Download MBBS (Bachelor of Medicine and Bachelor of Surgery) Thyroid malignancies PowerPoint PPT presentation
MALIGNANCIES
S3 UNIT
INTRODUCTION
? Commonest endocrine malignancy
? 1% of all malignancies
? Annual incidence - 3.7 per 1,00, 000 population
? Sex ratio 3:1 (Female : Male)
TOPICS
? Anatomy -Alphy Theres Teji
? Physiology and clinical -Ameena Muhammed
evaluation
? Aetiopathogenesis & -Amruthavarshini B.V
classification
? Investigation - Anagha K Karun
? Differentiated thyroid -Anakha M
Carcinoma
? Anaplastic carcinoma, -Anamika S
Medullary carcinoma,
Thyroid lymphoma
? Surgery & complications -Anandhu J B
? Prognosis & postop follow - Andrews Paul
up
THYROID
ANATOMY
ALPHY THERES
EMBRYOLOGY OF THYROID
? Thyroid gland- endodermal cells of floor
of pharynx
? Parafollicular cel s- neural crest
ANOMALIES OF POSITION
LINGUAL
THYROID
WEIGHT & DIMENSIONS
? Normal gland weighs : 20-25gm
? Each lobe : 5cm in length
3cm in breadth
2cm in thickness
? Isthmus : 1 . 2 c m in length & 1 . 2 c m in breadth
SITUATION AND EXTENT
CAPSULES OF THYROID
? True capsule: Peripheral
condensation of the
connective tissue of gland
? False capsule: Pretracheal
layer of deep cervical fascia
RELATIONS OF THE LOBES
Lobes are conical in shape
having:
? An apex
? A base
? Three surfaces:
lateral, medial and posterolateral
? Two borders: anterior
and posterior
? Apex
Superior thyroid artery
External laryngeal nerve
? Base
Inferior thyroid artery
Recurrent laryngeal nerve
Lateral surface:
? Sternohyoid
? Superior belly of omohyoid
? Sternothyroid
? Anterior border of
leidomastoid
sternocleidomastoid
Medial
surface
2 tubes- trachea
oesophagus
2 muscles
inferior
constrictor
cricothyroid
2 nerves
ext.laryngeal
recurrent
laryngeal
Posterolateral
surface: carotid sheath,
ansa cervicalis & cervical
sympathetic chain
Anterior border:
anterior branch of superior
thyroid artery
Posterior border:
? Inferior thyroid artery
? Anastomosis between superior
and inferior thyroid arteries
? Parathyroid gland
? Thoracic duct on left side
RELATIONS OF ISTHUMUS
? Two surfaces:
Anterior and posterior
o
r
? Two borders:
superior and inferior
BLOOD SUPPLY OF THYROID
ARTERIAL SUPPLY
? Superior thyroid artery
? Inferior thyroid artery
? Thyroidea ima
arteries
VENOUS DRAINAGE
? Superior thyroid vein
? Middle thyroid vein
? Inferior thyroid vein
? Kochers vein
LYMPHATIC DRAINAGE
JUGULAR LYMPH NODES
? periglandular ? prelaryngeal (Delphian) ? pretracheal
? paratracheal (along RLN) ? sup mediastinum ? deep cervical ? thoracic
duct
? Upper part via prelaryngeal LN to upper deep CLN
? Lower part via pretracheal and paratracheal LN to lower deep CLN
NERVE SUPPLY
? Mainly from middle cervical
ganglion
? Partly from superior and
inferior cervical ganglion
HISTOLOGY
? Follicles- structural
unit
? Secretory cells-
follicular and
parafollicular
PARATHYROID GLANDS
? Two pairs-superior and
inferior
? Lie on the posterior border
of thyroid
? Secrete parathormone
? blood supply from inferior
thyroid arteries
PHYSIOLOGY AND CLINICAL
EVALUATION
Ameena
Muhammed
PHYSIOLOGY
OF THYROID
GLAND
THYROID HORMONES
Follicular cells- Thyroxine[T4] 93%,
Triiodothyronine[T3] 7%
Parafollicular cells- Calcitonin
IODINE HEMOSTASIS
? Iodine- essential for hormone synthesis
? Daily requirement - 150 mcg
? Absorbed by intestine
Excretory routes
Urine - 80%
Stool- 15%
Rest through bile
THYROID HORMONE SYNTHESIS
1. Iodide trapping
Transport of iodide ions into colloid
Na+- I- symporter
2. OXIDATION
Iodide ion is oxidised to iodine by
peroxidase
3. BINDING
Iodine+ tyrosine residues of thyroglobulin =
MIT & DIT
4. COUPLING REACTION
MIT+DIT = T3
DIT+DIT= T4
5. HORMONE RELEASE
? When hormones are needed, Endocytosis and
Proteolysis of iodinated thyroglobulin
? Release of T3 ,T4 into circulation
? In blood, bound to albumin, thyroxine binding
globulin (TBG), thyroxine binding pre
albumin(TBPA)
? Unbound T3 & T4 is functional
6. PERIPHERAL CONVERSION
? Major product secreted is T4
? About 35% secreted T4 is converted into
T3 by 5'-deiodinase
? T3 is four times potent than T4 & causes
the peripheral actions.
TSH enhances the hormone production by
increasing:
?Iodination of tyrosine
?Proteolysis of thyroglobulin
?Number, size & secretory activity of cells
REGULATION OF SYNTHESIS
ACTIONS OF THYROID HORMONES
1. EFFECT ON BASAL METABOLISM
Increases the basal rate of metabolism
Increases heat production (Calorigenic action)
BMR increased to about 80% in
hyperthyroidism
2. CARDIOVASCULAR SYSTEM
Increase heart rate
Increases myocardial contraction
Increases systolic blood pressure
Decreases diastolic blood pressure
Enhances erythropoesis.
3. EFFECT ON GROWTH & DEVELOPMENT
Facilitate the effect of GH on tissues
Promote linear growth of bones
Enhance the activity of chondrocyte in Cartilage
Increases the osteoid activity and Bone remodelling
Eruption and development of Teeth
4. EFFECT ON NERVOUS TISSUE
Differentiation and maturation of brain cells
Growth of cerebral and cerebellar cortices and
basal ganglia
Development of synaptic connection
5. GI TRACT
Enhance motility
Increases production of digestive juices.
Increases appetite and food intake
6. EFFECTS ON REPRODUCTIVE SYSTEM
Follicular maturation and ovulation
Promote spermatogenesis
7. EFFECT ON KIDNEY
Increases renal outflow and GFR
CLINICAL EVALUATION
HISTORY TAKING
EXAMINATION
HISTORY TAKING
AGE
Papillary ca: young
Follicular ca: middle aged
Anaplastic ca, Lymphoma : old age
SEX
Females: male= 3:1
SWELLING
Papillary & follicular - slow growth
Anaplastic - fast growth
PAIN
Painless to start
PRESSURE EFFECT
Hoarseness, dysphagia, dyspnoea
PAST HISTORY
Radiation exposure
FAMILY HISTORY
MEN 2A, 2B
Cowden syndrome
Gardner syndrome
EXAMINATION
SIGNS OF MALIGNANCY
Stony hard swelling
Restriction of lateral mobility
infiltration of surrounding tissues.
Lymphadenopathy in neck
Berry's Sign
Horner Syndrome
Features of infiltration
Laryngotracheal complex- stridor & hemoptysis
Recurrent laryngeal nerve - hoarseness
Esophagus - dysphagia/ odynophagia
Carotid sheath - Berry's sign
Cervical sympathetic chain - Horner's syndrome
Evidence of Metastasis -
Pulsatile bony swelling in scalp or any pathological
fracture.
Abdominal distension & jaundice
Hemoptysis, dyspnoea & chest pain
ETIOPATHOGENESIS
AND
CLASSIFICATION
AMRUTHAVARSHINI B V
AETIOLOGICAL FACTORS
1. IONIZING RADIATION
? Most imp risk factor
radiation - external/radioiodine - under 5 yrs
? Commonest papilary carcinoma thyroid
? To treat benign condition in the first two decade of life
( tonsilitis, adenoiditis...etc)
? Adolescent - radiotherapy for Hodgkins lymphoma
**Chernobyl nuclear disaster in Ukraine,1986
2.GENETIC MUTATION
3.FAMILIAL
MEN 2A
MEN 2B
FAMILIAL MTC
COWDEN SYNDROME
GARDNER SYNDROME
MEN 2A
?Autosomal dominant inheritance
?Mutation of RET protooncogenes
?Characterized by :
Pheochromocytoma
Hyperparathyroidism
Medul ary carcinoma of thyroid
MEN 2B
?RET mutation
?Characterized by:
Medullary carcinoma thyroid
Pheochromocytoma
Mucosal neuromas of
lip,tongue,inner eyelid
Marfanoid habitus
Familial Medulary Thyroid Carcinoma
?RET proto-oncogene mutation
?only Medullary thyroid cancer
?20% of total cases of MCT
COWDEN SYNDROME
?AD inheritence - Mutation of PTEN gene on
chr 10
?Characterized by;
Differentiated thyroidcarcinoma
Carcinoma breast
Multiple hamartomas of skin
Neuroendocrine tumor
Endometrial cancer
GARDNER SYNDROME
Autosomal dominant inheritance
Mutation of APC gene in chromosome 5
Familial adenomatous polyposis
Multiple polyp in colon which predisposes to colon
cancer
?Characterized by:
Papillary carcinoma of thyroid
Colorectal cancer
Cancer of ampulla of vater
Hepatoblastoma
Osteomas of the jaw
CHRPE
Primary brain tumors
4. PRE EXISTING MNG
Follicular thyroid carcinoma
Dominant or rapidly growing
nodules in long standing
goiters
5. ENDEMIC AREAS
?Low iodine areas
? Follicular carcinoma - Increased TSH
secretion
6. HASHIMOTO'S THYROIDITIS
?Also caled diffuse non goitrous thyroiditis
? Hyperplasia - fibrosis - infiltration with plasma cels and
lymphocytes
?Non Hodgkins Lymphoma
?Half of the primary thyroid LYMPHOMA
CLASSIFICATION OF
THYROID NEOPLASMS
BENIGN follicular
adenoma
MALIGNANT primary follicular cells Follicular
differentiated (10%)
Papillary
(80%)
follicular cells Anaplastic
undifferentiated (5%)
parafollicular Medullary
cells (2.5%)
lymphoid cells Lymphoma
(2.5%)
MALIGNANT secondary metastatic colon,breast
melanoma,
local kidney
infiltration
INVESTIGATIONS OF
THYROID MALIGNACIES
ANAGHA K KARUN
INVESTIGATIONS
THYROID FUNCTION TEST [TFT]
THYROID IMAGING {USG,CT,MRI,PET scan,
X-RAY}
FINE NEEDLE ASPIRATION CYTOLOGY
[FNAC]
RADIOISOTOPE SCANNING{Tc 99m,I 123}
THYROID FUNCTION TESTS
? Immunochemiluminometric assay.
? Measures TSH, free T3 and free T4.
? Total T3 and T4 depend on TBG.
? Free T3 and T4 are important.
ULTRASONOGRAPHY
? Gold standard investigation
? Use high frequency probe in the
range 7.5-16 MHz
? Number, size, shape, margin, vascularity,
microcalcification
USES
?To differentiate cystic & solid swellings
?Non palpable , deep nodules
?Features of malignancy
?Lymph node assessment for metastasis
?USG guided FNAC
FEATURES OF MALIGNANCY
Hypo echoic
Increased vascularity
Micro calcifications
No peripheral halo
Poorly defined borders
Taler than wide
LN involvement
FNAC
? To conclude pathological diagonosis
? 95% accuracy,
83% sensitivity, 92% specificity
? USG guided aspiration
? Advantages :
- patient compliant
- simple & quick to perform
- repeated readily
?C/I : Toxic nodule
PROCEDURE
1.
10cc syringe & 23G needle inserted
2. Multiple passes are made( Minimum 6 aspirations )
3. capillary & suction technique
4. Papanicolaou stain
? Adequate smear: 6 aspiration with 6 cluster of cells
each containing 20 cells
Disadvantages
? Not possible to dif erentiate folicular adenoma and carcinoma.
? Sampling error (False neg. rate: 1-6% ) in non guided
FNAC.
RADIO ISOTOPE SCANNING
? I 123 or Tc 99m
? INDICATION
? Solitary thyroid nodule - toxic
? HOT : 5% malignant
? COLD : 20% malignant
X RAY
? Preoperatively, tracheal deviation or compression
? Retrosternal extension
COMPUTED
TOMOGRAPHY
INDICATIONS
? Retrosternal goitre
? Malignancy ( T&N Staging)
? Giant goitre with tracheal compression and
displacement
? Berry sign +ve
Iodine used with iv contrast , so not used in
malignancies.
MRI
? MR Angiography : vessel wall
involvement
? Advantage over CT:
-no iodine contrast
-no radiation exposure
POSITRON EMISSION
TOMOGRAPHY[PET]
?Recurrence and metastasis
LARYNGOSCOPY
?Preoperatively
?Mobility of VC
?Flexible Laryngoscopy
USES
Medico legal use
S.THYROGLOBULIN:
v No significance in initial evaluation
v in follow-up
v pre operative evaluation
Normal value 3?40ng/mL
INTRAOPERATIVE FROZEN SECTION
? Confirm nodal
involvement in PTC.
? Can avoid 2nd
procedure
DIFFERENTIATED THYROID
CARCINOMAS
ANAKHA M
? Differntiated thyroid carcinomas are;
Papillary thyroid carcinoma
Follicular thyroid carcinoma
Hurthle cell carcinoma
PAPILLARY THYROID CARCINOMA
? Most common malignancy -80%
? Excellent prognosis
? Important risk factor- radiation exposure in
childhood
? More common in females 2.5:1 ratio
? Peak incidence less than 40 years of age
? Micropapillary carcinoma
? Diffuse sclerosing variant
? Encapsulated variant
? Tall cell variant
? Columnar cell variant
CLINICAL FEATURES
? Palpable nodule ;incidental imaging finding;
painless lateral mass
? Lymphadenopathy is usually present
? Compression features less common
? Slowly progressive and less aggressive
tumour
? Spread via lymphatics
? Multicentricity can be anticipated in 70% of
patients
? GROSS FEATURES
-It can be hard or of varying consistency
-It can be solitary or multinodular
? MICROSCOPY
- orphan annie eye nucleus
- papillary projections with psammomma
bodies ,cystic spaces
PSAMMOM
PAPILLAR
MA
BODIES
Y
PATTERN
ORPHAN ANNIE NUCLEI
FOLLICULAR THYROID CARCINOMA
? 10% of all thyroid malignancies
? More commonly seen in female 3:1
? 40 to 60 yrs of age
? Either de novo or pre existing MNG
? Capsular invasion and angio invasion
? More aggressive,mortality twice than
papillary carcinoma
? Lymph node involement is less common
? Less favourable prognosis
? Blood born metastases common
CLINICAL FEATURES
? Presents as painless thyroid mass
? May coexist with MNG 5-10% CASES
? In advanced disease
-hoarseness of voice
-stridor
-berry's sign
-pathologic fractures
-pulsatile bony swelling in the scalp
HURTHLE CELL CARCINOMA
? Subtype of follicular thyroid carcinoma
? Consists of oxyphilic cells
? Increased no of mitochondria ,enlarged
granular eosinophilic cytoplasm
? 60-70 years of age
? More aggressive behaviour
? Secrete thyroglobulin
? 30% multicentric
? More chances of lymphatic spread
? Cells with abundant granular eosinophilic
cytoplasm
INVESTIGATIONS
? TSH levels
? FNAC of thyroid nodule and lymph node
? Ultrasound scan neck, CT scan neck
TNM STAGING
TUMOUR
? Tx ?Primary cannot be assessed
? T0-No evidence of primary
? T1-Tumour - 2cm
T1a ? 1 cm
T1b-> 1 2cm
? T2-limited to thyroid >2cm but 4cm
? T3 ?Limited to thyroid >4 cm or any tumour with minimal
extrathyroid extension
? T4 ? Any size with extensive extra thyroid extension
T4a :moderately advanced
T4b :very advanced
NODES
? Nx- Cannot be assessed
? N0- No regional node metastases
? N1-Regional node metastases
N1a-level 6
N1b-any/all other levels
METASTASES
? Mx-Cannot be assessed
? M0-No metastases
? M1-Metastases present
AJCC STAGING OF DTC
? STAGE <45 yrs
Stage 1- any T any N M0
Stage 2 ? any T any N M1
? STAGE >45 yrs
Stage 1 ?T1a,T1b,T2N0M0
Stage 2 ?T3N0M0
- T1,T2,T3N1M0
Stage 3-T4a any N M0
Stage 4A- T4bAny N M0
Stage 4b-Any T any N M1
TREATMENT
? Papillary thyroid carcinoma
? Total thyroidectomy + CCND
? Follicular thyroid carcinoma
- Total thyroidectomy +CCND
If lymph node seen in USG and proven in
FNAC? lateral lymph node dissection
MEDULLARY
CARCINOMA
THYROID
ANAMIKA S
INTRODUCTION
? 2 .5% of thyroid carcinoma
? Tumours of parafolicular C cells
FORMS
1. Sporadic form (80%)
2.Familial form(10 to 20%)
Medullary Thyroid carcinoma
(MTC)
INHERITED
SPORADIC
10-20%
80%
FAMILIAL Non
MEN 2A
MEN MTC
MEN 2B
FAMILIAL
SPORADIC
BILATERAL AND
ORIGINATE IN ONE LOBE
MULTICENTRICITY
YOUNGER AGE GROUP
ANY AGE
ASSOCIATED WITH C CELL
HYPERPLASIA
1.More aggressive
2.RET gene point mutation.
3.High levels of CEA and serum CALCITONIN.
4.Not TSH dependent
5.Do not take up radioactive IODINE.
6.Diarrhoea is a feature of 30% of cases.
MEDULLARY CARCINOMA
Cell balls and Amyloid
stroma
METASTASES
Liver ,Mediastinal
nodes,
bone(osteoblastic)lung,
trachea,
Blood borne metastases common
MOSTLY TO
LIVER
Cervical Lymph
nodes 50-60%
CLINICAL FEATURES
1.Thyroid swelling-neck lymph nodes
2.HTN , Pheochromocytoma ,mucosal neuroma-MEN 2
3.Paraneoplastic symptoms like cushings and carcinoids
INVESTIGATIONS
1.FNAC
2.SE.RUM CALCITONIN AND CEA
3.GENETIC TESTING FOR GERMLINE RET
MUTATION
4.THYROID AND NECK USG
? All patients should be screened for RET gene
point mutation ,pheochromocytoma and
hyperparathyroidism.
? Pheochromocytoma-to prevent hypertensive
crisis
1. Serum Ca-to rule out hyperparathyroidism.
2. 24 hr urine VMA and serum metanephrin,USG
abdomen- to rule out pheochromocytoma
3. If it is + ve ? CECT of abdomen
4. CECT or MRI chest and mediastinum ? if N1disease or
calcitonin greater than 400pg/ml
4. PET scan ? recurrence, Metastasis as they do not take
up radioiodine
TREATMENT
1.Surgery is the treatment of choice.
2.Tumour size more than 1cm,chance of
spread to regional nodes is 75%
3.Total thyroidectomy with elective central
neck dissection.
4.When central node (level 6) involved ?
Ipsilateral modified radical neck dissection.
? Hypercalcemia and PTH at time of
surgery-Only obviously enlarged
parathyroid removed
? If vascular pedicle of parathyroid is unable to
maintain ?auto transplantation of ? the gland
in sternocleidomastoid or brachioradialis of
non-dominant forearm.
? Somatostatin analogue (octreotide ,
lanreotide)for cushings syndrome , flushing
EXTERNAL BEAM RADIOTHERAPY
1.Resected T4 disease.
2.Unresected residual or recurrent tumour
3.Symptomatic bony metastasis.
POST OPERATIVELY
? Stimulated calcitonin assay to assess the
adequacy of resection
? L evothyroxine is indicated in all
patients .
? TSH-normal range
GENETIC SCREENING
MEN 2A
MEN 2 B
FAMILIAL MCT
TOTAL
TOTAL
THYROIDECTOMY
THYROIDECTOMY
-5YEARS
1 YEAR
? Prognosis is variable and depends on the stage at
diagnosis
? FMTC (best) > MEN-2A > Sporadic > MEN-2B
(worst)
? Chance of recurrence 50% & also high mortality
FOLLOW-UP
? Basal calcitonin-Fall after resection
Rise in recurrence, residual tumour and
metastasis.
? PET scan
? CEA
? USG (central and lateral neck compartments)
ANAPLASTIC
THYROID CARCINOMA
INTRODUCTION
? Undifferentiated carcinoma
? 5% of al thyroid malignancy
? Most aggressive
? Disease specific mortality 100%
? Occurs mainly in elderly women
TYPICAL MANIFESTATION
Older patient with
1. Dysphagia
2. Cervical tenderness
3. Painful, rapidly enlarging neck mass
4. Frequently have history of DTC and upto 50%
goitre
? May also Include superior venacava syndrome
? Deteroirates into tracheal obstruction
? Rapid local invasion of surrounding structures
SPREAD
? Rapid local invasion
? Blood as well as lymph spread present.
? Sites of Mets : lung , brain, bone, liver, kidney, skin, pancreas,
adrenal.
STAGING
MANAGEMENT
? Treatment of ATC is usually palliative
? Treatment of choice -RADIOTHERAPY
? Tracheal obstruction - ISTHMUSECTOMY
THYROID
LYMPHOMA
INTRODUCTION
Uncommon lymphoma
2 .5 %of al thyroid malignancies
Involve thyroid as a part of systemic
lymphoma or may arise primarily in thyroid.
PREDISPOSING FACTORS
Autoimmune diseases (Lymphocytic
thyroiditis)
Advanced age(>70 yr)
More frequent in women (four times)
SIGNS AND SYMPTOMS
? Rapid enlarging neck mass
? Hoarseness
? Dysphagia
? Fever
? Diffuse pain
PHYSICAL EXAMINATION
? Firm , slightly tender , fixed mass
INVESTIGATIONS
? Ultrasound
? MRI
? Trucut biopsy
? PET imaging
TREATMENT OF LYMPHOMA
RADI ?ATION+CHEMO= treatment of choice
Tracheal obstruction : urgent chemotherapy
CHOP/CVDP regimen:
Cyclophosphamide
Doxorubicin Vincristine
Role of surgery only in:
Biopsy
Pressure symptoms
No response to chemo .
sURGical manaGEmEnt
and
complications
Anandhu JB
Rol No : 16
q For a preoperatively proven case of
? Dif erentiated carcinoma
? Medullary Carcinoma
TOTAL THYROIDECTOMY
Central neck dissection
Modified Radical Neck Dissection
RATIONALE FOR
TOTAL THYROIDECTOMY
? Facilitates radioiodine ablation later.
? As there is chance for multifocal d/s.
? Facilitates use of thyroglobulin as tumor
marker in fol owup.
STEPS OF SURGERY
General anaesthesia with
endotracheal intubation.
Supine position - sand bag placed transversely under the
shoulders
A head ring ? to stabilize head
Table tilted up - 15 at the head end.
ROSE'S POSITION
? Horizontal curved - Midway between the notch of
the thyroid cartilage and suprasternal notch.
? One sternocleidomastoid to other.
? Skin, superficial fascia cut upto investing layer of
deep fascia
? Flaps are raised
o Upper upto laryngeal prominence
o Lower upto suprasternal notch
? Investing layer of deep fascia is incised vertically.
? Retract strap muscles laterally
? Identify the pedicles
1. Superior pedicle
? (sup. thyroid A & V)
2. Middle pedicle
? (middle thyroid V only)
3. Inferior pedicle
? (inferior thyroid A only)
? Ligate middle thyroid vein first.
? Ligate superior thyroid A & V separately &
close to capsule (CAPSULAR LIGATION)
? Ligate inferior thyroid A close to the gland
after safe guarding recurrent laryngeal nerve.
? ? Identification of parathyroid
? :Yellowish pink
? :Position ? in relation to ITA-RLN junction
? Sup. parathyroid ? above & behind
? Inf. Parathyroid ? below & anterior
? Identification of RLN
? 1.RIDDLE'S TRIANGLE
o Inferior thyroid artery- above
o Common Carotid artery- laterally (base)
o Trachea - medialy
? 2.Nerve traced upwards to point of its entry into the
larynx at the cricothyroid junction.
? 3.Tubercle of Zuckerkandl
RLN damage points.
1.At crossing with inferior
thyroid artery.
2. In the vicinity of ligament of
Berry
3.In Riddle's Triangle
4.Tubercle Of Zuckerkandl
? Ligament of Berry is divided.
? The thyroid gland is separated from the
underlying trachea.
? Complete hemostasis maintained
? Draining and Wound closure:
--Reapproximate strap muscles and
platysma
--Skin closure
Central compartment dissection
Thyroid and thymus
removed en bloc with
level VI nodes-
paratracheal,
pretracheal and
prelaryngeal.
? Based on lateral node status lateral neck
dissection is done.
COMPLICATIONS
OF
THYROIDECTOMY
? Intraoperative
? Early post operative
? Late post operative
INTRAOPERATIVE
COMPLICATIONS
? Haemorrhage
? Nerve injury
EARLY POSTOPERATIVE
? Haematoma
? Laryngeal edema
? Respiratory obstruction
? Hypoparathyroidism
? RLN injury & problems
? Thyrotoxic crisis
LATE POSTOPERATIVE
? Hypothyroidism
? Recurrent nodule
? Recurrent toxicity
? Wound infection
? Granuloma / keloid
HEMORRHAGE
Primary
Reactionary
Secondary
Treatment
?
Release of sutures
?
Evacuation of hematoma
?
Re exploration & control
bleeding
RESPIRATORY OBSTRUCTION
? Haematoma Laryngeal edema
?
Bilateral recurrent laryngeal nerve
? paralysis
Hypocalcemic tetany Tracheomalacia
?
?
MANAGEMENT
Release the tension haematoma If
not relieved - - - intubate
RECURRENT LARYNGEAL NERVE INJURY
? Hoarseness
? Dysphonia
? Paralytic aphonia
? Periodic aspiration
? Inef ective cough
RLN injury may be unilateral or bilateral.
UNILATERAL RLN PALSY
? Ipsilateral paralysis of all intrinsic muscles
except cricothyroid
In Indirect laryngoscopy,
? Vocal cord - median or paramedian
position
MANAGEMENT
? STEROIDS ? within 7 days of injury
(Prednisolone 15mg tid for 10 days)
? SPEECH THERAPY
? MEDIALIZATION OF THE CORD -
by Teflon injection
? LARYNGOPLASTY - if compensation does
not take place
Bilateral RLN palsy
Inspiratory stridor
Dyspnea or
Minimal dysphonia.
Management
? Emergency endotracheal
intubation
? Tracheostomy
? Cordectomy or endoscopic
laser treatment
? Thyroplasty
INJURY TO THE EXTERNAL
BRANCH OF SUPERIOR
LARYNGEAL NERVE
? Approximately in 20%
? Proximity to the superior thyroid artery.
? Loss of tension in the vocal cord
? VOICE FATIGUE - Diminished power and
range in the voice.
COMBINED PARALYSIS
UNILATERAL
? Paralysis of al muscles of larynx on one side except
interarytenoid.
? Cadaveric position ( 3.5mm from midline)
Treatment
? Speech therapy
? Injection of teflon paste
? Muscle or cartilage implanted to paralysed cord
BILATERAL
? Both cords in cadaveric position
? Total anesthesia of larynx
Aphonia
Aspiration
Features Inability to cough
Bronchopneumonia
Retention of secretion in the chest
Respiratory arrest
Treatment
1. Tracheostomy
2. Epiglottopexy ( epiglottis is folded
backwards and fixed to the arytenoid)
3. Plication of vocal cord to prevent aspiration
HYPOPARATHYROIDISM
? Transient in 50%
? Permanent in < 2%.
? Usually manifests within 72 hrs after surgery
? The first symptom is circumoral paresthesia.
SIGNS
CHVOSTEK SIGN TROUSSEAU'S SIGN
Management
? Emergency : 10 ml of 10% calcium
gluconate I .V over 10-15 mnts
Chronic patients :
? Calcium carbonate or Calcium
citrate
? Vitamin D3
THYROTOXIC CRISIS
(THYROID STORM)
1-2 % patients
Causes
? Inadequately prepared thyrotoxic patient
? Infection, trauma, diabetic ketoacidosis,
emergency surgery, stress
Treatment
Supportive measures
Anti adrenergic drugs ? D O C : Propranolol i.v
Thionamides ? Propyl thiouracil 200 mg 4th hrly
Iodide compounds ? 10-15 drops Lugol's iodide 8th
hrly
Glucocorticoids ? hydrocortisone 5 mg/kg 6th hrly
Bile acid suppressants ? cholestyramine 4 g 6th hrly
HYPOTHYROIDISM
? For papil ary and follicular carcinoma -
suppressive dose of thyroxine (200 ? 300
mcg per day)
? For medullary carcinoma -
supplementary dose of thyroxine (25 ?
100 mcg per day)
KELOID
STITCH GRANULOMA
PROGNOSIS
POSTOPERATIVE CARE
FOLLOW UP
Andrews Paul
PROGNOSIS
Many scoring systems are available
? AMES
? AGES
? MACIS
? TNM
AGES AND AMES
PARAMETER
LOW RISK
HIGH RISK
AGE (YRS)
<40
>40
GENDER
FEMALE
MALE
EXTEND
NO LOCAL EXTENTION LOCAL AND EXTRA
THYROID EXTENSION
METASTASIS
NONE
REGIONAL OR DISTANT
SIZE
<4 CM
>4 CM
GRADE
WELL DIFFERENTIATED POORLY
DIFFERENTIATED
MACIS
FACTORS
SCORE
DISTANT METASTASIS YES
3
NO
0
AGE
<39 years
3.1
>40 years
0.08 * age
INVASION INTO
YES
1
SURROUNDING AREAS NO
0
COMPLETENESS OF
Incomplete
1
SURGICAL RESECTION Complete
0
SIZE OF TUMOUR
0.3 * size(cm)
Sum Of MACIS Score
20 year survival
<
6.0
99%
6.0 ? 6.99
89%
7.0 ? 7.99
56%
> 8.0
24%
Postoperative Measures
Differentiated thyroid cancers
-Radioactive iodine scanning and
ablation
-TSH suppression
-Follow up testing
RADIOIODINE
SCAN
Goals
To identify
- any remaining normal thyroid tissue
- residual thyroid cancer cells
- metastatic disease
Pre requisites
TSH level > 30 mU/L
-stop thyroxine for 4-6 weeks
-Patient advised to be on low iodine diet
Low doses of radioactive I??? or I??? is used.
Given orally in liquid or capsule form.
? I??? : half life of 13 hrs, emits rays, better for
diagnostic scanning.
? I??? : half life of 8 days, emits and rays.
? If positive, Radio Remnant Ablation is done
? If negative, follow up with thyroglobulin level.
? If raised Tg level ? WBS + US neck
THYROGLOBULIN ESTIMATION
Serum tumor marker for DTC
Circulating anti thyroglobulin antibodies
interferes
Undetectable levels ? after thyroidectomy
with TSH suppression
Raised levels ? recurrence/metastasis.
Level above 2ng/l ? abnormal
RADIO REMNANT ABLATION
(RRA)
Radioactive iodine therapy (RAIT)
Purposes
? Remnant thyroid tissue ablation
? Adjuvant therapy with the intention of targeting
occult metastatic disease
? Primary treatment of known persistent disease
Indications
? Tumor size > 4 cm
? Gross extra thyroidal extension
? Distant metastases
? Tumor size < 4 cm with lymph node metastases
? Rising serum thyroglobulin level
? Radioactive I??? is used.
? Dose : 100-200 mCi
? Post ablation WBS done after 5-8 days
? In low risk patients ? with negative Tg and negative
cervical US no need for WBS
? In intermediate and high risk patients ? WBS after 6-
12 months of ablation + Cervical US at 6,12 months
and then annually for 3-5 years
? Concerns with RAIT
-isolation of patients
-C/I in pregnant, nursing women and
children
-Avoid pregnancy for 6 months.
? Complications : nausea and vomiting,
sialadenitis, vocal cord paralysis, bone marrow
suppression
TSH Suppression
- To prevent hypothyroidism
- To prevent recurrence of thyroid
cancer
? T4 or levothyroxine is given orally
? Suppressive dose of thyroxine ? 200-300 ?g/
day
? For patients with high risk DTC, TSH < 0.1 mU/L
? For intermediate risk DTC, TSH b/w 0.1 ? 0.5
mU/L
? For low risk DTC, TSH within 0.5 ? 2 mU/L
? Risks associated ? subclinical thyrotoxicosis,
cardiac irregularities, osteoporosis
Follow up
Physical examination
Lifelong TSH suppression
Thyroglobulin estimation
Anti thyroglobulin antibodies
Periodic neck ultrasound
Radioiodine imaging
Medullary Carcinoma
? Annual measurements of calcitonin and CEA
levels
? Ultrasound, CT, MRI, PET scans - localize
recurrent diseases
? 10 year survival rate is 80%
? Prognosis also depends on disease type - worst
in patients with MEN2B
Anaplastic Carcinoma
? Most aggressive form with disease specific
mortality approaching 100%
? External beam irradiation
? Palliative support and end of life planning
SUMMARY
? Commonest malignant endocrine tumor
? Risk factors : Radiation exposure , Genetic alterations
? Divided into differentiated , undif erentiated and medullary thyroid carcinomas
? Investigations:
Clinical examination ? history , physical examination Thyroid function tests
Imaging ? USG , X ray ,MRI , PET Pathological ? FNAC
? Treatment:
Papillary carcinoma ? total thyroidectomy + CCND Follicular
carcinoma ? total thyroidectomy+CCND
Medulary carcinoma ? total thyroidectomy + CC ND
Anaplastic carcinoma ? palliative treatment
THANK YOU
This post was last modified on 12 August 2021