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SURGICAL TREATMENT THYROID NODULES

SURGICAL TREATMENT THYROID NODULES

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SURGICAL TREATMENT THYROID NODULES

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  1. SURGICAL TREATMENTTHYROID NODULES Lidia Ionescu III rd. Surgical Unit UMF “G.T.Popa” Iasi

  2. 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: • General anesthesia • Rules of asepsia and antisepsia • Improved hemostasis

  3. 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.

  4. Etude rétrospectif 1990 – 2005 (Clinique III Chirurgie) : 125 cas de cancer thyroïdien différencié non médullaire 74,4 % des affections malignes thyroïdiennes

  5. 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: • Vocal cord paresis • Dysphagia • Dispnea

  6. 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%

  7. 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

  8. 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

  9. FNAC- thyroid cyst • Lobectomy when: • Persistent cyst after three aspirations • Size > 4 cm. • Complex cyst (solid and cystic components)-15% malignancy

  10. 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

  11. 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

  12. AMES system • Characteristic Low risk High risk • Age <45 years of age >45 years • Metastases No distant disease Distant disease • Extent No ET extension ET extension • Size < 5 cm > 5 cm

  13. AJCC stage for papillary and follicular thyroid cancer • Stage Age < 45 Age ≥ 45 • I T1-4, N1-2, M0 I T1, N0, M0 • II T1-4, N1-2, M1 II T2-3, N0, M0 III T4, N0, M0 T1-4, N1, M0 IV T1-4, N1-2, M1

  14. Prognostic factors Mortality at 25 years - low risc- 2% - high risk-50%

  15. Corrélation survie – age (seuil 45 ans) La survie est significativement plus réduite chez les patients de plus de 45 ans p = 0,01

  16. Corrélation survie – stadeT (seuil de 4 cm) T > 4 cm = facteur majeur de pronostic négatif p = .000

  17. Corrélation survie – extension extra capsulaire La présence de l’extension extra capsulaire est un facteur important de pronostic négatif p = .000

  18. Corrélation survie – métastases

  19. 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

  20. 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

  21. Surgical treatmentPapillary 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%

  22. 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.

  23. 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.

  24. The sentinel node is commonly defined as the initial lymph node to which the primary tumor drains

  25. TECHNICAL OVERVIEW OF SENTINELNODE 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.

  26. 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.

  27. 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

  28. Surgical treatmentFollicular 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.

  29. Surgical treatmentMedullary 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

  30. 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

  31. 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.

  32. 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.

  33. Total thyroidectomy – absolute indication - grossly abnormal opposite lobe, - large primary tumor with major extracapsular extension, - massive nodal disease, - elderly individual with bulky tumor.

  34. Pathologie thyroïdienne associée ( 48 % des cas )

  35. 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

  36. Formes anatomo-cliniques

  37. TRAITEMENT CHIRURGICAL Type de thyroïdectomie 90 % - exérèses thyroïdiennes complètes Totalisations - 13 % des cas

  38. C O N C L U S I O N SPoint de vue du chirurgien – dans les conditions actuelles* La chirurgie est le seul traitement curatif - - TT + 131I + suppression du TSH = traitement standardpour 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