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In the Name of God.

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Presentation on theme: "In the Name of God."— Presentation transcript:

1 In the Name of God

2 SURGICALTHYROID DISEASES
Sadaf Alipour Surgical Oncologist Assistant Professor Arash Women’s Hospital Tehran University of Medical Sciences

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6 Our Subject: What to operate? When to operate? How to operate?

7 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

8 Developmental Abnormalities

9 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

10 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

11 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.

12 Surgery of Thyroglossal Duct Cyst and sinus
"Sistrunk operation“ en bloc cystectomy and excision of the central hyoid bone to minimize recurrence.

13 !!! 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.

14 Lingual Thyroid Failure of median thyroid anlage to descend normally
May the only thyroid tissue present

15 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

16 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

17 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

18 !!! 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.

19 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

20 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

21 Hyperthyroidism Increased Hormone Synthesis (Increased RAIU)
Release of Preformed Hormone (Decreased RAIU) Graves' disease (diffuse toxic goiter) Thyroiditis—acute phase of Hashimoto's thyroiditis, subacute thyroiditis Toxic multinodular goiter Plummer's disease (toxic adenoma) Drug induced—amiodarone, iodine Factitious (iatrogenic) thyrotoxicosis "Hamburger thyrotoxicosis" Thyroid cancer Struma ovarii Hydatidiform mole TSH-secreting pituitary adenoma

22 Diffuse Toxic Goiter Graves’ Disease

23 Diffuse Toxic Goiter (Graves' Disease)
Etiology of autoimmune process: not known Thyroid gland diffusely and smoothly enlarged

24 Clinical Features of Graves Disease
Divided into those related to hyperthyroidism those specific to Graves' disease

25 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: amenorrhea decreased fertility miscarriages children: rapid growth early bone maturation older patients: AF CHF

26 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

27 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

28 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

29 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

30 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.

31 ? ? ? May be treated by: antithyroid drugs
Treatment May be treated by: antithyroid drugs thyroid ablation with radioactive 131I surgery ? ?

32 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

33 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

34 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

35 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

36 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

37 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

38 Toxic Multinodular Goiter

39 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

40 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

41 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

42 Preferred treatment: Surgery
Treatment of Toxic MNG Preferred treatment: Surgery Standard procedure: Subtotal thyroidectomy Remnant size not crucial because these require thyroid suppression to prevent recurrence

43 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

44 Toxic Adenoma (Plummer's Disease)

45 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

46 Treatment of Toxic Adenoma
Smaller nodules: antithyroid medications RAI Surgery (lobectomy and isthmectomy): preferred for: young patients larger nodules

47 Thyroiditis

48 Thyroiditis Classification:
acute subacute chronic each associated with a distinct clinical presentation and histology.

49 Acute (Suppurative) Thyroiditis

50 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

51 Presentation of Acute (Suppurative) Thyroiditis
Severe neck pain radiating to the jaws or ear fever and chills Odynophagia Dysphonia May Complications : systemic sepsis tracheal or esophageal rupture jugular vein thrombosis laryngeal chondritis or perichondritis sympathetic trunk paralysis

52 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.

53 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.

54 Painful Subacute Thyroiditis

55 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

56 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.

57 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

58 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

59 Presentation of Painless Subacute Thyroiditis
Usually 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.

60 Chronic Thyroiditis

61 Chronic Thyroiditis Lymphocytic (Hashimoto's) Thyroiditis Riedel's Thyroiditis

62 Hashimoto’s Thyroiditis

63 Hashimoto‘s Thyroiditis
The leading cause of hypothyroidism Autoimmune process More common in yr women (male:female ratio 1:10 to 20 )

64 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

65 Diagnosis of Hashimoto's
Elevated TSH and Thyroid autoantibodies usually confirm the diagnosis FNAB if: solitary suspicious nodule or rapidly enlarging goiter

66 A complication of Hashimoto: Thyroid lymphoma Rare
!!! of Hashimoto's A complication of Hashimoto: Thyroid lymphoma Rare Prevalence 80 times higher than control population

67 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

68 Riedel's thyroiditis

69 Riedel's thyroiditis = Riedel's struma or invasive fibrous 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

70 Presentation in Riedel's Thyroiditis
In 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

71 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

72 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

73 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

74 GOITER

75 Any enlargement of thyroid gland is referred to as a goiter
May be diffuse uninodular multinodular

76 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

77 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

78 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

79 Treatment of Goiter Euthyroids with small diffuse goiters:
no treatment Euthyroids with large goiters: exogenous hormone to reduce TSH Endemic goiters : iodine administration

80 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.

81 Solitary Thyroid Nodule

82 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.

83 Approach to Solitary Thyroid Nodule
History : Exposure to ionizing radiation Family history of thyroid and other malignancies associated with thyroid cancer. Dysphagia Dyspnea Choking Hoarseness:may malignant involvement of the RLNs Ask about: Time of onset Change in size Pain: unusual, raise suspicion for Intrathyroidal hemorrhage in a benign nodule Thyroiditis Malignancy

84 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

85 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

86 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.

87 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

88 After FNAB FNA of STN benign (65%) suspicious (20%) malignant (5%)
cysts and colloid nodules, risk of malignancy <3% suspicious (20%) Risk of malignancy 20%. malignant (5%) nondiagnostic (10%)

89 False-positive: 1% False-negative: 3% 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%

90 Solitary thyroid nodule
FNA-B

91 differentiating solid from cystic nodules identifying adjacent LAP
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

92 When not malignant or suspicious, lobectomy if :
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

93 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

94 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

95 THYROID CANCER

96 Malignant Thyroid Disease
<1% of all malignancies 2% of women cancers 0.5% of men cancers The most rapidly increasing cancer in women.

97 Hurthle Cell Carcinoma Medullary Carcinoma (MTC) Anaplastic Carcinoma
Specific Tumor Types Papillary Carcinoma Follicular Carcinoma Hurthle Cell Carcinoma Medullary Carcinoma (MTC) Anaplastic Carcinoma Thyroid Lymphoma Metastatic Carcinoma

98 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

99 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

100 Distant metastasis (M) MX = Distant metastases cannot be assessed
Staging - 3 Distant metastasis (M) MX = Distant metastases cannot be assessed M1 = No distant metastasis

101 Papillary Thyroid Cancer

102 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

103 Presentation of Papillary Tyroid Carcinoma
Mostly euthyroid Slow-growing painless mass in neck With locally advanced invasive disease: dysphagia dyspnea dysphonia

104 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

105 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

106 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

107 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

108 Follicular Thyroid Carcinoma

109 Follicular Carcinoma - 1
10% of thyroid cancers more commonly in iodine-deficient areas female-to-male ratio of 3:1 mean age at presentation:50 yr

110 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

111 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

112 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

113 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

114 Hürthle Cell Carcinoma

115 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

116 Postoperative Management of Differentiated Thyroid Cancer

117 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

118 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

119 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%

120 Follow-Up of Patients with Differentiated Thyroid Cancer

121 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

122 Medullary Thyroid Carcinoma

123 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

124 Syndrome Manifestations MEN2A MTC, pheochromocytoma, primary hyperparathyroidism, lichen planus amyloidosis MEN2B MTC, pheochromocytoma, Marfanoid habitus, mucocutaneous ganglioneuromatosis Familial MTC MTC

125 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

126 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

127 Diagnosis of MTC Established by :
History Physical examination Raised serum calcitonin Raised CEA levels FNAB cytology Attention to FH because 25% have familial disease

128 Pheochromocytoma HPT 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

129 Surgery in MTC If harboring pheochromocytoma: operated on first
Total thyroidectomy: treatment of choice because of high incidence of multicentricity more aggressive course the fact that 131I therapy usually is not effective

130 In locally recurrent or metastatic disease, tumor debulking to:
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

131 In carriers: Total thyroidectomy after confirmation of RET mutation
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

132 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.

133 Anaplastic Carcinoma

134 Anaplastic Carcinoma 1% of all thyroid malignancies
Women more commonly affected The majority in 7th and 8th decades

135 Symptoms in Anaplastic Carcinoma
long-standing neck mass rapid enlargement may painful dysphonia dysphagia dyspnea

136 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

137 Diagnosis of Anaplastic Carcinoma
Confirmed by FNAB Incisional biopsy occasionally needed Isthmusectomy with or without tracheostomy may be needed to alleviate tracheal obstruction

138 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

139 Thyroid Lymphoma

140 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

141 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

142 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

143 Prognosis of Thyroid Lymphoma
Overall 5-year survival rate: 50% Much lower survival if extrathyroidal disease

144 Metastatic Carcinoma

145 Thyroid : rare site of metastases Most metastases from:
Metastatic Carcinoma Thyroid : rare site of metastases Most metastases from: Kidney Breast Lung Melanoma

146 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.

147 Papillary Follicular Hurthle Medullary Anaplastic Lymphoma Percent 80% 10% 3% 5% 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 Yes LN Metastasis Yes... Diagnosis FNA Fna-Sx FNA,Calcit FNA/Bx Treatment Total Thy Lob-To Thy Isth,Trach ChT Prognosis Very good good Fair Fair-good Very poor Poor-good multifocal Yes,Fam ? Points Child,RT Subtype Fol 25%fam,Yo B Non Ho

148 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; p Search results in on the image sections :

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150 References: fn.bmj.com freepik.com Ghorayeb.com gravesdisease.com hbreviews.com healthhype.com healthypalm.com healthywaymagazine.com howtoloseitfast.com jpkc.fimmu.com meded.ucsd.edu medical-marijuana-dispensaries.findthebest.com medipptx.blogspot.com mifrah.com misyork.com natural-holistic-health.com natural-healthwellness.blogspot.com nejm.orgnejm.org netterimages.com nhs.uk nlm.nih.gov

151 References: nolovesincerer.blogspot.com obesityin.com offthemark.com panji1102.blogspot.com pediatrics.med.ubc.ca pedsradiology.com pnotebook.com prlog.org profilekiss.com pregnancy-risk.com radiologyassistant.nl radiopaedia.org rasinet.com selfishyayun.com skinsight.com sleeptips.sleepsonic.com stoptremors.com tabeebac.com tokyotrouble.wordpress.com women.webmd.com yoursurgery.com

152 Thank You


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