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  • Develops from the floor of the primitive pharynx during the 3rd week of gestation. The developing gland migrates along the thyroglossal duct to reach its final destination in the neck. This accounts for rare ectopic location of thyroid tissue at the base of the tongue. Also allows for thyroglossal duct cysts. Thyroid hormone synthesis begins around 11 weeks gestation.
  • Congenital hypothyroidism occurs in 1 in 4000 newborns and now a part of newborn screening in developed countries. Supplementation can prevent severe developmental abnormalities.
  • I disagree with dosing adjustments. I keep them on meds for 8 weeks, then recheck and titrate up from there every 6-8 weeks.
  • RAI= radioactive iodine
  • Hyperthyroidism-

Disorders of the Thyroid Gland Presentation Transcript

  • 1. Disorders of the Thyroid Gland
    Clinical Medicine I
    Elizabeth Bunting, MS, PA-C
    March 21, 2011
  • 2. Objectives
    Describe the anatomy of the thyroid gland, with regard to its relationship to:
    Other structures in the neck
    The parathyroid glands
    The major vessels
    Embryologic development
    Describe the regulation of thyroid metabolism, particularly:
    The role of the thyroid gland in the hypothalamus-anterior pituitary-thyroid axis
    The role of iodine within the gland in controlling thyroid function
  • 3. Objectives
    Discuss the synthesis and secretion of thyroid hormone, describing:
    The two principal thyroid hormones secreted
    Their relative utilization within the body
    How they are chemically related
    Describe the action of the hormones, particularly:
    The location of the receptors for thyroxine and triiodothyronine and their function
    The hormonal effect on cellular metabolism and development
    Define hyperthyroidism, list and describe the:
    Associated pathophysiology
    Common clinical presentations
    Significant historical and physical exam findings
    Diagnostic tests
    Management
  • 4. Objectives
    Define thyrotoxicosis, and describe its pathophysiology, clinical presentation, diagnostic work-up and management.
    Define hypothyroidism, list and describe the:
    Associated pathophysiology
    Common presentations
    Significant historical and physical exam findings
    Diagnostic tests
    Management
    Define myxedema and myxedema coma, and describe their pathologic process, clinical presentation, diagnostic work-up and management.
    Identify the different forms of thyroiditis and their distinguishing features and management
  • 5. Objectives
    Describe the various therapies, such as:
    Use of surgery, radioactive iodine, or anti-thyroid drugs for hyperfunction
    Use of thyroid hormone for hypofunction
    List and describe the types of thyroid cancer.
    Explain the signs and symptoms, pathophysiology and epidemiology of thyroid cancer.
    Discuss the diagnostic work-up and management of thyroid cancer.
    Discuss the prognosis for each of the major types of thyroid cancer.
  • 6. Thyroid Anatomy
  • 7. Parathyroid Glands
  • 8. Embryonic Development of the Thyroid Gland and hormones
  • 9. Thyroid Physiology
  • 10. Thyroid Physiology
    Makes
    Thyrotropin Releasing Horomone
    (TRH)
    Hypothalmus
    Anterior
    Pituitary
    Makes
    Thyroid Stimulating Hormone (TSH)
    Makes
    T3(Triiodothyronine)
    & T4 (Thyroxine)
    Thyroid Gland
  • 11. Thyroid
    Produces two related hormones
    T3 – triiodothyronine
    T4 – thyroxine
    These hormones play a critical role in
    Thermogenic homeostasis in adults
    Metabolic homeostasis in adults
    Cell differentiation during development
  • 12. Regulation of the Thyroid Axis
    TSH is the most useful physiologic marker of thyroid hormone action
    T3 and T4 are the dominant regulators of TSH production
    TSH is released in a pulsatile manner and exhibits a diurnal rhythm
    Highest levels at night
  • 13.
    • Thyroid hormones T4 and T3 feed back to inhibit hypothalamic production of thyrotropin-releasing hormone (TRH) and pituitary production of thyroid-stimulating hormone (TSH).
    • 14. TSH stimulates thyroid gland production of T4 and T3
  • Thyroid hormone synthesis, metabolism, and action
    • Iodide uptake is a critical first step in synthesis
    • 15. Deficiency is prevalent in many mountainous regions globally and if present, may lead to goiter
    • 16. If severe deficiency – hypothyroidism and cretinism
    • 17. Recommended daily intake
    • 18. 150 μg/d adults
    • 19. 90-120 μg/d children
  • Goiter
  • 20. Thyroid hormone synthesis, metabolism, and action
    • Iodide enters the thyroid and is used in production of both T3 and T4
    • 21. T4 contains 4 iodine atoms
    • 22. Removal of one of the iodine atoms leads to production of the potent hormone triiodothyronine (T3)
    T4 may be thought of as a precursor for the more potent T3
    T4 is converted to T3 in the peripheral tissues
  • 23. Thyroid hormone synthesis, metabolism, and action
    • Hormones are released from the thyroid and the vast majority are protein bound and deposited in peripheral cells
    • 24. Once in cells, hormones act as nuclear receptors
    • 25. T3 99.7%
    • 26. T4 99.98%
    • 27. The unbound hormone is available to tissues
    • 28. Serum concentrations
    • 29. T3 0.14 μg/dL
    • 30. T4 8 μg/dL
  • Thyroid hormone synthesis, metabolism, and action
    Laboratory evaluation of thyroid hormones
    TSH – first thing you assess
    Normal range 0.5-5 μU/ml
    Normal result excludes a primary abnormality of function
    Suppression = hyperthyroid
    Elevated=hypothyroid
    If abnormal TSH get
    Free T4
    Normal 0.8-2.8 ng/dL
    Elevated=hyperthyroid
    Suppression=hypothyroid
  • 31. Thyroid hormone synthesis, metabolism, and action
    • Tests to determine the etiology of thyroid dysfunction
    • 32. Anti-TPO – antithyroidperoxidase antibody
    • 33. Used to detect autoimmune thyroid disease
    • 34. Up to 80% of those with Graves’ disease have TPO antibodies
    • 35. 90% of those with Hashimoto’s thyroiditis have TPO antibodies
    • 36. Thyroid scanning and ultrasound
    • 37. Nuclear imaging
    • 38. Radioisotopes of iodine are selectively transported into the thyroid allowing for imaging
    • 39. Ultrasound
    • 40. Used in nodular thyroid disease
    • 41. Can detect nodules >3mm
    • 42. Also useful in eval of recurrent thyroid cancer
  • Hypothyroid Disorders
  • 43. Hypothyroidism
    Insufficiency in the amount of thyroid hormone in the body
    PRIMARY HYPOTHYROIDISM: thyroid gland failure despite proper stimulation from the pituitary
    SECONDARY HYPOTHYROIDISM: failure of the pituitary to produce TSH to stimulate the thyroid gland
    TERTIARY HYPOTHYROIDISM: failure of the hypothalamus
  • 44. Primary Hypothyroidism
    General Considerations
    Common: affects 1% of the general population and 5% over the age of 60
    Women > men 4:1 ratio
    Mean age at diagnosis is 60 years
    Prevalence increases with age
    Thyroid hormone deficiency affects almost all body functions
  • 45. Primary Hypothyroidism
    • Causes
    • 46. Iodine deficiency
    • 47. most common cause worldwide
    • 48. Autoimmune disease
    • 49. Hashimoto’s thyroiditis
    • 50. Iatrogenic
    • 51. treatment of hyperthyroidism
    Trauma to thyroid/pituitary/hypothalamus
    Radiation exposure
    Severe infection
    Neoplasia (pituitary tumor)
    Drugs – glucocorticoids, phenobarbital, phenytoin, salicylates (large doses), fluorouracil, androgens, amiodarone, interferon
  • 52. Primary Hypothyroidism
    Symptoms
    Common manifestations
    Weight gain
    Fatigue, lethargy
    Depression
    Weakness
    Dyspnea on Exertion
    Arthralgias/myalgias
    Muscle cramps
    Paresthesias
    Cold intolerance
    Constipation
    Dry skin, brittle hair and nails
    Headache
    Carpal Tunnel Syndrome
    Menorrhagia
  • 53. Primary Hypothyroidism
    Symptoms
    Less common
    Decreased appetite and weight loss
    hoarseness
    Decreased sense of taste and smell
    Deminished auditory acuity
    Signs
    Bradycardia
    Diastolic hypertension
    Thin, brittle nails, hair
    Peripheral edema
    Puffy face and eyelids (myxedema)
    Skin pallor or yellowing (carotenemia)
    Delayed DTR
    Goiter
  • 54. Primary Hypothyroidism
    Diagnostic findings
    TSH
    Free T4
    Treatment
    Treat the underlying cause if possible
    Thyroid replacement with T4
    Levothyroxine (Synthroid)
    Adults <60 years without evidence of heart disease
    Start with 25-75 μg qd
    Repeat TSH in 6 weeks
    Adjust dosage by 25 μg every 1-3 weeks based on TSH
    Goal – symptom relief and TSH in lower half of reference range
  • 55. Primary Hypothyroidism
    Treatment
    Adults >60 years or patients with known cardiac disease
    Start with 25-50 μg qd
    Medication increases cardiac contractility and oxygen demand and don’t want to precipitate an MI
    Repeat TSH in 6 weeks
    Adjust dosage by 25 μg every 1-3 weeks based on TSH
    Goal – symptom relief and TSH in lower half of reference range
  • 56. Primary Hypothyroidism
    Treatment
    Average daily replacement dose is usually 1.7μg/kg body weight (typically 100-150 μg)
    Once full replacement is achieved and TSH levels are stable you can extend f/u visits to 6 months and then yearly
    Take Levothyroxine (Synthroid) at least 4 hours between antacids, vitamins, seizure meds, food, lovastatin, sertraline – these medications affect T4 absorption or clearance
  • 57. Myxedema
    • Severe hypothyroidism
    • 58. Signs and symptoms
    • 59. Severe Fatigue
    • 60. Weakness
    • 61. Cardiac enlargement (myxedema heart)
    • 62. Pericardial effusions
    • 63. Psychosis (myxedema madness)
    • 64. Hypothermia
    • 65. Stupor or myxedema coma
    • 66. Hypoventilation, leading to hypoxia and hypercapnia
    • 67. Pituitary enlargement due to hyperplasia of TSH secreting cells
  • Myxedema
    Diagnostic studies
    T4 low
    TSH is increased
    Hyponatremia
    Hypoglycemia
    Anemia
    Hypotension
  • 68. Myxedema
    Treatment
    High mortality rate even with treatment
    Thyroid hormone replacement (initially IV then switch to oral)
    Levothyroxine 500μg IV bolus
    Continue orally at 50-100 μg/day
  • 69. Myxedema Coma
    Medical emergency
    Often induced by underlying infection: cardiac, respiratory, or CNS system illness, cold exposure or drug use
    Multiple organ abnormalities and progressive mental deterioration
    Very rare, but has high mortality rate
    Most commonly results from stressful situations (e.g. trauma, surgery, burns, infection)
    Can occur because of coexisting disease states (e.g. diabetes, MI, fluid and electrolyte abnormalities)
    Can be precipitated by certain medications
  • 70. Myxedema Coma
    Treatment
    IV thyroid hormone replacement
    Treat underlying infection, if present
    Monitor TSH
    Monitor glucose and sodium levels
    Warming if hypothermia (blankets only)
    Prognosis
    Mortality rate of 30 – 60%
    Poor prognosis if advanced age, bradycardia and persistent hypothermia
  • 71. Cretinism
    Congenital hypothyroidism
    Etiology
    1 in 4000 live births
    Pathology
    Hypoplasia or aplasia of the thyroid gland
    OR failure of the gland to migrate into normal anatomic location
    OR ineffective hormone due to enzyme deficiency
  • 72. Cretinism
    Clinical features
    Sluggishness
    Pale, gray, cool or mottled skin
    Nonpitting myxedema
    Constipation
    Large tongue
    Poor muscle tone
    Mental retardation
    Dry, brittle hair
  • 73. Cretinism
    Diagnostic studies
    Low T4
    Elevated TSH
    Delayed skeletal maturation on x-rays
    Treatment – thyroid hormone replacement
    Prevention
    Neonatal screening within 60 days of birth
    Improved prognosis with therapy started in first 2 months of life
  • 74. Hyperthyroid Disorders
  • 75. Hyperthyroidism
    Etiology
    Grave’s disease – most common
    Toxic multinodular goiter and thyroid adenomas
    Subacute (de Quervain) Thyroiditis
    Exogenous thyroid hormone
    Struma Ovarii (ovarian teratoma)
    No goiter
    Pituitary tumor secreting TSH
    Secondary hyperthyroidism
    Normal or increased TSH with diffuse goiter and elevated T4
    Medication induced Amioderone
  • 76. Grave’s disease
    Epidemiology
    Accounts for 60-80% of thyrotoxicosis
    Females > males at 8:1
    Typically occurs between ages 20-40
    Pathology
    Grave’s disease is an autoimmune disorder
    Involves the formation of autoantibodies that bind to the TSH receptors in the thyroid and stimulate gland hyperfunction
    Characterized by an increase synthesis and release of thyroid hormones
    Gland is typically enlarged
    Familial tendency (HLA-B8 and HLA-DR3)
  • 77. Grave’s disease
    Symptoms
    Descending order of frequency
    Hyperactivity, irritability, dysphoria
    Heat intolerance, increased sweating
    Palpitations
    Fatigue, weakness
    Weight loss (increased appetite)
    Diarrhea
    Polyuria
    Oligomenorrhea, loss of libido
  • 78. Grave’s disease
    Signs
    Descending order of frequency
    Tachycardia; A fib in the elderly, PACs
    Tremor
    Goiter may be present (absence of goiter does not rule out hyperthyroidism)
    Skin warm, moist
    Muscle weakness, proximal myopathy
    Exophthalmos, proptosis, lid lag with downward gaze (von Graefe sign) or retraction (Dalrymaple sign), staring appearance (Kicher sign)
    Thyroid dermopathy – pretibialmyxedema
    Hyperreflexia
    Thyroid acropachy (digital clubbing) rare
    Hypokalemic periodic paralysis
  • 79. Grave’s disease
    Diagnostic studies
    TSH
    T3 and T4 both total and free
    Anti-TPO positive in up to 80%
    TSH receptor antibody (TRaB) positive in 65%
    Imaging
    Thyroid RAI uptake and scan
    High in Grave’s Disease and toxic nodular goiter
    MRI of orbits if eye concerns
  • 80. Grave’s disease
    Management
    Clinical features generally worsen without treatment
    Treat by
    reducing thyroid hormone synthesis, using antithyroid drugs –propylthiouracil (PTU), methimazole
    Reducing the amount of thyroid tissue with radioiodine treatment (RAI)
    Causes progressive destruction of thyroid cells
    Reducing the amount of thyroid tissue with thyroidectomy
    If not responding to medical treatment
    Large goiters
    Beta-blockers (propanolol) for symptoms during early treatment with antithyroid drugs and radioiodine tx
  • 81. Thyroid Storm
    Rare
    Life-threatening emergency
    Exacerbation of hyperthyroidism/ thyrotoxicosis
    Usually precipitated by stress (surgery, infection, delivery, trauma)
    High mortality rate 30% even with treatment – cardiac failure, arrhythmia, or hyperthermia
    Pathology – same as hyperthyroidism with addition of stressor as above
  • 82. Definitions
    Hypothyroidism: hypoactive thyroid gland
    Hyperthyroidism: hyperactive thyroid gland
    Thyrotoxicosis: excessive thyroid hormone
    Thyroid storm: the life threatening result of excessive thyroid hormone and physical stress
    Myxedema: Severe result of lack of thyroid hormone
  • 83. Thyroid Storm
    Clinical features
    Exaggerated signs and symptoms of hyperthyroidism
    High fever
    Marked delirium
    Severe tachycardia
    Seizures
    Nausea, vomiting and diarrhea
    Dehydration
    Coma
    Jaundice
    Death
  • 84. Thyroid Storm
    Diagnostic studies
    Highly elevated T3 and T4
    EKG may show sinus tachycardia, a-fib or flutter
    Management
    Aggressive use of and large dose of propylthiouracil (PTU)
    Oral or IV Ipodate Sodium(decreases thyroid hormone production) with Iodide given 1 hour later as Lugol solution
    Propranolol given (cautiously if heart failure)
    Glucocorticoids (inhibits peripheral conversion of T4 to T3
  • 85. Toxic Multinodular Goiter
    Multiple thyroid nodules that range in morphology from hypercellular regions to cystic areas filled with colloid
    Women > men
    Clinical presentation
    Subclinical hyperthyroidism or mild thyrotoxicosis
    Usually elderly
    A fib, tachycardia
    Nervousness, tremor
    Weight loss
    Recent exposure to iodine, from contrast dyes or other sources, may precipitate or exacerbate thyrotoxicosis
  • 86. Toxic Multinodular Goiter
    Diagnostic testing
    T3 and T4 with T3 elevated to a higher degree
    TSH
    Thyroid scan shows heterogeneous uptake with multiple regions of increased and decreased uptake
    Treatment
    Management is challenging
    Antithyroid drugs in combination with beta blockers
    However this treatment often stimulates the growth of the goiter
    Radioiodine can be used to treat areas of autonomy
    Surgery provides definitive treatment
  • 87. Thyroiditis
    Classifications
    Acute thyroiditis (Suppurativethyroiditis)
    Subacutethyroiditis
    Painless or silent thyroiditis
    Hashimoto’s thyroiditis (Chronic lymphocytic thyroiditis)
    Riedel thyroiditis
  • 88. Thyroiditis
    Acute thyroiditis
    Rare
    Due to suppurative infection of the thyroid
    Typically occurs in children or young adults
    Signs and symptoms
    Thyroid pain often referred to throat or ears
    Small, tender goiter that may be asymmetric
    Fever, dysphagia and erythema over the thyroid
    Laboratory
    ESR
    WBC
    Normal thyroid function
  • 89. Thyroiditis
    • Diagnostic testing
    FNA biopsy shows infiltration by PMN leukocytes
    Culture of the sample can identify the organism
    • Treatment
    Antibiotics guided by culture
    Surgery may be needed to drain abscess
  • 90. De Quervain’sThyroiditis
    AKA SubacuteThyroiditis, granulomatousthyroiditis, giant cell thyroiditis
    Etiology – probably viral, may be preceded by viral URI
    Symptoms can mimic pharyngitis
    Peak incidence occurs between 30-50
    Women>men 3:1 ratio
  • 91. De Quervain’sThyroiditis
    Pathology
    Enlargement and patchy inflammatory infiltrate of thyroid
    During initial phase of follicular destruction, there is release of thyroid hormones, leading to increased circulating T3 and T4 and suppression of TSH
    After several weeks, the thyroid is depleted of stored thyroid hormone and a phase of hypothyroidism typically occurs, with low free T3 and T4 and moderately increased TSH levels
    Finally thyroid hormone and TSH levels return to normal as disease subsides
    Thyrotoxicosis hypothyroidism NL thyroid function
    lasts several weeks lasts 4-6 months returns within 12 months
    (develops in 50%)
  • 92. De Quervain’sThyroiditis
    Clinical features
    Often complain of sore throat
    Exquisitely tender thyroid with small goiter (one or both lobes may be affected)
    Pain is often referred to jaw or ear
    Sometimes fever
    Malaise and URI symptoms may precede the thyroid-related features
    There may be signs of thyrotoxicosis or hypothyroidism, depending on the phase of the illness
  • 93. De Quervain’sThyroiditis
    Diagnostic studies
    Lymphocytosis on CBC
    Elevated ESR
    Thyroid function tests evolve through 3 distinct phases over about 6 months
    Thyrotoxic phase - T3 and T4 elevated, TSH suppressed
    Hypothyroid phase
    Recovery phase
    Negative antibody tests
    Low thyroid radioiodine uptake (RAIU)
  • 94. De Quervain’sThyroiditis
    Treatment
    ASA or NSAIDS typically sufficient to control symptoms
    May use beta blockers for symptoms during thyrotoxicosis phase
    Thyroid hormone during hypothyroid stage may be needed
    RAI can be used to cause prompt fall of T3 and improve thyrotoxic symptoms
    Monitor thyroid function every 2-4 weeks using TSH and free T4
  • 95. Painless Thyroiditis
    Autoimmune thyroiditis
    Categories
    Sporadic
    Occurs in patients with underlying autoimmune thyroid disease
    Postpartum
    Occurs in 7.2% of women 3-6 months after pregnancy
    3 times more common in women with type 1 diabetes
    70% chance of recurrence with subsequent pregnancies
  • 96. Painless Thyroiditis
    Clinical features
    Clinical course similar to subacute thyroiditis except there is little to no thyroid tenderness
    Thyrotoxicosis stage lasting 2-4 weeks followed by hypothyroid stage for 4-12 weeks, and then resolution
    Labs
    Positive anti-TPO
    Normal ESR
    Management
    Initial stage usually mild
    Can use propranolol for symptoms if needed
    Second stage – thyroxine replacement – use only for 6-9 months as recovery is the rule
  • 97. Hashimoto’s Thyroiditis
    Chronic lymphocytic thyroiditis due to autoimmunity
    Epidemiology
    Women > men 6:1 ratio
    14.3% of Caucasians
    10.9% of Hispanics
    5.3% of Blacks
    Mean age at diagnosis is 60 years
    Prevalence increases with age
    Tends to be familial
  • 98. Hashimoto’s Thyroiditis
    Most common type of thyroid disorder in the US
    Pathology
    Immune mediated destruction of thyroid parenchyma
    B-lymphocytes invade the thyroid gland which leads to follicular atrophy and then fibrosis
    Initially may have hyperthyroidism due to passive release of stored thyroid hormone
    Detectable levels of anithyroid antibodies – anti-TPO or antithyroglobulin antibodies or both
    Only a small subset of individuals with elevated antithyroid antibody levels ever develop thyroid dysfunction
    Found in 3% of men and 13% of women
  • 99. Hashimoto’s Thyroiditis
    May be associated with other autoimmune diseases
    Type I diabetes, Addison’s disease, pernicious anemia
    Signs and symptoms
    May be hyperthyroid, euthyroid or hypothyroid
    Thyroid gland may be diffusely enlarged (goiter), firm or rubbery, usually nontender
    Surface of thyroid may be irregular or nodular
    Slow progression to hypothyroidism over years
    Patients often present with signs and symptoms of hypothyroidism
    Dry skin, decreased sweating, thinning of skin, myxedema, puffy face and eyelids, nonpittingpretibial edema, dry/brittle hair, depression
    Thyroid is diffusely enlarged, firm, and finely nodular
  • 100. Hashimoto’s Thyroiditis
    Diagnostic studies
    Thyroid function tests
    Hyperthyroid phase
    Free T4 levels higher than T3 due to it being the greater stored hormone
    Because T4 is less active than T3 the hyperthyroid symptoms are less severe than in other thyroiditis conditions
    TSH
    Hypothyroid state
    Free T4
    TSH
    Positive antithyroid antibodies
    Anti-TPO in 90%
    Antithyroglobulin antibodies in 40%
  • 101. Hashimoto’s Thyroiditis
    Imaging
    Ultrasound shows diffuse heterogeneous density and hyperechogenicity
    FNA for nodules
    Doppler may be needed to distinguish between Graves Disease and Hashimoto’s
    Treatment
    Thyroxine hormone replacement
    If hypothyroid
    Or if euthyroid with goiter present
    Will shrink the goiter by 30% in most cases over 6 months
  • 102. Riedel Thyroiditis
    AKA Invasive fibrous thyroiditis, Riedel struma, woody thyroiditis, ligneous thyroiditis, invasive thyroiditis
    Generally a manifestation of multifocal systemic fibrosis syndrome
    Causes hypothyroidism and sometimes hypoparathyroidism
    RARE
    Generally found in middle-aged or elderly women
    Signs and symptoms:
    Thyroid enlargement is asymmetrical and stony, hard and adherent to neck structures
  • 103. Riedel Thyroiditis
    Signs and symptoms cont’d:
    Compression of the thyroid causes dysphagia, dyspnea, pain and hoarseness
    Fibrosis happens in other areas of the body as well
    Treatment
    Tamoxifen can provide remission in 3-6 months
    Short term corticosteroids can help with compression
    Surgical decompression may be needed
  • 104. Thyroid Nodules
    Must consider cancer
    Pathology
    Adenomas, cysts, colloid nodules (most common nodules), localized thyroiditis, and cancer (mostly papillary and follicular)
    Clinical features
    Most are asymptomatic
    May have hyper- or hypothyroidism
  • 105. Thyroid Nodules
    Clinical features
    Suspect cancer if rapid growth, fixed in place with no movement on swallowing, hx of neck radiation, male sex, extremes of age
    Diagnostic studies
    TSH and free T4
    Fine needle aspiration and cytology
    Ultrasound
  • 106. Thyroid Nodules
    Management
    MUST exclude malignancy
    Treatment according to specific diagnosis
    If malignant, surgery followed by thyroid radioiodine ablation
  • 107. Thyroid Cancers
    Epidemiology
    Most common malignancy of the endocrine system
    Uncommon, diagnosed in less than 1% of the population
    Women > men 3:1 ratio
    Male sex associated with worse prognosis
    Incidence increases with age
    Classification
    Papillary carcinoma (most common)
    Follicular
    Medullary
    Anaplastic (most aggressive)
  • 108. Thyroid Cancers
    Risk Factors of thyroid cancer in pt with a thyroid nodule
    History of head and neck irradiation
    Age <20 or >45
    Bilateral disease
    Large nodule size, >4cm
    New or enlarging neck mass
    Male sex
    Nodule fixed to adjacent surfaces
    Genetic factors, especially medullary which has familial predisposition
  • 109. Thyroid Cancers
    Signs and symptoms
    Palpable, firm, nontender nodule in the thyroid
    Most are asymptomatic
    Possible hoarseness
    Possible neck pain
    Possible cervical LAD
    Only 5% of palpable thyroid nodules are malignant
    Thyroid function tests are usually normal
  • 110. Thyroid Cancers
    Diagnostic studies
    Serum calcitonin and CEA levels may be elevated in medullary cancer
    Usually seen as a “cold” nodule on radioactive iodine thyroid scan
    Ultrasound shows solid, well-formed nodule/s and can detect metastases in the neck
    FNA needed
    CT scan – used to detect metastases
    MRI and PET scans- distant mets
  • 111. Thyroid Cancers
    Treatment
    Surgical excision with near-total thyroidectomy with post-surgical radioablation of the remnant thyroid tissue
    Most tumors are still TSH responsive, TSH suppression is a mainstay of treatment
    Goal is TSH range 01.-0.5 IU/L
    Chemo used if mets are present
  • 112. Thyroid Cancers
    PapillaryFollicularMedullaryAnaplastic
    Incidence MOST 2nd MOST Uncommon LEAST
    COMMON COMMON COMMON
    Av. Age 42 50 50 57
    Females 70% 72% 56% 2%
    Deaths 6% 24% 33% 98%
    I uptake + ++++ 0 0
    Degree of + ++-+++ +-++++ ++++++++
    Malignancy
  • 113. Any Questions???
  • 114. References
    Jennifer Forbes, MHS, PA-C: many slides are hers from last year
    CMDT
    Harrison’s Principles of Internal Medicine
    Images:
    www.riversideonline.com/.../DS00396.cfm
    ehp.niehs.nih.gov/.../howdeshell-full.html
    healthfiles.net/disease/toxic-nodular-goiter/
    www.missionfoto.com/images/fall03/goiter.html