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[ Music ]>> Welcome to Cancer Newsline, a podcast series from the University of Texas, MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention, providing the latest information on reducing your family's cancer risk. I'm your host Lisa Garvin and today we'll be talking about an extremely rare form of thyroid cancer which is called anaplastic thyroid cancer or ATC. And one of the foremost experts on ATC is right here with us, my guest is Doctor Maria Cabanillas, she is an associated professor of endocrine neoplasia here at MD Anderson. So Doctor Cabanillas, very rare form of cancer, how many cases do you see in a typical year?>> At MD Anderson we usually see about 30 to 35 new cases a year. Plus we continue to see, of course, our patients that we're, that we continue to manage on an ongoing basis. So we have quite a bit of experience for such a rare tumor.>> And what is the nationwide occurrence, isn't it like less than 500?>> It's about, five to eight hundred new cases a year in the United States.>> And what is so, because, at least in the cancer world sometimes we think of thyroid cancer as being a friendlier type of cancer, easy to treat, successful treatment, what makes anaplastic thyroid cancer so different?>> Right, so anaplastic thyroid cancer is a completely different type of cancer. Whereas the most common type of thyroid cancer is papillary thyroid cancer, fairly easily treated with surgery and radioactive iodine, the difference really is that anaplastic thyroid cancer, is not treatable in most cases with surgery or with radioactive iodine. It's very, very aggressive, it grows rapidly and, can cause many symptoms before the patient is even aware that they have cancer.>> And what does the word anaplastic mean?>> It means that it's really no longer, it no longer looks like a normal thyroid cell, and it doesn't behave like a normal thyroid cell. So the markers for example, that we see with papillary and follicular thyroid cancer is called thymoglobulin as ur biomarker. We don't see that in anaplastic thyroid cancer because it doesn't express the normal proteins that thyroid cells usually express.>> Didn't it at one time used to be called undifferentiated, thyroid cancer?>> Yes, and this is part of the problem with diagnosing this disease very early on is that there are many different synonyms for this disease, it goes by anaplastic thyroid cancer, it goes by undifferentiated, sarcomatoid, giant cell and that causes a lot of confusion and delay in diagnosis.>> How do you get to standardize a disease category, how does that happen?>> Well that is usually done by, pathology groups, international pathology groups, and a lot of times the problem is that there really categorized by the way they look under the microscope. And anaplastic can actually take many different shapes under the microscope. So sometimes it looks like a sarcoma, sometimes it looks a little bit, like long spindly cells, and sometimes they're very large cells with lots of, division inside of them, of the nucleus. And therefore, because it looks so, it takes on so many different shapes, that causes a lot of confusion and misdiagnoses.>> Yeah, it sounds like a diagnostic nightmare.>> It is quite difficult, sometimes also, this disease is confused with thyroid lymphoma. And thyroid lymphomas are a completely different entity, they're treated differently, they have a completely different prognosis, so it's very important to establish the correct diagnosis so that the correct treatment can be given.>> How does it present, are the symptoms, they must be different than a typical thyroid cancer symptom.>> Correct. So because it grows so quickly, typically it presents with a large thyroid, a large neck mass. The patient may notice that they're having some difficulties swallowing, they may notice a feeling that they're being choked, especially when they lay down. Sometimes shortness of breath, and that's very different from the typical symptoms of papillary and follicular type thyroid cancers, where they often times are caught very early when they're very small, and the patient has no symptoms.>> What is the typical path that ATC patients take to get to MD Anderson, have they been previously treated, have they been correctly diagnosed. How do they usually arrive at your doorstep?>> They usually arrive after having had a surgery, that surprisingly is called anaplastic thyroid cancer, surprisingly to the surgeon, it was not expected most of the time. That's how most patients arrive. Other patients simply have a very large thyroid mass that is growing rapidly and that it's recognized that the patient needs immediate treatment and that it's a possibility they could have anaplastic thyroid cancer. And so some are sent without any kind of, biopsy yet, for us to determine what the, what the cancer is and start treatment.>> And I understand that, immediate treatment is of the essence with this disease.>> That's correct. Because it grows so quickly, some patients experience this tumor growing day by day, and therefore they can get very sick very quickly. Once a patient is very ill they're not really able to tolerate treatments for cancer, and therefore it's important that they arrive as early as possible. And so that we can start treatment as early as possible and try and avoid some of those symptoms that we discussed earlier.>> Is the staging the same? I'm not sure, if thyroid uses the TNM system.>> It does use the TNM system, it's a different stage. All anaplastic thyroid cancers are actually stage four, no matter how early or advanced they are, and that is simply because the staging system is built to, tell us what the risk of dying of the cancer is. And therefore, because anaplastic thyroid cancer has such a high, death rate, it's always staged as stage four. And that's very different from the other types of thyroid cancer.>> What is the typical ATC patient, young, old, white, black, male, female?>> That age is usually around sixty years old, but we do see patients that are presenting early in their thirties and forties, it's very rare but it does happen. But most of the patients are about sixty to eighty years old.>> Isn't anaplastic thyroid cancer, doesn't it sometimes start out differently and then becomes ATC?>> Yes, so that's called anaplastic transformation. And this is simply that the tumor used to be a, for example a papillary or follicular, what we call more differentiated which means it looks more like a normal cell. And then as it gains genetic mutations, this, it then becomes more aggressive and transforms into anaplastic. We believe that the majority of anaplastic thyroid cancers are actually derived from a more differentiated tumor and that they're simply not recognized early because often times papillary thyroid cancer and follicular thyroid cancer, patients exhibit no symptoms. And they only come to light when the tumor starts to really grow, transforming to anaplastic and then the patient experiences symptoms.>> Now does this disease metastasize readily or go to the lymph nodes readily?>> It metastasizes quite frequently, the majority of patients, when they present are already in advanced stage meaning they already have, a tumor that is going outside of the thyroid, invading, for example into the trachea, sometimes into the large vessels like the jugular and carotid in the neck. They're often times, they often times present with lymph node metastases, so they've spread to the lymph nodes. And even when we treat these patients with the usual treatment of radiation and chemotherapy, often times within four to six months they already have metastases to other parts of their body.>> So surgery is not a treatment option for ATC?>> Surgery is a treatment option for very few patients. And that's another reason why it's important to come early because, it may be that the patient is still within the window of opportunity to be able to go to surgery and have the tumor removed. But the majority of patients are not at that stage, they're usually to advanced to, to have surgery and, often times patients will ask well why don't you just take out what you can, even if you can't take it all out. And the answer to that really is that, even if we remove the tumor, we, it grows so quickly, it regrows so quickly, that it really just causes the patient to lose time, instead of getting more effective treatment.>> Are you using a particular type of radiation therapy or proton therapy?>> We are using what's called IMRT, this radiation is very much directed at where the tumor is instead of radiating the entire neck, we try and spare some of the normal tissue. We don't use proton therapy yet in this disease.>> And, for chemotherapy, are any targeted agents, applicable to this disease, or are you just using standard chemo?>> Typically what is recommended, if you look at the guidelines for how to treat anaplastic thyroid cancer, the recommendations are actually that the patient should be referred, that you should think first about putting them on a clinical trial. And the reason for that is that, the standard chemotherapy is usually not very effective, and therefore, clinical trials offer the best opportunity for the patient. We have seen some success with some of these newer targeted agents, these are drugs that, for example may be directed against the particular mutation that the patient has in their tumor. And therefore, it's important to recognize which patients have what mutation so that you can try and match them up with the correct, chemotherapy on a clinical trial. Right now these drugs are not, approved for the, for indication of anaplastic thyroid cancer, and therefore, patients really should be treated on a clinical trials.>> So it would be an off label.>> If you used it outside of the trial, it would be an off label indication, that's correct.>> And here at MD Anderson, because time is so important in diagnosing and treating this disease we've created a clinic called FAST, tell us about that.>> Yes, so FAST stands for facilitating anaplastic thyroid cancer specialized treatments, and essentially what we've done is that we've built a team of doctors with different specialties that see these patients because they're interested in trying to find, discover new therapies for these patients. And so we are a group of doctors who, talk to each other, we communicate to each, with each other about the patient and come up with the best treatment plan. The great thing about this program is that, we really built it from the ground up, meaning that we recognized that there were some barriers for patients to get appointments very quickly. And therefore, what we did is that we started at the point of entry of the patient, basically when the patient or the physician who's referring the patient calls us and says, I have anaplastic thyroid cancer, I have a patient with this disease, immediately, the team is mobilized. So that the person who's receiving that call in the, access center recognizes that this is really a very urgent diagnosis and that it needs to be treated as if, as if the patient were having, for example, a heart attack. It needs to be treated with a lot of seriousness and with a lot of speed. So, they have access to, to schedule immediate appointments for patients. Patients are offered very early appointments, they don't always, they're not always able to take those appointments but they are offered, usually appointments within several days of contacting us.>> What do you hope to see in the future, I mean it sounds like the prognosis is not great right now, but, do you hope maybe this clinic and other efforts will maybe extend survival?>> That is our hope. And, we've built a research program around FAST, so that we can develop new ways of thinking about how to treat this cancer. Rather than just simply trying out new drugs, is to really, rethink how we approach the disease. Meaning, usually what we would do is that we would offer radiation first and then we would think about this novel therapies. Well now we're trying to really think outside the box and say, is that the best approach, is there another way to do this?>> Thank you Doctor Cabanillas, very interesting information, it sounds like if somebody has this diagnosis they need to get themselves to a comprehensive cancer center.>> That is absolutely correct, that's, those are the places where you would encounter doctors who are very familiar with this disease. Remember that because it's so rare most doctors have never seen a single case. So it's best to go somewhere that, the physicians really understand the disease and what are the treatment options for the patient.>> Thank you.>> Thank you.>> [Background Music] If you have questions about anything you've heard today on Cancer Newsline, contact Ask MD Anderson at 1-877-MDA-6789 or online at ask. Thank you for listening to this episode of Cancer News Line. Tune in for the next podcast in our series.[ Music ] ................
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