THYROIDTHYROID

Presented by :Presented by :Hind Al_OsaimiHind Al_OsaimiSupervised by:Supervised by:

Dr_ Suliman JustaniaDr_ Suliman Justania

ANATOMYANATOMYThe thyroid gland consist of two lobes joint by an The thyroid gland consist of two lobes joint by an

isthmus ,with occasionally an embryological isthmus ,with occasionally an embryological extension of the isthmus superiorly called the extension of the isthmus superiorly called the pyramidal lobe. pyramidal lobe.

The normal gland weighs 20-25 g. The functioning The normal gland weighs 20-25 g. The functioning unit is the lobule supplied by a single arteriole unit is the lobule supplied by a single arteriole and consisting of 24-40 follicle which are lined and consisting of 24-40 follicle which are lined by cuboidal epithelium. The resting follicle by cuboidal epithelium. The resting follicle contain colloid in which thyroglobulin is stored.contain colloid in which thyroglobulin is stored.

B.B. Blood Supply: Blood Supply:

1-Superior thyroid arteries ____arise from 1-Superior thyroid arteries ____arise from external carotid artery.external carotid artery.

2-Inferior thyroid arteries ____ branch of 2-Inferior thyroid arteries ____ branch of thyrocervical trunk.( which arise from 1thyrocervical trunk.( which arise from 1stst part of subclavian A.)part of subclavian A.)

3-Thyroidea ima _____arise from aorta or 3-Thyroidea ima _____arise from aorta or brachiocephalic A.brachiocephalic A.

- venous drainage :- venous drainage :

1-superior thyroid vein __Internal jugular v.1-superior thyroid vein __Internal jugular v.

2- Middle thyroid vein __ Internal jugular v.2- Middle thyroid vein __ Internal jugular v.

3-Inferior thyroid vein__ Brachiocephalic v.3-Inferior thyroid vein__ Brachiocephalic v.

C.C.Lymphatic drainage :Lymphatic drainage :

-The lymph from thyroid gland drain mainly -The lymph from thyroid gland drain mainly laterally into the deep cervical lymph laterally into the deep cervical lymph nodes. nodes.

-Some lymphatic vessels pass to pre--Some lymphatic vessels pass to pre-laryngeal , pretracheal and paratracheal laryngeal , pretracheal and paratracheal lymph node.lymph node.

D .D .laryngeal nerves:laryngeal nerves:

1-Recurrent laryngeal __variable position 1-Recurrent laryngeal __variable position about 70% run in the tracheoesophageal about 70% run in the tracheoesophageal groove , 60% posterior to inferior thyroid groove , 60% posterior to inferior thyroid artery .artery .

2- Superior laryngeal nerve __run near the 2- Superior laryngeal nerve __run near the superior thyroid arteries.superior thyroid arteries.

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

The thyroid gland operates as part of a feedback The thyroid gland operates as part of a feedback mechanism involving the hypothalamus and the mechanism involving the hypothalamus and the pituitary gland.pituitary gland. The hypothalamus sends a signal to the anterior The hypothalamus sends a signal to the anterior pituitary gland through a hormone called TRH pituitary gland through a hormone called TRH (thyrotropin releasing hormone) which exerts a (thyrotropin releasing hormone) which exerts a +ve feedback on it, causing release of TSH +ve feedback on it, causing release of TSH (thyroid stimulating hormone) which stimulate (thyroid stimulating hormone) which stimulate the thyroid gland to take up iodine to form its the thyroid gland to take up iodine to form its own hormones, T4 and T3, which are stored by own hormones, T4 and T3, which are stored by binding to thyroglobuline in follicles.binding to thyroglobuline in follicles.

T3& T4 enter the bloodstream __bound T3& T4 enter the bloodstream __bound mainly to thyroid binding globulin & to mainly to thyroid binding globulin & to lesser extend to thyroid binding albumin . lesser extend to thyroid binding albumin . A small proportion remain free in A small proportion remain free in circulation.circulation. AT tissue level ,deiodinase enzyme AT tissue level ,deiodinase enzyme convert T4 to T3 which is physiologcally convert T4 to T3 which is physiologcally active hormone.active hormone.

The peripheral levels of circulating free T4 The peripheral levels of circulating free T4 constitute a feedback mechanism on the constitute a feedback mechanism on the pituitary TSH secreting capacity __ the low pituitary TSH secreting capacity __ the low circulating level induce increased TSH circulating level induce increased TSH secretion (as in Hashimoto’s disease) and secretion (as in Hashimoto’s disease) and vise versa (as in oral thyroxine therapy).vise versa (as in oral thyroxine therapy).

Common Disorders of the ThyroidCommon Disorders of the Thyroid

Thyroid disorders fall into three broad Thyroid disorders fall into three broad categoriescategories

a – Hypofunctiona – Hypofunction

b – Hyperfunctionb – Hyperfunction

c – Enlargementsc – Enlargements

) ) 11((Diffuse __ termed goiter regardless Diffuse __ termed goiter regardless of functional statusof functional status..

) ) 22((NoduleNodule..

ManagementManagement

History:History:-sings &symptom of hypo or hyperthyroidism-sings &symptom of hypo or hyperthyroidism-pressure symptom as -pressure symptom as

dysphagia ,dysphonia ,dyspnea &choking dysphagia ,dysphonia ,dyspnea &choking sensationsensation

-Change in voice-Change in voice-presence of mass__ duration ,progression& -presence of mass__ duration ,progression&

pain.pain.-H/O exposure to radiation , diet , drugs-H/O exposure to radiation , diet , drugs-Family hx.-Family hx.

Physical Examination:Physical Examination:

-Inspection-Inspection

-palpation-palpation

-percussion-percussion

-Auscultation-Auscultation

HypothyroidismHypothyroidism

classificationclassification

Autoimmune thyroiditis (chronic Autoimmune thyroiditis (chronic lymphocytic thyroiditis)lymphocytic thyroiditis)

- goitrous :Hashimoto’s thyroditis- goitrous :Hashimoto’s thyroditis - non-goitrous : primary myxoedema- non-goitrous : primary myxoedema

Iatrogenic :Iatrogenic : - post thyroidectomy.- post thyroidectomy. - after radioiodine therapy.- after radioiodine therapy. -drug induced (antithyroid drugs)-drug induced (antithyroid drugs)

Dyshormonogenrsis.Dyshormonogenrsis.

Goitrogens.Goitrogens.

Secondary to pituitary or hypothalamic Secondary to pituitary or hypothalamic disease.disease.

Clinical pictureClinical picture

Symptoms:Symptoms: -tiredness.-tiredness. -mental lethargy.-mental lethargy. -Headaches & dementia.-Headaches & dementia. -cold intolerance.-cold intolerance. -weight gain .-weight gain . -constipation.-constipation. -Menstrual disturbance.-Menstrual disturbance.

Signs:Signs: -Bradycardia.-Bradycardia. -Cold extremities.-Cold extremities. -periorbital puffiness.-periorbital puffiness. -Hoarse voice , slow speech -Hoarse voice , slow speech -enlarged toung.-enlarged toung. -Hair become dry & brittle.-Hair become dry & brittle. -Skin become dry, thickened &puffy.-Skin become dry, thickened &puffy. -Bradykinesia (slow movement ).-Bradykinesia (slow movement ). -Delay relaxation of ankle jerk reflex.-Delay relaxation of ankle jerk reflex.

Diagnosis:Diagnosis:

1-Low T4 & T3level with high TSH .1-Low T4 & T3level with high TSH .

2- High serum titers of antithyroid 2- High serum titers of antithyroid antibodies are characteristic of antibodies are characteristic of autoimmune disaese.autoimmune disaese.

Treatment:Treatment:

L-thyroxine _____0.1-0.2 mg orally once L-thyroxine _____0.1-0.2 mg orally once daily.daily.

Thyroid EnlargementThyroid Enlargement

classificationclassificationSimple goiter (euthyroid)Simple goiter (euthyroid)

1-Diffuse hyperplastic:1-Diffuse hyperplastic: -physiological -physiological -Pubertal-Pubertal -pregnancy-pregnancy 2-Multinodular goiter2-Multinodular goiter

Toxic Toxic 1-Diffuse __ graves’ disease1-Diffuse __ graves’ disease 2-Multinodular2-Multinodular 3-Toxic adenoma 3-Toxic adenoma

NeoplasticNeoplastic 1-Bengin1-Bengin 2-Malignant2-Malignant

InflammatoryInflammatory 1-Autoimmune :1-Autoimmune : -Chronic lymphocytic thyroditis-Chronic lymphocytic thyroditis -Hashimoto’s disease-Hashimoto’s disease 2-Granulomatous2-Granulomatous -De quervain’s thyroditis-De quervain’s thyroditis 3-Fibrosing 3-Fibrosing -Riedel’s thyroiditis-Riedel’s thyroiditis 4-Infective4-Infective -Acute (bacterial , viral thyroiditis ‘subacute thyroiditis’)-Acute (bacterial , viral thyroiditis ‘subacute thyroiditis’) -Chronic ( tuberculous , syphilitic )-Chronic ( tuberculous , syphilitic )

Other: __ amyloid.Other: __ amyloid.

Simple goiterSimple goiter

Aetiology:Aetiology:

-Simple goiter may develop as a result of -Simple goiter may develop as a result of stimulation of thyroid gland by TSH ,either stimulation of thyroid gland by TSH ,either as a result of inappropriate secretion from as a result of inappropriate secretion from a microadenoma in the anterior pituitary a microadenoma in the anterior pituitary gland or in response to a chronically low gland or in response to a chronically low level of circulating thyroid hormones .level of circulating thyroid hormones .

-The most important factor in endemic -The most important factor in endemic goiter is dietary iodine deficiency.goiter is dietary iodine deficiency.

-Defective hormone synthesis probably -Defective hormone synthesis probably accounts for many sporadic goiter.accounts for many sporadic goiter.

Stages in goiter formationStages in goiter formation

1-persistant growth stimulation cause 1-persistant growth stimulation cause diffuse hyperplasia ,all lobules are diffuse hyperplasia ,all lobules are composed of active follicles and iodine composed of active follicles and iodine uptake is uniform .This is a diffuse uptake is uniform .This is a diffuse hyperplastic goiter .hyperplastic goiter .2-later on a mixed pattern develops with 2-later on a mixed pattern develops with areas of active lobules and areas of areas of active lobules and areas of inactive lobule as a result of fluctuating inactive lobule as a result of fluctuating stimulation.stimulation.

3-Active lobules become more vascular & 3-Active lobules become more vascular & hyperplastic untill haemorrhage occure, hyperplastic untill haemorrhage occure, causing central necrosis & leaving only a causing central necrosis & leaving only a surrounding rind of active follices.surrounding rind of active follices.4-Necrotic lobules __ form nodules filled 4-Necrotic lobules __ form nodules filled with either iodine-free colloid or a mass of with either iodine-free colloid or a mass of new but inactive follicles.new but inactive follicles.5-Continual repetition of this process result 5-Continual repetition of this process result in a nodular goiter.in a nodular goiter.

Diffuse hyperplastic goiterDiffuse hyperplastic goiter

The goiter usually occur at puberty when The goiter usually occur at puberty when metabolic demand are high , it appears in metabolic demand are high , it appears in childhood in endemic area .childhood in endemic area .

IF TSH stimulation stops the goiter may IF TSH stimulation stops the goiter may regress but tend to be recur later at times regress but tend to be recur later at times of stress such as pregnancy.of stress such as pregnancy.

The goiter is soft diffuse & may become The goiter is soft diffuse & may become large enough to cause discomfort .large enough to cause discomfort .

A colloid goiter is a late stage of diffuse A colloid goiter is a late stage of diffuse hyperplasis when TSH stimulation has hyperplasis when TSH stimulation has fallen off & many follicle are in active and fallen off & many follicle are in active and full of colloid.full of colloid.Treatment:Treatment:-thyroxine 0.15-.2 mg daily should be -thyroxine 0.15-.2 mg daily should be given to suppress TSH .given to suppress TSH .-Thyroidectomy may be required for -Thyroidectomy may be required for pressure symptom or cosmotic.pressure symptom or cosmotic.

Nodular goiter (nontoxic)Nodular goiter (nontoxic)

Nodules are usually multiple forming a Nodules are usually multiple forming a multinodular goiter.multinodular goiter.Nodules may be may be colloid or cellularNodules may be may be colloid or cellularCystic degeneration & haemorrhage are Cystic degeneration & haemorrhage are common .common .All type of simple goiter are common in F All type of simple goiter are common in F more than M, and the presence of more than M, and the presence of estrogen receptor in normal thyroid tissue estrogen receptor in normal thyroid tissue and in nodular goiter is relevant.and in nodular goiter is relevant.

,,The pt is euthyroid ,presented with smooth The pt is euthyroid ,presented with smooth firm ,painless goiter .firm ,painless goiter .

Hardness and irregularity occur due to Hardness and irregularity occur due to calcification __ may stimulate carcinoma.calcification __ may stimulate carcinoma.

Painful nodule & rapid enlargement of a Painful nodule & rapid enlargement of a nodule raise suspicion of carcinoma but is nodule raise suspicion of carcinoma but is usually due to haemorrhage into a simple usually due to haemorrhage into a simple nodule.nodule.

Complications:Complications:Tracheal obstruction__due to compression Tracheal obstruction__due to compression

in a lateral or anteroposterior plane by in a lateral or anteroposterior plane by retrosternal extention of the goiter .acute retrosternal extention of the goiter .acute respiratory obstruction may follow Hge into respiratory obstruction may follow Hge into a nodule impacted in thoracic inlet.a nodule impacted in thoracic inlet.Secondary thyrotoxicosis.Secondary thyrotoxicosis.Carcinoma_ which is usually of follicular Carcinoma_ which is usually of follicular pattern.It is un common. pattern.It is un common.

Investigation:Investigation:

Test of thyroid function to exclude mild Test of thyroid function to exclude mild hyperthyroidism.hyperthyroidism.

Fine-needle aspiration .Fine-needle aspiration .

Ultrasound may confirm multiple nodule.Ultrasound may confirm multiple nodule.

Plain x-ray of chest & thoracic inlet__ may Plain x-ray of chest & thoracic inlet__ may show calcification or tracheal deviation.show calcification or tracheal deviation.

Treatment:Treatment:

-most of the pt are asymptomatic & do not require -most of the pt are asymptomatic & do not require operation .operation .

-Retrosternal extention with tracheal compression -Retrosternal extention with tracheal compression is an indication for operation. is an indication for operation.

-Operation may be indicated on cosmetic ground.-Operation may be indicated on cosmetic ground.

-The surgical operation either :-The surgical operation either :

(a) subtotal thyroidectomy.(a) subtotal thyroidectomy.

(b) Total thyroidectomy with immediate & lifelong (b) Total thyroidectomy with immediate & lifelong replacement of thyroxin __ for gland above 100 replacement of thyroxin __ for gland above 100 g in weight.g in weight.

Solitary thyroid noduleSolitary thyroid nodule50% of STN are truly solitary, the reminder are 50% of STN are truly solitary, the reminder are a part of nodular goitre and constitute a a part of nodular goitre and constitute a dominant nodule .dominant nodule .The majority of STN are benign ,about 5% are The majority of STN are benign ,about 5% are malignant.malignant.Causes:Causes:

-Multinodular goitre-Multinodular goitre -Haemorrhage or necrosis into a hyperplastic -Haemorrhage or necrosis into a hyperplastic

nodulenodule -Thyroid cyst-Thyroid cyst -Benign follicular adenoma (including toxic -Benign follicular adenoma (including toxic

adenoma)adenoma) -Carcinoma ( papillary or follicular )-Carcinoma ( papillary or follicular ) -Enlargement of the one lobe by a thyroiditis-Enlargement of the one lobe by a thyroiditis

Investigation :Investigation :

Thyroid function test to exclude solitary toxic Thyroid function test to exclude solitary toxic nodule.nodule.

Autoantibody titer __determine if the swelling is Autoantibody titer __determine if the swelling is a manifestation of chronic lymphocytic thyroditis. a manifestation of chronic lymphocytic thyroditis.

FNA to exclude malignancy.FNA to exclude malignancy.

Ultrasound__ diff. b/w solid & cystic ,determine Ultrasound__ diff. b/w solid & cystic ,determine whether the STN is a dominant nodule within whether the STN is a dominant nodule within MNG.MNG.

Thyroid isotope scan __give idea of the function Thyroid isotope scan __give idea of the function of the nodule( hot or cold) .of the nodule( hot or cold) .

If the isotope scan show a hot nodule & If the isotope scan show a hot nodule & TSH is suppressed __ so it is a asolitary TSH is suppressed __ so it is a asolitary toxic nodule.toxic nodule.

If the isotope scan show a cold nodule __ If the isotope scan show a cold nodule __ there is increase risk of malignancy.there is increase risk of malignancy.

Treatment:Treatment:Benign thyroid nodule does not required Benign thyroid nodule does not required treatment unless symptomatic or cosmetic.treatment unless symptomatic or cosmetic.FNA should be repeated after 1 year __if FNA should be repeated after 1 year __if remaine benign then further treatment.remaine benign then further treatment.Pt with suspicious nodule on FNA should Pt with suspicious nodule on FNA should under go thyroid lobectomy .under go thyroid lobectomy .If the nodule is solitary , solid ,hot & If the nodule is solitary , solid ,hot & cytology benign __it is a follicular cytology benign __it is a follicular adenoma __ for total lobectomy with adenoma __ for total lobectomy with excision of isthmus.excision of isthmus.

If the nodule is cold &the cytology show If the nodule is cold &the cytology show benign or atypical __ it is probably benign or atypical __ it is probably follicular adenoma - - - Total lobectomy follicular adenoma - - - Total lobectomy with isthmus is necessary.with isthmus is necessary.

- If the paraffin histopathology show If the paraffin histopathology show carcinoma a second operation to complete carcinoma a second operation to complete a near total thyroidectomy is indicated.a near total thyroidectomy is indicated.

- if cytology show undoubted malignancy if cytology show undoubted malignancy near total thyroidectomy is advisable at near total thyroidectomy is advisable at least to parathyroid gland & minimal least to parathyroid gland & minimal protecting thyroid gland about 1 g.protecting thyroid gland about 1 g.

HyperthyroidismHyperthyroidism

Hyperthyroidism is clinical state in Hyperthyroidism is clinical state in which there is excess circulating which there is excess circulating thyroid hormones leading to an thyroid hormones leading to an alteration in the basal metabolic alteration in the basal metabolic rate.rate.

CausesCauses

Diffuse toxic goiter (Graves disease)Diffuse toxic goiter (Graves disease)

Toxic multi-nodular goiterToxic multi-nodular goiter

Toxic adenoma.Toxic adenoma.

De quervains thyroiditis.De quervains thyroiditis.

Thyroid cancer.Thyroid cancer.

Clinical featureClinical feature

Symptoms include:Symptoms include:-tiredness-tiredness-nervousness &irritability-nervousness &irritability-tremor-tremor-insomnia-insomnia-sweating-sweating-heat intolerance-heat intolerance-weight loss-weight loss-excessive appetite-excessive appetite-palpitation-palpitation-diarrhea-diarrhea

Signs of thyrotoxicosis:Signs of thyrotoxicosis:-Thyroid goiter-Thyroid goiter-Tachycardia-Tachycardia-Hot , moist palms-Hot , moist palms-Agitation-Agitation-Eye sign__ exophthalmos-Eye sign__ exophthalmos Lid lag & lid retractionLid lag & lid retraction supraorbital &infraorbitalsupraorbital &infraorbital swellingswelling ophthalmoplegia ( double vision)ophthalmoplegia ( double vision) chemosis chemosis

Graves’ DiseaseGraves’ Disease( ( Diffuse toxic goiterDiffuse toxic goiter))

Autoimmune thyrotoxicosis (primary thyro-Autoimmune thyrotoxicosis (primary thyro-toxicosis)_ caused by an antibody raised against toxicosis)_ caused by an antibody raised against the TSH receptor (TRAB).the TSH receptor (TRAB).A diffuse vascular goiter appearing at the same A diffuse vascular goiter appearing at the same time as the hyperthyroidism.time as the hyperthyroidism.Usually in young women.Usually in young women.Frequently associated with eye signs.Frequently associated with eye signs.The hypertrophy & hyperplasia are due to The hypertrophy & hyperplasia are due to abnormal thyroid stimulating antibodies.abnormal thyroid stimulating antibodies.Total thyroidectomy will cure grave’s disease Total thyroidectomy will cure grave’s disease with postoperative hypothyroidismwith postoperative hypothyroidism

Toxic multinodular goiterToxic multinodular goiter

Simple nodular goiter is present for a long time before Simple nodular goiter is present for a long time before the hyperthyroidism.the hyperthyroidism.Usually in middle age or elderly.Usually in middle age or elderly.Pressure sing in the neck may be present.Pressure sing in the neck may be present. Not frequently associated with eye manifestation.Not frequently associated with eye manifestation.The gland is irregularly enlarged, and its cut surface The gland is irregularly enlarged, and its cut surface reveals many nodule which are solid (cellular) or cystic reveals many nodule which are solid (cellular) or cystic (colloid-filled). (colloid-filled). Cardiac arrhythmia & insidious cardiac failure are Cardiac arrhythmia & insidious cardiac failure are commoncommonIn many cases the nodules are inactive & it is the In many cases the nodules are inactive & it is the internodular thyroid tissue that is overactive.internodular thyroid tissue that is overactive.

Toxic noduleToxic nodule

This is a solitary overactive nodule which may This is a solitary overactive nodule which may be a part of a generalized nodularity be a part of a generalized nodularity

or a true toxic adenoma.or a true toxic adenoma.Because TSH secretion is suppressed by the Because TSH secretion is suppressed by the high level of circulating thyroid hormones , the high level of circulating thyroid hormones , the normal thyroid tissue surrounding the nodule is normal thyroid tissue surrounding the nodule is itself suppressed & inactived. itself suppressed & inactived. Cut surface shows a single lesion with a thin Cut surface shows a single lesion with a thin capsule , the nodule may show cystic capsule , the nodule may show cystic change .fibrosis and calcification.change .fibrosis and calcification.Technetium scan will show a solitary hot nodule.Technetium scan will show a solitary hot nodule.

De quervain’s thyroiditisDe quervain’s thyroiditis

It is a true subacute inflammation of the thyroid It is a true subacute inflammation of the thyroid gland.gland.

IT is often associated with mild hyperthyroidism .IT is often associated with mild hyperthyroidism .

IT may be caused by viral infection.IT may be caused by viral infection.

Main complaint is a sudden appearance of a Main complaint is a sudden appearance of a painful swelling in the neckpainful swelling in the neck

The pt may complain of malaise ,sore throat& The pt may complain of malaise ,sore throat& fever.fever.

IT is a self-limiting , it disappears in 1-3 month. IT is a self-limiting , it disappears in 1-3 month.

DiagnosisDiagnosis

Most of the cases are readily diagnosed Most of the cases are readily diagnosed clinically.clinically.

Low TSH level & high T3 &T4.Low TSH level & high T3 &T4.

TreatmentTreatment

Nonspecific measures ___ rest & Nonspecific measures ___ rest & sedation.sedation.

Antithyroid drug :e.g: propylthiouracil & Antithyroid drug :e.g: propylthiouracil & carbimazole.carbimazole.

Radioiodine__ destroy thyroid cell& Radioiodine__ destroy thyroid cell& reduce the mass of functioning thyroid reduce the mass of functioning thyroid tissue to below a critical level.tissue to below a critical level.

Surgery:Surgery:

1-In diffuse toxic goiter & toxic nodular goiter 1-In diffuse toxic goiter & toxic nodular goiter with overactive inter nodular tissue surgery with overactive inter nodular tissue surgery cure by reducing the mass of overactive cure by reducing the mass of overactive tissue (i.e reduce a thyroid tissue below a tissue (i.e reduce a thyroid tissue below a critical mass)critical mass)

2- In toxic nodular goiter & toxic nodule 2- In toxic nodular goiter & toxic nodule surgery cure by removing all of the surgery cure by removing all of the overactive thyroid tissue.__ this allow the overactive thyroid tissue.__ this allow the supressed normal tissue to function again.supressed normal tissue to function again.

Choice of therapeutic agentChoice of therapeutic agent

1- Diffuse toxic goiter :1- Diffuse toxic goiter : - over 45 __ radioiodine .- over 45 __ radioiodine . -under 45_surgey for large goiter & -under 45_surgey for large goiter &

antithyroid drugs for small goiter.antithyroid drugs for small goiter.2- Toxic nodular goiter:2- Toxic nodular goiter:

-surgery ( because it doesn’t response as -surgery ( because it doesn’t response as well to radioiodine or antithyroid drugs as well to radioiodine or antithyroid drugs as dose a diffuse toxic goiter)dose a diffuse toxic goiter)

3-Toxic nodule:3-Toxic nodule:

- surgery or radioiodine ((radioiodine is - surgery or radioiodine ((radioiodine is good over the age of 45))good over the age of 45))

4-Recurrent thyrotoxicosis :4-Recurrent thyrotoxicosis :

- radioiodine , but antithyroid drugs may be - radioiodine , but antithyroid drugs may be used in young female intending to have used in young female intending to have children.children.

Complication of surgeryComplication of surgery

Thyroid NeoplasmsThyroid Neoplasms

ClassificationClassification1.Benign1.Benign -Follicular adenoma.-Follicular adenoma.

2. Malignant2. Malignant A-PrimaryA-Primary -Follicular epithelium: -Follicular epithelium: differentiateddifferentiated .Follicular.Follicular .Papillary.Papillary -Follicular epithelium: -Follicular epithelium: undifferentiatedundifferentiated .Anaplastic.Anaplastic -Parafollicular cells-Parafollicular cells .Medullary.Medullary -Lymphoid cells -Lymphoid cells .lymphoma.lymphoma

B-SecondaryB-Secondary .Metastatic.Metastatic .Local infiltration.Local infiltration

Benign TumourBenign Tumour

Follicular adenomaFollicular adenoma : :

- It is present clinically as solitary nodule.- It is present clinically as solitary nodule.

-The differentiation between the follicular -The differentiation between the follicular carcinoma and adenoma can only made by carcinoma and adenoma can only made by histological examination ,that in adenoma there histological examination ,that in adenoma there is no invasion of the capsule or of pericapsular is no invasion of the capsule or of pericapsular blood vessels .blood vessels .

-Treatment ___ wide excision ( preferably a -Treatment ___ wide excision ( preferably a lobectomy )lobectomy ) . .

Malignant tumoursMalignant tumours60

1713

64

0

10

20

30

40

50

60

papillary ca

follicular ca

anaplastic ca

medullary ca

malignant lymphoma

Clinical characteristics that suggest Clinical characteristics that suggest MalignancyMalignancy

1.Gender ___ male gender(F:M__3:1 ??)1.Gender ___ male gender(F:M__3:1 ??)2.Age <15,>60 years2.Age <15,>60 years3.Hx of head & neck radiation 3.Hx of head & neck radiation 4.Family hx of thyroid cancer4.Family hx of thyroid cancer5.Rapidly enlarging nodule5.Rapidly enlarging nodule6.Hard single nodule & nodules fixed to 6.Hard single nodule & nodules fixed to

surrounding structuressurrounding structures7.Hx of thyroiditis7.Hx of thyroiditis8.Hoarseness8.Hoarseness9.Cervical lymphadenopathy9.Cervical lymphadenopathy

Papillary carcinomaPapillary carcinoma

- Slow growing ,60% multicentric .Slow growing ,60% multicentric .- M:F--- 1:3 .M:F--- 1:3 .- Common 20-30 yrs old.Common 20-30 yrs old.- Painless lump in the thyroid gland with enlarged Painless lump in the thyroid gland with enlarged

lymph gland.lymph gland.- 80-90% of postradiation ca of the thyroid.80-90% of postradiation ca of the thyroid.- Spread by lymphatics (50% have +ve node at Spread by lymphatics (50% have +ve node at

diagnosis) ,with good prognosis ,the presence of diagnosis) ,with good prognosis ,the presence of nodes does not affect prognosis.nodes does not affect prognosis.

- Type of surgery __Lobectomy with Type of surgery __Lobectomy with isthmusectomy .isthmusectomy .

If the tumor is >3 cm ,male >40 , female If the tumor is >3 cm ,male >40 , female >50 , distant metastasis or angioinvasion >50 , distant metastasis or angioinvasion then _____ Total thyroidectomy is then _____ Total thyroidectomy is indicated because of poor prognosis.indicated because of poor prognosis.

85% 10 yr survival.85% 10 yr survival.

Occult carcinoma:Occult carcinoma:

- Papillary carcinoma may present as an - Papillary carcinoma may present as an enlarged lymph node in Jugular chain with enlarged lymph node in Jugular chain with no palpable abnormality of the thyroid .The no palpable abnormality of the thyroid .The primary tumour may be about few primary tumour may be about few millimeter in size & termed occult.millimeter in size & termed occult.

-The term occult is now applied to all -The term occult is now applied to all papillary carcinoma < 1.5 cm papillary carcinoma < 1.5 cm

- These tumor have an excellent prognosis.- These tumor have an excellent prognosis.

Follicular carcinomaFollicular carcinoma

Unifocal , more aggressive.Unifocal , more aggressive.

M:F___1:3M:F___1:3

30_40 yrs old.30_40 yrs old.

Common presentation __ lump in the Common presentation __ lump in the neck.neck.

If tumor spread beyond the thyroid__ pt If tumor spread beyond the thyroid__ pt may complain of breathlessness , chest may complain of breathlessness , chest pain , pain or swelling in the bone. pain , pain or swelling in the bone.

Capsular & vascular invasion are Capsular & vascular invasion are prominent feature.prominent feature.

Blood-borne metastases.Blood-borne metastases.

Metastasis to lung &boneMetastasis to lung &bone

Total thyroidectomy is indicated .Total thyroidectomy is indicated .

40% 10 yr survival.40% 10 yr survival.

Anaplastic carcinomaAnaplastic carcinomaVery aggressive tumor.Very aggressive tumor.

It is the worst variety of thyroid tumor due its It is the worst variety of thyroid tumor due its rapid spread.rapid spread.

Local infiltration is an early feature.Local infiltration is an early feature.

The common complaint is a swelling in the neck The common complaint is a swelling in the neck rather than lump ( because the tumor is diffuse & rather than lump ( because the tumor is diffuse & infiltrating)infiltrating)

A dull aching neck pain is quit common.A dull aching neck pain is quit common.

Hoarseness or change in voice quality is a Hoarseness or change in voice quality is a diagnostic symptom because it implies infiltration diagnostic symptom because it implies infiltration of recurrent laryngeal nerve.of recurrent laryngeal nerve.

Many of these aggressive lesion present in an Many of these aggressive lesion present in an advanced stage with tracheal obstruction advanced stage with tracheal obstruction &required urgent tracheal decompression.&required urgent tracheal decompression.

Spread by lymphatic & blood stream.Spread by lymphatic & blood stream.

Chemotherapy & radiation may improve 5 %.Chemotherapy & radiation may improve 5 %.

Mean survival 2-4 months.( poor prognosis)Mean survival 2-4 months.( poor prognosis)

Medullary carcinomaMedullary carcinoma

Aggressive tumors.Aggressive tumors.It is a neoplasm of parafollicular ( c ) cell.It is a neoplasm of parafollicular ( c ) cell.C-cell calcitonin producing tumor.C-cell calcitonin producing tumor.High level of serum calcitonin >0.08 ng/mlHigh level of serum calcitonin >0.08 ng/mlSporadic form is unifocal with worse Sporadic form is unifocal with worse prognosis , familial form is multifocal with prognosis , familial form is multifocal with a better prognosis.a better prognosis.Involvement of lymph node occurs in Involvement of lymph node occurs in 50_60%.50_60%.

May occur in combination with adrenal May occur in combination with adrenal phaeochromocytoma & phaeochromocytoma & hyperparathyroidism in syndrome known hyperparathyroidism in syndrome known as multiple endocrine neoplasia type IIa as multiple endocrine neoplasia type IIa (MEN IIa)(MEN IIa)

--Blood-born metastases are commonBlood-born metastases are common..

--Treatment__ Total thyroidectomy with Treatment__ Total thyroidectomy with resection of involved lymph noderesection of involved lymph node..

LymphomaLymphoma

Usually affect female( may have hx of Usually affect female( may have hx of hashimoto’s)hashimoto’s)There is a rapid enlargement.There is a rapid enlargement.Compressive symptoms are common.Compressive symptoms are common.Sensitive for chemotherapy & radiotherapySensitive for chemotherapy & radiotherapySurgery for diagnosis & compressive Surgery for diagnosis & compressive symptomsymptomGood prognosis if there is no involvement Good prognosis if there is no involvement of cervical LN.of cervical LN.

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