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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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332
Surgical causes of hyperthyroidism
Causes Characteristics Management
H. Hashmi and K. Patel
Women>men
Solitary toxic
Nodule (5%)
Usually >3cm to be symptomatic
Thyroid scintigraphy distinguishes
solitary toxic nodule from TMN
goiter
Thyroid scintigraphy➔ hot nodule
Hot nodules are always benign and
do not require FNA
Thyroid Nodule
Thyroid nodule
Findings concerning
for cancer
Work up
Antithyroid medications (ATMs) are not effective
long-term management
Surgery is the preferred management (thyroid
lobectomy)
Single, rm nodule, adherence to surrounding muscle, asymmetric movement of thyroid
on swallowing, rapid growth, hoarseness, family history of cancer, and history of
radiation exposure
TSH should be measured to assess the presence of hypothyroidism or hyperthyroidism
If TSH is low ➔ radionuclide 123-iodine scan to rule out toxic nodule
If MEN2 is suspected ➔ measure calcitonin
American Thyroid Association ultrasound guidelines are used to decide which nodule
requires an FNA
Ultrasound
ATA classication Ultrasound features Management
Benign Cystic nodules Observation
Very low suspicion Spongiform or partially cystic
nodules
Low suspicion Isoechoic or hyperechoic solid
nodule, or partially cystic nodule
with eccentric solid area
Intermediate suspicion Hypoechoic solid nodule with
smooth margins
High suspicion Solid hypoechoic nodule,
partially cystic nodule with:
Irregular margins,
microcalcications, taller than
wide shape, punctate
calcications, evidence of
extrathyroidal extension
FNA ≥2cm
FNA if ≥1.5cm
FNA if ≥1cm
FNA ≥1cm
11 Endocrine
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Thyroid nodule
333
FNA is used in nodules with high-risk features on ultrasound and certain characteristics:
history of radiation exposure, family history of thyroid cancer, hoarseness, and rapid
growth of nodule
Fine needle aspirate
(FNA)
Bethesda classication
system
FNA is performed by palpation or is ultrasound guided
Follicular thyroid cancer cannot be determined by FNA➔ permanent section must be
used
The Bethesda classication system categorizes FNA ndings into six diagnostic classes
Bethesda classication System and their management
Category Risk of malignancy (%) Management
I-nondiagnostic or
unsatisfactory
II- benign 0–3 Clinical follow-up
III-atypia of
undetermined
signicance or follicular
lesion of undetermined
signicance
5–10 Repeat FNA with image
guidance + real-time
cytologic analysis
If continue to be
nondiagnostic ➔
lobectomy
6–18months
If single nodule volume
increase <50% or multiple
nodules by <20% ➔
follow-up in 3–5years
If single nodule volume
increase >50% or multiple
nodules by >20% ➔
repeat ultrasound-guided
FNA
6–18 Repeat FNA or lobectomy
IV-follicular neoplasm
or suspicious for
follicular neoplasm
V-suspicious for
malignancy
VI-malignant 94–96 Total thyroidectomy
Molecular testing Molecular testing can sometimes help in predicting a benign or a malignant nodule in
patients with suspicious or indeterminate FNA
Molecular testing should be used only if the results were to change management
Molecular testing may help further stratify risk and obviate the indication for surgery
10–40 Lobectomy
45–60 Lobectomy or total
thyroidectomy
334
Research
Reference Findings
H. Hashmi and K. Patel
Nikiforov YE, Carty SE, Chiosea SI, etal. Impact of
the multi-gene ThyroSeq next-generation sequencing
assay on cancer diagnosis in thyroid nodules with
atypia of undetermined signicance/follicular lesion of
undetermined signicance cytology. Thyroid.
2015;25(11):1217–1223
Alexander EK, Kennedy GC, Baloch ZW.Preoperative
diagnosis of benign thyroid nodules with indeterminate
cytology. N Engl J Med. 2012;367:705–715
Thyroid Cancer
Papillary thyroid cancer
Most common thyroid cancer (90% of all thyroid cancers)
Characteristics
Least aggressive, slow growing, and best prognosis
Atypia of undetermined signicance/follicular lesion of
undermined signicance (AUS/FLUS) is a common
indeterminate diagnosis, with the cancer risk ranging
from 6% to 48%. ThyroSeq v2.1 multi-gene NGS panel
of molecular markers provides both high sensitivity
and high specicity for cancer detection in thyroid
nodules with AUS/FLUS cytology, which should allow
improved management for these patients
The comparison of the predicted performance of
ThyroSeq v2.1 with that of the Arma GEC suggested
that the NPV of both assays for AUS/FLUS nodules are
expected to be similar, whereas the PPV are dissimilar,
with a signicantly better performance of ThyroSeq
Gene expression classier (GEC) test known as Arma
have a 90% sensitivity and 95% NPV in nodules with
AUS/FLUS cytology
Multicentric
Follicular variant papillary thyroid cancer demonstrates a follicular growth pattern but
cytologically, the tumors display the typical features of common-type papillary cancers
Noninvasive
follicular thyroid
neoplasm with
papillary-like
nuclear features
(NIFTP)
Risk factors Radiation therapy to neck
Biomarker
Because of the very low malignant potential, this type was renamed noninvasive follicular
thyroid neoplasm with papillary-like nuclear features
NIFTP ➔should be treated like a benign tumor
NIFTP exclusion criteria include the presence of true papillae (> 1%, psammoma bodies, an
inltrative border, and tumor necrosis
This diagnosis cannot be made on FNA it requires surgical pathology
Thyroglobulin level reects the extent of thyroid tumor burden
Thyroglobulin levels are increased by the administration of TSH ➔measure TSH when
determining thyroglobulin
Thyroglobulin is used for surveillance and future recurrences
11 Endocrine
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Papillary thyroid cancer
Psammoma bodies (concentric lamellated calcied structures)
335
Histology
Genetics BRAF mutation (most common mutation in PTC, up to 50%)
Preoperative work
up
Prognosis
Intranuclear inclusions and grooves
Orphan Annie nuclei
Papillae
For a patient whose FNA biopsy shows papillary carcinoma➔ contralateral thyroid lobe
ultrasound + cervical lymph node ultrasound
CT and MRI have very low sensitivity ➔ not recommended
Tall cell variant, insular, mucoid brous stroma ➔worse prognosis
Age<55, well differentiated, < 4cm ➔ low risk
Research
Reference Findings
Adam MA, Pura J, Gu L, etal. Extent of surgery for
papillary thyroid cancer is not associated with survival:
An analysis of 61,775 patients. Ann Surg.
2014;260(4):601–607
Lee YC, Na SY, Park GC, Han JH, Kim SW, Eun
YG.Occult lymph node metastasis and risk of regional
recurrence in papillary thyroid cancer after bilateral
prophylactic central neck dissection: a multiinstitutional study. Surgery. 2017;161(2):465–471
No survival advantage associated with total
thyroidectomy vs. lobectomy in papillary thyroid
cancer patients with tumors 1.0–4.0cm at a median
follow-up of 82months
Presence of occult LN metastasis was not signicantly
associated with regional recurrence in patients with
PTC who underwent total thyroidectomy and bilateral
prophylactic central lymph node dissection
Follicular thyroid cancer
More aggressive than PTC
Characteristics
Workup
Hurthle cell carcinoma is a subtype of follicular thyroid cancer (Hurthle cell carcinoma have a
greater risk of malignancy and metastasis and poorer prognosis); Hurthle cell carcinoma is
usually not RAI avid
Hematogenous spread most common
FNA cannot distinguish follicular benign versus malignant neoplasms
If FNA shows follicular cells ➔ lobectomy
336
Management of differentiated (papillary and follicular) thyroid cancer
Stage of the disease is based on the tumor size, nodal status, distant metastases
(TNM) system
Staging of Differentiated Thyroid Cancer
H. Hashmi and K. Patel
Staging/Grading
Preoperative work up
Management
Stage Age<55years
I T
II T
anyNanyM0
anyNanyM1
Age≥55years
T1–2N0M0
T1N1M0
T2N1M0
T3a-b N
III T4a N
I VA T4b N
IVB T
any Nany
Age<55 ➔ Stage I: any T, any N, Mo; Stage II: any T, any N, M
M0
any
M0
any
M0
any
M1
1
T1<2cm; T2, 2–4cm; T3, > 4cm; T4a, extrathyroidal extension; T4b, invades
surrounding structures; prevertebral fascia or encases carotid artery or mediastinal
vessels
Ultrasound for evaluation of the central and lateral neck lymph nodes
Locally advanced disease➔ CT
Primary therapy for differentiated (papillary and follicular) thyroid cancer is surgery
In clinically node-negative patients➔ the role of prophylactic central lymph node
dissection is controversial
Most common location for metastatic nodes is in the central neck on the ipsilateral
side of the tumor
Case Management
Low-risk tumors,
clinically node-negative
tumors
High-risk tumors,
tumors>4cm, tumors
with gross extrathyroidal
extension(T4) or
clinically apparent nodal
disease(N1)
Positive central lymph
nodes
Thyroid lobectomy
Total thyroidectomy + central (level VI) lymph node
dissection
Total thyroidectomy + central (level VI) lymph node
dissection
11 Endocrine
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Management of differentiated (papillary and follicular) thyroid cancer
337
Indications for adjuvant
radioactive iodine (RAI)
Prognosis
Positive lateral lymph
nodesa
Total thyroidectomy+ central lymph node dissection+
selective lateral lymph node dissection (level above and
below)
Gross or cytologically
Total thyroidectomy + central and lateral neck dissection
conrmed metastatic
disease
Low-risk micro-PTCs
Active surveillance is appropriate alternative to surgery
(<1.0cm)
a
Once metastasis involves the lateral neck (levels 2–5), the central neck nodes (level
6) are usually involved ➔ total thyroidectomy, central neck dissection, and left lateral
neck dissection
Large tumors (> 4.0cm), distant metastases, gross extrathyroidal extension or
aggressive histologic features, tumors from 1 to 4cm with high-risk histologies,
vascular invasion, or cervical lymph node metastases
Age is the most important factor regarding prognosis ➔ if the patient <55years ➔
cancer can only be stage 1 or stage 2
Additional factors that worsen the prognosis include male sex, capsular invasion,
metastasis, size >4cm, poor differentiation
Lymph node involvement in papillary carcinoma ➔ no effect on survival
Hurthle cell carcinoma ➔ increased risk of recurrence
Research
Reference Findings
Cooper DS, Doherty GM, Haugen BR, etal. Revised
American Thyroid Association Management
guidelines for patients with thyroid nodules and
differentiated thyroid cancer. Thyroid.
2009;19(11):1167–1214
According to the American Thyroid Association
management guidelines for adult patients with thyroid
nodules and differentiated thyroid cancer, diagnostic whole
body radioactive iodine scan, after thyroid hormone
withdrawal or recombinant human thyrotropin can be done
6months after RAI ablation for high/intermediate-risk
patients to evaluate for persistent/recurrent disease. If RAI
is negative with rising thyroglobulin (>10ng/mL),
18
uorodeoxyglucose–positron emission tomography
(18FDG- PET) should be considered
338
Medullary thyroid cancer
Multifocal and diffuse
H. Hashmi and K. Patel
Characteristics
Work up
Management
Follow-up
20% associated with MEN2A and MEN2B and Familial medullary thyroid cancer (RET
proto-oncogene)
80% are sporadic
Arises from parafollicular cells (secrete calcitonin)
Amyloid deposition
Measurement of serum calcium, calcitonin, carcinoembryonic antigen (CEA)
Genetic screening for RET mutation
Plasma-free metanephrines and normetanephrines➔ rule out pheochromocytoma)
Neck ultrasound
Nonmetastatic MTC ➔ Total thyroidectomy and bilateral central neck dissection
Preop imaging of the central compartment ➔ if positive ➔ CLND + ipsilateral neck dissection
Monitor calcitonin level for disease recurrence
Persistent elevation of calcitonin levels is most commonly due to persistent disease in the neck or
distant metastatic disease➔ ultrasound of neck
Anaplastic thyroid cancer (ATC)
ATC is a very aggressive cancer with a very poor prognosis (worst prognosis of all
Characteristics
Genetics P53
Staging All ATCs are automatically assigned stage IV
Management Surgical treatment of ATC is almost always only palliative
thyroid cancers)
Pathology shows vesicular appearance of nuclei
Thyroid lymphoma
Diagnosis Diagnosis can be made on FNA
Occasionally, an incisional biopsy or core needle biopsy is required
Excellent responses to chemotherapy alone unless signicant compressive symptoms are present
Management
High risk
versus low risk
Diffuse large B-cell lymphoma➔ CHOP (cyclophosphamide, hydroxy doxorubicin, vincristine,
prednisone) followed by radiation
High-risk characteristics: Large size, irregular borders, taller than wide in shape
Low-risk characteristics: More cystic components, clear borders, spongiform
11 Endocrine
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Thyroid cancer genes and biomarkers
Thyroid cancer Driver genes Biomarkers
PTC BRAF Thyroglobulin
339
MTC RET
Bcl-2 ➔ better prognosis
FTC PAX8
PPAR
NRAS
ATC p53
CEA/ bcl-2
Calcitonin➔ more sensitive for recurrence
Thyroidectomy
Preoperative preparation
Case Preoperative preparation
All patients undergoing thyroid surgery Preoperative voice assessment
For patients with invasive primary
tumor or lateral lymph node
involvement
Hyperthyroid patients with
thyrotoxicosis (treat preoperatively to
prevent thyroid storm)
CT neck with IV contrast
Preoperative laryngoscopy
Beta-blockers ➔ rst line to control symptoms
ATMs (Propylthiouracil ➔ for pregnant patients and methimazole) to
lower thyroid hormone production
Steroids to decrease peripheral conversion of thyroxine (T4) to active
triiodothyronine (T3)
Iodine solutions (saturated solution of potassium iodide or
potassium iodid-iodine (lugol solution) may be given 1–2weeks
before surgery to inhibit hormone synthesis, block hormone release,
and decrease vascularity of the gland prior to surgery
Key steps for thyroidectomy
Incision Make a transverse collar incision two
ngerbreadths superior to the
clavicular heads.
Incise through the skin, subcutaneous
tissue, and platysma muscle
Subplatysmal
aps
Raise the subplatysmal aps to the
level of the thyroid cartilage
superiorly and to the sternal notch
inferiorly
Separate the sternohyoid and
sternothyroid muscles from the
thyroid lobe
340
lar
l
Superior
d
yroid
Recurrent laryngeal nerve
Th
Key steps for thyroidectomy
H. Hashmi and K. Patel
Medially
rotate thyroid
gland
Expose
superior pole
vessels
Sweep sternothyroid muscle off the
thyroid and ligate and divide the
middle thyroid vein
Continue this dissection laterally and
posteriorly to the level of the
prevertebral fascia
Retract the thyroid inferiorly and
laterally to expose the avascular plane
between the thyroid and the
cricopharyngeal muscles
Identify the superior pole vessels and
ligate and divide these close to the
thyroid (divide close to thyroid to
avoid damaging external branch of
SLN)
External
yngeal
nerve
laryngeal
nerve
Internal
laryngea
nerve
Identify and
preserve
superior
parathyroid
Continue to inferiorly retract the
thyroid gland to expose the area deep
to the upper pole where the superior
parathyroid gland is located
Superior parathyroids are located on
the posterior side of the upper or
middle thyroid lobes, posterior and
lateral to RLN at the level of the
cricoid cartilage
yroid
Superior
parathyroi
gland
Inferior
parath
gland
Inferior
carotid ar
jugular vein
thyroid artery
thyroid vein
Esophagus
11 Endocrine
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Key steps for thyroidectomy
341
Retract thyroid gland medially, to help
identify the inferior thyroid artery and
Identify and
recurrent laryngeal nerve
preserve
recurrent
laryngeal
nerve a
Identify RLN at the cricoid at the
ligament of Berry (tracheal attachment
to the thyroid) near the tubercle of
Zuckerkandl (posterior pyramidal
Recurrent
laryngeal nerve
Common
thyroidal extensions) and the
tracheoesophageal groove.
The RLN passes posteriorly to the
inferior thyroid artery and is lateral to
the ligament of Berry
RLN is most susceptible to traction
injury near the ligament of Berry
during medial rotation of the thyroid
Ligate inferior thyroid artery after
identifying RLN
Identify and
preserve
inferior
parathyroid
The inferior parathyroids are located
within 1cm of the intersection of the
inferior thyroid artery and the RLN,
anterior and medial to the RLN
Intraoperative decision making about parathyroid
parathyroid
tery
Internal
Inferior
Middle
Superior
parathyroid
Superior
thyroid
artery/vein
Case scenario Management
Parathyroid gland found to be
congested
Parathyroid appears devascularized
and does not bleed when a small
incision is made in it
Parathyroid gland inadvertently
removed
Small incision in the gland away from the blood supply to relieve venous
congestion
If the gland does not return to a normal healthy appearance after incision
➔ autotransplantation is required
It is likely nonfunctional ➔ immediate reimplantation into a muscle
especially if other parathyroids functionality is questionable
Autotransplantation (place fragmented parathyroid into the strap
muscles, sternocleidomastoid muscle or forearm muscle) and close fascia
over the gland with permanent sutures (revascularization occurs in
4–6weeks usually)
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