Disclosures Nodal Management in Nothing to disclose Differentiated - PDF document

Disclosures Nodal Management in Nothing to disclose Differentiated Thyroid Carcinoma Jonathan George, MD, MPH Assistant Professor UCSF Head and Neck Oncologic & Endocrine Surgery Objectives Overview � Clinical Epidemiology in DTC � Describe anatomy and behavior of � Diagnostic Imaging and Biopsy thyroid cancer metastases � Surgical Management of the Neck � Understand management of neck for � Central Neck primary and recurrent DTC � Lateral Neck � Explain concepts and terminology in � Central/Lateral Neck Recurrence neck dissection for thyroid cancer DTC Epidemiology DTC Epidemiology � 2014 US Data on DTC: � Peak age at diagnosis � 45-55 years of age � Prevalence: 600,360 � Incidence: 62,980 � Thyroid cancer on the rise … Year Men Women Total 2010 11,000 34,000 45,000/year 2020 21,000 71,000 92,000/year 2030 39,000 144,000 183,000/year CA: A Cancer Journal for Clinicians. 2014, 64(4):252-71 Rahib et al. Cancer Research 2014, 74(11). SEER Stat Fact Sheets . Thyroid . 2013 . http://seer.cancer.gov/statfacts/html/thyro.html.

DTC Epidemiology DTC Epidemiology Incidence 5 year Survival 97.7% M F 1975: 3.1 6.4 Recurrence remains a 2010: 7.6 21.5 problem  up to 40% Mortality 2013 810 1040 Mortality Patients with recurrence  30 year FU (N=2883): Recurrence 30% higher mortality American Cancer Society. Thyroid cancer. 2013. Mortality 9% http://www.cancer.org/acs/groups/cid/documents/webcontent/003144-pdf Grogan RH, et al. AAES 34 th Annual Meeting, 2013. DTC Epidemiology DTC Epidemiology Increasing worldwide… …but so is screening 15-fold increase in Korea Jury is still out Ahn HS et al. Korea’s Thyroid Cancer “Epidemic” – Screening and Overdiagnosis. NEJM 371(19), Nov 6 2014. Ahn HS et al. Korea’s Thyroid Cancer “Epidemic” – Screening and Overdiagnosis. NEJM 371(19), Nov 6 2014. Risk Group Stratification in DTC Risk Group Stratification in DTC � Low risk � Intermediate risk � Good disease control � Microscopic extrathyroidal � Good survival extension � Lymph node metastasis � Intermediate risk � Aggressive histology � Moderate disease control � Vascular invasion � Reasonable survival � High risk � Poor disease control � Poor survival Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2009. and Differentiated Thyroid Cancer. Thyroid. 2009.

Regional Nodal Staging of DTC AJCC Staging in DTC >45 years Regional lymph nodes cannot be assessed Nx Stage T N M No regional lymph node metastasis N0 T1 N0 M0 I Regional lymph node metastasis T2 N0 M0 N1 II T3 N0 M0 III N1a Metastasis to level VI (pretracheal, paratracheal and T1-3 N1a M0 prelaryngeal/Delphian lymph nodes) T1-3 N1b M0 IVA N1b Metastasis to unilateral, bilateral or contralateral cervical T4a all N M0 or superior mediastinal lymph nodes T4b all N M0 IVB all T all N M1 IVB Lymph Node Metastasis and Risk Group Stratification in DTC Survival in DTC � Risk of Recurrence Based on Nodal Status 20-year DSS at Presentation Age Group N0 N1 � Clinical N0 <45 yrs 94% 100%* � Range 0-9%, Mean 4% � Clinical N0, Pathologic N1 by Elective ND >45 yrs 90% 79% p = 0.06 � Range 4-11.5%, Mean 6% � Clinical N1, Pathologic N1 (clinically apparent) � Range 10-42%, Men 22% Cranshaw, Surg Oncol 2008; Bardet, Eur J Endo 2008; So, Surgery 2010; Wada, Ann Surg 2003. Hughes et al. 1996 Thyroid Lymphatics Regional Lymphatic Metastatic Routes Considerations Inferior � RLN nodes, paratracheal nodes � � Cross-communication of intraglandular lymphatics  anterior superior mediastinum � Extensive bilateral drainage Superior � � High incidence of regional metastasis Prelaryngeal, pretracheal, � paraglandular nodes  � Multiple nodal groups at risk low/mid/upper jugular nodes � Lymphatic channels parallel venous drainage Lateral � lower and midjugular nodes  � transverse cervical nodes Posterior � RLN, paratracheal  � retropharyngeal, retroesophageal nodes

Imaging Evaluation Overview � Modalities � Clinical Epidemiology in DTC � Ultrasound ATA Guidelines 2009 � R21. Pre-op neck US for all patients � Diagnostic Imaging and Biopsy � Thyroid undergoing surgery for a malignant FNA � Central Neck result to stage neck disease. B � Surgical Management of the Neck � Lateral Neck � Central Neck Cooper et al. Thyroid 2009. � Lateral Neck Moreno et al, Thyroid 2012. � Negative findings predict excellent � Central/Lateral Neck Recurrence long-term regional control and survival Imaging Evaluation Imaging Evaluation � Modalities � Modalities � Ultrasound � Ultrasound � Thyroid � Other � Central Neck � MRI � Lateral Neck � CT � Iodine scanning � PET/CT Imaging Evaluation Imaging Evaluation � Modalities � Modalities � Ultrasound � Ultrasound � Other � Other ATA Guidelines 2009 However… � R22. Routine preoperative use of � MRI � MRI US and CT have improved other imaging studies is not sensitivity and comparable � CT � CT recommended. E specificity for nodal disease in � Iodine scanning � Iodine scanning thyroid cancer patients than either exam alone. � PET/CT � PET/CT Cooper et al. Thyroid 2009. Kim E. Thyroid 2008.

Imaging Evaluation Imaging Evaluation � Modalities � Modalities � Ultrasound � Ultrasound � Other � Other PET/CT CT or MRI � MRI � MRI � No role in initial diagnosis of � Lymph node metastasis DTC (incidentalomas only) � CT � CT � Recurrent disease � Low NPV, sensitivity, � Iodine scanning � Iodine scanning � Vocal cord paralysis specificity in DTC � Fixation of mass � PET/CT � PET/CT � Limited role in surveillance � Aerodigestive tract symptoms Deitlin 1997, Jadvar 1998, Feine 1998, Altenvoerde 1998, Chung 1999, Alnafasi 2000 Overview Nodal Evaluation with FNA US guidance � � Clinical Epidemiology in DTC � Reduces non-diagnostic rate � Diagnostic Imaging and Biopsy Diagnosis of papillary cancer is 99% accurate � � Surgical Management of the Neck Use to formulate or change surgical plan � � Positive neck FNA � Central Neck � Negative neck FNA � Lateral Neck Caveats: � � Central/Lateral Neck Recurrence � False negative rate = 1-6% Central Neck Central Neck Anatomy Anatomy Levels VI and VII Levels VI and VII � � A paramedian bilateral A paramedian bilateral � � compartment compartment Defined: Lymph Node � � Components � Carotid to carotid � Pre-cricoid laryngeal � Cricoid to innominate (Delphian) � Contains � Paratracheal lymphovascular � Retropharyngeal tissue, fat, thymus, � Retroesophageal parathyroid glands � Pretracheal

Central Neck Central Neck Central Neck Metastasis ATA Consensus Summary Mean prevalence in Therapeutic CND implies that � � nodal metastasis is apparent DTC ~ 60% clinically (preop or intraop) or Independent risk factor � by imaging (clinically N1a) for local recurrence � R27a: Therapeutic CND for Recurrence rates high patients with clinically � for macroscopic (10- involved central or lateral neck nodes should 30%) but not accompany total microscopic LN disease thyroidectomy. B Bardet et al 2008 DL Steward. ATA Surgery Working Group. Thyroid . 2009. Central Neck Central Neck ATA Consensus Summary ATA Consensus Summary Prophylactic ( Elective ) CND Prophylactic ( Elective ) CND � � implies nodal metastasis is implies nodal metastasis is not detected clinically or by not detected clinically or by imaging (clinically N0). imaging (clinically N0). � R27b: Prophylactic CND (ipsi � R27c: Near-total or total or bilateral) may be thyroidectomy without performed in patients with prophylactic CND may be PTC with clinically appropriate for small (T1/T2), uninvolved central neck LNs non-invasive, clinically node- for advanced tumors (T3/T4) negative PTCs and most C follicular cancer. C DL Steward. ATA Surgery Working Group. Thyroid . 2009. DL Steward. ATA Surgery Working Group. Thyroid . 2009. Central Neck Central Neck ATA Consensus Summary ATA Consensus Summary Oncologic Goals in CND � “’Berry picking’ implies removal � only of the clinically involved � Clear all macro- and LNs rather than a complete microscopic disease in nodal group within the the central neck compartment and is not � Provide accurate recommended.” postoperative staging that  Comprehensive may guide treatment and Compartmental surveillance Dissection � Upstages 30-50% of pts >45 yrs Hughes et al. Surgery 2010. DL Steward. ATA Surgery Working Group. Thyroid . 2009.