Thyroid Cancer Incidence is Diagnosis and Rising in the United States Management of Thyroid • 2008 Estimate for United States from NCI and Cancer: A Case-based American Cancer Society 1, 2 Approach � 37,340 New Cases � 1,590 Cause-related Mortalities � 388,386 patients with thyroid cancer Matthew D. Ringel. M.D. Professor, Department of Medicine • Incidence rate is increasing in both men and Division of Endocrinology, Diabetes, and women at fastest rate of all cancers Metabolism • Mortality has been stable since the early 1970s The Ohio State University College of Medicine and remains very low, but dependent on stage at diagnosis. 1 http://SEER.cancer.gov 2 www.cancer.org Potential Causes for the Increase Goals and Objectives in Thyroid Cancer Incidence • Increased use of thyroid ultrasound • Review current recommendations for the following in a case-based manner: • Increased availability of ultrasound-guided FNA of non-palpable nodules • Diagnostic testing for thyroid cancer diagnosis. � Supported by data from SEER database demonstrating increase is due nearly • Initial treatments for patients diagnosed completely to small, early stage papillary with thyroid cancer. thyroid cancers 1 • Key concepts in monitoring thyroid cancer. • True increased in incidence due to environmental or genetic factors • Controversies in the management of � Less likely due to no change in mortality rate recurrent thyroid cancer 1 Davies, et al. JAMA 2006;295:2164 1
Examples of Recent Society Illustrative Case Guidelines for Thyroid Cancer Diagnosis and Management • A 42 year old woman is in the office for and annual physical. • NCCN: Sherman SI: J Natl Compr Cancer Netw. 5:568—621; 2007. • She has no specific complaints other • American Thyroid Association: Cooper DS, et al. than fatigue. Thyroid. 16: 109-42, 2006. • She has no dry skin, constipation, or • European Thyroid Association: Pacini F, et al. Eur other signs/symptoms of J Endocrinol. 154: 787-803, 2006. hypothyroidism. • British Thyroid Association: London, Royal College of Physicians. 2002. • She has no heart palpitations, heat • AACE/AAES: Endocr Pract. 7: 202-220, 2001. intolerance or tremor. Guidelines Levels of Evidence Case • Modified USPSTF categories • Level A: Strongly Recommends: Based on strong • On physical examination, BP is 112/72; evidence that a service or intervention improves health outcomes. HR: 72 • Level B: Recommends: Based on fair evidence limited by the number, quality, or consistence of studies. • Neck exam reveals an ~2 cm rubbery • Level C: Recommends based on expert opinion thyroid nodule on the left that moves • Level D: Recommends against based on expert opinion. easily with swallowing. There are no palpable nodes. It is non-tender. No • Level E: Recommends against based in fair evidence. nodularity is noted in the right side. • Level F: Recommends against based on strong evidence. • Level I: Recommends neither for nor against based on • Remainder of the examination is normal. insufficient, poor quality, or conflicting evidence. 1. Cooper DS, et al Thyroid 2006 16; 2006 2. US Preventive Services Task Force Ratings: Strengths of Recommendations and Quality of evidence. Guide to Clinical Preventive Services, 3 rd ed. Periodic Updates 2000-2003. Agency for Healthcare Research and Quality. Rockville, MD. 2
Case Case • What are the key historical questions • What are the appropriate diagnostic tests you might ask to determine a risk of for this presumed solitary thyroid nodule? thyroid cancer? Case Case R1: ATA guidelines • Have you noticed a persistent hoarse voice or difficulty swallowing? “Measure serum TSH in the initial evaluation of a thyroid nodule.” Level: C • Do you have a family history of thyroid cancer? (particularly important for R2: “Thyroid sonography should be performed in all medullary thyroid cancer risk) patients with one or more selected nodules.” Level: B • Do you have a history of radiation Note: Nuclear Imaging of thyroid nodules at this exposure, particularly in childhood? stage should be performed in individuals with low TSH levels to determine if a nodule is “hot.” • In this case, the answer to all is “no”. Cooper DS, et al. Thyroid 2006. 16:109-142 3
Case Case • TSH is 1.2 m U/L (normal range 0.4-4.2 • R5: “Fine Needle Aspiration is the mU/L). procedure of choice in the evaluation of thyroid nodules.” Level A • Thyroid ultrasound confirms the � Only exception would be if the TSH is presence of a 2.2x2.3x2.1 cm nodule on low, in which case a nuclear medicine the left side. There is a smaller (iodine) scan would be performed 0.8x0.6x0.4 cm nodule on the right. No abnormal lymph nodes are identified in • Ultrasound-guided is often recommended, the central or lateral neck regions. but if not available and the nodule is palpated, palpation-guided is acceptable. • What is the appropriate next step? Cooper DS, et al. Thyroid 2006. 16:109-142 Thyroid Ultrasound Diagnostic Capabilities Example of Thyroid FNA • FNA can accurately diagnose papillary thyroid cancer. • FNA cannot accurately distinguish between benign and malignant follicular thyroid lesions. • FNA can accurately diagnose benign thyroid lesions • An insufficiency rate of approximately 10% is common 4
Diagnostic Accuracy Clinical Endpoints of FNA Results of FNA • PTC on the FNA has >95% accuracy; recommend surgery � Follicular lesion or Atypical Cells: 8.4% (total/near-total thyroidectomy). • Suspicious for PTC: >50% chance of PTC, recommend • 34% of those selected for surgery were surgery (total/near total thyroidectomy). malignant • Follicular Lesion: ~15-20% chance of FTC, recommend � Suspicious for Thyroid Cancer surgery either hemithyroidectomy or total/near total thyroidectomy. Scan may also be performed. If “hot” can • 58% of those selected for surgery were follow. If “warm” or “cold” surgery. malignant • Benign Nodules: Recommend monitoring with ultrasound periodically. Repeat FNA if nodule is large or is growing. � Diagnostic for Thyroid Cancer • Insufficient: Repeat FNA in 3-6 months. If repeatedly non- diagnostic recommend surgery to obtain diagnosis (either • 95% of those selected for surgery were hemithyroidectomy or total/near total). If grows, also malignant recommend surgery. Oertel YA, et al. Thyroid 2007: 17 (11) 1061-1066 Diagnostic Accuracy Case of FNA • FNA was performed under ultrasound • Oertel, et al 10,973 FNAs in 8598 patients: guidance. Retrospective review of FNAs between 1998 and 2006 at one institution � Results revealed cellular atypia, minimal � Benign: 86.3% colloid, evidence of nuclear grooves and intranuclear cytoplasmic inclusion • Repeat FNA in 1410 patients for clinical bodies. reasons � Felt to be consistent with papillary – Unchanged diagnosis in 90.5% thyroid cancer. – The majority (91/133) were insufficient on repeat. Oertel YA, et al. Thyroid 2007: 17 (11) 1061-1066 5
Should Preoperative Types of Treatment Utilized in Thyroid Cancer Patients Staging be Performed? • Surgical Thyroidectomy • R 21. “Preoperative neck ultrasound for the contralateral lobe and cervical (central and • Radioiodine Therapy bilateral) lymph nodes is recommended for all patients undergoing thyroidectomy for malignant • TSH-suppressive doses of L-thyroxine cytological findings on biopsy.” Level B • It is noted that in some settings, CT or MRI may • External Beam Radiation Therapy be performed if there is not local ultrasound experience, but these tests are not routinely • Chemotherapy/Clinical Trials recommended. Cooper DS, et al. Thyroid 2006. 16:109-142 Goals of Initial Therapy Case for Thyroid Cancer • ATA Guidelines: “Remove the tumor, disease that has extended beyond the thyroid capsule, and • You are asked by the patient if she should involved cervical lymph nodes.” have her entire thyroid gland removed or if • “To minimize treatment- and disease- related half can be removed. morbidity.” • “To permit accurate staging of disease.” • What are the recommendations for initial surgery for patients with diagnosed thyroid • “To facilitate postoperative treatment with radioactive iodine, where appropriate.” cancer? • “To permit accurate long-term surveillance for disease recurrence.” • “To minimize the risk of disease recurrence and metastatic spread.” Cooper DS, et al. Thyroid 2006. 16:109-142 6
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