Surgery - Thyroid Neoplasms

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Thyroid Vasculature

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Superior Thyroid Artery --First Branch off external carotid
Inferior Thyroid Artery --Branch off thyrocervical trunk
Superior & Middle Thyroid Veins drain to internal jugular vein
Inferior Thyroids Vein drains to Brachiocephalic Veins

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What % of pts have a pyramidal thyroid lobe

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50%

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Eponym for LN's around pyramidal thyroid lobe

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Delphian LNs

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Eponym: connecting fibers between thyroid and trachea

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Ligament of Berry

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% of pts have an IMA artery

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3% of pts (small inferior artery to thyroid from aorta or innominate)

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Eponym: most posterior extension of lateral thyroid lobes

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Tubercle of Zuckerkandl

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Nerves around Thyroid Gland

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Recurrent Laryngeal: found in tracheoesophageal grouves, dive behind cricothyroid muscle
damage--> no laryngeal adduxn --> hoarseness if u/l, ariway obstrx if b/l
Superior Laryngeal Nerve: unable to hit high pitches

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Most active form of Thyroid Hormone

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T3

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What is Synthroid

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T4

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Workup for Thyroid Nodule

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1. TSH
High/Normal TSH --> US
Benign --> Routine fu
Suspicious --> FNA
Low TSH --> I-123 for functionality
--> hypofnx --> US
--> hyperfnx = non-malig --> evaluate/tx for hyperthyroidism

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Sick Euthryoid

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Transient Decrease in T3 from hypocaloric & cytokines; Normal T4 & TSH
transient elevation in TSH upon recovery from critical illness
do not jump on subclinical hypothyroidism in p[t who has just recovered from critical illness

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History Suggestive of Thyroid Cancer

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Young male pt with FHx thyroid CA or Neck Radiation

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Signs suggested of Thyroid CA

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Single, Hard, Immobile, Cold Nodule with Lymphadenopathy
Increased Calcitoninn Levels

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Symptoms suggestive of Thyroid CA

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Voice changes, dysphagia, discomfort, rapid enlargement

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Most common cause of thyroid enlargement

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multinodular goiter

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Eponym: toxic multinodular goiter

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plummer's dz

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Indications of surgery with multinodular goiter

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cosmesis, compressive sx, unable to RO CA

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% of cold nodules which are malignant

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25%

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% of false negatives of FNA

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5%

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Reltive Freq of Thyroid CAs

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Papillary 80%
Follicular 10%
Medullary 5%
Clear Cell: 3%
Anaplastic: 2%

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Papillary Thyroid Carcinoma Risk Factors

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Radiation

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Pt profile: Papillary Thyroid Carcinoma

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30-something female hx rads

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Histology of papillary carcinoma

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psammomma bodies

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Spread of Papillary Thyroid CA

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Lymphatic

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10 year survival of Papillary Throid CA

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95%

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Tx for Papillary Thyroid CA

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<1.5cm & no hx rads: option of subtotal-thyroidectomy
else: total thyroidectomy
for both administer Synthroid post-op to suppress TSH
post-op I-131 to ID distant mets (then tx with ablative doses of I-131)
Palpable LNs:
--ipsilateral neck dissection if lateral
--central neck dissexn if central

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Lateral Aberrant Thyroid

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misnomer for metastatic papillary thyroid ca to LN

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Most Common Metastasis of Papillary Thyroid CA:

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Lungs

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Follicular Thyroid Adenocarcinoma Relative Frequency

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10% of Thyroid CA's 2nd most common (to Papillary with 80%)

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Spread of Follicular Thyroid CA:

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Hematogenous (aggressive)
I-131 uptake in Thyroid CA's by type
Thyroid CA's with Good I-131 uptake
Papillary, Follicular
Thyroid CA's without I-131 uptake
Hurthle Cell CA, Medullary, Anaplastic

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Thyroid CA's which require tissue diagnosis (cannot see with FNA)

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Follicular, Hurthle Cell (a type of follicular cell)

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Diagnosis of Follicular Thyroid CA

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Requires tissue diagnosis demonstrating capsular/vascular invasion
FNA would just look like thyroid tissue

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Most Common site of Follicular Thyroid CA metastasis:

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Bone

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10 Year Survival Rate of Follicular Thyroid CA:

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~85%

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Tx: Follicular Thyroid CA:

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Total Thyroidectomy
post-op I-131 scan

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The F's of Follicular Thyroid CA:

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Far-away mets (hematogenous to bone)
Female (3 to 1)
FNA can't make dx
Favorable Prognosis

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Hurthel Cell Thyroid CA Relative Frequency

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5% of all thyroid CA's, 3rd most common (papillary 80%, follicular 10%)

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Diagnosis of Hurthle Cell Thyroid CA

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Requires Ts diagnosis
Cannot see on FNA

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Tx: Hurthle Cell Thyroid CA:

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Total Thyroidectomy

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10 year suvival rate of hurthle cell thyroid CA

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~80%

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10 year survival Rates of Thyroid Cancer types

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Papillary: option of subtotal thyroidectomy if <1.5cm & no hx rads, else total
Follicular: Total
Hurthle Cell: total
Medullary: total + Median Node dissection
Anaplastic: Total + XRT & Chemo

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Medullary Thyroid CA Relative Frequency

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4th most common at 3%

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Treatment Modalities of Thyroid CA's by Type

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Papillary: option of subtotal thyroidectomy if <1.5cm & no hx rads, else total
Follicular: Total
Hurthle Cell: total
Medullary: total + Median Node dissection
Anaplastic: Total + XRT & Chemo

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Medullary Thyroid CA Risk Factors

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RET proto-oncogene
MEN2: Autosomal dominant

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Histology of Medullary Thyroid CA

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aMyloid buildup of calcitonin

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Tumor Marker of Medullary Thyroid CA

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Clacitonin

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Pentagastrin

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Causes an increase in calcitonin secretion
Useful for identifying medullary thyroid ca

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Drug which causes an increase in calcitonin secretion

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Pentagastrin
Useful for identifying medullary thyroid ca

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Diagnostic Modality of Medullary Thyroid CA

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FNA

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Diagnostic Modalities of Thyroid CA

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Papillary: (?)FNA
Follicular: Tissue Sample for Histology
Hurthle: Tissue Sample for Histology
Medullary: FNA
Anaplastic: FNA

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10 year survival of Medullary Thyroid CA

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80% --> 45% depending on whether LNs are involved

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Pt has Medullary Thyroid CA, screen for what?

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MEN2: pheo, hyperparathyroid

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Medullary Thyroid CA pt found to have Pheo

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Operate on Pheo first

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Tx: Medullary Thyroid CA:

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Total Thyroidectomy & Median LN dissexn
modified neck dissexn if lateral LNs are positive

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M's of Medullary Thyroid CA

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MEN2
aMyloid
Median LN dissexn required
Modified neck dissexn if lateral nodes are positive

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What is Anaplastic Thyroid Carcinoma

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Undifferentiated carcinoma arising in 75% of previously differentiated thyroid Ca's

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Histology of Anaplastic Thyroid Carcinoma

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Giant cells, spindle cells

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Diagnostic Modality of Anaplastic Thyroid Carcinoma

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FNA

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DDX: Anaplastic Thyroid Carcinoma

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Thyroid Lymphoma (much better prognosis)

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Tx: anaplastic thyroid carcinoma

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Small: Total Thyroidectomy + XRT/Chemo
Large: debulking surgery, trach, XRT/Chemo

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Px: anaplastic thyroid carcinoma

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dismal, most pts at stage 4 on presentation

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Blood Supply to parathyroids has been compromised intraoperatively

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auto-graft into SCM or forearm

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DDX: dyspnea s/p thyroidectomy

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hematoma vs bialteral recurrent laryngeal nerve damage

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Thyroid CA with amyloid histology

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Medullary (Calcitonin)

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Thyroid CA with spindle cells

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Anaplastic