Surgical Aspects of Thyroid Tumours

1. Surgical Aspects of Thyroid Tumours
Department of ENT and Head & Neck Surgery
Dr Shubham Dadoo

2. INTRODUCTION
 Thyroid cancer is most common endocrine tumour.
 Incidence 1.2-3.8 / 1 Lakh cases/ Yr.
 M/C Presentation – Solitary thyroid nodule in a
euthyroid Pt.
 2-4 times more frequent in females.
 Rare in children below 16 yrs

3. Predisposing FACTORS
• prolonged stimulation by elevated TSH;
• solitary thyroid nodule;
• ionizing radiation;
• genetic factors;
• chronic lymphocytic thyroiditis.

4. A nodule is more likely to be malignant if:
• there is a previous history of thyroid cancer;
• it is enlarging (particularly on suppressive doses of
thyroxine);
• the nodule develops under 14 or over 65 years of age;
• the patient is male;
• there is a past history of ionizing radiation;
• TSH is elevated;
• thyroid antibodies are positive.

5. a) Rapid tumour growth.
b) Very firm nodules.
c) Fixation to adjacent structures.
d) Vocal cord paralysis.
e) Regional LAP.
f) Family history of MTC or MEN.
g) Age <20 or >60 years.
h) Male sex.
i) Solitary nodule.
j) Elevated TSH.
k) History of head or neck irradiation.
l) Compression symptoms: dysphagia,
dysphonia, hoarseness, dyspnoea or cough.
Factors suggesting the diagnosis of thyroid carcinoma in
patients presenting with thyroid enlargement

6. CLASSIFICATION OF THYROID TUMOURS
BENIGN
A) Follicular cell adenoma.
B) Hurthle cell adenoma.
C) Teratoma.
SECONDARY:
MALIGNANT
PRIMARY
A) Papillary carcinoma
- Pure papillary.
- Mixed papillary-follicular.
- Follicular variant.
B) Follicular carcinoma
C) Hurthle cell carcinoma
D) Medullary carcinoma
E) Anaplastic carcinoma
F) Lymphoma
G) Sarcoma
H) Squamous cell carcinoma
SECONDARY
Kidney, Lung, Colon & Breast

7. PAPILLARY ADENOCA
• 80% of thyroid malignancy.
• Occurs in all age groups.
• Presents as solitary nodule in thyroid.
• EXTENT –
a) Minimal (microCa) <1.0 cm
b) Intra-thyroidal >1.0 cm
c) Extra-thyroidal- beyond gland capsule
and/or with lymph node metastases.
• Young adults (20-45 yrs)
• Female to male ratio is 3:1.
• High incidence of involvement of cervical lymph
nodes(60%) in levels 3 to 7

8. FOLLICULAR ADENOCA
• Occurs in older age groups.
• Most common in 50-59 yrs.
• 10 – 20 % of all thyroid malignancies.
• Most commonly presents as a solitary thyroid
nodule.
• Lymph node involvement is much less
common (about 10%)

9. HURTHLE CELL TUMOURS
• Extremely uncommon.
• Histological distinction between benign and malignant is
difficult.
• Malignant invade surrounding thyroid tissue and
extrathyroid structures.
• Lymph node metastases are common.

10. MEDULLARY THYROID CA
• 5% of all cases of thyroid malignancy.
• Occur as a part of MEN syndrome, as familial non-MEN
disease or it may be sporadic.
• In patients with MEN, it is frequently multifocal and bilateral
(90%).
• Cervical node metastases in 50% of cases.

11. ANAPLASTIC CARCINOMA
• More common in elderly and in women.
• Superimposed on a long standing goitre.
• Increases in size rapidly.
• Associated with otalgia, hoarseness and stridor.
• Aggresively malignant, high metastatic
potential.
• BAD prognosis.

13. INVESTIGATION PROFILE
• INCLUDES-
1) Radiology.
2) Laboratory investigations.
3) Cytology.

14. DIAGNOSTIC STRATEGY FOR EVALUATION OF
‘SOLITARY’ THYROID NODULE
Physical examination +Thyroid function tests
Treat thyroid dysfunction Refer for FNAC if no
if present. thyroid dysfunction
FNAC Results
Malignant Suspicious Benign Inadequate sample
Surgery Surgery Repeat FNAC Repeat
after 6 months FNAC

15. LABORATORY INVESTIGATIONS
INCLUDE: a) TSH
b) T3
c) T4
d) Serum calcium
e) Thyroid
f) If medullary carcinoma is suspected,
serum calcitonin should be measured.

16. CYTOLOGY
• FNAC- gold standard investigation.
FNAC SHOULD NOT BE RELIED UPON IN
PATIENTS WITH A HISTORY OF RADIATION
EXPOSURE TO EXCLDE THE MALIGNANCY.
INSTEAD NEEDLE-CORE BIOPSY IS
APPROPRIATE.

17.  Patients under 45 and women in general have
a better prognosis.
 Patients with papillary thyroid cancer have
better prognosis than other thyroid tumours.
 Nodal metastases are associated with worse
prognosis in elderly patients.
 For medullary thyroid cancers, age at
presentation,TNM staging, previous surgery,
extent of surgery, pre and post-op calcitonin
levels are important prognostic factors.
PROGNOSTIC FACTORS

18. TREATMENT POLICY
• Treatment modalities for thyroid malignancy
include:
 Surgery.
 Radioactive iodine.
 External beam radiotherapy.
 Thyroxine therapy.
 Chemotherapy.

19. • SURGERY is the mainstay of treatment
 Main aim of initial therapy:
- remove the primary tumour disease and
that which has spread to the thyroid gland
capsule and involved cervical lymph nodes.
SURGICAL MANAGEMENT

20.  Total thyroidectomy = 2 × total lobectomy +
isthmusectomy
 Subtotal thyroidectomy = 2 subtotal lobectomy +
isthmusectomy
 Near-total thyroidectomy = total lobectomy +
isthmusectomy + subtotal lobectomy
 Lobectomy = total lobectomy + isthmusectomy

21. NECK DISSECTION IN THYROID CANCER
 Elective neck dissection is not performed for DTC of
follicular cell origin
 Central compartmental ( level VI) is recommended
for all patients with clinically involved nodes
 Prophylactic central neck dissection in clinically N0
patients with T3 or T4 tumors

22. PAPILLARY THYROID CANCER
A) Cancer <=1cm with N0  LOBECTOMY and
THYROXINE SUPPRESSION THERAPY.
B) Cancer >1 cm in diameter / Multifocal disease /
History of previous radiation exposure in
childhoodTOTAL THYROIDECTOMY.

23. FOLLICULAR THYROID CARCINOMA
1) <1 cm in diameter and no capsular
invasionONLY LOBECTOMY.
2) Follicular carcinoma with evidence of
vascular invasion TOTAL THYROIDECTOMY.
3) > 4 cm in diameter- TOTAL OR NEAR-TOTAL
THYROIDECTOMY.

24. SOLITARY THYROID NODULE
FOLLICULAR LESION (Thy 3)- Diagnostic hemithyroidectomy.
SUSPICIOUS FOR CARCINOMA (Thy 4)- Diagnostic
hemithyroidectomy with or without complete frozen
section and proceed.
PAPILLARY CARCINOMA (Thy 5)- Total thyroidectomy with
or without neck dissection and central neck dissection in
high risk patients.
MEDULLARY CARCINOMA (Thy 5)- Total thyroidectomy and
level 6 + 7 dissection and lateral neck dissection in high
risk patients.

28. POSTOP CARE
a) In immediate post-op periodwatch for bleeding
and airway embarassment.
b) Blood count and serum calcium the morning after
surgery.
c) Following lobectomy Thyroxine replacement
not required unless patient develops subclinical
hypothyroidism.
d) TFT performed  6 weeks after surgery.
e) Following lobectomy for malignancysuppressive
doses of thyroxine
f) After total thyroidectomy for malignancy,
commence T4 immediately unless radioiodine
ablation is planned within next four weeks

29. COMPLICATIONS FOLLOWING
THYROIDECTOMY
EARLY:
Haemorrhage, voice change, airway obstruction
and temporary hypoparathyroidism.
INTERMEDIATE:
Seroma formation, infection and temporary palsy
of RLN and External branch of SLN.
LATE:
Subclinical hypothyroidism, permanent
hypoparathyroidism, permanent injury to RLN,
EBSLN, cutaneous nerves C2 and C3 and the
accessory nerve and a poor scar.