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Slide 1 :
THYROID CARCINOMAS PROF.N.DORAIRAJAN MS,FRCS(EDIN),FICS,FACS,FICA PROFESSOR AND HEAD OF THE DEPARTMENT DEPARTMENT OF GENERAL SURGERY MADRAS MEDICAL COLLEGE & GOVT GENERAL HOSPITAL CHENNAI ENDOCRINE SURGEON APOLLO HOSPITALS, CHENNAI PRESIDENT ELECT – INTERNATIONAL COLLEGE OF SURGEONS – INDIAN SECTION ADDL GOVERNOR – INTERNATIONAL COLLEGE OF SURGEONS – INTERNATIONAL SECTION EDITORIAL BOARD MEMBER – INTERNATIONAL SURGERY CHAIRMAN – ASI - TAMILNADU PONDICHERRY CHAPTER
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09/10/2000 NDR THYROID…….. THE ONLY ENDOCRINE GLAND THAT IS PALPABLE THE ONLY ENDOCRINE GLAND THAT MOVES UP AND DOWN THE ONLY GLAND IN WHICH THE HORMONE IS STORED OUTSIDE THE CELL IN THE FORM OF A COLLOID THE GLAND IN WHICH THE VEINS DOES NOT ACCOMPANY THE ARTERIES FIRST HORMONE FOR WHICH SYNTHETIC ORAL FORM WAS SYNTHESISED
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09/10/2000 NDR RELATIVE INCIDENCE PAPILLARY 80% 72.75% FOLLICULAR 17% 21.5% ANAPLASTIC 1.5% 3.25% MEDULLARY 0.5% 1.25% OTHERS 1% 1.25% (* Ref: N. DORAIRAJAN , CURRENT CONCEPTS IN SURGERY , OXFORD UNIVERSITY PRESS, INDIA 2000; P 1,2 G.H.*
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09/10/2000 NDR MALIGNANCIES ARISE FROM ANY OF THESE CELLS THE HISTOLOGY OF THYROID GLAND FOLLICULAR CELLS PARA FOLLICULAR “C” CELLS LYMPHOCYTES PAPILLARY FOLLICULAR HURTHLE ANAPLASTIC MEDULLARY CARCINOMA LYMPHOMA NON-HODGKINS
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09/10/2000 NDR CLASSIFICATION WELL DIFFERENTIATED THYROID CARCINOMAS ( WDTC) MEDULLARY THYROID CARCINOMA PRIMARY LYMPHOMA ANAPLASTIC CARCINOMA THE NEW GROUP : POORLY DIFFERENTIATED CARCINOMA
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09/10/2000 NDR THYROID GROWTH FACTORS THYROID STIMULATING HORMONE INSULIN LIKE GROWTH FACTOR EPIDERMAL GROWTH FACTOR TGF ? & ?
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09/10/2000 NDR PREDISPOSING FACTORS IRRADIATION TO THE NECK A HIGH LEVEL OF TSH HASHIMOTO’S THYROIDITIS ONCOGENES
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09/10/2000 NDR ONCOGENES RET /PTC ONCOGENE CHILDHOOD IRRADIATION MEN 2A : MEDULLARY CARCINOMA, PHEOCHROMOCYTOMA, PARATHYROID HYPERPLASIA MEN 2B :MEDULLARY CARCINOMA, PHEOCHROMOCYTOMA, MUCOSAL NEUROMAS & MARFANOID HABITUS PAPILLARY CARCINOMA MEDULLARY CARCINOMA
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09/10/2000 NDR ONCOGENES RAS ONCOGENE 20 TO 60 % OF MALIGNANCIES 60% FOLLICULAR ADENOMA THYROID STIMULATING GLOBULIN p53 GENE Rb GENE GSP ONCOGENE PRIMARILY FUNCTIONING NODULES 20 – 70% AGGRESSIVE HURTHLE CELL CARCINOMA
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09/10/2000 NDR ONCOGENES MUTATIONS OF p53,p15, p17 ( TUMOR SUPPRESSOR GENES) trk PROTO ONCOGENES Ret – ele TRANSLOCATIONS
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09/10/2000 NDR POINTERS TO MALIGNANCY A NODULE IN A MALE PATIENT A NODULE IN THE EXTREMES OF AGE A COLD/NONFUNCTIONING NODULE A REMOTE HISTORY OF EXPOSURE TO IRRADIATION IN THE HEAD AND NECK ( CHILDHOOD)
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09/10/2000 NDR STAGING CLASS I II III IV CLINICAL INTRATHYROIDAL CERVICAL ADENOPATHY LOCALLY INVASIVE DISEASE DISTANT METASTASES TNM T1-3N0M0 T1-3N1a-1bM0 T4NAnyM0 M1
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09/10/2000 NDR HISTORY,PHYSICAL EXAMN.&EVALUATION OF THE PT. IS SINE QUA NON THE SECRET OF CONSISTENTLY SAFE THYROID SURGERY IS GOOD EXPOSURE(RELEVANT?) MANAGEMENT OF BLOOD VESSELS EXPOSURE OF PARATHYROID GLANDS-VARIABLE IN LOCATION IDENTIFICATION PREPARATION OF RLN SURGICAL PROCEDURES HAVE THE POTENTIAL FOR COMPLICATIONS, AND THYROIDECTOMY IS NO EXCEPTION.
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09/10/2000 NDR “ANATOMICAL PLANES” THE SOFT AREOLAR TISSUE OF THE NECK AFFORDS AN IDEAL OPPURTUNITY FOR DISSECTION ALONG ANATOMICAL PLANES, WITH CAREFUL IDENTIFICATION OF ALL IMPORTANT STRUCTURES AS THE SURGERY PROCEEDS,LIGATING VESSELS CLOSE TO THE CAPSULE OF THE GLAND-”CAPSULAR DISSECTION”(EXTRA CAPSULAR).ULTIMATELY THE GLAND “FALLS OUT”
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09/10/2000 NDR IMMEDIATE HAEMORRHAGE > HAEMATOMA > RESPIRATORY OBSTRUCTION TRACHEAL COMP Tracheal instability Laryngeal edema Bil.vocal cord paralysis INTERMEDIATE RLN injury-vocal cord paralysis Hypoparathyroidism Thyroid crisis LATE Hypothyroidism Perforation of trachea &oesaphagus Seroma Extrusion of buried sutures
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09/10/2000 NDR TO DRAIN OR NOT TO DRAIN??? Million dollar ? Ruark DS et al Head Neck 1992- 14 Minimal complication rate of 3.6% with undrained neck incisions So routine propyhlactic drainage of thyroid wound unnecessary
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09/10/2000 NDR WHEN SURGEON IS UNCERTAIN OF HAEMOSTASIS Anaesthetist can perform valsalva maneuver Increased cervical pressure opens out bleeding points,making it easier to obtain haemostasis WOUND CLOSURE Apply manual pressure across the neck in the line of incision till the pt. is extubated Cough at the time of extubation increases venous pressure and so this will help in reducing it at the wound site When strap muscles are approximated a “weep-hole” is left at each margin Platysma is not closed-helps in dispersing the small vol. of blood
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09/10/2000 NDR RESPIRATORY OBSTRUCTION-STRIDOR First 48hrs due to Hge and haematoma Pt obtunded mentally by hypoxia-no anaesthesia required Bedside tracheostomy done-life saving TRACHEOMALACIA Large goitres weaken the tracheal rings Trachea collapses after the goitre is removed ET intubation or tracheostomy LARYNGEAL EDEMA Repeated and inept efforts to insert the ET High Fowler position O2 therapy – Tracheostomy Operating surgeon to be called immediately in case of respiratory stridor especially at night
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09/10/2000 NDR TO EXPOSE OR NOT TO EXPOSE (RLN) Prioleau: ”A RLN seen is injured” Crile: RLN is more sensitive to exposure than a normal peripheral nerve Judd & Lahey(1938): Advised routine exposure(injury <0.3%) Riddel:concept of “nerves at risk” Identification reduces risk.Experienced surgeon may dicontinue identification preparation of RLN.
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09/10/2000 NDR R.L.N.
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09/10/2000 NDR Author do not identify the RLN until the gland has been mobilised,excepting the tubercle of Zuckercandl and ligament of Berry The distal course of the RLN(2cms) where the injury is common cannot be seen until this point regardless of its earlier identification caudally Distal portion is covered by tubercle of Zuckercandl or lig of Berry
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09/10/2000 NDR PARATHYROID(2%) Anatomy of the gland &their bloodsupply-paramount importance Halstead & Evans (1907) described end artery supplying parathyroid If necessary divide branches of the inferior thyroid artery beyond the parathyroid on the thyroid gland capsule If a parathyroid appears congested-incision on the capsule liberates pressure from venous blod-allowes arterial flow If no recovery -autotransplantation
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09/10/2000 NDR PARATHYROID GLANDS
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09/10/2000 NDR HYPOCALCAEMIA Î incidence of inadvertent removal of one or more PT especially during surgery for CA thyroid Careful examn. of resected specimen to identify PT and Tx them “Hungry bones” associated with thyrotoxicosis may result in PO hypocalcemia Serum Ca levels to be checked in the 1st PO day
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09/10/2000 NDR AUTO Tx – INSURANCE AGAINST HYPOPARATHYROIDISM-INTELLECTUAL & PRACTICAL It is not clear in individual pts. who have had a PT auto Tx and possible damage to the other PT glands,whether it is the transplant or supernumerary PT that provides normocalcaemia. Reeves ; WJS ,2000
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09/10/2000 NDR LYMPHATIC DRAINAGE OF THE THYROID GLAND
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09/10/2000 NDR LEVELS OF LYMPH NODES IN THE NECK Developed by Memorial Sloan – Kettering Cancer Centre
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09/10/2000 NDR COMPARTMENTS OF THE NECK 4 compartments: Cerviocentral Cervicolateral right Cervicolateral left Mediastinal
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09/10/2000 NDR PATTERN OF LYMPH NODAL METASTASIS Spread in a sequential pattern Paratracheal nodes are first involved Surgery of thyroid and parathyroid – Randolph World journal of surgery March 2007 THYROID CENTRAL COMPARTMENT IPSILATERAL CONTRALATERAL In widespread primary tumour Recurrent tumour Tumour extending over the isthmus MEDIASTINAL Skip metastasis – 18%
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09/10/2000 NDR RISK FACTORS FOR LYMPH NODE METASTASIS Histological Subtype Tumor size Invasion Local,extra thyroidal,capsular,vascular Sex Male Age Paediatric age group – 80 % of nodal metastasis.
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09/10/2000 NDR PREOPERATIVE IMAGING FOR DETECTING NODAL METASTASIS High Resolution Ultrasound Detect and qualitatively evaluate the nodes. Metastatic nodes – dia > or = to 1 cm, hypoechoic/unhomogenous, irregular cystic appearance, internal calcification, rounded/bulging shape with increased AP diameter Positive predictive value – 93.3 % Technetium Tc 99m MIBI scan Useful with high thyroglobulin levels and negative high dose I 131 scan Higher sensitivity than CT and MRI in detecting mediastinal nodes. FDG PET Interpret nodes which are identified as scars in USG or CT Antonelli A et al , 1995 World journal of surgery 2007 High incidence of false negatives.
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09/10/2000 NDR Fine needle aspiration cytology (FNAC) in the diagnosis of lymph node metastasis FNAC alone was required to accurately diagnose lymph node metastasis of the thyroid in a majority of cases (17/24); however, in some cases ancillary techniques may be required for a definite diagnosis. Diagn. Cytopathol. 2006;34:240-245. © 2006 Wiley-Liss, Inc. Role of fine-needle aspiration cytology in the diagnosis of secondary tumors of the thyroid - twenty years' experienceManju Aron, M.D., D.N.B. (Path.), M.N.A.M.S., Kusum Kapila, M.D., F.I.A.C., F.R.C. (Path.), Kusum Verma, M.D., M.I.A.C., F.A.M.S. *Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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09/10/2000 NDR SENTINAL NODE BIOPSY Sentinel node biopsy is of use in non palpable metastasis but no proper trials are available for widespread use Studies with larger patient sample must be undertaken. Kalamen et al,WJS march 2007
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09/10/2000 NDR LYMPH NODAL DISSECTION MEDULLARY CARCINOMA THYROID Lymph node metastasis is common when tumor is >2 cm Aim is to prevent local recurrance and effect a biological cure Total thyroidectomy with central node dissection Neck lymph node block dissection whenever lymph nodes are involved Medullary Carcinoma as it has a high frequency of microscopic tumour spread and they cannot be ablated with I 131 Role of Modified Radical Neck dissection in Medullary Carcinoma Presence of palpable cervical nodes. Prophylactically when the lesion in thyroid is larger than 1.5 cm Mastery of surgery – NYHUS Principles and practices of surgery -SCHWARTZ
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09/10/2000 NDR LYMPH NODAL DISSECTION FOLLICULAR CARCINOMA THYROID Nodal metastasis is a significant prognostic factor. Recommend unilateral neck dissection for T3 and T4. Randomized controlled trials and case series report that prophylactic neck dissection is not mandatory. Clinically apparent nodes warrant neck nodal dissection Hurthle cell carcinomas- a variant of follicular Carcinoma has an aggressive course ,frequently metastasise to the nodes Need central nodal dissection as they cannot be ablated with I 131. Witte et al,World journal of surgery 2002 WJS 2002,EJS Onc 1999,ERC 2004
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09/10/2000 NDR LYMPH NODAL DISSECTION PAPILLARY CARCINOMA THYROID Neck nodal dissection is of much use in papillary Carcinoma than compared to follicular Carcinoma MANAGEMENT OF CLINICALLY NON PALPABLE NODES They are more invasive, involve recurrent laryngeal nerve, trachea or esophagus at an early stage. I 131 ablation after thyroidectomy without node dissection - 72% of nodes only are capable of concentrating. Complete resolution only in 68% of the above nodes MANAGEMENT OF CLINICALLY POSITIVE NECK Surgical removal is the preferred treatment I 131 ablation- if there is residual I 131 uptake Post operative External Beam Radiation – if there is no I 131 uptake. Surgery of thyroid and parathyroid – RANDOLPH Noguchi et al,1993
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09/10/2000 NDR TYPES OF NECK NODE DISSECTION Prophylactic Nodes which are normal pre or intraoperatively by palpation or imaging technique Therapeutic Clinically palpable nodes or nodes detected by imaging studies. Central Nodal dissection – Level VI Lateral nodal dissection – Level II to V Radical Modified radical or functional Extended Mediastinal dissection – Level VII
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09/10/2000 NDR Three types (medina 1989) commonly referred to not specifically named by committee TYPE I: PRESERVATION OF SPINAL ACCESSORY NERVE TYPE II: PRESERVATION OF SPINAL ACCESSORY NERVE AND INTERNAL JUGULAR VEIN TYPE III: PRESERVATION OF SPINAL ACCESSORY NERVE AND INTERNAL JUGULAR VEIN AND STRENOCLEDIOMASTOID (FUNCTIONAL NECK DISSECTION) MODIFIED RADICAL NECK DISSECTION MRND I MRND II MRND III
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09/10/2000 NDR APRON HALF APRON CONLEY DOUBLE Y H MACFEE MODIFIED SCHOBINGER SCHOBINGER INCISIONS
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09/10/2000 NDR FUNCTIONAL NECK DISSECTION Rationale : Reduce postsurgical shoulder pain and shoulder dysfunction. Improve cosmetic outcome. Removal of all fibrofatty tissue along IJV – level II to IV and V IJV,accessory nerve and Sternomastoid along with cervical sensory nerves Phrenic nerve along the scalenus anterior muscle are preserved unless they are invaded by the tumour
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09/10/2000 NDR FUNCTIONAL DISSECTION Dissection along the spinal accessory nerve is the most important as it is a frequent site of metastatic disease. Venous angle formed by subclavian and IJV – careful nodal dissection is a must since reoperation for recurrence at the site is very difficult. Lymph node often hide under IJV. Left side- thoracic duct must be carefully dealt with. Yasuhiro et al,WJS march 2007
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09/10/2000 NDR CENTRAL LYMPH NODE DISSECTION Involvement observed in 63 % of patients independently reflect a worse disease free survival Central compartment = the region bounded by the jugular veins, the hyoid bone ,and the sternal notch Removal of central nodes important in Medullary and Hurthle cell carcinoma Microscopic spread is high Do not take up I 131 and cannot be ablated In papillary carcinoma, removal of central nodes Decrease recurrence of PTC and likely improves the disease specific survival rate. There is a higher rate of permanent hypoparathyroidism Central nodal dissection is a must in patients especially >45 years, large tumour > 4 cm or locally invasive tumour Lundgren et al,Cancer 2006 Goteborg study,Berlin study,Oita study,multiple case series,WJS march 2007,1996,EJS 2000,Arch surg 1998
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09/10/2000 NDR MEDIASTINAL NODE DISSECTION Mediastinal node involvement is generally through pre and para tracheal and lateral cervical nodes. Contralateral nodal metastasis has been found to be usually associated with mediastinal metastasis(Sugenya et al). Mediastinal dissection For medullary CA with extra thyroid extension. For papillary Carcinoma,only if there is radiological evidence of spread(mackens et al). It requires median sternotomy and has complication like atelectasis, pneumonia and mediastinitis.
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09/10/2000 NDR LATERAL LYMPH NODE DISSECTION Tumour with lateral and mediastinal nodal spread are definitely considered more progressive. Therapeutic dissection must be carried out if the nodes are clinically palpable,as the patients will have recurrance and worse prognosis. Removal of LN’s anterior and posterolateral to the internal jugular vein from the mastoid to the subclavian vessels inferiorly and laterally to the spinal accessory nerve (level 2-5) Sparing the internal jugular vein, spinal accessory nerve and sternocleidomastoid muscle WJS march 2007
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09/10/2000 NDR PROPHYLACTIC NECK DISSECTION There is no consensus on the application of prophylactic dissection among the surgeons worldwide. Noguchi et al suggest prophylactic modified radical neck dissection as it improves the prognosis of patients with extrathyroid extension, females > 60 years. Mackens et al suggested dissection for tumour > 1 cm But many western researchers suggest wait and see policy for patients with no clinically apparent nodes. Patients with gross metastasis at initial surgery showed recurrence in lymph node in contralateral compartment Now prophylactic neck dissection is not performed for papillary microcarcinoma unless the tumour is classified as N1b WJS march 2007
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09/10/2000 NDR CONCLUSION Controversies reguarding sequential spread and skip lesions of lymphnode metastasis exist. Modified functional lymph node dissection is excellent for well differentiated thyroid carcinomas. Prophylactic lymphnode dissection is yet to find a place in the treatment modality. Sentinel lymphnode biopsy is yet to be streamlined as a treatment modality. In medullary carcinoma of the thyroid, a thorough and meticulous dissection is mandatory as recurrence rate is very high.
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09/10/2000 NDR FNAC OF THYROID
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09/10/2000 NDR FOLLICULAR CARCINOMAOF THYROID
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09/10/2000 NDR BONY METASTASIS
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09/10/2000 NDR SKULL METASTASES IN FOLLICULAR CARCINOMA
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09/10/2000 NDR Tc99 BONE SCAN
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09/10/2000 NDR THYROID BED AFTER TOTAL THYROIDECTOMY
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09/10/2000 NDR TRANSILLUMINATION
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09/10/2000 NDR MEDULLARY CARCINOMA - TOTAL THYROIDECTOMY WITH CENTRAL COMPARTMENT DISSECTION
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