1212thth
G. Rainey Williams Surgical SymposiumG. Rainey Williams Surgical Symposium
What Operation for Thyroid Cancer?What...
RASRAS
TOTALTOTAL
THYROIDECTOMYTHYROIDECTOMY
RASRAS
Questions?Questions?
RASRAS
IntroductionIntroduction
First reports of thyroidectomy from School of Salerno in Italy inFirst reports of thyroide...
RASRAS
Thyroid CancersThyroid Cancers
Differentiated cancersDifferentiated cancers
•
Papillary carcinomaPapillary carcinom...
RASRAS
Thyroid CancersThyroid Cancers
Differentiated cancersDifferentiated cancers
•
Papillary carcinomaPapillary carcinom...
RASRAS
Thyroid Nodule WorkupThyroid Nodule Workup
50% of population over 50 years have an US50% of population over 50 year...
RASRAS
Thyroid Nodule WorkupThyroid Nodule Workup
Check TSH levelCheck TSH level
•
If high, begin thyroid replacement unti...
RASRAS
Thyroid Nodule WorkupThyroid Nodule Workup
FNA results should be limitedFNA results should be limited
•
Benign goit...
RASRAS
Thyroid Nodule WorkupThyroid Nodule Workup
Benign diagnosisBenign diagnosis
•
Reultrasound in 6 monthsReultrasound ...
RASRAS
The ScienceThe Science
All recommendations are based on retrospectiveAll recommendations are based on retrospective...
RASRAS
Arguments for Total ThyroidectomyArguments for Total Thyroidectomy
Radioactive iodine may be used to detect and tre...
RASRAS
Arguments against total thyroidectomyArguments against total thyroidectomy
Total thyroidectomy may be associated wi...
RASRAS
ComplicationsComplications
Hypoparathyroidism should occur in less than 2% of patientsHypoparathyroidism should occ...
RASRAS
Papillary CarcinomaPapillary Carcinoma
Algorithm for Treatment of Possible PTCAlgorithm for Treatment of Possible P...
RASRAS
Papillary CarcinomaPapillary Carcinoma
If FNA is suspicious for papillary ca but notIf FNA is suspicious for papill...
RASRAS
Papillary/Differentiated CarcinomaPapillary/Differentiated Carcinoma
Up to 80% of patients found to have asymptomat...
RASRAS
Follicular NeoplasmsFollicular Neoplasms
14-29% are invasive cancer14-29% are invasive cancer
Frozen section analys...
RASRAS
Follicular NeoplasmsFollicular Neoplasms
Resection of lobe/isthmus with carefulResection of lobe/isthmus with caref...
RASRAS
HHüürthle Cell Neoplasmsrthle Cell Neoplasms
More aggressive than other differentiated thyroidMore aggressive than ...
RASRAS
Medullary CarcinomaMedullary Carcinoma
Presents as either an inherited syndrome (20%) or asPresents as either an in...
RASRAS
Medullary CarcinomaMedullary Carcinoma
Familial cases positive forFamilial cases positive for RETRET proto-proto-
o...
RASRAS
Medullary CarcinomaMedullary Carcinoma
If persistent elevated CEA or calcitonin, CTIf persistent elevated CEA or ca...
RASRAS
Medullary CarcinomaMedullary Carcinoma
RASRAS
Incidentaloma/Micrometastatic DiseaseIncidentaloma/Micrometastatic Disease
Lesions detected by imaging or found aft...
RASRAS
Incidentaloma/Micrometastatic DiseaseIncidentaloma/Micrometastatic Disease
Consider suspicious features:Consider su...
RASRAS
Incidentaloma/Micrometastatic DiseaseIncidentaloma/Micrometastatic Disease
RASRAS
Local Invasion of the NeckLocal Invasion of the Neck
Tracheal resection repaired primarilyTracheal resection repair...
RASRAS
Local Invasion of the NeckLocal Invasion of the Neck
Crycoid invasion with local muscle flap reconstructionCrycoid ...
RASRAS
Local Invasion of the NeckLocal Invasion of the Neck
Vertical hemilaryngectomyVertical hemilaryngectomy
RASRAS
Local Invasion of the NeckLocal Invasion of the Neck
Circumferential tracheal resection with primary anastomosisCir...
RASRAS
SummarySummary
Total thyroidectomy is surgery of choice forTotal thyroidectomy is surgery of choice for
differentia...
RASRAS
QuestionsQuestions
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What Operation for Thyroid Cancer

  1. 1. 1212thth G. Rainey Williams Surgical SymposiumG. Rainey Williams Surgical Symposium What Operation for Thyroid Cancer?What Operation for Thyroid Cancer? Ronald Squires, MD FACSRonald Squires, MD FACS Associate Professor of SurgeryAssociate Professor of Surgery Sections of General and Transplant SurgerySections of General and Transplant Surgery University of Oklahoma Health Science CenterUniversity of Oklahoma Health Science Center
  2. 2. RASRAS TOTALTOTAL THYROIDECTOMYTHYROIDECTOMY
  3. 3. RASRAS Questions?Questions?
  4. 4. RASRAS IntroductionIntroduction First reports of thyroidectomy from School of Salerno in Italy inFirst reports of thyroidectomy from School of Salerno in Italy in 11701170 Johann Dieffenbach of Berlin in 1848 stated that thyroidectomyJohann Dieffenbach of Berlin in 1848 stated that thyroidectomy was “one of the most thankless and most perilous undertakings”was “one of the most thankless and most perilous undertakings” in surgeryin surgery Outcomes were so poor that the French Academy of MedicineOutcomes were so poor that the French Academy of Medicine banned its practice in 1850banned its practice in 1850 Billroth performed 59 thyroidectomies from 1861-1867 with aBillroth performed 59 thyroidectomies from 1861-1867 with a 40% mortality—a later series from 1877-1881 reported 1640% mortality—a later series from 1877-1881 reported 16 thyroidectomies with 100% survivalthyroidectomies with 100% survival Theodore Kocher won the Nobel prize in medicine in 1909 forTheodore Kocher won the Nobel prize in medicine in 1909 for his contributions to thyroid surgery including many of thehis contributions to thyroid surgery including many of the techniques still used by modern day thyroid surgeonstechniques still used by modern day thyroid surgeons Halsted first to advocate and popularize subtotal thyroidectomyHalsted first to advocate and popularize subtotal thyroidectomy to preserve parathyroids and protect recurrent laryngeal nervesto preserve parathyroids and protect recurrent laryngeal nerves
  5. 5. RASRAS Thyroid CancersThyroid Cancers Differentiated cancersDifferentiated cancers • Papillary carcinomaPapillary carcinoma • Mixed papillary/follicular carcinomaMixed papillary/follicular carcinoma • Follicular carcinomaFollicular carcinoma • HHüürthle cellrthle cell Medullary carcinomaMedullary carcinoma Anaplastic carcinomaAnaplastic carcinoma Lymphoma of thyroidLymphoma of thyroid
  6. 6. RASRAS Thyroid CancersThyroid Cancers Differentiated cancersDifferentiated cancers • Papillary carcinomaPapillary carcinoma • Mixed papillary/follicular carcinomaMixed papillary/follicular carcinoma • Follicular carcinomaFollicular carcinoma • HHüürthle cellrthle cell Medullary carcinomaMedullary carcinoma
  7. 7. RASRAS Thyroid Nodule WorkupThyroid Nodule Workup 50% of population over 50 years have an US50% of population over 50 years have an US detectable thyroid noduledetectable thyroid nodule Prevalence of nonpalpable clinicallyPrevalence of nonpalpable clinically significant (1-1.5cm) nodes is 2-3%significant (1-1.5cm) nodes is 2-3% 90% of all nodules reflect benign disease90% of all nodules reflect benign disease Of the 10% of malignant nodules, 75% areOf the 10% of malignant nodules, 75% are papillary and 15% are follicularpapillary and 15% are follicular
  8. 8. RASRAS Thyroid Nodule WorkupThyroid Nodule Workup Check TSH levelCheck TSH level • If high, begin thyroid replacement until euthyroidIf high, begin thyroid replacement until euthyroid • If low, nuclear scan to check for hyperfunctioning noduleIf low, nuclear scan to check for hyperfunctioning nodule (very rarely malignant)(very rarely malignant) FNA with or without US guidance when euthyroidFNA with or without US guidance when euthyroid Nodules greater than 1cm in two dimensions areNodules greater than 1cm in two dimensions are clinically significantclinically significant 16% of patients with palpable nodules will have no16% of patients with palpable nodules will have no nodule visible by US and the vast majority will benodule visible by US and the vast majority will be diagnosed with Hashimoto’s thyroiditisdiagnosed with Hashimoto’s thyroiditis In multinodular goiter, masses > 1cm should beIn multinodular goiter, masses > 1cm should be biopsied (5-13% risk of cancer in these larger lesions)biopsied (5-13% risk of cancer in these larger lesions)
  9. 9. RASRAS Thyroid Nodule WorkupThyroid Nodule Workup FNA results should be limitedFNA results should be limited • Benign goiterBenign goiter • MalignancyMalignancy • Follicular neoplasmFollicular neoplasm • Nondiagnostic sampleNondiagnostic sample Diagnostic accuracyDiagnostic accuracy • Sensitivity > 92%Sensitivity > 92% • Specificity 91-98%Specificity 91-98%
  10. 10. RASRAS Thyroid Nodule WorkupThyroid Nodule Workup Benign diagnosisBenign diagnosis • Reultrasound in 6 monthsReultrasound in 6 months – If same or smaller, follow yearlyIf same or smaller, follow yearly – If larger, (15% increase in size in two dimensions) thenIf larger, (15% increase in size in two dimensions) then repeat FNArepeat FNA Indeterminate diagnosisIndeterminate diagnosis • Repeat FNA in 3 months or consider using US guidance ifRepeat FNA in 3 months or consider using US guidance if not previously usednot previously used Follicular cytology (80% benign disease)Follicular cytology (80% benign disease) • Thyroid scan (if “hot” nodule in euthyroid patient thenThyroid scan (if “hot” nodule in euthyroid patient then observe)observe) • All cold nodules and hot nodules in hyperthyroid patientsAll cold nodules and hot nodules in hyperthyroid patients should be removedshould be removed
  11. 11. RASRAS The ScienceThe Science All recommendations are based on retrospectiveAll recommendations are based on retrospective series or multivariate analysisseries or multivariate analysis Mathematical models are also utilized to extrapolateMathematical models are also utilized to extrapolate data to existing populationsdata to existing populations The incidence of thyroid carcinoma is 11,000 casesThe incidence of thyroid carcinoma is 11,000 cases per year in the US with 1,100 deathsper year in the US with 1,100 deaths Given the good overall survival, a prospective studyGiven the good overall survival, a prospective study would need at least 12,000 patients followed for awould need at least 12,000 patients followed for a minimum of 20 years to distinguish subtle therapeuticminimum of 20 years to distinguish subtle therapeutic differencesdifferences
  12. 12. RASRAS Arguments for Total ThyroidectomyArguments for Total Thyroidectomy Radioactive iodine may be used to detect and treat residualRadioactive iodine may be used to detect and treat residual normal thyroid tissue and local or distant metastasesnormal thyroid tissue and local or distant metastases Serum thyroglobulin level is a more sensitive marker forSerum thyroglobulin level is a more sensitive marker for persistent or recurrent disease when all normal thyroid tissue ispersistent or recurrent disease when all normal thyroid tissue is removedremoved In up to 85% of papillary cancer, microscopic foci are present inIn up to 85% of papillary cancer, microscopic foci are present in the contralateral lobe. Total thyroidectomy removes thesethe contralateral lobe. Total thyroidectomy removes these possible sites of recurrencepossible sites of recurrence Recurrence develops in 7% of contralateral lobes (1/3 die)Recurrence develops in 7% of contralateral lobes (1/3 die) Risk (though very low [1%]) of dedifferentiation into anaplasticRisk (though very low [1%]) of dedifferentiation into anaplastic thyroid cancer is reducedthyroid cancer is reduced Survival is improved if papillary cancer greater than 1.5cm orSurvival is improved if papillary cancer greater than 1.5cm or follicular greater than 1cmfollicular greater than 1cm Need for reoperative surgery associated with higher risk is lowerNeed for reoperative surgery associated with higher risk is lower
  13. 13. RASRAS Arguments against total thyroidectomyArguments against total thyroidectomy Total thyroidectomy may be associated with higherTotal thyroidectomy may be associated with higher complication rate than lobectomycomplication rate than lobectomy 50% of recurrences can be controlled with surgery50% of recurrences can be controlled with surgery Fewer than 5% of recurrences occur in the thyroidFewer than 5% of recurrences occur in the thyroid bedbed Tumor multicentricity has little clinical significanceTumor multicentricity has little clinical significance Prognosis of low risk patients (age, grade, extent,Prognosis of low risk patients (age, grade, extent, size) is excellent regardless of extent of resectionsize) is excellent regardless of extent of resection
  14. 14. RASRAS ComplicationsComplications Hypoparathyroidism should occur in less than 2% of patientsHypoparathyroidism should occur in less than 2% of patients Recurrent laryngeal nerve injury in virgin neck less than 0.5% ofRecurrent laryngeal nerve injury in virgin neck less than 0.5% of patientspatients Superior laryngeal nerve injury in virgin neck less than 2% ofSuperior laryngeal nerve injury in virgin neck less than 2% of patientspatients
  15. 15. RASRAS Papillary CarcinomaPapillary Carcinoma Algorithm for Treatment of Possible PTCAlgorithm for Treatment of Possible PTC
  16. 16. RASRAS Papillary CarcinomaPapillary Carcinoma If FNA is suspicious for papillary ca but notIf FNA is suspicious for papillary ca but not diagnostic then incidence is 54% cancerdiagnostic then incidence is 54% cancer Presence of microcalcifications on FNAPresence of microcalcifications on FNA suggestive of papillary ca (36% sensitivity,suggestive of papillary ca (36% sensitivity, 93% specificity, 76% accuracy)93% specificity, 76% accuracy) Pts with confirmed or highly suspiciousPts with confirmed or highly suspicious intraoperative finding should receive total orintraoperative finding should receive total or near total thyroidectomy (< 3 gm remnant)near total thyroidectomy (< 3 gm remnant) Prophylactic node dissection not indicatedProphylactic node dissection not indicated
  17. 17. RASRAS Papillary/Differentiated CarcinomaPapillary/Differentiated Carcinoma Up to 80% of patients found to have asymptomatic positive nodesUp to 80% of patients found to have asymptomatic positive nodes during series of prophylactic neck dissectionsduring series of prophylactic neck dissections 1,21,2 Clinically significant disease only develops in less than 10% ofClinically significant disease only develops in less than 10% of patients with microscopic lymph node metastasespatients with microscopic lymph node metastases 1,3,41,3,4 Central node dissection should be carried out if central nodes areCentral node dissection should be carried out if central nodes are enlarged and positive by frozen sectionenlarged and positive by frozen section Ipsilateral modified neck dissection has been shown to reduceIpsilateral modified neck dissection has been shown to reduce regional recurrence without improving survival if enlarged cervicalregional recurrence without improving survival if enlarged cervical node is positive by preop FNA or intraoperative frozennode is positive by preop FNA or intraoperative frozen55 Node Dissection:Node Dissection: 11 Am J Surg 122:464-471,1971Am J Surg 122:464-471,1971 22 World J Surg 18:359-367,1994.World J Surg 18:359-367,1994. 33 Surg Clin North Am 67:251-261,1987.Surg Clin North Am 67:251-261,1987. 44 Cancer 26:1053-1060, 1970Cancer 26:1053-1060, 1970 55 Textbook of Endocrine Surgery, WB Saunders, 1997, p90.Textbook of Endocrine Surgery, WB Saunders, 1997, p90.
  18. 18. RASRAS Follicular NeoplasmsFollicular Neoplasms 14-29% are invasive cancer14-29% are invasive cancer Frozen section analysis can be misleadingFrozen section analysis can be misleading Hallmarks of cancer are capsular or vascular invasionHallmarks of cancer are capsular or vascular invasion Follicular CA more likely hematogenous spreadFollicular CA more likely hematogenous spread Worse prognosis associated with increased age andWorse prognosis associated with increased age and stage at diagnosis compared to papillarystage at diagnosis compared to papillary >4cm nodule is 50-60% likely invasive disease>4cm nodule is 50-60% likely invasive disease
  19. 19. RASRAS Follicular NeoplasmsFollicular Neoplasms Resection of lobe/isthmus with carefulResection of lobe/isthmus with careful examination for gross invasion or nodalexamination for gross invasion or nodal diseasedisease Await final pathology of lobe/isthmus and ifAwait final pathology of lobe/isthmus and if positive, return to OR for completionpositive, return to OR for completion lobectomylobectomy Subsequent ISubsequent I131131 treatment, TSH suppressiontreatment, TSH suppression and monitoring of thyroglobulin (<2and monitoring of thyroglobulin (<2µµg/l)g/l)
  20. 20. RASRAS HHüürthle Cell Neoplasmsrthle Cell Neoplasms More aggressive than other differentiated thyroidMore aggressive than other differentiated thyroid carcinomas (higher mets/lower survival rates)carcinomas (higher mets/lower survival rates) Decreased affinity for IDecreased affinity for I131131 Need to differentiate from benign/malignantNeed to differentiate from benign/malignant Cancer in 13-35% of HCancer in 13-35% of Hüürthle cell FNAsrthle cell FNAs 65% of tumors > 4cm are malignant65% of tumors > 4cm are malignant If malignant, needs total thyroidectomy and IIf malignant, needs total thyroidectomy and I131131 withwith thyroglobulin assaysthyroglobulin assays Mets may be more sensitive to IMets may be more sensitive to I131131 than primarythan primary
  21. 21. RASRAS Medullary CarcinomaMedullary Carcinoma Presents as either an inherited syndrome (20%) or asPresents as either an inherited syndrome (20%) or as an incidental eventan incidental event More aggressive than the differentiated thyroidMore aggressive than the differentiated thyroid cancerscancers Does not respond to IDoes not respond to I131131 Multicentric in 20% of sporadic cases and in almost allMulticentric in 20% of sporadic cases and in almost all of inherited casesof inherited cases Much more likely to invade lateral lymph basinsMuch more likely to invade lateral lymph basins Need baseline CEA and calcitonin levelsNeed baseline CEA and calcitonin levels
  22. 22. RASRAS Medullary CarcinomaMedullary Carcinoma Familial cases positive forFamilial cases positive for RETRET proto-proto- oncogene mutationoncogene mutation If positive family history, then genetic testingIf positive family history, then genetic testing If MEN IIA or FMTC then total thyroidectomyIf MEN IIA or FMTC then total thyroidectomy and central lymph node dissection betweenand central lymph node dissection between ages of 5-6 yearsages of 5-6 years If MEN IIB then total thyroidectomy andIf MEN IIB then total thyroidectomy and central node dissection ages 6mos - 3 yearscentral node dissection ages 6mos - 3 years SURGERY IS ONLY EFFECTIVE THERAPYSURGERY IS ONLY EFFECTIVE THERAPY
  23. 23. RASRAS Medullary CarcinomaMedullary Carcinoma If persistent elevated CEA or calcitonin, CTIf persistent elevated CEA or calcitonin, CT scan for residual disease (50% of pts)scan for residual disease (50% of pts) Aggressive neck dissection advocated byAggressive neck dissection advocated by many if persistent diseasemany if persistent disease Consider laparotomy for possible liver metsConsider laparotomy for possible liver mets Prolonged survival with significant symptomsProlonged survival with significant symptoms not uncommon with widely metastatic diseasenot uncommon with widely metastatic disease
  24. 24. RASRAS Medullary CarcinomaMedullary Carcinoma
  25. 25. RASRAS Incidentaloma/Micrometastatic DiseaseIncidentaloma/Micrometastatic Disease Lesions detected by imaging or found afterLesions detected by imaging or found after surgery for unrelated indicationsurgery for unrelated indication Thyroid nodules common in population (4-Thyroid nodules common in population (4- 10% have palpable nodules any given time)10% have palpable nodules any given time) Female/male incidence 6.4 / 1.6%Female/male incidence 6.4 / 1.6% 12% detected by palpation vs. 45% by12% detected by palpation vs. 45% by imagingimaging Lesions less than 1 cm-observeLesions less than 1 cm-observe Lesions 1-2cm “gray zone”Lesions 1-2cm “gray zone” Lesions > 2cm are NOT INCIDENTALLesions > 2cm are NOT INCIDENTAL
  26. 26. RASRAS Incidentaloma/Micrometastatic DiseaseIncidentaloma/Micrometastatic Disease Consider suspicious features:Consider suspicious features: • Increased vascularityIncreased vascularity • Irregular marginIrregular margin • Central microcalcificationCentral microcalcification • Cervical adenopathyCervical adenopathy
  27. 27. RASRAS Incidentaloma/Micrometastatic DiseaseIncidentaloma/Micrometastatic Disease
  28. 28. RASRAS Local Invasion of the NeckLocal Invasion of the Neck Tracheal resection repaired primarilyTracheal resection repaired primarily
  29. 29. RASRAS Local Invasion of the NeckLocal Invasion of the Neck Crycoid invasion with local muscle flap reconstructionCrycoid invasion with local muscle flap reconstruction
  30. 30. RASRAS Local Invasion of the NeckLocal Invasion of the Neck Vertical hemilaryngectomyVertical hemilaryngectomy
  31. 31. RASRAS Local Invasion of the NeckLocal Invasion of the Neck Circumferential tracheal resection with primary anastomosisCircumferential tracheal resection with primary anastomosis
  32. 32. RASRAS SummarySummary Total thyroidectomy is surgery of choice forTotal thyroidectomy is surgery of choice for differentiated cancer as well as medullarydifferentiated cancer as well as medullary carcinoma of thyroidcarcinoma of thyroid Consider subtotal (less than 2gms residualConsider subtotal (less than 2gms residual tissue) if less experienced or hazardoustissue) if less experienced or hazardous operative environmentoperative environment No therapeutic advantage for totalNo therapeutic advantage for total thyroidectomy in setting of papillarythyroidectomy in setting of papillary microcarcinomamicrocarcinoma
  33. 33. RASRAS QuestionsQuestions

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