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 Disclaimer o I have no financial interests with any of the companies or technologies discussed in this presentation Overview o 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 Does Not Cause o Pressure o Weight gain o Dysphagia o Fatigue o Dyspnea 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 o Deaths Data o 23rd most common o New Cases o 1,980 deaths o 8th most common o 24th is Bone and o 53,990 Joint cancer o >3:1 Female to Male o 1:1 Female to Male Ratio ratio for deaths o 5th most common cancer in women 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 Cancer o 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