An approach to_thyroid_swelling_seminar A GOOD PRESENTATION ON THYROID SWELLING MOSTLY STN, PAPILLARY THYROID CA, FOLLICULAR THYROID CA ARE DEALT WITH

1. GROUP MEMBERS:
SUDAKSHINA DAS
DEBALINA BHATTACHARJEE
KOUSIK KARMAKAR
SAYAN BANERJEE
AN APPROACH TO THYROID
SWELLING

2. Gr0ss Anatomy
● Coverings:
 True capsule
 False capsule
 The false capsule is thickened to form ligament of Berry which connects medial surface of the lateral
lobe of the gland with cricoid cartilage. This attachment explains why the thyroid gland moves up and
down with deglutination.
 The space between true and false capsules is occupied by parathyroid glands and trunks of blood
vessels.
● Presenting Parts: The gland consists of:-
 Two lateral lobes.
 An isthmus.
 It forms a H-shaped mass and weighs about 25 gms.
 Each lobe consists of :-
 Apex and a base
 3 surfaces : anterolateral ,medial, posterolateral
 Anterior and posterior borders

3. Blood Supply of Thyroid Gland
● Arterial supply – the gland is
supplied by the following arteries:
1. Superior thyroid artery.
2. Inferior thyroid artery.
3. Arteria thyroidea ima.
4. Numerous accessory thyroid arteries.
● Venous drainage –Veins arise
from venous plexus which lies deep to the
true capsule and are drained by:
1. Superior thyroid vein.
2. Middle thyroid vein.
3. Inferior thyroid veins.
4. Sometimes a forth thyroid vein
(Kocher’s vein) emerges from lower
pole and drains into internal jugular
vein.

4. Nerve Supply
 The parasympathetics are
derived from both vagus and
recurrent laryngeal nerves.
 The postganglionic
sympathetic fibres arise from
superior, middle and inferior
cervical ganglion.

5. Lymphatic Drainage
 Lymphatics form a plexus
around the thyroid follicles.
 The upper group drains into
prelaryngeal and
jugulodigastric lymph nodes .
 The lower group drains into
pretracheal and a group of
lymph nodes along recurrent
laryngeal nerve.

6. Surgical Anatomy
 The thyroid gland is the most vascular endocrine gland.
 During thyroidectomy, the superior thyroid artery is ligated close to
superior pole of thyroid gland to avoid ligation of external laryngeal
nerve as the external laryngeal nerve lies away from superior
thyroid artery.
 The inferior thyroid artery is ligated away from inferior pole of the
gland because the recurrent laryngeal nerve lies near the inferior
thyroid artery in the inferior pole.
 Damage to external laryngeal nerve cause significant voice
alteration. Damage to recurrent laryngeal nerve may cause loss of
phonation.

7. Surgical Anatomy(contd....)
 During thyroidectomy the thyroid gland is removed along with the
true capsule to avoid haemorrhage during operation as a dense
capillary plexus is present deep to the true capsule of thyroid
gland.
 Before thyroidectomy the first vessel that is ligated is the middle
thyroid vein because it is the most prominent and shortest vessel.

8. Function of Thyroid Gland
• The hormones of thyroid gland are three in number-
-Thyroxine(T4)
-Triiodothyronine(T3)
-Calcitonin
• Synthesis of thyroid hormones involves the following steps-
1.Iodide trapping.
2.Oxidation.
3.Organification.
4.Coupling.
5.Release of thyroid hormones.

9. FUNCTION OF THYROID GLAND (cont...)

10. Regulation of thyroid hormone secretion
 TRH secreted from hypothalamus.
Rise in TRH augments secretion of
thyroid hormones by stimulating
TSH secretion from the pituitary.
 TSH secreted from anterior
pituitary, stimulates secretion of
hormone from thyroid.
 Negative feedback is exerted by
circulating T3 and T4 hormones.

11. Normal and abnormal levels of thyroid hormones
 Serum triiodothyronine (T3)- 1.2-3.1 nmol/litre.
 Serum thyroxine (T4)- 55-150 nmol/litre.
 Free T3 - 3.5-7.5 μmol/L.
 Free T4 -10-30 nmol/L.
 TSH- 0.3-3.3 mIU/L of plasma.
 Thyroglobulin – 0.5-50 μg/litre.

12. Normal and abnormal levels of thyroid hormones(Contd...)
 EUTHYROIDISM- It is a state of having normal thyroid
gland function.
 HYPERTHYROIDISM - It is a condition that occurs due to
excessive production of thyroid hormones by the thyroid
gland.
 HYPOTHYROIDISM – It is a more commoner disorder of the
thyroid gland in which the thyroid gland does not produce
enough thyroid hormone.

14. DEBALINA BHATTACHARJEE
8TH SEMESTER
MALDA MEDICAL COLLEGE
CLINICAL FEATURES AND
PATHOPHYSIOLOGY

15. CLASSIFICATION OF GOITER
 Simple goiter(Euthyroid)
 Diffuse hyperplastic-
o physiological
o pubertal
o pregnancy
 Multinodular goiter
 Toxic-
o Diffuse(graves disease)
o multinodular
o Toxic adenoma
 Neoplastic-
o Benign
o Malignant
 Inflammatory-
o Autoimmune- chronic lymphocytic
thyroiditis, Hashimoto’s thyroiditis
o Granulomatous- de-Quervan’s
thyroiditis
o Fibrosing- Riedel’s thyroiditis
o Infective- acute/subacute/chronic
thyroiditis
o Other- amyloidosis

16. The Natural History of Simple Goiter
 Stages in goiter formation are:
 Persistent growth stimulation causes diffuse hyperplasia; all lobules are
composed of active follicles and iodine uptake is uniform. This is a diffuse
hyperplastic goiter, which may persist for a long time but is reversible if
stimulation ceases.
 Later, as a result of fluctuating stimulation, a mixed pattern develops with areas
of active lobules and areas of inactive lobules.
 Active lobules become more vascular and hyperplastic until hemorrhage
occurs, causing central necrosis and leaving only a surrounding rind of active
follicles.
 Necrotic lobules coalesce to form nodules filled either with iodine-free colloid
or a mass of new but inactive follicles.
 Continual repetition of this process results in a nodular goiter. Most nodules
are inactive, and active follicles are present only in the internodular

17. Types of Simple Goiter
• Diffuse hyperplastic goiter
 Diffuse hyperplasia corresponds to the first stages of the natural history. The
goiter appears in childhood in endemic areas but, in sporadic cases, it usually
occurs at puberty when metabolic demands are high. If TSH stimulation ceases,
the goiter may regress, but tends to recur later at times of stress, such as
pregnancy. The goiter is soft, diffuse and may become large enough to cause
discomfort. A colloid goiter is a late stage of diffuse hyperplasia when TSH
stimulation has fallen off and when many follicles are inactive and full of colloid.
• Nodular goiter
 Nodules are usually multiple, forming a multinodular goiter. Occasionally, only
one macroscopic nodule is found, but microscopic changes will be present
throughout the gland; this is one form of a clinically solitary nodule. Nodules
may be colloid or cellular, and cystic degeneration and hemorrhage are common,
as is subsequent calcification. Nodules appear early in endemic goiter and later
(between 20 and 30 years) in sporadic goiter, although the patient may be
unaware of the goiter until his or her late 40s or 50s. All types of simple goiter
are more common in the female than in the male owing to the presence of
estrogen receptors in thyroid tissue.

18. Pathophysiology of Multinodular Goiter

19. Stages of MNG formation
Stage of hyperplasia and hypertrophy
Stage of fluctuation in TSH
Stage of formation of nodules(inactive)

20. Clinical Features of MNG
 Common in middle aged women
 Slowly progressive disease with many years of history
 Multiple nodules of different sizes are formed in both lobes,
also in isthmus, which is firm, non tender, nodular, moves
with deglutition
 Recent increase in size signifies malignant transformation
or haemorrhage

21. Solitary thyroid nodule
 It is a single palpable nodule in thyroid
on clinical examination in an otherwise
normal gland.
 Types-
 Toxic solitary nodule
 Nontoxic solitary nodule-
 Hot- means autonomous toxic
nodule. Normal surrounding
tissue is inactive so will not take
up isotope. Nodule is overactive.
 Warm- nodule and surrounding
tissue will tale up isotope.
 Cold- non-functioning nodule,
nodule will not take up isotope.

22. CLINICAL FEATURES
 Single nodule palpable in one or other lobes of the thyroid
gland is usually smooth and firm
 Lahey’s test does not show any other nodules in posterior
part of gland
 Thyroid nodule in children and elderly can be malignant
 Tracheal deviation towards opposite side is common,
confirmed by trail sign, 3 finger test, auscultation, and X ray
neck
 Commonest site of a nodule is at the junction of isthmus
with one of the lateral lobes

29. PRIMARY VS. SECONDARY
THYROTOXICOSIS

33. CLINICAL MANIFESTATIONS
The symptoms are-
 Gastrointestinal system-
 Weight loss
 Diarrhoea
 Cardiovascular system-
 Palpitations
 Shortness of breath at rest or on minimal exertion
 Angina
 Irregularity in heart rate
 Cardiac failure in elderly
 Neuromuscular system-
 Undue fatigue and muscle weakness
 Tremor

34.  Integument-
 Hair loss, gynecomastia
 Pruritus
 Palmar erythema
 Psychiatry-
 Irritability
 Nervousness
 Insomnia
 Sympathetic overactivity-
 Causes dyspnoea, palpitation, tiredness, heat intolerance, nervousness,
increase in appetite, decrease in weight
 Because of increased catabolism, they have increased appetite, decreased
weight and increased creatinine level which signifies myopathy

35. Signs of Thyrotoxicosis
 EYE SIGNS-
 Exopthalmos
 Lid retraction
 Stellwag’s sign (staring look)
 Von Graefe’s sign (lid lag sign)
 Joffroy’s sign
 Moebius sign
 CARDIAC SIGNS-
 Tachycardia is common
 MYOPATHY-
 Weakness of proximal muscles occurs- front thigh muscles, arm muscles
 Weakness is more when muscle contracts isometrically

36.  PERITIBIAL MYXOEDEMA-
 Usually bilateral, symmetrical, shiny, red thickened hard skin with coarse
hair in feet and ankles
 Due to deposition of myxoematous tissues in sin and subcutaneous planes
 Might or might not regress completely after treatment for toxicity

38. CLINICAL DIAGNOSIS &
INVESTIGATION IN A CASE OF
THYROID SWELLING
KOUSIK KARMAKAR
8th SEMESTER
MALDA MEDICAL COLLEGE

39. PROPER HISTORY
1. SWELLING:
• DURATION
• ONSET
• SITE
• PROGRESSION
• RAPID GROWTH
2. PAIN:
• DURATION
• SITE
• CHARACTER
• RADIATION
• OTHER FACTORS
3. PRESSURE SYMPTOMS:
• DYSPNEA/ DYSPHAGIA/
HOARSENESS OF VOICE
4. FEATURES OF HYPERTHYROIDISM:
(THYROTOXICOSIS)
• CNS WITN EYE
• CVS
• GIT
• MENSTRUAL
5. FEATURES OF HYPOTHYROIDISM:
1. LETHARGY
2. DEPOSTON OF FAT
3. DEEP, HUSKY VOICE
4. INTOLERANCE TO COLD
6. OTHERS

40. PROPER HISTORY

41. GENERAL SURVEY
1. FACIES
2. NECK GLAND
3. PULSE

42. On inspection-
o Number of swellings
o Site, size & shape of the swelling
o Location of the swelling
o Borders of the swelling w.r.t. sternocleidomastoid & suprasternal
notch
o Surface of the swelling- smooth/ nodular/ bosselated
o Skin over the swelling- redness & edema/ scars, sinuses & fistula/
dilated veins
o Visible pulsations over the swelling
o Tremor
o Upward movement on deglutition & protrusion of tongue
o Look for lower border of the swelling
o Pizzilo’s method
o Pemberton’s sign

43. • On palpation-
• Temperature
• Tenderness
• Conventional/ standard method- palpation of thyroid from behind
• Thumbs of both hands are kept at the nape of the neck and the other 4 fingers of
each hand are placed on each lobe & the isthmus
• Lower tracheal rings are also palpated- to check for retrosternal extension
• Lahey’s method- palpation of thyroid from front
• Deep/ posteromedial surface is palpated
• To palpate the left lobe properly, thyroid is pushed to the left from right side by the
left hand of the examiner and vice-versa
• Crile’s method- for palpation of small nodules on thyroid gland
• Place the thumb on the affected side over the thyroid & patient is asked to swallow
to check for small nodules

44. Whole thyroid not enlarged; only a single nodule:
• Location- lobe/isthmus
• Size
• Consistency- soft/firm
• Is the rest of the thyroid gland palpable???
When total gland is enlarged:
• Surface-
o Smooth- Colloid goiter, Grave’s disease
o Bosselated- MNG
• Consistency-
o Soft- Colloid goiter, Grave’s disease
o Firm- SNG, MNG
o Hard- Ca thyroid, Riedel’s thyroiditis
• Restricted mobility- Malignancy & chronic thyroiditis
• Palpate the lower border to check for retrosternal extension
• Pressure effects:
o Kocher’s test- typically positive in scabbard trachea of large & long-standing MNG
o Carotid sheath is pushed back by benign swelling where carotid pulsations felt
o Check for Horner’s syndrome (enophthalmos/ miosis/ anhidrosis/ pseudoptosis)
• Palpate for thrill
• Berry’s sign

45. • On percussion-
o Direct percussion / heavy strokes on manubrium-
 Resonant= normal
 Dull= retrosternal goiter
• On auscultation-
o Systolic bruit over the goiter in a case of primary toxic goiter due
to increased vascularity

46. LYMPH NODES
• EXAMINATION OF THE CERVICAL GROUP OF LYMPH NODES
• NUMBER, SITE, CHARACTER, SURFACE, MARGIN, CONSISTENCY,
MARGIN, ENLARGEMENT

47. TOXIC SIGNS

49. RETROSTERNAL PROLONGATION
•FROM HISTORY
•ON GENERAL SURVEY
1.LOCAL EXAMINATION
2.ENGORGED VEIN
3.MARGIN OF THYROID GLAND
4.PERCUSSION

50. PEMBERTON'S SIGN
• PROCEDURE:-
• ASK THE PATIENT TO RAISE BOTH RHE ARMS OVER THE HEAD
TOUCHING THE EARS AND MAINTAIN IT FOR 2-3 MINS.
• INTERPRETATION:-
• POSITIVE
• NEGATIVE

51. SYSTEMIC EXAMINATION

52. • Assess the cardiac condition :
• Bradycardia and tachycardia
• Assess the pulmonal condition :
• Slow respiration, shortness of breath
• Assess the abdominal condition :
• slowed or rapid peristaltic
• Assess the extremities condition :
• Tremor
• Thyroid dermopathy
• Moist hand, warm
• Dry skin
• Myxedema
• Assess the neuromuscular system
• Slow reflexes
• Hyper reflexes
• Assess the musculoskeletal system
• Muscular weakness

53. INVESTIGATION
1.FOR CONFIRMATION
2.STAGING
3.BASELINE INVESTIGATION FOR SURGICAL
INTERVENTION

54. FINE NEEDLE ASPIRATION BIOPSY
LABORATORY INVESTIGATION
IMAGING STUDIES
ULTRASONOGRAPHY
RADIO IODINE STUDIES (RADIOACTIVE IODINE UPTAKE SCAN[RAIU])
CT SCANNING AND MRI
X-RAYS

55. FINE NEEDLE ASPIRATION BIOPSY
MOST IMPORTANT DIAGNOSTIC TOOL. SAFE AND MINIMALLY INVASIVE
ULTRASONOGRAPHIC GUIDANCE  INCREASES THE ACCURACY OF
FNAB
• Indicated if:
• Palpation-guided FNAC non-diagnostic
• Complex (solid/cystic) nodule
• Palpable small nodule (<1.5 cm)
• Impalpable nodule
• Abnormal cervical nodes
• Nodule with suspicious US features
 GHARIB AND GOELLNER (1993) FOUND THAT
 69% OF FNAB RESULTS WERE BENIGN,
 4% WERE MALIGNANT,
 10% WERE INDETERMINATE, AND
 17% WERE NONDIAGNOSTIC.
SENSITIVITY 83%
SPECIFICITY 92%
FALSE-POSITIVE RATE WAS 2.9%, AND THEIR FALSE-NEGATIVE RATE
WAS 5.2%.

56. • Malignant (+ve) cytology
• Commonest is PTC(Papillary thyroid carcinoma):
• Characteristics cytological feature- psammoma bodies, orphan annie eye nuclei (cleaved
nuclei)
• Others include:
• Medullary thyroid carcinoma(amyloid deposits, intracytoplasmic calcitonin), anaplastic
carcinoma(cellular anaplasia) and high-grade metastatic cancers
• Suspicious cytology in FNAC
• Diagnosis cannot be made
• Includes:
• Follicular neoplasms,
• Atypical PTC, or
• Lymphoma
ORPHAN ANNIE EYE NUCLEI

57. FINE NEEDLE ASPIRATION BIOPSY
COMPLICATIONS
1. MINOR HEMATOMAAND ECCHYMOSIS  MOST COMMON
2. PUNCTURE OF THE TRACHEA, CAROTID ARTERY, OR JUGULAR VEIN MAY
OCCUR
• CAN BE MANAGED BY APPLYING LOCAL PRESSURE

58. FINE NEEDLE ASPIRATION BIOPSY
Limitation
Difficult to differentiate between follicular adenoma and carcinoma on
cytology as it depends upon capsular and angioinvasion
Options in follicular carcinoma
Frozen section biopsy
Unilateral lobectomy
True cut biopsy
Danger of hemorrhage and injury to trachea, recurrent laryngeal
nerve and vessels

59. LABORATORY INVESTIGATIONS
• Serum TSH levels
• Low level suggests
autonomously functioning
nodule (usually benign)
• Doesn’t rule out malignancy
• Serum calcitonin levels
• Highly suggestive of MTC if
increased
• More sensitive marker than
CEA
• PCR assays for germline
mutations in the RET proto-
oncogene
• Diagnostic in Familial
medullary thyroid carcinoma
• Pentagastrin-stimulated
calcitonin
• Used as tumour markers to
monitor patients who have
been treated for MTC
• Serum thyroglobulin levels
• Cannot differentiate between
benign and malignant disease
• Used in patients who
underwent total
thyroidectomy * for thyroid
cancer
• Patients undergoing non
operative management of
thyroid nodule
• * increased levels indicate
recurrence
• Urinary VMA, metanephrine and
catecholamine
• To rule out coexisting
Pheochromocytoma in MTC
• Serum levels of CEA
• Increased in MTC but
nonspecific
• Better indicator of prognosis
than Calcitonin
• New patients with MTC should be
screened for RET point
mutations, Pheochromocytoma
and HPT.

60. • Autoimmune thyroiditis may be associated with thyroid toxicity, failure or euthyroid goitre.
• Levels above 25 units/mL for TPO antibody and titres of greater than 1:100 for
antithyroglobulin are considered significant, although a proportion of patients with histological
evidence of lymphocytic (autoimmune) thyroiditis are seronegative.
• The presence of antithyroglobulin antibody interferes with assays of serum thyroglobulin with
implications for follow up of thyroid cancers.
• TSH receptor antibodies (TSH-Rab or TRAB) are often present in Graves’ disease.
THYROID
FUNCTIONAL STATE
TSH FREE T4 (FT4) FREE T3 (FT3)
EUTHYROID NORMAL (0.3-3.3 mIU/L) NORMAL (10-30 nmol/L) NORMAL (3.5-7.5 μmol/L)
THYROTOXIC UNDETECTABLE HIGH HIGH
MYXEDEMA HIGH LOW LOW
SUPPRESSIVE T4 THERAPY UNDETECTABLE HIGH HIGH; often NORMAL
T3 TOXICITY LOW/ UNDETECTABLE NORMAL HIGH
RANGE OF TESTS AVAILABLE

61. ULTRASONOGRAPHY
HIGHLY SENSITIVE FOR THYROID NODULES
CAN DEPICT NODULES ONLY A FEW MILLIMETERS IN SIZE
CAN DETECT NON PALPABLE THYROID NODULES
DIFFERENTIATE SOLID FROM CYSTIC NODULES
CAN DETECT ADJACENT LYMPHADENOPATHY
FEATURES SUGGESTIVE OF MALIGNANCY ON USG INCLUDE :
FINE STIPPLED CALCIFICATION
ENLARGED REGIONAL LYMPH NODES
USED TO FOLLOW THE SIZE OF SUSPECTED BENIGN NODULES

62. THYROID NODULE WITH FEW,
EASILY COUNTABLE
MICROCALCIFICATIONS
• SOLID, HYPOECHOIC, AND COARSE CENTRAL
CALCIFICATIONS
• LATER PROVED TO BE MEDULLARY
CARCINOMA
ULTRASONOGRAPHY

63. RADIOIODINE STUDIES
Recommended in patients having Follicular CA on FNAB and suppressed TSH.
Determine functional status of a nodule
• Based on radioisotope studies nodule can be →
Hot
 Autonomous toxic nodule
Warm
 Normally functioning
Cold
 Non functioning nodule (likely to be malignant but not always)
 Limitations of Thyroid scan
• Two dimensional scanning technique
• Inability to measure the size of a nodule accurately
• Missed malignant thyroid nodules

64. Thyroid Scan showing
cold nodule
Thyroid scan showing hot nodule
111 indium octreotide scanning
MTC (70% sensitive)

65. X-RAYS
• CXR and X-ray skull to rule out
metastatic deposits
• Skull metastasis more likely
in Follicular carcinoma
CT SCANNING
& MRI
• Used to evaluate soft-tissue
extension of large or
suspicious thyroid masses
into the neck, trachea, or
oesophagus
• To assess metastases to the
cervical lymph nodes
Images of a large, asymmetric multinodular
goiter. (A) Chest radiography shows marked
tracheal deviation to the right (arrow). (B) Chest
CT confirmed the presence of a large substernal
goiter on the left to the level of tracheal
bifurcation.

66. X-ray of skull showing a couple of painless,
progressively increasing swellings in the
occipitoparietal region of the scalp.

67. ROUTINE INVESTIGATIONS FOR FITNESS
1. COMPLETE HEMOGRAM
2. CHEST X-RAY
3. ECG
4. X-RAY NECK
5. BLOOD INVESTIGATIONS
6. URINE & STOOL EXAMINATION
7. ENT CHECK-UP

69. TREATMENT & FOLLOW-UP OF A
CASE OF THYROID SWELLING
SAYAN BANERJEE
8TH SEMESTER
MALDA MEDICAL COLLEGE

70. Lymph node levels
in neck

71. THYROID NODULE /
MASS
FNAB
Malignant or
suspicious
Benign
Follow
clinically
Surgery
Tissue
pathology
Indeterminate
Algorithm / Overview

72. MANAGEMEN
T OF A CASE
OF STN

73. Toxic Multinodular Goitre
• Elderly, long standing MNG
• Mainly cardiac
• NO EXTRATHYROIDAL FEATURES
• ↓TSH; ↑FT4, FT3
• RAIU : internodular tissue hot
• Tx: Make euthyroid → Thyroidectomy (STT, Hartley Dunhill, TT)
RAI (I131): Elderly, Poor risk patients

74. Toxic Adenoma (Plummer’s
disease)
• Single nodule
• Young, long-standing nodule, sudden growth and hyper-function
• RAIU: Hot nodule
• Small nodule: ATT, RAI
• Large nodule/ Young patients: Lobectomy

75. Surgery in a Hyperthyroid Patient
• Make patient euthyroid prior to surgery→
• Continue ATT upto morning of surgery
• Lugol’s Iodine or SSKI: 3 drops BD starting 10 days prior
• Inhibits release of hormone, ↓vascularity
• Propranolol

76. Operations on the Thyroid

77. Ipsilateral thyroid lobectomy is recommended:
1. Cyst persist after 3 attempts for aspiration
2. Cyst >4cm
3. Complex cyst with solid and cystic components higher chances of
malignancy (15 %)

78. Papillary thyroid carcinoma
TYPE TREATMENT
HIGH RISK or BILATERAL  Total or near total thyroidectomy
Minimal papillary carcinoma in
thyroid specimen
 Ipsilateral thyroid lobectomy and
isthmusectomy
Large, Locally aggressive/ metastatic
tumours
 Total thyroidectomy with excision of
adjacent involved structures if necessary
and appropriate nodal surgery followed by
radioablation with long term TSH
suppression
 Modified Radical neck dissection type III is done in case of
biopsy-proven lymph node metastases

79. Low risk groups
Points in favour of
total thyroidectomy
Point in favour of
lobectomy
 Enables the use of RAI to
detect and treat residual
thyroid tissue/mets
 Lobectomy has less
complication rate
 Makes serum Tg level more
sensitive for recurrent or
persistent disease
 Recurrence in remaining
tissue is unusual (5%) and
mostly curable by surgery
 Removes contralateral
occult cancer as sites of
recurrence (85% bilateral)
 Tumor multicentricity has
little prognostic
significance
 Reduces recurrence risk
and improved survival
 Prognosis is comparable to
total thyroidectomy
 Decreases the 1 % risk of
progression to anaplastic
cancer
 Reduces rate of re-
operation and complication
Generally total or near
total thyroidectomy is
recomended in low risk
groups provided
complication rates are low
<2 %

80. Indication of total thyroidectomy
NCCN guidelines
If any present
If all present
(thyroidectomy/lobectomy)
 Age <15y or >45y  Age 15 – 45 y
 Radiation history  No radiation history
 Known distant mets  No distant mets
 Bilateral nodularity  No nodularity
 Extrathyroidal invasion  No extrathyroidal invasion
 Tumour > 4cm  Tumour <4 cm
 Cervical lymph node mets  No cervical lymph nodes mets
 Aggressive variant  No aggressive variant

81. •Prophylactic lateral neck node dissection is NOT
recommended in PTC
•Cancer doesn’t metastasize systemically from lymph
nodes
•Micrometastasis can be ablated by RAI therapy

82. Residual disease Post operatively
•TSH + Tg and antithyroglobulin antibodies
• 2 to 12 weeks post operatively
•Total body RAI imaging
• Suspected or proven RAIEBRT
• Adequate RAI uptake  Radioiodine treatment and post treatment I131
imaging
•If no imaging performed  EBRT
•In all these cases suppress TSH with Levothyroxine.

83. •Total thyroidectomy resulted in improved survival over
other techniques
•Poorer outcomes were associated with age, stage T3/T4
disease, positive nodes, and tumour size

84. Metastatic disease
• CNS  Neurosurgical resection and/or image guided EBRT
• BONE Surgical palliation (weight bearing extremities and/or RAI
treatment and/or EBRT)
• bisphosphonate or denosumab therapy
• Embolization of metastatic deposits
• Other than CNS  surgical resection and/or EBRT of selected mets
and/or radioiodine
• Best supportive care

85. Follicular carcinoma
• Follicular lesion on FNAB  thyroid lobectomy (80 % are benign
adenomas)
• Thyroid cancer  Total thyroidectomy is recommended in →
• Older patients
• Lesion >4cm ( cancer risk is higher- 50 %)
• Intraoperative frozen section examination if
• Evidence of vascular or capsular invasion
• Adjacent lymphadenopathy is present
• Thyroid specimen  follicular carcinoma total thyroidectomy
• Nodal metastasis  therapeutic neck dissection
Prophylactic nodal dissection is unwarranted as nodal
involvement is infrequent

86. Hurthle cell carcinoma
• Unilateral Hurthle cell adenomas  lobectomy + isthmusectomy
• Invasive (on definitive paraffin section histology) total thyroidectomy +
central neck node removal
• Modified radical neck dissection if lateral nodes are palpable & identified
by USG
• TSH suppression
• Although RAI scanning and ablation usually are ineffective, they
probably should be considered to ablate any residual normal thyroid
tissue and occasionally ablate tumors because there is no other good
therapy.
Retinoic acid and PPAR-γ agonists have shown some benefit in these tumors in
vitro; but needs further research

87. Post operative management of
Differentiated Thyroid Cancer
1. Radioiodine scanning and ablation
2. External beam radiotherapy (EBRT)
3. Chemotherapy

88. 1.Radioiodine scanning and ablation
• RAI ablation is recommended in
• All patients with stage 3 and 4 disease
• All Patients with stage 2 disease <45 years
• Most patients ≥ 45 years with stage 2 disease
• Stage 1 disease with
• Aggressive histology
• Nodal metastases
• Multifocal disease
• Extrathyroidal or vascular invasion
• More senstive than X-ray/ CT in detecting metastatic disease
• Less senstive than Tg level except in Hurthle cell tumors
• 4-6 weeks after thyroidectomy, hypothyroid can be induced by
discontinuing replacement (T4 for 4 weeks or T3 for 2 weeks) to
obtain high serum TSH levels.

89. 1.Radioiodine scanning and ablation
(CONTD….)
• A diagnostic dose of 131I or 123I is given initially.
• Whole-body scanning is performed to detect any tissue taking up radioiodine.
• If any normal thyroid remnant or metastatic disease is detected, a
therapeutic dose of 131I is administered to ablate the tissue.
• Post-treatment scanning should also be performed because it may reveal
metastatic disease not otherwise noted.
• If a treatment dose of 131I is required, diagnostic thyroid scanning is repeated
after 6 months after initial treatment,
• If the diagnostic scan Positive  additional therapeutic dose is given. Process
is repeated until the diagnostic scan is negative
Role of recombinant human TSH
• Thyrogen stimulation avoids the discomfort of patients having to discontinue
thyroid replacement
• T4 stopped 1 day before TSH stimulation

90. Recent advances
Sorafenib* (Nexavar) was approved in November 2013 for
differentiated thyroid cancer (DTC) that is refractory to
radioactive iodine treatment.
*Sorafenib is a small molecular inhibitor of several tyrosine
protein kinases

91. Thyroid suppression
•Used after thyroidectomy and radioablation
•Reduces tumoural growth and recurrence rates
•Suppressive dose is 0.3 mg OD lifelong
•TSH levels should be < 0.1 mU/L

92. 2. External beam radiotherapy
•Used in unresectable, locally invasive or
recurrent disease
•In bone mets to decrease
•Risk of fractures
•Bone pain

93. 3. Chemotherapy
• Generally has no role
• Doxorubicin is used as radiation sensitizer in patients
undergoing external beam radiation

94. Medullary thyroid carcinoma
• If pheochromocytoma present  operated first
• Total thyroidectomy is the treatment of choice with bilateral central
neck node dissection
• Palpable cervical lymph nodes modified radical neck dissection
• Tumour >1 cm  ipsilateral Prophylactic modified radical neck
dissection
• If +ve then contralateral node dissection is done
• If unresectable
• Tumor debulking to reduce symptoms
• External beam radiation

95. Medullary thyroid carcinoma
Recent advances
Tyrosine kinase inhibitors
Imitanib
Zactima (reduces calcitonin and CEA levels)
Anti CEA monoclonal antibody
Labetuzumab
Laparoscopic Radiofrequency ablation
For Liver mets >1.5 cm (palliative)

96. •If patient is hypercalcemic at thyroidectomy
•Only enlarged parathyroid gland is removed
•RET mutation carrier  total thyoroidectomy
•MEN2A  before 6 years
•MEN2B  before 1 year
•Central neck node dissection
•Avoided in calcitonin negative and normal USG exam
•Done prophylactically in calcitonin positive and if USG
suggests cancer
•Maintenance dose of L-thyroxine

97. • All family members of patients with MTC should be evaluated with
serum calcitonin (genetic evaluation can also be done ) and if it is high
they should undergo prophylatic thyroidectomy ......

98. Anaplastic carcinoma
•If resectable
• Adjuant chemoradiotherapy
• Adriamycin is used for chemo.
•Tracheostomy and isthmusectomy to relieve
airway obstruction in unresectable cases

99. Lymphomas
•Mainstay  Chemotherapy
• CHOP ( Cyclophosphamide, Doxorubicin, vincristine, and prednisolone)
•Radiotherapy may also be given
•Thyroidectomy and nodal resection to alleviate airway
obstruction

101. Differentiated Thyroid Carcinoma
Thyroglobulin levels
Thyroglobulin is an useful marker of tumor recurrence
because well-differentiated thyroid cancers synthesize
thyroglobulin
•After total thyroidectomy levels should be
• <2 ng/ml if taking T4
• <5ng/ml if hypothyroid
• Levels >2ng/ml suggest metastatic or persistent normal tissue. (>95%)
•Tg and Tg antibodies measuresd initially 6 months
interval then annually if disease free.

102. Follow up imaging
•In low risk and –ve TSH stimulated Tg and cervical USG
routine whole bodyscan is not recommended after first
post operative scan
•After remnant ablation routine whole body scan after 6 to
12 months is recommended
Cervical USG
•To evaluate thyroid bed and lymph node  6 to 12
months post thyroidectomy then annually for 4 to 5 years
FDG PET SCAN
•If RAI and USG normal but Tg remain elevated

103. Medullary thyroid carcinoma
• Annual measurements of calcitonin and CEA levels.
• Regular USG , CT , MRI if required
• FDG PET scans
• Superior to other radionuclide based studies

104. Management of recurrence
• Localized
• Surgical excision
• Non localized
• 131I radioablation
• External beam radiotherapy