|






2 Bi-lobed gland over second and third
tracheal ring
2 piramidal lobe : 40 50 %
2 Weight : 20 30 gr
2 Epithelium lined follicle
2 Colloid : glycoprotein ( thyroglobulin )
2 Vascular stroma
2 True connective tissue capsule
K 
   

 
  



 





K

 


2 Knferior thyroid artery :

Thyrocervical trunk
Absent in up to 6%
2 Thyroidea ima :
directly from aorta , innominate artery or
right common carotid artery
2 Present in up to 12%
2 uperior thyroid vein : K V or common facial
vein
2 Knferior jugular vein : innominate vein or K V
2 Middle thyroid vein : K V
2 Lymphatic paratracheal nodes superior
mediastinum & middle deep cervical node
and lateral the neck



2 Median endodermal derivative that migrates

from the tongue base to its normal position in
the neck by 7th week .

2 The distal portion of this thyroglossal duct

forms the thyroid gland




2 Concentrate iodine
2 20 30 % is store in thyroid
2 mall percentage in hormone and nonthyroid
tissue
2 All tyrosine compounds are bound to
thyroglubulin and store in thyroid follicles as
colloid
2 The unbound thyroid hormone is responsible
for influencing metabolism .
|
 
 

2 7% of the population has remnants of the

thyroglossal duct
2 Cyst : anywhere along the length of duct
60% infrahyoid , 24% suprahyoid ,
1% intralingual
2 1-2 cm cystic mass that is mobile on
swallowing & protruding of the tongue
2 60% contain thyroid tissue
2 Malignancy is rare
2 Acute infection
2 Contain mucus like clear fluid
2 Kf it is become symptomatic it must be
removed
2 istrunk operation

 


2 ailure of thyroglossal duct to descend

2 A mass at the foramen cecum
2 Aysmptomatic or present with airway
obstruction
2 May be the only thyroid tissue

 

2 Anywhere along the migratory route of the

thyroid

2 Mediastinum , larynx , trachea , pericardium

or esophagus


 
 

 

Present in children persistent ultimobranchial

bodies or an intrathyroidal thyroglossal duct
cyst
K
 

  

 
  
 

2 M=
2 Preceded by an upper respiratory tract
infection
2 taph. The most common organism
2 Painful enlargement of the gland
2 ever
2 Abscess formation
 
 

 

2 More common in female

2 Difuse thyroid enlarement
2 Without pain or thyroid enlargement
2 Temporary hyperthyroidism
2 50% become hypothyroid which resolves in
6 month
  
 

2 Knitial hypothyroidism is mild

2 Lymphocytic infiltration and follicle disruption
2 elf-limiting disease
2 teroid may be of value
 
 
 

 

2 At all age most common at 5th decade

2 M
2 May be viral
2 Painful thyroiditis
2 Defuse thyroid enlargement
2 Malaise and fever
2 thyrotoxic


 

2 Ayperthyroidism : 1-3 month

2 Euthyroid : 1-3 weeks
2 Aypothyroid : 2-6 month
2 Recovery which is complete
2 Lymphocyte , monoycyte and giant cell
infiltration .

2 Treatment consist of analgesic steroid and

antiinflammatory agents .
A  


2 Common
2 Affecting 2 population
2 95 % in female Autoimmune etiology with
strong genetic predisposition
2 Diffusely enlarge with nodularity firm
2 Disrupted follicle with lymphocyte and
plasma cell infiltration and variable fibrosis
2 Residual hypothyroidism

 

  

 

2 Anti thyroglobulin and antimicrosomsal ab

are present up to 90%
2
A is diagnostic
2 Kncreased risk for developing B cell
lymphoma
X 
 

2 ncommon
2 M
2 Older patient
2 May be mediastinal & retroperitoneal fibrosis
2 ixed rock-hard thyroid enlargement
2 Gland replaced with fibrosisAirway obstruction and
dysphagia
2 Palliative surgery to relieve obstruction
A

 
    

2 3th and 4th decade

2 M : 71
2 Autoimmune etiology : abnormal Kg that fix on
TA receptor of thyroid epithelial cell
2 Diffuse toxic goiter
2 ophthalmopathy 55%
2 Dermophathy 5%



2  T3 , T4 , T3R
2 Thionamide , sympathetic blocker , iodine
2 Radioactive iodine



 

    

 
 

2 Refuse radioactive therapy

2 Thyroid nodules suspicious for malignancy
2 Must be rendered euthyroid prior to surgery
 

 
 

  

! 

  




|"
 

2 Older patient no ophthalmopathy or

dermophathy
2 Total thyroidectomy
2 Radioactive iodine but not successfully as
surgery
|" 
 

2 >ounger patient Quite large ( 2.5 3 cm )

2 urgical excision

 

"

2 Compensatory response
2 Common in female econdary to dietry
deficiency
2 ymptom and sign of pressure
  
 #$%

  



| 


2 Thyroid suppression
2 urgery:
cosmetic deformity
pressure symptom refractory to suppression
ear of malignancy
Development of toxicity
 &

@

 


2 Encapsulated tumor
2 Glandular epithelium with intratumoral
degenerative changes ( hemorrhage ,
fibrosis , calcification )
2 Rare thyrotoxicosis
2 Type : follicular,colloid , embryonal, fetal ,
Aurthle ???
 


  
 

'() '*%

2 Third 5th decade

2 M : 21
2 Kndolent with overall excellent prognosis
2 May arise from benign adenoma
2 Low-dose and high dose external RT
   

2 Occult ; <1.5 cm
2 Kntrathyroid ( 70% )
2 Extrathyroid : infiltrate larynx , trachea , strap
muscle , great vessel
  

2 Purely papillary
2 ome may have area of follicular
2 Anaplastic transformation is rar
2 Venous invasion in 10%
K
 
 
 
 

  
  





 




    


 



 
 
 

2 Advance age
2 Male gender
2 extrathyroid extension
2 Distant metastasis



2 Dedifferentiation
2 Vascular invasion
2 Atypical variants ( tall cell, columnar ,
sclerosing ) may have negative prognostic
significance
  

#*%

2 Vascular invasion
2 Metastasis to bone brain and liver
2 Anaplastic transformation is more common
2 Overtly invasive : infiltrate surrounding
structure ( MR 20-50%)
2 Minimally invasive : microscopically has
capsular invasion (MR 5%)

 
  


   








 
 

2 Advanced age
2 Male gender extrathyroid extension
2 Distant metastasis
2 Vascular invasion
2 anaplastic transformation trabecular growth
pattern
A  
 
*%

2 As a variant of follicular tumors

2 Overtly invasive :higher mortality rate
Aigher L
metastasis

2 Minimally invasive
 

 

A  

 |   
 A


 


 

  
 

 
 
 
+*%

2 10 20 % familial
2 poradic : in 5th decade
2 Multicentric ,lateral upper 23 of gland
2 Encapsulated , diffuse infiltrative
2 50% nodal metastasis
2 15-25% distant metastasis

$

2 Medullary thyroid cancer

2 C-cell hyperplasia
2 Adrenal pheochromocytoma
2 Adrenal medullary hyperplasia
2 Parathyroid hyperplasia

$@

Kn addition :
2 Mucosal neuromas
2 GK ganglioneuroma
2 Musculoskeletal abnormality

 
 

2 ME
type 2B
2
odal & distant metastasis
2 Extrathyroid extension
2 mall cell tumor pleomorphism
2 Poor calcitonin staining
2 Aigh CEA

  
 
#*%

2 Rare tumor
2 Arise in well-differentiated tumor
2 Older women
2 Advance stage early infiltration of
surrounding structure
2 mall cell , giant cell
2 Extremely poor prognosis

  
#+*%

2 Primarily in the thyroid

2 As a part of systemic disease
2 Arises in a gland with Aashimotos thyroiditis
2 Elderly women
2 Diffusely enlarged gland or nodule
2 Aypothyroidism
2 Diffuse large cell lymphoma
2 Good prognosis
 
 

2 arcoma
2 Mucoepidermoid carcinoma
2 CC
2 Kidney , colon , melanoma are the most
common distant site

  
 

|

 


2 mooth and diffuse ( usually benign )

2
odular
2 Multinodular goiter may harbor a neoplasm(
10-15% ) :
90% benign
10 % malignent
 

 



 

  

#$%

& 
 

2 Dysphagia ( discomfort on swallowing

obstruction )
2 Mild to moderate stridor chondromalacia
airway obstruction
2 TVC edema & RL
paralysis hoarseness
2 Retrosternal extension tracheal deviation
& VC

& 

 

2 tridor and hemoptysis

2 Rapid increasing in mass
2 RL
paralysis
2 Dysphagia & odynophagia
2 Brachial plexus infiltration
2 Painful enlargement



 

  

2 Kt is the only obvious clinical evidence of

thyroid cancer
2 Papillary metastasis may be cystic ( 20%)
2 ollicular carcinoma : distant metastasis
2 Medullary and anaplastic : extracapsular
extension







2 Most patients are euthyroid

2 Occasionally : hypothyroid
2 Rarely : hyperthyroid
2 Medullary :  calcitonin , ACTA , PG
secretion
  
 

,-


2 Patchy calcification :
Benign thyroid disease
Well differentiated carcinoma
Medullary carcinoma
  -X

2 Retrosternal extension
2 Tracheal deviation
2 Mediastinal nodal involvement
2 Pulmonary metastasis
-X  


   

2 Kt should be done if the patient complains of

significant dysphagia
2 Kt differentiate thyroid from nonthyroid causes
of dysphagia
X 
 

2 Determine the functional status of gland

2 Differentiate diffusely enlarge from nodular
2 Differentiate single nodule from multinodular
goiter
|..

2 Low cost
2 Ready available
2 hort half life
2 Optimal imaging
2 Only trapped , not organified
X  K


2 Kt is able to determine function

2 K is the best but is expensive and have very
short half life
| $(#

2 Detecting :
lymph node metastasis
retrosrernal extension
recurrent disease functioning
nodule within suppressed gland
 
 
  

   


A  
 
X 
 


  
 
 
 

 
 

A )  
 

   
 
  +
 

2 creening high risk patient ( prior RT )

2 Differentiating single nodule from multiple
2 Cystic or solid status
2 acilitating
A
2 Monitoring medically treated patient
2 Evaluating clinically negative neck for
metastasis
2 Recurrent disease after surgery
| 

&XK

2 Extrathyroidal extension
2 Retrosternal involvement
2 Metastatic disease
2 nnecessary in the evaluation of a routine
thyroid mass
  ,

2 Bone scan
2 CT scan of abdomen and chest
2 Octreotide study
@ 

2 T3
2 T4
2 TA
2 Thyroid Ab for Aashimoto thyroiditis
2 erum thyroglobulin
2 erum calcitonin in medullary carcinoma
especially if there is a family history
|  

   

 
   


 
#(
/
 
 

  
  
 

 





2 Obtain satisfactory specimen from nodule

2 it is of no value in microinvasive follicular
2 Kf the report is suspicious the patient should
probably proceed to surgery
2 Knadequate specimen repeat
A



2 The best results obtains from periphery

2 Multiple aspirates are frequently necessary

  

 " 

  
 
 
    

 
  


2 A portion of capsule and surrounding tissue

can be included
2 Kt is rarely indicated
 " 


 

  




2 Clinical or radiographic evidence of

infiltration
2 Clinical or radiographic evidence of regional
or distant metastasis
2
A positive for malignancy ( papillary ,
medullary , anaplastic )
2 Thyroid mass with raised serum level of
calcitonin
 
 




2 uspicious fine needle aspiration

2
odule refractory to suppression
2 olitary thyroid nodule with raised serum
thyroglobulin level
2 Recurrent cyst refractory to two aspirations and
thyroid suppression
2
odule going wrong , a solitary nodule increasing in
size and associated with pain
2 True single nodule in males elderly women children ,
or in any patient with a history of prior RT



|
 
 


 

" 
  
 
 
 

  

  


 

| 


2 Better oncologic operation in the case of

multicentric disease
2 Difficult residual thyroid suppression and
anaplastic transformation risk
2 Good postoperative scanning and radioactive
ablation
2 Postoperative thyroglobulin titrage
 


2 impler & time consuming

2 Lower morbidity
2
ot affected the prognosis of well
differentiated tumor
" 
"


2 Well-differentiated tumor : 9-16%

2 Kf gross tumor would be left using the shaving
technique wild field resection should be
performed .
2 RL
enveloped & paralyzed it should be
sacrificed .
2 Kf it is the only functioning nerve and the
tumor and the tumor can be dissected off this
should be done
 
 

 
"


 
0
 

 


  
2 uperficial thyroid cartilage : shave resection
2 Aemilarynx : vertical partial laryngectomy
2 Anterior larynx : hemilaryngectomy And
reconstruction
2 Cricoid and bilateral laryngeal involvement :
total laryngectomy
  X|

 

 
X

 


2 Kn all patient : pericapsular and paratracheal

node need to be removed routinely
2 Overt node in these area : sup. Mediastimun
and lateral neck exploration
  
 
 

2 Clinical node : 20-25%

2 Pathological node : 30-79%
2 Kt has no adverse effect on prognosis
2 Extracapsular extension does not appear to
have an ominous prognosis
  
 

2 Very rare < 10% clinically & 20%

pathologically
2
eck dissection are performed only for overt
metastasis
A  
 

2 30% lymphatic metastasis

2 unctional neck dissection should be
performed when disease is encountered
 
 
 

2 Metastasis : 50 63 %
2 Prophylactic paratracheal , superior
mediastinal and lateral neck dissection
2 Or : positive node in mediastinum and lateral
neck dissection is performed

=
 

2 Become hypothyroid and after 4-6 week

radioiodine scan
2 Any residual tissue : K ablation
2 Kn overt local or regional remnant & distant
metastasis should be used
2 urther 6 and 12 months scan and then
every 2 year
2 erum thyroglobulin every 6 months
 
 
 

2 Calcitonin level : every 3 months ( in first

year )
2 Every six months there after
2 Aigh calcitonin level : full metastatic work up
CT & MRK of the neck and octreotide scan
2
o overt disease : neck dissection and if it
done before RT to neck
  X|

2 Residual and inoperable disease or cancer that has

undergone anaplastic transformation
2 50 Gy
2 RT appears more effective than radioactive iodine in
treating local recurrence in WD cancer
2 K radioactive is the treatment of choice for distant
metastasis
2 RT is the treatment of choice in anaplastic
carcinoma
X   

Most disappointing results

  
 


2 Total thyroid ablation : T4 supplement

2 Kt is useful in controlling any microscopic
residual WD thyroid cancer that may have
been left locally , regionally or distantly

  

2 Low risk patient : 1-2 % MR

2 Aigh risk patient : 40 50 %
2 Aereditary & sporadic cancer have similar
survival ( 82% at 5 year )
2 Anaplastic cancer has a dismal survival
2 Early stage medullary : good prognosis