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Surgical Thyroid Disease

Surgical Thyroid Disease. Surgical Thyroid disease. Presentation and assessment Indications for surgery Risks of surgery Thyroid cancer / RAI protocol Discussion session. Surgical Thyroid Disease. Anatomical abnormality : goitre / nodule Functional abnormality : over /under active

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Surgical Thyroid Disease

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  1. Surgical Thyroid Disease

  2. Surgical Thyroid disease • Presentation and assessment • Indications for surgery • Risks of surgery • Thyroid cancer / RAI protocol • Discussion session

  3. Surgical Thyroid Disease • Anatomical abnormality : goitre / nodule • Functional abnormality : over /under active • Both : toxic nodule graves with big goitre

  4. Common presenting symptoms • Lump in neck • Feeling of pressure • Feeling of discomfort • Feeling of choking • Feeling of having to ‘double swallow’ • Don’t like the appearance and want to know what it is

  5. Lump in neck • Examination • Lymph node • Thyroid • Other

  6. Suggested pathway for lymph node in neck:present for 3-6/52, >2cm or increasing in size • With associated systemic symtoms ; fast track haematology referral • Asymptomatic : rapid access neck lump clinic ; same day panedoscopy, USS, FNA, Core cut

  7. If thought to be a thyroid abnormality • Helpful if USS requested at same time • Single nodule / multinodular / diffuse • Likely Benign or Malignant ? • What is it that is bothering the patient ?

  8. Discrete palpable nodule • FNA • Cyst : if resolves : discharge • Solid : Benign ; asymptomatic and <4cm : review symptomatic, >4cm or clinical anxiety : lobectomy • Solid : Follicular ; Lobectomy

  9. Discrete palpable nodule • FNA • Solid : Suspicious : • lobectomy • Solid : likely Malignant • thyroidectomy

  10. Indications for surgery • Diagnostic uncertainty (clinical or cytology) • Discrete lump over 4 cms • Cosmetic benefit • Relief of pressure symptoms • Correction of tracheal deviation /compression • Retrosternal extension • Thyroid eye disease (graves)

  11. Thyroid Surgery • Thyroid lobectomy (including isthmus and pyramidal lobe) • Total thyroidectomy

  12. Thyroid Surgery • Sup laryngeal nerves • Cutaneous sensory nerves • Recurrent laryngeal nerves • Para-thyroid glands • Post-operative thyroxine • Post-operative calcium replacement

  13. Thyroid cancer • 8-10 cases per year in Swindon • <1% of cancers • If managed early favourable prognosis • Most symptomatic nodules are not cancer (value of screening?) • Following surgery, MDT discussion but further treatments at Churchill Oxford

  14. RAI Treatment protocol and FU • After surgery pt on T3; stop 10/7 before admission (ideally TSH >30mU/L) • 131I 3.1Gbq (5.5Gbq if known mets) • Day 3 uptake scan to check 131I safe for home • Home on T3 20mU/l tds • 6/52 GP to check TSH (<0.5mU/l) • 3 months later ; stop T3 for 10/7 • Iodine uptake scan 150Mbq 131I

  15. RAI Treatment protocol and FU • If no uptake or <0.05% and thyroglobulin undetectable start T4 (150 – 200 microg /day • If uptake >0.25% ; residual thyroid tissue/disease further therapeutic/ ablative dose of 131I and repeat uptake scanning process

  16. Summary • Sound bites on some common functional and anatomical thyroid issues. • Discussion

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