1. Surgical management of benign thyroid disorders
Nidal Younes MD
Professor of Endocrine Surgery and Diabetic Foot Consultant- Jordan University Hospital

2. Albucasis ابو القاسم الزهراوي
A light in the dark middle ages in Europe
At-Tasrif liman 'Ajiza 'an at-Ta'lif (The Method of Medicine). At-Tasrif is a medical encyclopaedia compendium of 30 volumes compiled from medical data that Al-Zahrawi accumulated in a medical career that spanned five decades of teaching and medical practice without doubt Albucasis was the chief of all surgeons“ Pietro Argallata

3. Emil Theodor Kocher
1841 – 1917
1909 Nobel prize in medicine “physiology, pathology, surgery of thyroid”
promotion of aseptic surgery and scientific methods in surgery.
reducing the mortality of thyroidectomy to less than 1% 

4. Anatomy

5. Anatomy

7. Histology

8. Thyroid Hormone Synthesis
Iodide trapping
Oxidation of iodide and iodination of thyroglobulin
Coupling of iodotyrosine molecules within thyroglobulin (formation of T3 and T4)
Proteolysis of thyroglobulin
Deiodination of iodotyrosines
Intrathyroidal deiodination of T4 to T3

9. Hypothalamic Pituitary Axis

10. Effects of Thyroid Hormone
Fetal brain and skeletal maturation
Increase in basal metabolic rate
Inotropic and chronotropic effects on heart
Increases sensitivity to catecholamines
Stimulates gut motility
Increase bone turnover
Increase in serum glucose, decrease in serum cholesterol

11. Benign Thyroid Disease
Benign Nontoxic Conditions
Diffuse and Nodular Goiter
Benign Toxic Conditions
Toxic Multinodular Goiter
Graves’ Disease
Toxic Adenoma
Inflammatory Conditions
Chronic (Hashimoto’s) Thyroiditis
Subacute (De Quervain’s) Thyroiditis
Riedel’s Thyroiditis

12. Clinical presentation

13. Goiter
enlargement of the thyroid gland (local or diffuse) based on hyperplasia or degeneration

14. Classification Benign Nontoxic Conditions Benign Toxic Conditions
Diffuse and Nodular Goiter
Benign Toxic Conditions
Toxic Multinodular Goiter
Graves’ Disease
Toxic Adenoma

15. Diffuse nontoxic goiter
Iodine deficiency results in hypothyroidism
Increasing TSH causes hypertrophy of thyroid

16. Multinodular goiter
Follicles may become autonomous; certain follicles will have greater intrinsic growth and functional capability

17. Toxic multinodular goiter
Follicles continue to grow and function despite decreasing TSH

18. Thyroid nodule

19. Clinical case
52 y.o. female with no active medical problems. During routine physical, note a thyroid nodule. Told by a surgeon last year not to worry about it.
PE: 1 x 2cm R lower pole nodule.
What information do you want from the patient?

20. Thyroid exam

21. Age as a Risk Factor Age young patients (<20 years of age)
thyroid nodules are much more likely to be malignant (40-50%).
elderly (>60 years of age) -higher risk, especially of more aggressive thyroid tumors.

22. Gender and Thyroid Nodules
male -higher risk if nodule present
females
have many more nodules
less likely to be malignant.
still have majority of thyroid cancers

23. Other major risks Radiation to head and neck.
40% risk of thyroid cancer usually 25 years later.
Children with Hodgkin's lymphoma
Family History of MEN II, Gardner’s Syndrome, Cowden’s disease.

24. Red Flags Recent growth Soft tissue swelling Vocal changes Dysphagia
Signs of thyroid dysfunction

25. Clinical case
26 y.o. female with a 2-3 year history of goiter. No symptoms.
P.E.: 3x4 cm Right sided thyroid mass, firm, adherent to soft tissue.
What physical findings are worrisome?
How can you best clarify the nature of the nodule?

26. Diagnostic guidelines ATA 2009
Measure serum TSH in the initial evaluation of a patient with a thyroid nodule. If the serum TSH is subnormal, a radionuclide thyroid scan should be performed using either technetium 99mTc pertechnetate or 123I. Recommendation rating: A
Thyroid sonography should be performed in all patients with known or suspected thyroid nodules. Recommendation rating: A
FNA is the procedure of choice in the evaluation of thyroid nodules. Recommendation rating: A
US guidance for FNA is recommended for those nodules that are nonpalpable, predominantly cystic, or located posteriorly in the thyroid lobe. Recommendation rating: B

27. ATA Thyroid Nodules and Cancer Guidelines 2015
Differences between the and 2015
Recommendations
Sub-recommendations
References
Tables
Figures

28. Examples of Grading changes
• 2009
Recommendation: Measure serum TSH during the initial evaluation of a patient with a thyroid nodule. (Recommendation A) •
2015
Recommendation: Measure serum TSH during the initial evaluation of a patient with a thyroid nodule. (Strong recommendation, Moderate-quality evidence)

29. Thyroid Ultrasound Can identify presence of nodules. Thyroid
May be able to characterize follicular vs. solid.
Not able to rule our malignant nodule
Aid in biopsy.
Thyroid

30. Sonographic patterns
• High suspicion [malignancy risk 70-90%]: Solid hypoechoic nodule or solid hypoechoic component of a partially cystic nodule with one or more of the following features: irregular margins, microcalcifications, taller than wide shape.
• Intermediate suspicion [malignancy risk 10-20%]: Hypoechoic solid nodule without high suspicion features
• Low suspicion [malignancy risk 5-10%]: Isoechoic or hyperechoic solid nodule, or partially (> 50%) cystic nodule, with eccentric solid area without high suspicion features
• Very low suspicion
• Benign purely cystic

31. Fine-Needle Aspiration
Best tool for determining pathology other than surgical excision.
Can be as high as 80 % sensitive and 95% specific.
Operator dependent in obtaining adequate amount of tissue. 25 gauge needle is optimal.
Should not be relied on if negative in patient with previous neck irradiation.
Multifocal tumors common.

32. FNA Recommendations (8)
Recommendations for diagnostic FNA based on sonographic features:
Nodules > 1 cm with high suspicion sonographic pattern (Strong recommendation, Moderate-quality evidence)
B) Nodules > 1cm with intermediate suspicion sonographic pattern (Strong recommendation, Low-quality evidence)
C) Nodules > 1.5 cm with low suspicion sonographic pattern (Weak recommendation, Low-quality evidence)
D) Nodules > 2 cm with very low suspicion sonographic pattern (e.g. - spongiform) (Weak recommendation, Moderate-quality evidence

33. Interpreting the Biopsy Report
What you get:
benign
indeterminate
Suspicious/ malignant
inadequate specimen
What it means:
benign % likelihood it is benign
indeterminate- who knows?
suspicious- it’s malignant.
inadequate specimen - do it again (and again)

34. Treatment of Diffuse or Multinodular Goiter
Observation
I-131
Surgical Therapy
Total thyroidectomy
Subtotal thyroidectomy
Hemithyroidectomy

35. Graves’ Disease Most common form of thyrotoxicosis
Autoimmune etiology with familial predisposition
Thyroid receptor stimulating antibody unique to Graves’ disease; other autoantibodies present (TgAb, TPOAb)
Affects females five times more often than males

36. Presentation of Graves’ Disease
Thyrotoxicosis: palpitations, nervousness, easy fatigability, diarrhea, excessive sweating, intolerance to heat, weight loss
Eye signs
Diffuse goiter

37. Diagnosis of GD
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. 1/+00

38. Treatment Antithyroid Drugs Radioactive iodine Surgery
May require prolonged therapy
Radioactive iodine
May worsen ophthalmopathy unless followed by steroids
Surgery
Make patient euthyroid prior to surgery
Potassium iodide two weeks prior to surgery can decrease the vascularity of the gland

39. ATA guidelines 2011
RECOMMENDATION 22 Whenever possible, patients with GD undergoing thyroidectomy should be rendered euthyroid with methimazole. Potassium iodide should be given in the immediate preoperative period. 1/+00 

40. Thyroid Storm
Thyroid storm: manage aggressively with beta-blockers, calcium channel blockers, PTU, methimazole, sodium iodide, digitalis or diuretics for heart failure, fluid and electrolyte management

41. Toxic Adenoma
Autonomously functioning thyroid nodule hypersecreting T3 and T4 resulting in thyrotoxicosis (Plummer’s disease)
Almost never malignant
Rx with antithyroid drugs followed by either I-131 or surgery

42. Chronic Thyroiditis Also known as Hashimoto’s disease
Probably the most common cause of hypothyroidism in United States
Autoantibodies include: thyroglobulin antibody, thyroid peroxidase antibody, TSH receptor blocking antibody

43. Pathology of Chronic Thyroiditis
A dense infiltrate of plasma cells and lymphocytes with germinal center formation is seen in this thyroid. Cells of the individual colloid follicles often display abundant pink granular cytoplasm, which is referred to as oncocytic change, in this setting. These cells are referred to as Hurthle cells or oncocytes - these are metaplastic.

44. Presentation and Course
Painless goiter in a patient who is either euthyroid or mildly hypothyroid
Low incidence of permanent hypothyroidism
May have periods of thyrotoxicosis
Treat with levothyroxine

45. Subacute Thyroiditis De Quervain's thyroiditis
Most common cause of thyroid pain and tenderness
Acute inflammatory disease most likely due to viral infection
Transient hyperthyroidism followed by transient hypothyroidism; permanent hypothyroidism or relapses are uncommon
Inflammation of thyroid gland that includes granulomas
Painful swallowing (odynophagia), sore throat, thyroid region tenderness, fever, fatigue, malaise

46. Treatment of Subacute Thyroiditis
Symptomatic: NSAIDS or a glucocorticoid
Beta-blockers indicated if there are signs of thyrotoxicosis
Levothyroxine may be given during hypothyroid phase

47. Riedel’s Thyroiditis Rare disorder usually affecting middle-aged women
Likely autoimmune etiology
Fibrous tissue replaces thyroid gland
Patients present with a rapidly enlarging hard neck mass