Thyroid and Parathyroid Surgery

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1 Med 5 Surgery Refresher Course Thyroid and Parathyroid Surgery Dr Shirley Liu Resident Specialist Honorary Clinical Assistant Professor Team 2 Surgery Prince of Wales Hospital Case scenario: Thyroid Surgery 45 year old housewife Complained of anterior neck mass for 6 months Told to be goiter by GP She worried about thyroid cancer Attended your clinic for advice How would you manage her?

2 Assessment of thyroid nodules Anatomical Diagnosis (Hx + P/E + USG) Functional Diagnosis (TFT) Pathological Diagnosis (FNAC) History and physical examination Please refer to your med 3 notes

3 Important points in Hx and P/E Any features with increased risk of malignancy? History P/E 1. Very old or very young 2. Male gender 3. Family history of thyroid cancer 4. History of neck irradiation 5. Rapid increase in goiter size 6. Pressure symptoms 7. Voice hoarseness 8. Hard, irregular, fixed mass 9. Cervical LN Anatomical + functional diagnosis Solitary nodule Diffuse goiter Multinodular goiter Hyperthyroid Toxic adenoma Graves disease Toxic MNG Euthyroid Colloid/ adenomatous nodule Colloid goiter MNG Hypothyroid Thyroiditis Thyroiditis Thyroiditis

4 Goiter with hyperthyroidism Case scenario: 45 year old housewife Complained of anterior neck mass for 6 months Told to be goiter by GP She worried about thyroid cancer Attended your clinic for advice After initial assessment TFT confirms hyperthyroidism in this patient She was called back for further care How would you manage her? Goiter with hyperthyroidism Differential diagnosis Graves disease Toxic multinodular goiter Toxic adenoma Management = investigation + treatment Is further investigation required? What further investigation is required? What are the treatment options?

Goiter + Hyperthyroidism Thyroid scan Indicated in all thyrotoxic patients with nodules To differentiate toxic gland from toxic nodule Treatment options for Hyperthyroidism Anti thyroid drug

5 Goiter + Hyperthyroidism Thyroid scan Indicated in all thyrotoxic patients with nodules To differentiate toxic gland from toxic nodule Treatment options for Hyperthyroidism Anti thyroid drug Radioiodine (RAI) Surgery Pros Outpatient therapy No permanent hypothyroidism Cons Side effects of drugs Highest relapse rate Outpatient therapy Rapid control of toxic symptoms Can normalize thyroid size within 1 year Minimal side effects Radiation hazards Can worsen ophthalmopathy Most result in permanent hypothyroidism No radiation hazard Immediate control of toxic symptoms Immediate normalization of thyroid size Lowest relapse rate Inpatient therapy Surgical / GA risks Inevitable permanent hypothyroidism

6 Surgery for Hyperthyroidism Toxic adenoma Diffuse goiter / Toxic MNG Hemithyroidectomy Total thyroidectomy Subtotal thyroidectomy Types of thyroid surgery Lumpectomy Type Lobectomy Hemithyroidectomy Near total lobectomy Total thyroidectomy Near total thyroidectomy Subtotal thyroidectomy Isthmectomy Minimally invasive thyroidectomy Description Excision of a thyroid nodule Excision of one thyroid lobe + isthmus Excision of one thyroid lobe + isthmus A lobectomy leaving around <1g thyroid tissue Excision of both thyroid lobes + isthmus Lobectomy on one side + near total lobectomy on other one Excision of more than ½of lobe on each side + isthmus Excision of thyroid isthmus Endoscopic or robotic thyroidectomy

7 Goiter with hypothyroidism Case scenario: After initial assessment TFT confirms hypothyroidism in this patient She was called back for further care How would you manage her? Goiter with hypothyroidism All patients with hypothyroidism have thyroiditis Mainstay of treatment: Thyroxine replacement Surgery is NOT indicated unless pressure symptoms present

Euthyroid Goiter Diffuse goiter Multinodular goiter

required British Thyroid Association 2007 FNAC Thy1 Non

(10%) Follicular lesion/ neoplasm Hurthle cell lesion/

8 Euthyroid Goiter Diffuse goiter Multinodular goiter Solitary nodule Colloid goiter FNAC is definitely required British Thyroid Association 2007 FNAC Thy1 Non diagnostic (15%) Thy2 Benign (70%) Thy3 Indeterminate (10%) Follicular lesion/ neoplasm Hurthle cell lesion/ neoplasm Thy4 Suspicious of malignancy Thy5 Diagnostic of malignancy

British Thyroid Association 2007 FNAC Thy1 Non diagnostic

Benign (70%) Expectant management Thy3 Indeterminate (10%)

Hurthle cell neoplasm Vascular invasion Lack of colloid

9 British Thyroid Association 2007 FNAC Thy1 Non diagnostic (15%) To repeat FNAC With or without USG guidance Thy2 Benign (70%) Expectant management Thy3 Indeterminate (10%) Indeterminate FNAC Follicular neoplasm Capsular invasion Hurthle cell neoplasm Vascular invasion Lack of colloid Hypercellular Microfollicular pattern Lack of colloid Binucleated cells

10 How many are malignant? Overall malignancy rate ~ 15% Castro et al. Ann Intern Med 2005 Indeterminate FNAC Follicular neoplasm/ Hurthle cell neoplasm Hemithyroidectomy is indicated for excisional biopsy

11 FNAC = malignant Primary thyroid carcinoma Secondary carcinoma Lymphoma Undifferentiated carcinoma Differentiated carcinoma Workup for primary source ± Core biopsy ChemoRT Anaplastic carcinoma Papillary carcinoma Follicular carcinoma Medullary carcinoma FNAC = Papillary carcinoma? Small sized tumor Total thyroidectomy + central compartment dissection Ipsilateral modified radical neck dissection (if lateral node +ve)

12 Concept of microcarcinoma Definition of thyroid microcarcinoma: Size 1cm No lymph node metastasis No distant metastasis No extrathyroidal or capsular invasion Cancer not multifocal Papillary microcarcinoma Tumor size <1cm Total thyroidectomy Hemithyroidectomy 1. Papillary carcinoma tends to be multifocal 2. Prevent local recurrence which may progress to undifferentiated carcinoma (anaplastic Ca) 3. Allow postoperative thyroglobulin (Tg) monitoring 4. Allow adjuvant RAI 5. Morbidities still low in expert hands 1. Morbidities are lower (esp parathyroid and RLN injury) 2. Progression to undifferentiated carcinoma is uncommon 3. RAI is not required in most patients 4. No evidence to show inferior prognosis

13 FNAC = Follicular carcinoma Seldom encountered FNAC cannot differentiate adenoma and carcinoma Tendency of hematogenous spread Lymph node dissection not required FNAC = medullary carcinoma Check baseline calcitonin Exclude 25% familial cases 1. Ask family history 2. Calcium exclude hyperparathyroidism 3. 24hr urine catecholamine exclude phaeochromocytoma 4. Refer for genetic screening of RET oncogene Surgery as mainstay of treatment

14 Surgical treatment of thyroid cancer Papillary Ca Follicular Ca Medullary Ca Total thyroidectomy Yes Yes Yes Central compartment dissection Yes No Yes Ipsilateral MRND (functional neck dissection) Only if lateral LN +ve No Yes Complications of thyroidectomy Early complications Late complications 1.Reactionary hemorrhage 2.Recurrent laryngeal nerve injury 3.Superior laryngeal nerve injury 4.Parathyroid injury 1.Hypothyroidism 2.Wound complications

Common exam questions Case scenario: A 50 year old lady underwent total thyroidectomy this morning After transferring back to ward, she was noted to be desaturation and neck swelling.

15 Common exam questions Case scenario: A 50 year old lady underwent total thyroidectomy this morning After transferring back to ward, she was noted to be desaturation and neck swelling. The drain output became 500ml fresh blood. How would you manage her? Post thyroidectomy bleeding Reactionary hemorrhage Primary surgical failure within 24 hours Can cause immediate asphyxiation and death Hematoma compressing on venous return, causing laryngeal edema Management: Remove all the stitches from skin down to surgical fascia (very first thing to do!) Supplemental oxygen + resuscitation Arrange emergency operation for hemostasis

Recurrent laryngeal nerve injury Usually transient (0 2% only) Unilateral: voice hoarseness Bilateral: airway obstruction Treatment: Prevention is the best Cord medialisation procedures Parathyroid

16 Recurrent laryngeal nerve injury Usually transient (0 2% only) Unilateral: voice hoarseness Bilateral: airway obstruction Treatment: Prevention is the best Cord medialisation procedures Parathyroid injury Usually transient (up to 50%) Permanent hypoparathyroidism (variable rate) Treatment: Prevention is the best Immediate postop: intravenous Ca replacement Oral calcium supplements + vitamin D

17 Thyroid cancer: postoperative management Adjuvant treatment Radioiodine (RAI) Aim to ablate residual thyroid tissue Withhold T4 and iodine intake for 4 weeks before RAI External beam RT Indicated for high risk patients Extrathyroidal extension Residual disease Positive resection margins Suppressive T4 Indicated in ALL patients Titrate T4 level to suppress TSH to undetectable level FNAC Thy1 Non diagnostic (15%) Repeat FNAC Thy2 Benign (70%) Expectant management Thy3 Indeterminate (10%) Hemithyroidectomy as excisional biopsy Thy4 Thy5 Suspicious of malignancy Surgery is the mainstay of treatment Diagnostic of malignancy Surgery is the mainstay of treatment

18 Thyroglossal cyst Physical examination Midline cystic swelling Usually just lateral to midline Is treatment necessary? Yes, as it is prone to infection Treatment: Sistrunk operation Removal of thyroglossal cyst + duct tract + hyoid bone Parathyroid Surgery Case scenario: 75 year old lady Attended GP for leg pain Blood checked by GP Incidental finding of high Ca = 3.0 mmol/l GP immediately referred her to you How would you manage her?

Calcium regulation PTH 1.Stimulate osteoclast to increase bone resorption 2.Increase renal Ca absorption 3.Increase active vit D production Vitamin D 1.

19 Calcium regulation PTH 1.Stimulate osteoclast to increase bone resorption 2.Increase renal Ca absorption 3.Increase active vit D production Vitamin D 1.Stimulate osteoclast to increase bone resorption 2.Increase GI absorption of Ca To manage her Control hypercalcaemia first Then treat underlying causes

20 How to control hypercalcaemia? Saline rehydration Cause natriuresis and calciuresis Loop diuretics (furosemide) Increase natriuresis and calciuresis Bisphosphonates (palmidronate) Inhibit osteoclast activity Calcitonin / Glucocorticoid Inhibit osteoclast activity Dialysis To treat the underlying causes Hyperparathyroidism Renal failure Malignancy Granulomatous diseases Medications Increased bone turnover Primary hyperparathyroidism Secondary or tertiary hyperparathyroidism Paraneoplastic syndromes (PTHrP) Sarcoidosis Tuberculosis Thiazide diuretics Vitamin A or D intoxication Lithium intoxication Immobilization Paget s disease Thyrotoxicosis

21 Hypercalcaemia Investigate for underlying causes History and P/E focusing on Possible diseases above Possible causative medications Check serum PTH Low PTH High or normal PTH Non hyperparathyroidism causes No renal failure Renal failure present 1 st hyperpth 2 nd or 3 rd hyperpth Is treatment necessary for all cases of primary hyperpth? Indications for parathyroidectomy Severe hyperca 3.0 mmol/l Symptomatic hyperca Mild hyperca and asymptomatic: controversial 1. Young age <50 2. Low bone mineral density 3. Deteriorating CrCl 4. Increased 24hr urinary Ca excretion 5. Long term follow up difficult NIH consensus conference 2002

22 Symptoms of hypercalcaemia Bones Pain, fracture Moans Neuropsychiatric disturbances Groans Abdominal pain, pancreatitis, peptic ulcer Stones Renal stones Arrhythmia What are the causes for 1 st hyperpth? Parathyroid single adenoma 85% Parathyroid multi gland adenomas 5% Parathyroid hyperplasia 5% MEN1, MEN2, non MEN familial isolated hyperparathyroidism (FIHPT) Parathyroid carcinoma <5%

Surgical treatment: Parathyroidectomy Removal of the diseased parathyroid gland (single adenoma/ multi adenoma / 4 gland hyperplasia) Bilateral

intraoperative frozen section is required USG neck + MIBI 2 nd hyperpth vs 3 rd hyperpth 2 nd hyperpth Stimulated PTH secretion from parathyroid

23 Surgical treatment: Parathyroidectomy Removal of the diseased parathyroid gland (single adenoma/ multi adenoma / 4 gland hyperplasia) Bilateral neck exploration >90% successful Focused parathyroidectomy Preoperative localization is needed Preoperative localization not necessary But intraoperative frozen section is required USG neck + MIBI 2 nd hyperpth vs 3 rd hyperpth 2 nd hyperpth Stimulated PTH secretion from parathyroid hyperplasia Inadequate PO4 excretion Inadequate alpha 1 hydroxylase 3 rd hyperpth Autonomous PTH secretion from parathyroid hyperplasia even after renal tranplant

24 Med 5 Surgery Refresher Course Secondary and tertiary hyperpth Chronic renal failure Reduced renal tubular PO4 excretion Impaired renal conversion of active Vit D HyperPO4 Chelation of serum Ca Reduced intestinal Ca absorption HypoCa Stimulate PTH secretion from parathyroid chief cells Prolonged stimulation causes parathyroid hyperplasia Clinical diagnosis 1 st hyperpth 2 nd hyperpth 3 rd hyperpth Serum Ca High Low or normal High or normal Serum PO4 Low High Low PTH level High Extremely high Moderately high Treatment Depends on causes Medical 1.Oral Ca supplements 2.Vit D supplements 3.PO4 binders Surgical Renal transplant

25 Surgery for 3 rd hyperpth Surgical options Total parathyroidectomy Total parathyroidectomy with autotransplantation Subtotal parathyroidectomy (removal of 3.5 glands and leaving 0.5 gland in situ) Questions? liuyw@surgery.cuhk.edu.hk

Thyroid Nodule. Disclosure. Learning Objectives P A P A P A 3/18/2014. Nothing to disclose.

Thyroid Nodule. Disclosure. Learning Objectives P A P A P A 3/18/2014. Nothing to disclose. Thyroid Nodule Evaluating the patient with a thyroid nodule and some management options. Miguel V. Valdez PA C Disclosure Nothing to disclose. Learning Objectives Examination of thyroid gland Options for