1. Thyroid nodule History History Physical examination Physical examination –Euthyroid –Hypothyroid –Hyperthyroid Labs Labs –TSH –(antibodies)

2. Thyroid nodule Imaging Imaging –US –Scan if TSH is low

3. Toxic adenoma

4. Thyroid nodule Imaging Imaging –US –Scan if TSH is low –CT usually precedes referral FNA FNA –US-guided

5. Thyroid nodule There are 3 ways to diagnose a thyroid nodule: There are 3 ways to diagnose a thyroid nodule: ultrasound guided FNA ultrasound guided FNA

6. Thyroid nodule FNA result FNA result –Papillary carcinoma –Follicular LESION Carcinoma Carcinoma Adenoma Adenoma Adenomatous colloid nodule Adenomatous colloid nodule –Insufficient for diagnosis

7. Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer (Cooper, THYROID 2006;16:109-141(

8. Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer (Cooper, THYROID 2006;16:109-141) FNA Results

9. Thyroid nodule FNA result FNA result –Papillary carcinoma –Follicular LESION Carcinoma Carcinoma Adenoma Adenoma Adenomatous colloid nodule Adenomatous colloid nodule –Insufficient for diagnosis

10. Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer (Cooper, THYROID 2006;16:109-141) FNA Results

11. Thyroid nodule conservative approach for most patients with thyroid nodules that are cytologically indeterminate on fine-needle aspiration and benign according to gene- expression classifier results. conservative approach for most patients with thyroid nodules that are cytologically indeterminate on fine-needle aspiration and benign according to gene- expression classifier results. (Alexander, N Engl J Med. 2012;367:705-15)

12. Non-mailgnant indications for thyroidectomy Goiter Goiter

13. Non-mailgnant indications for thyroidectomy Goiter Goiter –Symptomatic

14. Non-mailgnant indications for thyroidectomy Goiter Goiter –Symptomatic –Esthetic

15. Non-mailgnant indications for thyroidectomy Goiter Goiter –Symptomatic –Esthetic Hyperthyroidism Hyperthyroidism

16. Before and after total thyroidectomy

17. THYROID CANCERS CALSSIFICATION: CALSSIFICATION:

18. THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS

19. THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS OTHER THYROID CANCERS

20. THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS Papillary Papillary

21. THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS Papillary Papillary Follicular Follicular

22. THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS Papillary Papillary Follicular Follicular OTHER THYROID CANCERS

23. THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS Papillary Papillary Follicular Follicular OTHER THYROID CANCERS Medullary Medullary

24. THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS Papillary Papillary Follicular Follicular OTHER THYROID CANCERS Medullary Medullary Anaplastic (?poorly differentiated papillary carcinoma) Anaplastic (?poorly differentiated papillary carcinoma)

25. Differentiated thyroid cancer FollicularPapillary Age Gender (Sex) Mode of Spread Multifocality Prognosis after surgery (20-y survival)

26. Differentiated thyroid cancer FollicularPapillary 35-5525-45Age Gender (Sex) Mode of Spread Multifocality Prognosis after surgery (20-y survival)

27. Differentiated thyroid cancer FollicularPapillary 35-5525-45Age FF Gender (Sex) Mode of Spread Multifocality Prognosis after surgery (20-y survival)

28. Differentiated thyroid cancer FollicularPapillary 35-5525-45Age FF Gender (Sex) Blood borne Lymphatic Mode of Spread Multifocality Prognosis after surgery (20-y survival)

29. Differentiated thyroid cancer FollicularPapillary 35-5525-45Age FF Gender (Sex) Blood borne Lymphatic Mode of Spread NoYesMultifocality Prognosis after surgery (20-y survival)

30. Differentiated thyroid cancer FollicularPapillary 35-5525-45Age FF Gender (Sex) Blood borne Lymphatic Mode of Spread NoYesMultifocality ExcellentExcellenter Prognosis after surgery (20-y survival)

31. Differentiated thyroid cancer Staging Staging –T1 - Tumor 2 cm or less in greatest dimension limited to the thyroid. –T2 - Tumor more than 2 cm, but not more than 4 cm, in greatest dimension limited to the thyroid. –T3 - Tumor more than 4 cm in greatest dimension limited to the thyroid. –T4a - Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve. –T4b - Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.

32. Differentiated thyroid cancer Staging Staging –N1a - Metastasis to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes). –N1b - Metastasis to unilateral, bilateral, or contralateral cervical or superior mediastinal lymph nodes.

33. Prognostic factors A G E S Age Age Sex (Gender) Sex (Gender) Extension Extension Size Size

34. Prognosis (Lahey Clinic) Age Age Metastasis Metastasis Extension Extension Size Size

35. Prognosis (Lahey Clinic) Age Age Metastasis (NOT lymph node) Metastasis (NOT lymph node) Extension Extension Size Size

36. Prognosis (Lahey Clinic) Age Age Metastasis (NOT lymph node) Metastasis (NOT lymph node) Extension (to neighboring structures) Extension (to neighboring structures) Size Size

37. Prognosis (Mayo Clinic) MACIS Prognostic score MACIS Prognostic score Metastasis, Age, Completeness of resection, vascular Invasion, Size. Metastasis, Age, Completeness of resection, vascular Invasion, Size. M + 3 if Metastasis is found M + 3 if Metastasis is found A = Age (y) x 0.08 A = Age (y) x 0.08 C + 1 if resection is inComplete C + 1 if resection is inComplete I + 1 if vascular invasion (pathologists report) I + 1 if vascular invasion (pathologists report) S0.3 x largest diameter in centimeters (Size) S0.3 x largest diameter in centimeters (Size)

38. Prognosis (MSKCC) Even more complicated scoring Even more complicated scoring Includes Includes –Tumor grade –Lymph node involvement –multifocality

39. Complications of thyroid surgery

40. Thyroid operations Lobectomy ± isthmus Lobectomy ± isthmus Near total thyroidectomy Near total thyroidectomy Total thyroidectomy Total thyroidectomy –± modified neck dissection for known involved lymph nodes

41. Operations for papillary carcinoma Lobectomy (low risk) Lobectomy (low risk) –Difficult to justify radical surgery for such a good prognosis cancer Total/near total thyroidectomy (high risk) Total/near total thyroidectomy (high risk) –Treatment with radioactive iodine-131 –Detection of distant metastases Total thyroidectomy + modified neck dissection (known lymph node metastasis) Total thyroidectomy + modified neck dissection (known lymph node metastasis)

42. Extensive spread of papillary carcinoma

43. Operations for follicular carcinoma Total thyroidectomy Total thyroidectomy Near total thyroidectomy Near total thyroidectomy –Treatment with radioactive iodine-131 –Detection of distant metastases

44. Adjuvant treatment Scan for residual glandular tissue Scan for residual glandular tissue –I 131 full body scan –Maximal TSH stimulation Destruction of thyroid remnant Destruction of thyroid remnant –High dose I 131 (Maximal TSH stimulation) Treatment Treatment –High dose I 131 (Maximal TSH stimulation) Suppressive T4 for life Suppressive T4 for life Follow up Follow up –Thyroglobulin (Tg) with maximal TSH stimulation –I 131 full body scan as indicated by Tg