Companion to Clinical Training Guidelines

on Principles of Surgical Management

THYROID &
BREAST

KB Galketiya (MBBS, MS, FRCS, FCSSL)

Senior Lecturer
Department of Surgery, Faculty of Medicine
These notes were compiled from the final year ward classes.

I expect medical students who attend the ward classes to use this as a guide
during their clinical training.

These notes, hopefully, will provide a frame work to build up knowledge by

further reading and not an alternative to standard text books.

KB Galketiya

1|Page
 Contents

01. Principles of Managing Thyroid Pathologies .................. 3

02. Euthyroid MNG .............................................................. 7

03. Toxic MNG ..................................................................... 8

04. Euthyroid Solitary Nodule of Thyroid ............................. 9

05. Toxic Solitary nodule .................................................... 12

06. Clinically Diffuse Euthyroid Goitre .............................. 13

07. Carcinoma of Breast ...................................................... 14

08. Patient Presenting with Nipple Discharge ..................... 16

2|Page
 01. Principles of Managing Thyroid Pathologies
At end of assessment following should be concluded

1. Presence of a Goiter –if present whether diffuse, multinodular or solitary

nodule
Confirmed by USS
2. Functional status-hyper/ eu/ hypo thyroid
Confirmed by TFT; if eu do only TSH, if hyper or hypo do full profile
3. Compression on trachea/ retrosternal extension
Confirmed by Xray neck, CECT neck and chest in selected cases
4. Any suspicion of malignancy; recent enlargement, hoarse voice, lymph
adenopathy

At the end important considerations are

1. Need for medical therapy-thyroxine if hypothyroid or high TSH levels

even if euthyroid/ antithyroid therapy if hyperthyroid
2. Need for surgery
➢ Malignancy or suspected malignancy
➢ Tracheal compression/ retro-sternal extension
➢ Selected patients with thyrotoxicosis
3. If surgery is indicated extent of removal, type of thyroidectomy
➢ Total for malignancy or bilateral involvement like benign MNG
➢ Hemithyroidectomy
▪ For suspected malignancy (Thy 3) in a solitary nodule (will
need completion thyroidectomy if becomes positive)
▪ Benign solitary enlargement requiring surgery for
compression on trachea or due to hyperthyroidism

Principles of treating thyrotoxicosis

1. Medical management with antithyroid drugs and beta blockers

2. Thyroid ablation by surgery or radioiodine in selected patients

3|Page
1) Medical management with antithyroid drugs and beta blockers
antithyroid drugs

a) Titration - depending on thyroxine level start a dose and adjust

according to thyroid functions. Its important not to over treat; patient
become hypothyroid, TSH will rise and the size of goiter will increase
which can be dangerous specially with large MNGs and ones with
retrosternal extensions as it may cause sudden respiratory obstruction.
(remember - do not start on antithyroid drugs for a low TSH level without
checking T3, T4 levels.

b) Block and replacement - start a high dose of antithyroid drugs with a

physiological dose of thyroxine. Antithyroids will near completely block
thyroid hormone and the physiological dose of thyroxine will keep the
patient euthyroid.
This is especially useful in retrosternal goiter and large MNGs (Think
why?)
Beta blocker is needed only for about six weeks. (find why?)

2. Thyroid ablation by surgery or radio-iodine in selected patients

a) This is indicated in MNGs and solitary nodules.

Large goiters-surgery; total for MNG/ hemi for STN
Smaller goiters-radio-iodine ablation
Ideally in toxic STNs an isotope scan before starting antithyroid therapy
is indicated to confirm that toxicity lies only in the solitary nodule.

b) Diffuse toxic goitre

Continue medical management for 18-24 months titrating the dose
according to thyroid function tests. Those who require reducing doses
are likely go in to remission with medical management alone.
After two years, stop treatment and follow up. Some remain in a
remission.
In case of recurrence restart antithyroid therapy and ablate the gland
with radio-iodine or by Total thyroidectomy
➢ Prior to thyroidectomy patient has to be euthyriod(think why?)
➢ Preparation for radio-iodine ablation in toxic goiter; therapy stopped

4|Page
 for about two weeks making the hyperfunctioning cells to be slightly
over active; then they take up radio-iodine better and preferentially
ablated over normally active cells minimzing post therapy
hypothyroidism.(think why is not done when fully toxic?)
➢ To show a reduction of function will take few weeks and if only
partially controlled can ablate with radio-iodine once more.
➢ Risk of post therapy hypothyroidism may occur very late and life
long follow up is indicated.
➢ Contraindications for radio-iodine ablation
• Absolute - pregnancy
• Relative - breast feeding
being in contact with small children

Thyrotoxic crisis

is sudden release of hormones due to stimuli in uncontrolled thyrotoxic patients.

Stimuli which may induce crisis

• Thyroidectomy (highest risk)
• Other surgeries
• Labour
• Sepsis
• Burn
• Major trauma

Management

1) beta blockers
i.v. 1mg over 1min - propranolol
repeat every 2-5 min up to max of 10 mg
(think why a small dose when given IV)
then propranolol oral 40-80 mg 8 hourly

2) i.v. steroids
(hydrocortisone)

5|Page
3) sponging due to hyperpyrexia

4) i.v. fluids

5) long-term antithyroid drugs

6|Page
 02. Euthyroid MNG
Investigations

1) USS
1. can see retrosternal extension
2. can assess gland size
3. to see suspicious nodules-if present, FNAC; US guided
2) TSH

Indications for surgery in euthyroid MNG

1) tracheal compression/ retrosternal extension

2) malignancy/ suspected malignancy in FNAC (THY 3/4/5)
3) patient's wish to do surgery due to cosmetic reasons

Surgery

Total thyroidectomy
retrosternal extension
1) most of the time can remove from neck incision (remember- blood supply
for retrosternal extension is from the neck)
2) 5% need sternotomy; these patients if done by thoracoscopy reduces
morbidity

Post op

➢ Check histopathology; if malignant appropriate follow up

➢ Start on thyroxine replacement; for adult 100-150micro grams; titrate
dose with TSH after 6 weeks and then annually

If there is no indication for surgery, follow up with repeat USS after one year

7|Page
 03. Toxic MNG
1) Learn clinical presentation

2) Investigations
➢ T3, T4, TSH
➢ USS

3) Treatment (refer article on management of thyroid pathologies)

➢ Antithyroid and propranolol (titration or block and replacement)
➢ Once controlled need thyroid ablation
• Total thyroidectomy for large glands
• Radio-iodine ablation for smaller glands (stop anti-thyroid 2weeks)
➢ Post ablation
Total thyroidectomy-thyroxine replacement (titrated by TSH)
Radio-iodine ablation-some will need depending on TFT values

8|Page
 04. Euthyroid Solitary Nodule of Thyroid
Confirm with USS and TSH

Thy 1 (need to repeat)

Thy 2 (colloid)

Perform FNAC Thy 3 (follicular)

Thy 4 (highly suspicious)
Thy 5 (Ca)
.
Colloid nodule

Compression on trachea

Yes. No

cosmetic No R/V in 6/12

with USS, may
need FNAC

Hemithyroidectomy.

Histopathology

Rarely may be Benign

malignant

Total thyroid Check TSH

ectomy. after 6weeks

if TSH is high
start thyroxine

9|Page
 FNAC- Follicular

Hemithyroidectomy

Benign. Malignant

Check TSH Total thyroidectomy

after 6 weeks

if TSH is high
start thyroxine

FNAC-Ca

Total thyroidectomy

Histopathology

Non differentiated Differentiated

Medullary C.A. Follicular/ Papillary

Follow up with Radio isotope scan

calcitonin. for secondaries &
for residual thyroid
Anaplastic Ca tissue.

Radiotherapy. If (+)ve
(Poor prognosis)
Radio iodine ablation.

Follow up with high

dose thyroxin to reduce TSH

Follow up of differentiated thyroid cancer is with thyroglobulin assay.

10 | P a g e
If thyroglobulin rises, repeat radio ablation.

After total thyroidectomy ideally the thyroglobulin has to be below the

sensitivity of assay (not measurable). However very low levels may be observed

How to prepare for radio isotope scan/ ablation

To maximize radio isotope intake by cells, TSH should be high. Therefore, omit
thyroxine 4-6 weeks prior to scan.

Other ways to avoid patient being hypothyroid for long

➢ Perform with artificial TSH therapy
➢ Keep patient on T3 therapy, stop for few days. T3 has a short half-life and
patient become hypothyroid immediately and TSH rises

Remember- in practice most oncologists treat all patients with a therapeutic

dose without a prior RI scan (think why?)

11 | P a g e
 05. Toxic Solitary nodule
Confirm -T3, T4, TSH, USS, ideally need Radio isotope scan
Perform FNAC - malignancy in a toxic nodule is reported rarely

Treatment

➢ Medical management (anti thyroid drugs)

➢ Once euthyroid-need ablation

Goiter size

large small

cannot ablate. Radio ablation

and may have additional
indication due to compression

Hemithyroidectomy

Refer principles of managing thyroid pathologies re radio-iodine ablation

12 | P a g e
 06. Clinically Diffuse Euthyroid Goitre
These are usually the physiological goitres

Investigations:

1. Ultrasound scan
2. TSH - if high or upper normal treat with thyroxine to suppress TSH
stimulation

Clinically diffuse hypothyroid goitre

Investigations - T3, T4 and TSH
Treat with thyroxine doses titrated according to levels

Clinically diffuse hyperthyroid goitre

These is usually Graves disease

Investigations:
1. Ultrasound scan
2. T3, T4 and TSH

Treatment

➢ start with medical management (refer article on principles of treating

pathologies of thyroid gland)
➢ Continue for two years titrating the dose according to thyroid function
tests. Those who require reducing doses are likely go into remission with
medical management alone.
➢ After two years, stop treatment and follow up. Some remain in a
remission.
➢ In case of recurrence restart antithyroid therapy and ablate the gland with
radioiodine or by Total thyroidectomy

13 | P a g e
 07. Carcinoma of Breast
Diagnosis

1) Symptomatic patients by triple assessment

Triple assessment - clinical, imaging, cytology/ histopathology
2) Asymptomatic patients by screening – by mammogram, if +ve do cytology/
histology
Learn about screening

Staging

By TNM
• T2N1M0 or below-early breast cancer
• More than T2N1M0-advanced breast cancer

Treatment
Involves
• Locoregional treatment - treating breast and axilla
• Systemic treatment
Depend on staging

Early breast cancer T2N1M0 or below – locoregional treatment

followed by systemic therapy
Advanced breast - > T2N1M0 - systemic therapy (chemotherapy)
followed by locoregional treatment.

Types of loco-regional therapy

Tumour Lymph nodes

Total Mastectomy Axillary clearance
Wide local excision (WLE) Sentinel node BX

From above following method may be selected

1. Total mastectomy + Axillary clearance – commonly done in our country
2. Total mastectomy and sentinel node biopsy

14 | P a g e
 3. Wide local excision and axillary clearance
4. Wide local excision and sentinel node biopsy

WLE-1cm margin is removed with tumour. Post op radiotherapy to residual

breast is mandatory.
WLE is done in selected patients after discussing with oncologist.

Axillary clearance-if its a adequate clearance a minimum of 10 nodes should

have been harvested.

Sentinel node Bx - Inject dye or radioisotopes around the areolar or around the
tumour. Peri-areolar injection is commonly used. Axilla is exposed with
incision. The first draining node is identified (staining with dye or by gamma
camera to detect radio-activity). Node is assessed by Frozen section.

Frozen section
• Positive - axillary clearance done.
• Negative - rest of nodes are not removed.

Types of systemic therapy

➢ Chemotherapy
➢ Hormonal therapy -Tamoxifen 20mg daily for five years if ER positive
➢ Other receptors - PR and HER; will provide prognostic information and
may aid in deciding on adjuvant chemotherapy

Management:

5 principles
1. Diagnosed by triple assessment & screening
2. Staging by TNM to classify as early or advanced (cut off- T2N1M0)
3. Low grade tumour- Locoregional & then systemic.
4. Advanced tumour- Systemic therapy & Locoregional therapy
5. Selection of Locoregional therapy

15 | P a g e
 08. Patient Presenting with Nipple Discharge
The history and examination will be based on the following differential
diagnoses
1. Physiological; an expressed secretion may occur during childbearing age
and during pregnancy
2. Prolactinoma
3. Mammary duct ectasia
4. Duct papilloma
5. Ca breast

History

1) Unilateral or bilateral
➢ Unilateral-indicates a ‘pathology’ of the involved breast
➢ Bilateral-a generalized cause; if spontaneous and lot, may indicate
prolactinoma/ if expressed and little likely to be physiological

2) Induced discharge or spontaneous

➢ Induced(expressed) by the patient is less significant of a pathology
than spontaneous discharge

3) Colour
➢ Clear/ straw colour - physiological/ duct ectasia
➢ Blood stained - Duct papilloma (single duct discharge)
Malignancy
Remember-the commoner cause for a blood-stained nipple
discharge is duct papilloma

4) Drug induced

5) Single or multiple duct discharge

➢ A bilateral induced discharge is the least significant of a pathology;
more often it is physiological.
➢ If it is a bilateral spontaneous copious discharge inquire symptoms
of a prolactinoma; headache/ disturbances of vision

16 | P a g e
Examination and Investigations

➢ Examination and imaging of breast

➢ Cytology of secretions
➢ When indicated
1) Prolactin level
2) CECT Brain

Treatment is directed to cause

• Physiological-reassure
• Duct ectasia – if symptoms are troublesome, removal of mammary
ducts if she is not planning future pregnancies
• Duct papilloma – excise involved duct
• Work out treatment for other aetiologies

17 | P a g e