Thyroid: Grave's disease, Thyroid nodules, thyroid storm, DTC, difficult Thyroid, thyroid surgery technologies facebook: happy Friday knight

1. Management of Graves’ Disease
and Thyroid Nodules
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3. Hyperthyroidism and Graves’ Disease

4. • Thyrotoxicosis: clinical state that results from
inappropriately high thyroid hormone action in
tissues generally due to inappropriately high
tissue thyroid hormone levels
• Hyperthyroidism: a form of thyrotoxicosis due
to inappropriately high synthesis and secretion
of thyroid hormone(s) by the thyroid

5. • Extra-thyroid sources of hormone: struma
ovarii, metastatic DTC, factitious
thyrotoxicosis
• Most common causes are Graves’ disease
(GD), toxic multinodular goiter (TMNG), and
toxic adenoma (TA)

6. Etiology

7. • A radioactive iodine uptake should be
performed when the clinical presentation of
thyrotoxicosis is not diagnostic of GD
• a thyroid scan should be added in the presence
of thyroid nodularity

8. Biochemical Evaluation
Condition T3 T4 TSH
Overt hyperthyroidism
Mild hyperthyroidism
Subclinical
hyperthyroidism

9. Treatment
• Symptomatic: beta blocker
• Specific
– I-131
– Antithyroid drugs
– surgery

10. Symptomatic Treatment

11. Graves’ Disease
• An autoimmune disorder
• Thyrotropin receptor antibodies (TRAbs)
stimulate TSH receptor  increasing thyroid
hormone production
• Clinical:
– symmetrical enlarged thyroid
– Recent onset of ophthalmopathy
– Moderate to severe hyperthyroidism

13. • Specific treatment
– I-131
– Antithyroid drugs
– Surgery: thyroidectomy
Graves’ Disease

14. I-131
• Favorable factors
– Females planning a pregnancy in the future (more
than 4-6 months)
– Ones that comorbidity increasing surgical risk
– Patients with previously operated or externally
irradiated neck
– Contraindicated to ATD use
– Lack of access to thyroid surgeon

15. I-131
• Contraindications
– Pregnancy and lactation
– Female planning a pregnancy in 4-6 moths
– Coexisting or suspicious thyroid cancer
– Individuals unable to comply with radiation safety
guidelines

16. I-131
• Preparation for I-131 therapy
– Beta blocker and methimazole are used for patients
with high risk for worsening hyperthyroidism (FT4
2-3 time upper normal limit
– For MMI:
• Discontinue 3 -5 days before I-131 administration
• Restarted 3 – 7 days later
• Taper over 4-6 weeks as thyroid function normalized

17. I-131
• Administration
– A single dose 10-15 mCi
– Obtain pregnancy test within 48 hrs

18. I-131
• Follow up
– Within 1 month with T3, T4
• If still thyrotoxic, monitor q4-6weeks
• If euthyroidism, monitor q1year
– When hyperthyroidism persists after 6 months
following therapy, retreatment with I-131 is
suggested

19. Antithyroid drugs
• Favorable factors
– High likelihood of remission (female, mild disease,
small goiters, low titer TRAb)
– Elderly
– Patients with high surgical risk
– Unable to follow safety guidelines
– Previously operated or irradiated neck
– Moderate to severe active Graves’ ophthalmopathy

20. Antithyroid drugs
• Contraindications
– Previous known major adverse reaction to ATDs
– PTU: liver failure, hypersensitivity,
agranulocytosis

21. Antithyroid drugs
• Initiation
– ATDs do not cure Graves’ hyperthyroidism
– MMI > PTU except 1st trimester pregnancy
– Before initiating, CBC and LFT should be
obtained

22. Antithyroid drugs
• Propylthiouracil (PTU):
– 50-150 mg tid
• Methimazole (MMI):
– Single daily dose
– Start with higher dose of 10-20 mg until euthyroid,
then titrate to 5 mg

23. Antithyroid drugs
• Monitoring
– FT4 is obtained 4 weeks after initiation
– When FT4 is normalized, T3 may be monitored
– CBC should be obtained during febrile illness,
routine monitoring is not recommended
– LFT should be obtained when pruritic rash,
jaundice, light-colored stool, dark urine, joint pain,
abdominal pain, anorexia, nausea, or fatigue

24. Antithyroid drugs
• Management of allergic reactions
– Minor cutaneous reaction  antihistamine without
cessation
– Persistent reaction  cessation and switching to
other ATDs, radioactive iodine, or surgery
– Serious reaction  switching ATDs not
recommended

25. Antithyroid drugs
• Duration
– MMI  12-18 months with tapering and
monitoring TSH until normal
– Monitor TRAb level
– If hyperthyroid after 18 months  take it longer,
radioactive iodine, surgery
– Remission = normal TSH, FT4, T3 after 1 year of
discontinuation

26. Surgery
• Favorable factors:
– Symptomatic compression
– Large goiter (>80g)
– Thyroid malignancy is suspected
– High TRAbs
– Moderate to severe active GO

27. Surgery
• Contraindication
– Serious comorbidity
– Pregnancy

28. Surgery
• Preparation
– Euthyroid before surgery
– Urgent: beta blocker and KI
– KI: lugol solution (100mg/ml) 50 – 100 mg po tid
x 10days

29. Surgery
• Near-total or total thyroidectomy is a
procedure of choice
– Nearly 0% recurrence
– Complications: hypocalcemia, recurrent or
superior laryngeal nerve injury, bleeding
• Refer to high-volume thyroid surgeon

30. Surgery
• Postoperative care
– Serum calcium or intact parathyroid hormone
levels
– As a result, calcium and calcitriol supplement can
be given
– Persistent hypocalcemia  measure serum
magnesium level

31. Surgery
• Postoperative care:
– Prophylaxis: CaCO3 1250-2500mg qid, tapering
500 mg q2days
– Calcitriol 0.5 mcg daily, continue for 1-2 weeks
– Elthroxin: daily dose 1.7 mcg/kg and serum TSH
measured 6-8 weeks

32. Thyroid Storm

33. Definition
• Thyrotoxicosis with any evidence of systemic
decompensation
• Life-threatening exacerbation of thyrotoxicosis
• Typically associated with Graves’ Disease
• High mortality rate if not immediately
recognized and treated aggressively

35. • Precipitants:
– Abrupt cessation of antithyroid drugs
– Surgery under unrecognized or inadequately
treated thyrotoxicosis
– Acute illness
– Rarely, following radioactive iodine therapy

36. Treatment
• Beta-adrenergic blockade
• Antithyroid drug therapy
• Inorganic iodide
• Corticosteroid therapy
• Volume resuscitation
• Aggressive cooling with
paracetamol and cooling
blankets
• Respiratory support
• Monitoring in an ICU

38. • PTU (50) 10 tabs po stat, then 5 tabs po q4hr
• Methimazole (5) 12 tabs po, RS
• Propranolol (40) 2 tabs po q4hr, titrate with
HR
• Lugol solution 250 mg po q6hr after starting
ATD 1 hr x 5-7 days
• Hydrocortisone 300 mg IV stat, then 100 mg
IV q8hr x 3 days

39. Prevention
• Euthyroid before surgery
• In urgent surgery, iodide, beta blocker, and
corticosteroid should be given
• Iodide
– Lugol solution: 50-100 mg po tid 10 days before
surgery
• Propanolol 40 mg po q8hr for 5 days
• Betamethasone 0.5 mg po q6hr for 5 days

40. Management of Adult Patients with
Thyroid Nodules

42. • The importance of thyroid nodule is to exclude
thyroid cancer (7-15% of cases)
• Non-palpable nodules detected on imaging is
called incidentaloma
• Nodules > 1cm should be evaluated
• Nodules with symptoms or lymphadenopathy
should also be evaluated despite of size < 1cm

43. Investigation
• TSH
• Thyroid sonography
• FNA

44. TSH
• If subnormal, a radionuclide thyroid scan
should be performed
• If normal or elevated, not perform

45. Thyroid sonography
• Look at thyroid and cervical lymph node
• Report:
– Size in 3 dimensions
– Location
– Sonographic feature:
• Composition calcification
• Echogenicity shape if taller than wide
• Margins vascularity

46. FNA
• Most accurate and cost-effective method
• US-guided FNA is preferred

48. 1
2
3

51. high suspicion > 70-90%

52. Intermediate suspicion 10-20%

53. Low suspicion 5 – 10%

54. Very low suspicion <3%

55. Benign < 1%

58. Cytology
• Nondiagnostic: repeat FNA with US guidance
• Repeatedly nondiagnostic: close observation or
surgical excision
• Benign: no treatment (follow up)
• Malignancy: surgery (Bethesda – near total
thyroidectomy)

59. Cytology
• Indeterminate (AUS/FLUS, FN, SUSP):
– Molecular marker may be considered
– BRAF, RAS, RET/PTC, PAX8/PPAR-gamma

60. Cytology
– Total thyroidectomy when
• Cytologically suspicious for malignancy
• Known mutation specific for carcinoma
• Sonographically suspicious
• Large > 4cm
• Familial thyroid caricoma
• History of radiation exposure
• Following lobectomy which is malignant
• Bilateral nodular disease

61. Cytology
• AUS/FLUS
– If FNA and molecular marker not performed,
surveillance or surgical excision (thyroid lobectomy)
may be performed
• FN:
– Surgical excision (Bethesda-lobectomy)
• Choices: lobectomy, near-total and total
thyroidectomy

62. Cytology
• Suspicious for malignancy cytology
– Same as malignancy cytology
– Bethesda – lobectomy or near-total thyroidectomy

63. Cytology
• Multiple thyroid nodules ≥ 1 cm  same as
solitary thyroid nodule
• Low TSH with multiple nodules 
radionuclide thyroid scan to determine
functionality  FNA in nodule ≥ 1cm with
isofunctioning or nonfunctioning

64. Follow-up
• Follow-up of nodules with benign cytology
– High suspicious: repeat US-guide FNA within 12
months
– Low to intermediate suspicion: repeat US within
12-24 months  20% increased 2 nodules
dimension with a minimal increase of 2 mm or
more than 50% change in volume or new
suspicious one  FNA

65. Follow-up
• Follow-up of nodules with benign cytology
– Very low suspicious: repeat US ≥ 24 months
– Two benign FNA cytology results: US surveillance
no longer indicated

66. Follow-up
• For nodules that do not meet FNA criteria
– High suspicion: repeat US in 6-12 months
– Low to intermediate: repeat US in 12-24 months
– Nodules > 1cm with very low suspicion and pure
cyst: repeat US ≥ 24 months
– Nodules ≤ 1cm with very low suspicion and pure
cyst: no follow up

67. Role of Therapy for Benign Nodules
• Routine TSH suppression in iodine sufficient
populations is not recommended
• If inadequate dietary intake, a daily
supplement 150 mcg of iodine is
recommended

68. Role of Therapy for Benign Nodules
• Surgery may be considered in growing nodules
if symptomatic (compressive or structural
symptoms)
• If asymptomatic: no surgery
• No data to guide recommendation on thyroid
hormone therapy

69. Thyroid Storm

71. Definition
• Thyrotoxicosis with any evidence of systemic
decompensation
• Life-threatening exacerbation of thyrotoxicosis
• Typically associated with Graves’ Disease
• High mortality rate if not immediately
recognized and treated aggressively

73. • Precipitants:
– Abrupt cessation of antithyroid drugs
– Surgery under unrecognized or inadequately
treated thyrotoxicosis
– Acute illness
– Rarely, following radioactive iodine therapy

74. Treatment
• Beta-adrenergic blockade
• Antithyroid drug therapy
• Inorganic iodide
• Corticosteroid therapy
• Volume resuscitation
• Aggressive cooling with
paracetamol and cooling
blankets
• Respiratory support
• Monitoring in an ICU

76. • PTU (50) 10 tabs po stat, then 5 tabs po q4hr
• Methimazole (5) 12 tabs po, RS
• Propranolol (40) 2 tabs po q4hr, titrate with
HR
• Lugol solution (1 drop = 10 mg) 25 drops po
q6hr after starting ATD 1 hr x 5-7 days
• SSKI (1 drop = 50 mg) 5 drops po q6r after
starting ATD 1 hr x 5-7 days
• Hydrocortisone 300 mg IV stat, then 100 mg
IV q8hr x 3 days

77. Prevention
• Euthyroid before surgery
• In urgent surgery, iodide, beta blocker, and
corticosteroid should be given
• Iodide
– Lugol solution: 4 – 6 drops po tid
– SSKI: 1 – 2 drops po tid 10 days before surgery
• Propanolol 40 mg po q8hr for 5 days
• Betamethasone 0.5 mg po q6hr for 5 days

78. References
Bahn et al (Chair). Hyperthyroidism and Other Causes of
Thyrotoxicosis: Management Guidelines of the American Thyroid
Association and American Association of Clinical Endocrinologists.
Thyroid. Vol 21, No. 6, (2011): p.593-646.
A Baeza A, Aguayo J, Barria M, Pineda G 1991 Rapid preoperative
preparation in hyperthyroidism. Clin Endocrinol (Oxf ) 35:439–442.
วิทยา ศรีดามา บรรณาธิการ. Clinical Practice Guideline 2010 เล่มที่ 1. กรุงเทพฯ: โรง
พิมพ์แห่งจุฬาลงกรณ์มหาวิทยาลัย, 2553

79. Thyroid:
Update in Thyroid Cancer,
Alternative Approach in Thyroid Surgery,
and Difficult Thyroid
Facebook: Happy Friday Knight
8th April 2016
Thailand

80. Update in
Management of Thyroid Cancer

81. Goal of Treatment
• Remove all of the primary tumor
• Minimize recurrence risk
• Facilitate postoperative treatment with RAI
• Permit accurate staging and risk stratification
• Permit accurate long term surveillance for
disease recurrence
• Minimize treatment-related mortality

83. 1
2
3

84. Investigations after Diagnosis DTC
• Preoperative neck ultrasound
• FNA of suspicious LN and Tg needle washout
• CT and MRI
• Vocal cord assessment

85. Preoperative Neck Ultrasound
• DTC, especially PTC involves cervical LN
metastases in 20-50%
• Micrometastasis (< 2mm) may approach 90%
• Sonographic features of pathological LN:
– Enlargement (≥8-10mm) - cystic change
– Loss of fatty hilum - calcification
– Round shape - peripheral vascularity
– hyperechogenicity

86. FNA of LN and FNA-Tg washout
• FNA thyroglobulin washout = thyroglobulin
concentration in washout fluid from fine-
needle aspiration (FNA)
– Suggestive cut-off Tg: 32 ng/ml
• May be helpful in
– Cystic node
– Inadequate cytology
– Discordance of cytology and imaging
Pak et al. Endocrine. 2015; 49: 70-77.

87. Neck Imaging: CT and MRI
• Appropriate in locally invasive DTC as adjunct
– Progressive dysphagia
– Respiratory compromise
– Hemoptysis
– Rapid tumor enlargement
– Significant voice change or finding of vocal cord
paralysis
– Mass fixation to airway or neck structures
– Substernal extension

88. Preoperative CT
• Can perform with iodine IV contrast because it
is generally cleared in 4-8 weeks

89. Vocal Cord Assessment
• Symptoms: hoarseness
• Re-do for completion thyroidectomy
• Posterior extrathyroidal extension or extensive
central node metastases

90. Operative Approach
• Near-total and total thyroidectomy with gross
removal of primary tumor
– Clinical T4 (thyroid cancer > 4cm or gross
extrathyroidal extension)
– Clinical N1 (clinically node metastasis)
– Clinical M1 (distant metastasis)
– May choose total thyroidectomy to
• Enable RAI
• Enhance follow up
• Patient preference

91. Operative Approach
• Lobectomy alone
– Thyroid cancer < 1cm
– Without extrathyroidal extension
– Clinical N0
– No prior head and neck radiation
– No familial thyroid cancer

92. Operative Approach
• Near-total and total thyroidectomy VS
lobectomy
– Thyroid cancer > 1cm and < 4cm
– Without extrathyroidal extension
– Clinical N0
– Lobectomy may be sufficient for low-risk PTC and
FTC

93. Active Surveillance
• Very low risk tumor
• High surgical risk due to comorbid conditions
• Relatively short life span
• Concurrent medical or surgical issues that need
to be addressed prior to thyroid surgery

94. Lymph Node Management
• Therapeutic central-compartment neck
dissection: clinically involved central nodes
• Therapeutic lateral-compartment neck
dissection: biopsy-proven metastatic LNpathy
• Prophylactic central-compartment neck
dissection: PTC + cN0 + T3/T4 or cN1b
• Thyroidectomy without prophylactic neck
dissection: T1/T2, noninvasive, cN0 PTC,
most FTC

96. Postoperative Staging
• AJCC/UICC staging is recommended for all
patients with DTC
• Provide prognostic information

99. Risk Stratification

101. BRAF mutation
• Point mutation
• 40-45% of PTC
• 30% of poorly differentiated CA and ATC
• Increased disease-specific mortality, higher
risk of recurrence

102. Postoperative Tg & anti TgAb
• Preoperative serum Tg and anti TgAb are not
recommended to measure
• Postoperative benefit:
– Assess persistent disease
– Assess the thyroid remnant
– Predict potential future disease recurrence
• Reach the nadir in 3 – 4 weeks post-op

103. Role of Postoperative Diagnostic Scanning
• Including with I131 diagnostic imaging,
SPECT-CT, RAI uptake measurement
• Benefit
– Identify thyroid remnant
– Detect distant metastasis

104. Role of RAI Ablation
After total thyroidectomy:
• Should be considered =>ATA intermediate risk
• Routinely recommended =>ATA high risk
• Not recommended =>
– ATA low risk
– Unifocal papillary microcarcinoma without other
adverse features
– Multifocal papillary microcarcinoma without other
adverse features

105. Time to Perform RAI Ablation,
• After total thyroidectomy and LT4 withdrawal
for 3-4 weeks
• TSH > 30 mIU/L
• rhTSH in patients that may preclude thyroid
hormone withdrawal:
– Comorbidities
– Inability to raise endogenous TSH

106. Posttherapy Whole Body Scan
• Is recommended after RAI remnant ablation or
treatment, to inform disease staging and
document the RAI avidity of any structural
disease

107. Role of TSH Initial Suppression
• LT4
• ATA high risk: < 0.1 mU/L
• ATA intermediate risk: 0.1 – 0.5 mU/L
• ATA low risk:
– With undetectable serum Tg: 0.5 – 2 mU/L
– With low-lever serum Tg: 0.1 – 0.5 mU/L
– Undergone lobectomy: 0.5 – 2 mU/L

109. Alternative Approach in
Thyroid Surgery

110. • Open through Kocher incision
• Endoscopic thyroid surgery

111. Classification of
Endoscopic Thyroid Surgery
• Approach
– Direct midline
– Regional
– Remote
– Transmucosal
• Maintainance of Working Space
– Gasless
– Insufflation
• Instrumental
– Manual
– robotic

112. Swanstrom LL and Sopher NJ. Mastery of endoscopic and laparoscopic surgery. 4th
ed. Philadelphia: LIPPINCOTT WlLLIAMS & WILKINS, a WOLTERS KLUWER
business, 2014

113. Swanstrom LL and Sopher NJ. Mastery of endoscopic and laparoscopic surgery. 4th
ed. Philadelphia: LIPPINCOTT WlLLIAMS & WILKINS, a WOLTERS KLUWER
business, 2014

114. Swanstrom LL and Sopher NJ. Mastery of endoscopic and laparoscopic surgery. 4th
ed. Philadelphia: LIPPINCOTT WlLLIAMS & WILKINS, a WOLTERS KLUWER
business, 2014

115. Clark JH, Kim HY, Richmon JD. Transoral robotic thyroid surgery. Gland
Surg. 2015 Oct;4(5):429-34.

116. Clark JH, Kim HY, Richmon JD. Transoral robotic thyroid surgery. Gland
Surg. 2015 Oct;4(5):429-34.

117. Clark JH, Kim HY, Richmon JD. Transoral robotic thyroid surgery. Gland
Surg. 2015 Oct;4(5):429-34.

118. Difficult Thyroid

119. Concern of Thyroid Surgeons
• Avoid unnecessary surgery
• Avoid intraoperative unexpected conditions
• Safe and low morbidity and mortality

120. • Difficult in diagnosis
• Difficult in management
• Difficult in surgery

121. Diificult in Diagnosis
• Rapidly growing thyroid mass
• Equivocal hyperthyroidism

122. Rapidly Growing Thyroid Mass
• Anaplastic thyroid carcinoma
• Hurthle cell carcinoma
• DTC
• Lymphoma
• Bleeding thyroid adenoma
• Bleeding nodular goiter
• Soft tissue tumor, fibromatosis, sarcoma
• Non-thyroidal mass: hemangioma or
lymphangioma

123. • Clinical picture is the most important clue
• FNA is not accurate
• May need fast and accurate diagnosis
• Probably need incision biopsy under GA with
frozen section
Rapidly Growing Thyroid Mass

124. Equivocal Hyperthyroidism
• Graves’ disease with nodules
• Thyroiditis
• Toxic multinodular goiter
• Different in treatment planning
– Surgery or not
– Extent of surgery

125. • Therapeutic diagnosis
• Thyroid scan and FNA may not help to
diagnose
• Not an urgent condition that indicate surgery
Equivocal Hyperthyroidism

126. Difficult in Management
• Uncontrolled hyperthyroidism
– Try step up ATD + beta blocker
– Lugol’s solution
– plasmapheresis

127. Difficult in Surgery
• Completion thyroidectomy, recurrent disease
• Organ invasion
• Non recurrent laryngeal nerve
• Substernal extension

128. Reoperation
• Problems:
– Scar
– Anatomical distortion
• Management:
– Preoperative evaluation
– Sharp dissection
– meticulous

129. Organ Invasion
• Management:
– Preoperative evaluation of other organs
involvement and resectability
– Need imaging
– Example: laryngeal and vascular involvement

130. Substernal Extension
• Sternotomy?

131. References
Swanstrom LL and Sopher NJ. Mastery of endoscopic and laparoscopic
surgery. 4th ed. Philadelphia: LIPPINCOTT WlLLIAMS & WILKINS,
a WOLTERS KLUWER business, 2014
Haugen BR et al. 2015 American thyroid association management
guidelines for adult patients with thyroid nodules and differentiated
thyroid cancer. Thyroid. 2015: 26(1); 28-92.
พุทธิพร เย็นบุตร. Update in management of thyroid cancer. April 2, 2016
ธัญวัจน์ ศาสนเกียรติกุล. Alternative approach in thyroid surgery. April 2, 2016
อดุลย์ รัตนวิจิตราศิลป์ . Difficult thyroid. April 2, 2016