Follicular Carcinoma of Thyroid in Q&A Local seminar

Medical Oncology department

By

Salah Mabruok Khalaf

South Egypt Cancer Institute 2012

Case disscusion

A 40 years old female with excessive sweating palpitation, wasting with polyphagia, diarrhea Examination: thyroid swelling about 2 cm, firm, mobile with deglutition, in left lobe and extend to isthmus. Patient has a past history of RT to neck for HL when aged 25 years.

1. what the best next step? A. TSH level. B. Radioactive iodine scan C. CT neck D. FNAC E. Thyroidectomy

TSH level was lower than normal 2. what the best next step? A. Thyroid lobectomy B. Radical thyroidectomy C. Radioactive iodine scan D. CT neck for staging E. Free T3 and T4

Radioactive iodine thyroid scan consistent with hot nodule Neck sonar revealed solid mass less than 1.5 cm 3. FNAC was indicated due to A. Low TSH level irrespective of iodine scan result B. Hot nodule on scan C. Solid nature of the mass D. Malignant suspicious due to previous RT

FNAC indication I. Sonar-based criteria

Sonographic suspicious features (hypoechoic, microcalcification, increased central vascularity, infiltrative margin or taller than wide in transverse plan)

Solid nodule
1.
2.

More than 1 cm if associated with sonographic suspious features More than 1.5 cm in absence of sonographic suspicion
More than 1.5 cm if associated with sonographic suspicious features More than 2 cm in absence of sonographic suspicion

Mixed solid and cystic

1. 2.

Spongiform nodule (microcystic component > 50% of nodules

II.

High risk Clinical feature RT exposure genetic predisposition

Patient was referred for FNAC and follicular neoplasia was the result 4. Thyroid lobectomy or total thyroidectomy A. No need as no evidence of malignancy with FNAC B. Better to be done as patient has high risk clinical feature. C. Must be done for definite diagnosis D. Repeat FNAC E. No need for surgery as therapy with radioactive iodine is enough

Lobectomy-isthmusectomy was done and revealed minimally invasive cancer then patient referred to surgeon for his opinion for further surgery 5. what is the best option? A. Completion of thyroidectomy B. Observation with replacement therapy C. Postoperative RT D. Answer A and B are valuable E. Postoperative chemotherapy

Patient was maintained under surveillance with replacement therapy After 2 years of follow up the patient develop Rt cervical lymph node enlargement about 2 cm, single, firm, mobile. 6. The best next step is A. FNAC of node B. CT/MRI neck C. TSH level D. Excisional biopsy of node

CT/MRI neck revealed RT thyroid lobe swelling 3 cm in diameter with increased central vascularity with Rt cervical LN and FNAC revealed follicular carcinoma Metastatic work up revealed multiple lung nodules

7. The tumor of the Rt lobe is considered A. Second primary B. Recurrence C. Both D. Neither

8. As regard follicular carcinoma after RT,

A. B. C.

D.

It is the most common of thyroid cancer after RT It is less common than papillary carcinoma It has poorer prognosis than that not associated with RT RT to can be re-adminstered if indicated

9. The following are more common in follicular than in papillary carcinoma EXCEPT
A. B.

C.
D. E.

Psammoma body Orphan Ann nucleus Lymph node metastasis Aggressiveness None of above

Papillary Cancer Histologic: Psammoma bodies, intranuclear groves and cytoplasmic inclusions Orphan Ann nucleus Multicentric: 30-50% Spread via Lymphaticspropensity for cervical node involvement Invasion of adjacent structures and distant mets uncommon

FOLLICULAR THYROID CANCER 15-20% Of Thyroid Cancers Well Differentiated Usually Encapsulated More Common Among Older Patients Woman > Man More Aggressive & Less Curable Than Papillary Blood Spread (lung and bone) 60% 10 Year Survival Types: Overtly Vs Minimally Invasive Hurthle Cell

Rarely associated with radiation exposure

Invasion into blood vessels (veins and arteries) within the thyroid gland is common

10. Stage of the tumor of that patient according to TNM staging

A.

B.
C. D.

I II IIII IV

STAGING OF THYROID CANCER

In differentiated thyroid carcinoma, several classification and staging systems have been introduced. However, no clear consensus has emerged favoring any one method over another AMES system/AGES System/GAMES system TNM system MACIS system University of Chicago system Ohio State University system National Thyroid Cancer Treatment Cooperative Study (NTCTCS)

TNM Staging

(All categories may be subdivided into (a) solitary tumor or (b) multifocal tumor.)

Primary tumor (T)

TX: Primary tumor cannot be assessed T0: No evidence of primary tumor T1: Tumor 2 cm or less in greatest dimension, limited to the thyroid T2: Tumor larger than 2 cm but 4 cm or smaller in greatest dimension, limited to the thyroid T3: Tumor larger than 4 cm in greatest dimension limited to the thyroid or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues)

T4a: Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve T4b: Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels

Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Regional lymph node metastasis
N1a: Metastasis to level VI (pretracheal, paratracheal, and prelaryngeal/Delphian on the cricothyroid membrane (precricoid) lymph nodes) N1b: Metastasis to unilateral or bilateral cervical or superior mediastinal lymph nodes

(Regional lymph nodes are the central compartment, lateral cervical, and upper mediastinal lNs)

Distant metastases (M)

MX: Distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis

AJCC Stage Groupings

Papillary or follicular thyroid cancer

Younger than 45 years Stage I Any T, any N, M0 Stage II Any T, any N, M1 Age 45 years and older Stage I T1, N0, M0 Stage II T2, N0, M0 Stage III T3, N0, M0 T1, N1a, M0 T2, N1a, M0 T3, N1a, M0

Papillary or follicular thyroid cancer (Age 45 years and older)

Stage IVA
T4a, N0, M0 T4a, N1a, M0 T1, N1b, M0 T3, N1b, M0 T2, N1b, M0 T4a, N1b, M0

Stage IVB

T4b, any N, M0

Stage IVC

Any T, any N, M1

University of Chicago system: Class Idisease limited to the thyroid gland Class IIlymph node involvement Class IIIextrathyroidal invasion Class IVdistant metastases.

National Thyroid Cancer Treatment Cooperative Study (NTCTCS) The NTCTCS created a staging approach that was applied prospectively to a registry of patients drawn from 14 cooperating institutions . Clinical pathologic staging was based upon: patient age at diagnosis tumor histology tumor size intrathyroidal multifocality extraglandular invasion metastases tumor differentiation

MAICS Scoring Developed by the Mayo Clinic for staging. It is known to be the most accurate predictor of a patient's outcome with papillary thyroid cancer (M = Metastasis, A = Age, I = Invasion, C = Completeness of Resection, S = Size) MAICS Score 20 year Survival <6 = 99% 6-7 = 89% 7-8 = 56% >8 = 24%

11. The best next step is:A. B. C. D. E.

Thyroidectomy with neck dissection alone RAI alone Neck RT Both A and B are correct Both A and C are correct

Radical Thyoidectomy without residual was done 12. The patient should be planned for

A. B. C. D. E.

Pre-therapy iodine scan RAI Chemoradiation Postoperative RT Close follow up with maintaining TSH low

I131? a postoperative course of therapeutic (ablative) doses of I131 results in a decreased recurrence rate among high-risk patients with follicular carcinomas. WHEN?= indications: (any present) Age < 15 y or > 45 y Radiation history Known distant metastases Bilateral nodularity Extrathyroidal extension Tumor > 4 cm in diameter Cervical lymph node metastases Aggressive variant

Pretherpy I123 scan was positive and RAI in a 30 mCi was taken one week after radioactive scanning with poor response 13. The reason for poor response may be due to A. Sublethal radiation stunning B. Low TSH level C. High grade tumor D. ow-dose iodine ablation L E. All of above

Pretherapy whole body iodine scan: If performed, a pretherapy scan should use a low dose of 131I (1 to 5 mCi) or 123I.
To detect residual thyroid tissue, thyroid cancer, and metastatic foci To reduce the potential for sublethal radiation stunningof thyroid tissue that prevents optimal uptake of future 131I therapy.

Stunning is defined as a reduction in uptake of the 131I therapy dose induced by a pretreatment diagnostic dose

Need high TSH level

131I

may be given either when the patient demonstrates biochemical evidence of hypothyroidism (feedback increased endogenous TSH) or after treating the patient with recombinant human TSH (exogenous TSH). Both methods are based on the principle that TSH stimulates 131I uptake in both residual thyroid tissue and residual carcinoma and that it permits ablation of both.

Dose of RAI The dosing of 131I for ablation is somewhat controversial. Low-dose ablation with less than 30 mCi administered on an outpatient basis:

For low-risk young patients For high-risk patients For all patients with metastatic disease that treated with repeated therapeutic doses of 131I

High-dose ablation with100 to 200 mCi

300 mCi

14. The best management of this patient is A. Systemic chemotherapy B. Palliative RT C. Target therapy with bevacizumab D. All of above

Stage IV Follicular

The most common sites of metastases are lymph nodes, lung, and bone. Treatment of lymph node metastases alone is often curative I131: Metastases that demonstrate uptake of this isotope. Radiation therapy for localized lesions unresponsive to I131. Resection of limited metastases don't uptake of I131. Thyroid-stimulating hormone suppression with thyroxine is also effective in many lesions not sensitive to I131. Chemotherapy has been reported to produce occasional complete responses of long duration. Patients unresponsive to I131 should also be considered candidates for clinical trials testing new approaches to this disease.

Standard treatment options:

1) 2) 3) 4) 5) 6)

Systemic chemotherapy

doxorubicin alone cisplatin and of doxorubicin (better) Combined chemotherapy with bleomycin, adriamycin, and platinum in advanced thyroid cancer. Several histologic types of thyroid carcinoma responded, but the best responses were observed in medullary and anaplastic giant-cell carcinomas.

Sorafenib Tosylate in Patients With Metastatic or Unresectable, Iodine Non-Avid, Resistant Thyroid Cancer Pazopanib Hydrochloride in Patients With Advanced Thyroid Cancer Sorafenib (Nexavar) in Patients With Advanced Thyroid Cancer Lenalidomide in Patients With Radioiodine-Unresponsive Unresectable Metastatic Papillary or Follicular Thyroid Carcinoma Bortezomib in Patients With Metastatic Papillary or Follicular Thyroid Cancer Unresponsive to Prior Radioiodine Therapy