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'

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

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

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

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

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

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

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

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

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

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)

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

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

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

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)

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)

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

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

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

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

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

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

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

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

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