THYROID GLAND Surgical Diseases

1. THYROID GLAND(Surgical Diseases) Prof. M.Rushdi. Khammash FRCSI Department of Surgery Faculty of Medicine J.U.S.T

2. Embryology Pharyngeal floor �median thyroid diverticulum- foramen caecum Thyroglossal duct Ultimobranchial bodies-Para follicular C cells

3. ANATOMY Lobes ---Lobules�Follicles Blood supply: Superior& Inferior arteries =.=====.=== Veins Relations: Tracheal rings Recurrent laryngeal nerve Superior laryngeal nerve Parathyroid glands

4. INVESTIGATION OF THE THYROID 1.Thyroid Hormones Thyroxin �T4� Triiodothyronine �T3� Thyroid stimulating hormone �TSH� Thyrotrophin releasing hormone �TRH� Free T4,T3,TSH Concentrations

5. Thyroid Antibodies Thyroid stimulating Ab. Thyroglobulin Thyroid peroxidase �Microsomal antigen� TSH Receptor antibodies Calcitonin

6. Thyroid Isotope Studies Isotope Uptake Iodine121,123 Technicium 99 Hot nodule, Cold nodule, Neutral, Diffuse

11. Ultrasonography Multiple Nodules 0.3mm Cystic vs Solid lesions CT and MRI

12. Needle BiopsyCutting and Fine needle Colloid nodule Papillary carcinoma Anaplastic carcinoma Thyroiditis Medullary carcinoma Lymphoma

13. Thyroglossal Cyst Persistance of the thyroglossal tract along its course between the tongue and thyroid cartilage. Presentation: Midline neck mass, cystic Teen age Complication: Infection Fistula Malignancy Investigations : US, Scan, FNAC Treatment : Surgery

15.  Goitre A non specific term to indicate enlargement of the thyroid gland

16. Classification of Goitre Simple Goitre Diffuse Hyperplastic Nodular Toxic Goitre Diffuse Toxic nodular Toxic solitary nodule Neoplastic Goitre Benign Malignant Thyroiditis Subacute granulomatous Autoimmune Reidel Acute suppurative Miscellaneous Chronic bacterial Actinomycosis Amyloidoses

17. Simple GoiterSporadic Endemic Iodine deficiency Physiological goiter (stress) Fluctuating levels of stimulation by the TSH = Coexistence of Active and Inactive nodules Hyperplasia �cystic degeneration �hemorrhage�colloid filled follicles�fibrosis --calcifications

18. Prevention and Treatment Simple M N Goiter Iodine uptake: Iodination of salt Food T4 administration Surgery

19. Investigations of MN Goiter Hormones: T4 , T3 , TSH Neck&Chest X ray Diagnostic investigations: Needle biopsy and FNAC Ultrasound Isotope scanning

20. Treatment Hormone administration Very little evidence to affect benign nodule, and MN Goiter Indications for surgery Clinical features and suspicious or definite FNAC result Mechanical symptoms Cosmetic

21. Surgical treatment Unilateral total lobectomy Frozen section examination( for suspicious nodule) Surgery for MNG Subtotal vs, total thyroidectomy.

22. Thyroid Nodules Are common,being a feature of many different thyroid diseases The essential clinical problem,particularly when the lesion is Solitary, is to distinguish between Benign and Malignant disease (nodule).

23. Assessmentof the thyroid status .A nodule in hyperthyroid patient is highly unlikely to be malignant Dominant nodule in MNG : Malignancy rate may approach that of solitary nodule 20% Consistency of the nodule Lymphadenopathy Voice changes Pressure symptoms

24. Clinical Assessment Mostly asymptomatic Acute development�Hemorrhage Growth rate Age Environmental and Geographical factor *endemic goiter and irradiation�

25. Thyroid Cancer Rare: Less than 1% of all malignancies Wide spectrum of biological behaveour If treated appropriately there is high survival rare Types :Papillary Follicular Anaplastic Medullary Lymphoma Rare secondary

26. Papillary Carcinoma Commonest Iodine rich areas Affects children and young adults more Previous neck irradiation

27. Pathology of papillary carcinoma Propensity for lymphatic spread: Both intathyroidal and extrathyroidal(lymph nodes) Multifocal Blood born spread is usually a late disease Size and extent: Minimal Lateral aberrant thyroid Intrathyroidal Extra thyroidal

28. Clinical presentation Thyroid nodule Cervical lymphadenopathy Voice changes Airway obstruction Distant metastasis �rare less than 1% Diagnosed by clinical assessment and FNAC

29. Follicular Carcinoma Higher incidence in iodine deficient areas Previous irradiation ?possible Female to male ratio 3:1 Affects older age group

30. Pathology Invariably encapsulated Solitary Exhibits vascular invasion and spread via the blood stream Lymphatic spread is a late phenomenon

31. Clinical features Discrete solitary nodule increasing in size Firm ,but could be cystic{hemorrhage} Metastatic disease:bone lung brain�.etc -Diagnosis: Cannot be diagnosed by FNAC. Suspicious and frozen section

32. Treatment of differentiated thyroid carcinoma Total Thyroidectomy is the treatment of choice. Treatment objectives: Eradicate the primary Reduce the incidence of metastasis Facilitate treatment of metastasis Minimal morbidity

33. Post operative treatment Thyroxin T4 Replacement Suppress TSH Thyroglobuline Sensitive indicator for residual or recurrent tumor Radioactive Iodine Detect metastatic disease Ablation

34. Anaplastic carcinoma Peak incidence 60-70 years Females more than males Rapid local tissue infiltration Rapid blood metastasis -Long standing goitre-rapid changes in voice and breathing FNAC is diagnostic Surgery radiotherapy chemotherapy