goldstein 2009 headnecksurgery
DESCRIPTION
Powerpoint about key items.TRANSCRIPT
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What Every Surgeon Should Know About Head and Neck SurgeryDavid P Goldstein MD FRCSCOtolaryngology-Head & Neck SurgerySurgical OncologyUniversity Health Network [email protected]
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ObjectivesFocus on approach to evaluation and management of a neck mass and Parotid masses
Briefly highlight key issues in diagnosis & management of following types of neck massCongenital disordersthyroglossal duct and branchial cleft cyst Salivary gland masses Carotid body tumor Squamous cell carcinoma
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Differential Diagnosis Congenital Thyroglossal duct cyst Branchial cleft cystLymphangioma
Inflammatory Infectious Non-infectious
NeoplasticPrimary malignanciesMetastases to nodes
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Approach to the Differential Diagnosis of Neck Masses Age Location, Location, LocationDuration of symptoms Risk factorsContents of neck mass
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Differential DiagnosisAge is a major determinant < 20 years C I N 20 40 years - ICN> 40 years -NICC= congenitalI= inflammatory N= neoplastic
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LocationAnterior Triangle Anterior- midlinePosterior- SCMInferior- clavicle Superior- mandible
Posterior Triangle Anterior- post border of SCMPosterior- trapezius Superior- junction of SCM & trapeziusInferior- clavicle
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Midline CongenitalThyroglossal duct cyst Dermoid
Lateral Neck/Ant CongenitalBranchial cleft cystThymic cyst
Posterior Neck vascular/Lymphatic malformation
Beware of the cystic neck mass in an adult Differential of Congenital Neck Masses Based on Location
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Differential Diagnosis of Neoplastic Neck Masses based on Location Lateral Anterior BenignSchwanomasCBTsSalivary gland
MalignanciesLymphomaNodal metastasisUADTSkinSalivary gland
Midline Anterior Thyroid Larynx cancerDirect extension Metastasis
Posterior Benign SchwanomasMalignant LymphomaNodal metastasisSkinUADTNon H & N Supraclavicular nodes (virchow nodes) Classically represents nodal metastases from below the diaphragm
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Differential Based on Growth Rate Slow growing over yearsTend to be benign or low grade malignancy
Rapidly growing neck massesInfectiousMalignant tend to progress over period of weeks to a few months
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Cystic Neck MassCongenital Thyroglossal duct cyst Branchial cleft cyst
Squamous cell cancerOropharyngeal/ tonsil primary
Thyroid CancerWDTC present with cystic mass Classically has dark brown appearance
Tail of parotid masses Warthins tumor
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Necrotic Neck MassInfectious Abscess Tuberculosis
Malignant Squamous cell carcinoma
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Work-Up of a Neck MassHistory Physical Inspection Palpation EndoscopyDiagnostic ImagingUS CT MRIPETBiopsy FNAOther Intraoperative endoscopyTB test
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HistoryDuration & growth rate of the massMalignant lesions tend to have progressive growth at more rapid rate than benign disease
Location Anterior, posterior or midline
Symptoms of inflammation or infectionMalignant neck masses with necrosis and skin involvement may mimic invasion Associated symptomsDysphagia, odynophagia, otalgia, hoarseness, oral cavity pain, nasal obstruction, epistaxis Suggests UADT malignancyB symptoms fever, weight loss & night sweats
Risk factors MalignancyTB exposureCat scratch
Keep the differential diagnosis in mind
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History Past medical history Skin cancerUADT malignancy SarcoidosisFungal infectionDental caries/dental work Trauma to head and neck Family historyThyroid cancerParagangliomas
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History- Risk Factors for MalignancyTobacco Cigarettes, chew, betel nut, cigar
Alcohol Two together are synergistic
VirusesHPV- oropharynx cancerEBV- nasopharynx cancersHIV- kaposis sarcoma, lymphoma
Immunosupression Transplant patients- Skin cancers, head and neck cancer
OccupationalWood working, leather work paranasal sinus cancer
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Risk Factors ContdPrevious head and neck cancer Develop second cancer in 18% of patients
Radiation exposure Salivary gland cancers, thyroid cancer, head and neck sarcomas
Autoimmune disordersSjogrens syndromelymphoma of salivary glandsHashimotos thyroiditisthyroid lymphoma
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Physical ExaminationNeck massLocation SizeFirmnessFixationPulsatilePresence of other neck masses or enlarged nodesMovement with tongue protrusion Auscultate for bruits if pulsatile
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Investigations If diagnosis of infectious or inflammatory is probable no further work up is necessary and appropriate therapy instituted
Suspected inflammatory disorders may require serologic tests
If there is any uncertainty in diagnosis or the suspected diagnosis is congenital or neoplastic further investigations are required
When in doubt on your exam do further investigations
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Fine Needle Aspiration Diagnostic accuracy 70% to 90% Simple/ cost effective US guidance increases yield & accuracy Indication almost any neck mass Only relative contraindication to FNA is pulsatile neck mass MOST IMPORTANT TEST- WHEN IN DOUBT PERFORM
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Fine Needle Aspiration Diagnose most head and neck cancers
Suspect lymphomaSend for flow cytometry
Cystic neck massSend washingsStain for thyroglobulin
Still a role for FNA in infectious and inflammatory disorders C & SPresence of pus does not necessarily exclude malignancy Squamous cell carcinoma can present with necrotic nodes
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Open BiopsyAlmost NO role in the initial work-up of a neck mass
ContraindicationsPulsatile massesParotid masses Suspected malignancies and FNA not been attempted
When to do Only after work-up is completed including FNA and diagnosis is still in question FNA is non-diagnostic FNA is negative but not in keeping with clinical picture
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Open BiopsySituations in which may be indicated Lymphoma FNA is suspicious for lymphoma & further tissue neededCystic neck mass FNA often inconclusiveSend cyst fluid for cytology Do full work-up prior to open biopsy Imaging and panendoscopy of UADT
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Open Biopsy
Incisional vs excisional biopsy Depends upon size, location and involvement if surrounding structures and suspected pathology
Keep in mind future surgery/neck dissectionMake the incision in line with potential incision one would use if further neck surgery is required
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Diagnostic Imaging Plain films Limited roleCXR
Ultrasound/DopplerUseful noninvasive testVascularitySolid vs Cystic Sensitive for adenopathyGuided FNACT scan & MRI Location Relation to other structuresVascularity Bone invasionMRI for soft tissue TongueNo dental artifactMRA/MRV
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MRI Soft tissue No dental artifact oral & oropharynxBone invasion
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CT scansBone imaging Soft tissue imagingDental artifact
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The Pulsating Neck MassDifferential DiagnosisNon-vascular mass situated near carotid artery Carotid body tumor (paraganglioma)Carotid artery aneurysm
Work-upImage first CT with contrast or MRI If confirmed vascular mass get MRI (MRA & MRV)Avoid FNA but not end of world Incisional biopsy contraindicated
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Presentation & Management of Specific Diagnosis
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Thyroglossal Duct CystPresentationMay occur at any age but most common in first 2 decades of life Midline at level of hyoid to thyroid, may be off centre May have hx of infectionClassic sign is rising with tongue extrusion
DiagnosisHistory & Physical Imaging
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Thyroglossal Duct Cyst CautionsMay have papillary ca arising in thyroglossal duct cyst rare but I perform FNACystic nodal metastasis from papillary thyroid ca to delphian node may have similar presentation
Treatment Excision sistrunk procedure (remove cyst with track up to tongue base including central portion of hyoid bone)Cosmetic and prevent recurrent infection
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Branchial Cleft CystPresentation mass along the anterior border of the SCM +/- a sinus tractSmooth painless slow growing unless infected, may fluctuate in size Treatment Surgical excision with removal of the tract Nerves at risk CN IX, X, XI XII
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Lymphoma hx of lymphadenopathy non-resolving B symptoms fever, night sweats, weight loss nodes soft mobile and rubbery, may be very large bull neck Diagnosis FNA- special solution & adequate amount Open biopsy- after FNA & lymphoma suspicious clinically must be sent fresh immunophenotyping & flow cytometry
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Carotid Body TumorCarotid body tumors (Paraganglioma)Arise from carotid body located at bifurcation between ICA & ECA Familial in up to 30%Bilateral or multiple
DiagnosisClassic imaging characteristics Vascular mass splaying ICA and ECA lyres signMRI get salt & pepper pattern from the flow voids
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Carotid Body TumorTreatment Excision Proximal and distal control of CAPrepared to bypass
ComplicationsVascular injury StrokeCN injury CN IX,X,XII
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Squamous Cell Carcinoma FNA Dx of SCCPrimary detectedNo Primary identified; Aka unknown primaryStage tumorTreat primary tumorTreat neck Imaging to stage the neck disease and help identify the primary source Panendoscopy in OR with biopsies of tongue base, hypopharynx, nasopharynx and unilateral tonsillectomy Treat neck and potential primary sites with radiation Primary Identified
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Squamous cell carcinomaGeneral Management PrinciplesStaging Hx, Px (flex scope)
Imaging CT Head and neck MR for tongue/tongue base Chest CT r/o synchronous primary
Panedoscopy/Quadroscopy (EUA under GA)Esophagoscopy, Bronchoscopy, Laryngoscopy, +/- nasopharynxUsed for cancers of larynx, hypopharynx and +/- oropharynx Assess the extent of the tumor & surgical resectabiltyObtain biopsy specimens Assess for 2nd primary
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Squamous cell carcinomaGeneral Management PrinciplesTreatment OptionsSurgeryRadiationChemotherapy Combination of bothRads or chemo can be given pre- or post op
Treat the primary site and the cervical lymph nodesTry and treat cervical lymph nodes with the same modality of therapy used for the primary site
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How do we decide which treatment to offer Provide the treatment that will offer the highest survival & control ratebased on literatureEarly stage disease often similar Advanced disease usually combinationQOL and morbidityOrgan preservation (larynx, hypopharynx)Preserve form and function (oropharynxSwallowing, speech, cosmesis
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Goals of TreatmentCureLocal regional control Survival
PalliationPainBleedingCosmesis
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Squamous cell carcinomaGeneral Management PrinciplesOral cavity surgeryOropharynx (tonsil, tongue base)- radiation or chemoradiation Hypopharynx cancer radiation or chemoradiation Larynx- transoral laser surgery for small tumors, radiation or chemoradiation for most Nasopharynx- chemoradiation or radiation
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AdenocarcinomaFNA diagnosis of adenocarcinoma in the neck from a distant siteLung, breast, GI, GUMay require an open biopsy to get more tissue for analysis to help identify site Image chest, abdo, pelvis Rarely treat the neck b/c metastatic disease - palliative therapy to prevent obstruction of trachea or esophagusNeck dissection - Only if primary site is controlled and patient is potentially curable
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Salivary Gland MassesMajor Salivary GlandsParotid- 80% (80%benign:20%malignant)Submandibular 15% (50:50)Sublingual (40:60)
Minor Salivary GlandsOral cavity/ oropharynxLarynxNose & paranasal sinuses
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ClassificationHemangiomasVascular malformationsLymphatic malformations1st Branchial cleft cyst
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ClassificationHIV TBAtypical TBActinomycosisCat-Scratch ToxoplasmosisTularemiaFungal
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History & Physical ExamMajority of neoplasms (benign or malignant) present as asymptomatic swelling
Risk factors for malignancyMajority idiopathicIonizing radiationSjogrens syndrome LymphomaSkin cancers
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Clinical Presentation of CancersPain Fixation & invasion of surrounding structures i.e. dermis, mandible TrismusFacial nerve paralysisAdenopathy
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Facial Nerve Paralysis with a Parotid MassVery rarely occurs with benign tumors12% to 15% parotid malignancies will exhibit facial paralysisPathologiesAdenoid cystic carcinomaPoorly differentiated carcinomaSCC
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Lab TestsSerology if suspect auto-immune process
Biopsy FNA mainstay Open biopsyVery rarely indicated for parotid masses: AVOID in most cases
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Fine Needle Aspiration
Debate about utility of FNA in parotid masses
Among all H & N sites the parotid gland is associated with the highest FNA inaccuracy rates
False negative rates higher then false positiveSensitivity rates reported can be as low as 38% when comes to recognizing malignant nature of parotid masses
Diagnostic precision is difficult
Determine high vs. low grade tumors is also difficult
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Why do an FNA?Accuracy in determining benign from malignant diseaseRates of ~ 90%
It may help in planning surgery especially informed consent
It may help in timing of surgery in resource restricted climate
Change clinical approach in up to 30% of patients
Results interpreted in the face of the clinical presentation and imaging
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Diagnostic ImagingUltrasoundIdentifying a massGuide FNAAssessing adenopathy
Technitium-99m Scan Diagnosis of Oncocytoma or Warthins tumor
Sialography Rarely used Little role in routine work-up of a parotid mass
CT Scan and/or MRIMain modalities for imaging parotid neoplasms
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Value of Imaging Know what you are getting intotip of iceberg with deep lobe involvementApproach
MalignancyResectabilitySkull baseStructures requiring resection Nodal statusFacial nerve statusAdenoid cystic carcinoma- proximal portion
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Common PathologiesBenign Pleomorphic adenoma Malignant degeneration into carcinoma ex-pleomorphic adenoma in 2-10% of pleomorphic adenomasWarthins tumor10% bilateral Malignant Mucoepidermoid carcinomaAdenoid cystic carcinomaMetastases from skin cancers
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Prognostic Factors with MalignancyHistologyHigh Grade Malignancies Older AgePain at presentationStage of primary tumor & nodal metastasesSkin invasionFacial nerve dysfunction Peri-neural growthPositive margins
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Malignant Secondary NeoplasmsDirect extensionCutaneous SCC/BCC
Lymphatic metastasesSCCMelanoma
Hematogenous MetastasesLung, Kidney, Breast
Direct extensionMetastatic SCC
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Factors in Decision MakingPatient factorsAge Co-morbiditiesPatients concerns
Tumor FactorsHistology Benign vs malignantDo you have a diagnosis & how certain are weGrowth rate Risk factors for malignancy
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SurgeryMajority can be managed with a superficial parotidectomySubtotal parotidectomyInvolvement of deep lobe Parotidectomy and transcervical approach to parapharyngeal space tumours
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Surgical ComplicationsTemporary VII nerve paresis=21%Freys syndrome=6%Infection=3.6%Hematoma=2.7%Hypertrophic scar=2.4%Seroma=0.8%Salivary fistula=0.4%
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Indications for Post-operative RadiotherapyHigh grade cancersRecurrent cancersGross or microscopic residual diseaseRegional lymph node metastasesEvidence of locally advanced tumors
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Thyroid Cancer
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Epidemic of Thyroid Cancer3.6 per 100 000 in 1973 8.7 per 100 000 in 2002represents 2.4 fold increaseDavies, L. et al. JAMA 2006;295:2164-2167.
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Thyroid MalignanciesWell-Differentiated Carcinomas (80-85%)Papillary Thyroid Carcinoma (PTC)Follicular Thyroid Carcinoma (FTC)Medullary Thyroid Carcinoma (5-10%)Anaplastic Thyroid Carcinoma (5-10%)Other malignanciesLymphomasDistant Metastases
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Well-Differentiated Thyroid Carcinoma Papillary Thyroid CA75-80% of thyroid carcinomasFrequently MultifocalDx on FNA or FSCommon Nodal DzInfrequent Distant DzSlightly Better PrognosisFollicular Thyroid CA5-10% of all thyroid carcinomasmore aggressive natural historySolitary LesionDx on final pathInfrequent Nodal DzCommon Distant DzSlightly Worse Prognosis
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Medullary Thyroid CarcinomaC - cell/parafollicular cell originMay be sporadic/nonfamilial (80%) or familial (20%)Familial formsMedullary thyroid carcinoma aloneMEN 2A (Sipples)MTC, Pheochromcytoma, HyperparathyroidismMEN 2BMTC, Pheochromocytoma, Mucosal Neuromas, Mutations on chromosome 10 for the RET proto-oncogeneRegional lymph node metastases - 50% Distant metastases
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Medullary Thyroid CarcinomaDiagnosis / ScreeningPentagastrin Stimulation with measurement of calcitonin levelsRet proto-oncogene screeningPatients who screen positive should undergo early thyroidectomyEarly intervention has resulted in 85% DFS at 15-20 yearsSerum calcitonin levels are used as a tumor marker in follow-up
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Medullary Thyroid CarcinomaTreatmentexclude pheochromocytomatotal thyroidectomycentral compartment lymphadenectomyelective lateral neck dissection for patients with palpable thyroid diseasetherapeutic lateral neck dissection for patients with palpable neck diseaseTreatmentAdjuvant external beam radiation may be used to enhance locoregional controlThe role of chemotherapy remains to be defined
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Anaplastic CarcinomaRare tumor noted for its rapid growth and nearly uniform lethal natureTypically develops in a pre-existing well differentiated thyroid carcinoma or a goiterPoor prognostic factorsAdvanced agePresence of regional or distant metastases
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Lymphoma of Thyroid Gland
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Thyroid NodulesApproximately 95% of thyroid nodules are benign4-7% of adults have thyroid nodulesWomen > menLikelihood of malignancy=5%Malignancy in clinically apparent nodules=20%
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Work-up of Thyroid NoduleHistoryexposure to ionizing radiationfamily history of thyroid carcinoma or other endocrine neoplasms (MEN syndromes)
Physical examinationVocal cord paralysisFixed and firmCervical nodes
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InvestigationsFNAThyroid U/STSH
No role for calcitonin, thyroglobulin and thyroid scintigraphy in the initial work-up
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FNA (R-A)Repeatedly Nondiagnostic (R-A)Cystic noduleSolid noduleObservation or surgerySurgery strongly consideredSuspicious for papillary ca or Hurthle cell neoplasmSurgery (R- A) Indeterminate Cytology (suspicious, follicular lesion or neoplasm)Follicular lesion Benign Follow (R-A)Thyroid scan HotCold (R-B) FNA
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Risk-group DefinitionsAGESA age (> 40)G gradeE extent of tumor extrathyroidal invasiondistant metastasesS size
Other TNM & MACIS AMESA age(M>40,F>50)M metastases (distant)E extent of tumorS size
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TreatmentSurgeryPost-operative radioactive iodinePost-operative thyroid suppressionExternal beam radiationPost-operative screening
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Total vs Less than Total ThyroidectomyEliminates all cancer and potential cancer (up to 50% CL)Allows RAIAllows monitoring with thyroglobulinDeals with tall cell and insular Ca & prevents transformation of PTC to anaplastic caNo compelling evidence for survival advantageDifficult for RAIThyroglobulin not possibleSpares the parathyroids & RLN
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Hemi vs Total ThyroidectomyLow risk diseaseControversialR.R decreased with total thyroidectomySome studies shown no difference
High risk patientsLocal & regional RR lower in total thyroidectomyPossibly improved cause specific survival
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Complications of ThyroidetcomyHypoparathyroidismTemp vs Permanent
Recurrent Laryngeal Nerve InjuryUnilat vs bilatTemp vs Perm
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ComplicationsPost-operative hematomaConcern re: airwayPrevent obstruction with incomplete strap muscle reapprox inferiorlyDrains do not prevent ManagementAirway emergency Open at bedside if patient in resp distress To OR
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Neck ManagementClinically negative neck no neck dissectionNodal metastases at presentationDo not adversely affect survivalDoes increase risk of locoregional recurrence80% of nodal metastases are central compartmentLateral ND only if clinically positive nodes or identified intra-op Functional neck dissection level II-VSpare IJV, SCM, CN XI, cervical plexus
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Radioactive Iodine Agent - I131EffectGoal of therapyScanThyroid ablationTherapeuticComplicationsShort termLong term
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Radioactive Iodine Only useful in cases of well differentiated thyroid malignanciesResultsOverall efficacy difficult to clearly delineateStudies have shown decreased locoregional recurrences and increased survival in some seriesLess efficacious in unresectable diseasePulmonary metastases respond better than bony metastases
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Thyroid Nodules in Pregnancy Uncertainty if nodules in pregnancy are more likely to be malignant than those found in non-pregnant womenNo population based studies
Recommendations (C)FNA unless low TSH Malignancy- follow with U/S Significant growth by 24 wks gestation surgery can be performed at that time pointRemains stable or diagnosed in 2nd half of pregnancysurgery may be performed after delivery Low TSHif persists after 1st trimester thyroid scan after pregnancy
Among solitary nodules with in determinant (suspicious, follicular neoplasm or Hurthle cell neoplasm) risk of malignancy is ~ 20%Procedure of choice in the evaluation of a thyroid nodule (Recommendation A)
Evaluation is the same except no RAI scan