SURGERY CLINICAL

CASE PRESENTATION
CARCINOMA THYROID
Biodata
• NAME :Mary
• AGE : 55 years
• SEX : Female
• Occupation : Homemaker
• Address : Ezhalloor
CHIEF COMPLAINTS
• Swelling at the front of neck since 2 years
History of presenting illness
• The patient came to OPD with complaint of swelling in front of
the neck, which was first noticed by her relatives around 2 years
ago which was around 3 * 3 cm . It was gradually increasing in
size till 3 months ago , from it showed rapid increase in size to
approximately double the size now
• History of decreased appetite. Loosening of clothes suggestive of
weight loss
History of presenting illness
• She has no h/o difficulty in swallowing of solid or liquid food,

• No h/o difficulty in breathing , hoarseness of voice

• No h/o other swellings in the neck, bone pain

• No history suggestive of hypothyroidism or hyperthyroidism

• No h/o pain over the swelling

PAST HISTORY
• No history of similar symptoms in the past
• No history of diabetes and hypertension
• No history of previous surgeries
• No history of radiotherapy in the past
TREATMENT HISTORY
• No h/o use of antithyroid drugs

• No h/o any drug allergy

MENSTRUAL HISTORY
• Menarche attained at 14 years of age
• Regular cycles of 28-30 days
• Regular flow of bleeding, not associated with pain
FAMILY HISTORY
 No history of any thyroid disease in the family or in the
locality
 No history of cancers in the family
PERSONAL HISTORY
• Diet: mixed

• Appetite: decreased

• Sleep: Undisturbed

• Bowel and bladder habits : Regular

• No h/o smoking and alcohol consumption

GENERAL EXAMINATION
• An Informed Consent was taken from the patient and the examination
was done in adequate natural light and exposure of the neck
• Conscious, well oriented to time, place and person and responds
verbally

• Patient was moderately built and nourished

• Facies - normal

• Skin – normal

• No eye signs
• PALLOR- absent
• ICTERUS- Absent
• CYANOSIS- Absent
• CLUBBING- Absent
• LYMPHADENOPATHY- Absent
• EDEMA- Absent
VITALS

• PULSE : 94 beats/min, regular, with Normal character

and volume

• RESPIRATORY RATE : 16 breaths/min

• TEMPERATURE : Afebrile

• BLOOD PRESSURE : 130/90 mmHg right upper arm

supine position using auscultatory method
NECK EXAMINATION
1. INSPECTION
• Globular swelling with bosselated surface of size
approximately 21* 14 cm seen on the front of neck which is
slightly to the left of midline and is superiorly extending upto
thyroid cartilage and inferiorly approximately 1.5 cm above
sternum with lower border visible. It moves with deglutition
• No dilated veins over swelling , Pemberton sign negative
• No scars, visible pulsation
2. PALPATION
• No local rise in temperature and tenderness
• Inspection findings were confirmed
• Size 21*14 cm along perpendicular direction
• Lower border is palpable and swelling is above sternum
• Consistency: firm to hard
• Margin: ill defined
• Surface : nodular
• The swelling is non mobile
• Trachea present in midline
• Kocher’s test – negative
• Carotid pulsation not felt; berry sign positive
• No lymph nodes palpable
PERCUSSION
Resonant notes heard over manubrium sterni

AUSCULTATION
No bruit heard
Systemic Examination
• Cardiovascular system : S1, S2 heard, no murmurs

Respiratory system: Normal vesicular breath sounds heard, No

added sounds
CNS: no focal neurological deficit
• Per Abdomen: Normal bowel sounds heard
Summary
• A 55 year old lady presented with swelling over front side of neck for 2 years
which is rapidly increasing in size for the last 3 months. She has decreased
appetite and weight loss, apart from which other features of compression,
hyperthyroid or hypothyroid are absent. On examination of neck there is a globular
swelling with bosselated surface of size approximately 21* 14 cm seen on the front
of neck which is slightly to the left of midline and is superiorly extending up to
thyroid cartilage and inferiorly approximately 1.5 cm above sternum with lower
border visible. . The swelling moves up and down with deglutition. It is not fixed to
skin and underlying structures. The swelling is hard in consistency with nodular
surface and irregular margins, limited intrinsic mobility, mobility in horizontal and
vertical plane . Lymph nodes are not palpable. There is no sign of toxicity or
retrosternal prolongation. Systemic examination findings are normal.
PROVISIONAL DIAGNOSIS
55 year old female with multinodular goitre., clinically euthyroid
state with no features of compression or metastasis,with
secondary malignant transformation
DIFFERENTIAL DIAGNOSIS

• Malignant Lymphoma: rapidly enlarging firm painless mass

in older women, symptoms caused by compression of trachea
and oesophagus are common, hoarseness of voice due to
local invasion and hypothyroidism.

• Riedel’s thyroiditis: women around 50 are affected. Slight

enlargement of gland with difficulty in swallowing and
hoarseness are usual symptoms
Investigations
• Thyroid function test (t3, t4, tsh)
• TSH (1-5 iu/ml) T4 (55- 150 nmol/L) T3 (1.2- 3.1 Nmol/L)

• Usg neck :This is gold standard investigation to determine the

physical characteristics of thyroid swellings
• (Identify nodules, number, size, vascularity, identify lymph nodes etc)

• Fnac: useful in pappillary carcinoma, lymphoma, colloid nodule,

thyroiditis
usg guided fnac more reliable, it identifies impalpable nodules, number,
nature vascularity
X-ray neck : used to assess tracheal compression and
displacement
Chest x-ray : to rule out retrosternal extension.
Flexible laryngoscopy: widely used preoperatively to determine
the mobility of the vocal cords.
• Thyroid scan : to identify which part is functional and non
functional.
Classification
Differentiated:
– Papillary (60%)
– Follicular (17%)
– Hurthle cell carcinomas
• Undifferentiated: Anaplastic carcinoma (10%)
• Medullary carcinoma: (5%)
• Malignant lymphoma: Mostly non-Hodgkin’s variety- B-cell
lymphoma
• Secondaries: From breast, colon, rectum or local spread.
Staging
DeGroot’s staging of carcinoma thyroid
Class I – Intrathyroidal
Class II – Cervical nodal metastasis
Class III- Extra thyroidal invasion
Class IV- Distant metastasis
PAPILLARY CARCINOMA OF THYROID
• Most common – incidence 60%
• Aetiology – irradiation
• Diagnosis- thyroid swelling with lymph node metastasis
• Microscopy – orphan annie – eye nuclei, psammoma bodies
• TSH depended
• Prognosis – excellent
• It is a slowly progressive and less aggressive tumour.
• Compression features are uncommon in papillary carcinoma thyroid.
• Lymphatic spread is common -
 Investigations
FNAC of thyroid nodule and lymph node.
• Procedure; It is done using 23 or 24 gauge needle fixed to specialised syringes which
creates negative pressure for aspiratio9n and contents are smeared on the slide. Dry
slides as well as slides fixed with 100% methanol are used for study
• Role of FNAC in thyroid swelling;
• Highly sensitive in papillary carcinoma of thyroid and also its nodal spread
• Useful to differentiate between benign and malignant
• Should be done all thyroid disease when there is a nodule or multiple nodules;
• Useful in lymphoma ,anaplastic carcinoma ,medullary carcinoma ,Hashimoto’s
thyroiditis.
• In follicular carcinoma it is not very useful as angio-invasion and capsular invasion
which are specific cannot be detected.
• Radioisotope scan shows cold nodule
• TSH [normal value 0-5IU/ml];level in the blood is higher.
• Plain x ray neck shows fine calcifications
• Ultrasound neck: to identify non palpable nodes in the neck
and also lymph nodes[number ,size, nature of the nodules,].
TREATMENT
• Treatment of the primary/2 choices . Pct without lymph nodes
(A) Total thyroidectomy
(B) Lobectomy[hemithyroidectomy]
Tumour multicentricity has little prognostic significance. Thus in
a few selected cases, lobectomy can be done
Lobectomy [hemithyroidectomy]
Indications
Pct less than 1 cm – no clinically palpable nodes, no extra
thyroid extension
Advantages
No hormone replacement
No hypoparathyroidism
Need not test thyroid function regularly
Treatment of pct with secondaries in
the lymph node
• Therapeutic lymph nodes dissection
• Carefully look for central compartment nodes- for enlargement
• If palpable and enlarged, they should be removed
• If nodes enlarged in the anterior triangle, they are dissected
and removed en bloc along with fat and fascia - functional
block dissection
• Structures such as internal jugular vein, sternomastoid
muscle, accessory nerve are not removed
Radio remnant ablation
• After surgery, thyroxine is not given for a period of 4 weeks.
Patient should be hypothyroid and TSH is around 30 mU/L
• At this stage , radioisotope scan is done to look for any
residual thyroid gland
• Even after total thyroidectomy, it is possible that some part of
thyroid tissue may be present near the trachea esophageal
groove
• This needs to be ablated with 50 to 150 mCi of radioiodine
Suppression of TSH
This is an important aspect in the postoperative period because
papillary carcinoma is a TSH dependent tumour.
To prevent the patient developing hypothyroidism in the
postoperative period and to suppress TSH, thyroxine 0.3 mg/day
is given.
• Failure of suppression of TSH to a level < 0.1 mU/litre suggest
inadequate dose of thyroxine or noncompliance
FOLLICULAR CARCINOMA OF
THYROID
Aetiology – endemic goitre
Incidence 17 %
Diagnosis- thyroid swelling with bony metastasis
Microscopy – angio invasion, capsular invasion
Spread – blood
Prognosis- good
TSH - depended
Investigations
• FNAC is inconclusive, because capsular and angioinvasion,
which are the main features in follicular carcinoma, cannot be
detected by FNAC.
• Follicular tumors >4 cm size are more likely to be malignant.
• Follow-up: Can be done using I123 scan or by thyroglobulin
estimation.
• Thyroglobulin levels in patients who have undergone total
thyroidectomy should be below 2 ng/ml.
• 95 percent of patients with persistent or recurrent thyroid cancer
of follicular origin will have thyroglobulin levels higher than 2 ng/ml
• High frequency ultrasound scan
• Plain x ray – osteolytic lesions
• Whole body scan I131 – multiple osseous metastasis
• Whole body MRI- bone metastasis
• CT scan- large tumor adherent to trachea, vessels in the neck
• Bone biopsy to find the site of the primary lesions
Treatment
• Total thyroidectomy.
• Postoperative radioactive iodine therapy.
• Maintenance dose of L-thyroxine 0.1 mg once daily life long.
HURTHLE CELL CARCINOMA
• Variant of follicular carcinoma
• 75% of follicular cells having oncocytic features
• They secrete thyroglobulin
Diagnosis
• Capsular / vascular invasion, distant metastasis
• Higher chance of spread to lymph nodes
• Higher chance of spread to distant sites also
Treatment
• Total thyroidectomy is the treatment of choice. In many
cases of Hurthle cell carcinoma, lymph nodes are enlarged.
Hence, modified radical neck dissection is done (MRND).

• TSH suppression and follow-up are regularly required

MEDULLARY CARCINOMA OF
THYROID
It arises from parafollicular cells which is derived from
ultimobranchial bodies and not from thyroid follicle
Spreads mainly to lymph nodes (60%).
Microscopy – Contain characteristic amyloid stroma.
• MCT is not TSH dependent and does not take up radioactive
iodine.
• Hormone production- calcitonin, prostaglandin, serotonin
Types

These tumours present in two different ways.

1. Sporadic is common, seen in about 80-90% of cases.
2. Familial variety present as a part of multiple endocrineneoplasia (MEN).
MEN Type I
• Pituitary adenoma
Parathyroid adenoma
Pancreatic adenoma
MEN Type Ila
Parathyroid adenoma
Phaeochromocytoma
Medullary carcinoma of thyroid
• MEN type llb
Marfanoid habitus
Mucosal Neuromas
Medullary carcinoma of the thyroid
Investigations
USG neck – mass
FNAC – amyloid stroma with dispersed malignant cells and C-cell
hyperplasia.
• Serum calcitonin level – In normal individual it is <10 pg/ml or
undetectable. If its unstimulated level is >100 pg/ml then it is
suggestive of MCT.
Treatment
1. Total thyroidectomy with radical neck dissection
• Before proceeding with surgery, look for an associated
phaeochromocytoma.

2. The lymph nodes are treated by radical block dissection

because they are fast-growing, when compared to papillary
carcinoma
ANAPLASTIC CARCINOMA OF
THYROID
• Diagnosis - It is a very aggressive tumour of short duration, presents with a swelling
in thyroid region which is rapidly progressive causing:
• Stridor and hoarseness of voice due to tracheal obstruction.
• ii. Dysphagia.
i. iii. Fixity to the skin.
Microscopy – poorly differentiated cells
Spread – local infiltration

Positive Berry’s sign—involvement of carotid sheath leads to absence of carotid

pulsation.
• Swelling is hard, with involvement of isthmus and lateral lobes.
Diagnosis
• FNAC, incision biopsy
• CT scan
Treatment
• Due to the gross local infiltration into the vital structure in the
neck such as common carotid artery and trachea the
resectability rate is low.
• However, very rarely a surgeon will get an opportunity to excise
isthmus so as to relieve compression of the trachea
Postoperative radiotherapy is given as a palliative treatment.
• In many cases, death occurs within 6 to 8 months.
Lymphoma

It is rare. Hashimoto’s thyroiditis can predispose to lymphoma.

Older patients are commonly affected.
The tumour can present as rapidly-growing, large thyroid swelling
(primary lymphoma).
Sometimes, it can appear as a part of generalised lymphoma (non-
Hodgkin’s variety).
FNAC may give the diagnosis-Tru cut biopsy is ideal.
lymphomas of the thyroid respond very well to chemotherapy and
radiotherapy
THYROIDECTOMY
PREOPERATIVE PREPARATION

• Blood grouping and cross matching.

• Indirect laryngoscopy. Patient is asked to tell ‘E’ to check the
abduction of vocal cord
• T3, T4, TSH , Thyroid antibodies
• ECG and cardiac fitness especially in toxic goitre
POSITION
• Under general anaesthesia patient is put in supine position
with neck hyperextended by placing a sandbag under the
shoulder, with table tilt of 15 degree head up to reduce venous
congestion[ ROSE POSITION]
INCISION
• Horizontal crease incision is done , 2 finger breadth above the
sternal notch [KOCHER’S THYROID INCISION]
STEPS
• Skin and platysma are incised, upper flap raised up to thyroid
cartilage , lower flap up to sternoclavicular joint.
• Deep fascia is opened vertically in the midline.
• Straps muscles are retracted laterally to expose the gland.
• Identify and ligate the middle thyroid vein which drains in to
internal jugular vein .
• Inferior thyroid vein which form a venous plexus in front of the
trachea are ligated and cut. Throidea ima artery is identified and
cut.
• Branches of inferior thyroid artery are found close to the
thyroid ,they are ligated medially preserving the blood supply to
the para thyroid gland.
• Recurrent laryngeal nerve may pass anterior ,posterior or through the
branches of the artery and care is taken to preserve it,[RLN is injured
near the ligament of berry when cautery or artery forceps is used
indiscriminately while cutting the ligament to free the thyroid lobe]
• Dissection of superior thyroid pedicle and upper pole: division of
sternothyroid muscle near its upper part helps to ligate superior
thyroid artery and vein they should be ligated individually .external
branch of SLN lies posteromedial to thyroid vessels and should be
identified and preserved .
• Preservation of parathyroid and blood supply.
• Division of isthmus and separation of thyroid lobe.
• Irrigation of wound
• Closure of wound.
TYPES;
• Hemithyroidectomy
• Subtotal thyroidectomy
• Partial thyroidectomy
• Near total thyroidectomy
• Total thyroidectomy
• Hartley dunhill operation
total thyroidectomy
Indications
• Age older than 45 years
• Contralateral nodules
• Prior irradiation
• Familial – differentiated thyroid carcinoma
• Extra thyroidal extension
• Regional / local metastasis
Complications of thyroidectomy
Haemorrhage
• Due to slipping of ligatures either of superior thyroid artery or other pedicles or
small veins.
• Causes tachycardia, hypotension, breathlessness and compression over the
trachea may cause severe stridor, respiratory obstruction due to tension
hematoma under strap muscles.
• Management: immediate release of sutures including that of deep fascia has to
be done and pressure over the trachea is released
• Then patient is shifted to operation theatre and under general anesthesia
exploration is done and bleeders are ligated.
• Blood transfusion may be required.
Respiratory obstruction
It may be due to
• Hematoma-has to be evacuated
• Laryngeal edema or bilateral RLN palsy or tracheomalacia-
emergency endotracheal intubation along with steroid
injections
Tracheostomy may be required as a life saving procedure.
Recurrent laryngeal nerve palsy
• It can be transient or permanent
• Transient- recover in 3 weeks to 3 months, require steroid supplements,
and speech therapy
• Permanent paralysis are rare, present with hoarseness of voice,
aphonia, aspiration, ineffective cough.
• RLN palsy can be unilateral or bilateral.
• Unilateral-no specific treatment is required, steroid should be started.
Prednisolone 20 mg tid for 10 days orally after food with gradual tapering
in another 10 days.
• Bilateral –emergency tracheostomy is needed. Lateralization of cord is
done by arytenoidectomy or vocal cord lateralistaion through endoscope.
hypoparathyroidism
• Mostly it is temporary due to vascular spasm of parathyroid
gland.
• Present with weakness, positive Chvostek sign-[tapping above
the angle of jaw to stimulate branches of facial nerve causes
twitching of the angle of mouth and eyelids, carpopedal spasm,
convulsions.
• Serum calcium estimation is done and then 10 ml of 10%calcium
gluconate is given iv 8th hourly, later supplemented by oral
calcium carbonate 500 mg 8th hourly,
• After 3 to 6 weeks drug is stopped and serum calcium level is
repeated
Thyroid crisis/thyroid
storm/thyrotoxic crisis
• Rare but severe life threatening complication of
hyperthyroidism with acute hypermetabolic state induced by
release of excessive thyroid hormones.
• It can be due to surgical or medical causes.
• causes ; occur in a thyrotoxic patient inadequately prepared
for thyroidectomy or thyrotoxic patient present with crisis
following an unrelated operation or stress
• Other causes-infection, trauma, preeclampsia, diabetic
ketoacidosis, emergency surgery, stress, or chemotherapy ,
diabetes mellitus.
Features-
• Present 12- 24 hours after surgery
• Hyperpyrexia[.>41 degree Celsius],severe dehydration,
circulatory collapse ,hypotension, palpitation , tachycardia,
tachypnoea, hyperventilation, cardiac arrythmias ,cardiac
failure.
• GI symptoms: vomiting ,diarrhea , jaundice.
• Restlessness, irritability, delirium, tremor, convulsions and
coma can occur.
• Baileys symptom complex of thyroid storm are –insomnia,
anorexia, diarrhea, vomiting, sweating, emotional instability,
fever, tachycardia, aggravated toxic features, multiorgan
dysfunction.
Investigations
• Raised T3 , T4 ,suppressed TSH
• Raised serum calcium.
• ECG and echocardiography
• Raised total count
• Altered liver function tests
• Altered electrolytes.
treatment
• Supportive measures-rehydration
• Antiadrenergic drugs- Propranolol
• Thionamides- propylthiouracil
• Iodide compounds- Lugol’s iodide or potassium iodide
• Glucocorticoids-it inhibit peripheral conversion of t4 to t3.
• Bile acid suppressants-to prevent reabsorption of thyroid hormone
from the gut.
• Digitoxin
• Treating specific causes like diabetes, sepsis .fliud and electrolyte
management.
Other complications
• Injury to external laryngeal nerve
• Hypothyroidism
• Wound infection.
• Keloid formation.
• Recurrent thyrotoxicoxis.
Thank you