Your SlideShare is downloading. ×
0
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Thyroid

14,074

Published on

Published in: Education, Health & Medicine
0 Comments
16 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
14,074
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
1,448
Comments
0
Likes
16
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. THYROID James Taclin C. Banez, M.D., FPSGS, FPCS
  • 2. Embryology <ul><li>Out pouching of the primitive foregut (3 rd wk of gestation) </li></ul><ul><li>Base of the tongue (foramen cecum). Endoderm cells. Medial thyroid anlage – forms thyroid follicular cell </li></ul><ul><li>4 th branchial pouch – forms lateral anlage. Neuroectodermal origin (ultimobranchial bodies). Forms parafollicular cells located at superoposterior region </li></ul>
  • 3. <ul><li>ANATOMY: </li></ul><ul><li>Location / Parts </li></ul><ul><li>Arteries / Venous drainage </li></ul><ul><li>Nerve Supply </li></ul><ul><ul><li>Sympathetic ( cervical ganglion ) </li></ul></ul><ul><ul><li>Parasympathetis ( vagus ) </li></ul></ul>
  • 4. <ul><li>ANATOMY: </li></ul><ul><li>Nerve Supply </li></ul><ul><ul><li>Sympathetic ( cervical ganglion ) </li></ul></ul><ul><ul><li>Parasympathetis ( vagus ) </li></ul></ul>
  • 5. <ul><li>ANATOMY: </li></ul><ul><li>Lymphatic Drainage: </li></ul><ul><ul><li>Central compartment </li></ul></ul><ul><ul><ul><li>Areas between the two carotid sheaths </li></ul></ul></ul><ul><ul><li>Lateral compartment </li></ul></ul><ul><li>Histology: </li></ul><ul><ul><li>Thyroid follicle ( thyroglobulin ) </li></ul></ul><ul><ul><li>C cells ( neuroectoderm – 4 th and 5 th ultimo brachial bodies ). </li></ul></ul>
  • 6. <ul><li>PHYSIOLOGY: </li></ul><ul><li>Synthesis &amp; secrets thyroid hormone (thyroid follicle) </li></ul><ul><ul><li>Iodide uptake </li></ul></ul><ul><ul><li>Oxidation of iodide to iodine and iodination of tyrosine in thyroglobulin to form MIT / DIT </li></ul></ul><ul><ul><li>Coupling of inactive iodotyrosine to form T4 /T3 </li></ul></ul><ul><ul><li>Thryoglobulin is hydrolized to free T3 and T4 </li></ul></ul><ul><li>Calcium Level </li></ul><ul><ul><ul><li>Calcitonin (C cell) </li></ul></ul></ul>
  • 7. Evaluation of Thyroid Diseases <ul><li>Clinical history and physical examination </li></ul><ul><li>Thyroid Function Test </li></ul><ul><ul><li>TSH determination: </li></ul></ul><ul><ul><ul><li>N = 0.5 to 5 uU/ml </li></ul></ul></ul><ul><ul><ul><li>The only test necessary in most pts w/ thyroid nodules that clinically appears to be euthyroid </li></ul></ul></ul><ul><ul><ul><li>The most sensitive and specific test for the diagnosis of hyper and hypothyroidism &amp; for optimizing T4 replacement &amp; suppressive therapy </li></ul></ul></ul><ul><ul><li>Total T4 ( 55 – 150nmol/L ) and Free T4 ( 12 to 28pmol ) reflects the output from the thyroid gland. </li></ul></ul><ul><ul><li>Total T3 ( 1.5 to 3.5 nmol/L ) Free T3 ( 3-9pmol ) – confirming the diagnosis of early hyperhtyroidism </li></ul></ul>
  • 8. Evaluation of Thyroid Diseases <ul><ul><li>Thyroid-releasing hormone : </li></ul></ul><ul><ul><ul><li>Use to evaluate pituitary TSH secretory function </li></ul></ul></ul><ul><ul><ul><li>Administer 500ug of TRH --&gt; there shd be an increase of 6uIU/ml from baseline </li></ul></ul></ul><ul><ul><li>Thyroid antibodies: </li></ul></ul><ul><ul><ul><li>For Hashimoto’s thyroiditis &amp; Graves’ dse </li></ul></ul></ul><ul><ul><li>Serum thyroglobulin </li></ul></ul><ul><ul><ul><li>Normally not released but is noted in cases of thyroiditis &amp; Graves’ dse </li></ul></ul></ul><ul><ul><ul><li>It’s level is impt in monitoring recurrent thyroid CA after total thyroidectomy and radioactive iodine ablation </li></ul></ul></ul>
  • 9. Evaluation of Thyroid Diseases <ul><li>Thyroid Imaging: </li></ul><ul><ul><li>Radioactive Imaging: I 123 &amp; I 131 </li></ul></ul><ul><ul><ul><li>Mass and it’s activity: COLD ( 15 – 20% malignant), HOT and WARM (&lt;5% malignant) nodules </li></ul></ul></ul><ul><ul><ul><li>F-fluorodeoxyglucose positron emission tomography – use to screen for metastases in thyroid CA if radioactive Iodine is negative . </li></ul></ul></ul>
  • 10. Evaluation of Thyroid Diseases <ul><li>Thyroid Imaging: </li></ul><ul><ul><li>Ultrasound: </li></ul></ul><ul><ul><ul><li>(-) radiation </li></ul></ul></ul><ul><ul><ul><li>Cystic or solid </li></ul></ul></ul><ul><ul><ul><li>Size and multicentricity </li></ul></ul></ul><ul><ul><ul><li>Can assess cervical lymphadenopathy </li></ul></ul></ul><ul><ul><ul><li>To guide FNA biopsy </li></ul></ul></ul><ul><ul><li>CT/MRI scan: </li></ul></ul><ul><ul><ul><li>Useful in evaluating the extent of large, fixed or substernal goiters &amp; their relationship to the airway and vascular structures </li></ul></ul></ul>
  • 11. Evaluation of Thyroid Diseases <ul><li>Fine Needle Aspiration Biopsy: </li></ul><ul><ul><li>Single most important test after clinical history &amp; PE in the evaluation of thyroid masses. </li></ul></ul><ul><ul><li>w/ or w/o ultrasound guidance </li></ul></ul>
  • 12. BENIGN THYROID DISORDERS <ul><li>HYPERTHYROIDISM (Thyrotoxicosis) </li></ul><ul><li>With increase thyroid hormone secretion </li></ul><ul><ul><li>Grave’s disease </li></ul></ul><ul><ul><li>Toxic nodular goiter </li></ul></ul><ul><ul><li>Toxic thyroid adenoma </li></ul></ul><ul><li>With out increased thyroid hormone secretion </li></ul><ul><ul><li>Sub-acute thyroiditis </li></ul></ul><ul><ul><li>Functioning metastatic thyroid cancer </li></ul></ul><ul><ul><li>Struma ovarii </li></ul></ul>
  • 13. HYPERTHYROIDISM <ul><li>GRAVE’S Disease (Diffuse Thyroid Goiter) </li></ul><ul><li>Most common form of thyrotoxicosis </li></ul><ul><li>Autoimmune </li></ul><ul><li>Female &gt; male; most prevalent 20-40 y/o </li></ul><ul><li>Thyroid stimulating antibody (immunoglobulin) </li></ul><ul><li>directed at the TSH receptor or the thyroid follicular cells. </li></ul><ul><ul><ul><li>LATS (long acting thyroid stimulating antibody) </li></ul></ul></ul><ul><ul><ul><li>TRAb (thyroid receptor antibody) </li></ul></ul></ul>
  • 14. HYPERTHYROIDISM <ul><li>GRAVE’S Disease (Diffuse Thyroid Goiter) </li></ul><ul><li>Manifestations: </li></ul><ul><ul><li>Signs/symptoms of thyrotoxicosis : Inc. Body Metabolism </li></ul></ul><ul><ul><ul><li>heat intolerance </li></ul></ul></ul><ul><ul><ul><li>sweating </li></ul></ul></ul><ul><ul><ul><li>weight loss, muscle wasting </li></ul></ul></ul><ul><ul><ul><li>tachycardia/atrial fibrillation </li></ul></ul></ul><ul><ul><ul><li>fine tremors </li></ul></ul></ul><ul><ul><ul><li>easy fatigability </li></ul></ul></ul><ul><ul><ul><li>hypoactive tendon reflexes </li></ul></ul></ul><ul><ul><ul><li>amenorrhea </li></ul></ul></ul><ul><ul><ul><li>decrease fertility </li></ul></ul></ul><ul><ul><ul><li>easy fatigability, agitation and excitability </li></ul></ul></ul><ul><ul><ul><li>diarrhea </li></ul></ul></ul>
  • 15. HYPERTHYROIDISM <ul><li>GRAVE’S Disease (Diffuse Thyroid Goiter) </li></ul><ul><li>Triad: </li></ul><ul><ul><ul><li>diffuse goiter </li></ul></ul></ul><ul><ul><ul><li>thyrotoxicosis </li></ul></ul></ul><ul><ul><ul><li>exopthalmos </li></ul></ul></ul><ul><li>Other: </li></ul><ul><ul><ul><li>hair loss </li></ul></ul></ul><ul><ul><ul><li>pretibial myxedema </li></ul></ul></ul><ul><ul><ul><li>gynecomastia </li></ul></ul></ul><ul><ul><ul><li>splenomegally </li></ul></ul></ul>(Glycosaminoglycans)
  • 16. HYPERTHYROIDISM <ul><li>GRAVE’S Disease: </li></ul><ul><li>Exopthalmos: </li></ul><ul><li>Due to increase retro-bulbar tissue: </li></ul><ul><ul><li>Spasm of the upper eyelid, revealing the sclera above the corneoscleral limbus (Dalrymple’s sign) </li></ul></ul><ul><ul><li>Lid lag (von graefes sign) </li></ul></ul><ul><ul><li>External ophthalmoplegia (inability to move the eyeball) </li></ul></ul><ul><ul><li>Supra and infraorbital swelling </li></ul></ul><ul><ul><li>Congestion and edema of the conjunctiva and sclera (chemosis) ----&gt; ulceration </li></ul></ul><ul><li>Progression --&gt; damage of optic nerve --&gt; decreases visual acuity and impairment of color vision ( malignant exopthalmos ) not corrected surgically --&gt; blindness </li></ul>Orbital fibroblast &amp; muscles share the A common antigen with thyrocytes
  • 17. HYPERTHYROIDISM <ul><li>Diagnosis: </li></ul><ul><ul><li>Autonomous thyroid function </li></ul></ul><ul><ul><ul><li>Low TSH </li></ul></ul></ul><ul><ul><ul><li>Elevated T3 / T4 </li></ul></ul></ul><ul><ul><ul><li>Thyroid scan ---&gt; diffuse elevated iodine uptake </li></ul></ul></ul><ul><ul><ul><li>Thyroid ultrasound </li></ul></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Choices: </li></ul></ul><ul><ul><ul><li>Antithyroid drugs </li></ul></ul></ul><ul><ul><ul><li>Radioactive iodine therapy </li></ul></ul></ul><ul><ul><ul><li>Surgery </li></ul></ul></ul><ul><ul><li>Choice depends on: </li></ul></ul><ul><ul><ul><li>Age </li></ul></ul></ul><ul><ul><ul><li>Severity of the disease </li></ul></ul></ul><ul><ul><ul><li>Size of the gland </li></ul></ul></ul><ul><ul><ul><li>Coexistent pathology (Ophthalmoplegia) </li></ul></ul></ul><ul><ul><ul><li>Other factors: </li></ul></ul></ul><ul><ul><ul><ul><li>Patient’s preference </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pregnancy </li></ul></ul></ul></ul>
  • 18. HYPERTHYROIDISM <ul><li>Antithyroid Drugs: </li></ul><ul><li>Propyl thiouracil (PTU) = 100-300mg TID </li></ul><ul><li>Methimazole (Tapazole) = 10-20 TID then OD </li></ul><ul><li>Carbimazole = 40mg OD </li></ul><ul><li>Inhibits the organic binding of iodine and coupling of iodotyrosine </li></ul><ul><li>PTU can also lower conversion of T4 to T3; it can also decrease thyroid autoantibody levels </li></ul>
  • 19. HYPERTHYROIDISM <ul><li>Disadvantage of these drugs. </li></ul><ul><ul><li>Crosses the placenta --&gt; inhibits fetal thyroid function </li></ul></ul><ul><ul><li>Excreted in breast milk </li></ul></ul><ul><ul><li>Side effects: </li></ul></ul><ul><ul><ul><ul><li>Skin rashes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fever </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Peripheral neuritis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Polyarteritis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Granulocytopenia (reversible) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Agranulocytosis / aplastic anemia (poor prognosis) </li></ul></ul></ul></ul>
  • 20. HYPERTHYROIDISM <ul><li>Beta blockers (propranolol) – to alleviate peripheral adrenergic effects </li></ul><ul><li>Advised medical management </li></ul><ul><ul><li>Small diffusely enlarge gland </li></ul></ul><ul><ul><li>larger glands that decreases in size due to antithyroid drugs </li></ul></ul><ul><li>Thyroidectomy / Radioactive Iodine Ablation </li></ul><ul><ul><li>Toxic nodule goiters </li></ul></ul><ul><ul><li>Large diffuse glands </li></ul></ul><ul><ul><li>Hyperthyroidism recurs when drug was discontinued </li></ul></ul>
  • 21. HYPERTHYROIDISM <ul><li>Radioactive Iodine Therapy: </li></ul><ul><li>Advantages: </li></ul><ul><ul><li>Avoidance of surgery (no injury to nerve / parathyroid gland) </li></ul></ul><ul><ul><li>Reduce cost &amp; ease of treatment </li></ul></ul><ul><li>Disadvantages: </li></ul><ul><ul><li>Lifelong thyroxin replacement therapy </li></ul></ul><ul><ul><li>Slower correction of hyperthyroidism </li></ul></ul><ul><ul><li>Higher relapse rate </li></ul></ul><ul><ul><li>Adverse effect of ophthalmopathy </li></ul></ul>
  • 22. HYPERTHYROIDISM <ul><li>Radioactive Iodine Therapy: </li></ul><ul><li>Suitable treatment: </li></ul><ul><ul><li>Small or moderate size goiter </li></ul></ul><ul><ul><li>Relapse after medical and surgical therapy </li></ul></ul><ul><ul><li>Antithyroid drug and surgery are contraindicated </li></ul></ul><ul><li>Contraindicated: </li></ul><ul><ul><li>Pregnant / breast feeding </li></ul></ul><ul><ul><li>Ophthalmopathy (progression of eye signs) </li></ul></ul><ul><ul><li>Isolated nodular goiter or toxic nodular goiter </li></ul></ul><ul><ul><li>Young age (children/adolescence) ----&gt; Infertility / carcinoma </li></ul></ul>
  • 23. HYPERTHYROIDISM <ul><li>Radioactive Iodine Therapy: </li></ul><ul><li>Complication of RAI tx: </li></ul><ul><ul><li>Exacerbations of thyrotoxicosis with arrhythmia </li></ul></ul><ul><ul><li>Overt thyroid storm (sudden release of TH) </li></ul></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><li>Risk of fetal damage </li></ul></ul><ul><ul><li>Worsening of eye sign </li></ul></ul><ul><ul><li>Hyperparathyroidism </li></ul></ul>
  • 24. HYPERTHYROIDISM <ul><li>Thyroid Surgery: </li></ul><ul><li>Indicated to: </li></ul><ul><ul><li>Young patient </li></ul></ul><ul><ul><li>With Grave ophthalmopathy </li></ul></ul><ul><ul><li>Pregnant </li></ul></ul><ul><ul><li>With suspicious thyroid nodule in Grave’s gland </li></ul></ul><ul><ul><li>Large nodular toxic goiter w/ low level of radioactive iodine uptake. </li></ul></ul><ul><li>Placed patient to euthyroid state prior to thyroid surgery: </li></ul><ul><ul><li>Antithyroid drugs </li></ul></ul><ul><ul><li>Lugol’s iodine solution (3 drops BID): SSKI supersaturated KI </li></ul></ul><ul><ul><ul><li>Decrease vascularity of the gland / inhibit release of thyroid hormone hence reduce the risk of thyroid storm </li></ul></ul></ul><ul><ul><li>Propranolol </li></ul></ul>
  • 25. HYPERTHYROIDISM <ul><li>Thyroid Surgery: </li></ul><ul><li>Thyroidectomy: </li></ul><ul><ul><li>Bilateral subtotal thyroidectomy </li></ul></ul><ul><ul><li>Total lobectomy &amp; subtotal lobectomy contra-lateral (Hartley-Dunhill) </li></ul></ul><ul><ul><li>Total thyroidectomy </li></ul></ul><ul><li>Advantages over RAI: </li></ul><ul><ul><li>Immediate cure of the disease </li></ul></ul><ul><ul><li>Low incidence of hypothyroidism </li></ul></ul><ul><ul><li>Potential removal of coexisting thyroid carcinoma </li></ul></ul><ul><li>Disadvantages: </li></ul><ul><ul><li>Complication ---&gt; nerve injury (1%) and hypoparathyroidism (13% transient/ 1% permanent). </li></ul></ul><ul><ul><li>Hematoma </li></ul></ul><ul><ul><li>Hypertrophic scar formation </li></ul></ul>
  • 26. HYPERTHYROIDISM <ul><li>Recurrent thyrotoxicosis after surgery---&gt; RAI </li></ul><ul><li>Treatment of Exopthalmos: </li></ul><ul><ul><li>Tape eyelids at night </li></ul></ul><ul><ul><li>Wear eyeglasses </li></ul></ul><ul><ul><li>Steroid eye drop / systemic steroid (60mg prednisone OD) alleviate chemosis. </li></ul></ul><ul><ul><li>Lateral tarsorrhaphy to oppose eyelids </li></ul></ul><ul><ul><li>Radio-orbital radiation or orbital decompression </li></ul></ul>
  • 27. HYPERTHYROIDISM <ul><li>Toxic Nodular Goiter (Plummers’ disease): </li></ul><ul><ul><li>No extrathyroidal manifestation </li></ul></ul><ul><ul><li>Milder than Grave’s disease </li></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Propranolol </li></ul></ul></ul><ul><ul><ul><li>Thyroidectomy (lobectomy with isthmectomy) </li></ul></ul></ul><ul><li>Toxic adenoma: </li></ul><ul><ul><li>Solitary toxic nodule (Follicular) tumor </li></ul></ul><ul><ul><li>Thyrotoxicosis is uncommon unless it is 3 cm in size or more. </li></ul></ul>
  • 28. <ul><li>Thyroid storm: </li></ul><ul><ul><li>Life threatening </li></ul></ul><ul><ul><li>Precipitated by : </li></ul></ul><ul><ul><ul><li>Infection (pharyngitis / pneumonitis) </li></ul></ul></ul><ul><ul><ul><li>Iodine 131 treatment </li></ul></ul></ul><ul><ul><ul><li>Thyroid surgery </li></ul></ul></ul><ul><ul><li>Prophylactic treatment: --- Surgery in euthyroid state </li></ul></ul>
  • 29. <ul><li>Thyroid storm: </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Fluid replacement </li></ul></ul></ul><ul><ul><ul><li>Antithyroid drug </li></ul></ul></ul><ul><ul><ul><li>Beta blocker </li></ul></ul></ul><ul><ul><ul><li>Lugol’s iodine solution </li></ul></ul></ul><ul><ul><ul><li>Hydrocortisone </li></ul></ul></ul><ul><ul><ul><li>Cooling blanket </li></ul></ul></ul><ul><ul><ul><li>Sedation </li></ul></ul></ul><ul><ul><ul><li>Extreme cases ----&gt; peritoneal dialysis or hemofiltration to lower T4&amp;T3 </li></ul></ul></ul><ul><ul><li>Avoid ASPIRIN ---&gt; increases free thyroid hormone levels </li></ul></ul>
  • 30. HYPOTHYROIDISM <ul><li>Causes: </li></ul><ul><li>Primary: </li></ul><ul><ul><li>Autoimmune thyroiditis </li></ul></ul><ul><ul><ul><li>Hashimotos thyroiditis </li></ul></ul></ul><ul><ul><ul><li>Primary myxedema </li></ul></ul></ul><ul><ul><li>Iatrogenic </li></ul></ul><ul><ul><ul><li>Thyroidectomy </li></ul></ul></ul><ul><ul><ul><li>Iodine 131 tx </li></ul></ul></ul><ul><ul><ul><li>Antithyroid drugs </li></ul></ul></ul><ul><ul><li>Congenital (Cretinism) </li></ul></ul><ul><ul><ul><li>Thyroid dysgenesis </li></ul></ul></ul><ul><ul><ul><li>Dyshormonogenesis </li></ul></ul></ul><ul><ul><li>Inflammatory </li></ul></ul><ul><ul><ul><li>Subacute thyroiditis </li></ul></ul></ul><ul><ul><ul><li>Riedels thyroiditis </li></ul></ul></ul><ul><ul><li>Metabolism </li></ul></ul><ul><ul><ul><li>Iodine deficiency </li></ul></ul></ul><ul><li>Secondary: </li></ul><ul><ul><li>Hypopituitarism </li></ul></ul><ul><ul><li>Hypothalamic hypothyroidism </li></ul></ul><ul><ul><li>Peripheral resistance to thyroid hormone * </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>L-thyroxine (50-100ug) </li></ul></ul><ul><ul><li>Will not work for * </li></ul></ul>
  • 31. THYROIDITIS <ul><li>Acute Suppurative Thyroiditis </li></ul><ul><ul><li>Uncommon </li></ul></ul><ul><ul><li>Associated with URTI </li></ul></ul><ul><ul><li>Staphylococcus, Streptococcus and Pneumococci </li></ul></ul><ul><ul><ul><ul><li>E. Coli </li></ul></ul></ul></ul><ul><ul><li>Sx: - acute thyroid pain </li></ul></ul><ul><ul><li>- dysphagia </li></ul></ul><ul><ul><li>- fever </li></ul></ul><ul><ul><li>Dx: - FNA ----&gt; smear and CS </li></ul></ul><ul><ul><li>Tx: - IV antibiotics / drain (abscess) </li></ul></ul>
  • 32. THYROIDITIS <ul><li>Nonsuppurative Thyroiditis: </li></ul><ul><ul><li>Hashimotos disease (Autoimmune lymphocytic thyroiditis) </li></ul></ul><ul><ul><ul><li>Most common form of chronic lymphocytic thyroiditis </li></ul></ul></ul><ul><ul><ul><li>Autoimmune disease: </li></ul></ul></ul><ul><ul><ul><ul><li>Antithyroglobulin / antimicrosomal antibodies </li></ul></ul></ul></ul><ul><ul><ul><li>10 x more in females; 30 – 60y/o </li></ul></ul></ul><ul><ul><ul><li>Familial; 50% in first degree relatives </li></ul></ul></ul><ul><ul><ul><li>Predisposing factors: </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Down syndrome </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Familial Alzheimer’s disease </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Turner syndrome </li></ul></ul></ul></ul></ul>
  • 33. THYROIDITIS <ul><li>Nonsuppurative Thyroiditis: </li></ul><ul><ul><li>Hashimotos disease (Autoimmune lymphocytic thyroiditis) </li></ul></ul><ul><ul><ul><li>Can co-exist with papillary CA </li></ul></ul></ul><ul><ul><ul><li>S/Sx: - Tightness in the throat (most common) </li></ul></ul></ul><ul><ul><ul><li> - Painless, nontender enlargement of gland </li></ul></ul></ul><ul><ul><ul><li>Dx: - Increase TSH, decrease T3 &amp; T4 </li></ul></ul></ul><ul><ul><ul><li> - (+) Anti-thyroid antibodies </li></ul></ul></ul><ul><ul><ul><li> - FNA ---&gt; rule out CA (confirmatory) </li></ul></ul></ul><ul><ul><ul><li>Tx: - Medical if w/o compression ----&gt; thyroid hormone </li></ul></ul></ul><ul><ul><ul><li>- Surgical: 1. Obstructive </li></ul></ul></ul><ul><ul><ul><li>2. Cosmetically unacceptable </li></ul></ul></ul><ul><ul><ul><li>3. Thyroid carcinoma coexist </li></ul></ul></ul>
  • 34. THYROIDITIS <ul><li>Nonsuppurative Thyroiditis: </li></ul><ul><ul><li>2. Riedels’ Thyroiditis : </li></ul></ul><ul><ul><ul><li>Marked dense invasive fibrosis that may involve surrounding structures </li></ul></ul></ul><ul><ul><ul><li>Can cause hypoparathyroidism </li></ul></ul></ul><ul><ul><ul><li>Unknown cause ( maybe part of fibrosclerosis – retroperitoneum, mediastinum, lacrimal gland and bile duct – sclerosing cholahgitis) </li></ul></ul></ul>
  • 35. THYROIDITIS <ul><li>Nonsuppurative Thyroiditis: </li></ul><ul><ul><li>Riedels’ Thyroiditis: </li></ul></ul><ul><ul><ul><li>S/Sx: - painless woody hard anterior neck mass w/c progresses causing compression symptoms </li></ul></ul></ul><ul><ul><ul><li> - Hoarseness - dyspnea </li></ul></ul></ul><ul><ul><ul><li> - stridor - dysphagia </li></ul></ul></ul><ul><ul><ul><li>Dx: - open thyroid biopsy – frozen section </li></ul></ul></ul><ul><ul><ul><li> - FNA biopsy is inadequate </li></ul></ul></ul><ul><ul><ul><li>Tx: - Isthmectomy – to relieve compression symptom </li></ul></ul></ul><ul><ul><ul><li> - Thyroxine replacement </li></ul></ul></ul><ul><ul><ul><li> - Tamoxifen </li></ul></ul></ul><ul><ul><ul><li> - Steroid </li></ul></ul></ul>
  • 36. GOITER <ul><li>Enlargement of the thyroid gland in a euthyroid pt not associated with neoplasm or inflammation: </li></ul><ul><ul><li>Familial: </li></ul></ul><ul><ul><ul><li>Inherited enzymatic defect (dyshormonogenesis) </li></ul></ul></ul><ul><ul><ul><li>Autosomal recessive </li></ul></ul></ul><ul><ul><ul><li>Hypothyroidism / euthyroid </li></ul></ul></ul><ul><ul><li>Endemic: </li></ul></ul><ul><ul><ul><li>Iodine deficiency </li></ul></ul></ul><ul><ul><li>Sporadic: </li></ul></ul><ul><ul><ul><li>No definite cause, excludes goiter caused by thyroiditis and neoplasm as well as endemic goiter </li></ul></ul></ul>
  • 37. GOITER <ul><li>Pathology: </li></ul><ul><ul><li>May be diffusely enlarged and smooth, or enlarged markedly nodular </li></ul></ul><ul><ul><li>Nodules are filled w/ gelatinous, colloid rich material and scattered between areas of normal thyroid tissues </li></ul></ul><ul><ul><li>With areas of degeneration, hemorrhage and calcification. </li></ul></ul>
  • 38. GOITER <ul><li>S/Sx: </li></ul><ul><li>Asymptomatic usually </li></ul><ul><li>Pressure symptoms usually </li></ul><ul><ul><li>Dysphagia </li></ul></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Paralysis of recurrent laryngeal nerve </li></ul></ul><ul><ul><li>Sudden pain associated with rapid enlargement of the gland ---&gt; hemorrhage into a colloid nodule or cyst </li></ul></ul><ul><ul><li>Superior venacaval syndrome due retro-sternal extension causing facial flushing that is accentuated by raising his arm above the head (Pemberton’s sign). </li></ul></ul>
  • 39. GOITER <ul><li>Dx: </li></ul><ul><ul><li>FNAC ---&gt; specially if one nodule predominates, or painful or has recently enlarged. To rule out CA </li></ul></ul><ul><ul><li>For diffuse – ultrasound to detect sub-clinical thyroid nodule </li></ul></ul><ul><ul><li>TSH, T3 &amp; T4 ---&gt; usually normal </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>No tx for euthyroid, small, diffuse goiter </li></ul></ul><ul><ul><li>Medical Tx: </li></ul></ul><ul><ul><ul><li>Thyroxine ---&gt; for large diffuse goiter; to depress TSH stimulation and reduce hyperplasia </li></ul></ul></ul><ul><ul><ul><li>Iodine ---&gt; for endemic goiter </li></ul></ul></ul><ul><ul><li>Surgery: </li></ul></ul><ul><ul><ul><li>Compression symptoms </li></ul></ul></ul><ul><ul><ul><li>Suspicion for malignancy </li></ul></ul></ul><ul><ul><ul><li>Cosmetically acceptable </li></ul></ul></ul>
  • 40. Solitary or Dominant Thyroid Nodule <ul><li>Most are benign (colloid nodule/adenomas) </li></ul><ul><li>Risk factors for thyroid CA: </li></ul><ul><ul><li>Low-dose radiation to head &amp; neck (&lt;2000 rad) </li></ul></ul><ul><ul><li>- &gt;2000rads causes destruction of thyroid gld. </li></ul></ul><ul><ul><li>- tends to be papillary type , multi-focal w/ higher incidence of LN metastases . </li></ul></ul><ul><ul><li>Family hx of thyroid CA </li></ul></ul><ul><ul><ul><li>- Medullary CA – inherited as an autosomal dominanat trait </li></ul></ul></ul><ul><ul><ul><li>- Papillary CA – 6% familial dse. </li></ul></ul></ul>
  • 41. Solitary or Dominant Thyroid Nodule <ul><li>Risk factors for thyroid CA: </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>- thyroid nodule in children and elderly are more likely to be malignant. </li></ul></ul><ul><ul><li>Signs </li></ul></ul><ul><ul><ul><li>Rapid enlargement of an old or new nodule </li></ul></ul></ul><ul><ul><ul><li>Symptoms of local invasion or compression symptoms </li></ul></ul></ul><ul><ul><ul><li>Consistency: Hard, gritty or fixed to surrounding structures </li></ul></ul></ul><ul><ul><ul><li>Palpable cervical lymphadenopathy </li></ul></ul></ul><ul><ul><ul><li>A cyst larger than 4 cm in diameter or in ultrasound is complex has 15% incidence of malignancy </li></ul></ul></ul>
  • 42. Management of Solitary Thyroid Nodule except for pt w/hx of external radiation exposure or a family hx of thyroid CA <ul><li>SOLITARY THYROID NODULE </li></ul><ul><li>FNAB </li></ul><ul><li>Non-diagnostic Benign Suspicious Malignant </li></ul><ul><li>Follicular lesion </li></ul><ul><li>Repeat FNAB Thyroidectomy </li></ul><ul><li>Cyst Colloid Nodule RAI Scan </li></ul><ul><li>aspirate Observe Hot Cold </li></ul><ul><li>consider T4 tx. </li></ul><ul><li>reaccumulate continued growth RAI or Thyroidectomy </li></ul><ul><li>x 3 compressive symptom Thyroidectomy </li></ul><ul><li>Thyroidectomy </li></ul>
  • 43. MALIGNANT THYROID <ul><li>90 – 95% are differentiated tumor w/ follicular origin </li></ul><ul><ul><li>Papillary thyroid adenocarcinoma </li></ul></ul><ul><ul><li>Follicular adenocarcinoma </li></ul></ul><ul><ul><li>Hurtle cell carcinoma </li></ul></ul><ul><li>6% arise from parafollicular cells: </li></ul><ul><ul><li>Medullary carcinoma of thyroid </li></ul></ul><ul><li>1% poorly differentiated </li></ul><ul><ul><li>Anaplastic thyroid carcinoma </li></ul></ul>
  • 44. MALIGNANT THYROID <ul><li>Oncogene associated w/ Thyroid carcinoma: </li></ul><ul><ul><li>RET oncogene: </li></ul></ul><ul><ul><ul><li>Seen in papillary and medullary thyroid CA </li></ul></ul></ul><ul><ul><ul><li>Located in chromosome 10 </li></ul></ul></ul><ul><ul><li>TRK – A: </li></ul></ul><ul><ul><ul><li>Chromosome 1 </li></ul></ul></ul><ul><ul><li>Mutated ras oncogenes: </li></ul></ul><ul><ul><ul><li>Follicular thyroid carcinoma , thyroid adenoma and multinodular goiter </li></ul></ul></ul><ul><ul><li>Mutated p53 gene: </li></ul></ul><ul><ul><ul><li>Anaplastic thyroid carcinoma </li></ul></ul></ul>
  • 45. MALIGNANT THYROID <ul><li>Papillary Thyroid Carcinoma: </li></ul><ul><ul><li>Most common (80%) </li></ul></ul><ul><ul><li>Predominant thyroid CA in children (75%) </li></ul></ul><ul><ul><li>Usually due to radiation exposure of the neck (85-90%) </li></ul></ul><ul><ul><li>Multi-focal (30-88%); has LN spread (para-tracheal &amp; cervical LN). </li></ul></ul><ul><ul><li>Can invade trachea, esophagus and recurrent laryngeal nerve; late hematogenous spread. </li></ul></ul><ul><ul><li>Mixed tumor (papillary &amp; follicular): variant of papillary CA, but classified as papillary for it biologically acts as papillary CA. </li></ul></ul><ul><ul><li>Orphan Annie Nuclei: </li></ul></ul><ul><ul><ul><li>Characteristic cellular feature </li></ul></ul></ul><ul><ul><ul><li>Abundant cytoplasm, crowded nuclei </li></ul></ul></ul><ul><ul><ul><li>and intra-nuclear cytoplasmic inclusion </li></ul></ul></ul>
  • 46. Papillary Thyroid Carcinoma: <ul><li>3 forms of papillary CA (based on size and extent): </li></ul><ul><li>Minimal or occult / micro carcinoma </li></ul><ul><ul><li>1 cm or less, no capsular invasion </li></ul></ul><ul><ul><li>Non-palpable and usually an incidental finding intra-op or autopsy </li></ul></ul><ul><ul><li>Recurrence rate ----&gt; 7% </li></ul></ul><ul><ul><li>Mortality ------------&gt; 0.5% </li></ul></ul><ul><li>Intra-thyroidal Tumors: </li></ul><ul><ul><li>&gt; 1cm and confined to the thyroid gland </li></ul></ul><ul><ul><li>(-) extra thyroidal invasion </li></ul></ul><ul><li>Extra-thyroidal Tumors: </li></ul><ul><ul><li>Locally advanced with invasion through the thyroid capsule into adjacent structures. </li></ul></ul><ul><li>All types can be associated w/ LN metastases and intra-thyroidal blood vessel invasion or occasionally metastases </li></ul>
  • 47. <ul><li>Papillary Thyroid Carcinoma: </li></ul><ul><li>S/Sx: </li></ul><ul><ul><li>Euthyroid, slow growing painless mass </li></ul></ul><ul><ul><li>Signs of local invasions: </li></ul></ul><ul><ul><ul><li>Dysphagia </li></ul></ul></ul><ul><ul><ul><li>Dyspnea </li></ul></ul></ul><ul><ul><ul><li>Hoarseness of voice </li></ul></ul></ul><ul><ul><li>Palpable cervical LN more apparent than primary lesion (lateral aberrant thyroid) </li></ul></ul><ul><ul><li>Uncommon distant metastases (lung metastases in children ) </li></ul></ul><ul><li>Diagnosis: </li></ul><ul><ul><li>FNAC (specific and sensitive for papillary, medullary and anaplastic) </li></ul></ul><ul><ul><li>CT/MRI in pts w/ extensive local or sub-sternal extension </li></ul></ul>
  • 48. <ul><li>Papillary Thyroid Carcinoma: </li></ul><ul><li>Prognostic indicators: (85% 10yrs survival) </li></ul><ul><li>AGES scale: </li></ul><ul><li>A- age G- grade E- extent S- size </li></ul><ul><li>MACIS scale: </li></ul><ul><li>M- metastases A- age C- completeness of resection </li></ul><ul><li>I- extra thyroidal invasion S- size </li></ul><ul><li>AMES </li></ul><ul><li>TNM </li></ul><ul><li>Distant metastases (bone): most significant prognostic indicator overall </li></ul>
  • 49. TNM Classification of Thyroid Tumors <ul><li>Primary tumor: (T) </li></ul><ul><li>TX – primary tumor not assessed </li></ul><ul><li>T0 – no evidence of primary tumor </li></ul><ul><li>T1 – tumor &lt;/= 2cm in diameter, limited to thyroid </li></ul><ul><li>T2 – tumor &gt; 2cm but &lt; 4cm, limited to thyroid </li></ul><ul><li>T3 – tumor &gt;4cm, limited to thyroid, or any tumor w/ </li></ul><ul><li>minimal extra-thyroidal invasion </li></ul><ul><li>T4a – any size that extend beyond capsule invading </li></ul><ul><li>subcutaneous soft tissue, larynx, trachea, esophagus, </li></ul><ul><li>recurrent laryngeal nerve or intrathyroidal anaplastic </li></ul><ul><li>cancer </li></ul><ul><li>T4b – tumor invading prevertebral fascia or encasing carotid </li></ul><ul><li>artery or mediastinal vessels or extrathyroidal anaplastic </li></ul><ul><li>cancer </li></ul>
  • 50. TNM Classification of Thyroid Tumors <ul><li>Regional LN (N) – include central, lateral, cervical and mediastinal LN </li></ul><ul><li>NX – regional LN cannot be assessed </li></ul><ul><li>N0 – no regional LN metastasis </li></ul><ul><li>N1 – regional LN metastasis </li></ul><ul><ul><li>N1a – metastases to level VI (pretracheal, </li></ul></ul><ul><ul><li>paratracheal and prelaryngeal/Delphian LN) </li></ul></ul><ul><ul><li>N1b – metastases to unilateral, bilateral or </li></ul></ul><ul><ul><li>contralateral cervical or superior mediastinal LN </li></ul></ul>
  • 51. TNM Classification of Thyroid Tumors <ul><li>Distant Metastasis (M) </li></ul><ul><li>MX – distant metastases cannot be assessed </li></ul><ul><li>M0 – no distant metastases </li></ul><ul><li>M1 – w/ distant metastases </li></ul>
  • 52. TNM Classification of Thyroid Tumors <ul><li>Papillary or Follicular Tumors: </li></ul><ul><li>STAGE TNM </li></ul><ul><li>Younger than age 45 y/o </li></ul><ul><li> I any T, any N, M0 </li></ul><ul><li>II any T, any N, M1 </li></ul><ul><li>Age 45 w/o and older </li></ul><ul><li> I T1, N0, M0 </li></ul><ul><li> II T2, N0, M0 </li></ul><ul><li>III T3, N0, M0; T1-3, N1a, M0 </li></ul><ul><li>IVA T4a, N0-1a, M0;T1-4a, N1b, M0 </li></ul><ul><li>IVB T4b, any N, M0 </li></ul><ul><li>IVC any T, any N, M1 </li></ul>
  • 53. TNM Classification of Thyroid Tumors <ul><li>Medullary Thyroid Cancer </li></ul><ul><li>STAGE TNM </li></ul><ul><li> I T1, N0, M0 </li></ul><ul><li> II T2-3, N0, M0 </li></ul><ul><li>III T1-3, N1a, M0 </li></ul><ul><li> IVA T4a, N0-1a, M0; T1-4a, N1b, M0 </li></ul><ul><li>IVB T4b, any N, M0 </li></ul><ul><li>IVC any T, any N, M1 </li></ul><ul><li>Anaplastic Cancer </li></ul><ul><li>STAGE TNM </li></ul><ul><li> IVA T4a, any N, M0 </li></ul><ul><li> IVB T4b, Any N, M0 </li></ul><ul><li>IVC Any T, any M, M1 </li></ul><ul><li> </li></ul>
  • 54. <ul><li>Papillary Thyroid Carcinoma: </li></ul><ul><li>Predict the risk of dying from Papillary CA </li></ul><ul><li>Low Risk Patient: </li></ul><ul><ul><li>Young </li></ul></ul><ul><ul><li>Well differentiated tumor </li></ul></ul><ul><ul><li>(-) metastasis </li></ul></ul><ul><ul><li>Small primary lesion </li></ul></ul><ul><li>High Risk Patient </li></ul><ul><ul><li>Older </li></ul></ul><ul><ul><li>Poorly differentiated tumor </li></ul></ul><ul><ul><li>(+) local invasion </li></ul></ul><ul><ul><li>(+) Distant metastasis </li></ul></ul><ul><ul><li>Large primary lesion </li></ul></ul>
  • 55. <ul><li>Papillary Thyroid Carcinoma: (SURGERY) </li></ul><ul><ul><li>For high risk tumors and bilateral tumors </li></ul></ul><ul><ul><ul><li>- Total or near total thyroidectomy: </li></ul></ul></ul><ul><ul><li>For low risk patients, small &amp; unilateral lesion </li></ul></ul><ul><ul><ul><li>Controversial </li></ul></ul></ul><ul><ul><ul><ul><li>Total thyroidectomy vs. Total lobectomy w/ Isthmectomy </li></ul></ul></ul></ul>
  • 56. <ul><li>Papillary Thyroid Carcinoma: (SURGERY) </li></ul><ul><ul><li>Proponent of Total Thyroidectomy: </li></ul></ul><ul><ul><ul><li>RAI can effectively detect and treat residual thyroid tissue and metastatic lesions. </li></ul></ul></ul><ul><ul><ul><li>The serum Tg becomes more sensitive marker of recurrent or persistent disease </li></ul></ul></ul><ul><ul><ul><li>Eliminates contralateral occult cancers as sites of recurrence (85% are multifocal) </li></ul></ul></ul><ul><ul><ul><li>Reduces the risk of recurrence &amp; improve survival </li></ul></ul></ul><ul><ul><ul><li>Decreases the 1% risk of progression to undifferentiated or anaplastic thyroid cancer </li></ul></ul></ul>
  • 57. <ul><li>Papillary Thyroid Carcinoma: (SURGERY) </li></ul><ul><ul><li>Proponent of Lobectomy: </li></ul></ul><ul><ul><ul><li>Total thyroidectomy associated w/ higher complication rate </li></ul></ul></ul><ul><ul><ul><li>Recurrence in the remaining thyroid tissue is unusual (5%) and most are curable by surgery. </li></ul></ul></ul><ul><ul><ul><li>Tumor multicentricity seems to have little prognostic significance </li></ul></ul></ul><ul><ul><ul><li>Have an excellent prognosis </li></ul></ul></ul>
  • 58. <ul><li>Papillary Thyroid Carcinoma: (SURGERY) </li></ul><ul><ul><li>Recommendation: </li></ul></ul><ul><ul><li>Being recommended that even low risk tumors should undergo total or near total thyroidectomy </li></ul></ul>
  • 59. <ul><li>Follicular Thyroid Carcinoma: </li></ul><ul><li>10%; Female &gt; Male (3:1), mean age= 50y/o </li></ul><ul><li>More frequent in Iodine deficiency area </li></ul><ul><li>Vascular invasion &amp; hematogenous spread is more common (bone, lung and liver). </li></ul><ul><li>Types: </li></ul><ul><ul><li>Minimally invasive tumor: </li></ul></ul><ul><ul><ul><li>Invasion into but not through the tumor capsule </li></ul></ul></ul><ul><ul><ul><li>Previously called atypical adenoma </li></ul></ul></ul><ul><ul><li>Invasive tumors (capsular/vascular) </li></ul></ul><ul><li>1% thyrotoxic </li></ul>
  • 60. <ul><li>Follicular Thyroid Carcinoma: </li></ul><ul><li>Dx / Tx: </li></ul><ul><ul><ul><li>FNAC not helpful ----&gt; lobectomy and isthmectomy (frozen section) ----&gt; (+) total thyroidectomy ----&gt; iodine 131 to detect distant metastases and for ablation. </li></ul></ul></ul><ul><li>Prognosis: </li></ul><ul><ul><ul><li>Age over 50y/o </li></ul></ul></ul><ul><ul><ul><li>&gt; 4cm size </li></ul></ul></ul><ul><ul><ul><li>Higher tumor grade </li></ul></ul></ul><ul><ul><ul><li>Marked vascular invasion </li></ul></ul></ul><ul><ul><ul><li>Marked extra-thyroidal invasion </li></ul></ul></ul><ul><ul><ul><li>Distant metastasis </li></ul></ul></ul><ul><li>Mortality: 40 % ----&gt; 10 yrs </li></ul>
  • 61. <ul><li>HURTLE CELL THYROID TUMOR: </li></ul><ul><li>3 – 5%, intermediate, uni-focal </li></ul><ul><li>Male : Female (2:1), spread by lymphatics </li></ul><ul><li>Derived from oxyphilic cells of the thyroid gld. </li></ul><ul><li>Possess TSH receptors and produces thyroglobulin </li></ul><ul><li>Only 10% takes up iodine hence thallium scan is used to localize distant metastasis </li></ul><ul><li>Often multifocal and bilateral </li></ul><ul><li>Dx: FNAC ----&gt; is useless; have to demonstrate vascular and </li></ul><ul><li>capsular invasion. </li></ul><ul><li>Tx: - total thyroidectomy for RAI ablation usually fails </li></ul><ul><li>- mod radical neck dissection if with palpable </li></ul><ul><li>cervical LN </li></ul><ul><li>- Thyroid suppression is suggested </li></ul><ul><li>Prognosis: 60% ------&gt; 5yr survival </li></ul>
  • 62. <ul><li>MEDULLARY THYROID CARCINOMA: </li></ul><ul><li>5-7%; Aggressive tumor; 50-60y/o </li></ul><ul><li>Arise from parafollicular or C cells of the thyroid (neuroectodermal-ultimobrachial bodies 4 th &amp;5 th branchial pouches. </li></ul><ul><li>Secrets calcitonin (95%); 85% secrets carcinoembryonic antigen (CEA) </li></ul><ul><li>Sporadic 90% </li></ul><ul><ul><ul><li>unifocal, usually 45y/o </li></ul></ul></ul><ul><ul><ul><li>worse prognosis </li></ul></ul></ul><ul><li>Familial 10% </li></ul><ul><ul><ul><li>Associated with: </li></ul></ul></ul><ul><ul><ul><ul><li>MEN IIA or Sipples’ syndrome (MTC, hyperplastic parathyroid and pheochromocytoma </li></ul></ul></ul></ul><ul><ul><ul><ul><li>MEN IIB (MTC, pheochromocytoma, ganglioneuromatosis and Marfan,s syndrome) </li></ul></ul></ul></ul><ul><ul><ul><li>Multifocal, usually 35 y/o </li></ul></ul></ul><ul><ul><ul><li>Better prognosis </li></ul></ul></ul>
  • 63. <ul><li>MEDULLARY THYROID CARCINOMA: </li></ul><ul><li>Does not concentrate Iodine 131, Thallium scan is used to localized distal metastasis. </li></ul><ul><li>Spread: </li></ul><ul><ul><ul><li>Lymphatics (neck and superior mediastinum) </li></ul></ul></ul><ul><ul><ul><li>Blood ---&gt; liver, bone (osteoblastic) and lung </li></ul></ul></ul><ul><ul><ul><li>Local invasion </li></ul></ul></ul><ul><li>Can secrets: </li></ul><ul><ul><ul><li>Calcitonin </li></ul></ul></ul><ul><ul><ul><li>Histamine </li></ul></ul></ul><ul><ul><ul><li>Serotinin (causes diarrhea) </li></ul></ul></ul><ul><ul><ul><li>ACTH 2-4% causing Cushing syndrome </li></ul></ul></ul><ul><ul><ul><li>CEA </li></ul></ul></ul><ul><ul><ul><li>Prostaglandin E2 and F2 alpha </li></ul></ul></ul><ul><li>Dx: </li></ul><ul><ul><ul><li>Hx ‘ PE; serum calcitonin, CEA, FNAC, Serum calcium </li></ul></ul></ul>
  • 64. MEDULLARY THYROID CARCINOMA : <ul><li>Tx: </li></ul><ul><ul><li>Total thyroidectomy </li></ul></ul><ul><ul><ul><li>Radiotherapy and chemotherapy ---&gt; failure </li></ul></ul></ul><ul><ul><li>MRND is done for: </li></ul></ul><ul><ul><ul><li>Palpable cervical LN </li></ul></ul></ul><ul><ul><ul><li>&gt;2cm tumor for 60% nodal metastasis </li></ul></ul></ul><ul><ul><li>Tumor debulking in cases of metastatic and local recurrence should be done to ameliorate symptoms of flushing and diarrhea and help to decrease the risk of death. </li></ul></ul><ul><ul><li>All pt should be screen for pheochromocytoma (MEN II) w/c shoud be resected first. </li></ul></ul><ul><ul><li>Selective removal of the parathyroid shd be done if preoperatively has hypercalcemia. </li></ul></ul><ul><li>Follow up: - serum calcium / CEA level </li></ul><ul><li>Prognosis: </li></ul><ul><ul><li>Localize -------&gt; 80% 10 year survival </li></ul></ul><ul><ul><li>(+) LN --------&gt; 45% 10 year survival </li></ul></ul><ul><ul><li>Best ------------&gt; Worst prognosis </li></ul></ul><ul><ul><ul><li>Familial non-MEN MTC -----&gt; MEN IIA ----&gt; Sporadic cases ------&gt; MEN IIB </li></ul></ul></ul>
  • 65. <ul><li>Anaplastic Thyroid Carcinoma: </li></ul><ul><ul><li>1 – 3% most aggressive, few survive &gt; 6 months </li></ul></ul><ul><ul><li>Most arise from previous differentiated thyroid CA </li></ul></ul><ul><ul><li>Low incident could be due to low iodine deficiency </li></ul></ul><ul><ul><li>70 – 80 y/o </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Radiotherapy ----&gt; doxorubicin ----&gt; debulking thyroidectomy ----&gt; completion with radiotherapy and chemotherapy </li></ul></ul>
  • 66. MALIGNANT THYROID <ul><li>LYMPHOMA: </li></ul><ul><ul><li>1 – 5% non-Hodgkin B cell </li></ul></ul><ul><ul><li>Usually develops in pts w/ chronic lymphocytic thyroiditis (Hashimotos thyroiditis) </li></ul></ul><ul><ul><li>S/Sx similar with anaplastic CA, compression symptoms is the most common </li></ul></ul><ul><ul><li>Tx: Chemotherapy </li></ul></ul><ul><ul><ul><ul><ul><li>Cyclophosphamide </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Doxorubicin </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Vincristine </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Prednison </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Radiotherapy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Surgery: - done for diagnosis and to alleviate compression symptoms </li></ul></ul></ul></ul><ul><ul><li>80% survival if confined to the gland; 40% it had spread </li></ul></ul><ul><li>Metastatic Carcinoma: </li></ul><ul><li>Rare; hypernephroma is the most common primary site </li></ul>
  • 67. T h a n k y o u

×