Chapter 57 / Endocrine 435
What is the prognosis with
the following procedures:
Complete excision?	90% 10-year survival
Incomplete excision?	25% 10-year survival
MULTIPLE ENDOCRINE NEOPLASIA
What is it also known as?	MEN syndrome
What is it?	Inherited condition of propensity to
	develop multiple endocrine tumors
How is it inherited?	Autosomal dominant (but with a significant
	degree of variation in penetrance)
Which patients should be	All family members of patients diagnosed
screened for MEN?	with MEN
MEN TYPE I
What is the common	Wermer’s syndrome (Think: Wermer
eponym?	Winner #1 type 1)
What is the gene defect in	Chromosome 11 (Think: 11 1)
MEN type I?
What are the most common	“PPP”:
tumors and their incidences?	Parathyroid hyperplasia ( 90%)

Pancreatic islet cell tumors ( 66%)

Gastrinoma: ZES (50%)

Insulinoma (20%)

Pituitary tumors ( 50%)

How can tumors for MEN-I be remembered?

How can the P’s associated with MEN-I be remembered?

What percentage of patients with MEN-I have parathyroid hyperplasia?

Think: type 1 Primary, Primary, Primary PPP Parathyroid, Pancreas, Pituitary

All the P’s are followed by a vowel: PA, PA, PI

90%

436 Section II / General Surgery
What percentage of patients	50%
with MEN-I have a
gastrinoma?
What other tumors	Adrenal (30%) and thyroid (15%)
(in addition to PPP) are	adenomas
associated with MEN-I?
MEN TYPE IIa
What is the common	Sipple’s syndrome (Think: Sipple
eponym?	Second #2 type 2)
What is the gene defect in	RET (Think: reT Two)
MEN type IIa?
What are the most common	“MPH”:
tumors and their incidences?	Medullary thyroid carcinoma (100%);
	Calcitonin secreted
	Pheochromocytoma ( 33%);
	Catecholamine excess
	Hyperparathyroidism ( 50%);
	Hypercalcemia
How can the tumors	Think: type 2 2 MPH or 2 Miles
involved with MEN-IIa be	Per Hour MPH Medullary,
remembered?	Pheochromocytoma, Hyperparathyroid
How can the P of MPH be	Followed by the consonant “H”—
remembered?	PHEOCHROMOCYTOMA (remember,
	the P’s of MEN-I are followed by vowels)
What percentage of	100%
patients with MEN-IIa have
medullary carcinoma of the
thyroid?
MEN TYPE IIb
What are the most common	“MMMP”:
abnormalities, their	Mucosal neuromas (100%)—in the
incidences, and symptoms?	nasopharynx, oropharynx, larynx,
	and conjunctiva
	Medullary thyroid carcinoma ( 85%)—
	more aggressive than in MEN-IIa
	Marfanoid body habitus (long/lanky)
	Pheochromocytoma ( 50%) and
	found bilaterally

How can the features of MEN-IIb be remembered?

How can you remember that MEN-IIb is marfanoid habitus?

What is the anatomic distribution of medullary thyroid carcinoma in MEN-II?

Chapter 57 / Endocrine 437

MMMP (Think: 3M Plastics)

Think: “TO BE marfanoid” II B marfanoid

Almost always bilateral (non–MEN-II cases are almost always unilateral!)

What are the physical	Mucosal neuromas (e.g., mouth, eyes)
findings/signs of MEN-IIb?	Marfanoid body habitus
	Pes cavus/planum (large arch of foot/
	flatfooted)
	Constipation

What is the most common GI complaint of patients with MEN-IIb?

What percentage of pheochromocytomas in MEN-IIa/b are bilateral?

What is the major difference between MEN-IIa and MEN-IIb?

Constipation resulting from ganglioneuromatosis of GI tract

70% (but found bilaterally in only 10% of all patients diagnosed with pheochromocytoma)

MEN-IIa parathyroid hyperplasia MEN-IIb no parathyroid hyperplasia

(and neuromas, marfanoid habitus, pes cavus [extensive arch of foot], etc.)

What type of parathyroid disease is associated with MEN-I and MEN-IIa?

What percentage of patients with Z-E syndrome have MEN-I?

Hyperplasia (treat with removal of all parathyroid tissue with autotransplant of some of the parathyroid tissue to the forearm)

25%

438 Section II / General Surgery

C h a p t e r 58 Thyroid Gland

THYROID DISEASE

ANATOMY

Identify the following	1.	Pyramidal lobe
structures:	2.	Right lobe
	3.	Isthmus
	4.	Left lobe

Define the arterial blood			Two arteries:
supply to the thyroid.			1.	Superior thyroid artery (first branch
				of the external carotid artery)
			2.	Inferior thyroid artery (branch of
		1		the thyrocervical trunk) (IMA
				artery rare)
2

Thyrocervical

trunk

		Chapter 58 / Thyroid Gland 439
What is the venous drainage	Three veins:
of the thyroid?	1.	Superior thyroid vein
	2.	Middle thyroid vein
	3.	Inferior thyroid vein

Name the thyroid lobe	Pyramidal lobe
appendage coursing toward
the hyoid bone from around
the thyroid isthmus.
What percentage of patients	50%
have a pyramidal lobe?
What veins do you first see	Anterior jugular veins
after opening the platysma
muscle when performing a
thyroidectomy?
Name the lymph node	Delphian lymph node group
group around the pyramidal
thyroid lobe.

What is the thyroid isthmus?

Which ligament connects the thyroid to the trachea?

What is the IMA (not I.M.A.) artery?

What percentage of patients have an IMA artery?

Midline tissue border between the left and right thyroid lobes

Ligament of Berry

Small inferior artery to the thyroid from the aorta or innominate artery

3%

440 Section II / General Surgery
Name the most posterior	Tubercle of Zuckerkandl
extension of the lateral
thyroid lobes.

Which paired nerves must be carefully identified during a thyroidectomy?

Recurrent laryngeal nerves, which are found in the tracheoesophageal grooves and dive behind the cricothyroid muscle; damage to these nerves paralyzes laryngeal abductors and causes hoarseness if unilateral, and airway obstruction if bilateral

What other nerve is at risk	Superior laryngeal nerve; if damaged,
during a thyroidectomy and	patient will have a deeper and quieter
what are the symptoms?	voice (unable to hit high pitches)
What is the name of the	Urban legend has it that it was Amelita
famous opera singer	Galli-Curci, but no objective data support
whose superior laryngeal	such a claim (Ann Surg 233:588, April
nerve was injured during	2001)
thyroidectomy?
PHYSIOLOGY
What is TRH?	Thyrotropin-Releasing Hormone
	released from the hypothalamus; causes
	release of TSH
What is TSH?	Thyroid-Stimulating Hormone released
	by the anterior pituitary; causes release of
	thyroid hormone from the thyroid

What are the thyroid hormones?

What is the most active form of thyroid hormone?

What is a negative feedback loop?

What is the most common site of conversion of T4 to T3?

T3 and T4

T3

T3 and T4 feed back negatively on the anterior pituitary (causing decreased release of TSH in response to TRH)

Peripheral (e.g., liver)

	Chapter 58 / Thyroid Gland 441
What is Synthroid®	T4
(levothyroxine): T3 or T4?
What is the half-life of	7 days
Synthroid® (levothyroxine)?
What do parafollicular cells	Calcitonin
secrete?
THYROID NODULE
What percentage of people	5%
have a thyroid nodule?
What is the differential	Multinodular goiter
diagnosis of a thyroid	Adenoma
nodule?	Hyperfunctioning adenoma
	Cyst
	Thyroiditis
	Carcinoma/lymphoma
	Parathyroid carcinoma
Name three types of	1. Inflammatory lesions (e.g., abscess,
nonthyroidal neck masses.	lymphadenitis)
	2. Congenital lesions (i.e., thyroglossal
	duct [midline], branchial cleft cyst
	[lateral])
	3. Malignant lesions: lymphoma,
	metastases, squamous cell carcinoma
What studies can be used to	U/S—solid or cystic nodule
evaluate a thyroid nodule?	Fine Needle Aspirate (FNA) S
	cytology
	123I scintiscan—hot or cold nodule
What is the DIAGNOSTIC	FNA
test of choice for thyroid
nodule?
What is the percentage of	5%
false negative results on
FNA for thyroid nodule?

442 Section II / General Surgery

What is meant by a hot versus a cold nodule?

What are the indications for a 123I scintiscan?

What is the role of thyroid suppression of a thyroid nodule?

In evaluating a thyroid nodule, which of the following suggest thyroid carcinoma:

History?

Nodule uptake of IV 131I or 99mT Hot—Increased 123I uptake functioning/

hyperfunctioning nodule Cold—Decreased 123I uptake

nonfunctioning nodule

1.Nodule with multiple “nondiagnostic” FNAs with low TSH

2.Nodule with thyrotoxicosis and low TSH

Diagnostic and therapeutic; administration of thyroid hormone suppresses TSH secretion, and up to half of the benign thyroid nodules will disappear!

1.Neck radiation

2.Family history (thyroid cancer, MEN-II)

3.Young age (especially children)

4.Male female

Signs?	1. Single nodule
	2.	Cold nodule
	3.	Increased calcitonin levels
	4.	Lymphadenopathy
	5.	Hard, immobile nodule
Symptoms?	1. Voice change (vocal cord paralysis)
	2.	Dysphagia
	3.	Discomfort (in neck)
	4.	Rapid enlargement
What is the most common	Multinodular goiter
cause of thyroid enlargement?
What are indications for	Cosmetic deformity, compressive
surgery with multinodular	symptoms, cannot rule out cancer
goiter?
What is Plummer’s disease?	Toxic multinodular goiter

	Chapter 58 / Thyroid Gland 443
MALIGNANT THYROID NODULES
What percentage of cold	25% in adults
thyroid nodules are
malignant?
What percentage of	1%
multinodular masses are
malignant?
What is the treatment of a	Most experts would remove the nodule
patient with a history of	surgically (because of the high risk of
radiation exposure, thyroid	radiation)
nodule, and negative FNA?
What should be done with	Send to cytopathology
thyroid cyst aspirate?
THYROID CARCINOMA
Name the FIVE main types	1. Papillary carcinoma: 80% (Popular
of thyroid carcinoma and	Papillary)
their relative percentages.	2. Follicular carcinoma: 10%
	3. Medullary carcinoma: 5%
	4. Hürthle cell carcinoma: 4%
	5. Anaplastic/undifferentiated
	carcinoma: 1% to 2%
What are the signs/	Mass/nodule, lymphadenopathy; most are
symptoms?	euthyroid
What comprises the	FNA, thyroid U/S, TSH, calcium level,
workup?	CXR, / scintiscan 123I
What oncogenes are	Ras gene family and RET proto-oncogene
associated with thyroid
cancers?
PAPILLARY ADENOCARCINOMA
What is papillary	Most common thyroid cancer (Think:
carcinoma’s claim to faim?	Papillary Popular) 80% of all
	thyroid cancers
What is the environmental	Radiation exposure
risk?

444 Section II / General Surgery

What is the average age?

What is the sex distribution?

What are the associated histologic findings?

Describe the route and rate of spread.

131I uptake?

What is the 10-year survival rate?

What is the treatment for:1.5 cm and no history of neck radiation exposure?

1.5 cm, bilateral, cervical node metastasis OR a history of radiation exposure?

30–40 years

Female male; 2:1

Psammoma bodies (Remember, P Psammoma Papillary)

Most spread via lymphatics (cervical adenopathy); spread occurs slowly

Good uptake

95%

Options:

1.Thyroid lobectomy and isthmectomy

2.Near-total thyroidectomy

3.Total thyroidectomy

Total thyroidectomy

What is the treatment for: Lateral palpable cervical lymph nodes?

Central?

Do positive cervical nodes affect the prognosis?

What is a “lateral aberrant thyroid” in papillary cancer?

What postoperative medication should be administered?

What is a postoperative treatment option for papillary carcinoma?

Modified neck dissection (ipsilateral)

Central neck dissection

NO!

Misnomer—it is metastatic papillary carcinoma to a lymph node

Thyroid hormone replacement, to suppress TSH

Postoperative 131I scan can locate residual tumor and distant metastasis that can be treated with ablative doses of 131I

	Chapter 58 / Thyroid Gland 445
What is the most common	Pulmonary (lungs)
site of distant metastases?
What are the “P’s” of	Papillary cancer:
papillary thyroid cancer (7)?	Popular (most common)
	Psammoma bodies
	Palpable lymph nodes (spreads most
	commonly by lymphatics, seen in
	33% of patients)
	Positive 131I uptake
	Positive prognosis
	Postoperative 131I scan to
	diagnose/treat metastases
	Pulmonary metastases
FOLLICULAR ADENOCARCINOMA
What percentage of thyroid	10%
cancers does it comprise?
Describe the nodule	Rubbery, encapsulated
consistency.
What is the route of spread?	Hematogenous, more aggressive than
	papillary adenocarcinoma
What is the male:female	1:3
ratio?
131I uptake?	Good uptake
What is the overall 10-year	85%
survival rate?
Can the diagnosis be made	No; tissue structure is needed for a
by FNA?	diagnosis of cancer
What histologic findings	Capsular or blood vessel invasion
define malignancy in
follicular cancer?
What is the most common	Bone
site of distant metastasis?
What is the treatment for	Total thyroidectomy
follicular cancer?

446 Section II / General Surgery

What is the postoperative treatment option if malignant?

What are the 4 “F’s” of follicular cancer?

Postoperative 131I scan for diagnosis/ treatment

Follicular cancer:

Far-away metastasis (spreads hematogenously)

Female (3 to 1 ratio)

FNA . . . NOT (FNA CANNOT diagnose cancer)

Favorable prognosis

HÜRTHLE CELL THYROID CANCER

What is it?

What percentage of thyroid cancers does it comprise?

What is the cell of origin?

131I uptake?

How is the diagnosis made?

Thyroid cancer of the Hürthle cells

5%

Follicular cells

No uptake

FNA can identify cells, but malignancy can be determined only by tissue histology (like follicular cancer)

What is the route of	Lymphatic hematogenous
metastasis?
What is the treatment?	Total thyroidectomy
What is the 10-year survival	80%
rate?
MEDULLARY CARCINOMA
What percentage of all	5%
thyroid cancers does it
comprise?
With what other conditions	MEN type II; autosomal-dominant
is it associated?	genetic transmission
Histology?	Amyloid (aMyloid Medullary)
What does it secrete?	Calcitonin (tumor marker)

What is the appropriate stimulation test?

Describe the route of spread.

How is the diagnosis made?

131I uptake?

What is the associated genetic mutation?

What is the female/male ratio?

What is the 10-year survival rate?

What should all patients with medullary thyroid cancer also be screened for?

If medullary thyroid carcinoma and pheochromocytoma are found, which one is operated on first?

Chapter 58 / Thyroid Gland 447

Pentagastrin (causes an increase in calcitonin)

Lymphatic and hematogenous distant metastasis

FNA

Poor uptake

RET proto-oncogene

Female male; 1.5:1

80% without LN involvement

45% with LN spread

MEN II: pheochromocytoma, hyperparathyroidism

Pheochromocytoma

What is the treatment?	Total thyroidectomy and median lymph
	node dissection
	Modified neck dissection, if lateral
	cervical nodes are positive
What are the “M’s” of	Medullary cancer:
medullary carcinoma?	MEN II
	aMyloid
	Median lymph node dissection
	Modified neck dissection if lateral
	nodes are positive
ANAPLASTIC CARCINOMA
What is it also known as?	Undifferentiated carcinoma
What is it?	Undifferentiated cancer arising in 75%
	of previously differentiated thyroid cancers
	(most commonly, follicular carcinoma)

448 Section II / General Surgery
What percentage of all	2%
thyroid cancers does it
comprise?

What is the gender preference?

What are the associated histologic findings?

131I uptake?

How is the diagnosis made?

What is the major differential diagnosis?

What is the treatment of the following disorders:

Small tumors?

Airway compromise?

What is the prognosis?

MISCELLANEOUS

Women men

Giant cells, spindle cells

Very poor uptake

FNA (large tumor)

Thyroid lymphoma (much better prognosis!)

Total thyroidectomy XRT/chemotherapy

Debulking surgery and tracheostomy, XRT/chemotherapy

Dismal, because most patients are at stage IV at presentation (3% alive at 5 years)

What laboratory value must be followed postoperatively after a thyroidectomy?

Calcium decreased secondary to parathyroid damage; during lobectomy, the parathyroids must be spared and their blood supply protected; if blood supply is compromised intraoperatively, they can be autografted into the sternocleidomastoid muscle or forearm

What is the differential	Neck hematoma (remove sutures and
diagnosis of postoperative	clot at the bedside)
dyspnea after a	Bilateral recurrent laryngeal nerve
thyroidectomy?	damage
What is a “lateral aberrant	Misnomer: It is papillary cancer of a
rest” of the thyroid?	lymph node from metastasis

	Chapter 58 / Thyroid Gland 449
BENIGN THYROID DISEASE
What is the most common	Graves’ disease
cause of hyperthyroidism?
What is Graves’ disease?	Diffuse goiter with hyperthyroidism,
	exophthalmos, and pretibial myxedema
What is the etiology?	Caused by circulating antibodies that
	stimulate TSH receptors on follicular
	cells of the thyroid and cause deregulated
	production of thyroid hormones (i.e.,
	hyperthyroidism)
What is the female:male	6:1
ratio?
What specific physical	Exophthalmos
finding is associated with
Graves’?
How is the diagnosis made?	Increased T3, T4, and anti-TSH receptor
	antibodies, decreased TSH, global uptake
	of 131I radionuclide
Name treatment option	1. Medical blockade: iodide,
modalities for Graves’	propranolol, propylthiouracil (PTU),
disease.	methimazole, Lugol’s solution
	(potassium iodide)
	2. Radioiodide ablation: most popular
	therapy
	3. Surgical resection (bilateral subtotal
	thyroidectomy)
What are the possible	Suspicious nodule; if patient is
indications for surgical	noncompliant or refractory to medicines,
resection?	pregnant, a child, or if patient refuses
	radioiodide therapy
What is the major	Hypothyroidism
complication of radioiodide
or surgery for Graves’
disease?
What does PTU stand for?	PropylThioUracil

450 Section II / General Surgery
How does PTU work?	1. Inhibits incorporation of iodine into
	T4/T3 (by blocking peroxidase
	oxidation of iodide to iodine)
	2. Inhibits peripheral conversion of T4
	to T3
How does methimazole	Inhibits incorporation of iodine into
work?	T4/T3 only (by blocking peroxidase
	oxidation of iodide to iodine)
TOXIC MULTINODULAR GOITER
What is it also known as?	Plummer’s disease
What is it?	Multiple thyroid nodules with one or
	more nodules producing thyroid hormone,
	resulting in hyperfunctioning thyroid
	(hyperthyroidism or a “toxic” thyroid state)

What medication may bring on hyperthyroidism with a multinodular goiter?

How is the hyperfunctioning nodule(s) localized?

What is the treatment?

Amiodarone (or any iodine-containing medication/contrast)

131I radionuclide scan

Surgically remove hyperfunctioning nodule(s) with lobectomy or near total thyroidectomy

What is Pemberton’s sign? Large goiter causes plethora of head with raising of both arms

THYROIDITIS

What are the features of ACUTE thyroiditis?

What is the cause of ACUTE thyroiditis?

What is the treatment of ACUTE thyroiditis?

Painful, swollen thyroid; fever; overlying skin erythema; dysphagia

Bacteria (usually Streptococcus or Staphylococcus), usually caused by a thyroglossal fistula or anatomic variant

Antibiotics, drainage of abscess, needle aspiration for culture; most patients need definitive surgery later to remove the fistula

What are the features of SUBACUTE thyroiditis?

What is the cause of SUBACUTE thyroiditis?

What is the treatment of SUBACUTE thyroiditis?

What is De Quervain’s thyroiditis?

How can the differences between etiologies of ACUTE and SUBACUTE thyroiditis be remembered?

What are the common causative bacteria in acute suppurative thyroiditis?

Chapter 58 / Thyroid Gland 451

Glandular swelling, tenderness, often follows URI, elevated ESR

Viral infection

Supportive: NSAIDS, steroids

Just another name for SUBACUTE thyroiditis caused by a virus (Think: De QuerVain Virus)

Alphabetically: A before S, B before V (i.e., Acute before Subacute and Bacterial before Viral and thus: Acute Bacterial and Subacute Viral)

Streptococcus or Staphylococcus

What are the two types of chronic thyroiditis?

What are the features of Hashimoto’s (chronic) thyroiditis?

What is the claim to fame of Hashimoto’s disease?

What is the etiology of Hashimoto’s disease?

What lab tests should be performed to diagnose Hashimoto’s disease?

What is the medical treatment for Hashimoto’s thyroiditis?

1.Hashimoto’s thyroiditis

2.Riedel’s thyroiditis

Firm and rubbery gland, 95% in women, lymphocyte invasion

Most common cause of hypothyroidism in the United States

Autoimmune (Think: HashimOTO AUTO; thus, Hashimoto autoimmune)

Antithyroglobulin and microsomal antibodies

Thyroid hormone replacement if hypothyroid (surgery is reserved for compressive symptoms and/or if cancer needs to be ruled out)