Transcript Slide 1

Lidia Ionescu
III rd. Surgical Unit
UMF “G.T.Popa” Iasi
Surgery of the thyroid gland
 Mortality- mid 19th century > 40%
 Theodor Billroth (1829-1894)
 Emil Theodor Kocher (1841-1917) MR<1%
 Safe and efficient surgery:
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General anesthesia
Rules of asepsia and antisepsia
Improved hemostasis
Surgery
 The main indications for surgery in thyroid nodules
are fear of malignancy, compression symptoms, and
cosmetic reasons
 Rising incidence of thyroid cancer in the areas affected
by the Chernobyl nuclear accident.
 The incidence of thyroid cancer, especially in the
pediatric age group, has increased by 12- to 34-fold in
regions of Belarus and Ukraine.
Etude rétrospectif
1990 – 2005 (Clinique III Chirurgie) : 125 cas de cancer thyroïdien
différencié non médullaire
74,4 % des affections malignes thyroïdiennes
Clinical assessment
of the thyroid nodules
 Majority of the nodules- benign
 10%-15% of solitary nodules are malignant, depending
on the selectivity for surgical procedures.
 Characteristics of suspected malignancy:
 - PMH of external irradiation
 - Age>40
 - Increasing size of an old nodule
 - Cervical lymphadenopathy
 - Signs of local invasion:
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Vocal cord paresis
Dysphagia
Dispnea
Clinical assessment
- Hard nodules: 2-3 times higher index of suspicion
- Hard nodule with fixity to the adjacent organs (muscle,
trachea, skin)
- Previous history of thyroid cancer
- Nodule that is "cold" on scan – 5% malignant
- Solid or complex on an ultrasound
Dominant nodule within MNG- malignancy< 5%
Features for Benign Thyroid Nodule
 Symptoms of hyperthyroidism or hypothyroidism
 Pain or tenderness associated with a nodule
 A soft, smooth, mobile nodule
 Multi-nodular goiter without a predominant
nodule
 "Warm" nodule on thyroid scan
 Simple cyst on an ultrasound
Investigations
FNAC- elective method with high sensitivity and
specificity, safe, inexpensive.
Limits:
 False positive 1%
 False negative 5%
 Suspicious 11%-20% - majority folicular cell neoplasm-
(25%) malignancy proven on histology due to capsular
and vascular invasion - follicular or Hurthle cell cancer
 Unsure method for pts. with external irradiation and
familial cancer due to multicentricity
FNAC- thyroid cyst
 Lobectomy when:
 Persistent cyst after three aspirations
 Size > 4 cm.
 Complex cyst (solid and cystic components)-15%
malignancy
Surgical treatment
FNAC-benign nodul- no surgery – observation or
surgery for cosmetic/ symptomatic complaints
Increasing size- repeat FNAC, USS for size - thyroxine
for TSH supression - 50% of nodules will decrease in
size but long-term treatment, potentially increasing
the risk of osteoporosis.
Increasing size in spite of treatment- lobectomy
Exception- total thyroidectomy in pts. with PMH of
external irradiation
Prognostic factors
 AGES score- evaluates the death risk in papillary
carcinoma
 A - age, G - grading, E - extension, S - size
 MACIS score
 M - Mts, A - age, C - completeness of surgery,
I - extrathyroid invasion of the tumour, S - size
AMES system
 Characteristic
 Age
 Metastases
 Extent
 Size
Low risk
High risk
<45 years of age >45 years
No distant disease Distant disease
No ET extension ET extension
< 5 cm
> 5 cm
AJCC stage for papillary and follicular thyroid
cancer
 Stage Age < 45
 I T1-4, N1-2, M0
 II T1-4, N1-2, M1
Age ≥ 45
I T1, N0, M0
II T2-3, N0, M0
III T4, N0, M0
T1-4, N1, M0
IV T1-4, N1-2, M1
Prognostic factors
Mortality at 25 years - low risc- 2%
- high risk-50%
Corrélation survie – age (seuil 45 ans)
La survie est significativement plus réduite chez les patients de plus de
45 ans
p = 0,01
Corrélation survie – stadeT (seuil de 4 cm)
T > 4 cm = facteur majeur de pronostic négatif
p = .000
Corrélation survie – extension extra capsulaire
La présence de l’extension extra capsulaire est un facteur important de
pronostic négatif
p = .000
Corrélation survie – métastases
La régression multi variée selon Cox pour le risque relatif montre que :
- la présence des métastases hématogènes  RR = 333,3
- l’extension extra capsulaire  RR = 12,54
- la multicentricité  RR = 6,36
SONT DES FACTEURS DE PRONOSTIC AVEC
SIGNIFICATION INDEPENDENTE
Surgical treatment
Papillary carcinoma
 Most frequent malignancy- 80%
 PMH- external irradiation
 Female/men ratio= 2/1
 Mean age at presentation 30-40 years
 Hard, whitish, flate nodule on section
 FNAC- high sensitive and specific
 Scintigraphy- not necessary
 CT/MRI- in pts. with local extension and
lymphadenopathy
Surgical treatment
Papillary carcinoma
Low risk patients- thyroid lobectomy RR: 4% -26%
High risk patients- total thyroidectomy
Total thyroidectomy + elective lymphadenectomy is
advisable:
- multicentricity- 85%
- low recurrence rate
- high sensitivity of Tg in predicting recurrences
(after TT - Tg should stay < 3ng/ml)
Accepted morbidity in TT- 1%
Classification of Neck Dissections
 Radical Neck Dissection (RND) - removal of all ipsilateral cervical lymph
node groups, together with SAN, SCM and IJV.
 Modified Radical Neck Dissection (MRND) - removal of all lymph node
groups routinely removed in a RND, but with preservation of one or more
nonlymphatic structures (SAN, SCM and IJV).
 Selective Neck Dissection (SND) Thus for oral cavity cancers, SND (I-III) is
commonly performed. For oropharyngeal, hypopharyngeal and laryngeal
cancers, SND (II-IV) is the procedure of choice.
 Extended Neck Dissection - This refers to removal of one or more additional
lymph node groups or nonlymphatic structures, or both, not encompassed by
the RND.
Generalized rationale for sentinel node mapping
 Sentinel lymph node biopsy (SLNB) was initially developed
as a minimally invasive surgical alternative to routine
(elective) complete lymphadenectomy.
 Primary reasons for sentinel node biopsy:
 - to minimize the morbidity of lymph node dissection
 - to make different the surgical procedure
 - to improve the accuracy of the nodal assessment.
The sentinel node is commonly
defined as the initial lymph node
to which the primary tumor drains
TECHNICAL OVERVIEW OF SENTINEL
NODE MAPPING
 The basic technique of sentinel node identification involves the injection of a
tracer that identifies the lymphatic drainage pathway from a primary tumor.
 Tracers: usually isosulfan blue or methylene blue, radioisotopes such Tc-
preoperative lymphoscintigraphy and intraoperative localization with a
gamma probe.
 Briefly, an appropriate amount of tracer is injected in locations that will mimic
the lymphatic drainage pattern of the tumor.
 A limited dissection is made to identify the blue node and/or the most
radioactive node.
SNB –Thyroid carcinoma
 Limiting lymphatic dissection when the SLN is not involved could also
potentially limit the morbidity of hypoparathyroidism and recurrent
laryngeal nerve injury that has been reported with lymphatic resection.
 If no metastases are identified within the SLN, no further lymphatic
dissection is performed,
 If the SLN contains metastases, the regional nodal basin is removed.
Follicular carcinoma
Incidence 10% of all thyroid cancers
Female/male ratio: 3/1
Age > 50
Solitary nodule - 90%
Vascular invasion
Distant metastases
Lymphadenopathy in 10% of cases and in advanced
stages
Two types: minimal invasion and frank invasion
Surgical treatment
Follicular carcinoma
Minimal invasion- lobectomy
Frank invasion- total thyroidectomy
Prophylactic lymphadenevtomy unnecessary
Elective lymphadenectomy in rare cases of nodal
involvement
Mortality at 10 years- 15%
Mortality at 20 years- 30%
Bad prognostic factors: age>45, low grading, size>4
cm, extrathyroid invasion, distant Mts.
Surgical treatment
Medullary carcinoma
5% incidence
Middle and superior gland location
Unilateral in 75% of cases
Familial cases, 90% multicentricity
Initial stages- lymphatic invasion
Advanced stages- local invasion and distant
metastases
Treatment- total thyroidectomy with bilateral
modified radical neck dissection
CEA and calcitonin- tumour markers
Anaplastic carcinoma
 Aggressive tumour
 6 months survival after diagnosis
 Female/male ratio: 1,5/1
 Age> 60 years
 Origine from differentiated cancers
 Rapid growth, rapid invasion
 Cervical lymph nodes involved
 Surgical treatment combined with RxT+ChT can give
12% survival at 2 years
Memorial Sloan-Kettering Cancer Center
The decisions regarding the extent of thyroidectomy
and postoperative adjuvant therapy
 Should be individualized based on:
 - the clinical characteristics of the thyroid
tumor,
 - on gross intraoperative findings
 - the risk group analysis.
When the opposite lobe is absolutely normal, is
there any need for doing a total thyroidectomy
on a routine basis?
The major arguments proposed for a total thyroidectomy
include:
 the presence of microscopic disease in the opposite lobe
 the need for RAI follow-up,
 the use of thyroglobulin as a tumor marker, which can be
used only after the total thyroidectomy
 the hypothetical small risk of anaplastic transformation.
Based on these arguments, various authors have advocated
routine use of total thyroidectomy in a patient presenting
with well-differentiated thyroid cancer.
Total thyroidectomy – absolute indication
- grossly abnormal opposite lobe,
- large primary tumor with major extracapsular
extension,
- massive nodal disease,
- elderly individual with bulky tumor.
Pathologie thyroïdienne associée
( 48 % des cas )
Clinical problem - follicular adenoma on frozen
section, and follicular carcinoma on permanent
section
 Many authors routinely advocate completion thyroidectomy.
 It should be appreciated that these patients generally fall into the low-risk
group with excellent long-term survival.
 Consider prognostic factors
Formes anatomo-cliniques
TRAITEMENT CHIRURGICAL
Type de thyroïdectomie
90 % - exérèses thyroïdiennes complètes
Totalisations - 13 % des cas
CON CLUSION S
Point de vue du chirurgien – dans les conditions actuelles
* La chirurgie est le seul traitement curatif - TT + 131I + suppression du TSH = traitement standard pour les patients avec le
cancer thyroidien differencie
- totalisation la plus précoce + 131 I pour les « surprises » histologiques
* Lymphadénectomie élective du compartiment central/latéral – pour des
adénopathies macroscopiques – documentation histopathologique
* Surveillance endocrinologique à long terme pour le diagnostic précoce des
récidives loco-régionales ou des métastases hématogènes