1) The document discusses the treatment and follow-up of thyroid swelling and thyroid cancer. It outlines surgical and medical management strategies for different types of thyroid nodules, cancers, and postoperative care. 2) Types of thyroid cancer discussed include papillary, follicular, medullary, and anaplastic carcinoma. Treatment options covered are surgery, radioiodine therapy, chemotherapy, and external beam radiation. 3) Follow-up care involves monitoring of thyroid function tests, tumor markers, and imaging to detect recurrence and provide additional treatment if needed. Lifelong thyroid hormone suppression is also recommended in many cases.

1. TREATMENT & FOLLOW-UP OF A
CASE OF THYROID SWELLING
SAYAN BANERJEE
8TH SEMESTER
MALDA MEDICAL COLLEGE

2. Lymph node levels
in neck

3. THYROID
NODULE/MASS
FNAC
Malignant or
suspicious
Benign
Follow
clinically
Surgery
Tissue
pathology
Indeterminate
Algorithm / Overview

4. Toxic Multinodular Goitre
• Elderly, long standing MNG
• Mainly cardiac
• NO EXTRATHYROIDAL FEATURES
• ↓TSH; ↑FT4,FT3
• RAIU : internodular tissue hot
• Tx: Make euthyroid → Thyroidectomy (STT, Hartley Dunhill, TT)
RAI (I131): Elderly, Poor risk patients

5. Toxic Adenoma (Plummer’s disease)
• Single nodule
• Young, longstanding nodule, sudden growth and hyper-function
• RAIU: Hot nodule
• Small nodule: ATT, RAI
• Large nodule/ Young patients: Lobectomy

6. Surgery in a Hyperthyroid Patient
• Make patient euthyroid prior to surgery→
• Continue ATT upto morning of surgery
• Lugol’s Iodine or SSKI: 3 drops BD starting 10 days prior
• Inhibits release of hormone, ↓vascularity
• Propranolol

7. Operations on the Thyroid

8. Unilateral thyroid lobectomy is recommended:
1. Cyst persist after 3 attempts for aspiration
2. Cyst >4cm
3. Complex cyst with solid and cystic components higher chances of
malignancy (15 %)

9. Papillary thyroid carcinoma
TYPE TREATMENT
HIGH RISK or BILATERAL  Total or near total thyroidectomy
Minimal papillary carcinoma in
thyroid specimen
 Unilateral thyroid lobectomy and
isthmusectomy
Large, Locally aggressive/ metastatic
tumours
 Total thyroidectomy with excision of
adjacent involved structures if necessary
and appropriate nodal surgery followed by
radioablation with long term TSH
suppression
 Modified Radical neck dissection type III is done in case of
biopsy-proven lymph node metastases

10. Low risk groups
Points in favour of total
thyroidectomy
Point in favour of lobectomy
 Enables the use of RAI to detect
and treat residual thyroid
tissue/mets
 Lobectomy has less complication
rate
 Makes serum Tg level more
sensitive for recurrent or
persistent disease
 Recurrence in remaining tissue
is unsual (5%) and mostly
curable by surgery
 Removes contralateral occult
cancer as sites of recurrence (
85% bilateral)
 Tumour multicetricity has little
prognostic significance
 Reduces recurrence risk and
improved survival
 Prognosis is comparable to total
thyroidectomy
 Decreases the 1 % risk of
progression to anaplastic cancer
 Reduces rate of re-operation and
complication
Generally total or near total
thyroidectomy is recomended in
low risk groups provided
complication rates are low <2 %

11. Indication of total thyroidectomy
NCCN guidelines
If any present
If all present
(thyroidectomy/lobectomy)
 Age <15y or >45y  Age 15 – 45 y
 Radiation history  No radiation history
 Known distant mets  No distant mets
 Bilateral nodularity  No nodularity
 Extrathyroidal invasion  No extrathyroidal invasion
 Tumour > 4cm  Tumour <4 cm
 Cervical lymph node mets  No cervical lymph nodes mets
 Aggressive variant  No aggressive variant

12. • Prophylactic lateral neck node dissection is NOT recommended in
PTC
• Cancer doesn’t metastasize systemically from lymph nodes
• Micrometastasis can be ablated by RAI therapy

13. Residual disease Post operatively
• TSH + Tg and antithyroglobulin antibodies
• 2 to 12 weeks post operatively
• Total body RAI imaging
• Suspected or proven RAIEBRT
• Adequate RAI uptake  Radioiodine treatment and post treatment I131 imaging
• If no imaging performed  EBRT
• In all these cases suppress TSH with Levothyroxine.

14. •Total thyroidectomy resulted in improved survival over
other techniques
•Poorer outcomes were associated with age, stage T3/T4
disease, positive nodes, and tumour size

15. Metastatic disease
• CNS  Neurosurgical resection and/or image guided EBRT
• BONE Surgical palliation (weight bearing extremities and/or RAI treatment and/or EBRT)
• bisphosphonate or denosumab therapy
• Embolization of metastatic deposits
• Other than CNS  surgical resection and/or EBRT of selected mets and/or radioiodine
• Best supportive care

16. Follicular carcinoma
• Follicular lesion on FNAB  thyroid lobectomy (80 % are benign adenomas)
• Thyroid cancer  Total thyroidectomy is recommended in →
• Older patients
• Lesion >4cm ( cancer risk is higher- 50 %)
• Intraoperative frozen section examination if
• Evidence of vascular or capsular invasion
• Adjacent lymphadenopathy is present
• Thyroid specimen  follicular carcinoma total thyroidectomy
• Nodal metastasis  therapeutic neck dissection
Prophylactic nodal dissection is unwarranted as nodal involvement is infrequent

17. Hurthle cell carcinoma
• Unilateral Hurthle cell adenomas  lobectomy + isthmusectomy
• Invasive (on definitive paraffin section histology) total thyroidectomy + central neck node
removal
• Modified radical neck dissection if lateral nodes are palpable & identified by USG
• TSH suppression
• Although RAI scanning and ablation usually are ineffective, they probably should be
considered to ablate any residual normal thyroid tissue and occasionally ablate tumors
because there is no other good therapy.
Retinoic acid and PPAR-γ agonists have shown some benefit in these tumors in
vitro; but needs further research

18. Post operative management of
Differentiated Thyroid Cancer
1. Radioiodine scanning and ablation
2. External beam radiotherapy (EBRT)
3. Chemotherapy

19. 1.Radioiodine scanning and ablation
• RAI ablation is recommended in
• All patients with stage 3 and 4 disease
• All Patients with stage 2 disease <45 years
• Most patients ≥ 45 years with stage 2 disease
• Stage 1 disease with
• Aggressive histology
• Nodal metastases
• Multifocal disease
• Extrathyroidal or vascular invasion
• More senstive than X-ray/ CT in detecting metastatic disease
• Less senstive than Tg level except in Hurthle cell tumors
• 4-6 weeks after thyroidectomy, hypothyroid can be induced by discontinuing replacement (T4 for 4
weeks or T3 for 2 weeks) to obtain high serum TSH levels.

20. 1.Radioiodine scanning and ablation
(CONTD….)
• A diagnostic dose of 131I or 123I is given initially.
• Whole-body scanning is performed to detect any tissue taking up radioiodine.
• If any normal thyroid remnant or metastatic disease is detected, a therapeutic dose of 131I is
administered to ablate the tissue.
• Post-treatment scanning should also be performed because it may reveal metastatic disease not
otherwise noted.
• If a treatment dose of 131I is required, diagnostic thyroid scanning is repeated after 6 months after initial
treatment,
• If the diagnostic scan Positive  additional therapeutic dose is given. Process is repeated until the
diagnostic scan is negative
Role of recombinant human TSH
• Thyrogen stimulation avoids the discomfort of patients having to discontinue thyroid replacement
• T4 stopped 1 day before TSH stimulation

21. Recent advances
Sorafenib* (Nexavar) was approved in November 2013 for
differentiated thyroid cancer (DTC) that is refractory to
radioactive iodine treatment.
*Sorafenib is a small molecular inhibitor of several tyrosine
protein kinases

22. Thyroid suppression
• Used after thyroidectomy and radioablation
• Reduces tumoural growth and recurrence rates
• Suppressive dose is 0.3 mg OD lifelong
• TSH levels should be < 0.1 mU/L

23. 2. External beam radiotherapy
• Used in unresectable, locally invasive or recurrent disease
• In bone mets to decrease
• Risk of fractures
• Bone pain

24. 3. Chemotherapy
• Generally has no role
• Doxorubicin is used as radiation sensitizer in patients
undergoing external beam radiation

25. Medullary thyroid carcinoma
• If pheochromocytoma present  operated first
• Total thyroidectomy is the treatment of choice with bilateral central neck
node dissection
• Palpable cervical lymph nodes modified radical neck dissection
• Tumour >1 cm  ipsilateral Prophylactic modified radical neck dissection
• If +ive than contralateral node dissection is done
• If unresectable
• Tumor debulking to reduce symptoms
• External beam radiation

26. Medullary thyroid carcinoma
Recent advances
Tyrosine kinase inhibitors
Imitanib
Zactima (reduces calcitonin and CEA levels
Anti CEA monoclonal antibody
Labetuzumab
Laparoscopic Radiofrequency ablation
For Liver mets >1.5 cm (palliative)

27. • If patient is hypercalcemic at thyroidectomy
• Only enlarged parathyroid gland is removed
• RET mutation carrier  total thyoroidectomy
• MEN2A  before 6 years
• MEN2B  before 1 year
• Central neck node dissection
• Avoided in calcitonin negative and normal USG exam
• Done prophylactically in calcitonin positive and if USG suggests cancer
• Maintenance dose of L-thyroxine

28. • All family members of patients with MTC should be evaluated with
serum calcitonin (genetic evaluation can also be done ) and if it is high
they should undergo prophylatic thyroidectomy ......

29. Anaplastic carcinoma
• If resectable
• Adjuant chemoradiotherapy
• Adriamycin is used for chemo.
• Tracheostomy and isthemectomy to relieve airway
obstruction in unresectable cases

30. Lymphomas
• Mainstay  Chemotherapy
• CHOP ( Cyclophosphamide, Doxorubicin, vincristine, and prednisolone)
• Radiotherapy may also be given
• Thyroidectomy and nodal resection to alleviate airway obstruction

32. Differentiated Thyroid Carcinoma
Thyroglobulin levels
Thyroglobulin is a useful marker of tumor recurrence because well-
differentiated thyroid cancers synthesize thyroglobulin
• After total thyroidectomy levels should be
• <2 ng/ml if taking t4
• <5ng/ml if hypothyroid
• Levels >2ng/ml suggest metastatic or persistant normal tissue. (>95%)
• Tg and Tg antibodies measuresd initially 6 months interval then annualy if
disease free.

33. Follow up imaging
• In low risk and –ive TSH stimulated Tg and cervical USG routine
whole bodyscan is not recommended after first post operative scan
• After remnant ablation routine whole body scan after 6 to 12
months is recommended
Cervical USG
• To evaluate thyroid bed and lymph node  6 to 12 months post
thyroidectomy then annually for 4 to 5 years
FDG PET SCAN
• If RAI and USG normal but Tg remain elevated

34. Medullary thyroid carcinoma
• Annual measurements of calcitonin and CEA levels.
• Regular USG , CT , MRI if required
• FGD PET scans
• Superior to other radionuclide based studies

35. Management of recurrence
• Localized
• Surgical excision
• Non localized
• 131 I radioablation
• External beam radiotherapy