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01/21/22 01/21/22 1 Surgical Treatment of Surgical Treatment of Goiter and Hyperthyroidism Goiter and Hyperthyroidism Haben Haben 1 1 1 1 1 1 1 1 1 1 10/29/2010 10/29/2010

Goiter Lecture

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Surgical Treatment of Goiter and Surgical Treatment of Goiter and HyperthyroidismHyperthyroidism

HabenHaben111111111110/29/201010/29/2010

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Assessment of thyroid nodulesAssessment of thyroid nodulesHistoryHistory

Rapid painless growth suggests malignancy Rapid painless growth suggests malignancy Sudden painful growth suggests haemorrhage into Sudden painful growth suggests haemorrhage into

degenerating colloid nodule degenerating colloid nodule Family history - 20% medullary carcinomas are familial Family history - 20% medullary carcinomas are familial

associated with MEN 2 Syndrome associated with MEN 2 Syndrome History of radiation exposure History of radiation exposure

Used in treatment of tonsillar hypertrophy, acne, Used in treatment of tonsillar hypertrophy, acne, thymicthymic enlargement enlargement

Increased incidence of thyroid malignancy - usually papillary Increased incidence of thyroid malignancy - usually papillary Most occult (<1.5 cm diameter) and multifocal Most occult (<1.5 cm diameter) and multifocal Usually good prognosisUsually good prognosis

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ExaminationExamination

80% solitary thyroid nodules occur in women 80% solitary thyroid nodules occur in women The risk of malignancy is increased three fold in men The risk of malignancy is increased three fold in men Malignancy more common in children and >60 years Malignancy more common in children and >60 years Assess whether true solitary or dominant nodule within Assess whether true solitary or dominant nodule within

goitre goitre True solitary nodule have 10% risk of malignancy True solitary nodule have 10% risk of malignancy Dominant nodule in multinodular goitre has 2-5% risk of Dominant nodule in multinodular goitre has 2-5% risk of

malignancy malignancy

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Evidence of fixation or nodal involvement Evidence of fixation or nodal involvement suggests malignancy suggests malignancy

Most patients will be clinically and biochemically Most patients will be clinically and biochemically euthyroid euthyroid

Obstructive signs - stridor, tracheal deviation, Obstructive signs - stridor, tracheal deviation, neck vein engorgement neck vein engorgement

Hoarseness and vocal cord paralysis suggests Hoarseness and vocal cord paralysis suggests recurrent laryngeal nerve palsy recurrent laryngeal nerve palsy

50% solitary thyroid nodules in children are 50% solitary thyroid nodules in children are cancers cancers

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InvestigationInvestigation Biochemical assessmentBiochemical assessment Thyroid functional status - Free T4 and TSH Thyroid functional status - Free T4 and TSH Thyroid Antibodies - anti-thyroglobulin and anti-Thyroid Antibodies - anti-thyroglobulin and anti-

microsomal microsomal If positive family history and possibility of If positive family history and possibility of

medullary carcinoma - calcitonin medullary carcinoma - calcitonin If suspicion of MEN2 Syndrome will need 24 hr If suspicion of MEN2 Syndrome will need 24 hr

urinary catecholamine estimations to exclude urinary catecholamine estimations to exclude phaeochromocytoma prior to surgery phaeochromocytoma prior to surgery

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Standard radiographyStandard radiography Chest radiography and thoracic inlet views Chest radiography and thoracic inlet views

if obstructive symptoms if obstructive symptoms

Isotope scanningIsotope scanning 131I , 123I or 99Tch scanning provides 131I , 123I or 99Tch scanning provides

functional assessment of thyroid functional assessment of thyroid Nodules classified as cold, warm or hot Nodules classified as cold, warm or hot

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Unable to differentiate benign and Unable to differentiate benign and malignant nodules malignant nodules

Most solitary thyroid nodules are cold Most solitary thyroid nodules are cold Most cancers arise in cold nodules Most cancers arise in cold nodules Risk of cancer in a cold nodule is 10-15% Risk of cancer in a cold nodule is 10-15% Risk of tumour in a hot nodule is negligible Risk of tumour in a hot nodule is negligible

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UltrasoundUltrasound Will define solitary and dominant nodules Will define solitary and dominant nodules Will distinguish solid and cystic lesions Will distinguish solid and cystic lesions Most sonographically solid lesions are Most sonographically solid lesions are

benign benign Cancer can occur in the wall of a cystic Cancer can occur in the wall of a cystic

lesion lesion No reliable criteria to distinguish benign No reliable criteria to distinguish benign

and malignant lesions and malignant lesions

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Fine needle aspiration cytologyFine needle aspiration cytology Should be first line investigation of the solitary Should be first line investigation of the solitary

thyroid nodule thyroid nodule With experienced cytologist diagnostic accuracy With experienced cytologist diagnostic accuracy

can be >95% can be >95% Possible cytopathological diagnoses are: Possible cytopathological diagnoses are:

Benign Benign Malignant Malignant Indeterminate Indeterminate Inadequate Inadequate

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Can distinguish benign and malignant Can distinguish benign and malignant tumours except follicular neoplasms tumours except follicular neoplasms

Diagnosis of follicular carcinoma depends Diagnosis of follicular carcinoma depends on the visualisation capsular invasionon the visualisation capsular invasion

If follicular neoplasm on FNA lesion will If follicular neoplasm on FNA lesion will require surgical excision require surgical excision

False negative rate less than 5% in most False negative rate less than 5% in most institutions institutions

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Indications for surgery after FNA cytologyIndications for surgery after FNA cytology All proven malignant nodules All proven malignant nodules All cytologically diagnosed follicular neoplasms All cytologically diagnosed follicular neoplasms All lesions exhibiting an atypical but non-All lesions exhibiting an atypical but non-

diagnostic cellular pattern on cytology diagnostic cellular pattern on cytology Cystic nodules which recur after aspiration Cystic nodules which recur after aspiration When on clinical grounds the index of suspicion When on clinical grounds the index of suspicion

of malignancy is high even if the cytology report of malignancy is high even if the cytology report suggests it is benign suggests it is benign

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HyperthyroidismHyperthyroidismCausesCauses

Graves’ diseaseGraves’ diseaseToxic nodular goiterToxic nodular goiterToxic thyroid adenomaToxic thyroid adenomaCNS disordersCNS disorders

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Grave’s DiseaseGrave’s Disease

Diffuse toxic goiterDiffuse toxic goiter

WomenWomen

20-40 years20-40 years

ImmunoglobulinsImmunoglobulins

Genetic susceptibilityGenetic susceptibility

Hyperplasia of the follicular cellsHyperplasia of the follicular cells

Diagnosis------Diagnosis------

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TreatmentTreatment

11..Radioiodine treatmentRadioiodine treatment131131IIEuthyroid for 3-4 weeksEuthyroid for 3-4 weeksAdvantage-----90% Advantage-----90%

Risks---hypothyroidism(10-15%) Risks---hypothyroidism(10-15%) PregnancyPregnancy

2.Antithyroid Medications2.Antithyroid MedicationsPTU, Methimazole,CarbimazolePTU, Methimazole,Carbimazoleinhibition of organification of intrathyroid inhibition of organification of intrathyroid

iodineiodine

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Toxic nodular goiterToxic nodular goiter

Plummer’s diseasePlummer’s disease

Endemic goiterEndemic goiter

Autonomous noduleAutonomous nodule

Mild courseMild course

Older patientOlder patient

Treatment :-Surgical Treatment :-Surgical

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Multinodular GoiterMultinodular Goiter

Endemic/SporadicEndemic/SporadicEndemic=IDD---10%Endemic=IDD---10%Diffuse enlargementDiffuse enlargementHeterogenousHeterogenousAsymmetrical nodularityAsymmetrical nodularityIodine deficiency/ Goiterogens Iodine deficiency/ Goiterogens

(cyanoglucosides,thioglycosides)(cyanoglucosides,thioglycosides)Euthyroid, HyperthyroidismEuthyroid, HyperthyroidismCarcinoma---5-10%Carcinoma---5-10%

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Classification of goiter (WHO) Classification of goiter (WHO)

• • Grade 0: Grade 0: No palpable or visible goiterNo palpable or visible goiter• • Grade 1:Grade 1: Mass consistent with enlarged Mass consistent with enlarged thyroid that is palpable but not visible when the thyroid that is palpable but not visible when the neck is in the neutral position; it also moves neck is in the neutral position; it also moves upwards in the neck as the subject swallows.upwards in the neck as the subject swallows.• • Grade 2: Grade 2: Swelling visible in a neutral position Swelling visible in a neutral position of neck and is consistent with an enlarged of neck and is consistent with an enlarged thyroid when the neck is palpatedthyroid when the neck is palpated

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Prevention and Medical treatmentPrevention and Medical treatment

Medical TreatmentMedical Treatment

Iodine/ ThyroxineIodine/ Thyroxine

PreventionPrevention

Iodisation of saltIodisation of salt

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Surgery is indicated for:Surgery is indicated for:1. Increase in size while on TSH 1. Increase in size while on TSH suppressionsuppression2. Pressure Symptoms2. Pressure Symptoms3. Toxic changes3. Toxic changes4. Suspected or proven malignancy4. Suspected or proven malignancy5. Cosmetic reasons5. Cosmetic reasons

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Substernal GoiterSubsternal Goiter

SecondarySecondary

Primary(1%)Primary(1%)

Compressive symptomsCompressive symptoms

Cervical approachCervical approach

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Solitary Thyroid NoduleSolitary Thyroid Nodule

Mostly benignMostly benign

F:M=4:1F:M=4:1

Suspect MalignancySuspect Malignancy

malemale

>50yrs>50yrs

ChildrenChildren

Rapid GrowthRapid Growth

local invasionlocal invasion

ClinicalClinical

RadiologicRadiologic

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Indications for Surgery of thyroid noduleIndications for Surgery of thyroid nodule Proven or suspected cancer Proven or suspected cancer Obstructive symptoms Obstructive symptoms Patient anxiety Patient anxiety Hyperfunctioning nodules resulting in Hyperfunctioning nodules resulting in

hyperthyroidism hyperthyroidism Cosmesis Cosmesis

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Thyroid CancersThyroid Cancers

Well DifferentiatedWell Differentiated

Papillary Carcinoma(70-75%)Papillary Carcinoma(70-75%)

multicentericmulticenteric

<1.5cm---lobectomy with isthmusectomy<1.5cm---lobectomy with isthmusectomy

>1.5cm---Total thyroidectomy>1.5cm---Total thyroidectomy

postop. Radioiodine treatmentpostop. Radioiodine treatment

Follicullar carcinoma(10-15%)Follicullar carcinoma(10-15%)

<2cm---<2cm---

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Medullary CarcinomaMedullary Carcinoma

Non FamilialNon Familial

Inherited/Familial—MEN I/IIInherited/Familial—MEN I/II

Total thyroidectomyTotal thyroidectomy

poorer prognosispoorer prognosis

Anaplastic carcinomaAnaplastic carcinoma

very aggressivevery aggressive

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Complications of thyroidectomy Complications of thyroidectomy Haemorrhage Haemorrhage Wound Complications Wound Complications

Sepsis Sepsis Hypertrophic scarring Hypertrophic scarring

Respiratory Obstruction Respiratory Obstruction Laryngeal mucosal oedema Laryngeal mucosal oedema Clot deep to strap muscles Clot deep to strap muscles Bilateral incomplete recurrent laryngeal nerve palsies Bilateral incomplete recurrent laryngeal nerve palsies Tracheomalacia Tracheomalacia

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Nerve Damage Nerve Damage Recurrent laryngeal nerve palsy Recurrent laryngeal nerve palsy Incomplete - cord moves to midline Incomplete - cord moves to midline Complete - cord in cadaveric position Complete - cord in cadaveric position Preoperative cord inspection is essential Preoperative cord inspection is essential 3% population have asymptomatic recurrent laryngeal 3% population have asymptomatic recurrent laryngeal

nerve palsy nerve palsy Hypocalcaemia Hypocalcaemia Pneumothorax Pneumothorax Air Embolism Air Embolism

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Thyroid Crisis Thyroid Crisis Fulminating hyperthyroidism Fulminating hyperthyroidism Hyperpyrexia Hyperpyrexia Arrhythmia Arrhythmia Cardiac Failure Cardiac Failure

Recurrent hyperthyroidism Recurrent hyperthyroidism Hypothyroidism Hypothyroidism