Surgery Papillary Thyroid CA

DISCUSSION
THYROID
Anatomy
located adjacent to the throid cartilage
connected in the midline by an isthmus
pyramidal lobe is present in about 50% of patients
thyroid lobes extend to the midthyroid cartilage superiorly and lie

adjacent to carotid sheaths and sternocleidomastoid muscles laterally
thyroid gland is enveloped by a loosely connecting fascia that is
formed from the partition of the deep cervical fascia into anterior and
posterior divisions
true capsule of the thyroid is a thin, densely adherent fibrous layer

that sends out septa that invaginate into the gland, forming
pseudolobules
thyroid capsule is condensed into the posterior suspensory or berry's

ligament ner the cricoid cartilage and upper tracheal rings
blood supply: superior & inferior thyroid arteries, thyroidea ima
venous drainage: superior, middle & inferior thyroid veins
nerve supply: right & left recurrent laryngeal nerve and superior
laryngeal nerve
lymphatic drainage: Intraglandular lymphatic vessels connect both

thyroid lobes through the isthmus and also drain to perithyroidal
structures and lymph nodes. Regional lymph nodes include pretracheal,
paratracheal, perithyroidal, RLN, superior mediastinal, retropharyngeal,
esophageal, and upper, middle, and lower jugular chain nodes.
IMAGING
Iodine-123 and iodine-131
are used to image the thyroid gland
Iodine 123 emits lowdose radiation, has a half-life of 12 to 14 hours,

and is used to image lingual thyroids or goiters.
In contrast, iodine-131has a half-life of 8 to 10 days and leads to

higher-dose radiation exposure
Therefore, this isotope is used to screen and treat patients with differentiated
thyroid cancers for metastatic disease.
The imagesobtained by these studies provide information not only about the
size and shape of the gland, but also the distribution of functional activity.
Areas that trap less radioactivity than the surrounding gland are termed cold
(Fig. 38-10), whereas areas that demonstrate increased activity are termed
hot.
The risk of malignancy is higher in cold lesions (20%) compared to hot or

warm lesions (<5%).
Technetium Tc 99m pertechnetate (99mTc)
is taken up by the thyroid gland and is increasingly being used for
thyroid evaluation.
This isotope is taken up by the mitochondria, but is not organified.
It also has the advantage of having a shorter half-life and minimizes

radiation exposure.
It is particularly sensitive for nodal metastases.

More recently, 18F-fluorodeoxyglucose (FDG) positron emission
tomography (PET) combined with computed tomography (CT) is being
increasingly used to screen for metastases in patients with thyroid
cancer in whom other imaging studies are negative.
Ultrasound
an excellent noninvasive and portable imaging study of the thyroid gland with
the added advantage of no radiation exposure
helpful in the evaluation of thyroid nodules, distinguishing solid from cystic

ones, and providing information about size and multicentricity.
Characteristics such as echotexture, shape, borders and presence of

calcifications, and vascularity can provide useful information regarding risk of
malignancy.
Also especially helpful for assessing cervical lymphadenopathy and to guide

FNAB
Computed Tomography/Magnetic Resonance Imaging Scan CT and
magnetic resonance imaging (MRI) studies
provide excellent imaging of the thyroid gland and adjacent nodes

and are particularly useful in evaluating the extent of large, fixed, or
substernal goiters (which cannot be evaluated by ultrasound) and
their relationship to the airway and vascular structures.
Noncontrast CT scans should be obtained for patients who are likely

to require subsequent RAI therapy. If contrast is necessary, therapy
needs to be delayed by several months.
Combined PET-CT scans are increasingly being used for Tg-positive,

RAI-negative tumors.
PAPILLARY THYROID CARCINOMA
Accounts for eighty percent of all thyroid malignancies in iodine-
sufficient areas
Predominant thyroid cancer in children and individuals exposed to

external radiation
Occurs more often in women; 2:1 female-to-male ratio; mean age at

presentation 30-40 years
Most patients are euthyroid and present with a slowing-growing

painless mass in the neck
Prognosis
Excellent prognosis with a ninety-five percent 10-year survival rate
Diagnosis
Established by FNAB of the thyroid mass or lymph node
Sites of metastases
Lungs
Bone
Liver
Brain
Treatment
Surgical
evidence-based management of thyroid cancers recommend a near-total or total
thyroidectomy for primary cancers >1 cm unless there are contraindications to surgery
Biopsy-proven lymph node metastases detected clinically or by imaging in the lateral

neck in patients with papillary carcinoma are managed with modified radical or
functional neck dissection
Prophylactic lateral neck node dissection is not necessary in patients with PTC, because
these cancers do not appear to metastasize systemically from lymph nodes, and
micrometastases often can be ablated with RAI therapy

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DISCUSSION

connected in the midline by an isthmus

pyramidal lobe is present in about 50% of patients

thyroid lobes extend to the midthyroid cartilage superiorly and lie

true capsule of the thyroid is a thin, densely adherent fibrous layer

thyroid capsule is condensed into the posterior suspensory or berry's

venous drainage: superior, middle & inferior thyroid veins

lymphatic drainage: Intraglandular lymphatic vessels connect both

Iodine 123 emits lowdose radiation, has a half-life of 12 to 14 hours,

In contrast, iodine-131has a half-life of 8 to 10 days and leads to

The risk of malignancy is higher in cold lesions (20%) compared to hot or

This isotope is taken up by the mitochondria, but is not organified.

It also has the advantage of having a shorter half-life and minimizes

It is particularly sensitive for nodal metastases.

helpful in the evaluation of thyroid nodules, distinguishing solid from cystic

Characteristics such as echotexture, shape, borders and presence of

Also especially helpful for assessing cervical lymphadenopathy and to guide

provide excellent imaging of the thyroid gland and adjacent nodes

Noncontrast CT scans should be obtained for patients who are likely

Combined PET-CT scans are increasingly being used for Tg-positive,

Predominant thyroid cancer in children and individuals exposed to

Occurs more often in women; 2:1 female-to-male ratio; mean age at

Most patients are euthyroid and present with a slowing-growing

Biopsy-proven lymph node metastases detected clinically or by imaging in the lateral

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