Thyroid Surgery for Graves’ Disease Alexander Shifrin, MD Department of Surgery Jersey Shore University Medical Center Case # 1 • 30 y.o. female with 5 year history of Graves’ disease • Treated with PTU x 2 years, came off, developed more symptoms of hyperthyroidism plus dermatitis • Restarted on Methimazol, feels better • Unable to come off medications • Unable to get pregnant • Came for advice on therapy options? • Surgery – total thyroidectomy (same day, under local/regional block) • Path – multinodular goiter, chronic thyroiditis c/w Graves’ disease 2 weeks post op Case # 1 Case # 2 • 43 yo f with Graves x 8 years. C/o inability to perform day-by-day functions (stopped her martial arts, unable to catch her breath, palpitations, anxiety). • Unable to come off of anti-thyroid meds • Developed 2cm, solid right thyroid nodule (US 3/2008) • FNA Bx – negative for malig. cells • Fam Hx – neg; No h/o radiation • Surgery – total thyroidectomy (same day, under local/regional block) • Path – follicular variant of papillary thyroid carcinoma, 1 cm, no LN 2 weeks post op Case # 3 • 57 y.o. female with 7 year history of Graves’ disease • Treated with Methimazol, can not come off of meds • f/u US (1/2008) - developed multinodular goiter with solid 3.8 cm cold nodule on Uptake scan + increased uptake throughout the rest of the thyroid (43% @ 24hr) • compressive symptoms: swallowing, breathing difficulties in supine position • Came for second opinion? • US guided FNA Bx – suspicious for papillary thyroid carcinoma • Surgery – (5/15/2008) total thyroidectomy (same day, under local regional block) • Path – papillary and follicular variant of papillary thyroid carcinoma, 1.8 x 1.6 cm Case # 4 • 54 yo female, h/o Graves’ for 4 years. • Suffered of severe, panic disorder with intolerable anxiety attacks, which precluded her daily life activities; problems with people relationship, lost her job because of it. Anxiety was worse when she was off thyroid meds. • Symptoms of difficulty swallowing solid – “stack in her throat”, hoarseness, shortness of breath. • Thyroid US – MNG; Nuclear Med Thyroid Uptake - c/w Graves’. • TFT’s – wnl on Methimazol • Meds: Methimazol, Propronalol, Lexapro, Xanax • Fam Hx: Mother – thyroidectomy for goiter, breast Ca. Cousin – thyroid Ca Case # 4 • Came for consultation with her friend – unable to control her panic attacks, so her friend can speak for her. Very emotional, constantly crying. • Surgery – total thyroidectomy. • Path – multinodular goiter • Follow-up in two weeks: - panic attacks resolved - stopped taking Xanax since surgery only on Lexapro - able to control her life, can deal with problems without tears and emotion - compressive symptoms resolved (swallowing, breathing problems) 2 weeks post op Toxic diffuse goiter • Robert James Graves – in the English-speaking world • Carl Adolph von Basedow - in continental Europe Graves’ disease: facts • Autoimmune disorder with an unpredictable clinical course. • Symptoms directly related to hormone excess • Manifestations in connective tissue: Graves´ ophthalmopathy and dermopathy • annual incidences: 40 per 100,000 in the US • 4 to 6 times more common in females, mostly between age 20 to 50. • 1% to 5% of patients with GD are children (peak at age 11 to 14 years) Graves disease: facts • strong hereditary and genetic component • Smoking is weakly associated with GD but strongly with the development of Graves ophtalmopathy • thyroid receptor antibodies activates the thyrotropin receptor (TSHR), leading to synthesis and production of thyroid hormones in the follicular cells and infiltration of lymphocytes in the thyroid [...]... with Graves' disease and a thyroid nodule Boostrom S University of Texas Otolaryngol Head Neck Surg 2007 Feb;136 • 49 prospective pt - thyroidectomy for Graves' disease, • Papillary thyroid carcinoma in 10% (60% multifocal, 60% lymph node metastases) • CONCLUSION: Total thyroidectomy for Graves' has minimal morbidity Patients with Graves' and a thyroid nodule are at an increased risk for malignancy... • Children before age 5 yo Is radioactive iodine safe? No data for small dose (Graves’) but there are date for iodine dose in patients treated for thyroid cancer The Risk of Second Primary Malignancies up to Three Decades after the Treatment of Differentiated Thyroid Cancer Brown AP,Tward JD J Clin Endocrinol Metab 2008 Feb;93(2):504-15 • METHODS: 30,278 patients with differentiated thyroid cancer... harmless in children, we continue to recommend surgery in this group How get patient ready for the safe surgery? The effect of anti -thyroid drug treatment duration on thyroid gland microvessel density and intraoperative blood loss in patients with Graves' disease Erbil Y et al Surgery 2008 Feb;143(2):216-25 • Preoperative preparation of the patient with Graves' disease is crucial to avoid intraoperative... Antithyroid medication Radioactive iodine ablation (131I) Thyroidectomy • • Indications vary based on geographical location: Radioactive iodine ablation preferred in the US Europe and Asia - antithyroid drugs or surgery are favored Absolute indications for surgery include the following: • Presence of GD and an associated suspicious or malignant thyroid nodule • Pregnancy, not controlled with antithyroid... days for gr B vs 1.9 days for gr A) and the lowest complication rate (5.1 % for gr B vs 8.6% for gr A) • Length of stay and complications were more determined by surgeon experience than hospital volume • Individual surgeon experience was significantly associated with complication rates and length of stay for thyroidectomy Effect of hospital volume of thyroidectomies on outcomes following substernal thyroidectomy... Graves' disease Phitayakorn R, Case Western, Cleveland Am J Surg 2008 Mar;195(3) • • • 93 pt - thyroidectomy for Graves' disease, 2 pt (2.2%) had an incidental papillary carcinoma The prevalence of incidental thyroid cancer was 3.6% and 6.2% in patients with nontoxic nodular goiter and toxic multinodular goiter, respectively - no statistical difference Total thyroidectomy is the preferred treatment for. .. bleeding 0.5 - 1% risk of infection Scar Lifelong thyroid replacement Surgical Treatment of Graves' Disease: Evidence-Based approach Stalberg P, at al World J Surg 2008 Mar 8 • The optimal treatment of Graves disease (GD) is still controversial: antithyroid medication? vs radioactive iodine (RAI)? vs Surgery? : • 1) Is surgery better than RAI or long-term antithyroid medication? • 2) What is the recommended... hyporarathyroidism (0.9% - 1.0%) Total thyroidectomy – no recurrence Subtotal thyroidectomy – 7.9% recurrence Palit Et al 2000 J Surg Res Witte et al 2000 WJ Surg • Unpredictable rate of euthyroidism after subtotal (how mach to leave?) up to 70% develops long term hypothyroidism Michie 1975 Br J Surg • Micropapillary thyroid carcinoma found in 8% of patients with GD Stalberg 2008 WJ Surg Incidental thyroid. .. Surgical Treatment of Graves' Disease: Evidence-Based Approach Stålberg P, at al World J Surg 2008 Mar 8 • CONCLUSION: • If surgery is considered - evidence-based criteria support total thyroidectomy as the surgical technique of choice for GD • Available evidence supports surgery in the presence of severe GO • Children with GD should be treated with an ablative strategy Whether total thyroidectomy or RAI -... be treated with a total thyroidectomy Instruments and Technique Why the thyroid surgery is safer at these days? Chose the right tools: 1) surgeon 2) instruments / technology “Surgeon volume as a predictor of outcomes in inpatient and outpatient endocrine surgery. ” Stavrakis A, at al Endocrine Surgical Unit and Center for Surgical Outcomes and Quality, VA System, Los Angeles Surgery 2007 Dec;142(6):887 . Thyroid Surgery for Graves’ Disease Alexander Shifrin, MD Department of Surgery Jersey Shore University Medical Center Case # 1 • 30 y.o. female with 5 year history of Graves’ disease • Treated. come off of anti -thyroid meds • Developed 2cm, solid right thyroid nodule (US 3/2008) • FNA Bx – negative for malig. cells • Fam Hx – neg; No h/o radiation • Surgery – total thyroidectomy (same . Hx: Mother – thyroidectomy for goiter, breast Ca. Cousin – thyroid Ca Case # 4 • Came for consultation with her friend – unable to control her panic attacks, so her friend can speak for her. Very