st

Surgery II 1.04

1 Sem/A.Y. 2016-2017

Surgical Diseases of the Thyroid Gland

Dr. Ampil

I.
II.
III.
IV.
V.
VI.
VII.

VIII.
IX.

August 30, 2016

OUTLINE
Diseases of the Thyroid Gland
Evaluation of thyroid diseases
Goiter
Thyroiditis
Thyroid cyst
Benign tumors
Malignant tumors
a. Papillary carcinoma
b. Follicular carcinoma
More aggressive neoplasms
Parathyroids

I.
DISEASES OF THE THYROID GLAND
Thyroid diseases are easy to diagnose unlike the abdomen
and thoracic cavity, where you barely see the lesions.
Usual presentation is anterior neck mass
Skin subcutaneous thyroid gland
Normally, the thyroid gland should not be palpable
Congenital Lesions
Embryologic life of the thyroid gland: it starts at the base of
the tongue (foramen cecum), pierces the hyoid bone and
migrates down the neck where it lies during the adult life
Any problem with the descent of the thyroid gland to the
neck will cause congenital abnormalities

Figure 2. Pyramidal lobe. Distal end of the thyroglossal duct

persists thus resulting to a third lobe of the thyroid.
3.

Ectopic Thyroid

Failure of the thyroid to descend completely into the neck

Results to thyroid tissue anywhere along the tract
Lingual/Sublingual Thyroid
o Mass or thyroid found at the base of the tongue
o Represents a failure of the median thyroid anlage to
descend normally and may be the only thyroid tissue
present
o Signs and Symptoms

Hypothyroid- if the thyroid gland is small

Obstructive symptoms- if the thyroid gland is big

(choking, dysphagia, airway obstruction)

Hemorrhage
o Treatment:

Radioactive iodine (RAI) ablation followed by

hormone replacement.

If small: Exogenous thyroid hormone to

suppress TSH

If large: Surgical excision; rarely needed but, if

required, should be preceded by an evaluation of
normal thyroid tissue in the neck to avoid
inadvertently rendering the patient hypothyroid.

Figure 1. Embryonic Migration of the Thyroid Gland.

1.

Thyroglossal Duct Anomalies

Cyst, sinus, fistula

Typically midline masses in childhood
80% below hyoid bone
Elevates with tongue protrusion
o Because embryologically, the thyroid gland originates
from the foramen cecum (base of the tongue). From
there, the thyroid gland goes down and splits into two.
The thyroglossal duct should degenerate upon birth. If
the thyroglossal duct persists thyroglossal duct
problems
Treatment: It is important to recognize thyroglossal duct
cyst from a simple cyst because treatment is different
o Simple cyst excise
o Thyroglossal duct cyst Sistrunk procedure
(remove the tract and part of the hyoid bone) since
it will recur if simply excised!

Distal end of thyroglossal duct persists

Projecting up from the isthmus, lying just to the left or right
of the midline
No pathologic problem most of the time
When the thyroid gland enlarges, the pyramidal lobe can
also enlarge.

2.

Pyramidal Lobe

50% of individuals

2018-A

Figure 3. Lingual/Sublingual Thyroid

II.
EVALUATION OF THYROID DISEASES
Thyroid problems usually appear as anterior neck mass
that moves up with deglutition

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Surgery II 1.04

Figure 5. Hypothalamus Pituitary Thyroid Axis. The

hypothalamus releases TRH, stimulating the anterior pituitary
gland to secrete TSH, which stimulates the thyroid to produce
thyroid hormones with iodine. Excess in thyroid hormones will
produce a negative feedback mechanism which suppresses
the production of TSH. Also, If TSH is increased, there is a
negative feedback to the hypothalamus which will decrease
TRH secretion.

Figure 4. Thyroid nodule

Initial Work-up
Thyroid function test: Initial diagnostic modality
- TSH, FT4, FT3 serum levels
If euthyroid: Ultrasound, Fine Needle Aspiration Biopsy
Cytology (FNABC)
If hyperthyroid: Thyroid scan
- Hot/warm nodule: treat as toxic nodule
- Cold nodule: FNABC

1. Thyroid Function Test

MOST ACCURATE TESTS of thyroid function

SERUM TSH (Thyroid Stimulating Hormone)

The most sensitive and specific test for determining
thyroid function
Reflect the ability of the anterior pituitary to detect FT4
levels
There is an inverse relationship between FT4 levels
and the logarithm of TSH concentration: small changes
in FT4 lead to a large shift in TSH levels

FREE T4 & FREE T3 ASSAY (FT4 & FT3)

Measure the biologically active thyroid hormones

which cause the clinical manifestations
FT4 is not performed as a routine screening tool in
thyroid disease. Use of this test is confined to cases
of early hyperthyroidism
FT3 is most useful in confirming the diagnosis of
early hyperthyroidism
Table 1. Interpreting Thyroid Function Tests (Memorize)
SERUM
FT4 AND FT3
DIAGNOSIS
TSH
ASSAY
High
Low
Hypothyroid
Subclinical
Normal
High
Hypothyroid
Low
High
Hyperthyroid
Subclinical
Normal
Low
Hyperthyroid
If the patient can only avail one test, request for TSH

2018-A

Other thyroid function test (Non-routine):

Total T4 & T3
Both are measured by radioimmunoassay
Measure both the free and bound components of
the hormones
T4 levels reflect the output from the thyroid gland
T3 levels in the non-stimulated thyroid gland are more
indicative of peripheral thyroid hormone metabolism;
not generally suitable for as a general screening
test

Thyroid antibodies
Include anti-Tg, antimicrosomal, or anti-TPO and
thyroid-stimulating immunoglobulin
indicate underlying disorder, usually an autoimmune
thyroiditis
High in 80% of patients with Hashimotos thyroiditis
and may also be elevated in Graves disease,
multinodular goiter, and thyroid neoplasms
(occasionally)

Thyroglobulin
Increases dramatically in destructive processes of the
thyroid gland (i.e. thyroiditis, Graves disease, toxic
multinodular goiter)
Most important use is in monitoring patients with
differentiated thyroid cancer for recurrence
2.

Ultrasound

Helpful in the evaluation of thyroid nodules, distinguishing

solid from cystic ones, and providing information about size

and multicentricity.
Major advantage: determine consistency of mass
o Simple cyst: thyroid cyst (purely fluid)
o Complex cyst: goiter (mixed)
o Solid nodule: tumor
Monitoring nodule size (for non-operative treatment)
o Can detect masses even if 1mm
o Detects non-palpable masses
Size and multicentricity
Cervical lymphadenopathy
Guides FNAB

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Surgery II 1.04

Evaluating
substernal
goiters
(extent,
compression)
Characteristics associated with carcinoma:
o Hypoechogenicity
o Irregular margins
o Increased nodular flow (Doppler)

Hypervascular increased blood flow

o Invasion/ regional lymphadenopathy

tracheal

Figure 6. Ultrasound of Thyroid Nodule

3.

Fine Needle Aspiration Biopsy Cytology (FNABC)

Single most useful diagnostic modality for diagnosing
thyroid nodules in euthyroid patients
Performed after ultrasound
Diagnostic: Cytopathologic Diagnosis (cells)
Therapeutic: Thyroid Cyst
o If its a thyroid cyst, you can just aspirate the contents
then the cyst will be gone
Limitations
o Technical expertise of the surgeon and the pathologist
o Differentiating Follicular CA vs Benign Adenoma
o Small nodule (hard to hit)

Do ultrasound-guided FNA
o Drawbacks of FNA in toxic patients (hyperthyroid):
not accurate since

They are more vascular which can lead to

Increased bleeding

Increased false positive result

- Cells are actively dividing and can be
mistaken for CA, so you do not do FNA for
nodules that are hot or warm
- If hyperthyroid you do a thyroid scan

Hypertrophic cells mistaken for CA

Figure 7. Fine Needle Aspiration Biopsy Cytology (FNABC).

Stick a needle through the mass then aspirate cells to get a
cytopathologic diagnosis.
4.

Radionuclide Imaging/Thyroid Scan

Iodine-123 (123I), iodine-131 (131I), or Technetium-99m

(99mTc) pertechnetate

2018-A

Iodine is preferred because it is more accurate

o Preferably I123 or 131 because 3-8% of warm nodules
are cold on pertechnetate scan
Iodine-123 - emits low dose radiation, half-life of 12 to
14 hours, and is used to image lingual thyroids or
goiters
Iodine-131 - half-life of 8 to 10 days and leads to
higher-dose radiation exposure, used to screen and
treat patients with differentiated thyroid cancers for
metastatic disease
Technetium-99m pertechnetate

Increasingly being used for thyroid evaluation

Taken up by the mitochondria, but is not

organified

Advantage of having a shorter half-life and

minimizes radiation exposure

Particularly sensitive for nodal metastases

Shows size and shape of the gland and distribution of
functional activity

COLD
o Areas that trap less radioactivity than the
surrounding gland
MALIGNANCY IS HIGHER (20%)

HOT
o Areas that demonstrate increased activity

Figure 8. Radionuclide Imaging/Thyroid Scan

5.

Other Diagnostics

Not routinely used, only for completion

Neck CT Scan: For lesions of borderline resectability. If
one is not sure if mass is resectable (preferably use double
contrast).

Laryngoscopy: Hoarseness or s/s of compression of

recurrent laryngeal nerve

Metastatic Work-Up: Symptom-Directed

Chest / Liver / Bone / Brain

Work-up for MEN: for medullary cancer

o Suspect if w/ family history of Multiple Endocrine
Neoplasia Type 2 (MEN 2A) or Medullary Thyroid
Cancer (MTC)
o High basal serum CALCITONIN: virtually diagnostic
for MTC
o Further work-up for primary hyperparathyroidism &
pheochromocytoma
CT/MRI provide excellent imaging of the thyroid gland and
adjacent nodes and are particularly useful in evaluating the
extent of large, fixed, or substernal goiters (which cannot
be evaluated by ultrasound) and their relationship to the
airway and vascular structures.
Non-Contrast CT Scans should be obtained for patients
who are likely to require subsequent RAI therapy.

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Surgery II 1.04
PET-CT scans: for Tg-positive, RAI-negative tumors

III.
GOITER
Most common thyroid disease in Filipinos
More than 80% of thyroid nodules of Filipinos turn out to be
goiter
Moves with swallowing
Can be classified whether nodular vs diffuse and toxic vs
nontoxic
Nodular vs Diffuse

Figure 9. (Left) Nodular Goiter: Unilateral enlargement (Right)

Goiter: Bilaterally symmetrical enlargement; like a scrotum in
the neck

Elevated TSH levels induce diffuse thyroid hyperplasia,

followed by focal hyperplasia, resulting in nodules that may

or may not concentrate iodine, colloid nodules, or
microfollicular nodules. The TSH-dependent nodules
progress to become autonomous
In the past, dietary iodine deficiency was the most
common cause of endemic goiter
Dietary goitrogens (kelp, cassava, and cabbage) also
participate in formation
Toxic vs Non-Toxic

Figure 10. Toxic vs Non-Toxic Goiter

1.

Non-Toxic Goiter

Most are thought to result from TSH stimulation secondary

to inadequate thyroid hormone synthesis and other

paracrine growth factors
May also be caused by problems of thyroid hormone
resistance
Nowadays, its very hard to have iodine deficiency since a
lot of food are fortified
May be diffuse, uninodular, or multinodular

2018-A

Familial goiters result from inherited deficiencies in

enzymes necessary for thyroid hormone synthesis
Endemic goiter refers to the occurrence of a goiter in a
significant proportion of individuals in a particular
geographic region

Signs and Symptoms

o Asymptomatic (approx. 80% of the time)

Theres just a mass that moves up with swallowing

Pressure sensation at the back

o Compressive symptoms

Dysphagia, orthopnea

Catarrh: frequent clearing of throat

Dysphonia (hoarseness)

Pemberton sign

facial flushing and dilatation of cervical veins

on raising the arms above the head

rarely seen
Caused by obstruction of venous return at the
thoracic inlet from a substernal goiter

MEMORIZE! Came out in the board exam

Physical Exam:
o Soft, diffusely enlarged gland (simple goiter) or
nodules of various size and consistency in case of a
multinodular goiter.
o Deviation or compression of the trachea may be
apparent.
Diagnosis:
o Euthyroid with normal TSH and low-normal or normal
free T4 levels.
o RAI uptake often shows patchy uptake with areas of
hot and cold nodules.
o FNAB is recommended in patients who have a
dominant nodule or one that is painful or enlarging, as
carcinomas have been reported in 5% to 10% of
multinodular goiters.
o CT scans are helpful to evaluate the extent of
retrosternal extension and airway compression
Treatment:
o Small, diffuse goiters do not require treatment
o Exogenous thyroid hormone to reduce the TSH
stimulation of gland growth for large goiters

May result in decrease and/or stabilization of

goiter size

Most effective for small diffuse goiters

o Endemic goiters are treated by iodine administration
o TSH suppression

Give high-dose exogenous thyroid hormone at

levels that suppress serum TSH
o Thyroidectomy: Surgical resection is reserved for
goiters that:

Continue to increase despite T4 suppression

Cause obstructive symptoms

Have substernal extension

Have malignancy suspected or proven by FNAB

Are cosmetically unacceptable

Near-total or total thyroidectomy is the

treatment of choice and patients require lifelong
T4 therapy
Table 2. Indications of TSH Suppression and thyroidectomy
as treatment options for Non-Toxic Goiter.
TSH suppression
Thyroidectomy
Patients from geographic
Large goiters
areas with iodine
Compressive symptoms
deficiency
Suspicious nodules
Young patients with small
Contraindications to TSH
thyroid nodules
suppression

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Nodular goiters with no
evidence of functional
autonomy

1. Post-menopausal
2. Older than 60 y/o
3. Osteoporosis
4. Cardiovascular disease
Failure of medical treatment

Table 3. Etiology of Non-toxic Goiter

CLASSIFICATION
SPECIFIC ETIOLOGY
Endemic
Iodine deficiency, dietary goitrogens
(cassava, cabbage)
Medications
Iodide, amiodarone, lithium
Thyroiditis
Subacute, chronic (Hashimotos)
Familial
Impaired hormone synthesis from
enzyme defects
Neoplasm
Adenoma, carcinoma
2. Toxic Goiter
Despite the normal thyroid hormone levels, theres still
production by either a tumor or the thyroid itself
Graves disease, toxic multinodular goiter and solitary
toxic nodule are most relevant to the surgeon
Clinical manifestations result from an excess of circulating
thyroid hormone
Hyperthyroidism/Thyrotoxicosis
Clinical Manifestations:

Heat intolerance, sweating & thirst,

Weight loss

Palpitations, atrial fibrillation

RESTING TACHYCARDIA: most reliable sign patients

may not present with other manifestation but this is always
present; indicates that patient is clinically hyperthyroid
(2017A)

Nervousness, fatigue, emotional lability, hyperkinesis, fine

tremors, muscle wasting, proximal muscle group weakness
with hyperactive tendon reflexes

Amenorrhea, decreased fertility

Facial flushing, warm & moist skin

Ophthalmopathy (eye signs)

Dermopathy (thickened skin in pretibial region)

i.

Graves Disease
Diffuse toxic goiter
o Familial predisposition
o Females 40-60 yrs
Possible triggers
o Postpartum state, iodine excess, lithium therapy, and
bacterial & viral infections
Etiology: Autoimmune
o Antibodies directed against the thyroid hormone receptor
o Stimulate thyrocytes to produce excessive thyroid
hormone
o Etiology is autoimmune that stimulates the thyroid to
produce excessive hormone
Clinical Manifestations

Can be divided into those related to hyperthyroidism

and those specific to Graves disease.

Hyperthyroid symptoms:
o Heat intolerance
o Increased sweating and thirst
o Weight loss despite adequate caloric intake

Symptoms of increased adrenergic stimulation

The most common GI symptoms include increased

frequency of bowel movements and diarrhea

50% of patients will develop clinically evident

ophthalmopathy

2018-A

Diagnosis
o High FT4 and/or FT3
o Low TSH
o Diffusely Hot uptake on radionuclide scan
o Auto-antibodies against
Thyrotropin receptor
Thyroglobulin
Peroxidase

Figure 11. Graves Disease on Radionuclide Scan

Treatment
o Anti-Thyroid drugs
To prepare patient for definitive treatment
High relapse rate if discontinued
Types:
- Propylthiouracil (PTU, 100-300mg TID)
- Methimazole (10-30mg TID) more potent than
PTU
Definitive treatment
o Surgery (thyroidectomy) recommended when RAI is
contraindicated
o Radioactive Iodine Ablation Therapy (RAI)
Causes progressive development of hypothyroidism
(over 70% in 11 years), requiring lifelong thyroxine
Has been shown to lead to progression of
opthalmopathy
Takes 3-6 months to achieve Euthyroid
Absolute contraindications include women who
are pregnant and breastfeeding

Table 4. Comparison of Surgery and RAI

SURGERY
RAI
Immediate ablation
Gradual ablation (40%
decrease in 1 yr)
Complete relief of
symptoms
Relief of most toxic
symptoms in 3-6 mos except
Definite histologic diagnosis
ophthalmopathy
Need to render euthyroid
Permanent hypothyroidism in
first
10 yrs
Surgical risks
Radiation effects (Not for
pregnant/breastfeeding)
Table 5. Indications for Surgery or RAI
SURGERY
RAI
Compressive symptoms
Small goiters (volume <
100mL)
Large nodules
- Require high amounts of
Without suspected
RAI
malignant potential
- Resistant to tx
Previous thyroidectomy
Immediate resolution of
High surgical risk
thyrotoxicosis needed
Suspicious nodule or
confirmed cancerous
For surgery, the patient needs to be euthyroid before surgery
(through anti-thyroid drugs for 3-4 week) to prevent thyroid
storm and decrease vascularity of the gland.

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Surgery II 1.04
Table 6. Adverse Effects of Surgery and RAI
SURGERY
RAI
Hemorrhage (<5%)
Hypothyroidism (10% in 5
yrs), progressive over time
RLN injury (3-8%)
Neck edema, thyroiditis (5 Hypo PT (2-5%)
10%)
Sialadenitis (11.5%)
Vocal cord paralysis (<5%)
GIT complaints (67%)
Acute radiation sickness (3050%)
Impaired fertility (10-45%)
Bone marrow suppression
(3-35%)
Taste dysfunction (37%)
Parathyroid dysfunction (560%)
Leukemia, bladder cancer
(<5%)
Nodule consistency
hardening
ii. Toxic Multinodular Goiter
Older than 50 years of age
Often have a prior history of a non-toxic multinodular
goiter
Over several years, thyroid nodules become autonomous to
cause hyperthyroidism
Diagnosis: TSH, FT4, FT3, thyroid scan
Treatment: Thyroidectomy
Table 7. Diagnosis and Treatment for Toxic and Non-toxic
Goiter.
Toxic
Non-toxic
Diagnosis
TSH, FT4, FT3
Thyroid Scan
Ultrasound, FNAB
Treatment
Surgery
None
RAI
TSH suppression
Anti-thyroid drugs
Surgery
Goiter summary

Most common thyroid disease in the Philippines (85%)

Types:
o Diffuse nontoxic
o Nodular nontoxic
o Diffuse toxic
o Nodular toxic
Diagnosis
o TSH, FT4, FT3

If toxic: Thyroid Scan

If non-toxic: Ultrasound, FNAB

o Toxic: surgery, RAI, anti-thyroid drug
o Non-toxic: none, TSH suppression, surgery
IV.
THYROIDITIS
Inflammatory disorder of the thyroid gland
May cause initial hyperthyroidism, then progress over
time to euthyroidism and then to hypothyroidism
Initial hyperthyroidism because inflammation irritates
causing more production of thyroid hormone then as the
cells are destroyed it usually progresses to euthyroidism
and ultimately hypothyroidism.
Not that common, usually an incidental finding

2018-A

Treatment for Thyroiditis

1. Medical treatment
Antibiotics for acute and sub-acute variants and then
monitoring of Thyroid Hormone levels
2. Indications for surgery:
o Malignancy cannot be ruled out (Like in Riedels)
o Significant signs of compression
o Failure of medical treatment
3. Serial monitoring of thyroid function as indicated (TSH, FT4
and FT3)
Acute Thyroiditis

Infectious cause
Streptococcus and anaerobes account for about 70% of
cases
More common in children, often preceded by an upper
respiratory tract infection or otitis media
Characterized by:
o Severe neck pain radiating to the jaws or ear
o Fever
o Chills
o Odynophagia
o Dysphonia
Diagnosis
o Established by leukocytosis on blood tests and FNAB
for Grams stain, culture, and cytology
o CT scans may help to delineate the extent of infection
o A persistent pyriform sinus fistula should always be
suspected in children with recurrent acute thyroiditis
o Barium swallow demonstrates the anomalous tract with
80% sensitivity

Treatment
o Antibiotics
o Possible debridement/drainage if suppurative or if with
presence of abscess
Parenteral antibiotics and drainage of abscesses
Sub-Acute Thyroiditis
Self-limiting remission in 2-4 months even without
intervention

Subtypes:
o Granulomatous (De Quervains)
o Lymphocytic
o Post-partum
Can be painless or painful

Table 8. Painful vs. Painless Sub-Acute Thyroiditis (from

2017A, take note)
PAINFUL
PAINLESS
ONSET
Gradual
AGE
30-40 years old
30-60 years old
women
women
HISTORY
Upper respiratory
Autoimmune; occurs
tract infection
in postpartum period
(<6 weeks)
PE
Gland is enlarged,
Normal sized or
exquisitely tender,
minimally enlarged,
and firm
slightly firm, nontender gland
DIAGNOSIS
Early stages: TSH
decreased; Tg, T4,
and T3 levels are
elevated due to the
release of preformed
thyroid hormone from
destroyed follicles

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Surgery II 1.04
TREATMENT

Aspirin and steroids;

Thyroidectomy if non
responsive to medical
treatment

B-blockers and
thyroid hormone
replacement for
symptomatic

Hashimotos Thyroiditis
Autoimmune
Antibodies develop against thyroid antigens
o Anti-thyroid peroxidase (anti-TPO) antibodies
o Anti-thyroglobulin (anti-Tg) antibodies
o Others: TSH receptor-blocking antibodies, thyroid
stimulating antibody, cytotoxic antibody
MOST COMMON INFLAMMATORY DISORDER OF THE
THYROID and the leading cause of hypothyroidism
Clinical Presentation
o More common in women between ages of 30 and 50
o Most common presentation is that of a minimally or
moderately enlarged firm granular gland discovered
on routine physical examination or the awareness of a
painless anterior neck mass
o 20% of patients present with hypothyroidism
o 5% presents with hyperthyroidism
o Classically, presents with diffusely enlarged, firm
gland, which also is lobulated.
Diagnostic Studies
o When suspected clinically, an elevated TSH and the
presence of thyroid autoantibodies usually confirm
the diagnosis.
o FNAB is indicated in patients who present with a
solitary nodule or a rapidly enlarging goiter

Treatment: Thyroid hormone replacement

1.

why FNAB cannot be used to differentiate the two. Its very

hard to demonstrate invasion from a needle specimen.)
2.

Toxic Adenoma (Plummer Disease)

Hyperthyroidism from a single hyperfunctioning nodule
Typically occurs in younger patients
Diagnosis: RAI scan hot nodule
Treatment:
Thyroidectomy
after
control
hyperthyroidism

of

Figure 12. Toxic Adenoma. Single, hyperfunctioning hot

nodule seen in young patients.

VII.
MALIGNANT TUMORS
Papillary well differentiated
Follicular well differentiated
Medullary
Anaplastic
Others

Riedels Thyroiditis
Chronic inflammatory disease causing dense fibrosis of
the gland
Dense fibrosis presents as a hard mass on the neck, so
this is why it is usually mistaken as cancer and then after
operation and looking at the excised thyroid, it turns out to
be thyroiditis.
Fibrosis may extend beyond thyroid capsule to the neck
May be mistaken for CA
Typically presents as a painless, hard anterior neck mass,
which progresses over weeks to years to produce
symptoms of compression, including dysphagia, dyspnea,
choking and hoarseness.
Physical exam reveals a hard, woody thyroid gland
with fixation to surrounding tissues.
Diagnosis is confirmed by open thyroid biopsy, because the
firm and fibrous nature of the gland renders FNAB
inadequate.
Surgery is the mainstay of the treatment

Figure 13. Well-differentiated Thyroid CA. Can either be

papillary or follicular.

V.
THYROID CYST
Exact cause: unknown
Theories:
o Lack of iodine in the diet
o Autoimmune disorder that causes inflammation of the
thyroid (Hashimotos disease)
o Genetic defect
o Exposure to radiation in childhood
Treatment: Needle aspiration +/- TSH suppression

VI.
BENIGN TUMORS
Follicular Adenoma
Hard to differentiate from follicular carcinoma
Only histologic difference from follicular carcinoma is
absence of capsular and blood vessel invasion (Thats

2018-A

Table 9. Frequencies of the Different Types of Thyroid

Carcinoma
Pathology
Frequency (%)
Papillary
80
Follicular
10
Hurthle cell
3
Medullary
5
Anaplastic
1
Others
1
90-95% are Well-Differentiated Cancers

PAPILLARY CARCINOMA
Relatively benign course
Compatible with long life
30-45% metastasis to lymph nodes
2:1 female-to-male ratio, and the mean age at presentation
is 30 to 40 years
Most patients are euthyroid and present with a slowgrowing painless mass in the neck.
Diagnosis:
o FNAB: If malignant, complete neck ultrasound is
strongly recommended to evaluate the contralateral

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lobe and for lymph node metastases in the central and

lateral neck compartments
Preference for lymphatic spread
1-2% distant metastasis
Common radiation induced CA
90-95% cure rate
Cells with intranuclear cytoplasmic inclusions (Orphan
Annie nuclei)
Calcified deposits (Psamomma Bodies)
Most patients with papillary carcinoma can expect an
excellent prognosis, with the 10-year survival rate
approaching 95% for the most favorable stages
Accounts for 80% of all thyroid malignancies in iodinesufficient areas and is the predominant thyroid cancer in
children and individuals exposed to external radiation.
Papillary carcinoma is the most common of the thyroid
neoplasms and is usually associated with an excellent
prognosis, particularly in female patients younger than 40
years.

Subtypes

Pure papillary, papillary follicular, follicular variant

Tall cell, columnar, diffuse sclerosing, clear cell, trabecular,

Hurthle cell variant and poorly differentiated
They are trying to find out which types are aggressive
compared to the rest, which is why there are so many
subtypes.

The pathologic diagnosis of papillary carcinoma depends

on the cytologic findings of well-recognized papillary
cytomorphology
Forms

Minimal/Occult/Microcarcinoma
o <\= 1cm
o Nonpalpable
o Detected only by ultrasound

Intrathyroidal: has not gone beyond the thyroid capsule

Extrathyroidal: has extended into the neck and nearby

structures
Treatment

Total or near-total thyroidectomy for high risk or bilateral

tumors and for primary cancers >1 cm unless with
contraindications

The 2009 ATA guidelines for thyroid cancer management

suggest that prophylactic (ipsilateral or bilateral) dissection
may be performed in patients with advanced (T3 or T4)
papillary thyroid carcinoma, whereas the procedure is not
needed for small (T1 and T2) tumors that are clinically
node negative.

Biopsy-proven lymph node metastases: modified radical

or functional neck dissection

3:1 female-to-male ratio

Mean age presentation: 50 years old
Cumulative mortality: 15% at 10 years and 30% at 20
years.

Prognostic Indicators
Table 10. AMES (Cady & Rossi)
A
Age: men <40 years old, women <50 years old
M
Metastases
E
Extrathyroid spread
S
Size of tumors (less than or >5cm)
Table 11. DAMES (Cady &Rossi)
D
DNA content measured by flow cytometry
A
Age: men <40 years old, women <50 years old
M
Metastases
E
Extrathyroid spread
S
Size of tumors
Table 12. AGES (Hay)
A
Age
G
Histologic Grade
E
Extrathyroid invasion
S
Metastatic tumor size
Table 13. MACIS (Hay)
M
Metastases
A
Age of presentation
C
Completeness of original resection
I
Extrathyroid invasion
S
Size of original lesion

Laudico, dela Pea, De Vera PGH:

o
o

Age
Histology (Nodal Metastasis had no impact)

Table 14. Clinical Predictors of Malignancy in Thyroid

Nodules (Ampil, Cortex, SIRF 1998)
Age
56 +/- 15 years
Size
4.5 +/- 1.4cm especially if solitary
Hard especially if solitary (Histology and
Consistency
multicentricity had no impact

There is no consensus on methods to classify which are

aggressive and which are not.
Staging for WDC (Well- Differentiated Carcinoma).
*Please see appendix for clearer picture.

FOLLICULAR CARCINOMA
Relatively benign course
Common in iodine-deficient areas (in comparison to
papillary which is common in iodine-sufficient areas)
Malignancy is defined by the presence of capsular and
vascular invasion
5-20% metastasis to lymph nodes
Spreads via bloodstream (in comparison to papillary
which spreads via lymphatic system)
2-5% distant metastasis
Associated with goiter in 10-15%
70-80% cure rate (papillary type still has a higher cure
rate)
Follicular and Papillary are relatively indolent

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Table 15. Staging for Well Differentiated Carcinoma
(Classic TNM Staging)

Figure 14. Extent of Thyroidectomy. A diagram showing

thyroid lobectomy to be done on <1cm WDC adenoma with a
contralateral normal lobe. For all other types especially if there
are bilateral nodules, we do total thyroidectomy. Subtotal
thyroidectomy is not indicated anymore.

Table 16.Staging of Papillary or follicular tumors

Complications of Thyroidectomy

Bleeding: Because it is a vascular area

Recurrent Laryngeal nerve injury: Causes Hoarseness. If

both recurrent laryngeal nerve injury, the vocal cords will
both close necessitating tracheostomy

Superior Laryngeal Nerve injury: Decrease volume of voice

Hypocalcaemia: Inadvertent involvement of the

parathyroids

Thyroid storm:This occurs if the patient was not euthyroid

to begin with.

Notice that in younger than age 45 years, the staging is

only up to stage II

In younger than age 45 years old, notice that even if there

is a metastasis it is still considered as stage II

It signifies that it isnt that aggressive when it is present for

ages <45 years old

This is the only cancer that has age as a factor

Treatment of WDC

Surgery
o Less than or equal to 1.0 cm (microcarcinoma),
solitary: Total lobectomy + Isthmusectomy
o More than 1.0 cm, multicentric: Total Thyroidectomy
(in Schwartzs it is >4 cm)

Extrathyroidal Spread
o Total thyroidectomy + Central neck dissection

(+) Lymph Node Metastasis

o Total thyroidectomy + Modified radical neck dissection

Extent of Thyroidectomy

Figure 15.Thyroidectomy

Figure 16. Location of the Parathyroid Glands on the

Thyroid. Proximity of the parathyroid causes it to be excised
along with thyroid upon thyroidectomy causing symptoms of
hypocalcaemia. You only need -1 to maintain parathyroid
function.

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Whole Body Iodine 131 Scan

Figure 17. Borders of the Central Neck. Superior: Thyroid

Cartilage; Medial: TE Groove; Lateral: Carotid Sheath; Inferior:
Suprasternal Notch
Adjuvant therapy

Radioactive iodine ablation

TSH suppression (Target serum TSH = 0)

NO ROLE: Chemotherapy/radiation therapy

Figure 19. Whole Body Iodine-131 Scan In A Thyroid

Cancer Patient With A Very High Thyroglobulin Level. This
means the cancer has come back. The red arrow shows
increased uptake (the dark spot) in a bone in the lower spine
and less uptake in the bones of the mid-pelvis. The very dark
area on the patients left leg is a urine bag.

1.

Figure 18. Monitoring Follow-up.

We monitor Serum Thyroglobulin (Tg) after thyroidectomy.
Ideally it should be decreased or 0 after the procedure
because it is produced by the thyroid gland.

2.

Tg levels in patients who have undergone total

thyroidectomy should be <2 ng/mL when the patient is

taking T4, and <5 ng/mL when the patient is hypothyroid
A Tg level >2 ng/mL is highly suggestive of metastatic
disease or persistent normal thyroid tissue
Approximately 95% of patients with persistent or recurrent
thyroid cancer of follicular cell origin will have Tg levels >2
ng/mL
Tg and anti-Tg antibody levels should be measured initially
at 6-month intervals and then annually if the patient is
clinically disease free
If serum Tg is still present after 6 months, we assume
recurrence.
If it is still positive, we work up the patient with a whole
body can. Areas with iodine will light up.

2018-A

3.

In cases where there is still positive serum

thyroglobulin (Tg) 6-12 months after total thyroidectomy
for a high risk well-differentiated carcinoma, one must
suspect recurrence since Tg is produced only by the
thyroid
When this happens, work up the patient and what is
usually done is Whole Body Iodine-131 Scan. It works in
a similar principle to RAI scan, but it is applied for the
whole body. The distant metastatic lesions will imbibe
iodine and will light up
Treatment for metastatic sites: Radioactive Iodine
Tablets
VIII.
MORE AGGRESSIVE NEOPLASMS
Hurthle Cell Carcinoma
Subtype of Follicular CA
More often multifocal and bilateral (30%), usually do not
take up RAI (5%), more likely to metastasize, associated
with higher mortality rate (20% at 10 years)
It does NOT respond to RAI
Treatment: Lobectomy and Isthmusectomy
Medullary Carcinoma
More aggressive than papillary/follicular
Arise from parafollicular or C cells of the thyroid
o C cells secrete calcitonin
o 25% occur within the spectrum of several inherited
syndromes (germline mutations in the RET protooncogene)

familial medullary thyroid cancer, MEN2A & B

Diagnosis:
o Raised serum calcitonin levels
o FNA cytology: confirms the diagnosis
o All new patients with MTC should be screened from
RET point mutations, pheochromocytoma &
hyperparathyroidism
Treatment:
o Minimum is total thyroidectomy + central neck
dissection (to decrease the recurrence)
Anaplastic Carcinoma
Most aggressive of all
Rapidly enlarging
Treatment:
o Tracheostomy + Radiotherapy (RT provides only 30%
success rate)

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Most of the time, because of the immense size of

the mass, thyroidectomy/resection may not be
possible. Thus, tracheostomy is done to address
the obstruction of airways
Total thyroidectomy / Chemotherapy / RT
o Done if the tumor is still resectable
o Palliative treatment

4.

Other rare cancers

Sarcoma
Lymphoma
The diagnosis is considered in patients with a goiter,
especially one that has apparently grown significantly
in a short period.
There is also an increased association between
lymphoma and Hashimoto's thyroiditis.
Ultrasound may demonstrate a classic pseudocystic
pattern
FNA can be diagnostic
The use of flow cytometry for monoclonality can
confirm diagnosis
Neck, chest, abdominal CT or MRI to assess
extrathyroidal spread
Most thyroid lymphomas are B cell in origin
Use of the CHOP regimen (cyclophosphamide,
hydroxydaunomycin [doxorubicin], vincristine, and
prednisolone) has been associated with excellent
survival.
Metastatic cancer
o Kidney, breast, lung, and melanoma
FNAB usually provides definitive diagnosis.
Resection of the thyroid, usually lobectomy, may be
helpful in many patients, depending on the status of
their primary tumor
IX.

PARATHYROIDS

Calcium Homeostasis
Parathyroid hormone (PTH): increases serum calcium
Vitamin D: stimulates the absorption of calcium and
phosphate from the gut
The first hydroxylation at carbon 25 occurs in the liver
The second hydroxylation at carbon 1 occurs in the
kidney in response to increased PTH levels.
1,25(OH)2D3 increases calcium and phosphate
resorption from the gastrointestinal tract and
stimulates bone resorption, which raises calcium
levels
Calcitonin: decreases serum calcium

Table 17. Actions of Major Calcium-Regulating Hormones

PTH

VIT. D

CALCITONIN

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BONE
Stimulates
resorption of
calcium and
phosphate

Stimulates
transport of
calcium
Inhibits
resorption of
calcium and
phosphate

KIDNEY
Stimulates resorption
of calcium and
conversion of
25(OH)D3; inhibits
resorption of
phosphate and
bicarbonate
Inhibits resorption of
calcium

Inhibits resorption of
calcium and
phosphate

INTESTINE
No direct
effects

Stimulates
calcium and
phosphate
absorption
No direct
effects

Figure 20. Calcium Homeostasis and Parathyroid Hormone

(PTH). 1,25(OH)2D3, 1,25-dihydroxycholecalciferol.

Hyperparathyroidism
There is excess PTH, thus there is hypercalcemia

Types:

Primary (PHPT)
o From abnormal parathyroid glands

Secondary
o A compensatory response to hypocalcemic states ie:

Chronic renal failure

Gastrointestinal malabsorption of calcium

Tertiary
o Chronically stimulated glands become autonomous,
resulting in persistence or recurrence of
hypercalcemia after successful renal transplantation
o Even though serum calcium is elevated, PTH is still
being continuously secreted.

Primary Hyperthyroidism (PHPT)

Arises from increased PTH production from abnormal
parathyroid glands and results from a disturbance of
normal feedback control exerted by serum calcium.
PHPT is characterized by increased parathyroid cell
proliferation and PTH secretion that is independent of
calcium levels
Causes

Parathyroid hyperplasia (20%)

Adenoma (80% single, if single adenoma)

Carcinoma (1%)

Low dose ionizing radiation

o Latency: 30 to 40 years
o Higher PTH levels and a higher incidence of
concomitant thyroid neoplasms than those who did not
have exposure

Family history
o MEN1, MEN2A, isolated familial HPT, and familial
HPT with jaw-tumor syndrome
o PHPT is the most common primary presentation of
MEN1 (80%)
Signs and Symptoms

Due to increased serum calcium

Classic pentad of symptoms

o Kidney stones, painful bones, abdominal groans,
psychic moans, and fatigue

Minimally symptomatic

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o

Weakness, fatigue, polydipsia, polyuria, nocturia, bone

and joint pain, constipation, decreased appetite,
nausea, heartburn, pruritus, depression, and memory
loss
Asymptomatic

Diagnosis

High serum calcium

First done if suspicion of PHPT is raised because of
signs and symptoms. If serum calcium is high, do
serum PTH.

High serum PTH assay

A high serum PTH suggests the pathology is indeed
primarily located in the parathyroids. Thus, perform a
parathyroid scan

Parathyroid scan
Presence of abnormal growth confirms the diagnosis,
thus, do parathyroidectomy.

Radiology
o Bone involvement
o Pathognomonic signs seen best on hand X-ray:
Subperiosteal resorption (most apparent on the radial
aspect of the middle phalanx of the second and third
fingers), bone cysts, and tufting of the distal phalanges
Treatment: Parathyroidectomy
o Subtotal

If dealing with an adenoma, usually, just one needs

to be removed, since not all parathyroids will be
enlarged.

If dealing with hyperplasia, the problem is that all 4

glands will be enlarged. You cant remove all four.
Thus, do a three-and-one-half parathyroidectomy,
leaving of one parathyroid in place.
o Total with autotransplantation in neck/forearm muscle

Alternative to 3 parathyroidectomy
Hypoparathyroidism
Causes

THYROID SURGERY: most common cause (inadvertent

injury during total thyroidectomy)
o Temporary hypoparathyroidism occurs in 90% of
all thyroidectomy cases. In the course of thyroid gland
dissection, edema of the parathyroids is unavoidable
thus it temporarily becomes dysfunctional and cannot
produce PTH.
o Permanent hypoparathyroidism remaining 5-10%.
Means the surgeon has inadvertently removed the
parathyroids

DiGeorges syndrome: congenitally absent parathyroid

Neonatal hypoparathyroidism: from hyperparathyroid

mother
Signs and symptoms: due to hypocalcemia causing increase
neuromuscular excitability

Circumoral and fingertip numbness and tingling

Mental symptoms: anxiety, confusion, and depression

(+) Chvostek sign (contraction of facial muscles elicited by

tapping on the facial nerve anterior to the ear)

(+) Trousseau sign (carpopedal spasm, which is elicited by

occluding blood flow to the forearm with a blood pressure
cuff for 2-3 min)

Tetany
Diagnosis

Decreased serum ionized calcium levels

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Treatment

Calcium tablets or IV infusion

Vitamin D supplements

1.
2.
3.
4.

GUIDE QUESTIONS
Most sensitive clinical symptom of hyperthyroidism
5 yr old boy presents with midline masses that moves upon
protrusion of the tongue, what is the mass?
Origin of thyroid:
The type of thyroiditis that causes fibrosis which may be
mistaken for cancer is
a. Acute
b. Lymphocytic
c. Hashimotos
d. Reidels

5.

The most accurate test to determine thyroid function is

serum:
a. TSH
b. Free T4
c. Free T3
d. Thyroglobulin

6.

A 45 year old male with thyroid mass left lobe, has normal
thyroid function next step in diagnostic work up is:
a. Anti-thyroid peroxidase determination
b. Radionuclide scan
c. CT scan
d. FNAB
Hint: the patient is euthyroid, not hyperthyroid so you can
perform this.

7.

A 30 year old female with anterior neck mass presents with

tachycardia, palpitations and a low serum TSH. The next
step in diagnosis is:
a. Serum thyroglobulin determination
b. Radionuclide scan
c. Head and neck CT scan
d. Ultrasound guided FNAB

8.

Thyroid ultrasound in a 55 year old male revealed a 3cm

solid mass in the right lobe. The most probable diagnosis is
a. Thyroid cyst
b. Toxic goiter
c. Non toxic goiter
d. Thyroid tumor

9.

Radionuclide scan of a 55 year old female with bilateral

thyroid enlargement reveals diffusely hot uptake. The most
probable diagnosis is
a. Graves disease
b. Toxic adenoma
c. Toxic nodular goiter
d. Thyroid carcinoma

10. A probably healthy 30-year old female develops

hyperthyroidism; thyroid scan shows a hot nodule in the left
lobe, with decreased uptake in the rest of the gland, which
of the following statements regarding the case is true?
a. Radioactive iodine ablation is the definitive treatment
of choice
b. Total thyroidectomy must be done on an emergent
basis
c. Hyperthyroidism must first be controlled using antithyroid drugs
d. The module is probably malignant

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11. The most common cause of thyroid nodule in the
Philippines is
a. Goiter *iodine deficiency goiter
b. Thyroiditis
c. Adenoma
d. Carcinoma

20. A 40 year old male with thyroid nodule has elevated serum
calcitonin levels. Biopsy of this mass will most probably
reveal:
a. Papillary carcinoma
b. Medullary carcinoma
c. Anaplastic carcinoma
d. Sarcoma

12. Thyroid stimulating hormone suppression therapy is likely

to be effective in which of the following patient with goiter:
a. Patient with symptoms of dysphagia and orthopnea
b. Post menopausal female age 55 year old
c. Patient from geographic area with iodine deficiency
d. Male patient with cardiovascular disease

21. Type of medullary carcinoma with the worst prognosis:

a. Non MEN familial type
b. MEN 2A
c. Sporadic type
d. MEN 2B

13. The treatment of choice for a 30 year old male with 2cm
thyroid cyst on ultrasound is:
a. Needle aspiration
b. Radioactive iodine
c. Thyroid hormone supplementation Thyroidectomy
d. Thyroidectomy

22. An example of primary hyperparathyroidism

hypercalcemia from:
a. Chronic renal failure
b. Gastrointestinal malabsorption
c. Parathyroid adenoma
d. Kidney transplantation

14. The most common malignancy of the thyroid gland is

a. Papillary
b. Follicular
c. Medullary
d. Anaplastic

23. The most common cause of hypoparathyroidism is

a. Di Georges syndrome
b. Neonatal type
c. Sepsis
d. Complication of thyroidectomy *inadvertent removal of
thyroid gland in surgery is the most common cause

15. The thyroid malignancy that is hard to differentiate from

adenoma by FNAB alone is
a. Papillary
b. Follicular
c. Medullary
d. Anaplastic
16. The thyroid malignancy is associated with the most
favorable prognosis is:
a. Papillary carcinoma
b. Hurthle carcinoma
c. Medullary carcinoma
d. Anaplastic carcinoma
Hint: Which among these is a well-differentiated tumor?
17. A 30 year old male with 5cm papillary carcinoma of the
thyroid and metastasis to the spine is considered as stage
a. I
b. II
c. III
d. IV
18. The surgical treatment of choice for a 35 year old male with
0.9cm well differentiated thyroid carcinoma, incidentally
detected on ultrasound guided FNAB, is:
a. Total lobectomy + isthmusectomy
b. Bilateral subtotal thyroidectomy
c. Total thyroidectomy
d. Total thyroidectomy + Central Neck dissection
Hint: Take note of the size of the carcinoma (0.9 cm)
19. FNAB of a thyroid nodule reveals cells with Orphan Annie
nuclei. Most probable diagnosis is:
a. Follicular adenoma
b. Follicular carcinoma
c. Papillary carcinoma
d. Lymphoma

2018-A

is

24. One day after undergoing thyroidectomy for thyroid

carcinoma, a 50 y/o female presents with circumoral
numbness and contraction of facial muscles elicited by
tapping on the facial nerve anterior to the ear their
diagnosis is best confirmed by determining the serum:
a. Total calcium
b. Ionized calcium
c. Vitamin D
d. Parathyroid hormone assay
25. A 30 y/o female consults for progressive weight loss, heat
intolerance and palpitation of 6 months. Serum TSH was
low with normal T4. The best confirmatory test for diagnosis
in this patient is:
a. FNAB
b. UTZ
c. Radionuclide scan
d. Serum TSH antibody level determination
26. The surgical procedure of choice for 60 y/o female with
6cm papillary thyroid carcinoma of the right thyroid with no
cervical lymph node metastasis is:
a. Ipsilateral lobectomy
b. Total thyroidectomy *because 6cm is big, so total
thyroidectomy is indicated
c. Total thyroidectomy + modified radical neck dissection
d. Total thyroidectomy + supraomohyoid dissection
27. A 30 y/o female presents with hard solitary nodule on the
right lobe of the thyroid gland. Serum TSH and free T3 and
T4 are normal. The next diagnostic step for this case is
a. Radionuclide scan
b. FNAB
c. Serum thymoglobulin determination
d. Ct scan
Hint: Note patients thyroid levels

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28. The type of thyroiditis wherein surgical debridement or
drainage may be necessary is:
a. Acute
b. Riedel
c. Hashimotos
d. De Quervains
29. A 35 y/o female with anterior mass that moves up with
deglutition has low FT#, low FT3, high TSH and positive
anti-TPO and anti Tg antibodies. The most probable
diagnosis is:
a. Graves disease non-toxic goiter
b. Non-toxic goiter
c. Thyroiditis
d. Carcinoma
30. These are known cells with intranuclear cytoplasmic
inclusions:
31. Follicular carcinoma spreads via:
32. Papillary carcinoma spreads via:
33. AGE in DAMES stands for:
34. True or false: CHEMOTHERAPY in adjuvant therapy has
no role in managing follicular carcinoma:

Answers:
1. Tachycardia
2. Thyroglossal Duct Cyst
3. Tongue
4. D
5. A
6. D
7. B
8. C
9. A
10. C
11. A
12. C
13. A
14. A
15. B.
16. A
17. B

18. A
19. C
20. B
21. D
22. C
23. D
24. B
25. C
26. B
27. B
28. A
29. C
30. Orphan Anne Nuclei
31. Blood Stream
32. Lymphatic System
33. MEN<40 years old;
WOMEN< 50 years old
34. True

OBJECTIVES
No objectives were given before the lecture.

REFERENCES
1. Lal G, Clark O. Thyroid, Parathyroid, and Adrenal.
th
Schwarrtz Principles of Surgery, 10 Ed (2015). 1521-1574.
2. 2017A Trans
3. Dr. Ampils recording

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APPENDIX

Table 15. Classic TNM Staging for Well-Differentiated Carcinoma

Table 16. TNM Staging for Papillary or Follicular Tumors of the Thyroid

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