CURRENT & FUTURE IN THYROID CARCINOMA,SHENG YUAN General Surgery , Changhai Hospital 2011-07-04,PART I,Surgical Anatomy of the Thyroid and Parathyroid Glands,2,Thyroid gland and its relations at the level of the thyroid cartilage,3,Thyroid gland and its relations at the level of the third tracheal ring,4,Superior and inferior thyroid arteries,5,Arterial supply of the thyroid derived from the four main vessels of the gland,6,Superior, middle and inferior thyroid veins,7,the inferior laryngeal nerve in relation to the inferior thyroid artery, the thyroid gland, and the parathyroid glands,8,the superior and inferior laryngeal nerves,9,Lymph node compartments separated into levels and sublevels,10,PART II,Classification & Characteristic of Thyroid Carcinoma,11,THYROID CARCINOMA,Papillary Thyroid Carcinoma Follicular Thyroid Carcinoma Medullary Thyroid Carcinoma Anaplastic Thyroid Carcinoma Unusual Thyroid Carcinoma,12,1. Papillary Thyroid Carcinoma,Follicular cell origin Most common (about 80%) Most in young patients Multifocal (up to 88.5%) Regional cervical lymph nodes involved 70% in low-risk group with 1-5% mortality 30% in high-risk group with 40% mortality,13,Table 1 Low-risk patients using AGES or AMES system,Variable Description Age Women younger than 50 years Men younger than 40 years Grade / Well differentiated /No Metastases Extent Confined to the thyroid Size Tumor with a maximal diameter of less than 4 cm,Table 2 High-risk patients using AGES or AMES system,Variable Description Age Women older than 50 years Men older than 40 years Grade / Poorly differentiated /Yes Metastases Extent Invasive to adjacent tissues or distant metastases Size Tumor with a maximal diameter of greater than 4 cm,TNM CLASSIFICATION SYSTEM FOR DIFFERENTIATED THYROID CARCINOMA,T1 Tumor diameter 2 cm or smaller T2 Primary tumor diameter 2 to 4 cm T3 Primary tumor diameter 4 cm limited to the thyroid or with minimal extrathyroidal extension T4a Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve T4b Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels TX Primary tumor size unknown, but without extrathyroidal invasion,16,TNM CLASSIFICATION SYSTEM FOR DIFFERENTIATED THYROID CARCINOMA,N0 No metastatic nodes N1a Metastases to level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes) N1b Metastasis to unilateral, bilateral, contralateral cervical or superior mediastinal nodes NX Nodes not assessed at surgery,17,TNM CLASSIFICATION SYSTEM FOR DIFFERENTIATED THYROID CARCINOMA,M0 No distant metastases M1 Distant metastases MX Distant metastases not assessed,18,STAGES,Patient age 45 years Patient age 45 years or older Stage I Any T, any N, M0 T1, N0, M0 Stage II Any T, any N, M1 T2, N0, M0 Stage III T3, N0, M0 T1-3, N1a, M0 Stage IVA T4a, N0, M0 T4a, N1a, M0 T1-3, N1b, M0 T4a, N1b, M0 Stage IVB T4b, Any N, M0 Stage IVC Any T, Any N, M1,19,2. Follicular Thyroid Carcinoma,Follicular cell origin 10% of all thyroid cancers From iodine-deficient areas Median age is in the sixth decade Metastasize via hematogenous pathways Distant metastasis is early(10-33%) AGES can be used as prognostic factors,3. Medullary Thyroid Carcinoma,A tumor of parafollicular cell (C cell) 5-10% of all thyroid cancers 70% occur sporadically, 30% are familial Multifocal,bilateral in most familial MTC Metastasis to regional lymph nodes is early,The Definition of MTC,MTC is a tumor of the thyroid C cell ,also known as the parafollicular cells which are of neural crest derivation and considered to be APUD system of neuroendocrine cells. C cells secrete calcitonin. Plasma im-munoreactive calcitonin is a sensitive and specific marker for the presence of MTC.,Table 3 Clinical presentations of MTC,Variable Characteristics of Tumor Associated abnormalities Sporadic Unilateral None MEN 2A multifocal, Hyperparathyroidism bilateral Pheochromocytomas MEN 2B multifocal Pheochromocytomas bilateral mucosal neuromas megacolon skeletal abnormalities FMTC multifocal None bilateral (non-MEN),Genetics of MTC,Gern-line defects in RET proto-oncogene are responsible for MEN 2A, MEN 2B, and FMTC.,4. Anaplastic Thyroid carcinoma,1-4% of all thyroid carcinoma Women and men at a ratio of 1:1.5 The peak incidence in the seventh decade Mean survival can be measured in months Symptoms (dysphagia,dysphonia,dyspnea) Metastases(lung, bone, brain, adrenal glands,and intra-abdominal nodes),5.Unusual Thyroid Cancers,Prim