Académique Documents
Professionnel Documents
Culture Documents
Surgery
LT4
(Lobectomy + Malignant
isthmusectomy)
Completion
Thyroidectomy
Palpable Thyroid Nodule
Thyroglossal Duct Cyst & Sinus
Ectopic Thyroid
Goiter
Thyroid cancer
DEVELOPMENTAL
ABNORMALITIES
Thyroglossal Duct Cyst and
Sinus
• During the 5th wk of gestation
thyroglossal duct lumen should
start to obliterate and disappear
by 8th wk of gestation.
• They may occur anywhere along
the migratory path of thyroid,
80% are found in
juxtaposition of hyoid bone
and heterotropic tissue at
20%.
• Asymptomatic but occasionally
become infected by oral bacteria
DEVELOPMENTAL
ABNORMALITIES
Thyroglossal Duct Cyst &
Sinus
• Thyroglossal duct Sinus result from
infection of the cyst secondary to
spontaneous or surgical drainage of
sinus
• Mass is well defined, 1-2 cm,smooth
moves upward with protrusion of
tongue
• Treatment: SISTRUNK OPERATION
consist of en bloc cystectomy and
excision of central hyoid bone.
• 1% are found to be cancer usually
papillary (85%)
DEVELOPMENTAL
ABNORMALITIES
Ectopic Thyroid
• Locations:
anywhere in the central neck, trachea,
esophagus, anterior mediastinum.
adjacent to the aortic arch
in the aortopulmonary window
within the upper pericardium
in the interventricular septum
extend off the inferior poles of the thyroid
gland
lateral to carotid sheath and jugular vein
previously (“lateral aberrant thyroid”)
• almost always represents metastatic thyroid cancer in lymph
nodes
Palpable Thyroid Nodule
Evaluate for
Hyperthyroidism Benign Malignant Follicular Non PET
Neoplasm/ Diagnostics scan
Suspicious
Non
FS
Solitary MNG Surgery Diagnostics
(TT/NTT +/- CCND)
* MRND Surgery
(Lobectomy + isthmusectomy;
< 3cm Surgery TT/NTT)
young (TT/NTT)
Surgery
LT4
(Lobectomy + Malignant
isthmusectomy)
Completion
Thyroidectomy
Test for thyroid function
Thyroid Function Tests
• Serum TSH
Thyrotropin (TSH, reference range 0.5–5 mU/mL)
- only test necessary in most patient with thyroid
nodules
- most sensitive and specific test for diagnosis of
hyper and hypothyroidism
• Total T4 (55-150 nmol/L) and Total T3 (1.5-
3.5 nmol/L)
- reflects the fraction of T4 bound to TBG and
other carrier proteins in the serum and also
the amount of free T4 in circulation
Test for thyroid function
Thyroid Function Tests
• Free T4 (12-28 pmol/L) and Free T3 (3-9 pmol/L)
-In patients with end-organ resistance to T4 (Refetoff
syndrome) T4 levels are increased, but TSH levels
usually are normal.
-In cases of early hyperthyroidism (normal total T4 but
inc. free T4)
• Thyrotropin Releasing Hormone
-evaluate pituitary TSH secretory function
• Thyroid Antibodies (antithyroglobulin/anti Tg,
antimicrosomal/antithyroid peroxidase/anti TPO, thyroid
stimulating immunoglobulin/TSI)
• Serum Thyroglobulin
-for monitoring patient with differentiated thyroid CA
recurrence.
Thyroid Imaging
Ultrasound
• excellent, noninvasive, less expensive,
readily available, no radiation exposure
• distinguishing solid from cystic one
Thyroid Imaging
Ultrasound
• provide info
size and multicentricity
assess cervical lymphadenopathy
guide fine needle aspiration biopsy
• cannot assess extent of thyroid outside
the neck (e.g substernal goiter)
Palpable Thyroid Nodule
Evaluate for
Hyperthyroidism Benign Malignant Follicular Non PET
Neoplasm/ Diagnostics scan
Suspicious
Non
FS
Solitary MNG Surgery Diagnostics
(TT/NTT +/- CCND)
* MRND Surgery
(Lobectomy + isthmusectomy;
< 3cm Surgery TT/NTT)
young (TT/NTT)
Surgery
LT4
(Lobectomy + Malignant
isthmusectomy)
Completion
Thyroidectomy
Thyroid Imaging
Radionuclide Imaging:
• Use to screen, treat, provide information
not only about size and shape but also
the distribution of functional activity of
the gland
“COLD“ refers to the area that trap less
radioactivity than the surrounding gland
risk of malignancy 15-20%
“HOT“ refers to the increased activity.
risk of malignancy < 5%
Thyroid Imaging
Radionuclide Imaging:
• iodine 123 (emits low dose radiation
with a HL 12-14 hrs) diagnostic
• iodine 131 (emits higher dose radiation
with HL 8-10 days) diagnostic &
therapeutic
• FDG PET or the flourodeoxyglucose
positron emission tomography (shorter
HL less radiation and use to screen
metastasis but expensive)
Thyroid Imaging
CT/MRI Scan
• excellent imaging of thyroid gland and
adjacent nodes and useful in evaluating
extent of thyroid and their relationship
to airway and vascular structures.
Hyperthyroidism
• Graves’ Disease
- it is an autoimmune disease of unknown cause
(post partum state, iodine excess, lithium
treatment, bacterial and viral infection)
- genetic factors
• HLA (Human Leukocyte Antigen) B8
• HLA DR3
• HLA DQAI * 0501
• All of which will stimulate T- Helper lymphocytes
–- stim. B lymphocytes–- produce antibodies
directed against thyroid hormone receptors.
- autoimmune disease
GRAVE’S DISEASE
• Clinical features
- heat intolerance, inc. sweating/thirst, wt loss
(despite adequate calories requirement)
- increased adrenergic stimulation (palpitation,
nervousness, fatigue, tremors)
- GI symptoms (diarrhea)
- female (ammenorrhea, dec. fertility, inc.
miscarriage)
- children (rapid growth with early bone
maturation)
- CVS atrial fibrillation/CHF
- ophthalmopathy (Von Graefe’s sign- lidlag,
Dalrymple’s sign- spasm upper eyelid,
prominent stare- inc. cathecholamine )
- pretibial myxedema
- dermopathy (1-2%)
- gynecomastia
GRAVE’S DISEASE
• Diagnosis
- TSH, free T3,T4
- I uptake and scan
- antibodies (TSH-R, TSab)
• Treatment
- antithyroid drugs (PTU 100-300mg
TID, methimazole 10-30mg TID,
betablockers Propanolol 20-40mg
QID)
- thyroid ablation with radioactive I
GRAVE’S DISEASE
Ipodate
Beta blockers
dexamethasone
GRAVE’S DISEASE
Controversy: Total VS Subtotal
thyroidectomy
Surgery
LT4
(Lobectomy + Malignant
isthmusectomy)
Completion
Thyroidectomy
FNAB/FNAC
• easily performed with inexpensive equipment in
the out patient department, it is essentially free
of complications, and above all it provides a
reliable and accurate tissue diagnosis in a high
proportion of patients
• Incidence of false positive results is 1% and false
negative of 3%.
• Less reliable in patient who have history of
head/neck irradiation because of higher likelihood
of multifocal lesions.
EMBRYOLOGY
THYROID gland Anatomy
Epithelial cells are of 2 types:
• principal cells (ie, follicular)
responsible for formation of the colloid
(iodothyroglobulin)
• parafollicular cells (ie, C, clear, light
cells)
produce the hormone calcitonin, a protein
central to calcium homeostasis
Palpable Thyroid Nodule
Evaluate for
Hyperthyroidism Benign Malignant Follicular Non PET
Neoplasm/ Diagnostics scan
Suspicious
Non
FS
Solitary MNG Surgery Diagnostics
(TT/NTT +/- CCND)
* MRND Surgery
(Lobectomy + isthmusectomy;
< 3cm Surgery TT/NTT)
young (TT/NTT)
Surgery
LT4
(Lobectomy + Malignant
isthmusectomy)
Completion
Thyroidectomy
Benign Thyroid Disorders
• THYROIDITIS (inflammatory Disorder of
thyroid gland)
Acute (Suppurative) Thyroiditis
• 70% are streptococci and anaerobes.
• Infection can spread via hematogenous/ lymphatic,
direct, penetrating trauma, and immunosuppression.
• common in children preceded by URTI or otitis media.
Subacute Thyroiditis
• painful (viral) or painless (autoimmune)
• cause by viral infection, genetics (HLA B35
haplotype)
• 3 phase - initially present as hyperthyroid ff by
euthyroid (90%) then hypothyroid (20-30%)
• diagnosis – TSH, T3, T4, ESR
• treatment – supportive, surgery is reserved for
failure of medical treatment and recurrent dse.
Benign Thyroid Disorders
• Chronic Thyroiditis
Chronic lymphocytic thyroiditis, more
commonly known as Hashimoto's
thyroiditis, after the physician who first
described the condition in 1912
autoimmune process
most common cause of hypothyroidism.
Activation of CD4+ T helper cells target
thyroid antigen ( Tg 60%, TPO 95%, TSH R
60%) destruction of thyrocytes
hypothyroidism
Benign Thyroid Disorders
• Chronic Thyroiditis
Painless anterior neck mass with minimally
or moderately enlarged firm gland) 20%
hypothyroidism and 5% hyperthyroidism
Diagnosis (increased TSH, decreased T4 and
T3),
(+) autoantibodies (confirmatory)
FNAB indicated for patient presents
with solitary suspicious nodule or rapidly
enlarging goiter.
Treatment : thyroid replacement, surgery is
indicated for suspicion of malignancy,
cosmetic and compressive symptoms.
Benign Thyroid Disorders
• Riedel’s thyroiditis
• AKA invasive fibrous thyroiditis
• replacement of all or part of thyroid
parenchyma by fibrous tissue
• cause by autoimmune dse associated
with sclerosing syndromes
• presents as painless, hard anterior neck
mass “ woody “ thyroid gland,
hypothyroidism and compressive
symptoms.
Surgery
LT4
(Lobectomy + Malignant
isthmusectomy)
Completion
Thyroidectomy
Malignant Thyroid Disease
• Thyroid cancer
• most common endocrine malignancy 95%
• most arises from follicular cells
• 90% are differentiated type (favorable
prognosis)
• thyroid nodules, less than 10% are malignant
Malignant Thyroid Disease
Tumor Types:
• Papillary Ca
Most common malignant type 70-80%
Accounts for 90% of radiation induced thyroid ca, 3%
familial
Multicentric 30-50%
More common in women 2:1, 30- 40yo
Presents as euthyroid, slow growing painless mass,
dysphagia, dyspnea, dysphonia
Lymph node metastasis is common
Diagnose thru FNA
Histopath: (+) psammoma, intranuclear grooves,
cytoplasmic inclusions leading to Orphan Annie
nuclei.
Prognosis: in general (+) excellent prognosis with a
greater than 95% 10 year survival rate.
Malignant Thyroid Disease
Papillary cancer
Low vs high risk criteria
LOW: F <50yo, M <40yo, well/mod
differentiated tumors, tumor < 4cms dm, tumor
confined to thyroid gland, no distant metastasis.
High: in contrast to low.
Treatment:
- lobectomy and isthmusectomy ( recurrence
rate 5% mortality rate 1% )
1. if less than 1cm size
2. without lymphatic/systemic
metastasis
3. > 1cm size if low risk
- total
1. high risk
2. history of head and neck irradiation
Papillary cancer
Controversies:
- Pro total
1. enables one to use RAI to detect and
treat residual thyroid
2. make serum Tg more sensitive marker
of recurrence
3. eliminate occult cancers at
contralateral site
4. reduce recurrence and improves
survival
5. decreases the risk of 1% progression to
anaplastic/undiff type
6. reduces need for reoperative sx
Papillary cancer
Controversies:
• Pro lobectomy
1. total is associated with higher
complication rate
2. recurrence in remaining thyroid
tissue is unusual (5%) most
are curable by surgery
3. tumor multicentricity is of little
prognostic significance
4. lobectomy still have excellent
prognosis.
Papillary cancer
Lymph node metastases in the
lateral neck in patients with
papillary carcinoma usually should be
managed with modified radical neck
dissection, and en-bloc dissection of
all fibrofatty tissue and lymphatic
tissue.
Papillary cancer
Usual cancer follow up, patients should
receive a yearly chest x-ray as well as
thyroglobulin levels Thyroglobulin is not
useful as a screen for initial diagnosis of
thyroid cancer but is quite useful in follow
up of well differentiated carcinoma (if a
total thyroidectomy has been performed).
A high serum thyroglobulin level that had
previously been low following total
thyroidectomy especially if gradually
increased with TSH stimulation is virtually
indicative of recurrence.
A value of greater than 10 ng/ml is often
associated with recurrence even if an
iodine scan is negative
Palpable Thyroid Nodule
Surgery
LT4
(Lobectomy + Malignant
isthmusectomy)
Completion
Thyroidectomy
Malignant Thyroid Disease
Follicular CA
• Follicular carcinoma, which accounts for
about 10 percent of thyroid
malignancies
• Solitary/surrounded by a tumor capsule
with presence of capsular and vascular
invasion (distinguished from follicular
adenoma)
• Female/male ratio is 3:1 with mean age
of 50yo
• Presents as painless solitary nodule or
as rapidly growing nodule w/in multi
nodular goiter.
Malignant Thyroid Disease
Follicular CA
• Spread hematogenously with
predilection for lungs and bones.
• Lymph node metastases are less
common 10% ( cervical )
• Treatment:
lobectomy and isthmusectomy are adequate
for minimally invasive follicular CA
near total or total thyroidectomy for invasive
type (major capsular invasion and
angioinvasion, aggressive behavior)
lymph node dissection for gross metastatic
disease
Malignant Thyroid Disease
• Hurthle Cell Ca
Account for 5% of all thyroid cancers
clinicopathologic features are similar to follicular
cancers
mortality rate of 30% at 10 years
possess TSH receptors and produce
thyroglobulin
multifocal and bilateral, are more likely to
metastasize to local nodes (25 percent), and
usually do not take up 131I
Management is similar to that of follicular
neoplasms
Malignant Thyroid Disease
Medullary CA
• accounts for about 5 percent of thyroid
carcinomas
• Represents a malignant transformation
of neuroectodermally derived
parafolicular cells.
• 75% sporadic and 25% hereditary
• Tumors typically are unilateral (75
percent)
• The presence of amyloid is a diagnostic
finding, but immunohistochemistry for
calcitonin has superseded it as a
diagnostic tumor marker
Malignant Thyroid Disease
Medullary CA
• C-cell hyperplasia is a premalignant
precursor of MTC
• Patients with MTC usually present with a
neck mass that may be associated with
palpable cervical lymphadenopathy (15
to 20 percent).
• Local pain is more common in patients
with these tumors, and local invasion
may produce symptoms of dysphagia,
dyspnea, or dysphonia.
• female-to-male ratio is 1.5:1.
Medullary thyroid cancer
• Tumors may secrete a
variety of peptides
including calcitonin, MEN IIA
calcitonin gene–related • These patients have a
peptide, CEA, syndrome characterized
histaminadases, by MTC,
prostaglandins E2 and pheochromocytoma, or
F2-alpha, and serotonin.
adrenal medullary
• Between 2 and 4
percent of patients with hyperplasia and
MTC develop Cushing's hyperparathyroidism.
syndrome as a result of MEN IIB
ectopic production of • MTC, bilateral
ACTH. Kidney stones
occur in patients with pheochromocytomas,
primary and ganglioneuromas
hyperparathyroidism, affecting mucosal
and hypertension occurs surfaces
in those with
pheochromocytoma
Medullary thyroid cancer
• Diagnosis of MTC is
established by
history, physical
examination, raised
serum calcitonin or
CEA levels, and
FNAC of the thyroid
mass
Patients with MEN IIB
have characteristic
facies with A.
marfanoid features
and B. thickened lips,
scalloping of the
tongue, and mucosal
ganglioneuromas.
Medullary thyroid cancer
Medullary thyroid cancer
total thyroidectomy with central LN
dissection is the minimum surgical
management of choice for patients with
MTC
Because tumors are of C-cell origin,
radioiodine therapy and levothyroxine
sodium TSH suppression therapy
usually are not helpful
External-beam radiotherapy for patients
with tumors at resection margins or
unresectable tumors is controversial. It is
recommended for patients with
unresectable residual or recurrent tumor,
although the results are debatable.
Medullary thyroid cancer
There is no effective
chemotherapy regimen
Prognosis: Prognosis depends on
patient age, histologic grade, and
status of surgical resection.
Patients with a worse prognosis tend
to be older, have higher-grade
lesions, and have undergone
incomplete surgical resection of the
lesion
Malignant Thyroid Disease
Anaplastic Ca
:2-6% of thyroid cancers
: one of the most aggressive malignancies
: 5 year survival rate of 3.6%
: treated prospectively over an 8-year period with
initial hyperfractionated radiotherapy with
doxorubicin, then debulking thyroidectomy,
followed by completion of radiotherapy and
chemotherapy.
: long term survival is still poor bec. of high
incidence of metastasis and local recurrence.
: unfortunately, regardless of the treatment given
majority of patient die w/in months of their
diagnosis.
Malignant Thyroid Disease
Lymphoma
less than 1% of thyroid malignancies.
• Most of the primary thyroid lesions are of the non-
Hodgkin's B-cell type.Metastatic Ca and Hashimoto’s
thyroiditis
• Patients with thyroid lymphoma usually respond rapidly
to chemotherapy
(CHOP—cyclophosphamide, doxorubicin,
vincristine, and prednisone), and combined
treatment with radiotherapy and chemotherapy is often
recommended.
• Thyroidectomy and nodal resection are used to alleviate
symptoms of airway obstruction in patients who do not
respond quickly to chemotherapy or chemotherapy and
radiotherapy but rarely warranted.
• The overall 5-year survival rate is about 50 percent
Palpable Thyroid Nodule
Surgery
LT4
(Lobectomy + Malignant
isthmusectomy)
Completion
Thyroidectomy
BLOOD SUPPLY
Arterial supply
• Superior thyroid artery
first anterior branch of the external
carotid artery
Cephalad to the superior pole, the
• Thyroidea ima
Arises directly from the aortic arch or the
innominate artery and enters the thyroid
gland at the inferior border of the isthmus
Present 1 to 4% of individuals
VENOUS DRAINAGE
3 pairs of venous drainage
• Superior thyroid vein
ascends along the superior thyroid artery
and becomes a tributary of the internal
jugular vein.
• Middle thyroid vein
follows a direct course laterally to the
internal jugular vein
• Inferior thyroid veins
to the brachiocephalic vein
NERVE SUPPLY
Left RLN
• arises from the vagus nerve then it
crosses the aortic arch, loops around
ligamentum arteriosum and ascend
medially in the neck w/in
tracheoesophageal groove
NERVE SUPPLY
Right RLN
• arises from the vagus as it crosses
posteriorly to right subclavian artery
before it ascend to neck.
• usually passes posterior to the artery
before ascending in the neck,
• its course being more oblique than the
left RLN
• may be nonrecurrent in 0.5 to 1% of
individuals and often is associated with
a vascular anomaly
NERVE SUPPLY
Identification of the nerves or their branches
often necessitates mobilization of the most lateral
and posterior extent of the thyroid gland, the
tubercle of Zuckerkandl, at the level of the cricoid
cartilage
The last segments of the nerves often course
below the tubercle and are closely approximated
to the ligament of Berry
Branches of the nerve may traverse the ligament
in 25% of individuals, and are particularly
vulnerable to injury at this junction
The RLNs terminate by entering the larynx
posterior to the cricothyroid muscle
NERVE SUPPLY
RLN innervate all intrinsic muscle of larynx
except cricothyroid, which are
innervated by external laryngeal nerves.
Injury to one RLN paralysis of the
ipsilateral vocal cord, which comes to lie in
the paramedian or the abducted position.
• paramedian position normal, but weak
voice
• abducted position hoarse voice and an
ineffective cough
NERVE SUPPLY
Bilateral RLN injury airway
obstruction, necessitating
emergency tracheostomy, or loss of
voice
If both cords come to lie in an
abducted position, air movement can
occur, but the patient has an
ineffective cough and is at increased
risk of repeated respiratory tract
infections from aspiration
NERVE SUPPLY
Superior laryngeal nerve also arises
from the vagus after their origin at
the base of the skull it travel along
with ICA and divide into 2 branches
at level of hyoid bone.
• Internal branch is sensory to supra
glottic larynx
Injury causes aspiration
NERVE SUPPLY
Determine risk
Accdg to ATA
Guidelines 2006
Low risk Intermediate or High Risk
Serum Tg q 6 mos
Empire RAI ablation
Neck US q 6 mos 100-200mci
* 30 mci
No
With Residual
residual Post tx scan
disease
disease (after 6 mos)
Whole body scan
(if extend of
See long term remnant could not
surveilance - uptake
be ascertained from + uptake
surgical report, or
young patient that
Surgery Imaging test to
overdosing of RAI
And/or localize and
would like to be
RAI Assess the resectability
avoided
and or guide EBRT
- uptake See long term surveillance
Surveilance and Maintenance
6 to 12 months after Post Surgery
Ablation
TSH Levels
(4-6 weeks post ablation)
Tg < 2 Tg > 2
TSH stimulated Tg
Tg<2 Tg >2
US - US+
Observe q6mos TSH, Tg and
Annual neck US until 5 years WB scan +/- imaging test
normal Surgery if warranted + RAI ablation, EBRT
T
H
A
N
K
Y
O
U
Physiology
Iodine Metabolism
Thyroid Hormone Synthesis, Secretion & Transport
Thyroid Hormone Function
Ingested iodide is trapped in the thyroid gland, oxidized, and bound to tyrosine
to form iodotyrosines in thyroglobulin. Coupling of iodotyrosyl residues forms
T4 and T3. Hormone secreted by the gland is transported in the serum. Some
T4 is deiodinated to T3. The hormone exerts its metabolic effect on the cell
and is ultimately deiodinated. The iodide is reused or excreted by the kidneys.
A second cycle goes on inside the thyroid gland with deiodination of
iodotyrosines generating iodide, which is reused without leaving the thyroid.
Physiology
Schema of the homeostatic regulation of thyroid function
• Secretion of TSH is regulated by a negative feedback
mechanism acting directly on the pituitary and is
normally inversely related to the
concentration of unbound hormone in the blood.
• Release of TSH is induced by TRH secretion, which
sets the level of the pituitary feedback mechanism.
• Factors regulating secretion of TRH are uncertain but
may include the free hormone in the blood and stimuli
from higher centers.