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Thyroiddisease
LiboLiMD
DepartmentofGeneralSurgery
SirRunRunShawHospital
Schoolofmedicine,ZhejiangUniversity
Thyroiddisease
LiboLiMD
AnatomyofThyroidAnatomyofThyroidAnatomyofThyroidAnatomyofThyroidThyroiddiseaseNontoxicgoiterHyperthyroidismThyroidCancerThyroiditisThyroiddiseaseNontoxicgoiterNontoxicGoiterGoiterfromtheFrench(goitre)andLatin(guttur),bothmeaningthroatDefinedasanenlargementofthethyroidglandEndemicwhenitinvolvesmorethan10%ofthepopulationThemajority,secondarytoiodinedeficiencyEspeciallyfoundinhighmountainregionsNontoxicGoiterGoiterfromtheNontoxicGoiter
ClinicalthinkingWhetherthepatienthaslocalsymptomsWhetherthegoiteristoxicornontoxicWhetheranyofthenodulesharboracancerThenumberandbilateralityofthenodulesTSHlevel,differentialdiagnosisofhypothyroidismorhyperthyroidismAppropriatetreatmentoptionsforeachparticularpatient
NontoxicGoiter
TakinghistoryAsymptomaticneckmassAcough,shortnessofbreath,stridor,orhoarsenessChokingoraspiration,dysphagia,orpainSymptomsofhyperthyroidismWhetherthepatienthascosmeticconcernsFromiodinedeficiencyregion
NontoxicGoiter
PhysicalexaminationWhetherthegoiterisconfinedtotheneckWhetherithasasubsternalcomponentWhethertrachealdeviationispresentThesizeandconsistencyofthegoiterThemobilityofthevocalcordsbyeitherindirectordirectlaryngoscopy
NontoxicGoiter
UltrasoundHowmanynodules?Bilateral?Ultrasoundcharacteristics
NontoxicGoiterCTscanNeckandchest,especiallysubsternalthyroidRareintrathoracicoraberrantthyroidNontoxicGoiterCTscanNontoxicGoiterFineneedleaspiration(FNA)SuspiciousmalignentgoiterNontoxicGoiterFineneedleaspNontoxicGoiter
TreatmentIodinedietreplacement(endemicgoitor)SurgicalresectionSymptomsLocalcompressionSecondaryhyperthyroidisimAnysuspiciousormalignantlesionCosmeticreasonsRadioiodinetherapy,highriskofptsThyroidhormonesuppression(notforsporadicgoiter)
SporadicNontoxicGoiterAsymptomaticEuthyroidMostbilaterallyNoefficiencyofthyroidhormonereplacementHighrecurrencepostoperatively30%~40%SporadicNontoxicGoiterAsymptNontoxicGoiter
HistoryofThyroidSurgeryFirstthyroidectomy,inParisin1791byPierre-JosephDesaultAntisepsis,hemostasis,andgeneralanesthesiainthe1840sthyroidsurgerybecamesafeTheodoreKocher,aNobelPrizein1909FromBern,SwitzerlandHispioneeringeffortsinthyroidsurgery
PrimaryHyperthyroidsim
Grave’sDiseasePrimaryHyperthyroidsim
GraveClinicalStatisticsGravesDiseaseisthemostcommoncauseofhyperthyroidism(60-80%)ofallcasesFemalesareaffectedmorefrequentlythanmen10:1.5Monozygotictwinsshow50%concordanceratesIncidencepeaksfromages20-40IncidenceissimilarinwhitesandAsians,butissomewhatdecreasedforAfricanAmericansClinicalStatisticsGravesDiseGraves'DiseaseAutoimmunesystemicdisorderThyroidreceptorantibodybindingtoandstimulatingtheTSHreceptorExcessivesynthesisandsecretionofthyroidhormoneUsuallydiffuselyandsymmetricallyenlargedandfirmGraves'DiseaseAutoimmunesystHyperthyroidism—uptakeA.NormalB.Graves’DzC.ToxicMultinodularGoiterD.ToxicAdenomaE.ThyroiditisHyperthyroidism—uptakeA.NormaHyperthyroidism
SymptomsHeatintolerance,sweating,palpitations,fatigueWeightloss,diaphoresis,increasedstoolfrequencyMuscleweakness,anxiety,insomniaNervousnessorrestlessness;irritability,emotionallabilityInwomen,irregularmenses
Hyperthyroidism
ClinicalfindingsTremor,tachycardia(A.fib),Goiter,lidlag,proptosis,periorbitaledema,exophthalmos;chemosis;hyperreflexiaWarm,moistskin;dermopathy;andpretibialedema,
osteoporosis
ExopthalamosinGravesDiseaseLidLaginGravesDiseaseExopthalamosinGravesDiseaseHyperthyroidism—treatmentBeta-blockers:controlsxsPropranololdecrperipheralT4->T3conversionGraves’DzPTU(safeinpregnancy)ormethimazoleRaresideeffect:agranulocytosisRadioactiveiodine75%oftreatedptsbecomehypothyroidSurgeryToxicAdenomaorTMNGRAIorsurgeryHyperthyroidism—treatmentBeta-Hyperthroidism
SurgerySurgicalapproachBilateralnear-totalortotalthyroidectomyIndicationofsurgery(InChina)CompressivesymptomsSecondaryoradenomaRecurrenceofmedicineoriodine-131NoefficiencyofmedicineSecondtrimesterofpregnancy
Surgeryforhyperthyroidism
PreoperativepreparationAbsolutelyrequiredantithyroiddrugs,for3to6weekswithagoalofnearlynormalizingtheT3andT4PropranololoratenololrapidlycontrolstheadrenergicsideeffectsofexcessT4andT3tachycardia,tremor,anddiaphoresisLugol'ssolutionrapidlybuttemporarilyrestoresnormalthyroidfunctionandreducesthyroidglandvascularity
SurgicalcomplicationsBleedingRecurrentLaryngealNerveDamageHypoparathyroidismandHypocalcemiaSuperiorlaryngealnervedamageThyroidstormSurgicalcomplicationsBleedinThyroidcancerThyroidcancerThyroidcancer
IntroductionThemostcommon,95%ofallendocrinecancersIncreasingfasterthananyothercancerMorethan90%,welldifferentiatedGoodlong-termprognosis
Thyroidcancer
ClinicalPresentationMost,clinicallywithapalpablenoduleUsuallyasymptomaticRarecases,withhoarseness,pain,dysphagia,dyspnea,coughing,orchokingspellsPain，withthesuspicionforMedullarythyroidcarcinomaAnaplasticcarcinomaLymphoma
PertinenthistoricalfactorspredictingmalignancyAhistoryofheadandneckirradiationTotalbodyirradiationforbonemarrowtransplantationExposuretofalloutfromtheexplosionoftheChernobylnuclearpowerplantin1986,especiallyinchildren;Afamilyhistoryofthyroidcancer;andrapidgrowthorhoarseness.Children,men,andadultsolderthan60yearshaveanincreasedriskofmalignancyPertinenthistoricalfactorspIncreasetheriskofthyroidcancerPersonalandfamilyhistoryofotherendocrinedisorders,specificallyhyperparathyroidism,pituitaryadenomas,pancreaticisletcelltumors,adrenaltumors,andbreastcancer.Afamilyhistoryofpapillaryormedullarycarcinoma(MENsyndromes),familialpolyposis,Gardner'ssyndrome,andCowden'ssyndromeIncreasetheriskofthyroidcPertinentphysicalfindingsSuggestingpossiblemalignancyGrittytexture”(顆粒樣）ofthethyroidnoduleCervicallymphadenopathyVocalcordparalysisFixationofthenoduletosurroundingtissuePertinentphysicalfindingsSuThyroidcancer
DiagnosisUltrasoundFeatureofmalignancyIrregularmarginsIntranodularvascularpatternMicrocalcificationsFineneedleaspiration(FNA)Themostreliableandcost-efficientmethod
Thyroidcancer
DiagnosisThyroidfunctiontestsSerummarkersThyroglobulin(TG)forwell-differentiatedthyroidcancerCalcitoninandCEAformedullarythyroidcancerAllptswithmedullarythyroidcancerRETproto-oncogenepheochromocytomaandhyperparathyroidism
Managementofthyroidcancer
ThegoalsoftherapyRemovalofprimarytumor,diseasethatextendsbeyondthethyroidcapsule,andinvolvedcervicallymphnodesMinimizationoftreatment-anddisease-relatedmorbidityAccuratediseasestagingFacilitationofpostoperativetreatmentwithradioiodinewhenappropriateAccuratelong-termsurveillanceMinimizationoftheriskofrecurrentlocalandmetastatictumor
Well-DifferentiatedThyroidCarcinoma
PapillaryThyroidCarcinoma
Themostcommonendocrinemalignancy，approximately80%ofnewcasesAssociatedwiththebestprognosisAtleasttwiceascommoninwomenasmenApeakageofpresentationof38to45years90%ofradiation-induced，familialin5%
PapillaryThyroidCarcinomaPapillaryThyroidCarcinomaWell-DifferentiatedThyroidCarcinoma
PrognosesTheriskofdeathapproximately5%inthelow-riskgroup40%inthehigh-riskgroupFortunately,mostpts(70%)inthelow-riskgroup
OtherhistologicalfactorsTopredictthebehaviorofthyroidcancerPloidyofthetumorAdenylatecyclaseresponsetothyroidstimulatinghormone(TSH)RadioiodineuptakeApositivepositronemissiontomographyscanEpidermalgrowthfactor(EGF)receptorlevelandvariousgeneprofilesOtherhistologicalfactorsToPapillaryThyroidCarcinoma
Theextentofsurgicalresection
ControversialAmericanrecommondationTotalorneartotalthyroidectomy
complicationrateoflessthan2%SelectivenodalresectionPostoperativetreatmentwithiodine-131Low-riskptslessthan1cmthyroidlobectomyandisthmectomyOKReoperationmultifocal,withnodalmetastases,orwithlocalinvasion
BenefitsoftotalthyroidectomyPostoperativeradioiodinescanningandablativetherapycanbeeffectiveSerumthyroglobulinlevelsarerenderedmoresensitivefordetectingrecurrentorpersistentdiseaseIntrathyroidalcancerthatispresentinmorethan50%ofpatientsisremovedThesmallriskofadifferentiatedthyroidcancerbecominganundifferentiatedcancerisdecreased.BenefitsoftotalthyroidectomPapillaryThyroidCarcinoma
Theroleoflymphnodedissection
AlsocontroversialMicrometastasistocervicallymphnodesiscommon(80%)ProphylacticcervicallymphnodedissectionisnotwarrantedFunctionalneckdissectionandcentralneckdissectionshouldgenerallybeperformedonlyinptswithclinicalorsonographicevidenceoflymphnodeinvolvement
FollicularThyroidCarcinomaApproximately10%ofallthyroidmalignanciesTypicallyolderthanPTCUsuallyinthesixthdecadeoflifeThefemale-to-maleratioisbetween2:1and5:1AslowlygrowingsolitarythyroidnoduleAtendencytospreadhematogenouslyRarelywithsymptomsofdistantmetastasistothebone,lung,brain,andliverFollicularThyroidCarcinomaApFollicularThyroidCarcinomaLessthan6%metastasizetothecervicallymphnodesApproximately25%ofptshaveextrathyroidalinvasion10%to33%havedistantmetastasisatthetimeofinitialdiagnosisFollicularThyroidCarcinomaLeTheprognosisoffollicularcancerSlightlyworsethanthatforpapillarycancerOverallsurvivalrangesfrom43%to95%at10yearsLifelongsurveillanceisnotnecessaryTheprognosisoffollicularcaTheprognosisoffollicularcancerTheimportantprognosticfactorsPresenceofmetastaticdiseaseOlderage(usually>40years)Degreeofinvasion(microcapsularvs.angioinvasionwithorwithoutcapsularandwidelyinvasive)DegreeoftumordifferentiationTheprognosisoffollicularcaFollicularThyroidCarcinomaDiagnosisThewholespecimenmustbeevaluatedforvascularandcapsularinvasion.DiagnosisoffollicularcancercannotbemadeonFNABFollicularThyroidCarcinomaDiFollicularThyroidCarcinomaTreatmentTherecommendedinitialoperationislobectomyandisthmectomyLymphnodedissectionisrarelywarrantedbecausenodalmetastasesareuncommonFollicularThyroidCarcinomaTrMedullaryThyroidCarcinoma7%ofthyroidcancers15%ofallthyroidcancer–relateddeathsApprox75%sporadic零星的,25%hereditaryFromccellsorparafollicularcellsLocatedlaterallyatthejunctionoftheuppertwothirdsofthethyroidglandatapproximatelythelevelofthecricoidcartilageMedullaryThyroidCarcinoma7%MedullaryThyroidCarcinomaInthesporadicformUsuallyasinglefocusofmalignancyUnilateraldiseasein85%ofcasesInthehereditaryformMultifocalandbilateralin90%ofcasesC-cellhyperplasiaMedullaryThyroidCarcinomaInThehereditaryformsofMTCThehereditaryformsofMTCMedullaryThyroidCarcinoma
TumormarkerSerummarkersforcalcitoninsupportthediagnosiscorrelatewithtumorbulk,nodal,anddistantmetastasisHighCEAlevelscorrelatewithapoorerprognosisFlushinganddiarrheaalsohaveaworseprognosis
MedullaryThyroidCarcinoma
LymphnodemetastasesPositivein70%ofpatients81%ofpatientshadcentralnodedisease81%hadipsilateralcervicalnodedisease44%hadcontralateralcervicalnodaldisease
PreventionorcureofMTCBysurgerymainlydependentontheinitialstageandtheadequacyoftheinitialoperationIndicationRET-positivepatientswithfamilialdiseasebeforetheageofpossiblemalignantprogressiontotalthyroidectomybeforeage6PreventionorcureofMTCBysuSurgicalmanagementforMTCDependsonthepresentationofthediseaseThyroidectomyandcentralnodedissectionCentrallymphnodedissectionsincreasetheriskofrecurrentlaryngealnerveinjuryandhypoparathyroidismSurgicalmanagementforMTCDeAnaplasticThyroidCarcinomaRare,1%to2%ofthyroidmalignanciesMorethanhalfofthedeathsfromthyroidcancerSurvivalismeasuredinmonthsCommonlyinpatientsolderthan60yearsUsuallypresentsasarapidlyexpandingthyroidmassAnaplasticThyroidCarcinomaRaAnaplasticThyroidCarcinomaLymphnodeenlargementFrequent(84%)andearlyLocaltumorextensioncauseFixationofthelarynx,esophagus,andcarotidvesselsDysphagia,dysphonia,anddyspneaarecommonSystemicmetastasesoccurin75%ofpts,Usuallyinvolvingthelungs,bone,brain,andadrenalglandsAnaplasticThyroidCarcinomaLyAnaplasticThyroidCarcinomaThediagnosisBeestablishedbyFNABDifferentiatedfromthatoflymphomaandpoorlydifferentiatedmedullarycarcinomaAnaplasticThyroidCarcinomaThAnaplasticThyroidCarcinoma
SurgeyUsuallynotcurative,withdistantmetastasesMultimodalitytreatment,slightlyimprovedoutcomesIndicatelocalcontrolin22%to76%ofptsMediansurvivalrangesfrom2.5to9months,with2-yearsurvivaloflessthan20%
SubacuteThyroiditisPainlessThyroiditisPainfulThyroiditisRareSubacuteThyroiditisPainlessTPainlessThyroiditisAlsocalledlymphocyticthyroiditisSpontaneouslyresolvinghyperthyroidismAnautoimmunedisorderTypicallyelevatedthyroidperoxidaseantibodylevelsLymphocyticinfiltrationofthethyroidPainlessThyroiditisAlsocallePainlessThyroiditis
ClinicalPresentationAgesof30and60years40%ptswiththeclassicalafour-stageclinicalcourse(1)Destruction-inducedthyrotoxicosis,(2)euthryoidism,(3)hypothyroidism,and(4)returntoeuthyroidismUsually,firmglandandnon-tenderwithsymmetrical,modestenlargementNearlyonethirdofpts,permanentlyhypothyroid
PainlessThyroiditis
ClinicalManagementManypatientsdonotrequiretherapyThyroidectomyisrarelyindicated
PainfulThyroiditisAlsocalleddeQuervain'sdisease,granulomatousthyroiditis,AviraletiologyPrecededbyupperrespiratoryinfectionPainfulThyroiditisAlsocalledPainfulThyroiditis
ClinicalManagementUsuallyself-limitedBeta-blockadeisindicatedtotreatthesymptomsofhyperthyroidismNonsteroidalanti-inflammatorymedicationsandprednisonemayalsobeusedforpain
ChronicThyroiditisChronicThyroiditisHashimoto'sthyroiditisThemostcommoninflammatorydiseaseAutoimmune,chronic,progressivelymphocyticthyroiditisUpto95%ofcasesoccurinwomenElevatedlevelsofcirculatingantibodiestothyroglobulin,thyroidperoxidase,andthyrotropinreceptorHashimoto'sthyroiditisThemosHashimoto'sthyroiditis
ClinicalPresentationUsuallyasymptomatic20%withhypothyroidismThemostcommoncauseofhypothyroidisminUSUsuallysymmetrical,firmgland
Hashimoto'sthyroiditis
Management
ThyroidhormonereplacementtherapyHypothyroidismElevatedTSH
Hashimoto'sthyroiditis
IndicationofsurgeyMalignancyissuspectedfromFNAbiopsyCompressivesymptomsfromalargegoiterCosmeticpurposes
ThankyouforyourattentionThankyouforyourattentionThyroiddisease
LiboLiMD
DepartmentofGeneralSurgery
SirRunRunShawHospital
Schoolofmedicine,ZhejiangUniversity
Thyroiddisease
LiboLiMD
AnatomyofThyroidAnatomyofThyroidAnatomyofThyroidAnatomyofThyroidThyroiddiseaseNontoxicgoiterHyperthyroidismThyroidCancerThyroiditisThyroiddiseaseNontoxicgoiterNontoxicGoiterGoiterfromtheFrench(goitre)andLatin(guttur),bothmeaningthroatDefinedasanenlargementofthethyroidglandEndemicwhenitinvolvesmorethan10%ofthepopulationThemajority,secondarytoiodinedeficiencyEspeciallyfoundinhighmountainregionsNontoxicGoiterGoiterfromtheNontoxicGoiter
ClinicalthinkingWhetherthepatienthaslocalsymptomsWhetherthegoiteristoxicornontoxicWhetheranyofthenodulesharboracancerThenumberandbilateralityofthenodulesTSHlevel,differentialdiagnosisofhypothyroidismorhyperthyroidismAppropriatetreatmentoptionsforeachparticularpatient
NontoxicGoiter
TakinghistoryAsymptomaticneckmassAcough,shortnessofbreath,stridor,orhoarsenessChokingoraspiration,dysphagia,orpainSymptomsofhyperthyroidismWhetherthepatienthascosmeticconcernsFromiodinedeficiencyregion
NontoxicGoiter
PhysicalexaminationWhetherthegoiterisconfinedtotheneckWhetherithasasubsternalcomponentWhethertrachealdeviationispresentThesizeandconsistencyofthegoiterThemobilityofthevocalcordsbyeitherindirectordirectlaryngoscopy
NontoxicGoiter
UltrasoundHowmanynodules?Bilateral?Ultrasoundcharacteristics
NontoxicGoiterCTscanNeckandchest,especiallysubsternalthyroidRareintrathoracicoraberrantthyroidNontoxicGoiterCTscanNontoxicGoiterFineneedleaspiration(FNA)SuspiciousmalignentgoiterNontoxicGoiterFineneedleaspNontoxicGoiter
TreatmentIodinedietreplacement(endemicgoitor)SurgicalresectionSymptomsLocalcompressionSecondaryhyperthyroidisimAnysuspiciousormalignantlesionCosmeticreasonsRadioiodinetherapy,highriskofptsThyroidhormonesuppression(notforsporadicgoiter)
SporadicNontoxicGoiterAsymptomaticEuthyroidMostbilaterallyNoefficiencyofthyroidhormonereplacementHighrecurrencepostoperatively30%~40%SporadicNontoxicGoiterAsymptNontoxicGoiter
HistoryofThyroidSurgeryFirstthyroidectomy,inParisin1791byPierre-JosephDesaultAntisepsis,hemostasis,andgeneralanesthesiainthe1840sthyroidsurgerybecamesafeTheodoreKocher,aNobelPrizein1909FromBern,SwitzerlandHispioneeringeffortsinthyroidsurgery
PrimaryHyperthyroidsim
Grave’sDiseasePrimaryHyperthyroidsim
GraveClinicalStatisticsGravesDiseaseisthemostcommoncauseofhyperthyroidism(60-80%)ofallcasesFemalesareaffectedmorefrequentlythanmen10:1.5Monozygotictwinsshow50%concordanceratesIncidencepeaksfromages20-40IncidenceissimilarinwhitesandAsians,butissomewhatdecreasedforAfricanAmericansClinicalStatisticsGravesDiseGraves'DiseaseAutoimmunesystemicdisorderThyroidreceptorantibodybindingtoandstimulatingtheTSHreceptorExcessivesynthesisandsecretionofthyroidhormoneUsuallydiffuselyandsymmetricallyenlargedandfirmGraves'DiseaseAutoimmunesystHyperthyroidism—uptakeA.NormalB.Graves’DzC.ToxicMultinodularGoiterD.ToxicAdenomaE.ThyroiditisHyperthyroidism—uptakeA.NormaHyperthyroidism
SymptomsHeatintolerance,sweating,palpitations,fatigueWeightloss,diaphoresis,increasedstoolfrequencyMuscleweakness,anxiety,insomniaNervousnessorrestlessness;irritability,emotionallabilityInwomen,irregularmenses
Hyperthyroidism
ClinicalfindingsTremor,tachycardia(A.fib),Goiter,lidlag,proptosis,periorbitaledema,exophthalmos;chemosis;hyperreflexiaWarm,moistskin;dermopathy;andpretibialedema,
osteoporosis
ExopthalamosinGravesDiseaseLidLaginGravesDiseaseExopthalamosinGravesDiseaseHyperthyroidism—treatmentBeta-blockers:controlsxsPropranololdecrperipheralT4->T3conversionGraves’DzPTU(safeinpregnancy)ormethimazoleRaresideeffect:agranulocytosisRadioactiveiodine75%oftreatedptsbecomehypothyroidSurgeryToxicAdenomaorTMNGRAIorsurgeryHyperthyroidism—treatmentBeta-Hyperthroidism
SurgerySurgicalapproachBilateralnear-totalortotalthyroidectomyIndicationofsurgery(InChina)CompressivesymptomsSecondaryoradenomaRecurrenceofmedicineoriodine-131NoefficiencyofmedicineSecondtrimesterofpregnancy
Surgeryforhyperthyroidism
PreoperativepreparationAbsolutelyrequiredantithyroiddrugs,for3to6weekswithagoalofnearlynormalizingtheT3andT4PropranololoratenololrapidlycontrolstheadrenergicsideeffectsofexcessT4andT3tachycardia,tremor,anddiaphoresisLugol'ssolutionrapidlybuttemporarilyrestoresnormalthyroidfunctionandreducesthyroidglandvascularity
SurgicalcomplicationsBleedingRecurrentLaryngealNerveDamageHypoparathyroidismandHypocalcemiaSuperiorlaryngealnervedamageThyroidstormSurgicalcomplicationsBleedinThyroidcancerThyroidcancerThyroidcancer
IntroductionThemostcommon,95%ofallendocrinecancersIncreasingfasterthananyothercancerMorethan90%,welldifferentiatedGoodlong-termprognosis
Thyroidcancer
ClinicalPresentationMost,clinicallywithapalpablenoduleUsuallyasymptomaticRarecases,withhoarseness,pain,dysphagia,dyspnea,coughing,orchokingspellsPain，withthesuspicionforMedullarythyroidcarcinomaAnaplasticcarcinomaLymphoma
PertinenthistoricalfactorspredictingmalignancyAhistoryofheadandneckirradiationTotalbodyirradiationforbonemarrow
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