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Dynamic Risk Group Analysis and Staging for Differentiated Thyroid Cancer

Introduction A defined set of clinical factors and pathologic characteristics have been used in different staging systems (e.g., Tumor, Node, and Metastases [TNM] with American Joint Committee on Cancer [AJCC]; metastasis, age, completeness of resection, invasion, and size [MACIS]; age, metastasis, extent, and size [AMES]; and age, gender, extent, and size [AGES]) to predict the risk of death in differentiated thyroid cancer. The most important of…

Noninvasive Follicular Thyroid Neoplasm With Papillary-Like Nuclear Features (NIFTP)

Video 23.1 Introduction to [CR] , Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features. Introduction Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) is a recently defined entity that was accepted by the World Health Organization (WHO) in 2017. Before 2016, these tumors were diagnosed as noninvasive encapsulated follicular variants of papillary carcinoma. The nomenclature change was proposed to optimize patient care, eliminate the stigma…

Follicular Thyroid Cancer

Introduction Follicular thyroid cancer (FTC) is a subset of follicular cell–derived thyroid cancer. It falls within the broad category of differentiated thyroid cancer (DTC) and is the second most common histologic subtype behind papillary thyroid cancer (PTC). Unlike PTC, the rate of FTC diagnosis is declining over time due to changes in the diagnostic criteria and maybe due to environmental factors such as iodine sufficiency. Compared…

Papillary Carcinoma Observation

Video 21.1 Introduction to [CR] , Papillary Carcinoma Observation. Introduction Recognizing that the incidence of papillary microcarcinoma (PMC) detected on autopsy and clinical screening studies far exceeded the prevalence of clinically apparent thyroid cancer more than 20 years ago, Miyauchi from the Kuma Hospital in Kobe, Japan, hypothesized that most PMCs would remain small and never develop into clinically significant disease. Furthermore, he posited that immediate…

Papillary Thyroid Microcarcinoma

Video 20.1 Introduction to [CR] , Papillary Thyroid Microcarcinoma. The World Health Organization (WHO) defines papillary thyroid cancers that are 10 mm or less in maximal diameter as papillary microcarcinomas. These are frequently incidentally discovered lesions. Previously, these lesions were called occult papillary cancers because they were primarily incidental findings at autopsy or after thyroidectomy. However, they are typically easily identified on high-resolution ultrasonography, which makes…

Papillary Thyroid Cancer

Introduction Classic papillary thyroid cancer (PTC) tends to have an indolent clinical course with low morbidity and mortality. Nonetheless, this disease has a wide spectrum of biologic and clinical behavior that can result in tumor recurrence and death, depending on patient and tumor features and the initial approach to management. The incidence of thyroid cancer is on the rise and though the reasons for this trend…

Molecular Pathogenesis of Thyroid Neoplasia

Introduction Over the past decade, there has been an enormous expansion of knowledge regarding the molecular pathogenesis of thyroid tumors and major advances in clinically applying this knowledge to enhance diagnostic approaches to thyroid nodules and informing clinical trials and treatments for patients with progressive disease. This includes not only somatic genomics (i.e., genetic changes only found in tumor cells) but also germline predisposing genomics (i.e.,…

Differentiated Thyroid Cancer Incidence

Video 17.1 Introduction to [CR] , Differentiated Thyroid Cancer Incidence. Incidence of Differentiated Thyroid Cancer Introduction Differentiated thyroid carcinoma (DTC) is the umbrella term that encompasses all malignancies arising from thyroid epithelial follicular cells and is the major form of thyroid carcinoma, comprising > 90% of total thyroid malignancies. This major category is subdivided into three types: papillary thyroid carcinoma (PTC), which comprises 80% to 85%…

Radiofrequency and Laser Ablation of Thyroid Nodules and Parathyroid Adenoma

Video 16.1 Laser and Radiofrequency Treatment of Thyroid Nodules and Parathyroid Adenoma. Video 16.2 RFA of a Thyroid Nodule Using the Trans-isthmic Approach and the Moving Shot Technique. Video 16.3 RFA of a Recurrent Tumor in the Subcutaneous Location with Hydrodissection and the Moving Shot Technique. Introduction Historically, surgery, radioiodine therapy, and levothyroxine medication have been the main treatment options for benign thyroid nodules; however, each…

Laryngeal Examination in Thyroid and Parathyroid Surgery

Video 15.1 Fiberoptic Laryngeal Exam: Laryngeal Anatomy and Function. Introduction Thyroid and parathyroid surgery is undertaken by surgeons from a variety of surgical disciplines and backgrounds. The implications of this type of surgery on the voice are a frequent patient concern and a major determinant of surgical quality outcomes. Although several neural and non-neural factors can influence voice outcomes, injury to the recurrent laryngeal nerve (RLN)…

Preoperative Radiographic Mapping of Nodal Disease for Papillary Thyroid Carcinoma

Papillary thyroid carcinoma (PTC) is the most common histologic type of thyroid carcinoma worldwide. Microscopic lymph node (LN) metastases occur in the majority of patients presenting with PTC. LN metastases are associated with an increased risk of local or regional recurrence of cancer, and they can be a negative prognostic indicator relative to survival in certain groups such as papillary thyroid cancer. LN metastases may necessitate…

Ultrasound of the Thyroid and Parathyroid Glands

Video 13.1 Ultrasound of the Thyroid and Parathyroid Glands: Equipment and Techniques. Introduction The clinical utilization of ultrasound (US) continues to expand, with increasing applications in the head and neck. US remains the primary imaging tool for the thyroid gland. It is cost effective, rapid in information accrual, well-tolerated by patients, and helps patients avoid unnecessary radiation exposure. The image processing capabilities of current US machines…

Fine-Needle Aspiration and Molecular Analysis

Video 12.1 Introduction to [CR] , Fine-Needle Aspiration and Molecular Analysis. Introduction Ultrasound-guided fine-needle aspiration (FNA) biopsy is the gold standard for diagnostic assessment of thyroid nodules, yet cytologic evaluation may be limited, with up to 30% of samples classified as cytologically indeterminate by the widely accepted Bethesda classification scheme (see chapter 11 Fine-Needle Aspiration of the Thyroid Gland– Bethesda II). Nodules characterized as Bethesda III…

Fine-Needle Aspiration of the Thyroid Gland: The 2017 Bethesda System

Video 11.1 Thyroid Nodule Fine-Needle Aspiration. Video 11.2 Fine-Needle Aspiration Slide Preparation. Introduction Fine-needle aspiration (FNA) is an essential test in the evaluation of a patient with a thyroid nodule. The result of the FNA determines, in large part, whether a patient can be followed clinically or referred for surgery. Guidelines have been established for selecting a nodule for aspiration. Once the decision has been made…

The Evaluation and Management of Thyroid Nodules

Video 10.1 Introduction to [CR] , The Evaluation and Management of Thyroid Nodules. Introduction Thyroid nodules are common and may be found in up to two-thirds of the population. By definition, thyroid nodules are discrete lesions contained within, yet radiologically distinct from, the parenchyma of the thyroid gland. A substantial increase in both thyroid nodule detection and thyroid cancer detection has occurred over the past three…

Reoperation for Benign Thyroid Disease

Introduction Thyroid disease is broadly divided into hypothyroidism, hyperthyroidism, structural abnormalities of the thyroid, and neoplasia of the thyroid gland (see Chapter 6 , Surgery of Cervical and Substernal Goiter). Thyroid cancer is a relatively uncommon malignancy in most countries, accounting for just 1% of all cancers in the United Kingdom and representing the 11th most commonly diagnosed cancer in Australia. In contrast, benign thyroid disease,…

Surgical Management of Hyperthyroidism

Introduction Primary hyperthyroidism is a condition in which the thyroid gland synthesizes and secretes inappropriately high levels of thyroid hormone(s), causing signs and symptoms of hypermetabolism and excess sympathetic nervous system activity. The term hyperthyroidism is distinct from thyrotoxicosis, a clinical state in which there is an inappropriately high thyroid hormone action in tissues. Thyrotoxicosis can result from hyperthyroidism as well as from other etiologies. Patients…

Approach to the Mediastinum: Transcervical, Transsternal, and Video-Assisted

It is not uncommon that resection of thyroid or parathyroid pathology requires entry into and exploration of the mediastinum. Although resection can often be achieved through a transcervical approach, surgeons treating thyroid and parathyroid diseases must be familiar with thoracic approaches to the mediastinum and the circumstances under which it might benefit to seek the involvement of a cardiothoracic surgeon either preoperatively or intraoperatively. In this…

Surgery of Cervical and Substernal Goiter

Video 6.1 Surgery for Cervical and Substernal Goiter. The word goiter is derived from “guttur,” the Latin term for throat. Surgery for goiter is as complex as it is rewarding. With goiter, the normally complex neck base anatomy is distorted in sometimes predictable and often unpredictable patterns. Size, goiter vascularity, distortion of anatomy, substernal extension, and restrictions imposed by the bony confines of the thoracic inlets…

Thyroglossal Duct Cysts and Ectopic Thyroid Tissue

Embryology The median anlage of the thyroid originates from the endodermal segment in the floor of the primitive pharynx at the foramen cecum located in the midline at the junction of the anterior two-thirds of the tongue (first branchial arch derivative) and posterior one-third (third branchial arch derivative) (see Chapter 2 , Applied Embryology of the Thyroid and Parathyroid Glands). Between 5 and 7 weeks of…