1. ד"ר חגי מזא"ה כירורגיה אנדוקרינית מבואות כירורגיה שנה ד'
גידולי בלוטת התריס
ד"ר חגי מזא"ה
כירורגיה אנדוקרינית
מבואות כירורגיה
שנה ד'

2. Indications for Surgery Benign
Compression symptoms:
Dyspnea
Dysphagia
Hoarseness
Hyperthyroidism:
Toxic nodule
Toxic MNG
Graves’ disease
Aesthetic concerns

3. Indications for Surgery Malignant
Papillary thyroid cancer (PTC)
Follicular thyroid cancer (FTC)
Medullary thyroid cancer (MTC)
Anaplastic thyroid cancer (ATC)
Lymphoma
Mets

4. Thyroid Cancer Most common malignancy of the endocrine system
Increasing incidence
2% of all new cancer diagnoses
Over 44,000/y expected to be diagnosed in the US

5. Thyroid nodules Very common Only 5% malignant
5% have palpable thyroid nodules
~50% have thyroid nodules on US
Only 5% malignant

6. Case 1
24 YOF
Upon shaving identified a 3 cm mass in her front neck

7. Case 1 Physician – History Physical examination Labs
Thyroid function (hyper/hypo)
Risk factors – family history, radiation history
Physical examination
Nodule
Other thyroid nodules
Cervical lymph nodes
Labs
Thyroid function tests

8. Case 1 Radiology – Ultrasound:
Most accurate imaging for thyroid nodules
Nodule location
Nodule size (3 dimensions)
Nodule growth
Nodule features:
Microcalcifications
Solid
Lack of Halo / hypoechoic rim
Taller more than wide
Irregular margins
Hypervascular
Hypoechoic
Local invasion

9. Case 1
US guided FNAB
Limited to cells (no vascular or capsular invasion)
Equivocal diagnosis

10. Case 1 FNAB result – Benign Management: Observation Repeat US
Repeat FNAB (?)

11. Case 2 FNAB result – Malignant Well-differentiated thyroid cancer:
Papillary (PTC) or Follicular (FTC)
Most common (>90% of thyroid cancers)
Very good prognosis (>95% 10YS)

12. Well-differentiated thyroid cancer Staging
Stage 1 – T< 2cm
Stage 2 – T 2-4cm
Stage 3 – T>4cm, N1a
Stage 4 – M1, N1b
< 45 y:
Stage 1 – any T, any N
Stage 2 – M1

13. Case 2 Well-differentiated thyroid cancer
Management:
Depends on size and LN status
≤ 1 cm – Lobectomy
> 1 cm – total thyroidectomy
Consider prophylactic CLND

14. Case 2 Well-differentiated thyroid cancer
Lateral LND –
FNAB proven involved LN

15. Case 2 Well-differentiated thyroid cancer
Adjuvant therapy:
Selective RAI
TSH suppression
Follow up:
P/E, Tg, Neck US
Up to 30% will require redo surgery (cervical lymph nodes)

16. Case 3 Medullary thyroid cancer
3-5% of all thyroid cancers
Parafollicular C cells
75% sporadic
25% hereditary
MEN IIA (MTC, pheochromococytoma, primary hyperparathyroidism)
MEN IIB (MTC, pheochromocytoma, neurogangliomas)
Familial MTC (non-MEN II)

17. Case 3 Medullary thyroid cancer
Physician –
History
Thyroid function (hyper/hypo)
Risk factors – family history, radiation history
Other endocrinopathies
Physical examination
Nodule
Other thyroid nodules
Cervical lymph nodes
Labs
Thyroid function tests
Calcitonin / CEA
Genetic counseling

18. Case 3 Medullary thyroid cancer
Radiology
Ultrasound – neck
CT – chest abdomen for mets
Management – aggressive!!!
Total thyroidectomy
Central lymph node dissection
Selective lateral lymph node dissection
Tumor size, preoperative US, calcitonin level

19. Case 3 Medullary thyroid cancer
Adjuvant therapy –
No RAI, No TSH suppression
Clinical trials drugs
Follow up –
CEA, calcitonin
Neck US
Prognosis
75-85% overall 10YS

20. Case 3 Medullary thyroid cancer
Prophylactic surgery
Mutation based:
Level 3 (Highest risk, 883, 918, 922) –
Within age 6-12 months
Level 2 (Higher risk, 611, 618, 620, 634) –
By the age of 5y
Level 3 (High risk, 609, 630, 768, 790, 791, 804, 891) –
By the age of 10y

21. Case 4 Other thyroid cancers
Anaplastic thyroid cancer:
1% of thyroid cancers
Undifferentiated thyroid cancer
Usually not resectable
Very poor prognosis (5% 5YS)
Thyroid Lymphoma
1-2% of thyroid cancers
No surgical treatment
CHOP / radiation

22. Thyroidectomy / lobectomy
Recommendation
Risk of Malignancy
Incidence
Result
Repeat FNA
1-4%
15%
Non diagnostic
Clinical follow up
0-3%
60-70%
Benign
Repeat FNA / lobectomy
5-15%
10%
FLUS
Lobectomy /
thyroidectomy
15-30%
20%
FL / FN
Thyroidectomy / lobectomy
60-75%
<10%
Suspicious for malignancy
Thyroidectomy
97-99% 5%
Malignant

23. Case 5 Follicular lesion
Follicular lesion / neoplasm
15-30% malignancy
Surgeon
Actually has to talk to the patient!!
Options – Lobectomy / total thyroidectomy
Lobectomy –
decreased complications
may not require thyroid replacement
may need ANOTHER surgery if malignant on pathology

24. Thyroidectomy Complications
Immediate / early
Bleeding
1-2%, mostly no intervention required
Hematoma requiring urgent drainage – rare
Transient hypocalcemia
Only following total thyroidectomy
10-20%
Transient hoarseness

25. Thyroidectomy Complications
Long term
Permanent hypocalcemia
2-4%
Permanent hoarseness
1-2%
Permanent hormone replacement therapy
(following thyroidectomy)