Clinical Guidance in Thyroid Cancers
Transcript of Clinical Guidance in Thyroid Cancers
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Clinical Guidance in Thyroid Cancers
Stephen Robinson
Imperial at St Mary’s
On behalf of BTA
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Background to thyroid cancer
• Incidence probably increasing slowly
• 1971-95; 2.3 women 0.9 men /100,000
• 2001; 3.5, 1.3
• Most common endocrine malignancy but 1% of all malignancies
• Outcome favourable
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OCIU Head and neck cancer report 2010
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Variation in survival of adult patients with thyroid cancer in Europe
• EUROCARE II, n=7504, 17 countries
• Age adjusted 5yr survival
• ♂ UK 64 Europe 67
• ♀ UK 74 Europe 78
• Finland, Iceland, Netherlands better
Teppo 1998 EJC 34:2248
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European consensus for the management of DTC
• Consensus management
• European Thyroid Association
• 2006 EJE 154:787
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Guidelines for management of thyroid cancer, second edition
• RCP role in delivery high quality care by setting standards and promoting excellence
• Joint with British Thyroid Association
• BTA, RCP RCP 2007
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Revised ATA management guidelines
• EB guidance
• Contemporary optimal care
• 2009 Thyroid 19:1167
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NCCN National Comprehensive Cancer Network
• Practice guidelines in oncology v.1.2009
• Very practical didactic guidance
• From nodule evaluation to cancer management
• www.nccn.org
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Key BTA/RCP recommendations differentiated thyroid cancer
• Access to multidisciplinary team• Patient focus• Surgery• Pathology• Radioiodine and radiotherapy• Aims of treatment• Summary of management of DTC• Follow up of DTC• Medullary thyroid cancer
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Multidisciplinary team
Dedicated Surgeon
Cytology
Radioisotope imagingCross sectional imaging
OncologistEndocrinologist
Histology
Palliative care
Biochemist
SpecialistNurse
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Specific MDT
Rare malignancy with requirement of broad MDT
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Patient focused service
• Full information, verbal, written and Information prescription
• Access to MDT member
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Cancer waiting times
GPreferral
1st Clinic attendance
Decision totreat
ThyroidSurgery
0 14 31 62
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Surgery
• Surgical preparation
• Surgeon should have training and expertise
• Complications
• Lymph node surgery
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Hospital volume influences choice of operation for thyroid cancer
• France n=4006
• >100 thyroid ops cf <10 thyroid ops
• Low vol Risk of unilateral op 2.45 (1.63-3.71)
• Med vol Risk of unilateral op 1.56 (1.27-1.92)
• Significant effect hospital volume on appropriateness of thyroid surgery
Lifante 2009 BJS 96:1284
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Sosa JA, Ann Surg, 228: 320-330, 1998
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Sosa JA, Ann Surg, 228: 320-330, 1998
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Surgeon volume as a predictor of outcome in endocrine surgery
• USA, n=13,997
• A=1-3, B=4-8, C=9-19, D=20-50, E=51-99, F>100
• A more complications OR 1.65 p<0.001
• F less OR 0.52 p<0.001
• Hospital volume negligible effectStavrakis 2007 Surgery 142:887
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23/45
0%
1%
2%
3%
4%
5%
0 50 100 150 200 250 300 350 400 450
Relationship between surgeon volume and rate of permanent unilateral RLNP in hemithyroidectomy for benign disease
<1% RLNP with >42 NAR/year
approximated observed Dralle H, Sekulla C
Zentralbl Chir 2005; 130: 428 - 433
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Specific surgeon
Expertise necessary in short and long term
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Pathology
• Pathologists should have Thyroid cytology and histopathology expertise and interest
• Tumour Node and distant metastasis
• Assigned to risk group
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Radioiodine ablation and therapy
• Oncologist with thyroid expertise and interest with ARSAC certificate
• RAI therapy in appropriate facility
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Aims of treatment
• Removal of all tumour
• Elimination of clinical radiological and biochemical evidence of recurrence
• Minimisation of unwanted effects of treatment
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Management
• MDT treatment plan
• Fine needle aspiration cytology and ultrasound, to plan surgery
• >1cm PTC or high risk DTC would need total thyroidectomy
• Thyroglobulin measurement
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Neck Ultrasound
• Mandatory
• Features of nodule
• Remaining thyroid
• Can be used as FNA guideMarqusee 2000 AIM 133:696
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Management continued
• Ablative 131I
• Post ablation scan
• Thyroxine treatment
• Ultrasound
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Specific team
Histo-cytopathology, Imaging, oncology, endocrinology
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Activity in the right side of the neck
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Lifelong follow up
• Long natural history
• Late recurrence treatable
• Monitor treatment
• T4 suppression
• Late effects of treatment
• Pregnancy
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Medullary thyroid cancer
• FNAC calcitonin
• Genetics All exons
• Counseling
• MEN2A 2B
• Minimum thyroidectomy and level VI node
• Prophylactic surgery
• Lifelong follow up
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Lymphatic DrainageThyroid Gland: Primary
– Pretracheal (VI)
– Paratracheal (VI)
– Lower Jugular (IV)
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Database
• Use at point of care
• Specific fields for thyroid cancer
• Utility for individual patient and audit
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Specific database
Importance of thyroid specific fields
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Conclusions
• Implementation of guidance
• Specialist Thyroid Surgeons
• Specialist Thyroid Multi disciplinary team
• Database with appropriate fields with update at point of care
• Lifelong follow up