Medullary Thyroid Carcinoma Part 3

• Staging:
  • TNM staging:
    • The pathological tumor, node, metastasis (pTNM) criteria for clinical / pathologic tumor staging (eighth edition) adopted by the Union for International Cancer Control (UICC) and the American Joint Committee on Cancer (AJCC) are based upon:
      • Tumor size
      • The presence or absence of extra-thyroidal invasion
      • Local and regional nodal metastases
      • Distant metastases 
  • Stage I :
    • Medullary thyroid cancers (MTCs) that are equal or less than 2 cm in diameter without evidence of disease outside of the thyroid gland
  • Stage II:
    • Tumors  greater than 2 cm confined to the thyroid or tumors of any size without lymph node metastasis that demonstrate gross extrathyroidal extension invading only the strap muscles (sternohyoid, sternothyroid, thyrohyoid, or omohyoid muscles)
  • Stage III:
    • Tumors of any size demonstrating metastatic lymph node involvement in the central neck (levels VI or VII; pretracheal, paratracheal, or prelaryngeal/Delphian, or upper mediastinal lymph nodes) with or without gross invasion into the strap muscles (sternohyoid, sternothyroid, thyrohyoid, or omohyoid muscles)
  • Stage IV :
    • Any distant metastases, or lymph node involvement outside of the central neck (level VI/VII), or gross invasion into other structures of the neck (beyond just strap muscle involvement)
• One study evaluated the prognostic significance of a previous TNM staging scheme in patients with MTC:
  • Most of whom were treated by total thyroidectomy and then followed for a median of four years:
    • Although the follow-up was short:
      • Mortality due to MTC was:
        • 0% stage I 
        • 13% in stage II
        • 56% in stage III
        • 100% in stage IV
• A subsequent analysis of MTC patients using the National Cancer Database and the SEER (Surveillance, Epidemiology, and End Results) data set demonstrated that the seventh and eighth editions of the AJCC staging system:
  • Were associated with five-year overall survival rates of:
    • 95% in stage I
    • 91% in stage II
    • 89% in stage III
    • 68% in stage IV
  • Furthermore:
    • Disease-specific survival rates were:
      • 100% in stage I
      • 99%  in stage II
      • 97%  in stage III
      • 82% in stage IV
• Dynamic risk stratification:
  • Using the same concepts that were initially developed for differentiated thyroid cancer:
    • Dynamic risk stratification for MTC allows clinicians to modify initial AJCC staging risk estimates over time based on:
      
      • The biological behavior the tumor and the response to therapy in individual patients
    • For application in MTC, the definitions of the response to therapy categories needed to be modified to utilize calcitonin and carcinoembryonic antigen (CEA) as tumor markers (rather than thyroglobulin):
      • At each follow-up visit, patients are classified as having one of the following clinical outcomes:
        • Excellent response:
          • An undetectable calcitonin and normal-range CEA in the absence of structurally identifiable disease
        • Biochemical incomplete response:
          • A detectable calcitonin or elevated CEA in the absence of structurally identifiable disease
        • Structural incomplete response:
          • The presence of recurrent or persistent structurally identifiable disease
  • In two retrospective studies examining MTC patients with a median of 5 to 7 years of follow-up:
    • An excellent response to therapy was associated with:
      • Structural disease recurrence rate of 1% to 4%
      • Biochemical recurrence rate of 11% to 15%
      • Disease-specific mortality of less than 3%
    • Patients with a biochemical incomplete response demonstrated a:
      • Structural disease recurrence rate of 32% to 37%
      • Biochemical recurrence rate of 51% to 53%
      • Disease-specific mortality of 11%
    • The poorest outcomes were seen in those patients with a structural incomplete response to initial therapy with:
      • Disease-specific mortality rates of 38% to 56%
• The calcitonin and CEA doubling times:
  • Can also provide meaningful insights into:
    • Prognosis
    • Expected course of disease progression that can further refine these response to therapy assessments

 

• What is Head and Neck Surgery?:
  • It is a surgical sub-specialty that deals mainly with benign and malignant tumors of the head and neck region, including:
    • The scalp, facial region, eyes, ears, nose, nasal fossae, paranasal sinuses, oral cavity, pharynx (nasopharynx, oropharynx, hypopharynx), larynx (supraglotic larynx, glottis larynx, subglotic larynx), thyroid gland, parathyroid gland, salivary glands (parotid glands, submandibular glands, sublingual glands, minor salivary glands), soft tissues of the neck, skin of the head and neck region.
      • The head and neck surgeon’s work area:
        • Does not cover tumors or diseases of the brain and other areas of the central nervous system or those of the cervical spine:
          • This is the neurosurgeon field.
  • Among the diagnostic procedures performed by the head and neck surgeon,  are the following:
    • Nasopharyngolaryngoscopy:
      • Performed to examine, evaluate and, possibly perform a biopsy, of oral cavity, pharyngeal and laryngeal lesions.
  • The surgeries most commonly performed by the head and neck surgeon are:
    • Total or near total thyroidectomies
    • Hemithryoidectomies (lobectomies)
    • Comprehensive neck dissections
    • Selective neck dissections
    • Maxillectomies:
      • Total maxillectomy
      • Subtotal maxillectomy
      • Infrastructure maxillectomy
      • Suprastructure maxillectomy
      • Medial maxillectomy
    • Mandibulectomy:
      • Segmental
      • Marginal
    • Tracheostomy
    • Salivary gland surgeries:
      • Parotid gland operations:
        • Limited superficial parotidectomy with identification and preservation of the facial nerve
        • Superficial parotidectomy with identification and preservation of the facial nerve
        • Near total parotidectomy with identification and preservation of the facial nerve
        • Total parotidectomy
      • Submandibular gland resection
      • Sublingual gland resection
    • Resection of tumors of the oral cavity:
      • Glossectomy
      • Resection of the floor of the mouth tumors
    • Resection of tumors of the pharynx
    • Resection of tumors of the larynx
    • Split-thickness skin grafts
    • Full-thickness skin grafts
    • Sentinel lymph node mapping and sentinel lymph node biopsy
    • Resection of malignant skin tumors (BCC, SCC, melanoma) of the head and neck region
• The formation of the head and neck surgeon includes mastering the following subjects:
  • Surgical Anatomy
  • History and Basic Principles of Head and Neck Surgery
  • Epidemiology, Etiology, and Pathology of Head and Neck Diseases
  • Diagnostic Radiology of the Head and Neck Region
  • Tumors of the Scalp, Skin and Melanoma
  • Eyelids and Orbit
  • Nasal Cavity and Paranasal Sinuses
  • Skull Base and Temporal Bone
  • Lips and Oral Cavity
  • Pharynx and Esophagus
  • Larynx and Trachea
  • Cervical Lymph Nodes
  • Thyroid and Parathyroid Glands
  • Salivary Glands
  • Neurogenic Tumors and Paragangliomas
  • Soft Tissue Tumors
  • Bone Tumors and Odontogenic Lesions
  • Reconstructive Surgery
  • Oncologic Dentistry and Maxillofacial Prosthetics
  • Principles of Radiation Oncology
  • Principles of Chemotherapy
  • Molecular Oncology, Genomics and Immunology
  • Nutrition
  • Biostatistic

 

• Rodrigo Arrangoiz MS, MD, FACS a head and neck surgeon / endocrine surgeon / surgical oncologist and is a member of Sociedad Quirúrgica S.C at the America British Cowdray Medical Center in Mexico City:

 

• Rodrigo Arrangoiz MS, MD, FACS:
  • Is a member of the American Head and Neck Society

• • He is a member of the American Thyroid Association:

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

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