Thyroid CA

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					      Thyroid CA
Treatment controversies
        Prof.H. Kayali,MD
   Head Dpt. of General Surgery
      Aleppo Medical School
Detailed Thyroid Anatomy

Recurrent laryngeal N, Upper,Lower
Parathyroid glandes
1.    The prevalence of cancer is higher in several groups:

2.    Children
3.    Adults less than 30 years or over 60 years old
4.    Patients with a history of head and neck radiation
5.    Patients with a family history of thyroid cancer
6.    Unexplained hoarseness or stridor with a goitre
7.    Painless thyroid mass enlarging rapidly over a period
8.       of a few weeks
9.    Palpable cervical lymphadenopathy
10.   Insidious or persistent pain lasting for several weeks
Extent of Surgery (depends on…)

Histological types and biological
Risk classification, staging &
Post surgical adjuvant treatment and
Surgical experience
       Total thyroidectomy

is the surgical management of choice for
patients with differentiated thyroid cancer
when it can be done safely with a low
complication rate
 & postoperative radioiodine ablation &
thyroid-stimulating hormone
suppressive therapy
       Total thyroidectomy
1.   Radioactive iodine may be used to detect
     and treat residual normal thyroid tissue
     and local/regional or distant metastases.

2. Serum thyroglobulin level is a more
    sensitive marker of persistent or
    recurrent disease when all normal
    thyroid tissue has been removed
       Total thyroidectom
3. In up to 85% of patients with papillary
  thyroid cancer, microscopic cancer foci are
  present in the contralateral lobe. By
  performing total thyroidectomy, these
  sites are removed as possible sites of

4. Recurrence develops in the contralateral
  lobe in approximately 7% of patients. Up
  to 50% of patients who develop recurrent
  cancer will die
from thyroid cancer
     Total thyroidectomy
5. Recurrence is decreased in patients
who underwent bilateral procedures
or total thyroidectomy.

6. The risk, although low, of
dedifferentiation into anaplastic thyroid
cancer is reduced
      Total thyroidectomy

7. Survival is improved for patients with
  papillary thyroid cancers larger than 1.5
  cm and for those with follicular thyroid
  cancers that are not minimally invasive.

8. The need for reoperative thyroid surgery,
  which may be associated with an
  increased risk of complications, is lower.
Analysis of surgical procedures performed in
  over 1500 US hospitals revealed
that among 5584 patients with thyroid
  cancer, the majority (77.4%)
underwent total thyroidectomy regardless of
  tumor histology and stage
The prognosis of low- risk patients by the
age, metastases, extent, size
(AMES); age, grade, extent, size
(AGES); and primary tumor, regional
lymph nodes, distant metastasis (TNM)
classifications is excellent in patients who
have undergone less than total
The debate as to whether lobectomy or total
thyroidectomy should be performed is
centered on the low-risk group
Because mortality a recurrence rates are
lower in this group, advocates of unilateral
thyroid lobectomy
Surgeons who perform total thyroidectomy,
however, believe that it is the indicated
surgical procedure, chiefly because in low-
risk patients with recurrence, 30% to
50% will die from thyroid cancer
In large retrospective series, patients
who underwent total or near-total
thyroidectomy with postoperative
radioactive iodine and TSH suppressive
therapy had lower recurrence rates
and better survival than those of patients
who underwent lesser procedures
multivariate analysis found that patients
who underwent completion
thyroidectomy within 6 months of
their primary operation developed
significantly fewer lymph node and
hematogenous recurrences and
survived significantly longer than
those in whom the second operation was
delayed for longer than 6 months
Performing lobectomy alone may result in a
5% to 10% recurrence rate in the
opposite thyroid lobe , a higher tumor
recurrence rate , and a high (11%)
incidence of subsequent pulmonary
metastases , High recurrence rates in
patients with cervical lymph node
In a recent update of Mazzaferri’s patient cohort,
surgery and
131I therapy had independent effects on
recurrence and cancer mortality
. After a median follow-up of 16.6 years, surgery
more extensive
than lobectomy was an independent variable
that reduced the likelihood of
cancer death by 50%
         Rationale for Total Thyroidectomy
        (Well differentiated Thyroid Cancer)
•   Bilateral cancers are common (30 – 85%)
•   Recurrent thyroid cancer occurs in 4.7 – 24% (mean
    recurrence 7% of patients)
•   50% of patients who develop recurrence die of their
•   Eliminates contralateral lobe disease.
•   Central recurrence associated with substantial mortality.
•   Reduces recurrence in all risk group of patient
•   Reduces mortality in patient at high risk.
Thank you

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