DISEASES OF THE THYROID GLAND

DR. K. DILEEPA BANAGALA

Clinical Surgery

OVERVIEW

What do you know about the WHO classification of goiters?

WHO Classification
• Based on the degree of visible enlargement
o Grade 0: Goitre is not palpable, not visible
o Grade 1A: Goitre is palpable, but not visible
o Grade 1B: Goitre is palpable and visible only on extension of the neck
o Grade 11: Goitre is palpable and visible without extension of the neck only at close proximity
o Grade 111: Goitre is palpable and visible even at a distance


Clinical Surgery

1. What are the possible causes of a simple colloid goiter? 2. What are the possible causes of a solitary thyroid nodule?
• Dominant nodule of a MNG
• Reduction of intake
o Iodine deficiency • Cyst
• Defects of metabolism • Adenoma
o Congenital defect in thyroxin synthesis • Carcinoma
• Excessive demand • Thyroiditis
o Pubertal growth
o Pregnancy 3. What are the possible causes of a diffuse goiter?
o Lactation • Simple colloid goiter
• Goitregens • Graves disease
o Cabbage, Manioc (Brassica family) • Thyroiditis
o PAS: Para amino salicylic acid
o Lithium
o Fluoride
• Drugs 4. What are the causes for rapid enlargement of thyroid gland?
o Thiouracil • Malignancy
o Carbimazole • Bleeding into a cyst in a MNG
o Amiodarone • Thyroiditis

5. Why does thyroid move with swallowing?

• Because it is covered by pretracheal fascia that’s attached to the oblique
line of thyroid cartilage which in turn moves with swallowing

6. What conditions cause pain in thyroid disease?

• Thyroiditis
• Anaplastic Ca
o Pain is referred to the ear if it infiltrates surrounding structures
• Bleeding into a cyst1:809 or a necrotic nodule in a multinodular goitre1:807

Clinical Surgery

A 30 year old female labourer presents with a painless lump at the lower neck anteriorly for the past 1 and ½ years. It moves up with swallowing. It has
slowly progressively increased in size. She is clinically hyperthyroid, but there is no evidence of compressive symptoms or malignant features.
What is the most likely diagnosis?

Thyrotoxicosis/ Hyperthyroid
Introduction6:722 Graves’ Vs. Plummer’s
• Thyrotoxicosis
o Symptoms and signs of increased metabolic rate and
Graves' Disease6:726,727 Plummer’s Disease6:728
sympathetic activity due to increased amount of thyroid
hormones • Immunological disorder • In long standing multinodular
• Hyperthyroidism • TSI: Thyroid stimulating goiter
o Syndrome resulting from hyperactivity of thyroid gland Immunoglobulin (IgG) • One or more of the nodules
which produce excess hormones o Previously known as become toxic
• Any age Long Acting Thyroid • Middle aged female
• Female: Male = 8:1 Stimulants (LATS)5 • Late onset
o All types of simple goitre are common in the females owing • Diffuse hyperplasia of the gland • Eye signs are rare
to the presence of oestrogen receptors in thyroid tissue1:806 • Young women: Age 20 – 40 • No dermopathy
years • Dominant symptoms
Causes6:722 • Strong family history o Cardiovascular
Associated With Hyperthyroidism • Gradual or abrupt onset
• Primary • Dominant symptoms
o Graves: Diffuse goiter o Eye signs (Infiltrative
§ Thyroid stimulating antibodies (IgG) ophthalmopathy)
o Plummer’s disease: Toxic MNG o Hypermetabolic
o Toxic adenoma: Solitary nodule symptoms
• Secondary • Thyroid dermopathy seen in a
o TSH-secreting pituitary adenoma (rare) minority
• Minimal cardiovascular problems
Not Associated With Hyperthyroidism
• Transient thyrotoxicosis
o Thyroiditis: Large amount of preformed hormones is
released after the destruction of follicles
• Struma ovari
o Struma ovarii is a rare ovarian teratoma defined by the
presence of thyroid tissue comprising more than 50% of the
overall mass
• Factitious thyrotoxicosis: Exogenous intake of thyroid hormones
Clinical Surgery

Thyroid Status

Symptoms Hyperthyroidism2:426,427 Hypothyroidism2:429 Signs Hyperthyroidism2:427,428 Hypothyroidism2:429,430

Metabolism • Stimulated metabolism and • Reduced metabolism and heat Face • Muscle wasting of cheek muscles: • Pallor/Anaemia: Normocytic
heat production production Hollow cheeks normochromic or iron
o Weight loss o Weight gain • Tremors of the tongue deficiency5
o Heat intolerance o Cold intolerance • Receding eye brows: Outer
o Sweating o Hyperlipidaemia third
Cardiac • Palpitations • Breathless on mild exertion • Periorbital puffiness
• Breathless on mild exertion • Angina: If patient already had Eyes Each may be unilateral or bilateral2:418 • No eye signs
• Angina: Due to coronary heart disease8 • Lid lag
vasospasm8 • Lid retraction
CNS • Tremor • Tiredness • Soft tissue oedema (esp retroorbital)
• Nervousness • Mental lethargy • Exophthalmos/proptosis
• Irritability • Depression • Chemosis
• Emotional disturbance – • Impairment of memory: • Corneal ulcers
depression, excitement Dementia • Ophthalmoplegia: Diplopia (superior
• Tiredness4:253 • Carpal tunnel syndrome3:179 rectus and inferior oblique most
• Lethargy4:253 affected)
• Restlessness Cardiac • Sinus tachycardia: Even during sleep • Bradycardia
• Nervousness • Systolic hypertension with widened • Pericardial effusion6:724
• Insomnia pulse pressure5
GIT • Increased appetite • Loss of appetite • Arrhythmias
• Weight loss • Constipation o Ectopics/ Atrial
• Nausea/Vomiting4:253 fibrillation
• Diarrhoea Muscles • Proximal myopathy • Proximal myopathy
GUT • Oligo/amennorrhoea • Menorrhagia • Wasting of shoulder girdle muscles • Inverted supinator jerk
• Infertility5 • Infertility5 Hands • Wasting of small muscles • Reduced pulse rate
• Loss of libido, erectile • Galactorrhoea5 • Fine tremors • Puffy, spade-like hands
dysfunction, gynaecomastia- • Gynaecomastia (rare than in • Excessive sweating • Cold hands
due to low serum free hyperthyroidism) • Areas of vitiligo4:253
testosterone5 • Thyroid acropachy4:253
• Increased frequency of o Finger clubbing and osteo-
urination: Possibly due to arthropathy
primary polydipsia and • Rarely palmer erythema5
hypercalciuria5 • Increased pulse rate
Skeletal • Increased linear growth in • Stunting of growth Legs • Hyper-reflexia5 • Slow movements
children • Pretibial myxedema • Ataxia
Skin • Hair loss (alopecia)4:253 • Hair loss (alopecia) • (Thyroid dermopathy): Seen in • Delayed relaxation of ankle
• Sweating • Vitiligo-after treatment of Graves' disease jerk
• Pruritus (Graves' disease)5 Graves' disease5 • Symmetrical non-pitting red plaques
• Vitiligo (Graves' disease) 4:253 • Dry skin over the shins
• Coarse hair5 • Ankle oedema in heart failure
Speech • Rapid speech5 • Slow
• Hoarseness of voice
Clinical Surgery
 This patient comes to the surgical clinic when you are there as the house officer. What investigations do you want to order?
Investigations4:256, 1:803
Thyroid Function Tests FNAC
• To confirm my clinical suspicion of hyperthyroidism / Asses the thyroid • If suspicious areas in USS
status
What are the advantages and disadvantages of FNAC?
TSH Free T4 Free T3 • Advantages:
Primary Hyperthyroidism Low High High o Highly specific and sensitive1:808
o Inexpensive
Secondary High High High o Does not need a high level of training/ skills
Hyperthyroidism
o Least invasive technique of obtaining a cell diagnosis
Sub-clinical Low Normal Normal
o OPD procedure
Hyperthyroidism
Primary Hypothyroidism High Low Low o No anesthesia is needed
• Disadvantages:
Secondary Hypothyroidism Low Low Low o Not possible to differentiate follicular adenoma from
carcinoma1:808
Sub-clinical High Normal Normal
Hypothyroidism
• Grading1:805

o Thy1: Non-diagnostic sample
USS Neck: To look for any suspicious areas5 o Thy2: Benign colloid nodule
• Hypoechoic areas o Thy3: Follicular lesion: Unable to see vascular/capsular invasion
• Increase central vasculature1:808 o Thy4: Probably thyroid cancer
• Microcalcifications1:808 o Thy5: Diagnostic for thyroid cancer
• Vertical diameter more than the transverse diameter You said that you wanted an FNAC. Have you seen a sample being
• Absent surrounding halo around the nodule collected? Where is it done? How is it performed?
• Irregular, poorly-defined margins
FNAC Procedure
Thyroid Autoantibodies1:802 • OPD procedure, without anesthesia1:808
• Thyroid peroxidase antibody (TPO) • Explain the patient what you are going to do and obtain consent
• TSH receptor antibody: TRab • Use 23 G 10 cc blue needle / syringe
• (Thyroid Stimulating Immunoglobulin) • Clean the area, prick the nodule 4-5 times maintaining negative
pressure
Radio Isotope Scan: I-123, Tc-99, I-131 • Push on to a slide, air dry and put it in 95% alcohol
• Hot nodule • Send to the lab for cytology

Clinical Surgery
 How will you treat this patient?

Treatment1:812

Treatment of Hyperthyroidism1:813 Treatment of The Goiter1:810

• Step 1: Make the patient euthyroid Surgery
o Antithyroid drugs • Indications: 5 C’s5
§ Carbimazole o Compression/large goiters (>80g)
§ Propylthiouracil o Cancer
o Control of sympathetic overdrive
o Control
§ Beta-blockers: Propranolol
o Lugol’s iodine use to prepare the patient for surgery in toxic gland o Cosmetic1:810
§ Only in preparation for surgery and in a thyrotoxic crisis1:815 o Cyst (Bleeding into)
§ I2 + KI drops added to milk taken twice daily for up to 10 days • Procedures
before surgery. o Total thyroidectomy
§ Need to operate within 10 days o Near-total thyroidectomy: < 1g left inside
§ Reduces the vascularity of the gland
o Sub-total thyroidectomy: > 1g left inside1:807
§ Contraindications
o Hemi-thyroidectomy (Lobectomy): Diseases lobe + Isthmus +
• Pregnancy
Pyramidal lobe + Cuff of opposite lobe
• Step 2: Remove or destroy the gland
o Radioactive Iodine
o Surgery

• Step 3: Treat hypothyroidism

o Thyroxine for life
§ Before meals on an empty stomach

Clinical Surgery
 What are the differences of each drug?

Drugs

Carbimazole5 Propylthiouracil5 Beta-blockers/Propranolol5

Action • Blocks synthesis of thyroxine
• Suppress the autoimmune process in
Graves’
• Does not reduce the size of the gland
• Gland may initially enlarge: Especially
toxic nodular goitres1:812
• Reduce thyroid autoantibody
• Blocks synthesis of thyroxine • Control of sympathetic overdrive
• Blocks peripheral conversion of T4 to T3 o Cardiac
• Reduce thyroid autoantibody o Tremor
• Gland may initially enlarge-esp toxic o Heat intolerance
nodular goitres1:812
• Inhibit peripheral conversion of T4
toT3

Contraindication/ • Contraindications • Indications • Contraindications

Indications o Liver disease: Liver transaminases o Patients sensitive to Carbimazole o Asthma
elevated more than 5-fold the upper o Pregnancy(first trimester) o Second and third-degree heart
limit of normal block
o Pregnancy: PTU is preferred in the o Cardiac failure
first trimester as teratogenic effects o Severe peripheral vascular disease
are more severe with carbimazole o Hypoglycemia-prone diabetics
• Indication
o Lactation: Due to concerns about
PTU-associated hepatotoxicity,
carbimazole is recommended in
breastfeeding5
o Chidren: FDA recommends PTU not
be prescribed as a first-line drug in
children5

Side Effects • Pruritis • Fulminant hepatic failure • Bronchospasm
• Skin rashes3:182 • Pruritis • Bradycardia
• Aganulocytosis: Sore throat or any other • Skin rashes
infection • Agranulocytosis
• Aplastic anaemia
• Aplastic anaemia

Clinical Surgery
 Radiodioactive Iodine
• I-131 administered orally as sodium iodide in solution or a capsule.5

Indications5 Contraindications1:812,5 Side Effects1:812

• Toxic diffuse goiter • Pregnancy and breastfeeding5 • Hypothyroidism
o Graves' disease (especially after a relapse) • Moderate to severe ophthalmopathy5 • Worsening of eye signs
• Toxic adenoma • Main carers of small children o TRAb levels initially rise with
• Toxic MNG53 o Patient must take radiation precautions for radioactive iodine5
• Inoperable several days after treatment, avoiding
• Minimal eye signs contact with children and pregnant
women8
• Those who are planning pregnancy

• Could be diagnostic or therapeutic • Given at CIM

o Isolation room
• Diagnostic o Given as capsules
o Look for recurrence o Depending on the dose need varying period of isolation especially
from children
• Therapeutic o Pregnancy and breastfeeding are contraindications
o For goiter ablation
o Removal of residuals in malignancy • To obtain maximum effect
o Patients needs to have adequate TSH levels for the gland or thyroid
tissue to uptake radio-iodine
o Therefore if on suppressive thyroxine therapy it should be
withdrawn atleast 4 weeks before radio-iodine scan / ablative
therapy

Clinical Surgery
 Surgery

As the house officer in the ward, how will you prepare this patient for surgery?

• Patient should be euthyroid before surgery o Special tests

§ X-ray neck – AP and lateral
(If thyrotoxicosis – with tissue handling à release of hormones à thyroid • To see tracheal deviation and tracheal compression
crisis) • Important to the anesthetist to look for spondylotic
changes which might contraindicate extended neck
(If hypothyroid à slow recovery from anaesthesia) positioning for thyroid surgery
§ ENT referral – Vocal cord assessment by Indirect
• Informed written consent laryngoscopy (IDL)
• Blood for grouping and DT • Pre-existing RLN palsy
§ Malignant infiltration of pharynx, larynx, vocal cords
• Pre-operative assessment for major surgery (history, examination &
investigations) Hypothyroidism/ Myxoedema
o FBC
o FBS Introduction2:429
o Coagulation profile • Common in middle and old age
o Heart
• More common in females
§ ECG
• Hyperthyroidism Causes6:723
o Tachycardia
o Atrial fibrillation Primary Hypothyroidism
• Hypothyroidism • Rare developmental abnormalities (thyroid dysgenesis)
o Bradycardia
• Congenital biosynthetic defect (dyshormogenetic goitre)*
o Low voltage QRS complexes
• Post-ablative
§ 2D Echo
• Surgery, radioiodine therapy, or external radiation
o Lungs • Hashimoto thyroiditis*
§ Chest X-ray (Tracheal deviation, tracheal compression, • Iodine deficiency*
retrosternal shadow) • Drugs (lithium, iodides, para-aminosalicylic acid)*

o Kidneys Secondary Hypothyroidism

§ Blood urea & serum creatinine • Pituitary failure
§ Serum electrolytes • Hypothalamic failure (rare)

*Associated with enlargement of thyroid (goitrous hypothyroidism)

Clinical Surgery

The patient returns to the ward following total thyroidectomy. You are the
receiving house officer. What will you do?
• Receive the patient
• Monitor: BP. PR, RR, UOP
• Keep propped up (Reduce oedema/ swelling of the site) and give steam
inhalation
• Observe for difficulty in breathing, stridor and post-operative complications
• Adequate pain relief
• IV fluids followed by oral feeding once patient regained consciousness
• Early mobilization

What are the post-operative complications of thyroidectomy?

Post -Operative Complications of Thyroidectomy1:815

Immediate (within 6h of surgery) Early (6-72h) Late (>72h)

• Primary haemorrhage • Reactionary haemorrhage: Haematoma • Secondary haemorrhage
o Intraoperative formation o After 1 week due to infection
• Nerve injuries o Within 24h of surgery • Hypothyroidism
o Recurrent laryngeal nerve 0.5% at 3 o Normalization of BP after hypotensive • Hypertrophic scar/ keloid formation
months post-op anesthesia o More likely if incision overlies sternum and
§ Unilateral o Slipped ligature in dark-skinned people
§ Bilateral
o Superior/external laryngeal nerve 2-3% • Laryngeal oedema
§ Loss of power and range of voice o Tracheal/Laryngeal mucosal damage
§ Unable to achieve high pitch o Arterial bleeding causing external
o Transverse cutaneous nerve compression and exceeding venous
§ Anesthesia of neck pressure
o Cervical sympathetic chain: Horner’s
syndrome • Hypoparathyroidism/Hypocalcemia: 2-5 days
• Thyroid storm (Due to ischaemia or removal of parathyroids)
• Stridor o Circumoral parasthesia1:816
o Tingling of extremities1:816
o Chvostek’s sign3:187
o Tetany/ Muscle spasm3:187
§ Carpopedal spasm: Trousseau’s
sign
§ Stridor
Clinical Surgery

A few hours after the surgery the patient was transferred to the ward, she suddenly became agitated, confused, with vomiting and diarrhea. On examination she
had high fever and was tachycardic.

What is the most likey diagnosis?

What action would you take as the house officer?1:815,5

• It’s an acute, life-threatening, hypermetabolic state induced by excessive • Treatment

release of thyroid hormones o ICU care
• Due to surgery in a thyrotoxic patiet (unprepared patient), trauma, infection, o O2
parturition, discontinuation of antithyroid drugs o IV fluid
• Mortality 10-30% o IV hydrocortisone
o Carbimazole
o Lugol’s iodine/Sodium iodide
o IV propranolol
• Clinical features
o Cool the patient with ice packs
o Fever/Hyperpyrexia
o Diuretics for cardiac failure
o Muscle damage
o Digoxin for uncontrolled atrial fibrillation
o Renal failure
o Sedation
o Hepatic failure with jaundice5
o Marked tachycardia
o Tachyarythmia, Atrial fibrillation
o Congestive heart failure, hypotension
o Hyperventilation
o Vomiting

o Diarrhoea

o Marked sweating3:187
o Anxiety
o Confusion/Delirium
o Agitation

Clinical Surgery

6 hours after the patient was brought to the ward, the nurse calls and informs you that the patient is dyspnoic with noisy in breathing.
What is the most likely diagnosis? What is the cause?

Causes

IMMEDIATE WITHIN FEW < 12 - 24 HOURS1:815 < 12 HOURS > 3 DAYS

Tracheomalacia5
• Long standing
MNG/Malignant
infiltration
• Softening of the tracheal
cartilage
• With removal of the goitre,
since the patient is under
GA, the trachea collapses
MINUTES
Bilateral, partial RLN Haematoma formation Laryngeal oedema Hypocalcemia1:815
damage
• Loss of nerve supply to • Secondary/reactionary • Damage to tracheal • Ischaemia to the parathyroid
the abductors of vocal haemorrhage and laryngeal mucosa glands
cords • Blood collects beneath the pre- • Damage to lymphatics • Removal of parathyroid glands
• Supply to the tracheal fascia • Laryngeal oedema • Reduced parathormone (PTH)
adductors remain intact • Compresses the trachea • Hypocalcaemia
• Larynx closes • Arterial bleeding causing • Spasm of laryngeal muscles3:187
external compression and
exceeding venouspressure

How do you treat stridor? You are the house officer at a surgical clinic, how would you assess and
Treatment1:815 manage a patient coming to the clinic after thyroidectomy?
• Prop up • I would assess his general well-being, complications of surgery and plan
o Makes breathing easier future management
• 100 % O2 via face mask • General
• Monitor o Relief of symptoms
o RR, PR, BP, SaO2 • Surgical complications
o Level of consciousness o Pain
• Look out for cyanosis o Swelling
• Inform seniors, anesthetist, theatre o Difficulty in breathing/ noisy breathing
• Find and treat the underlying cause o Features of hypocalcemia: Perioral or peripheral numbness,
• Find and treat the underlying cause tingling, spasm
o Tracheomalcia/Bilateral, partial RLN damage: Re-intubate o Features of hypothyroidism: Lethargy, loss of appetitite,
o Haematoma: Remove sutures in the ward to release some constipation
pressure and evacuate the haematoma in the theatre1:815 • Further management
o Laryngeal odema: IV dexamethasone and re-intubate o Trace and review histology report
o Hypocalcaemia: IV 10% Calcium Gluconate 10ml, monitor o Do thyroid function tests and serum calcium as necessary and
calcium levels decide on replacement therapy
o Give pain relief as necessary
Clinical Surgery

A 45 year old housewife, with a family history thyroid malignancy, presented with a painless thyroid enlargement for the past 6 months. It has rapidly increased in
size, with hoarseness of voice noticed since 2 weeks back.
What is the most likely diagnosis?

THYROID TUMOURS
Introduction 1:816
Benign
• Follicular adenoma

Malignant
• Primary malignancies
o Follicular epithelial cells
§ Differentiated
• Follicular carcinoma
• Papillary carcinoma
§ Undifferentiated
• Anaplastic carcinoma
o Para-follicular ‘C’ cells
§ Medullary carcinoma
o Lymphoid cells
§ Lymphoma
• Secondary malignancies
o Metastatic
§ Kidney
§ Breast3:183
§ Lung3:183
§ Prostate3:183
o Local infiltration
§ Upper aero-digestive tract squamous cancer

Clinical Surgery

Clinical Features
2:416-418, 421, 422

Patient Profile What makes a goiter more likely to be malignant?

• Geographic6:733 Malignant Features
o Incidence of follicular carcinoma is high in endemic goitrous • Risk of malignancy in discrete thyroid swellings greater in1:808
areas o Isolated Vs. dominant swelling
• Age o Solid Vs. cystic swellings
o Age < 15 years and > 65 years more likely to be malignant o Men vs women
• Gender • Painless
o Female : Male = 3:1 in malignancy o Pain, often referred to the ear, is frequent in infiltrating growths2:417
o Increased risk of malignancy in men • Euthyroid3:184
• Nodule characteristics4:255
o Firm/hard nodules
o Fixed nodules
Symptoms and Signs o Recent onset
• Giotre o Recent change in a long standing goitre2:416
o Moves up with swallowing § Rapid increase in size
o Does not move with protrusion of the tongue • Voice changes: Invasion of RLN3:179
• Stridor: Tracheal obstruction
Pain
• Horner’s syndrome: Cervical sympathetic chain infiltration
• Anaplastic Ca
o Partial ptosis
o Miosis
o Enophthalmos
o Anhydrosis
• Cervical lymphadenopathy: Papillary Ca2:431
• Pulsatile scalp lump: Follicular Ca1:818
• Berry’s sign
Etiological/ Risk Factors
• History of irradiation: Papillary Ca2:431
• Family history: Medullary Ca2:434
• Past history of Hashimoto’s thyroiditis
o Malignant lymphoma1:816
o Predisposed to papillary Ca6:725

Complications/ Metastasis4:240
• Cervical lymphadenopathy: Papillary Ca2:431
• Bone: Highly vascular
o Warm, pulsatile scalp lump: Follicular Ca1:818

Clinical Surgery

Investigations Staging 1:819
American Joint Committee on Cancer
o USS neck
o Solitary nodule or dominant nodule of MNG Tumour
o Look for USS features of malignancy • Tx: Primary cannot be assessed
• T0: No evidence of primary
• T1: Intrathyroidal tumour ≤2cm
• FNAC (if nodules are not classified as fully benign in USS) 1:808
o T1a: ≤1 cm
o T1b: >1 cm ≤2 cm
• Thyroid function tests • T2: Intrathyroidal tumour >2cm but ≤4 cm
• T3: Intrathyroidal tumour >4 cm or any tumour with minimal extrathyroid
extension
• CECT of neck and thorax • T4: Any size with extensive extra thyroidal extension
o LN involvement
o To assess extent of airway invasion1:803 Nodes
• Nx: Cannot be assessed
• MRI: Superior at determining the presence of prevertebral fascia • N0: No regional node metastases
invasion1:803 • N1: Regional node metastases

Metastases
• PET-CT scan: May be considered in recurrent thyroid cancer1:803
• Mx: Cannot be assessed
• M0: No metastases
• Radio isotope scan: I-131 • M1: Metastases present
o Cold nodule: 80% are benign1:804

• Thyroglobulin1:803
o As a baseline level

• Bone scan if bone pain is there3:184

• Medullary cancer3:184
o Check serum calcium
o Exclude pheaochromocytoma

Clinical Surgery

Your patient has a malignant solitary nodule. What are the principals of treating this patient?

• Curative surgery if possible

• Radio-iodine ablation in differentiated tumours
• TSH suppression to prevent recurrence

British Thyroid Association – Thyroid Cancer Guidelines

Category No: Category Type Plan

Thy1 • Thy1: Non-diagnostic sample • Repeat FNAC

Thy2 • Thy2: Benign colloid nodule • 2 benign results 3-6months apart are needed for
confirmation of benign disease.
• ‘High-risk’ patients need a lobectomy

Thy3 • Thy3: Follicular lesion • Hemithyroidectomy/ Lobectomy

• Completion thyroidectomy maybe necessary

Thy4 • Thy4: Probably thyroid cancer/ suspicious • Surgery to be decided at MDT meeting
• Biopsy for a suspected lymphoma

Thy5 • Thy5: Diagnostic for thyroid cancer • Same as 4

Clinical Surgery

Treatment
1:819-821

Surgery + Radio-iodine Ablation Therapy

• Total thyroidectomy +/- LN dissection
• Hemi-thyroidectomy/ Lobectomy
o Thy3: Follicular lesion
o Microcarcinoma (<1cm intrathyroidal papillary carcinoma) 4:256
• Central neck LN dissection

Medical treatment 4:256

• T4 (Thyroxine) or T3 (Levothyronine)
o Replacement of thyroid hormones
o TSH suppression
§ Target TSH < 0.1 micrograms/L)
§ For all patients except selected low-risk patients
undergoing lobectomy1:819,5
o T4: 100-200 micrograms/day
o T3: 20 micograms/tds
• T3/T4 has to be withdrawn prior to radioiodine scanning/ablation as
high levels of TSH are required to effectively drive the radioiodine into
cells
o T4: Need to stop 4 weeks before
o T3: Need to stop 2 weeks
§ Shorter half life
• Alternatively, recombinant human TSH (rhTSH) over 48hours can be
used without stopping T3 or T4

Pre-Ablation Isotope Scan

• To assess any remaining thyroid tissue
• Done only after total thyroidectomy and neck dissection for any residual
disease
o Metastatic thyroid cancer tissue cannot compete with normal
thyroid tissue in the uptake of iodine1:804,819

Follow Up
• Serum thyroglobulin every 6 months
• Diagnostic radioiodine scan in 6 months
o If negative, in 1 year
• If these become positive, whole body radioiodine scan, CT, MRI, PET-
CT
Clinical Surgery

Thyroid Tumours 1:818-820, 4:254, 3:183
Papillary Carcinoma Follicular Carcinoma Anaplastic Cancer Medullary Ca
Introduction • Multifocal3:183 • Unifocal • Extremely aggressive • Sporadic: 80% Vs. Familial:20%
• Non-encapsulated • Encapsulated • 50% are inoperable at diagnosis • Associated with MEN syndrome
• Causes • Can occur in pre-existing MNG • Compressive symptoms + • Also secretes
o Radiation2:431 • High in endemic goitrous areas6:733 o 5HT (Serotonin), PG,
• Compressive symptoms are rare • Compressive symptoms + ACTH, VIP, Calcitonin,
• If < 1cm size, termed as • Hurthle cell cancers CEA
microcarcinoma o Variant of follicular • Can present with diarrhea (due
o Poorer prognosis to PG or 5HT
Cell of Origin • Follicular epithelial cells • Follicular epithelial cells • Follicular epithelial cells • Parafollicular ‘C’ cells
Frequency • 80% • 10% • 5% • 2.5%
Age • 20 – 40 years • 40 – 60 years • > 60 years • 30 – 60 years Familial form in
children and young adults
Sex • Female > Male • Female > Male • Female > Male • Female = Male
Local Spread • Local infiltration + • May infiltrate • Massively infiltrates • Slow growing
Lymphatic • Yes +++ • Less • Yes +++ • Yes +
Spread • Cervical LN
Blood Spread • Less • Yes +++ Skull, ribs, long bones, • Yes +++ • Yes +
lung
• Warm and pulsatile: Vascular
Prognosis • Excellent • Good • Poor: Almost all dead within 6 • Prognosis similar to follicular
• 5 year survival is 90% • 5 year survival is 65% months1:820 5:274

TSH • Dependent • Dependent • Independent • Independent

Investigations • USS neck • USS neck • USS neck • USS neck
• FNAC: Diagnostic • FNAC inconclusive • FNAC: Diagnostic • FNAC: Diagnostic
o Psammoma bodies • High calcitonin and CEA levels
o Orphan Annie nuclei
Treatment • Total thyroidectomy • Hemi-thyroidectomy and review • External radiotherapy • Total thyroidectomy
• Cervical block dissection/ histology • Isthmusectomy if tracheal • Cervical block dissection
central node dissection • Completion thyroidectomy if compression o If LN spread
o If LN spread
malignant on histology
o Can use for histology • Chemotherapy
• Life long thyroxine: High dose • Tracheostomy is best avoided • Screening of family members
for TSH suppression • Life long thyroxine: High dose for
o Genetic screening
• Radioactive I-131 for metastasis TSH suppression o Serum calcitonin
• Radioactive I-131 for metastasis • Prophylactic thyroidectomy
• Life long thyroxine
Histology • Histology: Capsular and vascular • Histology: Amyloid
invasion degeneration, characteristic "cell
balls"
Tumour • Thyroglobulin • Thyroglobulin • None • Calcitonin
Marker
Clinical Surgery

Multiple Endocrine Neoplasia (MEN Syndrome)1: 820
• Inherited in an autosomal dominant pattern.

MEN Type I1:856 MEN Type IIa MEN Type IIb

• Pituitary gland tumours • Medullary thyroid carcinoma • Medullary thyroid carcinoma
• Pancreatic islet cell tumours • Adrenal pheochromocytoma (mostly bilateral) • Adrenal pheochromocytoma1:856
• Pancreaticoduodenal endocrine tumours • Primary hyperparathyroidism • Mucosal neuromas
• Primary hyperparathyroidism o Lips
o Tongue
o Inner aspect of eye lids
• Marfanoid habitus

In follicular cancer, should we always perform a completion

thyroidectomy after histology even if the tumour margins are clear?

• Yes, always because,
o Rarely it could be multifocal
o If there is residual thyroid tissue it will interfere with subsequent
radio-iodine treatment and when monitoring with thyroglobulin
tumour marker

Clinical Surgery

A 70 year old retired teacher, with a family history of goiter, has presented with a painless thyroid enlargement which has been present for 20 years duration. It
has progressively increased in size and is associated with compressive features but no evidence of malignancy or altered thyroid status.
What is the most likely diagnosis?

Clinical Features2:416-418, 421, 422

Patient Profile Complications
• Geographic
o High in endemic goitrous areas Compressive Symptoms
• Age • Dyspnoea/stridor
o Elderly o Tracheal displacement and compression (worse when lying flat) 4:250
• Gender • Dysphagia
o Female > Male o Oesophageal compression
• Hoarseness of voice
Symptoms and Signs o Pressure on the recurrent laryngeal (RLN) nerve by a large
• Giotre goitre4:250
o Moves up with swallowing o Malignant infiltration of one or both nerves3:179
o Does not move with protrusion of the tongue • Retrosternal extension4:251
o SVC: Obstruction
Etiological/ Risk Factors § Distended neck veins
• Same etiology as simple colloid goiters § Facial plethora / Facial swelling
§ Stridor
o Pemberton sign: Neck veins becoming distended when arms are
raised above the head
• Carotid artery
o Carotid displacement due to a large goitre

How do you investigate and treat this patient?

Clinical Surgery

PRIMARY HYPERPARATHYROIDISM
Introduction1:825,826 Investigations1:826-828
• Common endocrine disease • Serum parathyroid hormone (PTH) level
• Postmenopausal women: 1:500 • Serum calcium and phosphate level
• F:M = 3:1
• Incidental finding of raised serum calcium Primary Secondary1:833 Tertiary1:835
• The only known risk factor is a history of prior neck irradiation
• Pathological features PTH High High High
o 85% have a single parathyroid adenoma
o Small tumours Ca2+ High Low or Normal High
o 15% have multigland hyperplasia
• More associated with PO43- Low High High
o Familial disease (e.g. MEN syndromes type 1 and 2A)
o Chronic ingestion of lithium Diagnosis (CKD, GI
• Parathyroid cancer as a cause of primary hyperparathyroidism is rare: <1% malabsorption,
Liver disease, Vit
D deficiency)
Clinical Features1:825
• High-resolution neck ultrasound may identify tumours.
Features of hypercalcaemia
“Stones, Bones, Moans, Groans and Thrones” • Sestamibi (radioisotope) scan: Accumulates in mitochondria which are
"Bones, stones, abdominal groans and psychiatric overtones" abundant in parathyroid cells
o Localize adenomas (accurate in 50%)
• Stones
o Allows a focused approach
o Calcium based renal stones, hypercalcuria
§ Minimally invasive parathyroidectomy
• Bones
o Aches/pains localized in large joints
Treatment
o Osteopenia/osteoporosis
• Hypercalcaemic crisis is defined as serum total calcium exceeding 3.5
• Moans: Psychological/psychiatric symptoms
mmol/L
o Lethargy/ Depressed mood
• Patient typically presents with acute confusion, abdominal pain, vomiting,
o Mild memory impairment
dehydration and anuria1:826
• Groans: Non-specific gastrointestinal symptoms
o Abdominal pain
Medical: Hypercalcaemic crisis1:826 Surgical1:829
o Constipation
o Peptic ulcers • Aggressive rehydration • Bilateral neck exploration
o Acute pancreatitis • Establish large calibre IV access • Minimally invasive
• Thrones • Monitor urine output parathyroidectomy
o Polyuria • Monitor central venous pressure
o Polydypsia • IV furosemide
o Nocturia
o Constipation
Clinical Surgery


Clinical Surgery