KULIAH KEPALA-LEHER

Dr. Teguh Aryandono

Sub Bagian Bedah Onkologi FKUGM
THYROID
 Thyroid
Physiology
Endemic goiter
Benign Nonendemic goiter
- Solitary thyroid nodule
- Multinodular goiter
Hyperthyroidism
Thyroid Cancer
 Thyroid gland
Production of thyroxine (T4) and
Triiodothyronine (T3)
Production of calcitonin
Functional unit : follicle
Calcitonin: produced by C cells
(parafollicular cells)
Iodine : required for the synthesis of
thyroid hormone
Deficiency: endemic goiter and cretinism
 Endemic goiter
Etiology: iodine deficiency, goitrogenic
substance
Goitrogens : Thioglucosidesinhibiting
iodine transport in the thyroid gland
Vegetables : cabbage, staple food:
cassava, maize, bamboo shot, sweet
potatoes
 Biochemically
Clinical euthyroidism
Low T4, elevated TSH
Cretinism : low T3, T4 serum , markedly
elevated TSH
 Morphologic changes
Generalized epithelial hyperplasia, cellular
hypertrophy , reduction of follicular space
 Clinical presentation
Mechanical problems
Hard nodules : possible malignant
disease
 Treatment and prophylaxis
Iodination of salt
T4 therapy to supress TSH
Surgery
 Surgery
Large or increase of size while in
supression therapy
Mechanical obstruction (trahea,
esophagus, thoracic inlet)
Toxic change
Suspected or proven malignant change
Cosmesis reason
- subtotal, near total, total thyroidectomy
 Solitary thyroid nodule
Incidence of cancer : 11- 20%
Rapid, painless development of thyroid
mass
History of radiation exposure
Symptom of hyperthyroidism
Obstructive symptoms
 Examination
80% sol. nodule : women
Malignant potential : man 3x woman
Hard consistency and fixation : suspicious
of malignancy
Clinical mobility does not exclude cancer
 Investigation
Free T4 and TSH
Standard radiography
CT scan/ MRI
Radioisotope scanning (?)
Ultrasonography (?)
FNA
 Indication for operation
Proven malignancy in cytology
Follicular neoplasm in cytology
Nondiagnostic cellular pattern on cytology
Cystic nodule that recur after aspiration
High clinical index of suspicion for
malignancy
 Indication for operation
Obtructive symptoms
Hyperfunctioning nodule
Patient anxiety
Cosmesis

Operation : total lobectomy +

isthmusectomy ( hemithyroidectomy)
 Multinodular goiter
Female
Cause : unclear
Probably multifactorial : heredity,
dyshormonogenesis, iodine deficiency,,
naturally occuring goitrogens, circulating
thyroid growth factors.
Hyperplasia of the parenchyma, colloid
degeneration, formation of adenomatous
structures.
 Symptoms and signs
Thyroid enlargement
Obstruction or compression
Difficulty in breathing or swallowing or both
Voice change or hoarseness
Presence of inspiratory or expiratory
stridor
Hard texture : calcification
 Investigation
Free T4 and TSH
Plain radiography, CT, MRI
FNA
Others : ????
 Treatment
Surgery : bilateral subtotal lobectomy or
total thyroidectomy
T4 therapy for TSH suppression (?)
Radioactive iodine (?)
Hyperthyroidism : management
Thyroid suppression ( anti thyroid drugs)
Radioactive iodine
Surgery
Thyroid cancer
 THYROID CANCER
MOST COMMON ENDOCRINE CANCER
NUMBER OF DEATHS : 7% OF ALL NEW
THYROID CANCER
INCIDENCE OF THYROID NODULE IN
GENERAL POPULATION :4-6%
 TUMOR TYPES
PAPILLARY
FOLLICULAR
MEDULLARY
ANAPLASTIC
PAPILLARY AND FOLLICULAR :> 90%
MEDULLARY : 5-10%
 PAPILLARY CARCINOMA
MOST COMMON
EXCELLENT PROGNOSIS
OFTEN MULTIFOCAL WITHIN SINGLE
LOBULE
UP TO 40% : REGIONAL LYMPH NODE
METASTASES
FOLLICULAR CARCINOMA
LESS COMMON, SLIGHTLY WORSE
PROGNOSIS
METASTASIZE TO LUNG AND BONE
DIFFUCULT TO DISTINGUISH WITH
FOLLICULAR ADENOMA
HURTHLE CELL CARCINOMA :
VARIANT OF FOLLICULAR CARCINOMA
 Medullary carcinoma
From C cells (parafollicular cells), secrete
calcitonin
Sporadic : solitary mass
Familial : bilateral, multifocal
 Anaplastic carcinoma
High grade neoplasm
Aggressive invasion, lymph node and
distant metastases
 Signs and symptoms
Most of them : asymptomatic nodule
Pressure
Change in the voice
Hard and firm
Lymph node enlargement
 Diagnostic work-up
History
FNA
Imaging
Calcitonin level (medullary ca)
 Staging and prognosis
UICC

Risk estimation system

- AMES ( age, metastases,extent, size)
- AGES ( age,grade, grade , size)

Low, intermediate, high risk

 Treatment : surgery
Differentiated thyroid Ca ( pap and foll)
- Total lobectomy
- Total lobectomy + contralateral subtotal
lobectomy ( subtotal thyroidectomy)
- Total thyroidectomy
Medullary ca
- Total thyroidectomy and regional node
sampling
 Anaplastic Ca
- Total thyroidectomy ( if confined to the
local area)
- Tracheostomy often required
 Lymph node dissection
Therapeutic dissection
- medullary ca
- others with node involvement
Prophylactic dissection
 Radiotherapy
Radioactive iodine :
- Papillary and follicular ca
External radiotherapy:
- Papillary and follicular ca : locally
advanced
- Unresectable disease
- Recurrence after resection
- Palliation of bone metastases
 Medical therapy
Thyroid hormone replacement
Chemotherapy (??)
Salivary gland tumour
 More than 95%
Parotid
Submandibular
Submaxillary
Parotid - 90%
Submandibular - 10%
Submaxillary < 1%

¾ parotid tumor : benign

50% submandibular tumor : malignant
All sublingual tumor - malignant
 Benign
- pleomorphic adenoma, benign cystic
lymphomatosum
Malignant
- mucoepidermoid ca, adenoid cystic ca,
adenocarcinoma
 Patient evaluation
Asymptomatic swelling

Facial paralysis
Enlarged regional lymphnode
Fixation to skin and adjacent tissue
Pain, rapid growth
-- malignancy
 FNA
CT Scan
- extension
 Treatment
Surgery
Benign: superficial parotidectomy, excision
Malignant : surgery and radiation
Parotid : minimum -> superficial parotidectomy
Submandibular : excision tumor + fascia+ lymph
node
PRESERVE FACIAL NERVE FUNCTION
NO CHEMOTHERAPY