Surgery

1. Department of Surgery, RCSI.
Thyroid and
Parathyroid Disease

2. Department of Surgery, RCSI.
Thyroid diseases/Morphology
 Diffuse goitre
Simple goitre
 Iodine deficiency
 Congenital defects
 Goitrous agents in diet
Physiological
Smooth toxic goitre
Others

3. Department of Surgery, RCSI.
Thyroid diseases/Morphology
 Multinodular
progression of diffuse
 Solitary nodule

4. Department of Surgery, RCSI.
Presentation
 Symptoms
Asymptomatic
Pressure
Activity
 Signs
Morphology
Nodes
Retrosternal

5. Department of Surgery, RCSI.
Investigations
 All
Thyroid function test
Thyroid antibodies
 Selected
Is it malignant >FNAC
Is it a cyst > FNAC/US
Is it hot > Tc99m
 Other
CT/MRI

6. Department of Surgery, RCSI.
Solitary nodule

7. Department of Surgery, RCSI.
Thyroid Carcinoma
 Differentiated
Papillary
Follicular
Medullary
 Undifferentiated
Anaplastic
 Other
Lymphoma

8. Department of Surgery, RCSI.
Thyroid Carcinoma
 Papillary
 Commonest type (60%)
 Slow growing tumour
 Regional lymph node metastasis
 Found in children and adults
 Multifocal in origin
 Standard treatment is by total thyroidectomy and LN
dissection
 L-thyroxine to suppress TSH post-op is required in all
patients
 Prognosis even in the presence of LN metastases is
excellent

9. Thyroid Carcinoma
 Follicular
20% of thyroid malignancies
Well differentiated tumour
Occur in older age group than papillary
Slow growing tumour
Metastasis (haematogenous) to lungs and
bones mainly
Thyroid lobectomy (without metastasis)
Total thyroidectomy + radioactive iodine
(with mets)
Prognosis depend on extent of vascular
invasion 90% to 30% 10-year survival

10. Thyroid Carcinoma
 Medullary (1)
 Cells secrete calcitonin (tumour marker)
 Uncommon (< 5% of thyroid
malignancies)
 More common in females in the sixth
decade of life
 Slow growing
 Arises from parafollicular cells of the
thyroid
 Demonstrate ability to synthesize
amines and peptides

11. Department of Surgery, RCSI.
Thyroid Carcinoma
 Medullary (2)
Familial & sporadic types may occur
MEN type IIA (medullary thyroid Ca., pheo,
& hyperparathyroidism)
MEN type IIB (medullary thyroid Ca., pheo,
multiple mucosal neuroma, & typical
marfanoid facies)
Treatment is total thyroiectomy and LN
dissection
Prognosis worse than follicular
Overall 5-year survival of 50%

12. Department of Surgery, RCSI.
Thyroid Carcinoma
 Anaplastic
10% of all thyroid malignancies
Commonly in elderly females
Aggressive and rapid growth
 Pressure symptoms (oesophagus &
trachea)
 Laryngeal nerve paralysis
Complete resection not possible
Chemo & radiotherapy not very effective
Mets to LN, lungs, bone
Porognosis is very poor

13. Department of Surgery, RCSI.
Thyroid Lymphoma
Uncommon
Associated with Hashimoto’s thyroiditis
Occurs commonly in the 5th decade of life
Very responsive to radiotherapy

14. Department of Surgery, RCSI.
Thyroid Carcinoma
 Radioactive iodine
 Thyroid suppression
 Monitoring
Thyroglobulin
Calcitonin
CEA

15. Department of Surgery, RCSI.
Thyroid diseases/MNG
 Retrosternal extension
 Pressure
Dysphagia
Tracheal deviation stenosis
Dominant nodule
RLN palsy
Cosmesis
Hyperthyroid

16. Department of Surgery, RCSI.
Thyrotoxicosis
 Antithyroid drug
Carbimazole
PTU
 Radioactive iodine
 Surgery
Preoperative preparation

17. Department of Surgery, RCSI.
Parathyroid Disease

18. Department of Surgery, RCSI.
INTRODUCTION
 Anatomy / Embryology
 Physiology
 Pathology
 Surgery

19. Department of Surgery, RCSI.
Anatomy / Embryology

20. Department of Surgery, RCSI.
PHYSIOLOGY
 Parthyroid Hormone (PTH)
 Secreted by the Chief cells
 Levels are inversely conrolled by [Ca2+ ]
 Effects:
 Tubular reabsorption of Ca2+
 Osteoclastic resorption of bone
 Intestinal absorption of Ca2+
 Synthesis of 1-25DHCC (active Vit. D)
 Excretion of phosphate

21. Department of Surgery, RCSI.
PATHOLOGY
 HYPERPARATHYROIDISM
 1 : 1,000 prevalence
 F : M 2 : 1
 Usually mild / asymptomatic

22. Department of Surgery, RCSI.
Aetiology
 Primary ( PTH, normal or Ca 2+ )
 Adenoma 90%
 Hyperplasia 10%
 Carcinoma < 0.1%
 Secondary ( Renal) ( PTH appropriate to
low Ca 2+ )
 Chronic Renal Failure
 Vitamin D Deficiency

23. Department of Surgery, RCSI.
Parathyroid Adenoma : inferior rim of normal parathyroid
tissue admixed with adipose tissue cells

24. Department of Surgery, RCSI.
Signs / Symptoms
 Asymptomatic (mild, < 2.99)
 “Bones, stones, abdominal groans, psychic
moans”
Bones Bone pain, #’s, arthralgia
Renal Stones, polyuria
G.I. Pain, duodenal ulcer,
pancreatitis
Neuro. Depression, apathy
Cardiac Hypertension, heart block

25. Clinical Presentation
Symptom %
Asymptomatic
hypercalcaemia
50
Renal stones 28
Arthralgia 5
Peptic Ulcer 4
Hypertension 4
Bone disease / MEN 1 /
others
9

26. Department of Surgery, RCSI.
Indications for Surgery
Symptomatic hyperparathyroidism
Serum Ca 2+ . 3.0
Reduced creatinine clearance by 30 %
Renal stone on PFA
Hypercalciuria ( >400mg day –1 )
Reduced cortical bone density
Young patient ( < 50 y.o.)

27. Department of Surgery, RCSI.
SURGERY
 Success rate for surgical cure of primary
hyperparathyroidism should exceed 95%
 Until 10 years ago – bilateral neck
exploration.

28. Department of Surgery, RCSI.
SURGERY
 99mTc sestamibi: A new agent for
parathyroid imaging.
 Coakley et al, Nucl Med Commun, 1989
 Clinical usefulness of intraoperative “quick
parathyroid hormone” assay.
 Irvin,GL, Surgery, 1993
 Intraoperative identification of parathyroid
gland pathology. A new approach utilizing a
hand held gamma probe.
 Martinez DA, J Paedr. Surg, 1995

29. SESTEMIBI SCANNING
 99mTc 2-methyl-isobutyl-isonitrile
radionuclide (Tc-sestemibi)
 Discovered in 1989 to be useful in imaging of
parathyroid glands.
 Radioisotope uptake increases with gland
weight.
 MIBI concentrated in tissues rich in
mitochondria.
Heart
Salivary glands
Thyroid glands
Parathyroid glands

30. The Department of Surgery, RCSI
Summary
 Pre-operative quality imaging is essential
for successful unilateral
parathyroidectomy.
 Sestemibi is the gold standard
91% specificity
Allows intra-op Gamma probe confirmation
 Minimally invasive parathyroidectomy has
revolutionised adenoma surgery.