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A CPMC Regional CME Event
THYROID TREATMENT AND VITAMIN D UPDATE
- An Integrated Approach
Saturday October 27, 2012
THYROID SURGERY
Andrea H. Yeung, MD
San Francisco Otolaryngology Medical Group
OUTLINE OF DISCUSSION
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Indications
Risks
Technical considerations
Postoperative management and follow up
DISCLOSURES
• No Financial Disclosures
RISING INCIDENCE OF THYROID CANCER
OVER TIME
Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov). SEER Stat
Database: Incidence - SEER 9 Regs Public-Use, Nov 2005 Sub (1973-2003), National Cancer Institute,
DCCPS, Surveillance Research Program, Cancer Statistics Branch, released April 2006.
INCREASED INCIDENCE IN WOMEN
Age at the time of diagnosis of thyroid cancer in men and women from 1975 to 2006.
The incidence rate per 100 000 is about 3-fold higher in women compared with men,
and peak incidence occurs nearly 20 years earlier in women than men.
Sipos JA, Mazzaferi EL. Thyroid Cancer:Epidemiology and Prognostic Variables. Clinical
Oncology. 2010 22(6) 395-404
INCREASED INCIDENCE DUE TO RISE IN SMALL
PAPILLARY TUMORS
Davies L, Welch HG. JAMA 2006. 295(18)
Cramer JD, Fu P, Harth KC, et al. Analysis of the rising incidence of thyroid cancer using the
Surveillance, Epidemiology and End Results national cancer data registry. Surgery.
2010;148:1147-1153
THYROID CANCER INCIDENCE AND
MORTALITY 1973-2002
Davies L, Welch HG. JAMA 2006. 295(18)
INCREASING INCIDENCE OF THYROID NODULES
• Predominantly due to increased detection of
small papillary cancers
- Increased diagnostic scrutiny
• Known existence of a substantial reservoir of
subclinical cancer
• Stable overall mortality
• Increasing incidence reflects increased detection
of subclinical disease, not an increase in true
occurrence of thyroid cancer
INDICATIONS FOR THYROID SURGERY
• Thyroid malignancy
• Symptomatic goiter
- Compressive symptoms
• Aesthetic concerns due to goiter
• Medically refractory hyperthyroidism
• Contraindications
- Uncontrolled severe hyperthyroidism
- Pregnancy
GOALS FOR SURGICAL THERAPY FOR
DIFFERENTIATED THYROID CANCER
• Remove the primary tumor, disease that has
extended beyond the thyroid capsule, and involved
cervical lymph nodes
• Minimize treatment related morbidity
• Permit accurate staging of the disease
• Facilitate postop treatment with RAI
• Permit accurate long term surveillance for disease
recurrence
• Minimize the risk of disease recurrence and
metastatic spread
WHAT IS THE APPROPRIATE OPERATION?
• Nondiagnostic bx or indeterminate biopsy
- Initial lobectomy with possible need to return for
completion thyroidectomy
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Follicular neoplasm or Hurthle cell neoplasm
- Total thyroidectomy
• Large tumors >4cm
• Marked atypia is seen on biopsy
• Biopsy is suspicious for papillary thyroid carcinoma
• Family history of thyroid carcinoma
• History of radiation exposure
SURGERY FOR BIOSPY DX OF MALIGNANCY
• Total thyroidectomy
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>1cm
Contralateral thyroid nodules present
Regional and distant metastases
Personal history irradiation
First degree family history of thyroid cancer
Older age >45 because of higher recurrence risk
• Thyroid lobectomy
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<1cm
Low risk
Unifocal disease
Intrathyroidal PTC in the absence of prior radiation or involve
cervical nodal mets
LYMPH NODE DISSECTION
• Central neck dissection (level VI)
- Therapeutic for clinically involved central or lateral neck
LN
- Prophylactic with PTC with clinically uninvolved central
neck LN
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Advanced primary tumors (T3 and T4)
• Total thyroidectomy without prophylactic CND
- Small T1 or T2 noninvasive, clinically node negative
PTCs and most follicular cancers
• Lateral neck dissection
- Biopsy proven metastatic lateral cervical LAD
RISKS
• Hypocalcemia related to hypoparathyroidism
- transient hypocalcemia vary in the literature from between 5-50%
- Permanent hypocalcemia secondary to hypoparathyroidism (ie,
lasting more than 6 months) 0.5-2%
• Recurrent laryngeal nerve injury
- Permanent RLN paralysis occurs in 1-2% of thyroidectomies
• Superior laryngeal nerve injury
- Often asymmptomatic but may result in vocal fatigue and pitch
alteration in professional singers
• Hematoma
• Infection
• Thyrotoxic storm
INTRAOPERATIVE NERVE MONITORING
• Endotracheal tubes with integrated surface
electrodes that contact the vocal cords
• Allows for an intraoperative assessment of
nerve function
• May not have a significant difference in
reducing nerve injury, but can be used to
predict how well the nerve functions
postoperatively
TECHNIQUE
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Incision and exposure of thyroid gland
Releasing the superior pole
Identifying the parathyroid glands
Identifying the recurrent laryngeal nerve
Removing the thyroid gland
Neck dissection
Closure
INCISION AND EXPOSURE OF THE THYROID GLAND
RELEASING THE SUPERIOR POLE
IDENTIFYING PARATHYROID GLANDS
IDENTIFYING RECURRENT LARYNGEAL NERVE
NECK DISSECTION
REMOVAL OF THYROID AND CLOSURE
ALTERNATIVES TECHNIQUES AND METHODS
• Minimally invasive video assisted thyroidectomy
- Requires careful patient selection to ensure feasibility
- Decreased postop pain and faster recovery
- Increased operative time and cost
• Robotic assisted transaxillary thyroidectomy
- Better cosmetic result
- More invasive with wider dissection necessary
- Technically difficult
- Cost prohibitive
OTHER CONSIDERATIONS: SUBSTERNAL GOITER
• Most often does not require a sternotomy
• These patients are at an increased risk of recurrent
laryngeal nerve injury, with reports as high as 17.5%.
• Sternotomy
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Superior vena cava syndrome
Goiter with mediastinal blood supply
Posterior mediastinal goiter
Larger diameter to the intrathoracic component
Recurrent substernal goiters
Malignancy extending into the mediastinum
Presence of significant adhesions to mediastinal vessels or
pleura
POSTOPERATIVE COURSE
• Hemithyroidectomy
- 6 week postop TFTs 15% chance need for thyroid
hormone replacement
• Total thyroidectomy
- Calcium monitoring for iatrogenic hypoparathyroidism
- Parathyroid hormone as an adjunct or replacement to
measuring serum calcium levels in predicting
hypoparathyroidism
- 6 month postop ultrasound and Tg for survellience
PEARLS
• As diagnostic techniques have become more sensitive
particularly with the advent of ultrasound and FNA increasing
incidence of thyroid cancer may reflect an increased diagnostic
scrutiny
• The surgical technique of thyroidectomy, as well as adjunct
technology, continued to advance
• Most recently, various new instruments and approaches
including video-assisted thyroidectomy and robot-assisted
thyroidectomy have emerged