THYROID James Taclin C. Banez, M.D., FPSGS, FPCS
Embryology <ul><li>Out pouching of the primitive foregut (3 rd  wk of gestation) </li></ul><ul><li>Base of the tongue (for...
<ul><li>ANATOMY: </li></ul><ul><li>Location / Parts </li></ul><ul><li>Arteries / Venous drainage </li></ul><ul><li>Nerve S...
<ul><li>ANATOMY: </li></ul><ul><li>Nerve Supply </li></ul><ul><ul><li>Sympathetic ( cervical ganglion ) </li></ul></ul><ul...
<ul><li>ANATOMY: </li></ul><ul><li>Lymphatic Drainage: </li></ul><ul><ul><li>Central compartment </li></ul></ul><ul><ul><u...
<ul><li>PHYSIOLOGY: </li></ul><ul><li>Synthesis & secrets thyroid hormone (thyroid follicle) </li></ul><ul><ul><li>Iodide ...
Evaluation of Thyroid  Diseases <ul><li>Clinical history and physical examination </li></ul><ul><li>Thyroid Function Test ...
Evaluation of Thyroid  Diseases <ul><ul><li>Thyroid-releasing hormone : </li></ul></ul><ul><ul><ul><li>Use to evaluate pit...
Evaluation of Thyroid  Diseases <ul><li>Thyroid Imaging: </li></ul><ul><ul><li>Radioactive Imaging:   I  123  & I  131 </l...
Evaluation of Thyroid  Diseases <ul><li>Thyroid Imaging: </li></ul><ul><ul><li>Ultrasound: </li></ul></ul><ul><ul><ul><li>...
Evaluation of Thyroid  Diseases <ul><li>Fine Needle Aspiration Biopsy: </li></ul><ul><ul><li>Single most important test af...
BENIGN THYROID DISORDERS <ul><li>HYPERTHYROIDISM (Thyrotoxicosis)   </li></ul><ul><li>With increase thyroid hormone secret...
HYPERTHYROIDISM <ul><li>GRAVE’S Disease (Diffuse Thyroid Goiter) </li></ul><ul><li>Most common form of thyrotoxicosis </li...
HYPERTHYROIDISM <ul><li>GRAVE’S Disease (Diffuse Thyroid Goiter) </li></ul><ul><li>Manifestations: </li></ul><ul><ul><li>S...
HYPERTHYROIDISM <ul><li>GRAVE’S Disease (Diffuse Thyroid Goiter) </li></ul><ul><li>Triad: </li></ul><ul><ul><ul><li>diffus...
HYPERTHYROIDISM <ul><li>GRAVE’S Disease: </li></ul><ul><li>Exopthalmos: </li></ul><ul><li>Due to increase retro-bulbar tis...
HYPERTHYROIDISM <ul><li>Diagnosis: </li></ul><ul><ul><li>Autonomous thyroid function </li></ul></ul><ul><ul><ul><li>Low TS...
HYPERTHYROIDISM <ul><li>Antithyroid Drugs: </li></ul><ul><li>Propyl thiouracil (PTU)  = 100-300mg TID </li></ul><ul><li>Me...
HYPERTHYROIDISM <ul><li>Disadvantage of these drugs. </li></ul><ul><ul><li>Crosses the placenta --> inhibits fetal thyroid...
HYPERTHYROIDISM <ul><li>Beta blockers (propranolol) – to alleviate peripheral adrenergic effects </li></ul><ul><li>Advised...
HYPERTHYROIDISM <ul><li>Radioactive Iodine Therapy: </li></ul><ul><li>Advantages: </li></ul><ul><ul><li>Avoidance of surge...
HYPERTHYROIDISM <ul><li>Radioactive Iodine Therapy: </li></ul><ul><li>Suitable treatment: </li></ul><ul><ul><li>Small or m...
HYPERTHYROIDISM <ul><li>Radioactive Iodine Therapy: </li></ul><ul><li>Complication of  RAI tx: </li></ul><ul><ul><li>Exace...
HYPERTHYROIDISM <ul><li>Thyroid Surgery: </li></ul><ul><li>Indicated to: </li></ul><ul><ul><li>Young patient </li></ul></u...
HYPERTHYROIDISM <ul><li>Thyroid Surgery: </li></ul><ul><li>Thyroidectomy: </li></ul><ul><ul><li>Bilateral subtotal thyroid...
HYPERTHYROIDISM <ul><li>Recurrent thyrotoxicosis after surgery--->  RAI </li></ul><ul><li>Treatment of Exopthalmos: </li><...
HYPERTHYROIDISM <ul><li>Toxic Nodular Goiter (Plummers’ disease): </li></ul><ul><ul><li>No extrathyroidal manifestation </...
<ul><li>Thyroid storm: </li></ul><ul><ul><li>Life threatening </li></ul></ul><ul><ul><li>Precipitated by : </li></ul></ul>...
<ul><li>Thyroid storm: </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Fluid replacement </li></ul></ul></...
HYPOTHYROIDISM <ul><li>Causes: </li></ul><ul><li>Primary: </li></ul><ul><ul><li>Autoimmune thyroiditis </li></ul></ul><ul>...
THYROIDITIS <ul><li>Acute Suppurative Thyroiditis </li></ul><ul><ul><li>Uncommon </li></ul></ul><ul><ul><li>Associated wit...
THYROIDITIS <ul><li>Nonsuppurative Thyroiditis: </li></ul><ul><ul><li>Hashimotos disease  (Autoimmune lymphocytic thyroidi...
THYROIDITIS <ul><li>Nonsuppurative Thyroiditis: </li></ul><ul><ul><li>Hashimotos disease  (Autoimmune lymphocytic thyroidi...
THYROIDITIS <ul><li>Nonsuppurative Thyroiditis: </li></ul><ul><ul><li>2.  Riedels’ Thyroiditis : </li></ul></ul><ul><ul><u...
THYROIDITIS <ul><li>Nonsuppurative Thyroiditis: </li></ul><ul><ul><li>Riedels’ Thyroiditis: </li></ul></ul><ul><ul><ul><li...
GOITER <ul><li>Enlargement of the thyroid gland in a euthyroid  pt  not associated  with neoplasm or inflammation: </li></...
GOITER <ul><li>Pathology: </li></ul><ul><ul><li>May be diffusely enlarged and smooth, or enlarged markedly nodular </li></...
GOITER <ul><li>S/Sx: </li></ul><ul><li>Asymptomatic usually </li></ul><ul><li>Pressure symptoms usually   </li></ul><ul><u...
GOITER <ul><li>Dx: </li></ul><ul><ul><li>FNAC  ---> specially if one nodule predominates, or painful or has recently enlar...
Solitary or Dominant Thyroid Nodule <ul><li>Most are benign (colloid nodule/adenomas) </li></ul><ul><li>Risk factors for t...
Solitary or Dominant Thyroid Nodule <ul><li>Risk factors for thyroid CA: </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul>...
Management of Solitary Thyroid Nodule except for pt w/hx of external radiation exposure or a family hx of thyroid CA <ul><...
MALIGNANT THYROID <ul><li>90 – 95% are differentiated tumor w/ follicular origin </li></ul><ul><ul><li>Papillary thyroid a...
MALIGNANT THYROID <ul><li>Oncogene associated w/ Thyroid carcinoma: </li></ul><ul><ul><li>RET oncogene: </li></ul></ul><ul...
MALIGNANT THYROID <ul><li>Papillary Thyroid Carcinoma: </li></ul><ul><ul><li>Most common (80%) </li></ul></ul><ul><ul><li>...
Papillary Thyroid Carcinoma: <ul><li>3 forms of papillary CA (based on size and extent): </li></ul><ul><li>Minimal or occu...
<ul><li>Papillary Thyroid Carcinoma: </li></ul><ul><li>S/Sx: </li></ul><ul><ul><li>Euthyroid, slow growing painless mass <...
<ul><li>Papillary Thyroid Carcinoma: </li></ul><ul><li>Prognostic indicators:  (85% 10yrs survival) </li></ul><ul><li>AGES...
TNM Classification of Thyroid Tumors <ul><li>Primary tumor: (T) </li></ul><ul><li>TX  – primary tumor not assessed </li></...
TNM Classification of Thyroid Tumors <ul><li>Regional LN (N) –  include central, lateral, cervical and mediastinal LN </li...
TNM Classification of Thyroid Tumors <ul><li>Distant Metastasis (M) </li></ul><ul><li>MX – distant metastases cannot be as...
TNM Classification of Thyroid Tumors <ul><li>Papillary or Follicular Tumors: </li></ul><ul><li>STAGE TNM </li></ul><ul><li...
TNM Classification of Thyroid Tumors <ul><li>Medullary Thyroid Cancer </li></ul><ul><li>STAGE TNM </li></ul><ul><li>  I   ...
<ul><li>Papillary Thyroid Carcinoma: </li></ul><ul><li>Predict the risk of dying from Papillary CA </li></ul><ul><li>Low R...
<ul><li>Papillary Thyroid Carcinoma: (SURGERY) </li></ul><ul><ul><li>For high risk tumors and bilateral tumors  </li></ul>...
<ul><li>Papillary Thyroid Carcinoma: (SURGERY) </li></ul><ul><ul><li>Proponent of Total Thyroidectomy: </li></ul></ul><ul>...
<ul><li>Papillary Thyroid Carcinoma: (SURGERY) </li></ul><ul><ul><li>Proponent of Lobectomy: </li></ul></ul><ul><ul><ul><l...
<ul><li>Papillary Thyroid Carcinoma: (SURGERY) </li></ul><ul><ul><li>Recommendation: </li></ul></ul><ul><ul><li>Being reco...
<ul><li>Follicular Thyroid Carcinoma: </li></ul><ul><li>10%; Female > Male (3:1), mean age= 50y/o </li></ul><ul><li>More f...
<ul><li>Follicular Thyroid Carcinoma: </li></ul><ul><li>Dx / Tx: </li></ul><ul><ul><ul><li>FNAC not helpful ----> lobectom...
<ul><li>HURTLE CELL THYROID TUMOR: </li></ul><ul><li>3 – 5%, intermediate, uni-focal </li></ul><ul><li>Male : Female (2:1)...
<ul><li>MEDULLARY THYROID CARCINOMA: </li></ul><ul><li>5-7%; Aggressive tumor; 50-60y/o </li></ul><ul><li>Arise from paraf...
<ul><li>MEDULLARY THYROID CARCINOMA: </li></ul><ul><li>Does not concentrate Iodine 131,  Thallium scan  is used to localiz...
MEDULLARY THYROID CARCINOMA : <ul><li>Tx: </li></ul><ul><ul><li>Total thyroidectomy </li></ul></ul><ul><ul><ul><li>Radioth...
<ul><li>Anaplastic Thyroid Carcinoma: </li></ul><ul><ul><li>1 – 3% most aggressive, few survive > 6 months </li></ul></ul>...
MALIGNANT THYROID <ul><li>LYMPHOMA: </li></ul><ul><ul><li>1 – 5% non-Hodgkin B cell </li></ul></ul><ul><ul><li>Usually dev...
T h a n k   y o u
Upcoming SlideShare
Loading in …5
×

Thyroid

4,518 views
4,386 views

Published on

Published in: Education, Health & Medicine
2 Comments
5 Likes
Statistics
Notes
No Downloads
Views
Total views
4,518
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
338
Comments
2
Likes
5
Embeds 0
No embeds

No notes for slide

Thyroid

  1. 1. THYROID James Taclin C. Banez, M.D., FPSGS, FPCS
  2. 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. 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. 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. 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. 6. <ul><li>PHYSIOLOGY: </li></ul><ul><li>Synthesis & 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. 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 & for optimizing T4 replacement & 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. 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 --> 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 & 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 & 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. 9. Evaluation of Thyroid Diseases <ul><li>Thyroid Imaging: </li></ul><ul><ul><li>Radioactive Imaging: I 123 & I 131 </li></ul></ul><ul><ul><ul><li>Mass and it’s activity: COLD ( 15 – 20% malignant), HOT and WARM (<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. 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 & their relationship to the airway and vascular structures </li></ul></ul></ul>
  11. 11. Evaluation of Thyroid Diseases <ul><li>Fine Needle Aspiration Biopsy: </li></ul><ul><ul><li>Single most important test after clinical history & PE in the evaluation of thyroid masses. </li></ul></ul><ul><ul><li>w/ or w/o ultrasound guidance </li></ul></ul>
  12. 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. 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 > 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. 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. 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. 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) ----> ulceration </li></ul></ul><ul><li>Progression --> damage of optic nerve --> decreases visual acuity and impairment of color vision ( malignant exopthalmos ) not corrected surgically --> blindness </li></ul>Orbital fibroblast & muscles share the A common antigen with thyrocytes
  17. 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 ---> 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. 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. 19. HYPERTHYROIDISM <ul><li>Disadvantage of these drugs. </li></ul><ul><ul><li>Crosses the placenta --> 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. 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. 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 & 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. 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) ----> Infertility / carcinoma </li></ul></ul>
  23. 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. 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. 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 & 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 ---> 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. 26. HYPERTHYROIDISM <ul><li>Recurrent thyrotoxicosis after surgery---> 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. 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. 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. 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 ----> peritoneal dialysis or hemofiltration to lower T4&T3 </li></ul></ul></ul><ul><ul><li>Avoid ASPIRIN ---> increases free thyroid hormone levels </li></ul></ul>
  30. 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. 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 ----> smear and CS </li></ul></ul><ul><ul><li>Tx: - IV antibiotics / drain (abscess) </li></ul></ul>
  32. 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. 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 & T4 </li></ul></ul></ul><ul><ul><ul><li> - (+) Anti-thyroid antibodies </li></ul></ul></ul><ul><ul><ul><li> - FNA ---> rule out CA (confirmatory) </li></ul></ul></ul><ul><ul><ul><li>Tx: - Medical if w/o compression ----> 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. 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. 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. 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. 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. 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 ---> 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. 39. GOITER <ul><li>Dx: </li></ul><ul><ul><li>FNAC ---> 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 & T4 ---> 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 ---> for large diffuse goiter; to depress TSH stimulation and reduce hyperplasia </li></ul></ul></ul><ul><ul><ul><li>Iodine ---> 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. 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 & neck (<2000 rad) </li></ul></ul><ul><ul><li>- >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. 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. 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. 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. 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. 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 & 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 & 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. 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 ----> 7% </li></ul></ul><ul><ul><li>Mortality ------------> 0.5% </li></ul></ul><ul><li>Intra-thyroidal Tumors: </li></ul><ul><ul><li>> 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. 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. 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. 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 </= 2cm in diameter, limited to thyroid </li></ul><ul><li>T2 – tumor > 2cm but < 4cm, limited to thyroid </li></ul><ul><li>T3 – tumor >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. 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. 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. 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. 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. 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. 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 & 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. 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 & 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. 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. 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. 59. <ul><li>Follicular Thyroid Carcinoma: </li></ul><ul><li>10%; Female > Male (3:1), mean age= 50y/o </li></ul><ul><li>More frequent in Iodine deficiency area </li></ul><ul><li>Vascular invasion & 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. 60. <ul><li>Follicular Thyroid Carcinoma: </li></ul><ul><li>Dx / Tx: </li></ul><ul><ul><ul><li>FNAC not helpful ----> lobectomy and isthmectomy (frozen section) ----> (+) total thyroidectomy ----> 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>> 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 % ----> 10 yrs </li></ul>
  61. 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 ----> 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% ------> 5yr survival </li></ul>
  62. 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 &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. 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 ---> 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. 64. MEDULLARY THYROID CARCINOMA : <ul><li>Tx: </li></ul><ul><ul><li>Total thyroidectomy </li></ul></ul><ul><ul><ul><li>Radiotherapy and chemotherapy ---> 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>>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 -------> 80% 10 year survival </li></ul></ul><ul><ul><li>(+) LN --------> 45% 10 year survival </li></ul></ul><ul><ul><li>Best ------------> Worst prognosis </li></ul></ul><ul><ul><ul><li>Familial non-MEN MTC -----> MEN IIA ----> Sporadic cases ------> MEN IIB </li></ul></ul></ul>
  65. 65. <ul><li>Anaplastic Thyroid Carcinoma: </li></ul><ul><ul><li>1 – 3% most aggressive, few survive > 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 ----> doxorubicin ----> debulking thyroidectomy ----> completion with radiotherapy and chemotherapy </li></ul></ul>
  66. 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. 67. T h a n k y o u

×