable Tg No other abnormalities Tg detectable but institutional cut-off Detectable Tg and other abnormalities or Tg > institutional cut-off Decrease LT4 dose Yearly evaluation TSH, Tg on LT4 + neck US Repeat...

Hurthle Cell Carcinoma

Hurthle cell carcinoma (HCC) is rare, comprising 3-5 of all differentiated thyroid tumors. Also known as oncocytic or oxyphilic tumors, they have previously been considered a variant of follicular thyroid cancer 51 , although are now known to represent a distinct pathological entity 52 . Hurthle cells are rich in mitochondria and have a characteristic granular cytoplasm. They may occur in a variety of thyroid conditions including benign nodules, Hashimoto's thy-roiditis, and Hurthle cell...

Technical Strengths and Pitfalls of Serum Tg Measurement

Over the last decade, IMA methodology has largely replaced radioimmunoassays (RIA) for measuring serum Tg concentrations. IMA methods are favored by laboratories because they can be automated and require a shorter incubation to achieve maximal sensitivity, as compared with RIA 9,10 . Current Tg assays suffer from a number of technical limitations that negatively impact their clinical utility. These include (a) large between-method biases that preclude the use of different methods for serial...

Psychological Model of Adjustment to Cancer

When someone first receives the news that they have cancer, the greatest concern is usually survival. Patients often ask am I going to die In younger people particularly, there is likely to be a period of shock and disbelief as implicit assumptions about invincibility are shattered. The individual then goes through a process of appraisal which will greatly influence their adjustment to the disease. As individuals make sense of their diagnosis they address three key questions How great is the...

Fine Needle Aspiration Biopsy FNA

Fine Needle Aspiration Thyroid

Patients with either an isolated thyroid nodule or a multinodular goiter should be considered for FNA because the incidence of thyroid cancer Figure 1.8 Algorithm for the cost-effective evaluation and treatment of a patient with a thyroid nodule. (From Hegedus L. Clinical practice.The thyroid nodule. N Engl J Med 2004 351(17) 1764-1771. Copyright 2004 Massachusetts Medical Society. All rights reserved.) * In the original algorithm, FNA is not suggested for patients with strong suspicion of...

Hereditary Forms

In about 25 of cases the medullary thyroid carcinoma is one of the components of the multiple endocrine neoplasia type 2 syndrome, which is an autosomal dominant inherited syndrome with a variable degree of expressivity and an age-related penetrance. As shown in Table 21.1, three different hereditary syndromes can be classified according to the involved organs (a) multiple endocrine neopla- Table 21.1 Prevalence of different endocrine neoplasia and other clinical manifestations in MEN2...

Multidisciplinary Team MDT Advantages and Disadvantages

In the Introduction to NHS Cancer Plan, Three Year Progress Report - Maintaining the Momentum the National Cancer Director, Professor Mike Richards, said that the establishment of specialist cancer teams across the country has been one of the most important developments in recent years. These multidis-ciplinary teams bringing together surgeons, radiologists, pathologists, oncologists, palliative care specialists and other professionals are now helping to ensure that patients receive appropriate...

Thyroid Cancer

Shipsfigure Head

The use of CT and MRI in the management of thyroid cancer can be considered in two situations preoperative assessment and the follow-up of treated disease. The commonest situation preoperatively is that of a solitary or a dominant thyroid nodule. Cytology, ultrasound, and the clinical picture may indicate a likely diagnosis but often a definitive diagnosis is not available until formal histology can be performed on the operative specimen. In this situation CT and MRI have little to add and are...

Surgical Management

A level VI neck dissection can be done through a formal thyroid incision and simply involves an extended total thyroidectomy with removal of the soft tissue bearing areas of level VI that con- Figure 13.5 Standard thyroidectomy incision with bilateral thyroid utility extensions.AWplasty can be incorporated at the upper end of the utility incision in order to achieve a better scar. Figure 13.5 Standard thyroidectomy incision with bilateral thyroid utility extensions.AWplasty can be incorporated...

Papillary Carcinoma

When a definite diagnosis of papillary carcinoma has been made on FNA, the surgeon may proceed to total thyroidectomy with or without lymph node dissection. In cases with a suspi cious FNA, preoperative core biopsy or intraoperative frozen section may be used to confirm the diagnosis. Grossly, the tumor may range in size from less than 1 mm to several centimeters. Most are irregular in shape and infiltrate the gland. They are often associated with scarring. Some are encapsulated and others show...

Recurrent Cancer

Whether it has been 6 months or 50 years, recurrent thyroid cancer poses a special problem. If an adequate operation was performed at the initial setting, then the RLN and the parathyroids have been dissected and now are incor porated into a scar of varying thickness. The recurrences most often show up in the tra-cheoesophageal groove from the level of the thyroid cartilage level III to the thoracic inlet level VI . Often it is unclear if the tumor has obliterated a lymph node or if it has...