C (53:41)
Okay, so I just wanted to start with when people think of thyroid cancer, there's this idea out there that it's a good cancer. I just want to debunk that there is no good cancer. So for anybody who says that, don't ever say that everybody's journey is a little bit different. Thyroid cancer does, in general, have a very excellent prognosis, but they're very different types. When we're thinking about Thyroid cancer, I think of it as in three buckets. The first bucket is well differentiated thyroid cancer. The second bucket is the C cell medullary one. And the third bucket is anaplastic. The way that we differentiate those is based on the type of cell. For differentiated, it's going to be follicular for the medullary sisy cell and then we're going to see does it look like a thyroid cell, so is it differentiated or is it more like it's mutated into some other thing that's unrecognizable? And that's what puts it in the anaplastic category. For the differentiated one, Traditionally, most people just learned about two papillary and follicular. There's actually a third type that got reclassified by the WHO recently. In 2022, there was a subtype of follicular known as Herthel CE cell, and that got reclassified as its own third category under differentiated, now under oncocinic. So each of those three things, even though they're in the broader group of well differentiated, they do have slightly different pathophysiology and they have slightly different outcomes because of that. So the papillary is what people think of as the good cancer that a lot of people think of. That's the one that has a five year survival rate of like 99%. That 1 is actually spread through the lymph nodes. The majority of patients, it is confined to the thyroid gland on presentation, but about 20, 30% of people, it can actually go to the lymph nodes at the time of presentation. That's why we get our ultrasound to make sure that it hasn't spread. We want a really good ultrasound of those lymph nodes to make sure it hasn't spread because it changes our management. As I said earlier, I'm a less is more girl. Actually, the ATA has swung the pendulum a little bit on how much treatment these patients need. So thyroid cancer patients, traditionally everybody got a total thyroidectomy, everybody got radioactive iodine, and everybody got lots of thyroid hormone. So those days left, those days are gone. About 15 years ago, we stopped doing that. So now we have a hemithyroidctomy as a main treatment option, which we just take out half the thyroid gland. And we do radioactive iodine only in higher, intermediate to higher risk patients. And we don't do as much levothin suppression therapy. And I think that's going to be kind of important as we talk about the treatment for this patient later. So for the papillary we have A option of surgery as the primary treatment and then followed by if it's higher risk, we're due radioactivity. And that's very similar to how follicular works as well. But the difference is that follicular tends to to metastasize more through the bloodstream. And so you can get these distant meths to the bones. And so it has a slightly worse prognosis than papillary does, but they kind of get grouped together in the way that they're researched currently. But it does have a slightly worse prognosis than papillary. And papillary is about 80% of differentiated and follicular ends up being about 10 to 15%. And then oncocytic is rarer. It's about 2 to 3% of well differentiated thyroid cancers. And it, depending on the mutation, which Anna has done research in this, it can be really worse prognosis or some of the mutation will actually make it a little bit more towards a prognosis of like papillary and follicular thyroid cancer. So not everybody who has oncocytic is it's going to be bad in. But if it is, if you have certain mutations like tert mutation, it could be considerably workers. Okay, so those are the well differentiated. So those three. Then there's this category medullary. So everybody's probably heard of medullary because it's on your boards. It's associated with me. 2. So this is that genetic condition where you can have a pheochromocytoma with the thyroid cancer and this is caused by a majority of them are caused by RET mutations that tend to run in families. If it tends to be in a germline mutation and the treatment for this is actually surgery. And depending on the mutation, it might even be surgery and testing in your children. When you get the genetic testing, there's a genetic counselor that recommends what kind of screening is associated with your family and what kind of treatment moves forward based on the specific gene in the RET mutation that you have. There is no radioactive iodine treatment for medullary because it works on C cells and not the follicular cells. The radioactive iodine doesn't work in this group of patients. Comparatively to the differentiated one, we use normal tsh. There's no levodioxin suppression. Then the last group, which is the really, really bad thyroid cancer, it's actually bad cancer in general, comparatively to most cancers, is probably one that has the worst prognosis out there, which is anaplastic thyroid cancer. It's the most aggressive type. It's the one that we all get scared about because the patient wakes up with a huge, huge expanding neck mass overnight and they can literally choke to death within like a week or two if you. Depending on where we catch it in the cycle. Like it's, it's not great. So everybody in that category is actually stage four on presentation, and a five year life expectancy is pretty poor. It's like less than 10%. So we have been making strides on improving the outcomes in these patients based on recent testing. If they have a BRAF mutation, there's some new adjuvant chemotherapy that we can use to kind of shrink the tumor prior to resection. But we have a long way to go in that category. And the treatment for that is actually surgery if you catch it early enough that you can actually surgically resect it and then external beam radiation. So we don't use radioactive iodine and anaplastic, and we don't use TSH suppression in anaplastic because those two also don't work in anaplastic. So those are kind of the main overview of thyroid cancer. I would say when you're staging thyroid cancer, it comes in the classic four stages of other cancers. But interestingly for the well differentiated one, it's actually staged based on age. For the PTC, FTC and the oncocytic. If you're under the age of 55, you can only have a stage one or stage two. And stage one is anywhere in the the neck. And stage two is like distant metastatic disease. And the reason for that is even if you have distant metastatic disease, if you're young, your prognosis like these are treatable things and your 5 year and 10 year survival is still pretty good. It's not what's traditionally associated with the stage four, like breast cancer or colon cancer. So they try to restage it based on that. And then the same thing with anaplastic, because it's so terrible, everybody is a stage four in presentation. So there's a little bit differencing in stage three for thyroid cancer than is for other cancers. The other thing that we look at is that the ATA has these kind of risk stratification. So we're looking at if you're under 55 and you have a lot of neck disease, for your papillary thyroid cancer, your prognosis might still be okay as far as mortality and morbidity, but what is the risk of the cancer recurring after the primary treatment that we choose to do? So we put it in three buckets. In this low risk, which is the cancer coming back is usually less than 5%, somewhere between 1 and 2%. Intermediate risk, which can be anywhere from 10 to 30%, and high risk, which is usually associated over 40 to 50% risk that cancer is coming back. That really helps us define what we want to do for our primary treatment. So the more the risk of the cancer coming back, the more treatment we're going to do in the beginning. So if it's high risk, we're going to do a total thyroidectomy. If it's high risk, we're going to do radioactive iodine and if it's high risk, we're going to do extra thyroid hormone for suppression, at least in the beginning, as opposed to if it's low risk, we're going to back off on doing all of those things because of the risk of complications from all of the treatment options that we have. So I know that's a lot of information to take in.
