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Carolyn Dacey Seib, MD, MAS
Stanford University School of Medicine
Stanford, CA
April 19, 2022

The parathyroids are small, oval-shaped glands that tightly regulate serum calcium levels through the production of parathyroid hormone (PTH), which stimulates the release of calcium from bone, increased GI absorption of calcium, and decreased renal excretion of calcium. Most commonly, each person has four parathyroid glands that are located in the neck, with two on each side, behind and just below each lobe of the thyroid gland.

Given their proximity to the thyroid and critical role in maintaining calcium homeostasis, it is important for surgeons to identify and protect the parathyroid glands during thyroid surgery. They can be as small as a grain of rice and encased in fat, making them difficult to identify. In addition, each parathyroid gland has a delicate blood supply and may be adherent to the capsule of the thyroid. Therefore, fine dissection is needed to preserve them in situ and with intact blood flow. If all parathyroid glands are injured, devascularized, or inadvertently removed during total or completion thyroidectomy, patients may experience temporary or permanent hypoparathyroidism, which is decreased production of PTH that results in hypocalcemia. Symptoms of hypocalcemia due to hypoparathyroidism include numbness and tingling in the fingers and around the mouth, muscle cramps or, when more severe, laryngospasm, seizures and dysrhythmias due to QT prolongation. The mainstay of treatment for hypoparathyroidism is supplementation with calcium and active vitamin D, which can be cumbersome for patients if large or frequent doses are required to prevent symptoms.

Permanent hypoparathyroidism is associated with impaired quality of life and long-term renal complications.(1,2) Although historically thought to be rare, recent studies suggest this complication may occur in up to 5% to 15% of patients following thyroidectomy.(3,4) As a result, there has been a renewed focus on techniques to identify and preserve parathyroid glands during operations in the neck. The most promising methods include near-infrared autofluorescence (NIRAF), which comes in probe-based and image-based systems, and parathyroid angiography using the fluorescent dye indocyanine green (ICG). NIRAF relies on the fact that parathyroids exhibit fluorescence, meaning when illuminated with light of a specific wavelength they reflect light back with a different wavelength. This allows the parathyroid glands to be differentiated from surrounding thyroid, fat, or lymph nodes and more easily identified.(5) In randomized clinical trials, NIRAF has been shown to improve the identification of parathyroid glands during thyroid surgery and decrease the rates of parathyroid autotransplantation, inadvertent parathyroid removal, and postoperative hypocalcemia.(6,7) However, autofluorescence is an intrinsic property of parathyroid tissue, detectable when the gland is in or out of the body, and does not predict viability. Parathyroid angiography with ICG can assess parathyroid gland perfusion at the conclusion of thyroidectomy to make decisions about parathyroid autotransplantation and guide postoperative calcium supplementation.(8,9) Given the documented short-term benefits of these tools are promising, additional studies are underway to determine long-term outcomes with their use. In addition to meticulous surgical technique, fluorescence imaging systems hold promise as adjunct tools to identify and preserve functional parathyroid glands during thyroid operations and reduce the risk of postoperative hypoparathyroidism.

References:
1. Büttner M, Musholt TJ, Singer S. Quality of life in patients with hypoparathyroidism receiving standard treatment: a systematic review. Endocrine. 2017;58(1):14-20.
2. Mitchell DM, Regan S, Cooley MR, et al. Long-Term Follow-Up of Patients with Hypoparathyroidism. The Journal of Clinical Endocrinology & Metabolism. 2012;97(12):4507-4514.
3. Maurer E, Maschuw K, Reuss A, et al. Total versus near-total thyroidectomy in Graves disease: results of the randomized controlled multicenter TONIG-trial. Annals of surgery. 2019;270(5):755-761.
4. Lončar I, Noltes ME, Dickhoff C, et al. Persistent Postthyroidectomy Hypoparathyroidism in the Netherlands. JAMA Otolaryngology–Head & Neck Surgery. 2021.
5. Solórzano CC, Thomas G, Berber E, et al. Current state of intraoperative use of near infrared fluorescence for parathyroid identification and preservation. Surgery. 2021;169(4):868-878.
6. Benmiloud F, Godiris-Petit G, Gras R, et al. Association of Autofluorescence-Based Detection of the Parathyroid Glands During Total Thyroidectomy With Postoperative Hypocalcemia Risk: Results of the PARAFLUO Multicenter Randomized Clinical Trial. JAMA Surgery. 2020;155(2):106-112.
7. Dip F, Falco J, Verna S, et al. Randomized Controlled Trial Comparing White Light with Near-Infrared Autofluorescence for Parathyroid Gland Identification During Total Thyroidectomy. Journal of the American College of Surgeons. 2019;228(5):744-751.
8. Vidal Fortuny J, Belfontali V, Sadowski S, Karenovics W, Guigard S, Triponez F. Parathyroid gland angiography with indocyanine green fluorescence to predict parathyroid function after thyroid surgery. Journal of British Surgery. 2016;103(5):537-543.
9. Vidal Fortuny J, Sadowski S, Belfontali V, et al. Randomized clinical trial of intraoperative parathyroid gland angiography with indocyanine green fluorescence predicting parathyroid function after thyroid surgery. Journal of British Surgery. 2018;105(4):350-357.

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

For more information on Thyroid Topics please visit: https://www.thyroid.org/thyroid-information/

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Catherine F. Sinclair, BSc (Biomed), MBBS (Hons), FRACS, FACS
Monash University, Malvern, Australia
Icahn School of Medicine at Mount Sinai, New York, NY
January 20, 2022

The rise of thyroid thermal ablative (TA) techniques in North America over the past 3 years has been rapid. These techniques have emerged as compelling alternatives to surgery for benign nodular disease. Multiple international studies have shown excellent long-term nodule volume reductions, minimal complications, rapid recovery, and efficacy in avoidance of thyroid hormone supplementation. Long-term follow-up data for North American populations is not yet available, however early results mirror those of international series. Future randomized trials comparing long-term outcomes of TA to surgery will better define the value of TA for thyroid nodule management.

Disease indications for TA are gradually evolving from benign nodules to include malignancy, regional metastatic disease, and hyperparathyroidism. The most promising of these new indications is papillary thyroid microcarcinoma (PTMC) where recent case series with 2-5 years follow-up have demonstrated low to non-existent rates of disease progression and metastases. If this data is validated in larger trials with longer follow-up durations, TA may well become the preferred treatment modality for select, localized PTMC although patient selection guidelines and indications for treatment will need to be carefully considered and characterized.

Apart from disease indications, some fundamental aspects of TA are still being refined.

• Is there an optimal patient age range for TA?
• Should TA be utilized prophylactically on smaller nodules that are not yet symptomatic in anticipation of future symptoms?
• What is the optimal energy to be delivered to ensure sustained nodule volume reduction?
• How much does nodule composition determine treatment response?
• What is the optimal follow-up protocol for ablated nodules and optimal timing for repeat ablation procedures?
• Should there be regulation of pre-requisite skills / training for physicians wishing to commence TA programs?

These are just some of the questions that will need to be addressed to ensure our patients are selected appropriately, are adequately counselled about risks and benefits, are assured of optimal procedural safety, and experience consistent treatment outcomes. Answering these questions will require multidisciplinary collaboration and forward planning and will ultimately define TA’s role in treatment algorithms for neck endocrine disease.

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

For more information on Thyroid Topics please visit: https://www.thyroid.org/thyroid-information/

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The post Thyroid Health Blog: Thermal Ablation for Thyroid Disease: Where are we in 2022? appeared first on American Thyroid Association.

Sara Ahmadi, MD, ECNU
Brigham and Women’s Hospital
Boston, MA
November 19, 2021

Thyroid nodules and thyroid cancer are common clinical problems in adults. The yearly incidence of thyroid cancer in the United States has almost tripled from 4.9 per 100,000 in 1975 to 14.3 per 100,000 in 2009. It has been predicted that thyroid cancer will replace colorectal cancer as the fourth leading cancer diagnosis by 2030(1,2).

Surgery is the primary treatment for thyroid cancer. Most patients with differentiated thyroid cancer have an excellent outcome with a 98% long-term disease-specific survival.

Traditional therapy with total thyroidectomy and radioactive iodine(RAI) has not shown added benefit in patients with low-risk differentiated thyroid cancer and might result in more harm. Thyroid lobectomy, selective use of radioactive iodine, and active surveillance have gained attention in recent years. They have been recommended as potential management options for low-risk thyroid cancer and micropapillary thyroid cancer in the current American Thyroid Association guidelines(2). This has led to significant changes in clinical practice. A study of 35,291 patients using National Surgery Quality Improvement Program Data showed that there has been a 10-fold increase in the rate of thyroid lobectomy rather than total thyroidectomy after the publication of 2015 ATA guidelines(3).

However, many patients with differentiated thyroid cancer may overestimate the mortality implications, which may drive their willingness to undergo more aggressive treatment(4).

The Discrete Choice Survey Study of a cohort of 150 patients with newly diagnosed differentiated thyroid cancer or thyroid nodule requiring surgery showed that risk of thyroid cancer recurrence impacted patient’s preference around surgical treatment options the most, followed by risk of requiring completion thyroidectomy and recurrent laryngeal nerve injury. The risk of hypocalcemia and hypothyroidism had the least impact on patients’ preferences around treatment options. This study also showed that the average patient would prefer total thyroidectomy unless the risk of requiring completion thyroidectomy can be reduced to 30% or less(5).

Patients’ concern and worry can also limit their acceptability of less aggressive treatment options. A survey of 243 patients with papillary thyroid cancer enrolled in an active surveillance program showed cancer worry is common among these patients. However, the patient’s level of concern improves over time(6).

Patient-physician communication also plays an essential role in providing the patient with a good understanding of the risks and benefits of different treatment options and an informed decision-making process. Computerized patient decision aids in addition to usual care can be associated with a significant increase in patients’ medical knowledge around treatment options and a reduction in decisional conflict at the time of decision making(7). In a recent study, 1319 patients with thyroid cancer in whom selective use of radioactive iodine was recommended were surveyed to assess patient perspectives regarding RAI decision making. More than half of the patients perceived they did not have a choice regarding RAI. These patients were also more likely to receive RAI and to have lower decision satisfaction(8).

There has been a significant change in clinical practice since the publication of the 2015 ATA guidelines. It is of vital importance that we improve our understanding of patients’ preferences, ensure excellent patient-physician communication, and use educational decision aids in conjunction with physician counseling to facilitate shared-decision making.

References:
1. Rahib L, Smith BD, Aizenberg R, Rosenzweig AB, Fleshman JM, Matrisian LM. Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer research. 2014;74(11):2913-2921.
2. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid : official journal of the American Thyroid Association. 2016;26(1):1-133.
3. Ullmann TM, Gray KD, Stefanova D, et al. The 2015 American Thyroid Association guidelines are associated with an increasing rate of hemithyroidectomy for thyroid cancer. Surgery. 2019.
4. Dixon PR, Tomlinson G, Pasternak JD, et al. The Role of Disease Label in Patient Perceptions and Treatment Decisions in the Setting of Low-Risk Malignant Neoplasms. JAMA Oncol. 2019.
5. Ahmadi S, Gonzalez JM, Talbott M, et al. Patient Preferences Around Extent of Surgery in Low-Risk Thyroid Cancer: A Discrete Choice Experiment. Thyroid : official journal of the American Thyroid Association. 2020;30(7):1044-1052.
6. Davies L, Roman BR, Fukushima M, Ito Y, Miyauchi A. Patient Experience of Thyroid Cancer Active Surveillance in Japan. JAMA Otolaryngol Head Neck Surg. 2019;145(4):363-370.
7. Sawka AM, Straus S, Rodin G, et al. Thyroid cancer patient perceptions of radioactive iodine treatment choice: Follow-up from a decision-aid randomized trial. Cancer. 2015;121(20):3717-3726.
8. Wallner LP, Reyes-Gastelum D, Hamilton AS, Ward KC, Hawley ST, Haymart MR. Patient-Perceived Lack of Choice in Receipt of Radioactive Iodine for Treatment of Differentiated Thyroid Cancer. J Clin Oncol. 2019;37(24):2152-2161.

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

For more information on Thyroid Topics please visit: https://www.thyroid.org/thyroid-information/

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Trisha D. Cubb, MD
Weill Cornell Medical College
Houston Methodist Academic Institute
Houston, TX
May 20, 2021

After receiving a diagnosis of papillary thyroid cancer, intuitively, the thought has been that surgery is the next step. While this was the standard in the past, we now know that in specific situations immediate surgery may not be necessary.

The incidence of thyroid cancer has increased significantly over the last three decades in large part due to tumors being identified incidentally on imaging studies. It is important to note that despite the increased rate of detection, the mortality rate from thyroid cancer remains very low and unchanged. Therefore, many of these cancers are low risk, and if left alone, would likely not pose a threat to the patient. There has been significant research looking at monitoring low risk thyroid cancers without surgery especially when surgically removing the tumor could potentially do more harm than good. This monitoring approach without surgical intervention is known as active surveillance.

In general, to be eligible for active surveillance: the tumor should be ≤1-1.5cm, there should not be any evidence of lymph node metastases, there should not be suspicion of more aggressive subtypes such as tall cell or sclerosing variant papillary thyroid cancer, and the tumor should not be located near a vulnerable area where growth could compromise important structures such as the trachea or the recurrent laryngeal nerve.

Active surveillance should be done at a medical center with a multidisciplinary approach and ultrasound expertise. Active surveillance typically entails monitoring with ultrasound every 6 months initially with extension of the surveillance interval over time.

While undergoing surveillance, if there is significant growth (≥3mm) of the nodule, evidence of lymph node involvement, extension into adjacent structures, or change in patient preference, then surgical intervention is recommended. Surgery at time of disease progression has been shown to have the same excellent prognosis. There have been ongoing prospective studies on active surveillance over the course of the last twenty years that have shown a low rate of progression (10-15%) and no deaths or development of distant metastasis during active surveillance.

The decision to pursue active surveillance is a shared decision between the patient and the physician after discussion of the risks and benefits based on each patient’s unique circumstances. Additional factors when considering active surveillance include: cost and time associated with appointments needed for surveillance, age of patient, medical comorbidities, and the possible increased emotional burden or anxiety that can result from opting to not remove the cancer at time of initial diagnosis.

The “best” treatment strategy will differ depending on each patient, so I hope that this information encourages discussion between patients and their endocrinologists to help decide which treatment option is best for them.

References:
1. Sugitani I, Ito Y, Takeuchi D, Nakayama H, Masaki C, Shindo H, Teshima M, Horiguchi K, Yoshida Y, Kanai T, Hirokawa M, Hames KY, Tabei I, Miyauchi A. Indications and Strategy for Active Surveillance of Adult Low-Risk Papillary Thyroid Microcarcinoma: Consensus Statements from the Japan Association of Endocrine Surgery Task Force on Management for Papillary Thyroid Microcarcinoma. Thyroid. 2021 Feb;31(2):183-192.
2. Molinaro E, Campopiano MC, Pieruzzi L, Matrone A, Agate L, Bottici V, Viola D, Cappagli V, Valerio L, Giani C, Puleo L, Lorusso L, Piaggi P, Torregrossa L, Basolo F, Vitti P, Tuttle RM, Elisei R. Active Surveillance in Papillary Thyroid Microcarcinomas is Feasible and Safe: Experience at a Single Italian Center. J Clin Endocrinol Metab. 2020 Mar 1;105(3):e172–80.
3. Tuttle RM, Alzahrani AS. Risk Stratification in Differentiated Thyroid Cancer: From Detection to Final Follow-up. J Clin Endocrinol Metab. 2019 Mar 15;104(9):4087–100.
4. Tuttle RM, Fagin JA, Minkowitz G, Wong RJ, Roman B, Patel S, Untch B, Ganly I, Shaha AR, Shah JP, Pace M, Li D, Bach A, Lin O, Whiting A, Ghossein R, Landa I, Sabra M, Boucai L, Fish S, Morris LGT. Natural History and Tumor Volume Kinetics of Papillary Thyroid Cancers During Active Surveillance. JAMA Otolaryngol Head Neck Surg. 2017 Oct 1;143(10):1015-1020.
5. Miyauchi A. Clinical Trials of Active Surveillance of Papillary Microcarcinoma of the Thyroid. World J Surg. 2016 Mar;40(3):516-22.
6. Ito Y, Miyauchi A, Inoue H, Fukushima M, Kihara M, Higashiyama T, Tomoda C, Takamura Y, Kobayashi K, Miya A. An observational trial for papillary thyroid microcarcinoma in Japanese patients. World J Surg. 2010 Jan;34(1):28-35.
7. ATA Thyroid Patient Information- Microcarcinomas of the Thyroid Gland https://www.thyroid.org/microcarcinomas-thyroid-gland/

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

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Coauthors Akira Miyauchi, Yasuhiro Ito, and Hitomi Oda, Kuma Hospital, Kobe, Japan, report that in only 8% of patients with PMC evaluated during the study period did the tumor increase in size by 3 mm or more, and only 3.8% of patients had a new metastasis. PMCs were least likely to grow in older patients (60 years of age or older). Furthermore, compared to a management approach of “active surveillance,” patients who underwent immediate surgery had significantly higher risks of unfavorable events and more than 4 times the total cost of PMC treatment.

“The seminal observations by the groups from Kuma Hospital and the Cancer Institute Hospital in Tokyo from Japan indicate that the vast majority of papillary thyroid microcarcinomas have an indolent behavior and that active surveillance may be an alternative approach in many patients,” says Peter A. Kopp, MD, Editor-in-Chief of Thyroid^® and Professor of Medicine, Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. “Similar prospective studies are now underway in other parts of the world. Ultimately, the goal is to avoid unnecessary treatment. The challenge that lies ahead of us is to identify the small group of patients with papillary thyroid microcarcinomas that require active intervention.”

About the Journal
Thyroid^®, the official journal of the American Thyroid Association^®, is an authoritative peer-reviewed journal published monthly online with open access options and in print. The Journal publishes original articles and timely reviews that reflect the rapidly advancing changes in our understanding of thyroid physiology and pathology, from the molecular biology of the cell to clinical management of thyroid disorders. Complete tables of content and a sample issue may be viewed on the Thyroid website The complete Thyroid^® Journal Program includes the highly valued abstract and commentary publication Clinical Thyroidology^®, led by Editor-in-Chief Jerome M. Hershman, MD and published monthly, and the groundbreaking videojournal companion VideoEndocrinology^™, led by Editor Gerard Doherty, MD and published quarterly. Complete tables of content and sample issues may be viewed on the Thyroid website.

About the Society
The American Thyroid Association^®(ATA) is the leading worldwide organization dedicated to the advancement, understanding, prevention, diagnosis, and treatment of thyroid disorders and thyroid cancer. ATA is an international membership medical society with over 1,700 members from 43 countries around the world. Celebrating its 94th anniversary, the ATA delivers its mission — of being devoted to thyroid biology and to the prevention and treatment of thyroid disease through excellence in research, clinical care, education, and public health — through several key endeavors: the publication of highly regarded professional journals, Thyroid^® , Clinical Thyroidology^® , and VideoEndocrinology^™; annual scientific meetings; research grant programs for young investigators, biennial clinical and research symposia; support of online professional, public and patient educational programs; and the development of guidelines for clinical management of thyroid disease and thyroid cancer. The ATA promotes thyroid awareness and information through its online Clinical Thyroidology^® for the Public (distributed free of charge to over 11,000 patients and public subscribers) and extensive, authoritative explanations of thyroid disease and thyroid cancer in both English and Spanish. The ATA website serves as the clinical resource for patients and the public who look for reliable information on the Internet.

About the Publisher
Mary Ann Liebert, Inc., publishers is a privately held, fully integrated media company known for establishing authoritative peer-reviewed journals in many promising areas of science and biomedical research, including Diabetes Technology & Therapeutics, Journal of Women’s Health, and Metabolic Syndrome and Related Disorders. Its biotechnology trade magazine, GEN (Genetic Engineering & Biotechnology News), was the first in its field and is today the industry’s most widely read publication worldwide. A complete list of the firm’s more than 80 journals, books, and newsmagazines is available on the Mary Ann Liebert, Inc., publishers website.

The post Active Surveillance of Low-Risk Papillary Microcarcinoma of the Thyroid Proposed as First-Line Management appeared first on American Thyroid Association.

What is the thyroid gland?

The thyroid gland is a butterfly-shaped endocrine gland that is normally located in the lower front of the neck. The thyroid’s job is to make thyroid hormones, which are secreted into the blood and then carried to every tissue in the body. Thyroid hormone helps the body use energy, stay warm and keep the brain, heart, muscles, and other organs working as they should. (Figure 1)

Courtesy of Greg Randolph, MD
Figure 1
Enlarge Image

General Information

Thyroid operations are advised for patients who have a variety of thyroid conditions, including both cancerous and benign (non-cancerous) thyroid nodules, large thyroid glands (goiters), and overactive thyroid glands. There are several thyroid operations that a surgeon may perform, including:

1. excisional biopsy – removing a small part of the thyroid gland (rarely in use today);
2. lobectomy – removing half of the thyroid gland (the most frequent way to remove a nodule); (Figure 2)
3. total thyroidectomy, which removes all identifiable thyroid tissue. (Figure 2)

Courtesy of Andrew Hinson, MD
Figure 2

There are specific indications for each of these operations. The main risks of a thyroid operation involve possible damage to important structures near the thyroid, primarily the parathyroid glands (which regulate calcium levels) and the recurrent and external laryngeal nerves (which control the vocal cords).

Questions and Considerations

When thyroid surgery is recommended, patients should ask several questions regarding the surgery including:

1. Why do I need an operation?
2. Are there other means of treatment?
3. How should I be evaluated prior to the operation?
4. How do I select a surgeon?
5. What are the risks of the operation?
6. How much of my thyroid gland needs to be removed?
7. Will I need to take a thyroid pill after my operation?
8. What can I expect once I decide to proceed with surgery?
9. What will be my physical restrictions following surgery?
10. Will I lead a normal life after surgery?

1. Why do I need an operation?
The most common reason for thyroid surgery is to remove a thyroid nodule, which has been found to be suspicious through a fine needle aspiration biopsy (see Thyroid Nodule brochure). Surgery may be recommended for the following biopsy results:

1. cancer (papillary cancer); (Figure 3)
2. possible cancer (follicular neoplasm or atypical findings); or
3. inconclusive biopsy;
4. molecular marker testing of biopsy specimen which indicates a risk for malignancy.

Surgery may be also recommended for nodules with benign biopsy results if the nodule is large, if it continues to increase in size or if it is causing symptoms (pain, difficulty swallowing, etc.). Surgery is also an option for the treatment of hyperthyroidism (Grave’s disease or a “toxic nodule” (see Hyperthyroidism brochure), for large and multinodular goiters and for any goiter that may be causing symptoms.

Courtesy of Greg Randolph, MD
Figure 3
Enlarge Image

2. Are there other means of treatment?
Surgery is definitely indicated to remove nodules suspicious for thyroid cancer. In the absence of a possibility of thyroid cancer, there may be nonsurgical options of therapy depending on the diagnosis. You should discuss other options for therapy with your physician who has expertise in thyroid diseases.

3. How should I be evaluated prior to the operation?
As for other operations, all patients considering thyroid surgery should be evaluated preoperatively with a thorough and comprehensive medical history and physical exam including cardiopulmonary (heart) evaluation. An electrocardiogram and a chest x-ray prior to surgery are often recommended for patients who are over 45 years of age or who are symptomatic from cardiac disease. Blood tests may be performed to determine if a bleeding disorder is present.

Any patients who have had a change in voice or who have had a previous neck operation (thyroid surgery, parathyroid surgery, spine surgery, carotid artery surgery, etc.) and/or who have suspected invasive thyroid disease should have their vocal cord function evaluated preoperatively. This is necessary to determine whether the recurrent laryngeal nerve that controls the vocal cord muscles is functioning normally and is becoming a norm of practice. Finally, if medullary thyroid cancer is suspected, patients should be evaluated for coexisting adrenal tumors (pheochromocytomas) and for hypercalcemia and hyperparathyroidism.

4. How do I select a surgeon?
In general, thyroid surgery is best performed by a surgeon who has received special training and who performs thyroid surgery on a regular basis. The complication rate of thyroid operations is lower when the operation is done by a surgeon who does a considerable number of thyroid operations each year. Patients should ask their referring physician where he or she would go to have a thyroid operation or where he or she would send a family member.

5. What are the risks of the operation?
The most serious possible risks of thyroid surgery include:

1. bleeding that can cause acute respiratory distress,
2. injury to the recurrent laryngeal nerve that can cause permanent hoarseness, and breathing problems with possible tracheotomy in rare cases if injury is sustained on both sides and
3. damage to the parathyroid glands that control calcium levels in the body, causing hypoparathyroidism and hypocalcemia.

These complications occur more frequently in patients with invasive tumors or extensive lymph node involvement, in patients requiring a second thyroid surgery, and in patients with large goiters that go below the collarbone. Overall the risk of any serious complication should be less than 2%. However, the risk of complications discussed with the patient should be the particular surgeon’s risks rather than that quoted in the literature. Prior to surgery, patients should understand the reasons for the operation, the alternative methods of treatment, and the potential risks and benefits of the operation (informed consent).

6. How much of my thyroid gland needs to be removed?
Your surgeon should explain the planned thyroid operation, such as lobectomy (hemi) or total thyroidectomy, and the reasons why such a procedure is recommended. For patients with papillary or follicular thyroid cancer many, but not all, surgeons recommend total or neartotal thyroidectomy when they believe that subsequent treatment with radioactive iodine might be beneficial. For patients with large (>1.5 cm) or more aggressive cancers and for patients with medullary thyroid cancer, more extensive lymph node dissection is necessary to remove possibly involved lymph node metastases.

Thyroid lobectomy may be recommended for overactive one-sided nodules or for benign one-sided nodules that are causing symptoms such as compression, hoarseness, shortness of breath or difficulty swallowing. A total or near – total thyroidectomy may be recommended for patients with Graves’ Disease (see Hyperthyroidism brochure) or for patients with enlarged multinodular goiters.

7. Will I need to take a thyroid pill after my operation?
The answer to this depends on how much of the thyroid gland is removed. If half (hemi) thyroidectomy is performed, there is an 80% chance you will not require a thyroid pill UNLESS you are already on thyroid medication for low thyroid (Hashimoto’s thyroiditis). If you have your entire (total) or remaining (completion) thyroidectomy, then you have no internal source of thyroid hormone remaining and you will need lifelong thyroid hormone replacement.

8. What can I expect once I decide to proceed with surgery?
Once you have met with the surgeon and decided to proceed with surgery, you will be scheduled for your pre-op evaluation (see above) and will meet with the anesthesiologist (the person who will put you to sleep during the surgery). You should have nothing to eat or drink after midnight on the day before surgery and should leave valuables and jewelry at home. The surgery usually takes 2-2½ hours, after which time you will slowly wake up in the recovery room. Surgery may be performed through a standard incision in the neck or may be done through a smaller incision with the aid of a video camera (Minimally invasive video assisted thyroidectomy). Under special circumstances, thyroid surgery can be performed with the assistance of a robot through a distant incision in either the axilla or the back of the neck. There may be a surgical drain in the incision in your neck (which will be removed after the surgery) and your throat may be sore because of the breathing tube placed during the operation. Once you are fully awake, you will be moved to a bed in a hospital room where you will be able to eat and drink as you wish. Many patients having thyroid operations are hospitalized for about 24 hours and can be discharged on the morning following the operation.

9. What will be my physical restrictions following surgery?
Most surgeons prefer a brief limitation is extreme physical activities following surgery. This is primarily to reduce the risk of a post operative neck hematoma (blood clot) and breaking of stitches in the wound closure. These limitations are brief, usually followed by a quick transition back to unrestricted activity. Normal activity can begin on the first postoperative day. Vigorous sports, such as swimming, and activities that include heavy lifting should be delayed for at least ten days to 2 weeks.

10. Will I be able to lead a normal life after surgery?
Yes. Once you have recovered from the effects of thyroid surgery, you will usually be able to doing anything that you could do prior to surgery. Some patients become hypothyroid following thyroid surgery, requiring treatment with thyroid hormone (see Hypothyroidism brochure). This is especially true if you had your whole thyroid gland removed. Thyroid hormone replacement therapy might be delayed for several weeks if you are to receive radioactive iodine (RAI) therapy unless there is a plan for you to receive TSH injection prior to RAI.

References

Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer (2009)

Revised American Thyroid Association Guidelines for the Management of Medullary Thyroid Carcinoma The American Thyroid Association Guidelines Task Force on Medullary Thyroid Carcinoma (2015)

Radiation Safety in the Treatment of Patients with Thyroid Diseases by Radioiodine ¹³¹I: Practice Recommendations of the American Thyroid Association (2011)

American Thyroid Association Statement on Surgical Application of Molecular Profiling for Thyroid Nodules: Current Impact on Perioperative Decision Making (2015)

American Thyroid Association Statement on Optimal Surgical Management of Goiter (2014)

American Thyroid Association Statement on Outpatient Thyroidectomy (2013)

American Thyroid Association Consensus Review and Statement Regarding the Anatomy, Terminology, and Rationale for Lateral Neck Dissection in Differentiated Thyroid Cancer (2012)

Thyroid Surgery Brochure for Saving and Printing (PDF File, 538 KB)

Thyroid Surgery Brochure for Saving and Printing (PDF File, 248 KB)

The post Thyroid Surgery appeared first on American Thyroid Association.

The poster, “The Importance of Clinician-Performed Ultrasound for the Proper Initial Surgical Management of Endocrine Surgery,” presented by Kevin Parrack, presents several key results. Preoperative ultrasound performed by a surgeon detected affected lymph nodes that could not be felt on physical examination and were not identified on previous imaging studies performed by a radiologist in 31% of cases. Previous imaging tests done by radiology could have included US, computed tomography (CT), or magnetic resonance imaging (MRI). Among the patients who had radiologist-performed US specifically before being referred to an endocrine surgeon, 35% had non-palpable cancerous lymph nodes detected on clinician-performed US. The discovery that the cancer had spread beyond the thyroid gland altered the surgical plan and allowed for removal of the affected lymph nodes at the time of the thyroidectomy.

“Ultrasound prior to thyroidectomy is an important tool for planning surgery, in that it can delineate local extent of tumor and likely nodal metastases better than physical exam and alternative imaging modalities,” says Julie Ann Sosa, MD, Program Committee Co-Chair; Professor of Surgery and Medicine, Chief, Section of Endocrine Surgery, and Director of Health Services Research, Department of Surgery, Duke University School of Medicine; and Leader, Endocrine Neoplasia Diseases Group, Duke Cancer Institute and Duke Clinical Research Institute, Durham, NC..”Different providers can perform the ultrasound and neck mapping, including surgeons, radiologists, endocrinologists, and pathologists. These data are significant in that they suggest the surgeon is uniquely positioned to perform ultrasound in a way that it affords critical information that would not otherwise be available for optimizing surgical approach.”

About the ATA

The American Thyroid Association (ATA) is the leading worldwide organization dedicated to the advancement, understanding, prevention, diagnosis and treatment of thyroid disorders and thyroid cancer. ATA is an international individual membership organization with over 1,700 members from 43 countries around the world. Celebrating its 90^th anniversary, ATA delivers its mission through several key endeavors: the publication of highly regarded monthly journals, THYROID, Clinical Thyroidology (CT), VideoEndocrinology and CT for Patients; annual scientific meetings; biennial clinical and research symposia; research grant programs for young investigators, support of online professional, public and patient educational programs through www.thyroid.org; and the development of guidelines for clinical management of thyroid disease. Visit www.thyroid.org for more information.

Media Contact
Bobbi Smith
Executive Director of the American Thyroid Association
Email: thyroid@thyroid.org

The post Surgeon Should Perform Preoperative Ultrasound to Avoid Missing Metastases in Differentiated Thyroid Cancer appeared first on American Thyroid Association.

Youben Fan, from Affiliated Sixth People’s Hospital, Shanghai, China, reports no difference in cure rates between the two approaches, or in the frequency with which treated patients have persistent or recurrent hyperparathyroidism. MIVAP demonstrated several advantages compared to BNE, including a lower incidence of early severe hypocalcemia, a higher cosmetic satisfaction rate, shorter operations, less postoperative pain, and shorter hospital stays. These findings are presented in the poster entitled “Minimally Invasive Video-assisted Parathyroidectomy Compared with the Conventional Open Operation for Primary Hyperparathyroidism: A Randomized Controlled Trial.”

“Primary hyperparathyroidism is a common condition for which parathyroidectomy is curative,” says Julie Ann Sosa, MD, Program Committee Co-Chair; Professor of Surgery and Medicine, Chief, Section of Endocrine Surgery, and Director of Health Services Research, Department of Surgery, Duke University School of Medicine; and Leader, Endocrine Neoplasia Diseases Group, Duke Cancer Institute and Duke Clinical Research Institute, Durham, NC. “While bilateral neck exploration has been the traditional approach, minimally invasive parathyroidectomy has emerged as an alternative technique associated with improved patient outcomes, largely based on retrospective, single institution or surgeon clinical series. This report is potentially exciting because it represents a randomized controlled trial and specifically looks at minimally invasive, video-assisted parathyroidectomy as compared to traditional open parathyroidectomy.”

About the ATA

The American Thyroid Association (ATA) is the leading worldwide organization dedicated to the advancement, understanding, prevention, diagnosis and treatment of thyroid disorders and thyroid cancer. ATA is an international individual membership organization with over 1,700 members from 43 countries around the world. Celebrating its 90^th anniversary, ATA delivers its mission through several key endeavors: the publication of highly regarded monthly journals, THYROID, Clinical Thyroidology (CT), VideoEndocrinology and CT for Patients; annual scientific meetings; biennial clinical and research symposia; research grant programs for young investigators, support of online professional, public and patient educational programs through www.thyroid.org; and the development of guidelines for clinical management of thyroid disease. Visit www.thyroid.org for more information.

Media Contact
Bobbi Smith
Executive Director of the American Thyroid Association
Email: thyroid@thyroid.org

The post Advantages of Minimally Invasive Surgery to Treat Hyperparathyroidism appeared first on American Thyroid Association.