What to operate? When to operate? How to operate?

152
In the Name of God

Transcript of What to operate? When to operate? How to operate?

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In the

Name

of God

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SURGICALTHYROIDDISEASES

Sadaf AlipourSurgical OncologistAssistant ProfessorArash Women’s HospitalTehran University of Medical Sciences

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Our Subject:

What to operate?When to operate?How to operate?

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Surgery Goals (general) An organ has a malfunction that cannot be

treated madically An organ is getting huge sizes and the

pressure effects cannot be treated medically

An organ harbors a mass/tumor that must be excised

There is a mal-placed or developmental anomaly that needs to be excised

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Developmental Abnormalities

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Thyroglossal Duct Cyst and Sinus The most commonly

encountered congenital cervical anomalies

Anywhere along the migratory path of the thyroid

80% in juxtaposition to the hyoid

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Thyroglossal Duct Cyst and Sinus heterotopic thyroid tissue

in 20% usually asymptomatic occasionally infected by

oral bacteria: thyroid duct sinus secondary drainage of the cyst

Accompanied by minor inflammation of surrounding skin

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Diagnosis of Thyroglossal Duct Cyst Clinically: usually by observing

a 1- to 2-cm, smooth, well-defined midline neck mass that moves upward with protrusion of the tongue.

Routine thyroid imaging not necessary

Thyroid scintigraphy and ultrasound: document the presence of normal thyroid tissue in the neck.

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Surgery of Thyroglossal Duct Cyst and sinus

"Sistrunk operation“

en bloc cystectomy and excision of the central hyoid bone to minimize recurrence.

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!!! of Thyroglossal Duct Cyst and sinus

1% contain cancer, 85% papillary Squamous, Hürthle cell, and anaplastic cancers also

reported but rare. Medullary thyroid cancers (MTCs) are not found in

thyroglossal duct cysts. Role of total thyroidectomy controversial Surgery advised in older patients with large tumors,

particularly if with additional thyroid nodules and evidence of cyst wall invasion or lymph node metastases.

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Lingual Thyroid Failure of median

thyroid anlage to descend normally

May the only thyroid tissue present

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Treatment in Lingual Thyroid

Necessary only if :

1) Obstructive symptoms:• choking • dysphagia• airway obstruction• hemorrhage

2) Hypothyroidism ( frequent) Medical treatment :

• exogenous thyroid hormone or

• RAI ablation followed by hormone replacement

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Surgery in Lingual Thyroid Surgical excision rarely needed If required, should be preceded by evaluation of

normal thyroid tissue in the neck to avoid inadvertently rendering the patient hypothyroid

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Ectopic Thyroid Found anywhere in the central neck compartment

› esophagus› trachea› anterior mediastinum› adjacent to the aortic arch› in the aortopulmonary window› within the upper pericardium› in the interventricular septum› Often, "tongues" of thyroid tissue seen extending off the

inferior poles particularly in large goiters

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!!! in Ectopic Thyroid

When thyroid tissue lateral to carotid sheath and jugular vein (termed lateral aberrant thyroid): almost always metastatic thyroid cancer in lymph nodes

Even if not apparent on exam or US, the ipsilateral thyroid lobe contains a focus of papillary thyroid cancer (PTC), which may be microscopic.

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Pyramidal Lobe In 50%, the distal end of the thyroglossal duct

persists : a pyramidal lobe projecting up from the isthmus, just to the left or right of the midline.

NL: not palpable

In thyroid hypertrophy : enlarged

and palpable

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Surgery Goals (general) An organ has a malfunction that cannot be

treated madically An organ is getting huge sizes and the

pressure effects cannot be treated medically

An organ harbors a mass/tumor that must be excised

There is a mal-placed or developmental anomaly that needs to be excised

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HyperthyroidismIncreased Hormone Synthesis (Increased RAIU)

Release of Preformed Hormone (Decreased RAIU)

Graves' disease (diffuse toxic goiter) Thyroiditis—acute phase of Hashimoto's thyroiditis, subacute thyroiditisToxic multinodular goiter

Plummer's disease (toxic adenoma)

Drug induced—amiodarone, iodine Factitious (iatrogenic) thyrotoxicosis

"Hamburger thyrotoxicosis"

Thyroid cancer Thyroiditis—acute phase of Hashimoto's thyroiditis, subacute thyroiditisStruma ovarii

Hydatidiform mole

TSH-secreting pituitary adenoma

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Diffuse Toxic Goiter

Graves’ Disease

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Diffuse Toxic Goiter (Graves' Disease)

Etiology of autoimmune process: not known

Thyroid gland diffusely and smoothly enlarged

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Clinical Features of Graves Disease

Divided into › those related to hyperthyroidism › those specific to Graves' disease

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Clinical Features ofhyperthyroidism in Graves Disease

Hyperthyroid symptoms:• heat intolerance• increased sweating• hair loss• weight loss despite

adequate caloric intake• palpitations• nervousness• fatigue• emotional lability

• tremors• diarrhea• women:

amenorrheadecreased fertilitymiscarriages

• children:rapid growthearly bone maturation

• older patients: AFCHF

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Clinical Features of Hyperthyroidism in Graves Disease

On physical examination:

• weight loss• facial flushing • warm and moist skin • african americans:

darkening of skin• tachycardia or atrial

fibrillation • widening of the

pulse pressure

• fine tremor• muscle wasting• proximal muscle group

weakness• hyperactive tendon reflexes

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Clinical Features Specific to Graves Disease

50% : ophthalmopathy spasm of the upper eyelid revealing the sclera above the

corneoscleral limbus (Dalrymple's sign) prominent stare, due to catecholamine excess lid lag (von Graefe's sign) periorbital edema conjunctival swelling and congestion (chemosis) keratitis proptosis limitation of upward and lateral gaze (from involvement of

the inferior and medial rectus muscles, respectively) blindness due to optic nerve involvement

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Clinical Features Specific to Graves Disease

1-2%: dermopathy : deposition of glycosaminoglycans leading to thickened skin in pretibial region and dorsum of the foot

Gynecomastia common in young men Rare subperiosteal bone formation and swelling in

metacarpals (thyroid acropachy) Onycholysis, or separation of fingernails from their

beds

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Clinical Features of Graves Disease

On physical examination:› thyroid usually diffusely

and symmetrically enlarged

›enlarged pyramidal lobe

›may bruit or thrill and loud venous hum in supraclavicular space

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Diagnostic Tests for Graves’ disease Suppressed TSH Elevated /NL f T4 or T3 or f T3 If eye signs present, other tests generally not needed. If no eye findings: RAIU scan necessary Confirms diagnosis: elevated uptake and diffusely

enlarged gland Elevated Anti-Tg and anti-TPO in75%, non-specific Elevated TSH-R or thyroid-stimulating Abs (TSAb):in

90% :diagnostic MRI of orbits: useful in evaluating ophthalmopathy.

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Treatment

May be treated by:›antithyroid drugs› thyroid ablation with radioactive 131I

›surgery

?

??

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Antithyroid Drugs Generally used in preparation for RAI

ablation or surgery Drugs commonly used:

› propylthiouracil (PTU, 100 to 300 mg three times daily)

› methimazole (10 to 30 mg three times daily, then once daily)

Methimazole has a longer half-life and can be dosed once daily

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RAI for Treatment of Graves’ Disease

The mainstay of Graves' disease treatment in North America.

Most often used in:› older patients with small or moderate-sized goiters

› relapse after medical or surgical therapy

› Contraindication of antithyroid drugs or surgery

Absolute contraindications to RAI:› pregnant or breastfeeding women

Relative contraindications :› young patients (i.e., especially children and adolescents)

› thyroid nodules› ophthalmopathy

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RAI for Treatment of Graves’ Disease The major advantages:

› no surgery› reduced overall treatment costs› ease of treatment

Antithyroid drugs given until euthyroid Only 50% euthyroid 6 months after treatment The remaining still hyperthyroid or already hypothyroid After 1 year, 2.5% develop hypothyroidism each year The higher the initial dose of 131I, the earlier the onset and

the higher the incidence of hypothyroidism

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Surgical Treatment of Graves’ Disease

Indications:(a) confirmed cancer or suspicious thyroid nodules

(b) young people

(c) pregnant or desire to conceive soon after treatment

(d) severe reactions to antithyroid medications

(e) large goiters causing compressive symptoms

(f) reluctant to RAI therapy Relative indications:

› Moderate to severe Graves' ophthalmopathy particularly in smokers

› desiring rapid control of hyperthyroidism with a chance of being euthyroid,

› poor compliance to antithyroid medications

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Type of Surgery in Graves’Disease

total or near-total thyroidectomy› cancer› refuse RAI therapy › severe ophthalmopathy › life-threatening reactions to antithyroid

medications (vasculitis, agranulocytosis, or liver failure)

Subtotal thyroidectomy (leaving a 4- to 7-g remnant)› all remaining patients

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Surgical Treatment of Graves’ Disease

Antithyroid drugs given up to the day of surgery to be euthyroid

Generally Lugol's iodide solution beginning 7 to 10 days preoperatively (three drops twice daily) to reduce vascularity and risk of precipitating thyroid storm

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Toxic

Multinodular

Goiter

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Toxic Multinodular Goiter Often a prior history of nontoxic

multinodular goiter Over several years, enough

thyroid nodules become autonomous to cause hyperthyroidism.

Usually in older people

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Presentation in Toxic MNG

Symptoms and signs of hyperthyroidism similar to Graves’, extrathyroidal manifestations absent

Presentation of hyperthyroidism often insidious May hyperthyroidism only apparent when on low

dose thyroid hormone suppression for goiter May hyperthyroidism precipitated by iodide-

containing drugs (jodbasedow hyperthyroidism): contrast media amiodarone

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Diagnostic Studies in Toxic MNG Blood tests are similar

to Graves:› Suppressed TSH

› Elevated free T4 or T3

RAIU increased: multiple nodules with increased uptake and suppression of the remaining gland

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Treatment of Toxic MNG

Preferred treatment: Surgery Standard procedure: Subtotal

thyroidectomy Remnant size not crucial

because these require thyroid suppression to prevent recurrence

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Treatment of Toxic MNG RAI reserved for :

Elderly with very poor operative risks if› no airway compression from the goiter

and› thyroid cancer not a concern.

Uptake is less than in Graves' disease: larger doses of RAI needed

RAI-induced thyroiditis may cause swelling and acute airway compromise, and leaves the goiter intact, with the possibility of recurrent hyperthyroidism

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Toxic Adenoma

(Plummer's Disease)

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Toxic Adenoma

RAIU: "hot" nodule with suppression of rest of thyroid

Recent growth of a long-standing nodule Hyperthyroidism from a single

hyperfunctioning nodule Symptoms of hyperthyroidism, typically in

younger patients Physical examination : solitary thyroid nodule

without palpable thyroid tissue on contralateral side

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Treatment of Toxic Adenoma

Smaller nodules: › antithyroid medications › RAI

Surgery (lobectomy and isthmectomy): preferred for:› young patients› larger nodules

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Thyroiditis

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Thyroiditis

Classification:› acute› subacute› chronic

each associated with a distinct clinical presentation and histology.

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Acute (Suppurative) Thyroiditis

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Acute (Suppurative) Thyroiditis

Thyroid : resistant to infection Often preceded by upper respiratory tract

infection or otitis media More common in children 70%: Streptococcus and anaerobes

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Presentation of Acute (Suppurative) Thyroiditis

Severe neck pain radiating to the jaws or ear

fever and chills

Odynophagia Dysphonia

May Complications :systemic sepsistracheal or esophageal rupture jugular vein thrombosis laryngeal chondritis or perichondritis sympathetic trunk paralysis

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Diagnosis of Acute (Suppurative) Thyroiditis

Leukocytosis on blood tests FNAB for Gram's stain, culture, and cytology CT scans: delineate the extent of infection

A persistent pyriform sinus fistula should always be suspected in children with recurrent acute thyroiditis. A barium swallow demonstrates the anomalous tract with 80% sensitivity.

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Treatment of Acute (Suppurative) Thyroiditis

Parenteral antibiotics Drainage of abscesses If pyriform sinus fistulae

› Complete resection of the sinus tract, including the area of the thyroid where the tract terminates, to prevent recurrence.

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Painful Subacute Thyroiditis

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Painful Subacute Thyroiditis

Exact etiology unknown, may be viral Most commonly in 30- to 40-yr women Sudden or gradual onset of neck pain, may

radiate toward mandible or ear Often history of preceding upper respiratory

tract infection Thyroid enlarged, exquisitely tender, and firm

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Presentation of Painful Subacute Thyroiditis

Classically progresses through 4 stages:1- an initial hyperthyroid phase, due to

release of thyroid hormone

2- followed by a euthyroid phase

3- hypothyroidism which occurs in 20 to 30%

4- resolution and return to euthyroid state in >90%

A few patients develop recurrent disease.

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Treatment of Painful SubacuteThyroiditis Primarily symptomatic.

› Aspirin and other NSAIDs for pain relief› Steroids may indicated in more severe cases› Short-term thyroid replacement may needed

Thyroidectomy reserved for the rare patient who has a prolonged course not responsive to medical measures or for recurrent disease

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Painless Subacute Thyroiditis May be autoimmune may occur:

› sporadically

or› in postpartum period

at about 6 weeks after delivery in women with high TPO antibody titers in early pregnancy

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Presentation of Painless Subacute Thyroiditis

Usually 30- 60 yr woman. Physical examination : normal sized or minimally

enlarged, slightly firm, nontender gland Clinical course parallels painful thyroiditis If symptomatic: may require beta blockers and thyroid

hormone replacement

Thyroidectomy or RAI ablation only indicated for the rare patient with recurrent, disabling episodes of thyroiditis.

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Chronic Thyroiditis

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Chronic Thyroiditis

Lymphocytic (Hashimoto's) Thyroiditis

Riedel's Thyroiditis

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Hashimoto’s Thyroiditis

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Hashimoto‘s Thyroiditis

The leading cause of hypothyroidism

Autoimmune process More common in 30-50 yr

women (male:female ratio 1:10 to 20 )

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Clinical Presentation of Hashimoto

The most common presentation: mildly enlarged firm granular gland

or painless anterior neck mass

20%: hypothyroidism 5% : hyperthyroidism (Hashitoxicosis) physical examination: diffusely enlarged,

firm , lobulated gland enlarged pyramidal lobe often palpable

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Diagnosis of Hashimoto's

Elevated TSH

and Thyroid autoantibodies

usually confirm the diagnosis FNAB if:

› solitary suspicious nodule

or› rapidly enlarging goiter

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!!! of Hashimoto's

A complication of Hashimoto: Thyroid lymphoma

Rare Prevalence 80 times higher than

control population

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Treatment of Hashimoto

In overtly hypothyroid patients:

thyroid hormone replacement, with a goal of maintaining normal TSH levels

Surgery occasionally indicated for:› suspicion of malignancy› goiters causing compressive symptoms› cosmetic deformity

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Riedel's thyroiditis

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Riedel's thyroiditis Rare = Riedel's struma or invasive fibrous thyroiditis Replacement of all or part of the thyroid

parenchyma by fibrous tissue, also invades into adjacent tissues

Etiology controversial, may be autoimmune Associated with other focal sclerosing

syndromes: mediastinal, retroperitoneal, periorbital, retro-orbital fibrosis and sclerosing cholangitis

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Presentation in Riedel's Thyroiditis

In 30-60 yr Painless hard anterior neck mass, which progresses

over weeks to years Symptoms of compression:

› dysphagia› dyspnea› choking› hoarseness

May symptoms of hypothyroidism and hypopara as the gland is replaced by fibrous tissue

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Diagnosis in Riedel's Thyroiditis

Hard, "woody" thyroid gland with fixation to surrounding tissues

Diagnosis needs to be confirmed by open thyroid biopsy, because the firm and fibrous nature of the gland renders FNAB inadequate

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Treatment in Riedel's thyroiditis

Mainstay of treatment: surgery Chief goal of operation: decompression of

trachea by wedge excision of thyroid isthmus and make a tissue diagnosis

More extensive resections not advised due to infiltrative nature of fibrotic process

If hypothyroid: treated with thyroid hormone replacement

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Surgery Goals (general) An organ has a malfunction that cannot be

treated madically An organ is getting huge sizes and the

pressure effects cannot be treated medically

An organ harbors a mass/tumor that must be excised

There is a mal-placed or developmental anomaly that needs to be excised

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GOITER

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Goiter

Any enlargement of thyroid gland is referred to as a goiter

May be › diffuse› uninodular› multinodular

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Goiter - Clinical Features(1)

Mostly asymptomatic But often pressure sensation in neck Having to clear their throats frequently

(catarrh). As the goiters become very large:

compressive symptoms such as dyspnea and dysphagia

Dysphonia from RLN injury rare, except if cancerous

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Goiter - Clinical Features(2)

Obstruction of venous return at the thoracic inlet from a substernal goiter results in a positive Pemberton's sign—facial flushing and dilatation of cervical veins upon raising the arms above the head

Sudden enlargement of nodules or cysts due to hemorrhage may cause acute pain.

Physical examination may reveal a soft, diffusely enlarged gland (simple goiter) or nodules of various size and consistency in case of a multinodular goiter.

Deviation or compression of the trachea may be apparent

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Goiter -Diagnostic Tests Usually euthyroid: normal TSH and low-normal or

normal f T4 If some nodules develop autonomy: suppressed TSH or

hyperthyroid RAI scan: often patchy uptake with areas of hot and

cold nodules FNAB recommended in dominant nodule or one that is

painful or enlarging

!!! Carcinomas reported in 5 to 10% multinodular goiters

CT scans: evaluate extent of retrosternal extension and airway compression

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Treatment of Goiter

Euthyroids with small diffuse goiters:

no treatment Euthyroids with large goiters:

exogenous hormone to reduce TSH Endemic goiters :

iodine administration

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Surgical Treatment of Goiter

Surgical resection for goiters that:› continue to increase despite T4 suppression› cause obstructive symptoms› have substernal extension› have malignancy suspected or proven by FNAB› are cosmetically unacceptable

Subtotal thyroidectomy is the treatment of choice

Patients require lifelong T4 therapy to prevent recurrence.

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Solitary Thyroid Nodule

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Solitary Thyroid Nodule

Present in approximately 4% of people in USA

But thyroid cancer has a much lower incidence (40 new cases per 1 million)

Therefore, it is of utmost importance to determine which patients with solitary thyroid nodule would benefit from surgery.

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Approach to Solitary Thyroid Nodule

Ask about: Time of onset Change in size Pain: unusual, raise

suspicion for Intrathyroidal

hemorrhage in a benign nodule

Thyroiditis Malignancy

History :• Exposure to ionizing

radiation• Family history of

thyroid and other malignancies associated with thyroid cancer.

DysphagiaDyspneaChokingHoarseness:may malignant

involvement of the RLNs

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Physical Examination in STN

Best palpated from behind patient with neck in mild extension

The cricoid cartilage is an important landmark, as the isthmus is situated just below it

Nodules that are hard, or fixed to surrounding structures such as the trachea or strap muscles are more likely to be malignant

The cervical chain of lymph nodes should be assessed as well as the nodes in the posterior triangle

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Diagnostic Approach in STN

FNAB has become the single most important test in the evaluation of thyroid masses

Can be performed with or without ultrasound guidance

Ultrasound guidance recommended for:› nodules difficult to palpate › cystic or solid-cystic nodules that recur after

aspiration

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FNA in STN A 23-gauge needle is inserted into the thyroid

mass, and several passes are made while aspirating the syringe.

After releasing the suction on the syringe, the needle is withdrawn and the cells are immediately placed on prelabeled dry glass slides.

Some are immersed in a 70% alcohol solution and others are air dried.

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FNA of STN

If a bloody aspirate is obtained, the patient should be repositioned in a more upright position and the biopsy repeated with a finer (25- to 30-gauge) needle

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FNA of STN

After FNAB› benign (65%)cysts and colloid nodules, risk of malignancy <3%

› suspicious (20%)Risk of malignancy 20%.

› malignant (5%)› nondiagnostic (10%)

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FNA of STN FNAB less reliable in history of head and

neck RT or FH of thyroid cancer, due to higher likelihood of multifocal lesions and occult cancer

If hyperthyroid, risk of malignancy 1% False-positive: 1% False-negative: 3%

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Solitary thyroid nodule

FNA-B

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Imaging in STN US helpful for

›nonpalpable nodules›differentiating solid from cystic

nodules› identifying adjacent LAP › following the size of benign

nodules diagnosed by US

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Surgery of STN

When not malignant or suspicious, lobectomy if :› cyst persists after three aspirations › cysts >4 cm› complex cysts with solid and cystic

components› nodule enlarges on TSH suppression› compressive symptoms› cosmetic reasons

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Surgery of STN

Exception :total or near-total thyroidectomy if› previous thyroid RT › family history of thyroid cancer

because high incidence of cancer

and decreased reliability of FNAB

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Surgery Goals (general) An organ has a malfunction that cannot be

treated madically An organ is getting huge sizes and the

pressure effects cannot be treated medically

An organ harbors a mass/tumor that must be excised

There is a mal-placed or developmental anomaly that needs to be excised

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THYROID

CANCER

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Malignant Thyroid Disease

<1% of all malignancies

2% of women cancers

0.5% of men cancers

The most rapidly increasing cancer in women.

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Specific Tumor Types

•Papillary Carcinoma •Follicular Carcinoma•Hurthle Cell Carcinoma •Medullary Carcinoma (MTC)•Anaplastic Carcinoma •Thyroid Lymphoma •Metastatic Carcinoma

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Staging -1 Primary tumor (T) TX = Primary tumor cannot be assessed T0 = No evidence of primary tumor T1 = Tumor ≤2 cm in diameter, limited to thyroid T2 = Tumor >2 cm but <4 cm in diameter, limited to thyroid T3 = Tumor >4 cm in diameter, limited to thyroid, or any tumor with

minimal extrathyroidal invasion T4a = Any size tumor extending beyond capsule to invade

subcutaneous soft tissue, larynx, trachea, esophagus, or recurrent laryngeal nerve, or intrathyroidal anaplastic cancer

T4b = Tumor invading prevertebral fascia, or encasing carotid artery or mediastinal vessels; or extrathyroidal anaplastic cancer

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Staging - 2 Regional lymph nodes (N) : NX = cannot be assessed N0 = No LN metastasis N1 = Regional LN metastasis

› N1a = Metastases to level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes)

› N1b = Metastases to unilateral, bilateral, or contralateral cervical or superior mediastinal lymph nodes

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Staging - 3

Distant metastasis (M) MX = Distant metastases

cannot be assessed M1 = No distant metastasis

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Papillary Thyroid Cancer

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Papillary Tyroid Carcinoma 80% of all thyroid cancers The predominant thyroid cancer in

children and individuals exposed to external radiation

2:1 female-to-male ratio Mean age at presentation: 30 to 40

yr

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Presentation of Papi l lary Tyroid Carcinoma

Mostly euthyroid Slow-growing painless mass in neck With locally advanced invasive

disease:› dysphagia› dyspnea› dysphonia

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Spread of Papillary Tyroid Carcinoma

Lymph node metastases common, especially in children and young

Distant metastases uncommon initially, but may ultimately develop in 20%

The most common metastatic sites:› Lungs› Bone› Liver› Brain

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Diagnosis and Prognosis of PTC

Diagnosis by FNAB of thyroid mass or lymph node

Once diagnosed on FNAB, neck US for evaluation of contralateral lobe and lymph node

excellent prognosis >95% 10-year survival rate

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Surgical Treatment of PTC - 1

Total or near-total thyroidectomy When PTC diagnosed by FNAB,definive

surgery without frozen When probable PTC: thyroid lobectomy – if

PTC confirmed in final histology:completion thyroidectomy

If minimal PTCs (<1 cm) confined to thyroid without angioinvasion: no further med surgery needed

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Surgical Treatment of PTC - 2

During thyroidectomy, enlarged central neck nodes should be removed

Biopsy-proven lymph node metastases in lateral neck : modified radical or functional neck

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Follicular Thyroid

Carcinoma

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Follicular Carcinoma - 1

10% of thyroid cancers more commonly in iodine-

deficient areasfemale-to-male ratio of 3:1mean age at presentation:50 yr

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Presentation of Follicular Carcinoma

Usually present as solitary thyroid nodules Occasionally history of rapid size increase History of long-standing goiter Pain uncommon, unless hemorrhage Unlike papillary cancers, cervical LAP

uncommon initially (about 5%), although distant metastases may be present

In <1% hyperfunctioning, leading to thyrotoxicosis

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Diagnosis of Follicular Carcinoma

FNAB unable to distinguish benign from carcinomas

Preoperative diagnosis of cancer difficult unless distant metastases present

Large follicular tumors (>4 cm) in older men: more likely to be malignant

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Surgery of Follicular Carcinoma

When follicular lesion diagnosed by FNAB: lobectomy because at least 80% benign adenomas

Some recommend total thyroidectomy in older patients with follicular lesions >4 cm (50%risk of cancer).

Intraoperative frozen-section not helpful

Total thyroidectomy should be performed when thyroid cancer is diagnosed

No prophylactic nodal dissection because nodal involvement infrequent

If nodal metastases: therapeutic neck dissection

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Prognosis of Follicular Carcinoma

Cumulative mortality :15% at 10 years and 30% at 20 years

Poor long-term prognosis predicted by:› age over 50 years old at presentation› tumor size >4 cm› higher tumor grade› marked vascular invasion› extrathyroidal invasion› distant metastases at time of diagnosis

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Hürthle Cell Carcinoma

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Hürthle Cell Carcinoma 3% of all thyroid malignancies Considered a subtype of follicular thyroid cancer Not diagnosed by FNAB More often multifocal and bilateral (30%) Do not take up RAI More likely to metastasize to local nodes (25%)

and distant sites Higher mortality rate (20% at 10 yr) Surgical rules similar to follicular neoplasms

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Postoperative Management of Differentiated Thyroid Cancer

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Thyroid Hormone T4 is necessary as:

› replacement therapy after total or near-total thyroidectomy

› suppression of TSH and reducing the growth stimulus for any possible residual thyroid cancer cells

TSH maintained at about 0.1 in low-risk and <0.1 in high-risk patients

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Radioiodine Therapy Screening and treatment facilitated by

removal of all normal thyroid tissue, which effectively competes for iodine uptake

Metastatic differentiated thyroid cancer detected and treated by 131I in 75%

Early detection very important to improve prognosis

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Radioiodine Therapy

T4 therapy discontinued weeks before scanning with 131I

T3 during this time period

T3 discontinued 2 weeks to allow TSH to rise

The usual protocol : a screening dose of 1 to 3 mCi of 123I and measuring uptake 24 hours later. After a total thyroidectomy, this value should be <1%

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Follow-Up of Patients with Differentiated Thyroid Cancer

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Thyroglobulin Measurement Tg: <2 ng/mL in total thyroidectomy under

T4therapy , and <5 when hypothyroid

Tg >2: metastatis or persistent normal thyroid tissue

Tg and anti-Tg antibody : measured initially at 6-month intervals and then annually

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Medullary Thyroid

Carcinoma

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MTC - 1 5% of thyroid malignancies Arises from the parafollicular or C cells C cells secrete calcitonin Concentrated superolaterally in thyroid lobes Most sporadical 25% with inherited syndromes ( familial MTC,

MEN2A, and MEN2B) All the inheriteds secondary to mutations in the

RET proto-oncogene

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Syndrome Manifestations

MEN2A MTC, pheochromocytoma, primary hyperparathyroidism, lichen planus amyloidosis

MEN2B MTC, pheochromocytoma, Marfanoid habitus, mucocutaneous ganglioneuromatosis

Familial MTC MTC

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MTC -2

Neck mass May palpable cervical LAP (15 to 20%) Pain or aching more common Local invasion may produce:

› dysphagia

› dyspnea

› dysphonia

Distant blood-borne metastases to the liver, bone (frequently osteoblastic), and lung occur later

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MTC - 3 Female-to-male ratio is 1.5:1 50-60 yr Familial cases : younger age In extensive metastatic disease: diarrhea frequent 2 to 4% develop Cushing's syndrome as a result of

ectopic ACTH production Unilateral (80%) in sporadic disease Multicentric in familial cases Bilateral tumors in up to 90% of familial patients

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Diagnosis of MTC

Established by :› History

› Physical examination

› Raised serum calcitonin

› Raised CEA levels

› FNAB cytology

Attention to FH because 25% have familial disease

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Diagnosis of MTC

Because not possible to distinguish sporadic from familial disease at initial presentation, all new patients with MTC should be screened for:

› RET point mutations

›Pheochromocytoma

›HPT Calcitonin and CEA: identify patients with

persistent or recurrent MTC

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Surgery in MTC

If harboring pheochromocytoma: operated on first

Total thyroidectomy: treatment of choice because of

high incidence of multicentricitymore aggressive coursethe fact that 131I therapy usually is not effective

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Surgery in MTC

In locally recurrent or metastatic disease, tumor debulking to:

› ameliorate symptoms of flushing and diarrhea

›decrease risk of death from recurrent central neck or mediastinal disease

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MTC Treatment

In carriers: Total thyroidectomy after confirmation of RET mutation› before age 6 in MEN2A

›before age 1 in MEN2B

to improves survival rates

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Postop Follow-Up and Prognosis of MTC

Follow up: Annual measurements of calcitonin and CEA levels

10-year survival rate 80% but decreases to 45%

with lymph node involvement

Prognosis best in non-MEN familial MTC and worst in MEN2B.

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Anaplastic Carcinoma

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Anaplastic Carcinoma

1% of all thyroid malignancies

Women more commonly affected

The majority in 7th and 8th decades

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Symptoms in Anaplastic Carcinoma

long-standing neck mass rapid enlargement may painful dysphonia dysphagia dyspnea

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Signs in Anaplastic Carcinoma

Large tumor May be fixed to surrounding

structures May be ulcerated with areas of

necrosis Lymph nodes usually palpable May evidence of metastasis

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Diagnosis of Anaplastic Carcinoma

Confirmed by FNAB Incisional biopsy occasionally

needed Isthmusectomy with or without

tracheostomy may be needed to alleviate tracheal obstruction

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Treatment and Prognosis of Anaplastic Carcinoma

One of the most aggressive thyroid malignancies Few patients surviving 6 months beyond diagnosis All forms of treatment :disappointing If presentation as resectable mass: may small

improvement in survival with thyroidectomy, especially in younger individuals

Combined adjuvant RT and ChT in resectable disease: prolonged survival

Tracheostomy may needed for airway obstruction

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Thyroid Lymphoma

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Thyroid Lymphoma

<1% of thyroid malignancies Most: non-Hodgkin's B-cell type May part of a generalized lymphomatous

condition, but most develop in chronic lymphocytic thyroiditis

Usually symptoms similar to anaplastic carcinoma, although often painless

May presentation with acute respiratory distress

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Diagnosis of Thyroid Lymphoma

Usually suggested by FNAB

Core needle or open biopsy may necessary for definitive diagnosis

Staging studies should be obtained to assess extent of extrathyroidal spread

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Treatment of Thyroid Lymphoma

Rapid response to chemotherapy (CHOP—cyclophosphamide, doxorubicin, vincristine, and

prednisone), with improved survival Combined treatment with RT and ChT often

recommended Thyroidectomy and nodal resection for

alleviation of airway obstruction if:› no quick response to above regimens

› those who have completed the regimen before diagnosis

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Prognosis of Thyroid Lymphoma

Overall 5-year survival rate: 50%

Much lower survival if extrathyroidal disease

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Metastatic Carcinoma

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Metastatic Carcinoma

Thyroid : rare site of metastases Most metastases from:

›Kidney

›Breast

›Lung

›Melanoma

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Metastatic Carcinoma Often suggest the source of the metastatic

disease:› clinical examination

› review of the patient's history

Definitive diagnosis: usually by FNAB

Resection of the thyroid, usually lobectomy, may be helpful in many patients, depending on the status of their primary tumor.

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Papillary Follicular Hurthle Medullary Anaplastic Lymphoma

Percent 80% 10% 3% 5% 1% 1%

Age 30-40 50 // 50-60, <Fa 60-80

Sex F/M=2/1 F/M=3/1 // F/M=1.5/1 F > M

Pain No No // Yes Yes No

LN Yes No Yes Yes Yes Yes

Metastasis No Yes Yes Yes Yes Yes...

Diagnosis FNA Fna-Sx // FNA,Calcit FNA FNA/Bx

Treatment Total Thy Lob-To Thy Lob-To Thy Total Thy Isth,Trach ChT

Prognosis Very good good Fair Fair-good Very poor Poor-good

multifocal No No Yes Yes,Fam ? ?

Points Child,RT Subtype Fol 25%fam,Yo B Non Ho

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References:

Lal G, Clark OH.Thyroid, parathyroid, and adrenal. In: Brunicardi FC AD, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE, editor. Schwartz’s Principles of Surgery. 9th ed. USA: McGraw-Hill; 2010. p. 1343-1408

Search results in www.google.com on the image sections :

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References: www................................aafp.orgabigstory.blogspot.comaboutcancer.comacclaimimages.comafaq.wordpress.comannals.orgbest-of-web.combjo.bmj.combritannica.combrooksidepress.orgcancerinthecity.comcvphysiology.com

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References: www................................fn.bmj.comfreepik.comGhorayeb.comgravesdisease.comhbreviews.comhealthhype.comhealthypalm.comhealthywaymagazine.comhowtoloseitfast.comjpkc.fimmu.commeded.ucsd.edu

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Thank

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