Surgical Thyroid Disease

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Surgical Thyroid Disease
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Surgical Thyroid disease

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

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Surgical Thyroid Disease

• Anatomical abnormality goitre / nodule
• Functional abnormality over /under active
• Both toxic nodule
• graves with big goitre

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Common presenting symptoms

• Lump in neck
• Feeling of pressure
• Feeling of discomfort
• Feeling of choking
• Feeling of having to double swallow
• Dont like the appearance and want to know what
  it is

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Lump in neck

• Examination
• Lymph node
• Thyroid
• Other

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Suggested pathway for lymph node in neckpresent
for 3-6/52, gt2cm 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

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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 ?

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Discrete palpable nodule

• FNA
• Cyst if resolves discharge
• Solid Benign
• asymptomatic and lt4cm review
• symptomatic, gt4cm or clinical anxiety
  lobectomy
• Solid Follicular
• Lobectomy

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Discrete palpable nodule

• FNA
• Solid Suspicious
• lobectomy
• Solid likely Malignant
• thyroidectomy

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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)

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Thyroid Surgery

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

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Thyroid Surgery

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

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Thyroid cancer

• 8-10 cases per year in Swindon
• lt1 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

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RAI Treatment protocol and FU

• After surgery pt on T3 stop 10/7 before
  admission (ideally TSH gt30mU/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 (lt0.5mU/l)
• 3 months later stop T3 for 10/7
• Iodine uptake scan 150Mbq 131I

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RAI Treatment protocol and FU

• If no uptake or lt0.05 and thyroglobulin
  undetectable start T4 (150 200 microg /day
• If uptake gt0.25 residual thyroid
  tissue/disease further therapeutic/ ablative dose
  of 131I and repeat uptake scanning process

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Summary

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