Thyroid Modified

THYROID
Mark Louie Lanting, MD

Palpable Thyroid Nodule
Scintigraphy Low TSH; Normal/High

+/- U.S.
FNAB
Hot Normal/Cold Repeat FNA
US guided
Evaluate for
Hyperthyroidis
m Benign Malignant Follicular Non PET
Neoplasm/ Diagnostics scan
Suspicious
Non
FS
Solitary MNG Surgery Diagnostics
(TT/NTT +/- CCND)
* MRND Surgery
(Lobectomy + isthmusectomy;
< 3cm Surgery TT/NTT)
young (TT/NTT)
Surgery
LT4
(Lobectomy + Malignant
isthmusectomy)
Completion
Thyroidectomy
 Thyroglossal Duct Cyst & Sinus
 Ectopic Thyroid
 Goiter
 Thyroid cancer
DEVELOPMENTAL
ABNORMALITIES
 Thyroglossal Duct Cyst and
Sinus
• During the 5th wk of gestation
thyroglossal duct lumen should
start to obliterate and disappear
by 8th wk of gestation.
• They may occur anywhere along
the migratory path of thyroid,
80% are found in
juxtaposition of hyoid bone
and heterotropic tissue at
20%.
• Asymptomatic but occasionally
become infected by oral bacteria
DEVELOPMENTAL
ABNORMALITIES
 Thyroglossal Duct Cyst &
Sinus
• Thyroglossal duct Sinus result from
infection of the cyst secondary to
spontaneous or surgical drainage of
sinus
• Mass is well defined, 1-2 cm,smooth
moves upward with protrusion of
tongue
• Treatment: SISTRUNK OPERATION
consist of en bloc cystectomy and
excision of central hyoid bone.
• 1% are found to be cancer usually
papillary (85%)
DEVELOPMENTAL
ABNORMALITIES
 Ectopic Thyroid
• Locations:
 anywhere in the central neck, trachea,
esophagus, anterior mediastinum.
 adjacent to the aortic arch
 in the aortopulmonary window
 within the upper pericardium
 in the interventricular septum
 extend off the inferior poles of the thyroid
gland
 lateral to carotid sheath and jugular vein
previously (“lateral aberrant thyroid”)
• almost always represents metastatic thyroid cancer in lymph
nodes

+/- U.S.
FNAB
US guided
Evaluate for
Hyperthyroidism Benign Malignant Follicular Non PET
Suspicious
Non
FS
(TT/NTT +/- CCND)
* MRND Surgery
young (TT/NTT)
Surgery
LT4
isthmusectomy)
Completion
Thyroidectomy
Test for thyroid function
 Thyroid Function Tests
• Serum TSH
Thyrotropin (TSH, reference range 0.5–5 mU/mL)
- only test necessary in most patient with thyroid
nodules
- most sensitive and specific test for diagnosis of
hyper and hypothyroidism
• Total T4 (55-150 nmol/L) and Total T3 (1.5-
3.5 nmol/L)
- reflects the fraction of T4 bound to TBG and
other carrier proteins in the serum and also
the amount of free T4 in circulation
Test for thyroid function
 Thyroid Function Tests
• Free T4 (12-28 pmol/L) and Free T3 (3-9 pmol/L)
-In patients with end-organ resistance to T4 (Refetoff
syndrome) T4 levels are increased, but TSH levels
usually are normal.
-In cases of early hyperthyroidism (normal total T4 but
inc. free T4)
• Thyrotropin Releasing Hormone
-evaluate pituitary TSH secretory function
• Thyroid Antibodies (antithyroglobulin/anti Tg,
antimicrosomal/antithyroid peroxidase/anti TPO, thyroid
stimulating immunoglobulin/TSI)
• Serum Thyroglobulin
-for monitoring patient with differentiated thyroid CA
recurrence.
Thyroid Imaging
 Ultrasound
• excellent, noninvasive, less expensive,
readily available, no radiation exposure
• distinguishing solid from cystic one
Thyroid Imaging
 Ultrasound
• provide info
 size and multicentricity
 assess cervical lymphadenopathy
 guide fine needle aspiration biopsy
• cannot assess extent of thyroid outside
the neck (e.g substernal goiter)

+/- U.S.
FNAB
US guided
Evaluate for
Suspicious
Non
FS
(TT/NTT +/- CCND)
* MRND Surgery
young (TT/NTT)
Surgery
LT4
isthmusectomy)
Completion
Thyroidectomy
Thyroid Imaging
 Radionuclide Imaging:
• Use to screen, treat, provide information
not only about size and shape but also
the distribution of functional activity of
the gland
 “COLD“ refers to the area that trap less
radioactivity than the surrounding gland
 risk of malignancy 15-20%
 “HOT“ refers to the increased activity.
 risk of malignancy < 5%
Thyroid Imaging
 Radionuclide Imaging:
• iodine 123 (emits low dose radiation
with a HL 12-14 hrs)  diagnostic
• iodine 131 (emits higher dose radiation
with HL 8-10 days)  diagnostic &
therapeutic
• FDG PET or the flourodeoxyglucose
positron emission tomography (shorter
HL less radiation and use to screen
metastasis but expensive)
Thyroid Imaging
 CT/MRI Scan
• excellent imaging of thyroid gland and
adjacent nodes and useful in evaluating
extent of thyroid and their relationship
to airway and vascular structures.
Hyperthyroidism
• Graves’ Disease
- it is an autoimmune disease of unknown cause
(post partum state, iodine excess, lithium
treatment, bacterial and viral infection)
- genetic factors
• HLA (Human Leukocyte Antigen) B8
• HLA DR3
• HLA DQAI * 0501
• All of which will stimulate T- Helper lymphocytes
–- stim. B lymphocytes–- produce antibodies
directed against thyroid hormone receptors.
- autoimmune disease
GRAVE’S DISEASE
• Clinical features
- heat intolerance, inc. sweating/thirst, wt loss
(despite adequate calories requirement)
- increased adrenergic stimulation (palpitation,
nervousness, fatigue, tremors)
- GI symptoms (diarrhea)
- female (ammenorrhea, dec. fertility, inc.
miscarriage)
- children (rapid growth with early bone
maturation)
- CVS atrial fibrillation/CHF
- ophthalmopathy (Von Graefe’s sign- lidlag,
Dalrymple’s sign- spasm upper eyelid,
prominent stare- inc. cathecholamine )
- pretibial myxedema
- dermopathy (1-2%)
- gynecomastia
GRAVE’S DISEASE
• Diagnosis
- TSH, free T3,T4
- I uptake and scan
- antibodies (TSH-R, TSab)
• Treatment
- antithyroid drugs (PTU 100-300mg
TID, methimazole 10-30mg TID,
betablockers Propanolol 20-40mg
QID)
- thyroid ablation with radioactive I
GRAVE’S DISEASE
Ophthalmopathy- 50% periorbital

edema, conjunctival
swelling/congestion or CHEMOSIS,
proptosis Pretibial myxedema- 3-5%
GRAVE’S DISEASE
• Surgery treatment?
• Is recommended when RAI is
contraindicated:
• have confirmed cancer or with suspicious
thyroid nodules
• Young
• pregnant/desire to conceive soon
• allergies to antithyroid meds
• compressive symptoms
• reluctant to undergo RAI
GRAVE’S DISEASE
• Relative indication:
• desire rapid control of hyperthyroidism
• poor compliance to meds
• Patient should be rendered euthyroid
before operation by giving Lugol’s
iodide solution, SSKI supersaturated
potassium iodide 3 drops BID 10 days
 also decreases the vascularity of
gland and risk of thyroid storm
GRAVE’S DISEASE
• Bilateral subtotal thyroidectomy, in which
about 1 to 2 g of thyroid tissue is left on
both sides, or a total lobectomy on one side
and a subtotal thyroidectomy on the other
side (Hartley-Dunhill procedure)
• Recurrent thyrotoxicosis is usually managed
by radioiodine treatment.
• Long term ff up is maintained by yearly
TSH measurement to detect late onset
hypothyroid or recurrent hyperthyroid.
GRAVE’S DISEASE
• Subtotal thyroidectomy
 Rapid cure rate in 90% of cases
 Eliminates compressive symptoms from large
MNG
 Does not worsen ophthalmopathy
 Safe in pregnant women during 2nd trimester
 Complications: RLN injury,
hypoparathyroidism
GRAVE’S DISEASE
 Restore to euthyroid state:
• Inhibit TH synthesis: Thionamides
• Inhibit release of TH from thyroid gland:
 Iodide : also given for 10-14 days prior to
surgery to decrease vascularity

 Lithium carbonate
 Ipodate
• Decrease peripheral effects of TH: PTU, steroids,

iopanoic acid
 For urgent surgery

• Euthyroid state in 5-7 days
 Thionamide
 Beta blockers
 Oral iopanoic acid (500 mg BID) +
dexamethasone
GRAVE’S DISEASE
 Controversy: Total VS Subtotal
thyroidectomy
 Meta-analysis of 35 RCTs (Palit 2000)

• Surgery treated hyperthyroidism in 92% of
cases especially after Total thyroidectomy
• Subtotal thyroidectomy has 8% recurrence
rate
• NO significant difference in complication rates
 Surgery is more effective and less costly
VS lifelong antithyroid drugs and RAI
- Vidal 2003
TOXIC MULTINODULAR GOITER
• Toxic Multinodular Goiter
- more than 50 yo
- have history of nontoxic
multinodular goiter
- “Jodbasedow Phenomenon“
hyperthyroidism precipitated by
iodine containing drugs such as
contrast media and amiodarone.
- same s/sx to Grave’s dse but less
severe and extrathyroidal
manifestation are absent.
TOXIC MULTINODULAR GOITER
• Toxic Multinodular Goiter
- diagnostic studies are similar to Grave’s
dse
- treatment: Hartley Dunhill procedures
(remnant size is not that crucial can be
treated with thyroid hormone suppression
and less recurrence rate)
- total thyroidectomy are reserved if no
normal thyroid tissue is present
- RAI reserved for very poor operative risks
PLUMMER’S DISEASE/
TOXIC ADENOMA
• PLUMMER’S DISEASE/TOXIC ADENOMA
-hyperthyroidism from a single hyperfunctioning nodule
(attained a size of 3 cms)
- characterized by somatic mutation in TSH receptor gene,
G- protein stimulating gene (gsp)
- presents as solitary thyroid nodulewithout palpable
thyroid tissue contralateral side
- RAI scanning shows “hot” nodule with suppression of the
rest of the gland.
- medical treatment: antithyroid drugs, RAI
- surgery: lobectomy and isthmusectomy
• Recommendation:
• Toxic adenoma:
 Ipsilateral lobectomy + isthmectomy
• MNTG:
 Ipsilateral lobectomy + isthmectomy + contralateral subtotal
lobectomy
THYROID STORM /
THYROTOXIC CRISIS
• THYROID STORM / THYROTOXIC CRISIS
- Exacerbation of hyperthyroidism precipitated by
infection, surgery, or trauma
- Fever, seizure, cardiac failure, coma
- Treatment: O2 supplement, hemodynamic support,
antipyretic
- Lugol’s solution or sodium ipodate ( IU ) 0.25mg IV
Q6 to decrease uptake and secretion of thyroid
- PTU 600mg LD then 200-300mg Q6 to block
oxidation, coupling, peripheral conversion
- Propanolol 40-60mg Q4 to dec. tachy and other
adrenergic manifestation and dec. peripheral conversion T4
to T3.
- Glucocorticoids (DEXA 2mg Q6) also block hepatic
thyroid conversion.
THYROID STORM /
THYROTOXIC CRISIS

+/- U.S.
FNAB
US guided
Evaluate for
Hyperthyroidis
Suspicious
Non
FS
(TT/NTT +/- CCND)
* MRND Surgery
young (TT/NTT)
Surgery
LT4
isthmusectomy)
Completion
Thyroidectomy
FNAB/FNAC
• easily performed with inexpensive equipment in
the out patient department, it is essentially free
of complications, and above all it provides a
reliable and accurate tissue diagnosis in a high
proportion of patients
• Incidence of false positive results is 1% and false
negative of 3%.
• Less reliable in patient who have history of
head/neck irradiation because of higher likelihood
of multifocal lesions.
EMBRYOLOGY
THYROID gland Anatomy
 Epithelial cells are of 2 types:
• principal cells (ie, follicular)
 responsible for formation of the colloid
(iodothyroglobulin)
• parafollicular cells (ie, C, clear, light
cells)
 produce the hormone calcitonin, a protein
central to calcium homeostasis

+/- U.S.
FNAB
US guided
Evaluate for
Suspicious
Non
FS
(TT/NTT +/- CCND)
* MRND Surgery
young (TT/NTT)
Surgery
LT4
isthmusectomy)
Completion
Thyroidectomy
Benign Thyroid Disorders
• THYROIDITIS (inflammatory Disorder of
thyroid gland)
 Acute (Suppurative) Thyroiditis
• 70% are streptococci and anaerobes.
• Infection can spread via hematogenous/ lymphatic,
direct, penetrating trauma, and immunosuppression.
• common in children preceded by URTI or otitis media.
 Subacute Thyroiditis
• painful (viral) or painless (autoimmune)
• cause by viral infection, genetics (HLA B35
haplotype)
• 3 phase - initially present as hyperthyroid ff by
euthyroid (90%) then hypothyroid (20-30%)
• diagnosis – TSH, T3, T4, ESR
• treatment – supportive, surgery is reserved for
failure of medical treatment and recurrent dse.
• Chronic Thyroiditis
 Chronic lymphocytic thyroiditis, more
commonly known as Hashimoto's
thyroiditis, after the physician who first
described the condition in 1912
 autoimmune process
 most common cause of hypothyroidism.
 Activation of CD4+ T helper cells  target 
thyroid antigen ( Tg 60%, TPO 95%, TSH R
60%)  destruction of thyrocytes 
hypothyroidism
• Chronic Thyroiditis
 Painless anterior neck mass with minimally
or moderately enlarged firm gland) 20%
hypothyroidism and 5% hyperthyroidism
 Diagnosis (increased TSH, decreased T4 and
T3),
(+) autoantibodies (confirmatory)
FNAB indicated for patient presents
with solitary suspicious nodule or rapidly
enlarging goiter.
 Treatment : thyroid replacement, surgery is
indicated for suspicion of malignancy,
cosmetic and compressive symptoms.
• Riedel’s thyroiditis
• AKA invasive fibrous thyroiditis
• replacement of all or part of thyroid
parenchyma by fibrous tissue
• cause by autoimmune dse associated
with sclerosing syndromes
• presents as painless, hard anterior neck
mass “ woody “ thyroid gland,
hypothyroidism and compressive
symptoms.
Gross pathology of Riedel (fibrosing) thyroiditis.

The cut edge is avascular with a characteristic white color.
• Riedel’s thyroiditis
• diagnosis FNAB is inadequate, do open
thyroid biopsy
• treatment, surgery ( chief goal of
operation is to decompress the trachea
by wedge excision ) because of
infiltrative nature of fibrotic that would
obscure usual landmarks and
structures…
• Hypothyroid is treated by hormone
replacement , corticosteroids.
Gross pathology of Riedel (fibrosing) thyroiditis.

The cut edge is avascular with a characteristic white color.
• Goiter
• any enlargement of thyroid gland
• Goiter
• Pathophysio
• stimulation of TSH secondary to inadequate thyroid
hormone synthesis  diffuse thyroid hyperplasia 
focal hyperplasia  nodules
• thyroid gland enlarge in order to maintain a
euthyroid state.
• usually asymptomatic, (+) pressure sensation,
as it become very large (+) compression
symptoms, “ catarrh” ( clear throats
frequently ), dysphonia, Pemberton’s sign
(retrosternal extension result in impeded blood
flow in SVC ---- flush face and dilatation of
veins over the chest wall (prominent when
patient raises his arms above head)
 Diagnosis thru
• Thyroid function test
• FNAB (if with dominant nodule or one
that is enlarging and painful)
 Carcinomas noted in 5-10% of multinodular
goiters
• RAI (patchy uptake with areas of hot and
cold nodule)
• CT scan (evaluate extension)
 Treatment
• euthyroid patient with small, diffuse
goiters do not require tx, some physicians
give exogenous thyroid hormone to
reduce TSH stimulation of gland growth
• Endemic type are treated by iodine
administration
 Surgery are reserved for
1. continue to increase in size despite T4
suppression
2. cause obstructive symptoms
3. have substernal extension
4. suspicion of malignancy/proven
malignancy by FNA
5. cosmetically
 Subtotal thyroidectomy
• the tx of choice
• lifelong T4 therapy to prevent recurrence.
Solitary Thyroid Nodule
• discrete swelling in an otherwise

impalpable gland. Whereas a discrete
swelling in a gland with clinical
evidence of generalized abnormality
in the form of a palpable contralateral
lobe or generalized mild nodularity is
termed as dominant nodule.
• About 70% of discrete thyroid
nodules are clinically isolated and
about 30% are dominant.
• increased risk of malignancy compared with
other thyroid swellings.
• incidence of malignancy in solitary thyroid
nodules varies from 5% to 20% in different
surveys. whereas the incidence of malignancy in
multinodular goitre is only 3-5%.
• seen commonly in both sexes, are four to
six times more common in females
• Most are detected between the ages of 30
and 50 years
• Majority are benign
The indication for operative treatment of a solitary thyroid
nodule are summarized below
1. All Proved Malignant nodules on FNAC
2. All cytologically diagnosed Follicular Neoplasms
3. All lesions exhibiting an atypical but nondiagnostic
cellular pattern of cytology.
4. Cystic nodules which recur following repeated aspiration
5. When on clinical grounds, the index of suspicion of
malignancy is high, even if the cytology report
suggests benign disease
6. Obstructive symptoms, actual or potential
7. Patient anxiety
8. Hyper functioning nodule resulting in hyperthyroidism.
9. Cosmesis
10. Thyroid nodule in a patient with history of radiation to
head, neck or chest, because radiation associated carcinoma
is multifocal and FNAC result may be misleading.
11. In a patient with Grave's disease, the presence of cold
nodule. (The chances of malignancy being 510%
 standard surgical procedure in a patient with
a single nodule should be thyroid
lobectomy
on the side of the lesion with resection of
the Isthmus of the gland in continuity. For a
proved malignant lesion Near-total
thyroidectomy vs total.
 Simple thyroid cysts resolve with aspiration in
75% of cases,other require 2 or 3 aspiration if
persistent unilateral lobectomy is recommended.
Also for cysts greater than 4 cms in dm and for
complex cysts.
• Radioiodine scintiscan may be employed 6 weeks
postsurgery to monitor for metastases.
• Uptake in the lungs, lateral neck, or around the
recurrent laryngeal nerve indicates metastasis or
residual disease.
• If these are discovered, therapeutic dosing of 131I is
indicated to ablate remaining tumor cells.
• Thyroglobulin levels also may be used to monitor
for recurrence of disease, but only if a total
thyroidectomy has been performed.
• Levels vary based on replacement therapy.
• Levels more than 1 ng/mL in patients on
replacement therapy and 10 ng/mL in patients
off thyroxine indicate recurrence of disease
• In patients with medullary thyroid cancer,
calcitonin levels may be used to monitor for
recurrence.
 Antithyroid medications are given preoperatively
to stabilize a toxic thyroid nodule.
 Beta-blockers may be used for cardiac
arrhythmias.
 Thyroid replacement is necessary after
thyroidectomy. This therapy must be continued
for life. Prescribe full replacement doses to
minimize TSH stimulation of residual tumor cells.

+/- U.S.
FNAB
US guided
Evaluate for
Hyperthyroidis
Suspicious
Non
FS
(TT/NTT +/- CCND)
* MRND Surgery
young (TT/NTT)
Surgery
LT4
isthmusectomy)
Completion
Thyroidectomy
Malignant Thyroid Disease
• Thyroid cancer
• most common endocrine malignancy 95%
• most arises from follicular cells
• 90% are differentiated type (favorable
prognosis)
• thyroid nodules, less than 10% are malignant
 Tumor Types:
• Papillary Ca
 Most common malignant type 70-80%
 Accounts for 90% of radiation induced thyroid ca, 3%
familial
 Multicentric 30-50%
 More common in women 2:1, 30- 40yo
 Presents as euthyroid, slow growing painless mass,
dysphagia, dyspnea, dysphonia
 Lymph node metastasis is common
 Diagnose thru FNA
 Histopath: (+) psammoma, intranuclear grooves,
cytoplasmic inclusions leading to Orphan Annie
nuclei.
 Prognosis: in general (+) excellent prognosis with a
greater than 95% 10 year survival rate.
Papillary cancer
 Low vs high risk criteria
LOW: F <50yo, M <40yo, well/mod
differentiated tumors, tumor < 4cms dm, tumor
confined to thyroid gland, no distant metastasis.
High: in contrast to low.
 Treatment:
- lobectomy and isthmusectomy ( recurrence
rate 5% mortality rate 1% )
1. if less than 1cm size
2. without lymphatic/systemic
metastasis
3. > 1cm size if low risk
- total
1. high risk
2. history of head and neck irradiation
Papillary cancer
 Controversies:
- Pro total
1. enables one to use RAI to detect and
treat residual thyroid
2. make serum Tg more sensitive marker
of recurrence
3. eliminate occult cancers at
contralateral site
4. reduce recurrence and improves
survival
5. decreases the risk of 1% progression to
anaplastic/undiff type
6. reduces need for reoperative sx
Papillary cancer
 Controversies:
• Pro lobectomy
1. total is associated with higher
complication rate
2. recurrence in remaining thyroid
tissue is unusual (5%) most
are curable by surgery
3. tumor multicentricity is of little
prognostic significance
4. lobectomy still have excellent
prognosis.
Papillary cancer
 Lymph node metastases in the
lateral neck in patients with
papillary carcinoma usually should be
managed with modified radical neck
dissection, and en-bloc dissection of
all fibrofatty tissue and lymphatic
tissue.
Papillary cancer
 Usual cancer follow up, patients should
receive a yearly chest x-ray as well as
thyroglobulin levels Thyroglobulin is not
useful as a screen for initial diagnosis of
thyroid cancer but is quite useful in follow
up of well differentiated carcinoma (if a
total thyroidectomy has been performed).
 A high serum thyroglobulin level that had
previously been low following total
thyroidectomy especially if gradually
increased with TSH stimulation is virtually
indicative of recurrence.
 A value of greater than 10 ng/ml is often
associated with recurrence even if an
iodine scan is negative

+/- U.S.
FNAB
US guided
Evaluate for
Hyperthyroidis
Suspicious
Non
FS
(TT/NTT +/- CCND)
* MRND Surgery
young (TT/NTT)
Surgery
LT4
isthmusectomy)
Completion
Thyroidectomy
 Follicular CA
• Follicular carcinoma, which accounts for
about 10 percent of thyroid
malignancies
• Solitary/surrounded by a tumor capsule
with presence of capsular and vascular
invasion (distinguished from follicular
adenoma)
• Female/male ratio is 3:1 with mean age
of 50yo
• Presents as painless solitary nodule or
as rapidly growing nodule w/in multi
nodular goiter.
 Follicular CA
• Spread hematogenously with
predilection for lungs and bones.
• Lymph node metastases are less
common 10% ( cervical )
• Treatment:
 lobectomy and isthmusectomy are adequate
for minimally invasive follicular CA
 near total or total thyroidectomy for invasive
type (major capsular invasion and
angioinvasion, aggressive behavior)
 lymph node dissection for gross metastatic
disease
• Hurthle Cell Ca
 Account for 5% of all thyroid cancers
 clinicopathologic features are similar to follicular
cancers
 mortality rate of 30% at 10 years
 possess TSH receptors and produce
thyroglobulin
 multifocal and bilateral, are more likely to
metastasize to local nodes (25 percent), and
usually do not take up 131I
 Management is similar to that of follicular
neoplasms
 Medullary CA
• accounts for about 5 percent of thyroid
carcinomas
• Represents a malignant transformation
of neuroectodermally derived
parafolicular cells.
• 75% sporadic and 25% hereditary
• Tumors typically are unilateral (75
percent)
• The presence of amyloid is a diagnostic
finding, but immunohistochemistry for
calcitonin has superseded it as a
diagnostic tumor marker
 Medullary CA
• C-cell hyperplasia is a premalignant
precursor of MTC
• Patients with MTC usually present with a
neck mass that may be associated with
palpable cervical lymphadenopathy (15
to 20 percent).
• Local pain is more common in patients
with these tumors, and local invasion
may produce symptoms of dysphagia,
dyspnea, or dysphonia.
• female-to-male ratio is 1.5:1.
Medullary thyroid cancer
• Tumors may secrete a
variety of peptides
including calcitonin,  MEN IIA
calcitonin gene–related • These patients have a
peptide, CEA, syndrome characterized
histaminadases, by MTC,
prostaglandins E2 and pheochromocytoma, or
F2-alpha, and serotonin.
adrenal medullary
• Between 2 and 4
percent of patients with hyperplasia and
MTC develop Cushing's hyperparathyroidism.
syndrome as a result of  MEN IIB
ectopic production of • MTC, bilateral
ACTH. Kidney stones
occur in patients with pheochromocytomas,
primary and ganglioneuromas
hyperparathyroidism, affecting mucosal
and hypertension occurs surfaces
in those with
pheochromocytoma
• Diagnosis of MTC is
established by
history, physical
examination, raised
serum calcitonin or
CEA levels, and
FNAC of the thyroid
mass
 Patients with MEN IIB
have characteristic
facies with A.
marfanoid features
and B. thickened lips,
scalloping of the
tongue, and mucosal
ganglioneuromas.
 total thyroidectomy with central LN
dissection is the minimum surgical
management of choice for patients with
MTC
 Because tumors are of C-cell origin,
radioiodine therapy and levothyroxine
sodium TSH suppression therapy
usually are not helpful
 External-beam radiotherapy for patients
with tumors at resection margins or
unresectable tumors is controversial. It is
recommended for patients with
unresectable residual or recurrent tumor,
although the results are debatable.
 There is no effective
chemotherapy regimen
 Prognosis: Prognosis depends on
patient age, histologic grade, and
status of surgical resection.
 Patients with a worse prognosis tend
to be older, have higher-grade
lesions, and have undergone
incomplete surgical resection of the
lesion
 Anaplastic Ca
:2-6% of thyroid cancers
: one of the most aggressive malignancies
: 5 year survival rate of 3.6%
: treated prospectively over an 8-year period with
initial hyperfractionated radiotherapy with
doxorubicin, then debulking thyroidectomy,
followed by completion of radiotherapy and
chemotherapy.
: long term survival is still poor bec. of high
incidence of metastasis and local recurrence.
: unfortunately, regardless of the treatment given
majority of patient die w/in months of their
diagnosis.
 Lymphoma
less than 1% of thyroid malignancies.
• Most of the primary thyroid lesions are of the non-
Hodgkin's B-cell type.Metastatic Ca and Hashimoto’s
thyroiditis
• Patients with thyroid lymphoma usually respond rapidly
to chemotherapy
(CHOP—cyclophosphamide, doxorubicin,
vincristine, and prednisone), and combined
treatment with radiotherapy and chemotherapy is often
recommended.
• Thyroidectomy and nodal resection are used to alleviate
symptoms of airway obstruction in patients who do not
respond quickly to chemotherapy or chemotherapy and
radiotherapy but rarely warranted.
• The overall 5-year survival rate is about 50 percent

+/- U.S.
FNAB
US guided
Evaluate for
Hyperthyroidis
Suspicious
Non
FS
(TT/NTT +/- CCND)
* MRND Surgery
young (TT/NTT)
Surgery
LT4
isthmusectomy)
Completion
Thyroidectomy
BLOOD SUPPLY
 Arterial supply
• Superior thyroid artery
 first anterior branch of the external
carotid artery
 Cephalad to the superior pole, the
external branch of the superior

laryngeal nerve runs with the
superior thyroid artery before turning
medially to supply the cricothyroid
muscle.
BLOOD SUPPLY
 Arterial supply
 High ligation of the superior
thyroid artery during

thyroidectomy places this nerve at
risk of inadvertent injury  produce
dysphonia by altering pitch regulation.
BLOOD SUPPLY
 Arterial supply
 The cricothyroid artery is a potentially
bothersome branch of the superior

thyroid artery, which runs cephalad to
the upper pole and runs toward the
midline on the cricothyroid ligament.
This vessel can be lacerated during
emergent cricothyroidotomy.
BLOOD SUPPLY
• Inferior thyroid artery
 arises from the thyrocervical trunk, a
branch of the subclavian artery

 crosses the recurrent laryngeal nerve
(RLN), necessitating identification of the

RLN before the arterial branches can be
ligated
BLOOD SUPPLY
• Thyroidea ima
 Arises directly from the aortic arch or the
innominate artery and enters the thyroid
gland at the inferior border of the isthmus
 Present 1 to 4% of individuals
VENOUS DRAINAGE
 3 pairs of venous drainage
• Superior thyroid vein
 ascends along the superior thyroid artery
and becomes a tributary of the internal
jugular vein.
• Middle thyroid vein
 follows a direct course laterally to the
internal jugular vein
• Inferior thyroid veins
 to the brachiocephalic vein
NERVE SUPPLY
 Left RLN
• arises from the vagus nerve then it
crosses the aortic arch, loops around
ligamentum arteriosum and ascend
medially in the neck w/in
tracheoesophageal groove
NERVE SUPPLY
 Right RLN
• arises from the vagus as it crosses
posteriorly to right subclavian artery
before it ascend to neck.
• usually passes posterior to the artery
before ascending in the neck,
• its course being more oblique than the
left RLN
• may be nonrecurrent in 0.5 to 1% of
individuals and often is associated with
a vascular anomaly
NERVE SUPPLY
 Identification of the nerves or their branches
often necessitates mobilization of the most lateral
and posterior extent of the thyroid gland, the
tubercle of Zuckerkandl, at the level of the cricoid
cartilage
 The last segments of the nerves often course
below the tubercle and are closely approximated
to the ligament of Berry
 Branches of the nerve may traverse the ligament
in 25% of individuals, and are particularly
vulnerable to injury at this junction
 The RLNs terminate by entering the larynx
posterior to the cricothyroid muscle
NERVE SUPPLY
 RLN innervate all intrinsic muscle of larynx
except cricothyroid, which are
innervated by external laryngeal nerves.
 Injury to one RLN  paralysis of the
ipsilateral vocal cord, which comes to lie in
the paramedian or the abducted position.
• paramedian position  normal, but weak
voice
• abducted position  hoarse voice and an
ineffective cough
NERVE SUPPLY
 Bilateral RLN injury  airway
obstruction, necessitating
emergency tracheostomy, or loss of
voice
 If both cords come to lie in an
abducted position, air movement can
occur, but the patient has an
ineffective cough and is at increased
risk of repeated respiratory tract
infections from aspiration
NERVE SUPPLY
 Superior laryngeal nerve also arises
from the vagus after their origin at
the base of the skull it travel along
with ICA and divide into 2 branches
at level of hyoid bone.
• Internal branch is sensory to supra
glottic larynx
 Injury causes aspiration
NERVE SUPPLY
• External branch (Amelita Galla Cursi or

high note)
 lies on the inferior pharyngeal constrictor
muscle and descends alongside the superior
thyroid vessels before innervating the
cricothyroid muscle
 Injury causes inability to tense the
ipsilateral vocal cord and hence difficulty
"hitting high notes," projecting the
voice, and voice fatigue during
prolonged speech
Anatomy
 Innervation:
• Principal  from the autonomic
nervous system
 Parasympathetic fibers  from the vagus
nerves
 Sympathetic fibers  from the superior,
middle, and inferior ganglia of the
sympathetic trunk
Anatomy
 Parathyroid Glands
• 4 glands which derived their
blood supply primarily
from branches of
inferior thyroid artery
• The superior gland are
located dorsal to RLN
and inferior are usually
found ventral to RLN
Anatomy
 Lymphatic System
• Pretracheal, Paratraheal,
Perithyroidal, RLN, Sup. Mediastinal,
Retropharyngeal, Esophageal, Upper,
middle lower Int. jugular
Thyroid Surgery
 patient is positioned supine, with a
sandbag between the scapulae
 The head is placed on a donut
cushion and the neck is extended
 A Kocher transverse collar incision, typically
4 to 5 cm in length, is placed in or parallel to
a natural skin crease 1 cm below the cricoid
cartilage
 The subcutaneous tissues and platysma are incised
sharply and subplatysmal flaps are raised superiorly
to the level of the thyroid cartilage and inferiorly to
the suprasternal notch
Thyroid Surgery
 The strap muscles are divided in the
midline along the entire length of the
mobilized flaps, and the thyroid gland is
exposed.
 On the side to be approached first, the
sternohyoid muscles are separated from
the underlying sternothyroid muscle by
blunt dissection until the internal jugular
vein and ansa cervicalis nerve are
identified.
Thyroid Surgery
 The strap muscles rarely need to be
divided to gain exposure to the thyroid
gland. If this maneuver is necessary, the
muscles should be divided high to preserve
their innervation by branches of the ansa
cervicalis.
 If there is evidence of direct tumor
invasion into the strap muscles, the portion
of involved muscle should be resected en
bloc with the thyroid gland.
Thyroid Surgery
 The sternothyroid muscle is then dissected
off the underlying thyroid by a combination
of sharp and blunt dissection, thus exposing
the middle thyroid veins
 The thyroid lobe is retracted medially and
anteriorly and the lateral tissues are swept
posterolaterally using a peanut sponge
 The middle thyroid veins are ligated and
divided
Thyroid Surgery
 The superior thyroid pole is identified by
retracting the thyroid first inferiorly and
medially and then the upper pole of the
thyroid is mobilized caudally and laterally
 The dissection plane is kept as close to the
thyroid as possible and the superior pole
vessels are individually identified,
skeletonized, ligated, and divided low on
the thyroid gland to avoid injury to the
external branch of the superior laryngeal
nerve
Thyroid Surgery
 The RLNs should then be identified. The nerves
can be most consistently identified at the level of
the cricoid cartilage.
 The parathyroids usually can be identified within
1 cm of the crossing of the inferior thyroid artery
and the RLN, although they also may be ectopic
in location.
 The lower pole of the thyroid gland should be
mobilized by gently sweeping all tissues dorsally.
 The inferior thyroid vessels are dissected,
skeletonized, ligated, and divided as close to the
surface of the thyroid gland as possible to
minimize devascularization of the parathyroids
(extracapsular dissection) or injury to the RLN.
Thyroid Surgery
 The RLN is most vulnerable to injury in the
vicinity of the ligament of Berry
 The nerve often passes through this
structure along with small crossing arterial
and venous branches
• Use of the electrocautery should be avoided in
proximity to the RLN.
 Once the ligament is divided, the thyroid
can be separated from the underlying
trachea by sharp dissection
Thyroid Surgery
 The recurrent
laryngeal nerve
runs through the
posterior superior
suspensory
ligament of the
thyroid (Berry's
ligament) before
entering the
cricothyroid muscle
Thyroid Surgery
 Parathyroid glands that are located
anteriorly on the surface of the thyroid
cannot be dissected from the thyroid with
a good blood supply or that have been
inadvertently removed during the
thyroidectomy should be resected,
confirmed as parathyroid tissue by frozen
section, divided into 1-mm fragments, and
reimplanted into individual pockets in the
sternocleidomastoid muscle.
 The sites should be marked with silk
sutures and a clip.
Thyroid Surgery
 If a subtotal thyroidectomy is to be
performed, once the superior pole
vessels are divided and the thyroid
lobe mobilized anteriorly, the thyroid
lobe is cross-clamped with a Mayo
clamp, leaving approximately 4 g of
the posterior portion of the thyroid.
Thyroid Surgery
 The thyroid remnant is suture ligated,
taking care to avoid injury to the RLN.
Routine drain placement rarely is
necessary.
 After adequate hemostasis is obtained, the
strap muscles are reapproximated in the
midline.
 The platysma is approximated in a similar
fashion.
 The skin can be closed with subcuticular
sutures or clips.
Neck Dissection
 Central compartment (medial to the carotid
sheath) lymph nodes frequently are involved in
patients with papillary, medullary, and Hürthle cell
carcinomas and should be removed at the time of
thyroidectomy, preserving the RLNs and
parathyroid glands.
 Central neck dissection is particularly important in
patients with medullary and Hürthle cell carcinoma
because of the high frequency of microscopic
tumor spread and because these tumors cannot be
ablated with 131I.
 An ipsilateral modified radical neck dissection is
indicated in the presence of palpable cervical
lymph nodes or prophylactically in patients with
medullary carcinoma when the thyroid lesion is >1
cm.
Neck Dissection
 A modified radical (functional) neck dissection
can be performed via the cervical incision used
for thyroidectomy, which can be extended
laterally to the anterior margin of the trapezius
muscle (MacFee extension). The procedure
involves removal of all fibro-fatty tissue along the
internal jugular vein (levels II, III, and IV) and
the posterior triangle (level V).
 In contrast to a radical neck dissection, the
internal jugular vein, the spinal accessory nerve,
the cervical sensory nerves, and the
sternocleidomastoid muscle are preserved unless
they are adherent to or invaded by tumor.
Neck Dissection
 The procedure begins by opening the plane
between the strap muscles medially and the
sternocleidomastoid muscle laterally.
 The anterior belly of the omohyoid muscle is
retracted laterally, and the dissection is carried
posteriorly until the carotid sheath is reached.
 The internal jugular vein is retracted medially
with a vein retractor and the fibro-fatty tissue
and lymph nodes are dissected away from it by a
combination of sharp and blunt dissection.
Neck Dissection
 The lateral dissection is carried along the
posterior border of the sternocleidomastoid
muscle, removing the tissue from the posterior
triangle
 The deep dissection plane is the anterior scalenus
muscle, the phrenic nerve, the brachial plexus,
and the medial scalenus muscle
 The phrenic nerve is preserved on the scalenus
anterior muscle, as are the cervical sensory
nerves in most patients
 Dissection along the spinal accessory nerve
superiorly is most important because this is
a frequent site of metastatic disease
Complications of Thyroid Surgery
 Nerves, parathyroids, and surrounding structures
are all at risk of injury during thyroidectomy
• Injury to the RLN
 occur by severance, ligation, or traction,
 occur in <1% of patients undergoing thyroidectomy by
experienced surgeons
 most vulnerable to injury during the last 2 to 3 cm of its
course
 also can be damaged if the surgeon is not alert to the
possibility of nerve branches and the presence of a
nonrecurrent nerve, particularly on the right side.
 If injured  primary reapproximation of the perineurium
using nonabsorbable sutures
• Injury to the external branches of the
superior laryngeal nerve in
approximately 20% of patients
 Intraoperative RLN and external laryngeal
nerve monitoring techniques
• Continuous monitoring using endotracheal tube
electrodes
• Intermittent monitoring by periodic stimulation
and laryngeal palpation
• Cervical sympathetic trunk injury in
invasive thyroid cancers and
retroesophageal goiters
• Transient hypocalcemia (from surgical injury or
inadvertent removal of parathyroid tissue)
 up to 50% of cases,
 permanent hypoparathyroidism occurs <2%
 more likely in patients who undergo concomitant
thyroidectomy, central and lateral neck dissection
• Postoperative hematomas or bleeding
• Bilateral vocal cord dysfunction with airway
compromise  immediate reintubation and
tracheostomy
• Seromas
• Wound cellulitis and infection
• Injury to surrounding structures such as
the carotid artery, jugular vein, and
esophagus
Postsurgical evaluation and Therapy after Appropriate Surgery Performed Based on
Recommendation
After appropriate surgery:
Total thyroidectomy
With or without neck
dissection
Determine risk
Accdg to ATA
Guidelines 2006
Low risk Intermediate or High Risk
Serum TSH maintained at 0.1-2

mu/L
Serum Tg q 6 mos
Empire RAI ablation
Neck US q 6 mos 100-200mci
* 30 mci
No
With Residual
residual Post tx scan
disease
disease (after 6 mos)
Whole body scan
(if extend of
See long term remnant could not
surveilance - uptake
be ascertained from + uptake
surgical report, or
young patient that
Surgery Imaging test to
overdosing of RAI
And/or localize and
would like to be
RAI Assess the resectability
avoided
and or guide EBRT
- uptake See long term surveillance
Surveilance and Maintenance
6 to 12 months after Post Surgery
Ablation
TSH Levels
(4-6 weeks post ablation)
Low Risk, Free of Disease Presented as intermediate or Persistent disease

TSH within low normal range High Risk but clinically disease free TSH maintained at <0.1 mu/L
(0.1 to 2 mu/L) TSH maintained at 0.1 to 0.5 mu/L Indefinitely in the absence of
For 5 to 10 years contraindication
A. Serum Thyroglobulin B. Cervical ultrasound

During TSH suppression
*(Negative anti TG antibodies)
Tg < 2 Tg > 2
TSH stimulated Tg
Tg<2 Tg >2
US - US+
Observe q6mos TSH, Tg and
Annual neck US until 5 years WB scan +/- imaging test
normal Surgery if warranted + RAI ablation, EBRT
T
H
A
N
K
Y
O
U
Physiology
 Iodine Metabolism
 Thyroid Hormone Synthesis, Secretion & Transport
 Thyroid Hormone Function
• Steps in the synthesis of thyroid hormone are:

 (1) active trapping and concentration of iodide in
the follicular cell;
 (2) synthesis/iodination, rapid oxidation of iodide to
iodine to form MIT, DIT (monoiodotyrosines/diiodo)
 (3) coupling of these iodotyrosines (monoiodo- and
diiodotyrosine) to form
the active thyroid hormones T4 (tetraiodothyronine or
thyroxine ) and T3 ( triiodothyronine ).
 (4) hydrolyzed of thyroglobulin to release free T3 and
T4.
 (5) yield of iodide, reused by thyrocytes.
PHYSIOLOGY
 Ingested iodide is trapped in the thyroid gland, oxidized, and bound to tyrosine
to form iodotyrosines in thyroglobulin. Coupling of iodotyrosyl residues forms
T4 and T3. Hormone secreted by the gland is transported in the serum. Some
T4 is deiodinated to T3. The hormone exerts its metabolic effect on the cell
and is ultimately deiodinated. The iodide is reused or excreted by the kidneys.
A second cycle goes on inside the thyroid gland with deiodination of
iodotyrosines generating iodide, which is reused without leaving the thyroid.
Physiology
 Schema of the homeostatic regulation of thyroid function
• Secretion of TSH is regulated by a negative feedback
mechanism acting directly on the pituitary and is
normally inversely related to the
concentration of unbound hormone in the blood.
• Release of TSH is induced by TRH secretion, which
sets the level of the pituitary feedback mechanism.
• Factors regulating secretion of TRH are uncertain but
may include the free hormone in the blood and stimuli
from higher centers.

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THYROID

Mark Louie Lanting, MD

Scintigraphy Low TSH; Normal/High

Scintigraphy Low TSH; Normal/High

Scintigraphy Low TSH; Normal/High

Ophthalmopathy- 50% periorbital

surgery to decrease vascularity

• Decrease peripheral effects of TH: PTU, steroids,

 For urgent surgery

 Oral iopanoic acid (500 mg BID) +

 Meta-analysis of 35 RCTs (Palit 2000)

Scintigraphy Low TSH; Normal/High

Scintigraphy Low TSH; Normal/High

Gross pathology of Riedel (fibrosing) thyroiditis.

Gross pathology of Riedel (fibrosing) thyroiditis.

• discrete swelling in an otherwise

Scintigraphy Low TSH; Normal/High

Scintigraphy Low TSH; Normal/High

Scintigraphy Low TSH; Normal/High

external branch of the superior

thyroid artery during

bothersome branch of the superior

branch of the subclavian artery

(RLN), necessitating identification of the

• External branch (Amelita Galla Cursi or

Serum TSH maintained at 0.1-2

Low Risk, Free of Disease Presented as intermediate or Persistent disease

A. Serum Thyroglobulin B. Cervical ultrasound

• Steps in the synthesis of thyroid hormone are:

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