Surgical Thyroid Disease

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

Surgical Thyroid Disease Anatomical abnormality : goitre / nodule Functional abnormality : over /under active Both : toxic nodule graves with big goitre

Common presenting symptoms Lump in neck Feeling of pressure Feeling of discomfort Feeling of choking Feeling of having to ‘double swallow’ Don’t like the appearance and want to know what it is

Lump in neck Examination – Lymph node – Thyroid – Other

Suggested pathway for lymph node in neck: present for 3-6/52, >2cm 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

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 ?

Discrete palpable nodule FNA – Cyst : if resolves : discharge – Solid : Benign ; asymptomatic and <4cm : review symptomatic, >4cm or clinical anxiety : lobectomy – Solid : Follicular ; Lobectomy

Discrete palpable nodule FNA Solid : Suspicious : lobectomy Solid : likely Malignant thyroidectomy

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)

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

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

Thyroid cancer 8-10 cases per year in Swindon <1% 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

RAI Treatment protocol and FU After surgery pt on T3; stop 10/7 before admission (ideally TSH >30mU/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 (<0.5mU/l) 3 months later ; stop T3 for 10/7 Iodine uptake scan 150Mbq 131I

RAI Treatment protocol and FU If no uptake or <0.05% and thyroglobulin undetectable start T4 (150 – 200 microg /day If uptake >0.25% ; residual thyroid tissue/disease further therapeutic/ ablative dose of 131I and repeat uptake scanning process

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