1. Risikobasert behandling ved tumor thyroidea Til norsk ved Thorleif Ellingsen overlege ,NH Sykehuset stfold Med tillatelse av Ashok Shaha , M.D. , F.A.C.S. Head and Neck ServiceMemorial Sloan-Kettering Cancer Center New York , N.Y.

2.

Professor Ashok Shaha

3. 4. 5. 6. 7. Thyroid Literature Thyroid disease 136,053 Thyroid tumors 33,554 Thyroid Google search36million Medline

New Paper on Thyroid Disease Every 3 Hours

New Paper on Thyroid Cancer Every 8 Hours

Thyroid Cancer Google search21million 8. Thyroid Cancer Incidence & Mortality 1974 to 2004 Overall Thousands Women Men Mortality 9. Thyroid Cancer A Unique Human Neoplasm

Age is the most important prognostic factor

No stage III & IV cancers in pts below 45

Multicentricity of thyroid cancer is frequent

no prognostic impact

Microscopic tumor laboratory cancer

Nodal metastasis has no impact on outcome

Impact of extrathyroidal spread

Grade of the tumor & histologic poorly

differentiated features

10. A ge G rade E xtension S ize Differentiated Cancer of the Thyroid Prognostic Factors AGES(Mayo Clinic) A ge M etastasis E xtension S ize AMES(Lahey Clinic) 11. Low Risk Thyroid Cancer Low Risk 737 (86%) 2% High Risk 121 (14%) 46% Total Cases Dead of Disease Comparison of Risk Group Definitions AGES (1946 - 1970) AMES (1961 - 1980) Mayo Clinic: Pap Ca Lahey Clinic: Pap & Fol Ca Low Risk 737 (86%) 2% High Risk 121 (14%) 46% 12. Differentiated Thyroid Cancer Rx Expectations

80% do well after lobectomy alone

5% die, regardless of Rx

15% require aggressive surgery & RAI

13. 14. 15. 16. 17. 18. 19. 20. Risk Group Definitions Age (years) 45 Distant metsM0 M+ M0 M+ Tumor size T1/T2 T3/T4 T1/T2 T3/T4 (4cm) (4cm) Histology & Papillary Follicular Papillary Follicular Grade &/or &/or high grade high grade Low Risk Intermediate Risk High Risk Differentiated Cancer of the Thyroid 21. 22. Risk Stratification inThyroid Cancer

Low:

Intermediate:

High:

Low Risk PtLow Risk Tumor (45) High Risk Pt High Risk Tumor 23. Differentiated Thyroid Cancer 1980-1980 SURVIVAL: Lobectomy vs. Total Low Risk Group PROPORTION SURVIVING 100% 99% 24. 25. 26. Differentiated Thyroid Cancer Prognostic Factors AGES AMES APES DAMES GAMESMACIS Mayo Clinic Lahey Clinic SwedishMSKCCMayo 1987 group Clinic 1993 A ge A ge A ge D NA ploidyG rade M etastasis G rade M etastasis P loidy A ge A ge A ge (distant) E xtra- E xtra- E xtra- M etastasisM etsC ompleteness capsularcapsular capsular of resection tumor tumor tumor S ize S ize S ize S ize S izeS ize E xtent E xtra-I nvasion capsulartumor 27. Indications for Total Thyroidectomy

Grossly palpable disease in both lobes

High risk patient with high risk tumor

Radiated patient

Young patient with large nodal metastasis

to facilitate RAI

Patient with distant metastasis likely to

require RAI

28. Thyroid Cancer: The Case for Total Thyroidectomy ORLO H. CLARK, KENNETH LEVIN, QI-HUA ZENG, FRANCIS S. GREENSPAN & ALLAN SIPERSTEIN Veterans Administration Medical Center &The University of California, San Francisco,U.S.A. Eur J Cancer 21(2):305-313, 1988. 29. The fact that total thyroidectomy can be performed safely does not necessarily mean that it is indicated in all patients with thyroid cancer... An operation not worth doing is not worth doing well. Collin Thomas Chapel Hill 30. p