CURICULUM VITAE

NAMA : dr. Kiki Akhmad Rizki, SpBK(Onk), Mkes,MMRS

TEMPAT/TGL LAHIR: Bandung, 03 - 02 - 1970
JABATAN : Ketua Tim Keselamatan Pasien RSHS
KaSubBag Bedah Instalasi Rawat Jalan RSHS
KaSubBag Keselamatan Pasien Komite Mutu RSHS
Staf Divisi Bedah Onkologi, RSHS/FK - UNPAD
PENDIDIKAN : 1. Fakultas Kedokteran UNPAD Bandung, 1995
2. Spesialis Ilmu Bedah FK.Unpad, 2004
3. Magister Kesehatan, 2004
4. Konsultan Bedah Onkologi , 2010
5. Magister Management Rumah Sakit, 2014
TREATMENT OF THYROID
CARCINOMA
KIKI A. RIZKI
SURGICAL ONCOLOGY DIVISION, DEPARTEMENT OF SURGERY
HASAN SADIKIN HOSPITAL/MEDICAL FACULTY PADJADJARAN UNIVERSITY
BANDUNG
 INTRODUCTION

• Carcinoma of the thyroid gland is an uncommon cancer,

but none the less, is the most common malignancy of

the endocrine system (90% of all endocrine cancers).

• Constitute less than 1% of all human malignant tumors

 DIAGNOSIS
• HISTORY :
- RISK FACTOR
• THYROID EXAMINATION
• THYROID FUNCTION TEST
• ULTRASONOGRAPHY
• FINE NEEDLE ASPIRATION BIOPSI
• X RAY NECK
• CT SCAN / MRI
• THYROID SACNNING ?
 TREATMENT
• SURGERY :
Isthmolobectomy VS total thyroidectomy

• ADJUVANT THERAPY
- NO ABLATION vs ABLATION
 2015 ATA Guidelines
Changing Diagnostic and Treatment Recommendation

• Less aggressive detection

• Less aggressive surgery for low risk PTC
• Less RAI therapy for remnant ablation
• Lower dose RAI for remnant ablation
• Central compartment Node excision optional for
Low risk PTC
ATA INITIAL RISK STARIFICATION
 SURGERY
ISTHOMLOBECTOMY vs TOTAL LOBECTOMY

• Minimal PTCs are defined as cancers smaller than 1

cm, which do not extend beyond the thyroid capsule

and are not metastatic or angioinvasive.

• Death rate 0.1% and recurrence rate 5%.

• Isthmolobectomy may be an appropriate definitive

procedure.
 SURGERY
ISTHOMLOBECTOMY vs TOTAL LOBECTOMY
• Total or near total thyroidectomy is the preferred operation for high risk

patients with PTC.

• Opinions differ in low risk PTC (Hemi vs total) Most of these patients have

an excellent prognosis as long as gross tumor is completely resected.

Some surgeons advocate less than a complete thyroidectomy to avoid

hypoparathyroidism and recurrent laryngeal nerve injury.

 RELATIVE SURVIVAL RATES AT 5 YEARS

Thyroid Low Risk

97.5% 99.9%

1 patient in 1000 affected

with low-risk thyroid cancer
and treated will die due to
thyroid cancer

Slow progression or regression

Surveillace Epidemiology and End Results.
http://seer.cancer.gov/statfacts/html/thyro.html
 SURGERY
ISTHOMLOBECTOMY vs TOTAL LOBECTOMY
• Arguments in favour of total thyroidectomy

– Multifocal disease

– facilitates postoperative use of 131I to ablate residual thyroid

tissue and to identify and treat residual or distant tumor.

– Increases thyroglobulin sensitivity as a indicator of residual

disease.
 NO ABLATION vs ABLATION

Radioiodine Remnant ablation (RRA)

• Defined as “the destruction of residual

macroscopically normal thyroid tissue after surgical

thyroidectomy”.

• Used as an adjunct to surgical treatment when the

primary FCDC has been completely resected.

 NO ABLATION vs ABLATION
• Three Potential advantages (RRA):

a) 131I may destroy microscopic cancer cells

b) Subsequent detection of persistent or recurrent

disease byradioiodine scanning is facilitated.

C) After RRA, the sensitivity of serum Tg measurements

is improved during follow up

• Issue of RRA in low risk patients remains unsettled.

DIFFERENTIATED USE OF RADIOIODINE
NO ABLATION vs ABLATION
DIFFERENTIATED USE OF RADIOIODINE
NO ABLATION vs ABLATION
 THYROGLOBULIN vs THYROID SCANNING
Long term follow up
(I). Thyroglobulin
• Highly specific tumor marker for differentiated thyroid
cancer.
• Level should be <2 ng/ml after surgery and ablation.
• Most useful in patients with high risk FCDC when TSH
level is high after either levothyroxine withdrawal or rh
TSH administration.
 THYROGLOBULIN vs THYROID SCANNING
• Reliable marker of persistent, recurrent or metastatic
diseases
• Low preoperative thyroglobulin levels have been
suggested to be associated with less differentiated
tumors and having a poor prognosis.
• After near total or total thyroidectomy, thyroglobulin
levels fall down below 5-10 ng/ml by postop day 25
(Half Life 65 hrs).
 THYROGLOBULIN vs THYROID SCANNING

Thyroid scanning

• Levothyroxine discontinued for 6 weeks before scan; T3

given during first 4 weeks (TSH should be > 25 Iu/ml)

• 131I WBS generally performed 48-72 hrs. after giving

2-5 mCi of 131I

 POVIDONE IODINE vs ALKOHOL
• Iodine can be absorbed through intact skin in
time dependent manner.

• If thyroid scanning performed in 4 weeks after

thyroidectomy, alkohol is alternative antiseptic
for operation, because iodine absorbed skin
can be miss interpreation in thyroid scanning

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 SUMMARY
• Treatment thyroid cancer less agresive for PTC

• Isthmolobectomy is treatment choice forlow

risk PTC

• No Ablation for low risk PTC

• Thyroglobulin use for lonf term follow up

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