Surgery II 6.8 Dr.

Ampil
THYROID AND PARATHYROIDS Not Lectured

OUTLINE PYRAMIDAL LOBE

I. Congenital Lesions
50 % of individuals
II. Evaluation of Thyroid Disease
III. Goiter Distal end of thyroglossal duct persists
IV. Hyperthyroidism/Thyrotoxicosis Projecting up from the isthmus, lying just to the left or right of the
V. Toxic Goiter midline.
VI. Non-toxic Goiter Very common, and of no clinical significance, unless a surgeon decides
VII. Thyroiditis to do a total thyroidectomy
VIII. Thyroid Cyst No pathologic problem most of the time
IX. Being Tumors
When the thyroid gland enlarges, the pyramidal lobe can also enlarge
X. Malignant Tumors
XI. Parathyroid Glands

REFERENCES
1. PPT (2015 Lecture)
2. 2016A Trans
3. 2015B Trans
4. Schwartz/Sabiston

CONGENITAL LESIONS
Unlike the abdomen and thoracic cavity, the neck is a relatively
superficial so its easier to diagnose thyroid disease, usually presenting
with an ANTERIOR NECK MASS Figure 2. Pyramidal Lobe
Normally, the thyroid gland should not be palpated
Embryologic life of the thyroid gland: it starts at the base of the tongue ECTOPIC THYROID
and goes down the neck where it lies during the adult life Failure of the thyroid to descend completely into the neck
Any problem with the descent of the thyroid gland to the neck will Results to thyroid tissue anywhere along the tract
cause congenital abnormalities
LINGUAL / SUBLINGUAL THYROID
THYROGLOSSAL DUCT ANOMALIES (Cyst, Sinus, Fistula) Mass or thyroid found at the base of the tongue
Thyroglossal duct (lifted from 2015B Trans) If you excise it, the patient will no longer have a thyroid
o The tract from the base of the tongue all the way to the neck Represents a failure of the median thyroid anlage to descend normally
o Supposed to disappear after the thyroid goes down and may be the only thyroid tissue present
Thyroglossal duct cysts are the most commonly encountered S/Sx:
CONGENITAL CERVICAL anomalies o Hypothyroid symptoms
Typically midline masses in childhood o Obstructive symptoms
80% below hyoid bone o Choking, dysphagia, airway obstruction
ELEVATES with tongue protrusion Treatment:
o Upon protrusion, the thyroid gland goes up through the patent If small in size, Exogenous thyroid hormone to suppress TSH
thyroglossal duct Radioactive iodine (RAI) ablation followed by hormone
During the embryologic life, the thyroid gland originates from the replacement
foramen cecum at the base of the tongue. From there, it will Surgical excision is rarely needed, but if required, should be
descend and will split into two forming the 2 lobes of the thyroid preceded by an evaluation of normal thyroid tissue in the neck to
gland. The thyroglossal duct is supposed to degenerate upon birth. avoid inadvertently rendering the patient hypothyroid (If big)
If it persists thyroglossal duct problems
Clinical Importance: distinguish thyroglossal duct from simple cyst
because they have different treatment
Cyst excise
Thyroglossal duct cyst Sistrunk Procedure
If the thyroglossal duct cyst is simply excised, it will recur
No external sinuses but may infect
Treatment: SISTRUNK Procedure removal of the mass and the entire
tract all the way to the base of the tongue, until the hyoid bone Figure 3. Lingual or Sublingual Thyroid
This procedure consists of en bloc cystectomy and excision of the
central hyoid bone to minimize recurrence

Figure 1. Thyroglossal Duct

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 Surgery II 6.8

EVALUATION OF THYROID DISEASE o Thyroid antibodies

Thyroid problems usually appear as anterior neck masses
Usually, a thyroid mass moves up with swallowing
o Thyroglobulin
Include anti-Tg, antimicrosomal, or anti-TPO and thyroid-
stimulating immunoglobulin
indicate underlying disorder, usually an autoimmune
thyroiditis
High in 80% of patients with Hashimotos thyroiditis and may
also be elevated in Graves disease, multinodular goiter, and
thyroid neoplasms (occasionally)
Increases dramatically in destructive processes of the thyroid
gland (i.e. thyroiditis, Graves disease, toxic multinodular
goiter)
Most important use is in monitoring patients with
differentiated thyroid cancer for recurrence

INITIAL WORK-UP
Initial diagnostic modality is thyroid function test
o TSH, FT4, FT3
If euthyroid
Figure 4. Hypothalamus Pituitary Thyroid Axis. The hypothalamus
o Ultrasound
releases TRH, stimulating the anterior pituitary gland to secrete TSH, which
o FNABC
stimulates the thyroid to produce thyroid hormones with iodine. Excess in
If hyperthyroid
thyroid hormones will produce a negative feedback mechanism which
o Thyroid scan
suppresses the production of TSH. Also, If TSH is increased, there is a
Hot / warm nodule: treat as toxic nodule
negative feedback to the hypothalamus which will decrease TRH secretion.
Cold nodule: FNABC
THYROID FUNCTION TESTS
ULTRASOUND
MOST ACCURATE TESTS of thyroid function
Main advantage: determine consistency of mass
o SERUM TSH (Thyroid Stimulating Hormone)
o Simple cyst = thyroid cyst (purely fluid)
The most sensitive and specific test for determining thyroid
o Complex cyst = goiter (has both cystic and solid components)
function
o Solid nodule = tumor
Reflect the ability of the anterior pituitary to detect free T4
Noninvasive, no radiation exposure
levels
Monitoring nodule size (for non-operative tx)
There is an inverse relationship between free T4 levels and
the logarithm of TSH concentration small changes in in free Size & multicentricity: can detect masses even 1mm
T4 lead to a large shift in TSH levels Detects non-palpable masses
o FREE T4 & FREE T3 ASSAY (FT4 & FT3) Cervical lymphadenopathy
Measure the biologically active thyroid hormones which Guide fine-needle aspiration (FNA) biopsy
cause the clinical manifestations Evaluating substernal goiters (extent, tracheal compression)
FT4 is not performed as a routine screening tool in thyroid Characteristics associated w/ CA
disease. Use of this test is confined to cases of early o Hypoechogenicity
hyperthyroidism o Irregular margins
FT3 is most useful in confirming the diagnosis of early o Increased nodular flow (Doppler)
hyperthyroidism Hypervascular increased blood flow
o Invasion / regional lymphadenopathy
Table 1. Interpreting Thyroid Function Tests (Memorize)
SERUM TSH FT4 AND FT3 ASSAY DIAGNOSIS
High Low Hypothyroid
High Normal Subclinical Hypothyroid SOLID COMPLEX
Low High Hyperthyroid
Low Normal Subclinical Hyperthyroid
*If the patient can only avail one test, request for TSH
CYST
Others:
o Total T4 & T3
Both are measured by radioimmunoassay
Measure both the free and bound components of the
hormones
Figure 5. Ultrasound Results
T4 levels reflect the output from the thyroid gland
T3 levels in the non-stimulated thyroid gland are more
indicative of peripheral thyroid hormone metabolism; not
generally suitable for as a general screening test

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 Surgery II 6.8
FINE NEEDLE ASPIRATION BIOPSY CYTOLOGY (FNABC)
Performed after ultrasound
Single most useful diagnostic modality for diagnosing thyroid nodules
in euthyroid patients
Diagnostic: Cytopathologic Diagnosis (cells)
Therapeutic: Thyroid Cyst
o If its a thyroid cyst, you can just aspirate the contents then the
cyst will be gone
Limitations
o Technical expertise of the surgeon and the pathologist
o Differentiating Follicular CA vs Benign Adenoma
o Small nodule (hard to hit)
Do ultrasound-guided FNA
o Drawbacks of FNABC in toxic patients (hyperthyroid), not
accurate
More vascular which can lead to Increased bleeding, cells are
actively dividing and can be mistaken for CA, so you do not do
FNA for nodules that are hot or warm
If hyperthyroid you do a thyroid scan
o Increased false positive result
o Hypertrophic cells mistaken for CA
RADIONUCLIDE IMAGING / THYROID SCAN
Iodine-123 (123I), iodine-131 (131I), or Technetium-99m (99mTc)
pertechnetate
Iodine is preferred because it is more accurate
o Preferably I123 or 131 because 3-8% of warm nodules are cold on
pertechnetate scan
Iodine-123 - emits low dose radiation, half-life of 12 to 14 hours,
and is used to image lingual thyroids or goiters
Iodine-131 - half-life of 8 to 10 days and leads to higher-dose
radiation exposure, used to screen and treat patients with
differentiated thyroid cancers for metastatic disease
Technetium-99m pertechnetate
Increasingly being used for thyroid evaluation
Taken up by the mitochondria, but is not organified
Advantage of having a shorter half-life and minimizes
radiation exposure
Particularly sensitive for nodal metastases
Thyroid gland is the only organ in the body that takes up iodine.
If you give radioactive iodine, expect all of the iodine to be
imbibed in the thyroid.
Shows size and shape of the gland and distribution of functional activity
COLD
o Areas that trap less radioactivity than the surrounding gland
MALIGNANCY IS HIGHER (20%)
HOT
o Areas that demonstrate increased activity
Figure 6. Thyroid Scan
More recently, 18F-fluorodeoxyglucose (FDG) positron emission
tomography (PET) combined with computed tomography (CT) is being
increasingly used to screen for metastases in patients with thyroid
cancer in whom other imaging studies are negative.
The L-team | Kheita, Jean, Renan, Ikey, Bea, James, Sher, Lori, Aleya
OTHER DIAGNOSTICS
Not routinely used, only for completion
Neck CT Scan
o For lesions of borderline resectability
If not sure if mass is resectable (preferably use double
contrast)
Laryngoscopy
o Hoarseness or s/s of compression of recurrent laryngeal nerve
Metastatic Work-Up
o Symptom-Directed
Chest / Liver / Bone / Brain
Work-up for MEN: for medullary cancer
o Suspect if w/ family history of Multiple Endocrine Neoplasia Type 2
(MEN 2A) or Medullary Thyroid Cancer (MTC)
o High basal serum CALCITONIN - virtually diagnostic for MTC
o Further work-up for primary hyperparathyroidism &
pheochromocytoma
CT/MRI provide excellent imaging of the thyroid gland and adjacent
nodes and are particularly useful in evaluating the extent of large, fixed,
or substernal goiters (which cannot be evaluated by ultrasound) and
their relationship to the airway and vascular structures.
Non-Contrast CT Scans should be obtained for patients who are likely
to require subsequent RAI therapy.
PET-CT scans - for Tg-positive, RAI-negative tumors
GOITER
Most common thyroid disease in Filipinos
More than 80% of thyroid nodules of Filipinos turn out to be goiter
Moves with swallowing
Can be classified whether nodular vs. diffuse and toxic vs. nontoxic
NODULAR VS DIFFUSE
Figure 7. (Left) Nodular Goiter: unilateral enlargement
(Right) Diffuse Goiter: bilaterally symmetrical enlargement; like a scrotum
in the neck
Any enlargement of the thyroid gland
Endemic goiter - occurrence of a goiter in a significant proportion of
individuals in a particular geographic region
o In the past, dietary iodine deficiency was the most common cause
of endemic goiter
o Dietary goitrogens (kelp, cassava, and cabbage) also participate in
formation
Elevated TSH levels induce diffuse thyroid hyperplasia, followed by
focal hyperplasia, resulting in nodules that may or may not concentrate
iodine, colloid nodules, or microfollicular nodules. The TSH-dependent
nodules progress to become autonomous.
Page 3 of 11
 Surgery II 6.8

TOXIC GOITER Physical Exam

o Soft, diffusely enlarged gland (simple goiter) or nodules of various
size and consistency in case of a multinodular goiter
o Deviation or compression of the trachea may be apparent
Diagnostic Tests
o Patients are usually Euthyroid with normal TSH and low-normal or
normal free T4 levels.
o RAI uptake often shows patchy uptake with areas of hot and cold
nodules.
o FNAB is recommended in patients who have a dominant nodule or
one that is painful or enlarging, as carcinomas have been reported
in 5% to 10% of multinodular goiters.
o CT scans are helpful to evaluate the extent of retrosternal
extension and airway compression.
Treatment
o Most euthyroid patients with small, diffuse goiters do not require
treatment
o Exogenous thyroid hormone to reduce the TSH stimulation of
Figure 8. Toxic Goiter gland growth for large goiters
May result in decrease and/or stabilization of goiter size
Despite the normal thyroid hormone levels, theres still production by Most effective for small diffuse goiters
either a tumor or the thyroid itself o Endemic goiters are treated by iodine administration
S/Sx: Thyrotoxic symptoms o Surgical resection is reserved for goiters that:
a. Continue to increase despite T4 suppression
NON-TOXIC GOITER b. Cause obstructive symptoms
c. Have substernal extension
d. Have malignancy suspected or proven by FNAB
e. Are cosmetically unacceptable
Near-total or total thyroidectomy is the treatment of choice,
and patients require lifelong T4 therapy

Table 2. Etiology of Non-Toxic Goiter

CLASSIFICATION SPECIFIC ETIOLOGY
Endemic Iodine Deficiency, Dietary Goitrogens (Cassava, Cabbage)
Medications Iodide, Amiodarone, Lithium
Thyroiditis Subacute, Chronic (Hashimotos)
Familial Impaired Hormone Synthesis From Enzyme Defects
Neoplasm Adenoma, Carcinoma
Resistance to Thyroid Hormone
Figure 9. Non-Toxic Goiter
HYPERTHYROIDISM/THYROTOXICOSIS
Most are thought to result from TSH stimulation secondary to Clinical manifestations result from an excess of circulating thyroid
inadequate thyroid hormone synthesis and other paracrine growth hormone
factors Clinical Manifestations
Signs and Symptoms: o Heat intolerance, sweating & thirst, weight loss, palpitations, atrial
o ASYMPTOMATIC (80%) fibrillation
Theres just a mass that moves up with swallowing o Resting Tachycardia : most reliable sign
Pressure sensation at the back (in the neck from the book) o Nervousness, fatigue, emotional lability, hyperkinesis, fine
o Compressive Symptoms (as they become large) tremors, muscle wasting, proximal muscle group weakness with
Dysphagia, orthopnea (dyspnea in the book) hyperactive tendon reflexes
Catarrh - frequent clearing of throat o Amenorrhea, decreased fertility
Dysphonia hoarseness o Facial flushing, warm & moist skin
From RLN injury is rare, except when malignancy is o Ophthalmopathy (eye signs)
present o Dermopathy (thickened skin in pretibial region)
PEMBERTON SIGN It is important to distinguish disorders such as Graves disease and toxic
Facial flushing and dilatation of cervical veins on raising nodular goiters that result from increased production of thyroid
the arms above the head hormone from those disorders that lead to a release of stored hormone
Rarely seen from injury to the thyroid gland (thyroiditis) or from other non-thyroid
Caused by obstruction of venous return at the thoracic glandrelated conditions.
inlet from a substernal goiter Graves disease, toxic multinodular goiter, and solitary toxic nodule are
MEMORIZE! Came out in the board exam most relevant to the surgeon
Sudden enlargement of nodules or cysts due to hemorrhage
may cause acute pain

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 Surgery II 6.8

Table 3. Differential Diagnosis of Hyperthyroidism Definitive treatment:

INCREASED HORMONE RELEASE OF PREFORMED o Radioactive Iodine Ablation Therapy (RAI)
SYNTHESIS (INCREASED RAIU) HORMONE (DECREASED RAIU) Mainstay treatment in North America
Graves Disease (Diffuse Toxic Causes progressive development of hypothyroidism (over
Goiter) 70% in 11 years), requiring lifelong thyroxine
Toxic Multinodular Goiter Thyroiditis - Acute Phase of Has been shown to lead to progression of opthalmopathy
Toxic Adenoma Hashimotos Thyroiditis, Takes 3-6 months to achieve Euthyroid
Drug InducedAmiodarone, Subacute Thyroiditis Absolute contraindications include women who are pregnant
Iodine Factitious (Iatrogenic) breastfeeding
Thyroid Cancer Thyrotoxicosis o Surgery (thyroidectomy)
Struma Ovarii Hamburger Thyrotoxicosis Surgery is recommended when RAI is contraindicated:
Confirmed cancer or suspicious thyroid nodule
Hydatidiform Mole
Young
TSH-Secreting Pituitary Adenoma
Pregnant
RAIU = radioactive iodine uptake; TSH = thyroid-stimulating hormone
Had severe reactions to anti-thyroid medications
Have large goiters with compressive symptoms
TOXIC GOITER
Reluctant to undergo RAI therapy
GRAVES DISEASE
Indications for Treatment
Diffuse toxic goiter
o Surgery
o Familial predisposition
Compressive symptoms (e.g. dysphagia, orthopnea)
o Females 40-60 yrs
Large nodules
Possible triggers
Require high amounts of RAI
o Postpartum state, iodine excess, lithium therapy, and bacterial &
Resistant to treatment
viral infections
Suspicions for malignancy
Etiology
Immediate resolution of thyrotoxicosis is needed
o Autoimmune
The patient needs to be euthyroid before surgery ( through
o Antibodies directed against the thyroid hormone receptor
anti-thyroid drugs for 3-4 week) to prevent thyroid storm and
o Stimulate thyrocytes to produce excessive thyroid hormone
decrease vascularity of the gland
Etiology is autoimmune that stimulates the thyroid to produce
o RAI
excessive hormone
Small goiters (<100mL)
Clinical Features:
Without suspected malignant potential
o Can be divided into those related to hyperthyroidism and those
Previous thyroidectomy
specific to Graves disease.
High surgical risk
o Hyperthyroid symptoms:
Heat intolerance
Table 4. Comparison of Surgery and RAI
Increased sweating and thirst
SURGERY RAI
Weight loss despite adequate caloric intake
Gradual ablation
o Symptoms of increased adrenergic stimulation Immediate ablation
(40% in 1 year)
o The most common GI symptoms include increased frequency of
Complete relief of symptoms Relief of most toxic symptoms in 3-6
bowel movements and diarrhea
months
o 50% of patients will develop clinically evident ophthalmopathy Definitive histologic diagnosis
(except ophthalmopathy)
Diagnosis
Permanent hypothyroidism in 10
o High FT4 and/or FT3 Need to render euthyroid first
years
o Low TSH
o Diffusely Hot uptake on radionuclide scan Surgical risk radiation effects
o Auto-antibodies against:
Thyrotropin receptor Table 5. Adverse Effects of Surgery vs RAI
Thyroglobulin SURGERY RAI
Peroxidase Hypothyroidism 10% in 5 yrs
Neck edema, thyroiditis 5-10%
Sialadenitis 11.5%
Vocal cord paralysis <5%
Hemorrhage <5% GIT complaints 67%
RLN (recurrent laryngeal Acute radiation sickness 30-50%
nerve) injury 3-8% Impaired fertility 10-45%
Hypo-parathyroidism 2-5% Bone marrow suppression 3-35%
Figure 10. Thyroid Radionuclide Scan of Graves Disease Taste dysfunction 37%
Parathyroid dysfunction 5-60%
Treatment Leukemia, bladder cancer <5%
o Anti-Thyroid drugs Nodule consistency hardening
To prepare patient for definitive treatment
High relapse rate if discontinued
Types
Propylthiouracil (PTU, 100-300mg TID)
Methimazole (10-30mg TID)
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 Surgery II 6.8

TOXIC MULTI-NODULAR GOITER SUMMARY GOITER

Usually older than 50 years of age Most common thyroid disease in Philippines (85% of thyroid disease)
Often has; prior history of a non-toxic multi-nodular goiter Types
Over several years the thyroid nodules become autonomous to cause o Diffuse nontoxic
hyperthyroidism o Nodular nontoxic
Diagnosis: o Diffuse toxic
o TSH, FT4, FT3, thyroid scan o Nodular toxic
Treatment: Diagnosis
o Thyroidectomy o TSH, FT4, FT3
If toxic : Thyroid scan
Non-toxic : Ultrasound, FNAB
Treatment
o Toxic: surgery, RAI, anti-thyroid drug
o Non-toxic: none, TSH suppression, surgery

THYROIDITIS
Inflammatory disorder of the thyroid gland
May cause initial hyperthyroidism, then progress over time to
hypothyroidism
Figure 11. Toxic Multi-Nodular Goiter
Thyroiditis usually is classified into acute, subacute, and chronic forms,
each associated with a distinct clinical presentation and histology
NON-TOXIC GOITER
Result from iodine deficiency and/or TSH stimulation, or idiopathic ACUTE (SUPPURATIVE) THYROIDITIS
Nowadays, its very hard to have iodine deficiency since a lot of food
Infectious cause
are fortified
The thyroid gland is inherently resistant to infection due to its extensive
Most of the time idiopathic
blood and lymphatic supply, high iodide content, and fibrous capsule.
May be diffuse, uninodular, multinodular Infectious agents can seed it via:
Familial goiters result from enzyme deficiencies necessary for thyroid o Hematogenous or lymphatic route
hormone synthesis o Direct spread from persistent pyriform sinus fistulae or
Endemic goiter refers to occurrence of a goiter in a significant thyroglossal duct cysts
proportion on individuals in a particular geographic region (*you should o Result of penetrating trauma to the thyroid gland
know - mountain area where no seafood) o Immunosuppression.
Diagnosis: Streptococcus and anaerobes account for about 70% of cases
o TSH, FT4, FT3 More common in children often preceded by an upper respiratory tract
o Ultrasound infection or otitis media
o FNAB Characterized by
If multinodular do FNAB on dominant nodule and/or any o Severe neck pain radiating to the jaws or ear, fever,
suspicious nodule on ultrasound o Chills
Treatment (Suppression vs. Surgery): o Odynophagia
o TSH suppression (conservative treatment) o Dysphonia
Give high dose exogenous thyroid hormone at levels that will Diagnosis
suppress TSH o Established by leukocytosis on blood tests and FNAB for Grams
o Thyroidectomy stain, culture, and cytology
o CT scans may help to delineate the extent of infection
Table 6. Indications for TSH suppression vs. Thyroidectomy o A persistent pyriform sinus fistula should always be suspected in
TSH SUPPRESSION THYROIDECTOMY children with recurrent acute thyroiditis
Patients from geographic areas o Barium swallow demonstrates the anomalous tract with 80%
Large goiters
with iodine deficiency sensitivity
Young patient with small nodule Compressive symptoms Treatment
Nodular goiter with no evidence o Parenteral antibiotics and drainage of abscesses
Suspicious nodules
of functional anatomy o Patients with pyriform sinus fistulae require complete resection of
Contraindication of TSH suppression the sinus tract, including the area of the thyroid where the tract
Post-menopausal terminates, to prevent recurrence.
Older than 60 y/o
Osteoporosis SUBACUTE THYROIDITIS
Cardiovascular disease Self-limiting
Failure of medical treatment o Remission in 2-4 months
Subtypes
o Granulomatous (De Quervains)
o Lymphocytic
o Postpartum
Can be painless or painful

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 Surgery II 6.8

Table 7. Painful and Painless Subacute Thyroiditis Physical exam reveals a hard, woody thyroid gland with fixation to
PAINFUL PAINLESS surrounding tissues.
ONSET Gradual Diagnosis is confirmed by open thyroid biopsy, because the firm and
AGE 30-40 years old women 30-60 years old women fibrous nature of the gland renders FNAB inadequate.
Autoimmune; occurs in Surgery is the mainstay of the treatment
Upper respiratory tract
HISTORY postpartum period (<6
infection TREATMENT OF THYROIDITIS
weeks)
Gland is enlarged, Normal sized or minimally Medical Treatment
PE exquisitely tender, enlarged, slightly firm, non- Indications for surgery
and firm tender gland o Malignancy cannot be ruled out
Early stages: TSH o Significant signs of compression
decreased; Tg, T4, and T3 o Failure of medical treatment
levels are elevated due to Serial monitoring of thyroid function as indicated
DIAGNOSIS
the release of preformed
thyroid hormone from THYROID CYST
destroyed follicles Exact cause is unknown
Aspirin and steroids; Theories:
B-blockers and thyroid o Lack of iodine in the diet
Thyroidectomy if non
TREATMENT hormone replacement for o Autoimmune disorder that causes inflammation of the thyroid
responsive to medical
symptomatic (Hashimotos disease)
treatment
o Genetic defect
CHRONIC THYROIDITIS o Exposure to radiation in childhood
LYMPHOCYTIC (HASHIMOTOS) THYROIDITIS Treatment: needle aspiration +/- TSH suppression
Autoimmune
MOST COMMON INFLAMMATORY DISORDER OF THE THYROID and BENIGN TUMORS
the leading cause of hypothyroidism FOLLICULAR ADENOMA
Antibodies develop against thyroid antigens Hard to differentiate from follicular carcinoma
o Anti-thyroid peroxidase (anti-TPO) antibodies o Only histologic difference from follicular carcinoma is absence of
o Anti-thyroglobulin (anti-Tg) antibodies capsular & blood vessel invasion
o Must check for serum assays of anti-TPO and anti-TG antibodies o Do a preoperative biopsy
Others
o TSH receptor-blocking antibodies, Thyroid stimulating Ab, PLUMMER DISEASE (TOXIC ADENOMA)
Cytotoxic Ab Hyperthyroidism from a single hyperfunctioning nodule
Clinical Presentation Typically occurs in younger patients
o More common in women between ages of 30 and 50 Diagnostics: RAI scan; hot nodule
o Most common presentation is that of a minimally or moderately Treatment: Thyroidectomy after control of hyperthyroidism
enlarged firm granular gland discovered on routine physical
examination or the awareness of a painless anterior neck mass MALIGNANT TUMORS
o 20% of patients present with hypothyroidism Well-differentiated
o 5% presents with hyperthyroidism o Papillary
o Classically, presents with diffusely enlarged, firm gland, which also o Follicular
is lobulated. Medullary
Diagnostic Studies Anaplastic
o When suspected clinically, an elevated TSH and the presence of Others
thyroid autoantibodies usually confirm the diagnosis.
o FNAB is indicated in patients who present with a solitary nodule or Table 8. Frequency of Thyroid Carcinomas.
a rapidly enlarging goiter 90-95% of thyroid carcinomas are well differentiated cancers
Treatment PATHOLOGY FREQUENCY (%)
o Thyroid hormone replacement *Papillary 80
Follicular 10
RIEDELS THYROIDITIS Hurthle cell 3
Chronic inflammatory disease causing dense fibrosis of the gland Medullary 5
Fibrosis may extend beyond thyroid capsule to the neck
Anaplastic 1
May be mistaken for CA
Others 1
Causes intense fibrosis and presents as a hard mass on the neck, so this
is the one most operated on
The Etiology of this disorder is controversial, and it has been reported CLINICAL MANIFESTATIONS
to occur in patients with other autoimmune diseases. Initially asymptomatic
This association, coupled with the presence of lymphoid infiltration and Usually euthyroid
response to steroid therapy, suggests a primary autoimmune etiology. Progressive growth
Typically presents as a painless, hard anterior neck mass, which Invasion of structures
progresses over weeks to years to produce symptoms of compression, o Recurrent laryngeal nerve, esophagus, trachea,
including dysphagia, dyspnea, choking and hoarseness. Neck node enlargement
o Invasion of strap muscles, IJV, carotid
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 Surgery II 6.8

PAPILLARY CARCINOMA 2-5% distant metastasis

Relatively benign course Associated with goiter in 10-15%
Compatible with long life 70-80% cure rate (papillary type still has a higher cure rate)
30-45% metastasis to lymph nodes (but this had no impact on survival) Follicular and Papillary are relatively indolent
Accounts for 80% of all thyroid malignancies in iodine-sufficient areas 3:1 female-to-male ratio (2015B)
and is the predominant thyroid cancer in children and individuals Mean age presentation: 50 years old (2015B)
exposed to external radiation Cumulative mortality: 15% at 10 years and 30% at 20 years
Papillary carcinoma is the MOST COMMON OF THE THYROID
NEOPLASMS and is usually associated with an excellent prognosis, PROGNOSTIC INDICATORS FOR WELL-DIFFERENTIATED CARCINOMA
particularly in female patients younger than 40 years DAMES (Cady and Rossi)
2:1 female-to-male ratio, and the mean age at presentation is 30 to 40 D DNA content measured by flow cytometry
years A Age: men <40 years old, women <50 years old
Most patients are euthyroid and present with a slow-growing painless M Metastases
mass in the neck E Extrathyroid spread
Diagnosis: FNAB S Size of tumors (less than or >5 cm)
o If malignant, complete neck ultrasound is strongly recommended AGES (Hay)
to evaluate the contralateral lobe and for lymph node metastases
A Age
in the central and lateral neck compartments
G Histologic Grade
Preference for LYMPHATIC SPREAD
E Extrathyroidal invasion
1-2% distant metastasis
S Metastatic tumor size
Common radiation induced CA
MACIS (Hay)
90-95% cure rate
M Metastases
Cells with intranuclear cytoplasmic inclusions = ORPHAN ANNIE NUCLEI
A Age of presentation
Calcified deposits = PSAMOMMA BODIES
C Completeness of original resection
Most patients with papillary carcinoma can expect an excellent
I Extrathyroidal invasion
prognosis, with the 10-year survival rate approaching 95% for the most
favorable stages S Size of original lesion
Laudico, dela Pea, De Vera PGH
SUBTYPES o Age
The pathologic diagnosis of papillary carcinoma depends on the o Histology (nodal metastasis had no impact)
cytologic findings of well-recognized papillary cytomorphology Predictors of thyroid nodules malignancy, Ampil, Cortex, SIRF 1998
Pure papillary, papillary follicular, follicular variant Age 56 +/- 15 years
Tall cell, columnar, diffuse sclerosing, clear cell, trabecular, Hurthle cell Size 4.5 +/-1.4 cm especially if solitary
variant and poorly differentiated Hard especially if solitary (Histology and
Consistency
o They are trying to find out which types are aggressive compared to multicentricity had no impact)
the rest, which is why there are so many subtypes o There is no consensus on methods to classify which are aggressive
and which are not
FORMS
Minimal/Occult/Microcarcinoma Table 9. Prognostic Risk Classification for Patients with Well-Differentiated
o < 1cm Thyroid Cancer (AMES or AGES)
o Non-palpable LOW RISK HIGH RISK
o Detected only by ultrasound AGE <40 years >40 years
Intrathyroidal has NOT gone beyond the thyroid capsule SEX Female Male
Extrathyroidal has extended into the neck and nearby structures No local extension,
Capsular invasion,
EXTENT intrathyroidal, no capsular
extrathyroidal extension
TREATMENT invasion
Total or near-total thyroidectomy for high risk or bilateral tumors and METASTASIS None Regional or distant
for primary cancers >1 cm unless with contraindications. SIZE <2 cm >4 cm
The 2009 ATA guidelines for thyroid cancer management suggest that GRADE Well differentiated Poorly differentiated
prophylactic (ipsilateral or bilateral) dissection may be performed in
patients with advanced (T3 or T4) papillary thyroid carcinoma, whereas E. STAGING FOR WELL-DIFFERENTIATED CARCINOMA
the procedure is not needed for small (T1 and T2) tumors that are Primary tumor (T)
clinically node negative Tx Primary tumor cannot be assessed
Biopsy-proven lymph node metastases modified radical or functional T0 No evidence of primary tumor
neck dissection T1 Tumor 2 cm in diameter, limited to thyroid
T2 Tumor >2 cm but <4 cm in diameter, limited to thyroid
FOLLICULAR CARCINOMA Tumor >4 cm in diameter, limited to thyroid, or any tumor with
Relatively benign course T3
minimal extrathyroidal invasion
Common in iodine-deficient areas Any size tumor extending beyond capsule to invade subcutaneous
Malignancy is defined by presence of capsular and vascular invasion T4a soft tissue, larynx, trachea, esophagus, or recurrent laryngeal
5-20% metastasis to lymph nodes nerve, or intrathyroidal anaplastic cancer
Spreads via BLOODSTREAM/HEMATOGENOUS SPREAD (in comparison Tumor invading pre-vertebral fascia, or encasing carotid artery or
T4b
to papillary which spreads via lymphatic system) mediastinal vessels; or extrathyroidal anaplastic cance
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 Surgery II 6.8

Regional lymph nodes (N)include central, lateral cervical, and upper COMPLICATION OF THYROIDECTOMY
mediastinal nodes Bleeding - because it is a vascular area
Nx Regional lymph nodes cannot be assessed Recurrent Laryngeal nerve injury causes hoarseness. If both
N0 No regional lymph node metastasis recurrent laryngeal nerve injury the vocal cords will both close
N1 Regional lymph node metastasis necessitating tracheostomy
Metastases to level VI (pretracheal, paratracheal, and Superior Laryngeal nerve injury decrease volume of voice
N1a
prelaryngeal/Delphian lymph nodes) Hypocalcaemia inadvertent involvement of the parathyroids
Metastases to unilateral, bilateral, or contralateral cervical or Thyroid storm occurs if the patient was not euthyroid to begin with
N1b
superior mediastinal lymph nodes

Distant metastasis (M)

Mx Distant metastases cannot be assessed
M1 No distant metastasis

Table 10. TNM Classification of Thyroid Tumors

PAPILLARY OR FOLLICULAR TUMORS (WELL-DIFFERENTIATED) Figure 13. Location of the parathyroid glands on the thyroid. Proximity of the
STAGE TNM parathyroid causes it to be excised along with thyroid upon thyroidectomy
< 45 years causing symptoms of hypocalcaemia. You only need -1 to maintain
I Any T, any N, M0 parathyroid function.
II Any T, any N, M1
45 years
I T1, N0, M0
II T2, N0, M0
III T3, N0, M0; T13, N1a, M0
Iv a T4a, N01a, M0; T14a, N1b, M0
IV b T4b, any N, M0
IV c Any T, any N, M1
Figure 14. Borders of the Central Neck. Superior: Thyroid Cartilage. Medial:
Notice that in younger than age 45 years, the staging is only up to TE Groove. Lateral: Carotid Sheath. Inferior: Suprasternal Notch
stage II
In younger than age 45 years old, notice that even if there is a ADJUVANT THERAPY
metastasis it is still considered as stage II Radioactive iodine ablation
It signifies that it isnt that aggressive when it is present for ages <45 TSH suppression (Target serum TSH = 0)
years old NO ROLE: Chemotherapy/radiation therapy
This is the only cancer that has age as a factor
MONITORING AND FOLLOW-UP
TREATMENT OF WELL-DIFFERENTIATED CARCINOMA
Surgery
o < 1.0 cm (microcarcinoma), solitary: Total lobectomy +
Isthmusectomy
o >1.0 cm, multicentric: Total Thyroidectomy (Schwartzs it is >4 cm)
Extrathyroidal Spread
o Total thyroidectomy + Central neck dissection
(+) Lymph Node Metastasis
o Total thyroidectomy + Modified radical neck dissection
Extent of Thyroidectomy

Figure 15. Algorithm for Monitoring

We monitor Serum Thyroglobulin (Tg) after thyroidectomy. Ideally it

should be decreased or 0 after the procedure because it is produce by
the thyroid gland
Tg levels in patients who have undergone total thyroidectomy should
be <2 ng/mL when the patient is taking T4 , and <5 ng/mL when the
Figure 12. A diagram showing thyroid lobectomy to be done on <1cm WDC
patient is hypothyroid
adenoma with a contralateral normal lobe. For all other types especially if
A Tg level >2 ng/mL is highly suggestive of metastatic disease or
there are bilateral nodules, we do total thyroidectomy. Subtotal
persistent normal thyroid tissue
thyroidectomy is not indicated anymore.
Approximately 95% of patients with persistent or recurrent thyroid
cancer of follicular cell origin will have Tg levels >2 ng/mL
Tg and anti-Tg antibody levels should be measured initially at 6-month
intervals and then annually if the patient is clinically disease free

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 Surgery II 6.8

If serum Tg is still present after 6 months, we assume recurrence FNA can be diagnostic
If it is still positive, we work up the patient with a whole body can. The use of flow cytometry for monoclonality can confirm diagnosis
Areas with iodine will light up Neck, chest, abdominal CT or MRI to assess extrathyroidal spread.
Most thyroid lymphomas are B cell in origin
WHOLE BODY IODINE-131 SCAN Use of the CHOP regimen (cyclophosphamide,
In cases where there is still positive serum thyroglobulin (Tg) 6-12 hydroxydaunomycin [doxorubicin], vincristine, and prednisolone)
months after total thyroidectomy for a high risk well-differentiated has been associated with excellent survival.
carcinoma, one must suspect recurrence since Tg is produced only by Metastatic cancer
the thyroid o Kidney, breast, lung, and melanoma
When this happens, work up the patient and what is usually done is FNAB usually provides definitive diagnosis.
Whole Body Iodine-131 Scan. It works in a similar principle to RAI scan, Resection of the thyroid, usually lobectomy, may be helpful in
but it is applied for the whole body. The distant metastatic lesions will many patients, depending on the status of their primary tumor
imbibe iodine and will light up
Treatment for metastatic sites: Radioactive Iodine Tablets PARATHYROID GLANDS
CALCIUM HOMEOSTASIS
HURTHLE CELL CARCINOMA Parathyroid hormone (PTH): increases serum calcium
Subtype of follicular CA Vitamin D: increases serum calcium by stimulating the absorption of
More often multifocal and bilateral (30 %), usually do not take up RAI calcium and phosphate from the gut.
(5 %), more likely to metastasize, associated with higher mortality rate o The first hydroxylation at carbon 25 occurs in the liver
(20% at 10 years). o The second hydroxylation at carbon 1 occurs in the kidney in
It DOES NOT respond to RAI. response to increased PTH levels.
Treatment: lobectomy and isthmusectomy o 1,25(OH)2D3 increases calcium and phosphate resorption from the
gastrointestinal tract and stimulates bone resorption, which raises
MEDULLARY CARCINOMA calcium levels
More aggressive than papillary/follicular carcinoma Calcitonin: decreases serum calcium
Arise from parafollicular or C cells of the thyroid
o C cells secrete calcitonin Table 10. Actions of Major Calcium-Regulating Hormones
o 25% occur within the spectrum of several inherited syndromes BONE KIDNEY INTESTINE
(germline mutations in the RET ) proto-oncogene Stimulates resorption of
Stimulates
Familial medullary thyroid cancer, MEN2A & B PARA- calcium and conversion of
resorption of No direct
Diagnosis THYROID 25(OH)D3; inhibits
calcium and effects
o Raised serum calcitonin levels this finding clinches the diagnosis HORMONE resorption of phosphate
phosphate
o FNA cytology confirms the diagnosis and bicarbonate
o Once diagnosed, all new patients with MTC should be screened for Stimulates
Stimulates
RET point mutations, pheochromocytoma, & hyperparathyroidism Inhibits resorption of calcium and
VITAMIN D transport of
Treatment calcium phosphate
calcium
o Minimum is total thyroidectomy + central neck dissection absorption
Inhibits
ANAPLASTIC CARCINOMA resorption of Inhibits resorption of No direct
CALCITONIN
Most aggressive of all calcium and calcium and phosphate effects
Rapidly enlarging phosphate
o Doctors experience: A patient with anaplastic carcinoma was
admitted once, but whose surgery was delayed for 1 month
because of financial constraints. The tumor was observed to be
growing bigger and bigger every day before their very eyes
Treatment:
o Tracheostomy + Radiotherapy (RT provides only 30% success rate)
Most of the time, because of the immense size of the mass,
thyroidectomy/resection may not be possible. Thus,
tracheostomy is done to address the obstruction of airways.
o Total thyroidectomy / Chemotherapy / Radiotherapy
Done if the tumor is still resectable
o Palliative treatment Figure 16. Calcium homeostasis and parathyroid hormone (PTH).
1,25(OH)2D3, 1,25-dihydroxycholecalciferol.
J. OTHER RARE CANCERS
Sarcoma HYPERPARATHYROIDISM
Lymphoma There is excess PTH, thus there is hypercalcemia
The diagnosis is considered in patients with a goiter, especially one Primary (PHPT)
that has apparently grown significantly in a short period. o From abnormal parathyroid glands, usually due to a tumor
Other initial symptoms include hoarseness, dysphagia, and fever. Secondary
There is also an increased association between lymphoma and o A compensatory response to hypocalcemic states
Hashimoto's thyroiditis. Chronic renal failure
Ultrasound may demonstrate a classic pseudocystic pattern. Gastrointestinal malabsorption of calcium

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 Surgery II 6.8
Tertiary
o Chronically stimulated glands become autonomous, resulting in
persistence or recurrence of hypercalcemia after successful renal
transplantation
o Even though serum calcium is elevated, PTH is still being
continuously secreted.
PRIMARY HYPERTHYROIDISM (PHPT)
Arises from increased PTH production from abnormal parathyroid
glands and results from a disturbance of normal feedback control
exerted by serum calcium.
PHPT is characterized by increased parathyroid cell proliferation and
PTH secretion that is independent of calcium levels
Causes
o Parathyroid hyperplasia (20%)
o Adenoma (80% single if single adenoma)
o Carcinoma (1%)
o Low dose ionizing radiation
Latency: 30 to 40 years
Higher PTH levels and a higher incidence of concomitant
thyroid neoplasms than those who did not have exposure
o Family history
MEN1, MEN2A, isolated familial HPT, and familial HPT with
jaw-tumor syndrome
PHPT is the most common primary presentation of MEN1
(80%)
Signs and Symptoms
o Due to increased serum calcium
o Classic pentad of symptoms
Kidney stones (80%), painful bones(15 to 20%), abdominal
groans, psychic moans & fatigue
o Minimally symptomatic
Weakness, fatigue, polydipsia, polyuria, nocturia, bone &
joint pain, constipation, decreased appetite, nausea,
heartburn, pruritus, depression, & memory loss
o Asymptomatic
Diagnosis
o High serum calcium
First done if suspicion of PHPT is raised because of signs and
symptoms. If serum calcium is high, do serum PTH.
o High serum PTH assay
A high serum PTH suggests the pathology is indeed primarily
located in the parathyroids. Thus perform a parathyroid scan.
o Parathyroid scan
Presence of abnormal growth confirms the diagnosis, thus, do
parathyroidectomy.
o Radiology
Bone involvement
Pathognomonic signs seen best on hand X-ray: Subperiosteal
resorption (most apparent on the radial aspect of the middle
phalanx of the second and third fingers), bone cysts, and
tufting of the distal phalanges
Treatment: Parathyroidectomy
o Subtotal
If dealing with an adenoma, usually, just one needs to be
removed, since not all parathyroids will be enlarged.
If dealing with hyperplasia, the problem is that all 4 glands
will be enlarged. You cant remove all four. Thus, do a three-
and-one-half parathyroidectomy, leaving of one
parathyroid in place.
o Total parathyroidectomy with autotransplantation or transfer of
a gland to a neck or forearm muscle
Alternative to 3 parathyroidectomy.
The L-team | Kheita, Jean, Renan, Ikey, Bea, James, Sher, Lori, Aleya
HYPOPARATHYROIDISM
Causes
o Di Georges syndrome - congenitally absent parathyroid
o Neonatal hypoparathyroidism - from hyperparathyroid mother
o THYROID SURGERY: leading to injury to the parathyroid, most
common cause, 95% of cases (total thyroidectomy)
Temporary hypoparathyroidism occurs in 90% of all
thyroidectomy cases. In the course of thyroid gland
dissection, edema of the parathyroids is unavoidable thus it
temporarily becomes dysfunctional and cannot produce PTH.
Permanent hypoparathyroidism remaining 5-10%. Means
the surgeon has inadvertently removed the parathyroids.
Signs and Symptoms
o Hypocalcemia causing increased neuromuscular excitability
o Circumoral and fingertip numbness and tingling
o Mental symptoms: anxiety, confusion, and depression
o (+) CHVOSTEK SIGN: Contraction of facial muscles elicited by
tapping on the facial nerve anterior to the ear
o (+) TROUSSEAU SIGN: Carpopedal spasm, which is elicited by
occluding blood flow to the forearm with a blood pressure cuff for
23 min
o Tetany
o These signs and symptoms must be monitored in a patient who
has undergone thyroidectomy.
Diagnosis
o Decreased serum ionized calcium levels
Treatment
o Calcium tablets or IV infusion
o Vitamin D supplements
I can't think of a single reason why I should be a surgeon, but I can think of a
thousand reasons why I should quit. They make it hard on purpose. There
are lives in our hands. There comes a moment when it's more than just a
game, and you either take that step forward or turn around and walk away. I
could quit but here's the thing, I love the playing field. Dr. Meredith Grey
(Greys Anatomy)
LAST TRANS FOR SURGERY!!! The L-team now signing off :)) See you clerkship!
God bless for the upcoming exams!! :D
Editors note: Good luck to everyone!! Last push for third year!!
DOnt quIT!!
Edited by: Kyle Ompoc
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