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SURGICAL MANAGEMENT
OF THYROID DISEASE:
PEARLS FOR THE PCP Edsel Kim, M.D.
Otolaryngology-Head and Neck Surgery The Oregon Clinic
Providence Brain and Spine Institute Pituitary and Thyroid Update
September 2015
Disclaimer
o I have no financial interests with any of the
companies or technologies discussed in this
presentation
Overview o History
o Anatomy
o Workup
o Indications for Surgery
o Purpose of Surgery
o What can the Patient expect?
o Case Studies
History
o Medical treatment of goiters
o 1600 BC – Chinese used burnt sponge and seaweed
o Surgery first discussed in 990 AD in the Middle East
o 1880-Ludwig Rehn – 1st known thyroidectomy
History
o By 1920s, fairly commonplace
o William Halstead
o “feat which today can be accomplished by any
competent operator without danger or mishap”
Anatomy
Anatomy
Anatomy
o Thyroid Gland – 15-25
gms
o Triiodothyronine (T3)
o Tetraiodothyronin (T4, thryoxine)
o Calcitonin
o Parathyroid Glands
o 4 pea sized glands
which regulate
calcium levels
Thyroid Nodule Workup
Thyroid Nodule
o On ultrasound, up to 50% of women and 20% of men
over the age of 50 can have nodules
o Clinically can affect up to 5% of population
o Thyroid cancer present less than 10% of all nodules
Thyroid Nodule Symptoms
o Compression
o General rule of thumb, >3 cm in diameter
o Dysphagia
o Dyspnea
o Hoarseness
o Pressure
o In general does not cause pain!
o Hemorrhagic cyst, thyroiditis
o Thyroid cancer is painless
Thyroid Nodule-Benign
o Benign
o 3% - False negative by FNA
o Generally require yearly U/S for surveillance
o Can be extended if nodules are stable
o If there is a significant increase in size (>20% in 2
dimensions or >50% in volume), recommend repeat FNA
Indications for Surgery –
Benign Disease
o Symptoms of compression
o Nodule generally has to be at least 3 cm
o Quality of life
o Hemi vs total thyroidectomy dependent on nodule size
and location
o Treatment of hyperthyroidism if medical treatment is
not indicated or tolerated
Thyroid Cancer Snapshot
NCI and SEER data
o 62,450 new cases of thyroid cancer in 2015
o 15K Men, 47K Women
o 1,950 will die of thyroid cancer
o Median age at death is 73
o Incidence of thyroid cancer is increasing more rapidly than any other cancer in the US
o More than doubled between 1992-2012
o Mortality is steady during same timeframe
o 1.1% of men and women will be diagnosed with thyroid cancer at some point in their lifetime
Thyroid Cancer Statistics –
NCI and SEER data
o Overall 5 yr survival – 97.9%
o Staging
o Localized (Primary site) – 68%
o Regional (ie LN) – 26%
o Distant – 4%
o 5 yr relative survival rates
o Localized – 99.9%
o Regional – 97.8%
o Distant – 54.1%
Thyroid Cancer Statistics
o 10 yr survival
o Papillary cancer – 93%
o Follicular – 85%
o Medullary – 75%
o Undifferentiated/Anaplastic – 14%
o Most studies cite 5yr survival at <7%
Papillary Thyroid Cancer
o 70-80% of all thyroid
cancers
o >3 F: 1 M
o 30 – 50 yo
o Prior XRT is risk factor
o Excellent long term
prognosis
o Better with younger
age <45
o Smaller size (<4cm)
o > 90% 5 yr survival
o Up to 30% recurrence
o Up to 50% lymph
node involvement
Follicular Thyroid Cancer
o FNA – Follicular lesion
o 20-30% of follicular lesion/neoplasm by FNA are cancer
o 10-15% of all thyroid cancer
o 3 F: 1 M
o Tends to be in middle age population (40-60 yr)
o Overall cure rate > 80-90%
o More common to have hematogenous than lymphatic spread
Medullary Thyroid Cancer
o Approximately 5%
o Arise from parafollicular cells – calcitonin
o Early spread to LN
o Better prognosis when confined to thyroid
o Most are spontaneous (80%)
o Can be associated with MEN IIA/B
o Prophylactic LN dissection is recommended
Anaplastic Thyroid Cancer
o Very aggressive
o Fast growing with early metastases
o Median survival is 5 months
o Invariably lethal <5% - 5 yr survival
o Most common in men > 65
Neck Dissection in Thyroid
Cancer o Central nodal dissection is
commonly advocated for
thyroid cancer
o Area between hyoid bone,
carotid artery and suprasternal
notch/innominate artery
o Decreases risk of nodal
recurrence
o Decreased risk of injury to
RLN, parathyroid in re-do
operations
Benefits of Central Nodal
Dissection
o Studies show up to 40-65% prophylactic N0 central
nodal dissections have positive disease
o RLN and parathyroid are generally clearly defined
o If there is positive disease, treatment (ie RAI) may be
more aggressive and vice versa
o Older patients may not have iodine avid disease
o Surgery is primary treatment modality
Benefits of Central Nodal
Dissection
o Incidence of neck recurrence (15%) is predominantly
in the central neck compartment (up to 90%).
o In those cases with recurrence, central nodal dissection is always advocated even if disease is only clinically
evident laterally
o Much higher incidence of RLN injury and permanent
hypoparathyroidism in salvage CND
Benefits of Central Nodal
Dissection
o Traditional teaching was that lymph node status did
not affect survival
o Recent study reviewing 10,000 records in
Surveillance, Epidemiology and End Results (SEER)
shows +LN in pts >45yo with PTC and all pt with FTC
were associated with 46% increased risk of death
Risks of Central Nodal
Dissection
o Increased risk of temporary and permanent
hypoparathyroidism
o Increased risk of nerve injury?
Risks of Central Nodal
Dissection
o While up to 90% of pts may have micrometastases,
only 10% of these will have clinically significant
disease
o Current 2009 guidelines from the American Thyroid
Association (ATA) regarding this issue does
recommend central nodal dissection in pt with
thyroid cancer
Neck Dissection in Thyroid
Cancer
o Lateral compartment
should be addressed
for gross nodal
metastases
o Should be done in
conjunction with
central neck
o Preoperative Neck
Mapping U/S
Neck Dissection in Thyroid
Cancer
o Nodal disease should be looked in terms of
compartments
o Surgical management should reflect this philosophy
o In general, node sampling should be avoided
o SLNB has not been shown to be beneficial
o If extensive disease is seen and thought to be
overwhelming, then better to close than to sample
nodes
2009 American Thyroid
Association (ATA) Guidelines
o T1/2 PTC – Total/near-total thyroidectomy without
CND may be sufficient
o For T3/4 PTC, Grade C (expert opinion)
recommendation given for prophylactic central
compartment neck dissection
Complications of Thyroid
Surgery
o Bleeding
o Infection
o Nerve Injury
o Recurrent Laryngeal Nerve
o Superior Laryngeal Nerve
o Hypoparathyroidism/ Hypocalcemia
Complications of Thyroid
Surgery
o Bleeding (2%)
o Can cause dysphagia, airway compression
o Treating team should be immediately notified with any
question
o If pt is in extremis, the incision should be opened
immediately
o Suture removal kit should always be at the bedside
Complications of Thyroid
Surgery
o Nerve injury
o Recurrent laryngeal nerve (1-5%)
o Superior laryngeal nerve (2-6%)
RLN Injury
o Unilateral
o Initially can be in paramedian position with relatively
normal voice
o Can get worse over days
o Breathy, hoarse voice
o Aspiration
o Dysphagia
o Bilateral
o Airway obstruction/Distress
RLN Injury
o Diagnosis
o Laryngoscopy
o EMG
Complications of RLN Injury
o Prevention
o 1-2% - if nerve is identified
o 4-6% if nerve is not identified
o 2-12% for repeat surgery
RLN Injury
o Intraoperative Nerve
Monitoring
o Helps to confirm
nerve anatomy
o Cons –
o No studies have
shown difference
o Equipment
malfunctions
Hypoparathyroidism
o Only relevant in total thyroidectomy/completion thyroidectomy
o Permanent hypoparathyroidism occurs in 1-10%
o Transient hypocalcemia is 5-40%
o Percentage is inversely correlated with surgeon experience
o Treatment is oral calcium supplementation and Vitamin D
o Greater than 6 months is considered permanent
Complications of Thyroid
Surgery-Hyperthyroidism
Complications of Thyroid
Surgery
o In general is avoided pre-operatively with thyroid
suppresion
o Propylthoiuracil (PTU), methimazole (MMI)
o Dx – Elevated TFTs, LFTs, Ca, Glucose
o Tx – Block thyroid hormone synthesis
o PTU is preferred as it also blocks peripheral conversion of
T3 to T4
o Iodine can inhibit thyroid iodine uptake
o Propanolol also blocks T3-T4
Purpose of Surgery –
Thyroid Cancer
o Diagnostic Lobectomy in cases with suspicious pathology
o Remove primary disease and any extension
o Lymph nodes
o Local extension
o Permit accurate staging
o Prognostication
o Facilitate postoperative treatment
o Lower thyroid tissue load helps radioactive iodine ablation
o Long term surveillance
What to expect?
o 40 yo F with an incidental, asymptomatic 2 cm solid
nodule
o TFTs normal
o No risk factors
o FNA – Follicular lesion of undetermined significance
(FLUS)
What to expect?
What to expect?
o ~20-30% of all FNA are indeterminate lesions
o Veracyte – Afirma test
o Extracts gene expression data from sample and
compares it to a database of known benign and
malignant disease
What to expect?
o Afirma testing
o Cost - $5200
o Estimated to eliminate 1/3 of the 75,000 surgeries done
yearly for indeterminate thyroid nodules
o Avg cost of surgery - $10-15,000
o 5% of cancers are missed with Veracyte
What to expect?
o Incision length
o Traditional
o 8-10 cm
o Minimally invasive
o 4-5 cm
o Robotic/Scarless
o Transaxillary
o Recovery
o 1 week
What to expect?
o Many surgeons will send hemithyroidectomies home
the same day
o Some centers advocate this to have total
thyroidectomy done as an outpatient
o Readmission rate (up to 5%)
o Hypocalcemia
o Seroma
Case Study 1- Thyroid
o 69 yo retired RN with long history of a substernal
goiter
o Worsening dyspnea, orthopnea, dysphagia
o Followed by endocrine (not here)
o Recommended not to have surgery
o Eventually sought care herself
Case Study 1- Thyroid
Case Study 1- “Thyroidzilla”
o OR – Substernal thryoidectomy, limited sternotomy
o 2 day hospitalization
o 2 week recovery
o Normal voice and calcium
o Normal swallowing and breathing
o Hiking at 1 month
Case Study 2
o 43 yo F with increasing DOE and SOB
o PSH for attempted thyroid surgery 3 yrs ago
o PE –mass above sternal notch
o Obvious stridor
o Recent political asylum (2 days in US)
Case Study 2
Case Study 2- Thyroid
o Joint case with
Thoracic Surgery
o Full Sternotomy,
excision of substernal
goiter to diaphragm
o Marked improvement
in breathing and
swallowing
o Normal
voice/swallowing/calc
ium
Conclusion
o Thyroid surgery can be a safe and rewarding surgery
for patients
o Indications for thyroid surgery are well studied
o Care pathways are continuously defined through the
American Thyroid Association (ATA)
o Coordination of care with endocrinology and surgery
can provide the best outcome for patient
![ehr.wrshealth.com · Web viewPLEASE OBTAIN PRE-Iodine 131 SERUM LABS: LABLE. ICD10: Thyroid Cancer (C73), Postop Hypothyroidism (E89.0), H/o Thyroid cancer (Z85.850), [X] 84443 TSH,](https://img.pdfslide.us/doc/110x75/5cd7356c88c9935d038cacba/ehr-web-viewplease-obtain-pre-iodine-131-serum-labs-lable-icd10-thyroid.jpg)
