SURGICAL MANAGEMENT OF THYROID/PARATHYROID …/media/Files...o Thyroid cancer present in 7-15% of...
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SURGICAL MANAGEMENT OF THYROID/PARATHYROID DISEASE Edsel Kim, M.D. Otolaryngology - Head and Neck Surgery The Oregon Clinic Providence Brain and Spine Institute Pituitary, Thyroid and Parathyroid Update February 2018
Transcript of SURGICAL MANAGEMENT OF THYROID/PARATHYROID …/media/Files...o Thyroid cancer present in 7-15% of...
SURGICAL MANAGEMENT
OF THYROID/PARATHYROID
DISEASEEdsel Kim, M.D.
Otolaryngology-Head and Neck SurgeryThe Oregon Clinic
Providence Brain and Spine InstitutePituitary, Thyroid and Parathyroid Update
February 2018
Disclaimer
o I have no financial interests with any of the
companies or technologies discussed in this
presentation
Overviewo Thyroid Surgery
o History
o Anatomy
o Workup
o Thyroid Cancer Subtypes
o Complications
o Parathyroid Surgery
o Case Studies
o Future Trends
History
o Medical treatment of goiters
o 1600 BC – Chinese used burnt sponge and seaweed
o Surgery first discussed in 990 AD in the Middle East
o 1880-Ludwig Rehn – 1st known thyroidectomy
History
o By 1920s, fairly commonplace
o William Halstead
o “feat which today can be accomplished by any
competent operator without danger or mishap”
Anatomy
Anatomy
o Parathyroid
o Paired superior and
inferior
o Inferior can be more variable in location
o Inferior glands are
ventral to the
recurrent laryngeal
nerve
o Superior glands are
dorsal to the nerve
Thyroid Nodule
o Palpable in up to 5% of women
o 1% of men
o Evident by U/S in up to 68% of population
o Thyroid cancer present in 7-15% of all nodules
o Physical exam
o Incidentaloma
o U/S, CT Scan, PET Scan
Haugen, B., et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with
Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. Jan 2016 26(1):1-133
Nontoxic Thyroid Nodule -
Symptoms
o Can Cause
o Pressure
o Dysphagia
o Dyspnea
o Does Not Cause
o Weight gain
o Fatigue
o Hair loss
o In general does not
cause pain!
o Hemorrhagic cyst,
thyroiditis
Indications for
Thyroid Surgery
o Symptoms of compression
o Nodule generally has to be at least 3 cm
o Much larger nodules can be asymptomatic
o Cancer or question of cancer by FNA
o Inability to tolerate antithyroid medication/treatment
in hyperthyroid state
Thyroid Nodule - Workup
o TFTs/Ultrasound
o FNA
o Best diagnostic test
o Establishes tissue diagnosis
o Benign - 50-60%
o Suspicious – 10%
o Cancer - 5%
o Nondiagnostic - 20%
o Gene expression classification / 7 gene testing
o Aims to reduce need for diagnostic thyroid surgery
Williams, B., et al. Rates of thyroid malignancy by FNA diagnostic criteria. Journal of Otolaryngology Head &
Neck Surgery. 2013. 42:61.
Thyroid Cancer Statistics
o ACS 2018 Estimated
Data
o New Cases
o 8th most common
o 53,990
o >3:1 Female to Male
Ratio
o 5th most common
cancer in women
o Deaths
o 23rd most common
o 1,980 deaths
o 24th is Bone and
Joint cancer
o 1:1 Female to Male
ratio for deaths
American Cancer Society, Key statistics for thyroid cancer, 2018
Thyroid Cancer Statistics
o 5 yr survival (2015 NCI/SEER data)
o Localized – 99.9%
o Regional - 97.8%
o Distant – 55%
o 5 yr survival by type
o Papillary cancer (PTC) – 98%
o Follicular – 85%
o Medullary – 75%
o Undifferentiated/Anaplastic – <5%
SEER stat fact sheets: Thyroid Cancer – 2016
AJCC Cancer Staging Manual 7th Edition – Thyroid
2015 ATA Guidelines for WDTC
(Well Differentiated Thryoid
Cancer)
o For WDTC 1.0-4.0 cm that are low risk,
o No Extrathyroidal extension
o Clear margins
o Clear lymph nodes
o May consider hemithyroidectomy as being curative
o Otherwise, would consider total thyroidectomy,
prophylactic central nodal dissection
Haugen, B., et al. 2015 American Thyroid Association Management Guidelines for Adult Patients
with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. Jan 2016 26(1):1-133
2017 AJCC Staging Manual, 8th
Ed. for Differentiated Thyroid
Cancer
o All patients less than 55yo with any T and N status is
Stage 1
o All patients 55 yo or older with tumors <4cm confined
to the thyroid have stage 1 disease
o All patients 55 yo or older with tumors >4cm confined
to the thyroid have stage 2 disease regardless of LN
status
Perrier, N. D., Brierley, J. D. and Tuttle, R. M. (2018), Differentiated and anaplastic thyroid carcinoma: Major
changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA: A Cancer
Journal for Clinicians, 68: 55–63. doi:10.3322/caac.21439
Neck Dissection in Thyroid
Cancero Central nodal dissection for
WDTC
o Area between hyoid bone,
carotid artery and suprasternal
notch/innominate artery
o Decreases risk of nodal
recurrence
o Decreased risk of injury to
RLN, parathyroid in re-do
operations
Neck Dissection in Thyroid
Cancer
o Lateral compartment
should be addressed
for cervical nodal
metastases
o All patients with
suspicious/cancer
thyroid FNA need
neck mapping
ultrasound
Active Surveillance for Low
Risk Thyroid Cancer
o Papillary thyroid cancer < 1.5 cm with no LN or other
concerning U/S findings
o Surveillance U/S every 6 mo for 2 yrs then yearly
o Surgery – if there is growth >3mm, +LN or patient
preference
o 11/291 (3.8%) had interval growth >3mm by 5 years
o Patients <50 are more likely to need surgery
Tuttle, RM et al. Natural History and Tumor Volume Kinetics of Papillary Thyroid Cancers During Active
Surveillance. JAMA Otolaryngol Head Neck Surgery. 2017 Oct 1;143 (10) 1015-1020. doi: 10.1001/
jamaoto.2017.1442.
Complications of
Thyroid/Parathyroid Surgery
o Bleeding ( 0.5-2%)
o Recurrent laryngeal nerve injury
o Temporary (3%)
o Permanent (0.5-8%)
o Hypoparathyroidism/hypocalcemia
o Temporary (25-40%)
o Permanent (1-9%)
o External branch superior laryngeal nerve injury (up to 56%)
o Complications are inversely related to surgeon volume
Meltzer C., Otolaryngology Head and Neck Surgery. 2016: 155 (3) 391-401
Zambudio, A., Ann Surgery. 2004 Jul: 240(1) 18-25
Complications of Thyroid
Surgery
o Bleeding (0.5-2%)
o Can cause dysphagia, airway compression
o Treating team should be immediately notified with any
question
o If patient is in extremis, the incision should be opened immediately
o Suture removal kit should always be at the bedside
Meltzer C, et al. Risk of Complications after Thyroidectomy and Parathyroidectomy: A Case Series with Planned
Chart Review. Otolaryngol Head Neck Surg. 2016 May 3.
RLN Injury
o Unilateral
o Breathy, hoarse voice
o Initially can be in paramedian position with relatively
normal voice
o Can get worse over days/weeks
o Aspiration
o Dysphagia
o Bilateral
o Airway obstruction/Distress
Meltzer C, Klau M, Gurushanthaiah D, et al. Risk of Complications after Thyroidectomy and Parathyroidectomy: A
Case Series with Planned Chart Review. Otolaryngol Head Neck Surg. 2016 May 3.
Intraoperative Nerve
Monitoring
o Benefits
o Helps to confirm
nerve anatomy
o May help to decrease
operative time
o Con
o Studies are equivocal
o Equipment
malfunctions
RLN Injury
o Diagnosis
o Laryngoscopy
o EMG
o Prevention
o 0.2-2% - if nerve is identified
o 4-6% if nerve is not
identified
o 2-12% for repeat
surgery
Meltzer C, Klau M, Gurushanthaiah D, et al. Risk of Complications after Thyroidectomy and Parathyroidectomy:
A Case Series with Planned Chart Review. Otolaryngol Head Neck Surg. 2016 May 3.
External Branch Superior
Laryngeal Nerve injury
– Symptoms
• Can’t sing/raise pitch
• Choking
• Aspiration
– Diagnosis
• Rotated larynx
• Loss of sensation on affected side
– Treatment
• Voice therapy
Hypoparathyroidism/
Hypocalcemia
o Transient hypocalcemia 25-40%
o Permanent hypoparathyroidism occurs in 1-3%
o Percentage is inversely correlated with surgeon experience
o Treatment is oral calcium supplementation and Vitamin D
o Greater than 6 months is considered permanent
o Recombinant PTH - off label
Meltzer C, Klau M, Gurushanthaiah D, et al. Risk of Complications after Thyroidectomy and
Parathyroidectomy: A Case Series with Planned Chart Review. Otolaryngol Head Neck Surg. 2016 May 3.
Primary Hyperparathyroidism
o Hyperparathyroidism
o Symptoms
o Fatigue, bone pain, depression, GERD, kidney stones,
osteoporosis, hypertension, mental fogginess
o Only 20% are symptomatic
o 1% of adult population
o 2% above 55 yo
o 3 F : 1 M
Bilezikian JP, Silverberg SJ. Clinical practice. Asymptomatic primary hyperparathyroidism. N Engl J Med. 2004
Apr 22. 350(17):1746-51
The American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons
position statement on the diagnosis and management of primary hyperparathyroidism.
Endocr Pract. 2005 Jan-Feb ;11(1):49-54.
Hyperparathyroidism
o Primary Hyperparathyroidism
o Elevated PTH and Ca
o 90% - Single Adenoma
o 5% - Multiple Adenomas
o 5% - 4 gland hyperplasia
o <1% - Parathyroid cancer
o Tertiary Hyperparathyroidism
o After prolonged secondary hyperparathyroidism
o Kidney failure – inability to convert Vit D
o Failed medical tx
Normocalcemic primary
hyperparathyroidism
o Elevated PTH, Normal Calcium
o 10-15% - PTH levels at high range of normal
o All other causes need to be ruled out
o Vit D deficiency, low Ca intake, GI, Renal,
hypercalciuria
o 22% become hypercalcemic
o Need monitoring
Bilezikian, J. P., & Silverberg, S. J. (2010). Normocalcemic primary hyperparathyroidism. Arquivos Brasileiros
de Endocrinologia E Metabologia, 54(2), 106–109.
Guidelines for Treatment
o 2 governing bodies
o Guidelines for the management of asymptomatic primary
hyperparathyroidism: summary statement from the Fourth
International Workshop. J Clin Endocrinology Metabolism.
2014 Oct;99(10):3561-9. Bilezkian, J. et al.
o American Association of Endocrine Surgeons (AAES)
Guidelines for Definitive Management of Primary
Hyperparathyroidism (JAMA Surg. 2016;151(10):959-968.)
Consensus Surgical Indications for
Symptomatic Primary
Hyperparathyroidism
o Kidney Stones
o Osteoporosis
o Fragility fractures
Consensus Surgical Indications for
Asymptomatic Primary
Hyperparathyroidism
o 1.0 mg/dL above the upper limit of the reference range
for serum calcium
o Creatinine clearance < 60ml/min
o 24 urine Ca >400mg/day
o Age younger than 50 years
Additional recommendations (strong)
for surgery (AAES)
o Suspected Parathyroid carcinoma
o Patients are unwilling/unable to comply with surveillance
o Patients with neurocognitive or neuropsychiatric symptoms attributable to pHPT
o Ideally should be conducted by those who perform>10 cases/year
o Operative management is more effective and cost effective than long-term observation or pharmacologic therapy
Parathyroid Surgery
o Surgical Treatment
o Standard approach
o All 4 glands are explored and identified
o Minimally invasive approach
o Abnormal gland is localized and surgery is directed
o Intraoperative PTH levels can be checked
o Radioguided parathyroidectomy
o Gamma probe
o Preoperative localization
Parathryoid Surgery
o Preoperative Imaging
o High definition Ultrasound
o Sestamibi/SPECT CT Scan
o CT Scan/MRI
o 4D CT Scan
o Helps to localize disease
o Decreases operative time and exposure
o Faster recovery
o 95% Surgical Cure rate, 83% after reoperation
Parathyroid Surgery
o 4 gland hyperplasia
o 3.5 glands are removed
o 0.5 gland is left or reimplanted in easily accessible
muscle
o Ectopic glands, 3 or 5 glands
o Retroesophageal, thymus, carotid sheath, anterior and
posterior mediastinum
o Parathyroid Carcinoma
o Familial Hyperparathyroidism
Parathyroid Surgery
o Risks
o Recurrent laryngeal nerve injury (0.1-5%)
o Postoperative Hypocalcemia (1-30%)
o 4 gland exploration, 4 gland hyperplasia, “Hungry bone
syndrome”
o Numbness, tingling, Chvostek’s sign
o Failure to cure disease (5%)
o Outcomes
o Failure to improve symptoms
Meltzer C, Klau M, Gurushanthaiah D, et al. Risk of Complications after Thyroidectomy and
Parathyroidectomy: A Case Series with Planned Chart Review. Otolaryngol Head Neck Surg. 2016 May 3.
Parathyroid Surgery-
Outcomes
Murray S. et al. Timing of Symptom Improvement After Parathyroidectomy for Primary Hyperparathyroidism.
Surgery. 2013;154(6):10.1016/j.surg.2013.09.005. doi:10.1016/j.surg.2013.09.005
Case Study 1- Thyroid
o 69 yo retired RN with long history of a substernal
goiter
o Worsening dyspnea, orthopnea, dysphagia
o Followed by endocrine (not here)
o Recommended not to have surgery given size
o Eventually sought care herself
Case Study 1- “Thyroidzilla”
o OR – Substernalthryoidectomy, limited sternotomy
o 2 day hospitalization
o 2 week recovery
o Normal voice and calcium
o Normal swallowing and breathing
o Hiking at 1 month
Case Study 2- Parathyroid
o 28 yo M with several
month h/o enlarging
facial mass
o Vague constitutional
symptoms
Case Study 2- Parathyroid
o Lateral rhinotomy
approach
o Subtotal
maxillectomy, partial
palatectomy
Case Study 2- Parathyroid
o Post-op
o Routine Ca was elevated
o Ionized Ca – 1.91
o PTH – 917
o Path
o Brown tumor – Giant Cell tumor
o More commonly seen in Africa
o Return to OR for neck exploration
Case Study 2- Parathyroid
o Bilateral adenomas
o Intra-op PTH 917-579–
84
Commonly asked Questions
Thyroid/Parathyroid Surgeryo Incision length
o 4-5 cm for thyroid
o 2.5-4 cm for parathyroid
o Operative time (removal of gland)
o Hemithyroid - 40 min
o Total thyroid – 75 min
o Parathyroid – 15 min
o LOS
o 1 day for total thyroid
o Outpatient – hemithyroid, parathyroid
o Recovery/Return to work
o < 1 wk. Minimal discomfort
Commonly asked Questions
Thyroid Surgery
o Can just the nodule be removed?
o Almost always, no.
o Do I need to be on thyroid medication if half my
thyroid is removed?
o 2015 ATA guidelines – 24% of patients need
replacement medication
o Am I going to feel the same if I need replacement
medication?
o In general, yes but 10-20% of patients initially have a difficult time with dosing
Future of Thyroid Surgery
o Personalized Medicine
o BRAF, Afirma
o Trend towards less aggressive treatment of WDTC
o Hemithyroidectomy instead of total thyroidectomy
o Forego radioactive iodine ablation
o Dependent on risk stratification
o Improved monitoring of the external branch of the
superior laryngeal nerve (EBSLN)
o Recombinant PTH for hypoparathyrodism
Conclusion
o Thyroid and parathyroid surgery can be a safe and rewarding surgery for patients
o Indications for thyroid and parathyroid surgery are well studied
o Care pathways are continuously defined through the American Thyroid Association (ATA)
o Coordination of care with endocrinology and surgery can provide the best outcome for patient
o Contact – [email protected] / PHS EPIC messaging
