PSGS Review 2015

+

+

PSGS Review 2014

Surgery

Head and Neck

Ida Marie Tabangay Lim,MD Ida Marie Tabangay Lim,MD

Ida Marie Tabangay Lim,MD Ida Marie Tabangay Lim,MD

FPCS,FPSGS,FPAHNSI FPCS,FPSGS,FPAHNSI

FPCS,FPSGS,FPAHNSI FPCS,FPSGS,FPAHNSI

+

+

THYROID GLAND DISASS

+

+

ANATOMY



_{N adult thyroid gland light brown in}

color ; firm , weighs

15 to 20 g

15 to 20 g

.



_{formed by}

_{two lateral lobes}

_{two lateral lobes}

connected centrally by an

isthmus.

isthmus.



_{the lobes are 4 cm long, 2 cm wide,}

and 2 to 4 mm thic!, with the

isthmus 2 to " mm thic!.

+

+



_{#yramidal lobe $}

_{80 percent}

_{80 percent}

_{of indi%iduals; usually &ust to}

the

left of the midline

left of the midline

, e'tending u(ward from the

isthmus along the anterior surface of the thyroid cartilage.

)t is

a remnant of the

a remnant of the thyroglossal duct

thyroglossal duct

+

+

+

+



_{superior thyroid arteries}

_{superior thyroid arteries}

_{! "r#$}

%ranc& external carotid

external carotid

artery

artery



_{inferior thyroid arteries}

_{inferior thyroid arteries}

_!

ari#e 'r() $&e thyrocervical

thyrocervical

trunk

trunk

(' $&e #u%c*avian ar$erie#



_{Occa#i(na**y a}

_{fth artery -}

_{fth artery}

-the thyroidea ima

the thyroidea ima

+ (rigina$ing

direc$*y 'r() $&e aortic arch or

aortic arch or

the innominate artery

the innominate artery,

-*((d #u..*y / '(ur )a(r

ar$erie#

+

+



_{Superior thyroid vein}

_{Superior thyroid vein}

and

middle thyroid

middle thyroid

vein

vein

$ internal jugular

internal jugular

vein

vein



_The

_{inferior thyroid}

_{inferior thyroid}

veins

veins

*usually forming

a (le'us that drains into

the brachiocephalic

brachiocephalic

vein.

vein.

+

+

Ner%e +u((ly

 _{)nner%ation of the gland is by sym(athetic fibers from the}

su(erior and middle cer%ical sym(athetic ganglia. The fibers enter with the blood %essels and are %asomotor in action.

 _{#arasym(athetic fibers are deri%ed from the %agus ner%e and}

+

+

Regu*a$i(n (' T&yr(id Ac$ivi$y

Hy.($&a*a)ic!.i$ui$ary!$&yr(id a3i# H5P5O6! $&e .rinci.a* &()e(#$a$ic c(n$r(* (' $&yr(id &(r)(ne #ecre$i(n ,

elease of T 4 and T- is stimulated by thyrotro(in or thyroid- stimulating hormone (TSH) from the ant. pituitary

Secretion of TSH is directly suppressed by T 4 and T3 (a negative feedback loop). TSH release also is stimulated by the hypothalamic hormone thyrotropin-releasing hormone (TH).

+

+

+

+

+ynthesis of Thyroid hormone

 _{S$e.# in $&e #yn$&e#i# (' $&yr(id &(r)(ne are/}



_{16 ac$ive $ra..ing and c(ncen$ra$i(n (' i(dide in}

$&e '(**icu*ar ce**7



_{26 ra.id (3ida$i(n (' i(dide $( i(dine7}



_{86 *inkage (' i(dine wi$& $yr(#ine re#idue# in}

$&yr(g*(%u*in7



_{46 c(u.*ing (' $&e#e i(d($yr(#ine# )(n(i(d(!}

and dii(d($yr(#ine6 $( '(r) $&e ac$ive $&yr(id

&(r)(ne# T 4 and T8,

+

+

+

+

+

+

-NIGN THYROID

DISORDRS

+

+

THYROGLO!L "#$T !%O&!L'(

THYROGLO!L "#$T !%O&!L'(

HYPRTHYROIDIS9

%O"#L!R GO'T(R

%O"#L!R GO'T(R

OL'T!RY THYRO'" %O"#L(

OL'T!RY THYRO'" %O"#L(

THYRO'"'T'

THYRO'"'T'

)eni*n Thyroid Gland

)eni*n Thyroid Gland

"isorders

+

+

_{(&)RYOLOGY O TH( THYRO'"}

_{(&)RYOLOGY O TH( THYRO'"}

GL!%"

GL!%"

,

, _{Ori*inates from the ase of Ori*inates from the ase of}

the ton*ue the ton*ue

,

, _{$audal mi*ration to the neck $audal mi*ration to the neck} ,

, _{Thyroid tissue may e found Thyroid tissue may e found}

from from the the ase ase of of the the ton*ue ton*ue toto the mediastinum

+

+

 _{.yramidal loe.yramidal loe}



Lin*ual thyroid Lin*ual thyroid

 _{u-sternal/ mediastinal thyroidu-sternal/ mediastinal thyroid}

 _{Thyro*lossal duct cystThyro*lossal duct cyst}

Thyroid

Thyroid

!nomalies

!nomalies

+

+

T&yr(g*(##a* duc$ cy#$

&id-line

&id-line

mass

mass w&ic&

)(ve# wi$&

ton*ue

ton*ue

protrusion

protrusion

9ay re#u*$ $(/

1,

econdary infection

econdary infection

01

01

:().re##i(n

8, ;i#$u*a

4, 9a*ignancy ! 1< 2=<

wi$& '(cu# in $&e

$&yr(id

g*and6

+

+

HYPRTHYROIDIS9

 _{?$&yr($(3ic(#i# ? ! c*inica*}

#yndr()e cau#ed %y

ina..r(.ria$e*y &ig& $&yr(id &(r)(ne ac$i(n in $i##ue# genera**y due $( e3ce##ive *eve*# (' ac$ive $&yr(id &(r)(ne #ecre$ed in$( $&e circu*a$i(n

 _{Grea$ )a(ri$y @B<6 are}

due $( e3ce## &(r)(ne# 'r() $&e $&yr(id g*and (r e3(gen(u# #(urce

 _{?&y.er$&yr(idi#) C ! a '(r)}

(' $&yr($(3ic(#i# due $( ina..r(.ria$e*y &ig& #yn$&e#i# and #ecre$i(n (' $&yr(id &(r)(ne#6 %y $&e $&yr(id g*and

 _{3ce##  $&yr($(3ic(#i#}  _{Rare*y due $( e3ce## TRH (r}

+

+

&anifestations of hyperthyroidism due to2

&anifestations of hyperthyroidism due to2



increased circulatin* active thyroid

increased circulatin* active thyroid

hormones

hormones

+

+

:au#e#

1, Pri)ary T&yr(id Pr(%*e)/



_{Increa#ed .r(duc$i(n (' $&yr(id}

&(r)(ne 'r() $&e g*and/

a,Grave#E di#ea#e diFu#e $(3ic

g(i$er6

%, T(3ic #(*i$ary (r )u*$in(du*ar

g(i$er P*u))erE# di#ea#e6,

+

+

:au#e#

2, 3$ra$&yr(ida* cau#e#/

a, Leak (' $&yr(id &(r)(ne#  _{Acu$e #$age (' $&yr(idi$i#}

%,;ac$i$i(u# &y.er$&yr(idi#)  _{ e3(gen(u# $&yr(id &(r)(ne6}

_{S$ru)a (varii}

_{Sec(ndary &y.er$&yr(idi#)}  _{TSH #ecre$ing .i$ui$ary $u)(r}

+

+

+

+

TSH A##ay



_{Sing*e %e#$ #creening $e#$ '(r &y.er$&yr(idi#)}



_{In )(#$ (u$.a$ien$ c*inica* #i$ua$i(n# i# $&e}

)(#$ #en#i$ive $e#$ '(r de$ec$ing )i*d

#u%c*inica*6 $&yr(id &(r)(ne e3ce## (r

de"ciency,

+

+

+

+

+

+

_GR!3(

_GR!3(

_’’

_"'(!(

_"'(!(

 _{!utoimmune disease!utoimmune disease}

 _{Thyroid receptor antiodies 4TR!5Thyroid receptor antiodies 4TR!5}

- thyroid stimulatin* immuno*loulins 4T'5 - thyroid stimulatin* immuno*loulins 4T'5 - thyroid stimulatin* antiodies 4T!5 - thyroid stimulatin* antiodies 4T!5

+

+

Grave#

/

Di#ea#e

 _{An au$(i))une di#(rder  (ver#$i)u*a$i(n (' $&yr(id}

g*and %y an$i%(die# direc$ed $( $&e $&yr(id!#$i)u*a$ing &(r)(ne TSH6 rece.$(r (n $&e $&yr(id '(**icu*ar ce**#,

 _{T&i# an$i%(dy #$i)u*a$e# i(dine u.$ake+ $&yr(id}

+

+

TR'!"

TR'!"



_{"i6usely enlar*ed}

_{"i6usely enlar*ed}

thyroid *land

thyroid *land



_{Hyperthyroidism}

_{Hyperthyroidism}

+

+



_TH

_TH



T7/T8

T7/T8

+

+

_.L#&&(R

_.L#&&(R

’’

 "'(!(

 "'(!(



_{T(3ic n(du*ar g(i$er}



_{One (r )(re n(du*e# in ende)ic g(i$er}

%ec()ing &y.er'unc$i(ning

au$(n()(u# TSH! rece.$(r )u$a$i(n#6



_{9i*der #y).$()#7 n( e3$ra$&yr(ida* SS3}



_{Drug#RAI T3 ! un.redic$a%*e re#u*$}

+

+

T(3ic 9u*$in(du*ar G(i$er

 _{O*der .re#en$a$i(n $&an Grave#E di#ea#e,}

 _{T&e $&yr(id!g*and g(i$er# c&arac$eri#$ica**y &ave (ne (r}

)(re n(du*e# (n .a*.a$i(n,

 _{Sy).$()# #uc& a# dy#.&agia and dy#.nea )ay %e .re#en$,}

S()e g(i$er# are re$r(#$erna*,

 _{Sy).$()# are ('$en )i*d+ and a$ria* "%ri**a$i(n in $&e}

e*der*y i# 'reJuen$*y $&e (n*y c*inica* "nding a.ar$ 'r() $&e g(i$er,

 _{diagn(#i# i# #ugge#$ed %y $&e &i#$(ry and .&y#ica*}

e3a)ina$i(n and c(n"r)ed %y d(cu)en$ing a #u..re##ed #eru) TSH *eve* and rai#ed $&yr(id &(r)(ne *eve*,

+

+

T(3ic 9u*$in(du*ar G(i$er

 _{Surgery i# $&e $rea$)en$ (' c&(ice}

 _{181I a%*a$i(n )ay %e u#ed in .a$ien$# w&( are}

un#ui$a%*e '(r #urgery+ %u$ %ecau#e &a# &ig& 'ai*ure ra$e wi$& $&i# $rea$)en$

+

+

_{THYRO'" TOR&}

_{THYRO'" TOR&}

 _{een in unprepared sur*ical patientseen in unprepared sur*ical patients}  _{Hyperthyroid pts under*oin* non-Hyperthyroid pts under*oin*}

non-thyroidal operation thyroidal operation

 _{i*ns and symptoms of i*ns and symptoms of thyrotoxicosis arethyrotoxicosis are}

ma*nied ma*nied

 _{&ana*ement&ana*ement}



_prevention

_prevention



_{anti-thyroid dru*s}

_{anti-thyroid dru*s}



_{eta-lockers}

_{eta-lockers}

+

+

&ana*ement of Hyperthyroidism

&ana*ement of Hyperthyroidism

4Graves9 "isease5

4Graves9 "isease5

 _{&edical&edical}

 _{Radioactive iodineRadioactive iodine}

+

+

_{&("'$!L &!%!G(&(%T}

_{&("'$!L &!%!G(&(%T}

_{(uthyroid state is achieved in 8-: ;k (uthyroid state is achieved in 8-: ;k}

_{!nti-thyroid dru*s- inhiit hormono*enesis ;ithin!nti-thyroid dru*s- inhiit hormono*enesis ;ithin}

the thyroid *land1

the thyroid *land1! _{propylthiouracil-.T#propylthiouracil-.T#}

- decreases the peripheral conversion of - decreases the peripheral conversion of T8 to T7

T8 to T7

- methima<ole-Tapa<ole - methima<ole-Tapa<ole -

- carima<ole-%eo-&ercacarima<ole-%eo-&erca<ole<ole

_{)eta-lock)eta-lockers- ers- lock lock the the eta-adrener*iceta-adrener*ic}

peripheral manifestations of the hyperthyroid peripheral manifestations of the hyperthyroid state

stateand decreases the peripheral conversion ofand decreases the peripheral conversion of T8 to T7

T8 to T7

+

+

&edical Treatment

&edical Treatment

 _{Relapse rate in =0-=> months ? @ABRelapse rate in =0-=> months ? @AB}

 _{ide e6ects especially in prolon*ed use ide e6ects especially in prolon*ed use - rashesC- rashesC}

feverC neuritisC a*ranulocytosisC feverC neuritisC a*ranulocytosisC

 _{$rosses the placenta - fetal *oiter$rosses the placenta - fetal *oiter}  _{HypothyroidismHypothyroidism}

 _{.atient compliance.atient compliance}

 _{%o moridity related to sur*ery%o moridity related to sur*ery}

 _{Treatment of choice for small *oiters D pre*nantTreatment of choice for small *oiters D pre*nant}

patients 4.T#5 patients 4.T#5

+

+

R!"'O!$T'3( 'O"'%( Tx

R!"'O!$T'3( 'O"'%( Tx



_{tandard dose - =A m$i ? >@AA cGy}

_{tandard dose - =A m$i ? >@AA cGy}



_{$ure rate is dose dependent}

_{$ure rate is dose dependent}



_{@ m$i - EAB}

_{@ m$i - EAB}



_{=A m$i - >EB}

_{=A m$i - >EB}



_{=@ m$i - F:B}

_{=@ m$i - F:B}

+

+

R!' Treatment

R!' Treatment

 _{HypothyroidismHypothyroidism}

 _{=@B ;ithin = year=@B ;ithin = year}

 _{7B every year thereafter7B every year thereafter}  _{.ermanent.ermanent}

 _{&ay a**ravate exophthalmos - 77B&ay a**ravate exophthalmos - 77B}  _{(xacerate thyrotoxicosis/thyroid storm(xacerate thyrotoxicosis/thyroid storm}  _{$rosses placenta - no pre*nancy for = year$rosses placenta - no pre*nancy for = year}  _{&ay cause infertility in ;omen&ay cause infertility in ;omen}

 _{&ay increase risk of cancer in children&ay increase risk of cancer in children}

 _{$ontraindicated in pre*nant D reast feedin*$ontraindicated in pre*nant D reast feedin*}

patients patients

+

+

R!' Treatment

R!' Treatment



_{(ase of treatment}

_{(ase of treatment}



_{Hi*hly e6ective esp1 in di6use}

_{Hi*hly e6ective esp1 in di6use}

*oiters

*oiters



_{%o moridity related to sur*ery}

_{%o moridity related to sur*ery}



_T

_Treatment

_{reatment of choi}

_{of choice for}

_{ce for failed}

_failed

sur*ical mana*ement

sur*ical mana*ement



_The

_{The e6ect}

_{e6ect is}

_{is seen}

_{seen in}

_{in =1@}

_{=1@ to}

_{to 8}

₈

months

months

+

+

#RG(RY

#RG(RY



_{$omplete and permanent control of}

_{$omplete and permanent control of}

toxicity

toxicity



_{Rapid control of symptoms}

_{Rapid control of symptoms}



_{Removal of mass}

_{Removal of mass}



_{Treatment of choice for hu*e *oiters}

_{Treatment of choice for hu*e *oiters}



_{%eeds pre-operative preparation}

_{%eeds pre-operative preparation}

+

+

Grave#

/

di#ea#e ! Surgica* care

T&yr(idec$()y/

1,

I' i$ i# $&e c&(ice (' $&e .a$ien$

2,

_{Sec(nd $ri)e#$er (' .regnancy}

8,

;ai*ure re#i#$ance (r in$(*erance6 ('

drug $&era.y

+

+

+

+

:(n$raindica$i(n# $( .ar$icu*ar

T3

+

+

_{&OR)'"'TY R(L!T(" TO}

_{&OR)'"'TY R(L!T(" TO}

#RG(RY

#RG(RY



_{Inury $( $&e recurren$ and #u.eri(r}

*aryngea* nerve#



_{Hy.($&yr(idi#)}



_{Hy.(.ara$&yr(idi#)}



_{He)a$()a+ #er()a}

+

+

_{%O"#L!R %O%-TO'$ GO'T(R}

_{%O"#L!R %O%-TO'$ GO'T(R}



_{n*arge)en$ ('}

$&e $&yr(id



_{N( $(3ici$y}



_{N( cancer}

+

+

_$!#(

_$!#(



!!&&''LL''!!L GL GOO'T'T((RR ((%%""((&&''$ G$ GO'O'TT((RR ..OORR!!""''$$ GO'T(R GO'T(R In&eri$ed eny)a$ic de'ec$ I(dine de"ciency in die$ %o denite cause %o denite cause can e can e estalished estalished I).aired i(dine )e$a%(*i#) #ua**y a##(cia$ed wi$& &y.($&yr(idi#) 9(un$ain(u# regi(n#

+

+

_{'%"'$!T'O% OR}

_{'%"'$!T'O% OR}

#RG(RY

#RG(RY



_{Huge g(i$er w&ic& i#}

c(#)e$ica**y

unacce.$a%*e



_{:().re##i(n #y).$()#}



_{Su#.ici(n (' )a*ignancy}

+

+

_{"O&'%!%T OR OL'T!RY}

_{"O&'%!%T OR OL'T!RY}

THYRO'" %O"#L(

THYRO'" %O"#L(

 _{&ost are eni*n - colloid *oiter or adenoma&ost are eni*n - colloid *oiter or adenoma}

 _{@-=@B are mali*nant2 0-7 fold increase if nodule @-=@B are mali*nant2 0-7 fold increase if nodule isis}

solid solid

 _{8AB incidence in the presence risk factors - 8AB incidence in the presence risk factors - lo; doselo; dose}

neck irradiationC 4+5 family history neck irradiationC 4+5 family history

+

+

+

+

;ac$(r# #ugge#$ing increa#ed

ri#k (' )a*ignan$ .($en$ia*

 _{Hi#$(ry (' &ead and neck irradia$i(n}

 _{;a)i*y &i#$(ry (' )edu**ary $&yr(id carcin()a 9T:6 (r )u*$i.*e}

end(crine ne(.*a#ia $y.e 2 9N26



Age M20 (r @0 year#! =0< M20 y(6

 _{9a*e #e3!80< ST6}  _{Gr(wing n(du*e}

 _{Hard c(n#i#$ency! 40< incidence P!PGH6}  _{:ervica* aden(.a$&y}

 _{;i3ed n(du*e}

+

+

Laoratory (valuation

Laoratory (valuation



_{Seru) TSH #&(u*d %e $e#$ed "r#$+ wi$& a}

$&ird!genera$i(n a##ay



_{I' TSH *eve* i# *(w M0,= )icr(!I)L6+}

)ea#ure 'ree T4 and $rii(d($&yr(nine T867



_{i' TSH *eve* i# &ig& @=,0 )icr(!I)L6+}

)ea#ure 'ree T4 and $&yr(id .er(3ida#e

an$i%(dy TPOA%6



_{Seru) ca*ci$(nin #&(u*d %e )ea#ured i' ;NA}

(r 'a)i*y &i#$(ry #ugge#$# )edu**ary $&yr(id

carcin()a

+

+

_{Radionuclide cannin*}

_{Radionuclide cannin*}



_{Per'(r) $&yr(id #cin$igra.&y '(r a $&yr(id}

n(du*e (r 9NG i' $&e TSH *eve* i# %e*(w $&e

*(wer *i)i$ (' $&e n(r)a* range (r i' ec$(.ic

$&yr(id $i##ue (r a re$r(#$erna* g(i$er i#

#u#.ec$ed



_{In i(dine!de"cien$ area#+ .er'(r) $&yr(id}

#cin$igra.&y '(r a $&yr(id n(du*e (r 9NG

even i' $&e TSH *eve* i# in $&e *(w!n(r)a*

range

+

+

*$ra#(und

)

)eennii**n n ffeeaattuurreess &a&allii**nnaannt t ffeeaattuurreess

Hy.erec&(ic n(du*e Regu*ar )argin# (r &a*( T&in wa** cy#$

gg#&e** (r a)(r.&(u# ca*ci"ca$i(n wi$& #&ad(wing P(*aried c(**(idc()e$ (r ca$K# eye6

9u*$in(du*ari$y wi$&(u$ a d()inan$ n(du*e

Perin(du*ar va#cu*aria$i(n (n D(..*er

Decrea#ing #ie (ver $i)e

Hy.(ec&(ic n(du*e

-*urred (r irregu*ar )argin Inva#i(n (' )u#c*e (r #urr(unding #$ruc$ure# n*arged cervica* n(de# 9icr(ca*ci"ca$i(n# wi$&(u$ #&ad(wingrea* $i)e6

In$ran(du*ar va#cu*aria$i(n (n D(..*er

9(re $a** $&an wide )icr(n(du*e# M 1,= c)6 Increa#ing #ie (n TSH #u..re##i(n

+

+

%!

%!

!c(#$ eFec$ive diagn(#$ic $((* $( diFeren$ia$e w&e$e&r n(du*e i# %enign (r )a*ignan$

:y$(*(gic diagn(#e# #&(u*d %e (rganied in$( 4 ca$eg(rie# 1, inadeJua$e )a$eria*

2, %enign 8, #u#.ici(u#

+

+

%!$

%!$

%!$

%!$

o llow up

1 year

! epea t " #

$obectomy

Symptoms

%enign

$obectomy

# t yp ical o r S u sp ici o u s

&hyroidectomy

'alignant

 " #

+

+

ummary of Recommendations for

ummary of Recommendations for

&ana*ement and Treatment of Thyroid

&ana*ement and Treatment of Thyroid

%odules

%odules



_{:*inica* )anage)en$ (' $&yr(id n(du*e#}

#&(u*d %e guided %y $&e re#u*$# (' S

eva*ua$i(n and ;NA %i(.#y



_{%!-.ositive Thyroid %odule}

_{%!-.ositive Thyroid %odule}



_{;(r a $&yr(id n(du*e wi$& .(#i$ive}

)a*ignan$6 ;NA re#u*$#+ #urgica*

$rea$)en$ i# rec())ended

+

+

%!-%e*ative Thyroid

%!-%e*ative Thyroid

%odule

%odule

 _{#e (' #u..re##ive $&era.y wi$& *ev($&yr(3ine LT46 )ay}

%e c(n#idered in $&e '(**(wing/

 _{Pa$ien$# 'r() ge(gra.&ic area# wi$& i(dine de"ciency}  _{Y(ung .a$ien$# wi$& #)a** $&yr(id n(du*e#}

 _{N(du*ar g(i$er# wi$& n( evidence (' 'unc$i(na* au$(n()y}

 _{c()%ined wi$& a#.ira$i(n i' n(du*e i# cy#$ic}

 _{#e (' LT4 $&era.y #&(u*d %e av(ided in )(#$ ca#e# and}

e#.ecia**y in $&e '(**(wing/

 _{Large $&yr(id n(du*e# and g(i$er#+ .ar$icu*ar*y in $&e .re#ence} (' #y).$()# (r #ign# (' 'unc$i(na* au$(n()y

 _{:*inica**y #u#.ici(u# *e#i(n# (r *e#i(n# wi$& an inadeJua$e} cy$(*(gic #a).*e

 _{P(#$)en(.au#a* w()en and )en (*der $&an 0 year#}  _{Pa$ien$# wi$& cardi(va#cu*ar di#ea#e}

+

+

;ac$# $( re)e)%er wi$& #u..re##ive

$&era.y

 _{LT4 $rea$)en$ induce# a c*inica**y #igni"can$ reduc$i(n (' $&yr(id}

n(du*e v(*u)e in (n*y a )in(ri$y (' .a$ien$# 20!=0< #ucce## ra$e6

 _{L(ng!$er) TSH #u..re##i(n )ay %e a##(cia$ed wi$& %(ne *(##}

and arr&y$&)ia in e*der*y .a$ien$# and )en(.au#a* w()en

 _{LT4 $rea$)en$ #&(u*d never %e 'u**y #u..re##ive e3(gen(u#}

$&yr(3ine $( )ain$ain TSH *eve* a$ 0,8!8 u)*,6

 _{N(du*e regr(w$& i# u#ua**y (%#erved a'$er ce##a$i(n (' LT4}

$&era.y

 _{I' n(du*e #ie decrea#e#+ LT4 $&era.y #&(u*d %e c(n$inued *(ng}

$er)

 _{I' $&yr(id n(du*e gr(w# during LT4 $rea$)en$+ rea#.ira$i(n and}

+

+

ur*i

ur*ical

cal T

Treatmen

reatmentt

1,

A##(cia$ed *(ca* #y).$()# e,g,,

c().re##i(n

2,

Hy.er$&yr(idi#) 'r() a *arge $(3ic

n(du*e+ (r &y.er$&yr(idi#) and

c(nc()i$an$ 9NG

8,

Gr(w$& (' $&e n(du*e

4,

Su#.ici(u# (r )a*ignan$ ;NA re#u*$#

 _{Pa$ien$ %e*(ng# $( &ig& ri#k gr(u.}  _{N(du*e i# #(*id}

+

+

Radi(i(dine

Indica$i(n#/

1, ;(r #)a** g(i$er# v(*u)e M100 )L6

2, In $&(#e wi$&(u$ #u#.ec$ed )a*ignan$

.($en$ia*

8, In .a$ien$# wi$& a &i#$(ry (' .revi(u#

$&yr(idec$()y

+

+

RAI

N($ $&e "r#$!*ine $&era.y

1, I' c().re##ive #y).$()# are .re#en$

2, I' .a$ien$# &ave *arge n(du*e# $&a$

reJuire &ig& a)(un$#

(' radi(i(dine

and )ay %e re#i#$an$ $( $rea$)en$

8, I' i))edia$e re#(*u$i(n ('

$&yr($(3ic(#i# i# de#ired

+

+

+

+

_{THYRO'"'T'}

_{THYRO'"'T'}

 _Ha#&i)($(/#  _{De Quervain/#}  _Riede*/#  _{Acu$e Su..ura$ive}

+

+

Ha#&i)($(

/

# Di#ea#e

! 9(#$ c())(n '(r) (' $&yr(idi$i#

! :&r(nic *y).&(cy$ic $&yr(idi$i#

!

_{Au$(i))une $&yr(idi$i#}

!

_{T&yr(id au$(an$i%(die#}

1, an$i!$&yr(id .er(3ida#e

2, an$i$&yr(g*(%u*in au$(an$i%(die#

! Gene$ic .redi#.(#i$i(n

+

+

HASHI9OTO

/

S DISAS

! :*inica* 9ani'e#$a$i(n#/

/ AFec$# w()en c())(n*y

/ 9(#$ 'reJuen$ c().*ain$ ! en*arge)en$ (' $&e neck w .ain

 $enderne## in $&e regi(n (' $&e neck

/ )(#$ individua*# are ini$ia**y &y.er$&yr(id and #u%#eJuen$*y %ec()e# eu$&yr(id (r &y.($&yr(id

+

+

HASHI9OTO

/

S DISAS

!

Diagn(#$ic "nding#/ T&yr(id an$i%(die# ! Trea$)en$

1, DiFu#e g(i$er! LT4 #u..re##i(n 2, N( g(i$er n( $&era.y

8, N(du*ar g(i$er! #u..re##i(n (r #urgery 4, Surgery ! .re##ure #y).$()# + #u#.ici(n ('

+

+

THYRO'"'T'

THYRO'"'T'



_{Genera**y )anage)en$ i#}

_n(n!

#urgica*

! T&yr(id &(r)(ne re.*ace)en$ '(r

_{$&e &y.($&yr(idi#)}

! S$er(id#

! Sy).$()a$ic re*ie' (' .ain+ 'ever+

e$c,

+

+

ROL( O #RG(RY '%

ROL( O #RG(RY '%

THYRO'"'T'

THYRO'"'T'

 _{T( re*ieve c().re##i(n}

 _{I' )a*ignancy cann($ %e ru*ed (u$}  _{:(#)e$ic indica$i(n}

+

+

De Quervain

/

#

 _{Su% acu$e $&yr(idi$i#}

 _{gian$ ce** $&yr(idi$i#+ i# an unc())(n+ acu$e}

ina))a$(ry di#ea#e (' $&e $&yr(id,

 _{'ever+ )a*ai#e+ and uni*a$era* (r %i*a$era* $&yr(id .ain}

and a recen$ &i#$(ry (' an u..er re#.ira$(ry $rac$ (r vira* in'ec$i(n )ay %e given7 $ran#ien$ #y).$()# (' &y.er$&yr(idi#)

 _{Pa*.a$i(n (' $&e $&yr(id g*and )ay revea* a $ender+ "r)}

+

+

De Quervain

/

#

 _{Hi#$(*(gica**y c&arac$eried %y an acu$e ina))a$(ry reac$i(n}

(' $&e $&yr(id g*and, Degenera$ive $&yr(id '(**ic*e# are #urr(unded %y gian$ ce**# '(r)ing granu*()a#

 _Trea$)en$/



NSAIDS '(r .ain re*ie'

 _{;(r #evere ca#e#/ Predni#(*(ne 40 )g (nce dai*y '(r 1 $( 2 week#+}

'(**(wed %y a gradua* reduc$i(n (' $&e d(#e (ver $&e en#uing )(n$&

 _Pr(gn(#i#

 _{*a#$# 1 $(  week# and re#(*ve# #.(n$ane(u#*y}

 _{9(#$ .a$ien$# &ave c().*e$e re#(*u$i(n (' $&e di#ea#e}

 _{10 .ercen$ (' .a$ien$# e3.erience .er)anen$ &y.($&yr(idi#) and}

+

+

Riede*

/

#

 _{)arked den#e+ inva#ive "%r(#i# $&a$ )ay e3$end %ey(nd $&e}

$&yr(id ca.#u*e and inv(*ve #urr(unding #$ruc$ure#, ;i%r(#i# )ay inv(*ve $&e #$ra. )u#c*e#+ %*((d ve##e*#+ $rac&ea+ e#(.&agu#+ and+ (n (cca#i(n+ $&e .ara$&yr(id g*and#+ w&ic& *ead# $( &y.(.ara$&yr(idi#),

 _{Severe ca#e# can re#u*$ in $&e .a$ien$E# %ec()ing &y.($&yr(id,}  _{:().re##ive #y).$()#/ &(ar#ene##+ #$rid(r+ and dy#.nea+}

dy#.&agia )ay %e .re#en$

 _{T&ere ('$en i# ra.id en*arge)en$ (' $&e $&yr(id g*and+ w&ic&}

+

+

Riede*

/

#

 _{re#e)%*e# ana.*a#$ic $&yr(id cancer+ e3ce.$ $&a$ $&e}

g(i$er i# #)a**er

 _{Diagn(#i# u#ua**y i# e#$a%*i#&ed %y ;NA:+ a*$&(ug&}

(.en %i(.#y (cca#i(na**y i# needed,

 _{Trea$)en$ wi$& $a)(3i'en and #$er(id# ('$en i# &e*.'u*,}

I#$&)ec$()y $( re*ieve c().re##ive #y).$()# (r $( e#$a%*i#& $&e diagn(#i# i# nece##ary in #()e .a$ien$#,

 _{T&yr(3ine re.*ace)en$ $&era.y i# nece##ary in}

+

+

+

+

'ncidence2

'ncidence2

'ncidence2

'ncidence2 

2005 Philippine Cancer

2005 Philippine Cancer

Facts and Estimates

Facts and Estimates

6



_

$&

)(#$ c())(n '(r %($& #e3e# c()%ined

8,8<6+ 1=

$&

*eading #i$e in )en  1,=<6 and



$&

a)(ng 'e)a*e# =<6



_{In 200=+ e#$i)a$ed 8+=21 new ca#e#+ == in}

)a*e# and 2+ in 'e)a*e#,



_{T&ere wi** %e 1+012 dea$&#+ 24= in )a*e# and}

+

+

_{!*e and ex distriution2}

_{!*e and ex distriution2}

_{!*e and ex}

_{!*e and ex distriution2}

_{distriution2}



2005 Philippine Cancer Facts and

Estimates

6

 _{9(#$ c())(n cancer (' w()en a$ age# 1=! 24}

 _{Incidence a)(ng 'e)a*e re#iden$# in $&e P&i*i..ine# i#}

+

+

Histolo*ic distriution

Histolo*ic distriution

Histolo*ic distriution

Histolo*ic distriution

/

Well differentiated

type



_Papillary

₈₀

%



_{Follicular cancer}

5 – 10 %



_{Medullary cancer}

5 – 9 %

Anaplastic type



_{1 – 2 %}

+

+

Diagn(#i#/

History



_{Eposure to ioni!in" radiation}

# dental $rays



_{Fa&ily 'istory}



_{Presence of difficulty s(allo(in")}

+

+

.ro*nostic indices utili<ed in

.ro*nostic indices utili<ed in

.ro*nostic indices utili<ed in

.ro*nostic indices utili<ed in

thyroid cancer mana*ement

thyroid cancer mana*ement

thyroid cancer mana*ement

thyroid cancer mana*ement

Memoria

l

0os(ital

Mayo

1linic,

35

Mayo 1linic,

33-6ahey

1linic

7arolins!a

)nstitute

(#')

(#')

S

S

#(

#

()

)S

S '

'#

#*

*++S

S

#'

#

')

)S

S

,

,#

#'

')

)S

S

( (rade # #ge ' 'etastase s ) )'tension S Si8e # #ge ( (rade ) )'tensio n S Si8e 9istant ' 'etastasis # #ge * *om(leteness of esection ++n%asion S Si8e # #ge ' 'etastase s ) )'tension S Si8e , ,NA # #ge ' 'etastases ) )'tension S Si8e

+

+

tructural assessment of a

tructural assessment of a

tructural assessment of a

tructural assessment of a

thyroid nodule2

thyroid nodule2

thyroid nodule2

thyroid nodule2

 _{PHYSI:AL >A9INATION}  _{I9AGING TSTS/}  _{LTRASOND}  _{:T S:AN}  _9RI

+

+

P&y#ica* 3a)ina$i(n



_{:().*e$e &ead and neck}

e3a)ina$i(n



In#.ec$i(n+ .a*.a$i(n ('

$&yr(id g*and! n($e i$#

#ie+ )(%i*i$y+ c(n#i#$ency+

"3a$i(n



_{Laryng(#c(.y $(}

d(cu)en$ )(%i*i$y (' $&e

c(rd#



_{Pa*.a$e '(r cervica*}

*y).& n(de#

+

+

"ia*nosis2

"ia*nosis2

Biopsy

Biopsy

;ine need*e a#.ira$i(n :y$(*(gy /

!

&ard )a##

!

)a## a##(cia$ed wi$& neck n(de#

#u#.ici(u# '(r )a*ignancy

+

+

%!$

%!$

%!$

%!$

o llow up

1 year

! epea t " #

$obectomy

Symptoms

%enign

$obectomy

# t yp ical o r S u sp ici o u s

&hyroidectomy

'alignant

 " #

+

+

_{unctional assessment of a}

_{unctional assessment of a}

_{unctional assessment of a}

_{unctional assessment of a}

thyroid nodule2

thyroid nodule2

thyroid nodule2

thyroid nodule2

+

+

+

+

De"ni$i(n (' $er)#

 _{T($a* $&yr(idec$()y  #urgica* .r(cedure $&a$ re)(ve#}

en$ire $&yr(id g*and

 _{Near $($a* $&yr(idec$()y  Re)(va* (' near*y a** (' eac&}

$&yr(id *(%e *eaving unre#ec$ed (n*y a #)a** .(r$i(n (' $&e g*and adacen$ $( $&e en$rance (' $&e recurren$ *aryngea* nerve in$( $&e *aryn3,

 _{Su%$($a* $&yr(idec$()y  re)(va* (' )(#$ %u$ n($ a** ('}

eac& *(%e (' $&e $&yr(id

 _{Har$*ey Dun&i** (.era$i(n! re)(va* (' 1 en$ire *a$era* *(%e}

wi$& i#$&)u# and .ar$ia*#u%$($a* re)(va* (' (..(#i$e *a$era* *(%e, I$ i# d(ne in n(n $(3ic 9NG,

+

+

T($a* $&yr(idec$()y i# rec())ended



_{Pri)ary $u)(r @ 1c)}



_{i$& ri#k 'ac$(r#! c(n$ra*a$era* n(du*e#+}

regi(na* (r di#$an$ )e$a#$a#e#



_{Hi#$(ry (' radia$i(n $&era.y $( $&e &ead}

and neck area



_{;ir#$ degree re*a$ive wi$& DT:}

+

+

Advan$age# (' T($a* T&yr(idec$()y

 _{I).r(ved #urviva* and recurrence ra$e#}  _{Acce.$a%*e ra$e (' c().*ica$i(n#}

1, -i*i)(ria UY+ 3$en$ (' #urgery aFec$# #urviva* '(r .a.i**ary $&yr(id cancer+ Ann Surgery,24+ 8=! 8B12006

2, Hay + I e$ a*,Pa.i**ary $&yr(id carcin()a )anaged a$ $&e 9ay( c*inic during #i3 decade# 140!16/ $e).(ra* $rend# in ini$ia* $&era.y and *(ng $er) (u$c()e in 2+444 c(n#ecu$ive*y $rea$ed .a$ien$#, (r*d V Surg 2+B!BB=20026

8, Hay +I e$ a*, Predic$ing (u$c()e in .a.i**ary $&yr(id carcin()a/deve*(.)en$ (' a re*ia%*e .r(gn(#$ic #c(ring #y#$e)in a c(&(r$ (' 1+ .a$ien$# #urgica**y $rea$ed a$ (ne in#$i$u$i(nnduring 140 $&r(ug& 1B, Surgery 114186

+

+

_{.apillary thyroid}

_{.apillary thyroid}

microcarcinoma4/?=Amm5

microcarcinoma4/?=Amm5

 _{9u*$i'(ca* di#ea#e! 1=!48<}  _{-i*a$era* di#ea#e  41<}

 _{:ervica* n(de inv(*ve)en$! 18!}

4<

 _{3$ra$&yr(ida* $u)(r e3$en#i(n!}

1=!21<  _{a#cu*ar inva#i(n!8,=<}  _{Di#$an$ )e$a#$a#e#!1,0!2,B<}  _{10 year #urviva* !100<}  _{L(c(regi(na* recurrence} 'ree #urviva*  2<  _{Di#$an$ )e$a#$a#i#!'ree} #urviva*  <

Su..(r$ '(r T($a* $&yr(idec$()y Argu)en$ again#$ aggre##ive $rea$)en$

+

+

Le## $&an $($a* $&yr(idec$()y re#erved

'(r /



_{Tu)(r# M 1 c) 7 )icr(.a.i**ary carcin()a7}

uni'(ca*+ in$ra$&yr(ida*+ *(w ri#k



N( .ri(r &ead and neck irradia$i(n



_{N( c*inica**y (r radi(*(gica**y inv(*ved}

*y).& n(de#

+

+

_{9anage)en$ (' $&e}

regi(na* n(de#

+

+

_{Pr(.&y*ac$ic v# T&era.eu$ic}



_{?.r(.&y*ac$icC! re)(va* (' n(de#}

c(n#idered n(r)a* .re (r in$ar(.era$ive*y 

%y .a*.a$i(n (r i)aging6



_{?$&era.eu$icC! re)(va* (' n(de# *ike*y $(}

c(n$ain )e$a#$a$ic di#ea#e %a#ed (n

.a*.a$i(n+ i)aging #$udie# (r %i(.#y,

+

+



_{Pr(.&y*ac$ic neck di##ec$i(n n($}

rec())ended



_{I' n(de .(#i$ive+ $&e )(#$}

c(n#erva$ive neck di##ec$i(n i#

warran$ed

%eck dissection in Thyroid

%eck dissection in Thyroid

$ancer

+

+

_{T&era.eu$ic Neck Di##ec$i(n}

_{:en$ra* c().ar$)en$ neck} di##ec$i(n! '(r .(#i$ive cen$ra* *y).& n(de# _{9(di"ed Radica* neck}

di##ec$i(n! i' wi$& *a$era* c().ar$)en$ n(de#

+

+

.ost-op &ana*ement

.ost-op &ana*ement

.ost-op &ana*ement

.ost-op &ana*ement



_{I 181 '(r a%*a$i(n (' re#idua* n(r)a* $&yr(id}

$i##ue and (r )e$a#$a$ic di#ea#e



T&yr(id &(r)(ne '(r #u..re##i(n '(r &ig&

ri#k cancer7 re.*ace)en$ '(r *(w ri#k



_{I 181 w&(*e %(dy #can $( de$ec$ re#idua*}

n(r)a* $&yr(id $i##ue and (r )e$a#$a$ic

di#ea#e



_{;(**(w! u. .&y#ica* e3a)+ #eru)}

+

+

COMMON HEAD AND NECK

COMMON HEAD AND NECK

MALIGNANCIES:

MALIGNANCIES:

An Overview

+

+

_{Anatomic +ites and subsites}

_{Anatomic +ites and subsites}

of the 0ead and Nec!

of the 0ead and Nec!

"asal

"asal

antrum

antrum

nasopharyn-

oropharyn-

hypopharyn-esophagus

esophagus

ral cavity

ral cavity

laryn-+

+

+

+

+

+

#haryn'

 _{:ase of the tongue}  _{+oft (alate}

+

+

+

+

0ead and

+

+

:asics of 1arcinogenesis

:asics of 1arcinogenesis

:ancer deve*(.)en$

n%ironmental <actors

1arcinogen e'(osure )nherited factors

0ost defenses

+

+

(tiolo*y and Risk actors

(tiolo*y and Risk actors

(tiolo*y and Risk actors

(tiolo*y and Risk actors

1hemical

)nfecti%e

n%ironment

Tobacco

alcohol

(stein$barr

(stein$barr

%irus

%irus

0uman

0uman

(a(illoma

(a(illoma

%irus

%irus

0)=

0)=

>= rays

>= rays

adiation

?ood dust

nic!el

+

+

Tumor #rogression Model in 0N+11

Tumor #rogression Model in 0N+11

Normal mucosa :enign hy(er(lasia or Alternate (recursor 9ys(lasia 1arcinoma in situ )n%asi%e cancer

-@ am(lification

3(

( "B

-(,

5 ( (C-B

@ cyclin 9B

-@ bB

4 @ DB

"(



4@

+

+

Theories on 1arcinogenesis

Theories on 1arcinogenesis

$hemical carcino*enesis $hemical carcino*enesis

$hemical carcino*enesis $hemical carcino*enesis

Ini$ia$ing 'ac$(r

Ini$ia$ing 'ac$(r DNADNA :arcin()a:arcin()a S::A6S::A6

Pr()($ing agen$Pr()($ing agen$// a*c(&(* a*c(&(* vi$a)in de"ciency vi$a)in de"ciency *(ca* ina))a$i(n *(ca* ina))a$i(n

+

+

Theories on 1arcinogenesis

Theories on 1arcinogenesis

=iral carcinogenesis E

=iral carcinogenesis E

_{F its role is still unclear but sus(iciousFits role is still unclear but sus(iciousGG}

_{%idence of 0#= " and  in +11A of the (aransal%idence of 0#= " and  in +11A of the (aransal}

sinuses, nasal ca%ity H laryn' sinuses, nasal ca%ity H laryn'

+

+

Natural 0istory of 0ead H Nec! +11A

Natural 0istory of 0ead H Nec! +11A

N(r)a* #$ra$i"ed #Jua)(u# e.i$&e*iu)

N(r)a* #$ra$i"ed #Jua)(u# e.i$&e*iu)

P#eud(#$ra$i"ed :(*u)nar ci*ia$ed e.i$&e*iu)

P#eud(#$ra$i"ed :(*u)nar ci*ia$ed e.i$&e*iu)

Initiating &

Initiating &

Promoting agents

Promoting agentsLeuk(.*akiaLeuk(.*akia

Hy.er.*a#ia .a.i**()a$(#i#Hy.erkera$(#i#6

Hy.er.*a#ia .a.i**()a$(#i#Hy.erkera$(#i#6

P#eud(e.i$&e*i ()a$(u# &y.er.*a#ia6

P#eud(e.i$&e*i ()a$(u# &y.er.*a#ia6

ry$&r(.*akia ry$&r(.*akia Dy#.*a#ia6 Dy#.*a#ia6 :arcin()a in #i$u :arcin()a in #i$u Inva#ive carcin()a Inva#ive carcin()a

+

+

The

The

The

The

I

I

I

I

%atural History

%atural History

%atural History

%atural History

J

J

J

J

of $ancer

of $ancer

of $ancer

of $ancer

Normal Cell “Premalignant” Cell Malignant Cell “Local” Growth Palpable LN Mets Radiologic LN Mets “Micrometastasis” in RLN Distant Metastasis D E A T  L!mphatic Capillar! "n#asion Genetic $%or En#ironmental "nteractions

+

+

Management of

Management of

Nodal Metastases

Nodal Metastases

+

+

ationale for Management of Occult

ationale for Management of Occult

Nodal Metastases

Nodal Metastases



_{0N+11 are characteri8ed mainly by}

_{0N+11 are characteri8ed mainly by}

_{loco-regional}

_{loco-regional}

progression and low risk of distant metastases

progression and low risk of distant metastases

,

,

(riority is gi%en to loco$regional control

(riority is gi%en to loco$regional control



_{Although the natural history of the}

_{Although the natural history of the}

_{F(rimary tumor}

_F

_{(rimary tumor}

_{G is}

_G

_is

a ma&or consideration,

a ma&or consideration,

the extent of metastatic

the extent of metastatic

cancer

cancer

in the cer%ical nodes determines

in the cer%ical nodes determines

locoregional control and survival

locoregional control and survival

!K$$/#'$$ 0AA7

!K$$/#'$$ 0AA7

Re*ional

+

+

ationale for 6ocoregional Management

ationale for 6ocoregional Management

 _{6ocal modalities including surgery and radiothera(y remain6ocal modalities including surgery and radiothera(y remain}

cornerstones of treatment cornerstones of treatment

+

+

9efinition of terms

 _{!linically positive neck- node I  cm, s(herical rather than flat}

o%oid, and harder than nonmetastatic lym(h node

 _{"acrometastases$ node which can be identified either on # or by}

+

+

9efinition of terms

 _{!linically occult metastases * undetected by clinical or radiogra(hic}

e'am;

 _{Also called subclinical metastasesE}

 _{)stablished occult )stablished occult metastasesmetastases// detected by light microsco(y}  _{ccult ccult micrometastasesmicrometastases// sub(athological or submicrosco(ic}

 _{smaller than 2 mm de(osit of malignant cell ;}  _{detected by )01 andJor molecular analysis}

+

+

6ym(hatic #atterns of <low in 0ead H

Nec!

 _{2 to -C lym(h node in the head and nec!}

 _{J- of total number of nodes in the body}

+

+

+u(erficial lym(hatic networ!

 _{6ie between the s!in and su(erficial fascia}

 _{fferents drain inferiorly along the ma&or %eins of the face and}

+

+

9ee( lym(hatic networ!



_{+eries of node that run dee( to the}

sternocleidomastoid muscle and follow the internal

&ugular %ein from the base of the s!ull to the

brachioce(halic &unction



_{fferents drain into the %enous system at this &unction}



_{Two im(ortant grou(E &ugulodigastric and &ugulo$}

+

+

0ead H Nec! 6ym(hatic drainage

 _{F6ym(hatic drainage of the head and nec! follows a relati%ely}

constant and se@uential route.G

ou%iere, 3- 6indberg, 352

 _{Therefore, it is (ossible that the first draining lym(h node sB is}

also (redicti%e of metastatic s(read in +11 of the head and nec!

+

+

0ead H Nec! 6ym(hatic drainage

 _{:y !nowing the (rimary tumor site and understanding the}

(athways of lym(hatic tumor s(read, the region of the nec! at highest ris! for metastatic disease can be (redicted

+

+

#robable (rimary tumor regions in

#robable (rimary tumor regions in

cer%ical lym(h node metastases

cer%ical lym(h node metastases

*ervical node *ervical node region level region level according to according to 'edina 18 'edina 18 $ocali3ation of lymph $ocali3ation of lymph node 'etastases node 'etastases

4robable primary tumor regions 4robable primary tumor regions

++ SSuubbmmeennttaal l nnooddeess Submandibular nodes Submandibular nodes

$ipsanterior floor of the mouth $ipsanterior floor of the mouth &ongue palate chee6

&ongue palate chee6 ++++ 77uugguullooddiiggaassttrriic c nnooddeess

pper jugular nodes pper jugular nodes pper posterior cervical pper posterior cervical nodes nodes ro/naso/hypopharyn-laryn-oral cavity ro/naso/hypopharyn-laryn-oral cavity $aryn-hypopharyn-thyroid $aryn-hypopharyn-thyroid

"asopharyn-++++++ ''iid d jjuugguullaar r nnooddeess &&hhyyrrooiid d ggllaanndd  cceerrvviiccaal l eessoopphhaagguuss ++99 $$oowweer r jjuugguullaar r nnooddeess

Supraclavicular nodes Supraclavicular nodes

&hyroid gland cervical esophagus &hyroid gland cervical esophagus $ungs(+&(&&hyroidbreast $ungs(+&(&&hyroidbreast 9

9 44oosstteerriioor r cceerrvviiccaall triangle nodes triangle nodes

"asopharyn-+

+

Memorial +loan$7ettering 1ancer 1enter

Memorial +loan$7ettering 1ancer 1enter

6e%eling +ystem of 1er%ical 6ym(h Nodes

+

+

<irst echelon nodes at highest ris! for metastases for early <irst echelon nodes at highest ris! for metastases for early

dissemination by metastatic cancer from oral ca%ity (rimary lesion dissemination by metastatic cancer from oral ca%ity (rimary lesion

+

+

The first echelon lym(h nodes at highest ris! for metastasis from

The first echelon lym(h nodes at highest ris! for metastasis from

(rimary tumors of the hy(o(haryn' and laryn'

+

+

The first echelon lym(h nodes at highest ris! for

The first echelon lym(h nodes at highest ris! for

+

+

The first echelon lym(h nodes at highest ris! for metastases

The first echelon lym(h nodes at highest ris! for metastases

from (arotid gland (rimary

+

+

<irst echelon lym(h nodes at highest ris! for metastases

<irst echelon lym(h nodes at highest ris! for metastases

from a (rimay tumor from the submandibular and sublingual glands

+

+

0ead H Nec! 6ym(hatic drainage

 _{0owe%er, des(ite these generali8ed (atterns of drainage,E}

 _{There is great %ariability in the 0HN lym(hatic flow}

 _{This may be due in (art to the %ast number of lym(hatics and} nodes

 _{Also due to anatomical %ariations between the afferent and} efferent lym(hatics in a gi%en node

+

+

Treatment of egional 6ym(hatics

 _{0istorical de%elo(mentE}

 _{adical Nec! 9issection$ 1rile, 3"}

 _{Modified Nec! 9issection$ +uare83"-B; :occa and} #ignataro3"5B

 _{+electi%e Nec! 9issection, Kesse  35B}

6N9 E

+

+

+

+

+

Modified adical Nec! 9issection

Modified adical Nec! 9issection

MN9 Ty(e  MN9 Ty(e2

-+

+

+electi%e Nec! 9issection

+electi%e Nec! 9issection

+u(raomohyoid N9 'tended su(raomohyoid N9

1entral com(artment N9

oral ca%ity

+

+

+electi%e Nec! 9issection

+electi%e Nec! 9issection

KugularanterolateralBN9 #osterolateral N9

scal( oro$,hy(o$

(haryn' laryn'

+

+

Treatment of egional lym(hatics



_{0N+11 s(reads %ia lym(hatics to the regional nodes}



_{#resence of lym(h node metastases is an im(ortant}

(rognostic factor , decreasing sur%i%al by CL  Al%i ,

33"B



_{arly detection is crucial to treatment (lanning}



_{#,M),1T ,>+ are not so reliable in detecting occult}

metastases ?oolgar,33CB



_{Nec! dissection is the only accurate method to stage the}

+

+

Treatment of the 1linically No Nec!

1ontro%ersy E



Obser%ation or lecti%e Nec! 9issection

6N9B

+

+

Treatment of the 1linically No Nec!



_{)ncidence of occult metastasis * -L}



_{=an den :re!el, 33"}



_{:yers, 3}

+

+

Treatment of N Nec!

 _Obser%eE

 _{Fwait and see F a((roach results in a high (ro(ortion of (atients}

de%elo(ing metastatic disease

 _{lecti%e Nec! 9issection}

 _{Associated morbidity}

 _{0igh (ro(ortion of unnecessary surgery}

 _{%en if occult metastases are remo%ed, does it confer any sur%i%al}

4atients at !is6

4atients at !is6



:igh

:igh &

& stage

stage

&he ;"

&he ;"

₀₀

< "ec6

< "ec6



:igh

:igh grade

grade



,epth

,epth of

of infiltration

infiltration



Site

Site

+

+

1ommon round

 _{Treatment of the early nec! disease carries a better (rognosis than}

late nec! disease

 _{F>ntreated micrometastases are e'(ected to (roliferate gradually}

+

+

#robable +olution to the 9ilemma

 _{+electi%e nec! dissection was utili8ed as a com(romise}

+

+

ationale for +electi%e Nec! 9issection



_{There are defined first echelon nodes at highest ris!}

of nodal metastases from different (rimary sites



_{Therefore, selecti%e nec! dissection is indicated in}

(atients with high ris! of occult metastases.



_{+ome of these (atients de%elo( ino(erable nec!}

metastases and conse@uent distant metastases

des(ite close follow u(.

*urrent 4hilosophy in the

*urrent 4hilosophy in the 'anagement

'anagement

of *ervical $ymph "ode 'etastases

of *ervical $ymph "ode 'etastases

"

"

==



'!",

'!", >?+

>?+ for

for "

"

₂₂

and "

and "

₁₁

disease

disease



Selective

Selective nec6 d

nec6 dissection

issection for limited

for limited "

"

₁₁

disease

disease



Supraomohyoid

Supraomohyoid nec6

nec6 dissecti

dissection

on for

for oral

oral cavity

cavity primaries

primaries



7ugular

7ugular node

node dissect

dissection

ion for

for pharyngolaryngeal primaries

pharyngolaryngeal primaries



!adical nec6 dissection for "

!adical nec6 dissection for "

_@@

disease and other

disease and other

select circumstances

select circumstances

"

"

₀₀



'ultiple

'ultiple positive

positive nodes

nodes



)-tranodal

)-tranodal spread

spread

4..!.&.

4..!.&.

+ndications for

+ndications for 'ultidisciplinary &

'ultidisciplinary &rea

reatment

tment

of SAuamous *ell *ancers of the

of SAuamous *ell *ancers of the

:ead and "ec6

:ead and "ec6



:igher

:igher &

& stage

stage +++

+++ +9

+9



4ositive

4ositive margins

margins



minous pathologic features

minous pathologic features



:igh

:igh ris6

ris6 of mic

of micromets

romets in "

in "0 nec6

0 nec6



'ultiple

'ultiple nodal

nodal metastases

metastases "2b

"2b



'assive

'assive nodal

nodal metastases

metastases "@

"@



)-tra

)-tra nodal

nodal spread

spread



minous pathologic features

minous pathologic features



:igh ris

:igh ris6 of

6 of distant m

distant metastases

etastases B&@ or

B&@ or B"1

B"1



,istant

,istant metastases

metastases

&

&

"

"

'

'

+

+

,iagnosis and 'anagement of

,iagnosis and 'anagement of

4aro

4arotid (land

tid (land &

&u

umors

mors

; ;

+

+

Ma&or sali%ary glands

#arotid gland +ubmandibular gland

+ublingual gland

+

+

alivary Gland Tumors

alivary Gland Tumors

alivary Gland Tumors

alivary Gland Tumors

6ocation

6ocation LL MalignantMalignant L :eniL :enigngn

#arotid

#arotid

2 L 2 L 5 $L5 $L

+ubmandibular

+ubmandibular

4 L 4 L " L" L

+ublingualJMinor

+ublingualJMinor

" L " L 4 L4 L

+

+