Risk Group Stratification in Thyroid Cancer

• Age is a very strong predictor of outcome:
  • In differentiated thyroid cancer
• Nearly 2/3 of the patients are younger that 55 years of age
  • They have a great long term survivorship:
    • Nearly 100% at 20 years

• The majority of patients with thyroid cancer are women:
  • In this study from MSKCC
    • 73% of the cases were in women
• Women have a slightly better 20 year survival (96%) compared to men (87%)

• 94% of patients had papillary thyroid carcinoma with a very good longterm survival (93.7%) compared to follicular (87.9%) and Hurthle cell carcinomas (88%)

• In this study from MSKCC 92% of the patients had tumors less than 4 cm in size:
  • Tumors less that 4 cm in size had an excellent long term survival (95.2%) compared to tumors larger than 4 cm (74.5%)

• Gross extra-thyroid extension (ETE) only occurs in a minority of patients (9%):
  • This patients have a worse overall survival (74.9%) compared intra-thyroidal tumors (95.9%) and tumors with microscopic (96.6%) extra-thyroidal extension

• Lymph node metastasis in general has a negative impact in long term survival:
  • However this difference is relatively small:
    • 96.2% in node negative patients vs. 89.2% in node positive patients
  • Studying the effect of lymph node metastasis in thyroid cancer survival:
    • Lymph node metastasis only had an adverse effect on survival in older patients (older than 55 years):
      • There is a progressive decline in disease specific survival as the years go bye
  • Young patients with and without nodal metastasis have excellent long term survival

• Distant metastasis will have an impact on long term survival:
  • Fortunately only 1.9% of differentiated thyroid cancers with present with distant metastasis

• Only stage II patients with an ATA high risk category will have a a progressive increase in mortality as the years pass.

• The surgical outcome between total thyroidectomy and lobectomy is comparable when compared for:
  • Local recurrence free survival
  • Neck recurrence free survival
  • Distant recurrence free survival
  • Disease specific survival
  • Overall survival

• What to do if the differentiated thyroid cancer is located to the isthmus and the lateral lobes are normal and no lymph node metastasis?
  • Is simple isthmusectomy the appropriate procedure?

• When to perform more that a total thyroidectomy?
  • Gross extra thyroidal extension (anteriorly or posteriorly)

• An R0 resection is fundamental when operating for gross extrathryoidal extension and performing more than a total thyroidectomy:
  • Patients in which an R0 resection can be performed will have long term survival exceeding 95% compared to patient with an R1 resection (60%)
  • R1 or R2 resections leads to a 40% decrease in survival

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