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Thyroid Pathologies- Introduction, Benign diseases and Carcinoma Thyroid

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Dear Viewers,
Greetings from " Surgical Educator"
I have uploade a PPT presentation consist of Introduction, Benign diseases and Carcinoma Thyroid. By watching the accompanying video and reading the PPT, you will become competent in diagnosing and treating any thyroid pathologies.
you can watch my surgery teaching videos in the following links
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Thyroid Pathologies- Introduction, Benign diseases and Carcinoma Thyroid

  1. 1. THYROID INTRODUCTION AN OVRVIEW Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical college Melaka 75150 Malaysia
  2. 2. Must To Know Core Clinical Problems 1.Acute RLQ pain 2.Acute RUQ pain 3.Acute epigastric pain 4.Acute LLQ pain 5.Dysphagia 6.Abdominal lumps 7.Upper GI hemorrhage 8.Lower GI hemorrhage 9.Obstructive Jaundice 10.Breast lumps, Mastalgia & Nipple discharge 11.Neck swellings- Thyroid & Non thyroidal 12.Groin swellings 13.Scrotal swellings 14.Limb ischemia- Acute & Chronic 15.Varicose veins 16.Renal & Ureteric colic 17.Hematuria 18.Acute retention of urine
  3. 3. THYROID  Surgical Anatomy  Surgical Physiology  Surgical Pathology  Symptomatology  Investigations
  4. 4. ANATOMY
  5. 5. PHYSIOLOGY
  6. 6. PHYSIOLOGY
  7. 7. Thyroid- Pathology Simple (non-toxic) goiter Simple hyperplastic goiter Multinodular goiter & Solitary nodule Toxic goitre Diffuse goiter (Graves’ disease) Toxic multinodular goiter(Plummer’s disease) Toxic nodule (Gotsche’s disease) Neoplastic goiter Benign Adenoma Malignant Papillary Follicular Anaplastic Medullary Inflammatory De Quervain’s thyroiditis Riedel’s thyroiditis Autoimmune Hashimoto’s thyroiditis Goiter-Enlargement of thyroidgland
  8. 8. Thyroid- Symptoms Symptoms of Hyperthyroidism  Loss of weight inspite of voracious appetite  Heat intolerance  Nervous & irritable  Loose stools  Oligomenorrhea/Amenorrhea Symptoms of Hypothyroidism  Weight gain- obese  Hoarseness of voice  Loss of eyebrow lashes laterally Symptoms of pressure effects  Dyspnea  Dysphagia  Recurrent laryngeal nerve palsy Symptoms of distant metastasis  Chest pain, cough and hemoptysis  Headache and seizures  Abdominal distension and pain  Generalised bone pain Cardinal Symptom Enlargement of Thyroid Goiter
  9. 9. Thyroid- Investigations  Thyroid function test - T3, T4 and TSH  USG Neck - Solid or cystic swelling  FNAC of the thyroid swelling - Benign or malignant except follicular Ca  Radioactive iodine I123 scan - Especially in Solitary nodule Warm, hot or cold
  10. 10. THYROID Benign Thyroid Diseases AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical college Melaka 75150 Malaysia
  11. 11. Thyroid- Pathology Simple (non-toxic) goiter Simple hyperplastic goiter Multinodular goiter & Solitary nodule Toxic goiter Diffuse goiter (Graves’ disease) Toxic multinodular goiter(Plummer’s disease) Toxic nodule (Goetsch’s disease) Neoplastic goiter Benign Adenoma Malignant Papillary Follicular Anaplastic Medullary Inflammatory Autoimmune: Chronic lymphocytic thyroiditis Hashimoto’s disease Granulomatous: De Quervain’s thyroiditis Fibrosing: Riedel’s thyroiditis Infective: Acute (bacterial thyroiditis, viral thyroiditis ‘subacute thyroiditis’) Chronic (tuberculous,syphilitic) Other: Amyloid- colloid goiter
  12. 12. Simple Goiter Simple (non-toxic) goiter Simple hyperplastic goiter Diffuse enlargement of the whole thyroid gland because of iodine deficiency, physiological stress like puberty and pregnancy Multinodular goiter & Solitary nodule Focal enlargement of the gland either mono-nodular or multinodular Pathogenesis of a thyroid nodule ✓ TSH stimulation will lead on to diffuse hyperplasia composed of active follicles. This is called diffuse hyperplastic goiter which is reversible. ✓ Later as a result of fluctuating TSH stimulation, mixed patterns of active and inactive lobules develop ✓ Active lobules become more vascular, hyperplastic followed by hemorrhage and central necrosis ✓ The necrotic lobules coalesce to form a nodule filled with either iodine-free colloid or inactive follicles ✓ Repetition of this process will result in a nodular goiter. Most nodules are inactive and active follicles are present only in the internodular tissue.
  13. 13. Thyroid- Definitions GOITER: any enlargement of thyroid gland Thyrotoxicosis : Symptoms of thyroid hormone excess due to increased synthesis in thyroid follicles or exogenous thyroid hormone supplementation. Hyperthyroidism : Features of thyroid hormone excess due to increased synthesis of thyroid hormone by the gland.
  14. 14. Causes of Thyrotoxicosis ✓ Diffuse toxic goitre (Grave’s disease) ✓ Toxic nodular goitre (Toxic MNG)- Plummer’s disease ✓ Toxic nodule (Toxic adenoma)- Goetsch’s disease ✓ Thyrotoxicosis factitia (Due to excess exogenous thyroid hormone supplementation) ✓ Jod-Basedow thyrotoxicosis (Iodide induced) ✓ Thyroiditis ✓ Malignancies of thyroid. ✓ Trophoblastic tumor (Due to thyroid stimulating action of HCG produced by this tumor) ✓ Ectopic thyroid tissue (Struma ovarii)
  15. 15. Toxic Goiter-Graves Disease ✓ Described by Irish physician Dr.Robert Graves in 1835 ✓ Common in females ✓ Age : 20-40 years ✓ Pathogenesis: Thyroid stimulating immunoglobulins (TSI) of IgG class produced by lymphocytes stimulate TSH receptor. ✓ Ophthalmopathy: Fibroblast proliferation and increased glycosaminoglycans production induced by TSI (?antigenic similarity between orbital tissues and thyroid.)
  16. 16. Graves Disease- Symptoms ✓ Calorigenic :Weight loss inspite of voracious appetite,heat intolerance, increased sweating, tiredness ✓ Nervous : Tremors,anxiety,nervousness, increased activity. ✓ CVS: Dyspnoea, palpitations, pedal edema (due to CCF) ✓ Menstrual : Amenorrhoea/ oligomenorrhoea ✓ Miscellaneous: Loose stools ✓ Ocular : Diplopia, pain and increased lacrimation (due to corneal ulcer)
  17. 17. Graves Disease- Signs ✓ Thyroid :Diffuse enlargement with bruit and visible pulsations ✓ CVS ✓ Pulse : Increased sleeping pulse rate with wide pulse pressure. ✓ Stages of development of thyrotoxic arrhythmias : Multiple extra systoles → Paroxysmal atrial tachycardia → Paroxysmal atrial fibrillation → Persistent AF not responding to digoxin. ✓ Dermopathy : Pretibial myxedema due to increased mucopolysaccharide deposition. ✓ Thyroid acropachy : Dermopathy associated with clubbing of toes ✓ Tremors: Outstretched hands,tongue ✓ Hyerreflexia: Increased reflexs ✓ Plummer’s Sign: Proximal myopathy
  18. 18. Graves Disease- Eye Signs ✓ Von Graefe’s sign (lid lag) ✓ Stellwag’s sign (characteristic stare with infrequent blinking) ✓ Dalrymple’s sign (widened palpebral fissure) ✓ Naffziger’s sign : For proptosis ✓ Moebius sign : Loss of convergence (Due to ophthalmoplegia) ✓ Joffroy’s sign: Absence of wrinkling of forehead on looking up. ✓ Graves disease is diagnosed when features of thyrotoxicosis is associated with ophthalmopathy +/- dermopathy
  19. 19. Graves Disease- Signs
  20. 20. Graves Disease- Eye Signs + Pretibial Myxedema
  21. 21. Graves Disease- Diagnosis ✓ Most cases can be diagnosed clinically. ✓ Thyroid function test : Raised T3,T4 with decreased TSH. ✓ Thyroid scan : I123 scan-Diffuse increased uptake. ✓ FNAC : Relative contraindication in the presence of thyrotoxicosis.
  22. 22. Graves Disease- I123 Scan
  23. 23. Graves Disease-Histopathology Follicular hypertrophy with scanty colloid
  24. 24. Graves Disease-Treatment ✓ Medical ✓ Radio-Iodine ✓ Surgery
  25. 25. Medical Treatment ✓ Anti thyroid drugs : Carbimazole and propylthiouracil ✓ Mechanism of action : Inhibit thyroid peroxidase and thereby interfere with iodination of tyrosine residues in thyroglobulin and coupling of iodotyrosine residues to form T3 and T4. ✓ Dose : Start with high dose (Carbimazole 10mg TDS ) once control is achieved dose is reduced (5 mg BD or TDS) ✓ Alternatively block and replacement regimen is used – Continue with high dose of antithyroid drugs with thyroxine supplementation (0.1 mg OD) . Decreased risk of iatrogenic hypothyroidism . ✓ Adverse effects : Granulocytopenia, Aplastic anemia
  26. 26. Medical Treatment Can be used even in children and young adults. Hypothyroidism if induced is reversible No complications associated with surgery. Disadvantages: Prolonged treatment is required since relapse rate is high. Drug toxicity Advantages:
  27. 27. Medical Treatment- Beta blockers ✓ Propranolol most commonly used ✓ Indications : ✓ For symptomatic control When antithyroid drugs are initiated till biochemical control is achieved ✓ Thyroid storm Along with iodide for preop preparation. ✓ Dose : 20-40 mg QID (Max dose – 600mg/day)
  28. 28. Medical Treatment- Iodides ✓ Lugol’s iodine most commonly used preparation (5% iodine in 10% potassium iodide solution). ✓ Mechanism of action : Inhibition of thyroid hormone release (Thyroid constipation) Decreases vascularity of the gland ✓ Uses: Preop preparation : 10-14 days prior to surgery Thyroid storm :iodinated contrast agents (sodium iopodate ) given i.v. ✓ Dose : Lugol’s iodine 5 drops TDS in milk.
  29. 29. Radioactive Iodine Ablation ✓ I131 most commonly used ✓ Indications : ✓ Patients with small to moderate enlargement of gland and in whom antithyroid drugs have clearly not worked. ✓ Patients not willing for surgery or for whom surgery is contraindicated. ✓ Recurrence after surgical or medical therapy.
  30. 30. Radioactive Iodine Ablation 1.Euthyroid state achieved by using antithyroid drugs for 3-4weeks before treatment. 2.Interruption of antithyroid drugs for 3-4 days before and after Iodine treatment to permit adequate accumulation and retention of administered iodine. 3.Pretreatment radioiodine scan done (25-100 micro curie of I131 given) to calculate therapeutic dose. 4.Therapeutic dose of radio-iodine given (usually 8-12 milli curie) orally.
  31. 31. Radioactive Iodine Ablation ✓ Patient rendered euthyroid by 8-12 weeks after treatment. ✓ Disadvantages : ✓ Hypothyroidism : incidence 10-15% by 1 year which increases by 3% in each succeeding year. ✓ Exacerbation of cardiac arrhythmias in elderly ✓ Fetal damage-hence contraindicated in pregnant and lactating women ✓ Also contraindicated in children ✓ Worsening of ophthalmopathy – avoided by using prophylactic steroids ✓ Can induce Thyroid storm if patients are not rendered euthyroid before radio- iodine administration
  32. 32. SURGERY ✓ Indications : ✓ Failure of medical/radioiodine treatment ✓ Younger patients particularly adolescents ✓ Pregnant patients ✓ Patients with suspicious masses contained within the large thyroid. ✓ Patients with severe cosmetic deformities or tracheal compression causing discomfort.
  33. 33. SURGERY ✓ Extent of surgery : Subtotal or Total thyroidectomy ✓ Advantage of total thyroidectomy : ✓ Recurrence is avoided ✓ Patients with ophthalmopathy are stabilized most successfully by total thyroidectomy.(Due to removal of entire antigenic focus) ✓ Patients should be rendered euthyroid before surgery to avoid thyroid storm.
  34. 34. Complications of Surgery Tension hematoma
  35. 35. Thyroid Storm-Treatment ✓ Supportive measures : Correction of dehydration with I.V fluids and hyperpyrexia with cooling blankets ✓ Antithyroid drugs : Propylthiouracil preferred.Given through Ryle’s tube if patient can’t take orally.(Parenteral forms not available). ✓ Iodinated contrast agents (sodium iopodate)-1gm given I.V ✓ Propranolol 2mg I.V with ECG monitoring (if patient cannot take orally) or 40-80mg Q6h ✓ Large doses of dexamethasone : 2mg Q6h (inhibit hormone release, peripheral conversion of T4toT3 and provide adrenal support). ✓ Life threatening circumstances : Peritoneal or hemodialysis to lower T3 andT4 levels.
  36. 36. Ophthalmopathy- Treatment ✓ Mild disease – Conservative measures: Elevating the head at night Protection of eye ball and avoiding corneal drying by applying 1%methylcellulose eye drops or plastic shields. ✓ Severe cases –large doses of prednisolone (100-120 mg/day) ✓ Malignant exopthalmos : Orbital decompression
  37. 37. Thyrotoxicosis in Pregnancy ✓ Radio-Iodine : Contraindicated. ✓ Surgery : Can be done in second trimester Chance of miscarriage with surgery. ✓ Antithyroid drugs : Propylthiouracil preferred (Placental transfer less) Can cause fetal goitre. Avoided by keeping antithyroid drug dosage to minimum to prevent rise in TSH.
  38. 38. Toxic Multinodular Goiter- Plummer’s Disease ✓ Seen in long standing goiter when one or more nodules become autonomous. ✓ Cardiovascular symptoms predominate ✓ Radionuclide scan: Can demonstrate autonomous nodules. ✓ Treatment : ✓ Antithyroid drugs : Can control symptoms but relapse invariably occurs with discontinuation of medications. ✓ Propranolol can be used for symptomatic control. ✓ Radio-iodine : Effective. But larger doses are required 20-30 milli curie
  39. 39. Toxic Multinodular Goiter- Plummer’s Disease ✓ Chance of hypothyroidism with radio-iodine is less compared to grave’s disease due to variable activity of different portion of the gland allowing previously quiescent area to function in place of those destroyed by I131. ✓ Surgery : Preferred treatment (Total thyroidectomy)
  40. 40. Primary Vs Secondary Thyrotoxicosis
  41. 41. Toxic Nodular Goiter- Goetsch’s Disease Treatment Hemithyroidectomy after making patient euthyroid Small nodule Radio active iodine ablation
  42. 42. THYROIDITIS
  43. 43. ACUTE THYROIDITIS
  44. 44. SUBACUTE THYROIDITIS De Quervain’s Thyroiditis
  45. 45. CHRONIC THYROIDITIS Hashimoto’s Thyroiditis
  46. 46. CHRONIC THYROIDITIS Reidel’s Thyroiditis
  47. 47. THYROID CARCINOMA THYROID AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical college Melaka 75150 Malaysia
  48. 48. Ca Thyroid- Objectives OBJECTIVES ✓ Classification ✓ Etiology ✓ Pathophysiology ✓ Histology ✓ Presentation ✓ Diagnosis of various Carcinomas ✓ Treatment
  49. 49. Neoplastic Goiter Classification ✓ Adenoma ✓ Carcinoma ✓ Primary -A.Epithelial diffrentiated – 1.Papillary 2.Follicular -B. Epithelial Undiffrentiated- 3.Anaplastic -C. Parafollicular cells - 4. Medullary -D. Lymphoid cell -5. Lymphoma ✓ Secondary- Melanoma, Ca breast, Renal Ca
  50. 50. Ca Thyroid- Etiology ✓ Female gender ✓ History of radiation administered in infancy and childhood , [ in 9 %] Avg. Latent Period >10 yrs  Papillary Ca ✓ Excessive Iodine Consumption Papillary Ca ✓ History of goiter  Anaplastic / Follicular Ca ✓ Frankshift Mutation of RET gene Papillary Ca ✓ Point Mutation of RET gene  Medullary Ca ✓ P53 gene mutation Anaplastic Ca ✓ Loss of Gene at 11q  Follicular Ca
  51. 51. AdenomaThyroid ✓ Benign lesion derived from Follicular Epithelium ✓ Usually single,well encapsulated ✓ Present as painless single nodule ✓ Discrete lesions with glandular / acinar Follicular pattern. ✓ Papillary change is not typical but if present suggests Papillary Ca ✓ Trucut biopsy to confirm diagnosis ✓ FNAC can not make out capsular/vascular invasion ✓ Treatment: Hemithyroidectomy ✓ Closely packed follicles, trabeculae or solid sheets ✓ No capsular or vascular invasion ✓ Completely enveloped by thin fibrous capsule ✓ Different from surrounding gland
  52. 52. AdenomaThyroid- FNAC
  53. 53. Papillary Ca Thyroid ✓ Most common type of Thyroid ca – 75 to 80%. ✓ Female : Male = 2 : 1 . ✓ Mean age at presentation – 35 yrs. ✓ More common in persons exposed to radiation. ✓ Macroscopic – Hard, whitish, calcified,Unencapsulated ✓ Slow growing malignant tumor which is multifocal in origin ✓ Often present as painless neck mass or lateral cervical lymphadenopathy
  54. 54. Papillary Ca Thyroid
  55. 55. Papillary Ca Thyroid ✓ Microscopic features – 1. Cuboidal cells with abundant cytoplasm 2. Intranuclear cytoplasmic inclusions ‘ORPHAN ANNIE EYED NUCLEI’ . 3. Fibrovascular stroma with calcium deposits ‘PSAMOMMA BODIES’. ✓ Lymphatic spread – Intrathyroidal ~90% and to Paratracheal and cervical LN ~50%
  56. 56. Papillary Ca Thyroid
  57. 57. Follicular Ca Thyroid ✓ Female : Male = 3 : 1 . ✓ Accounts for 15 to 20 % of all Thyroid Ca ✓ Mean age at presentation – 50 yrs. ✓ More frequent in IODINE DEFICIENT AREAS. ✓ History of long standing goitre . ✓ PATHOLOGY - ✓ Usually ENCAPSULATED & SOLITARY. ✓ Spreads usually By Blood ,Most commonly to Lungs, Brain & Bone. ✓ Lymph node metastases in <10 % cases.
  58. 58. Follicular Ca Thyroid
  59. 59. Follicular Ca Thyroid ✓ Currently, a follicular carcinoma cannot be distinguished from a follicular adenoma based on cytologic, sonographic, or clinical features alone. ✓ Pathogenesis of follicular carcinoma may be related to iodine deficiency and various oncogene and/or microRNA activation. ✓ Follicular carcinoma tends to be more cellular with a thick irregular capsule, and often with areas of necrosis and more frequent mitoses. ✓ It is distinguished from a follicular adenoma on the basis of capsular invasion and vascular invasion
  60. 60. Follicular Ca Thyroid
  61. 61. Hurthle Cell Carcinoma ✓ Variant of FOLLICULAR CELL Ca. ✓ Derived from ‘OXYPHIL CELLS’ of thyroid. Function of these cells is not known. ✓ Cells are stuffed with mitochondria & possess the TSH receptors and produce thyroglobulin. ✓ As compared to follicular type – usually multifocal & bilateral and more likely to metastatise to LN [ >25%]. ✓ HCC are encapsulated thyroid tumours that contain more than 75% oncocytic cells, which stain pink under the microscope as they are packed with mitochondria ✓ The characteristic feature is the distinct granular acidophilic cytoplasm
  62. 62. Medullary Ca Thyroid ✓ Female : Male = 1.5 : 1 . ✓ Accounts for 15 to 20 % of all Thyroid Ca ✓ Mean age at presentation – 50 to 60 yrs. ✓ Can occur in four clinical settings: ✓ 1. Sporadic - ~ 70 % cases,usually unilateral ✓ 2. Familial - ~ 30 % ,cases,usually Bilateral
  63. 63. Medullary Ca Thyroid ✓ Pathology – 1. Usually occurs in upper poles 2. Originates from Parafollicular C cells ✓ Gross: Single or multiple ✓ Typically nonencapsulated ✓ Solid, gray / tan / yellow, firm, may be infiltrative ✓ Larger lesions have hemorrhage and necrosis, tumor usually in mid or upper portion of gland (with higher concentration of C cells)
  64. 64. Medullary Ca Thyroid ✓ Pathology – ✓ Microscopic – Why called Medullary ? ✓ Sheets of Spindle shaped neoplastic cells with AMYLOID [Altered Calcitonin] in between. Cells Stains for Calcitonin, CEA, Serotonin, VIP ✓ Spreads to LN Initially ~ 75 % ✓ Cellular specimen staining positively for calcitonin with immunoperoxidase. ✓ Loosely cohesive fragments of spindle- shaped cells; amyloid is present as amorphous blue material intimately associated with neoplastic cells.
  65. 65. Medullary Ca Thyroid
  66. 66. Anaplastic Ca Thyroid ✓ Accounts for ~ 8 to 10 % of all Thyroid Ca ✓ Female : Male = 1.5 : 1 . ✓ Mean age at presentation – 70 to 80 yrs. ✓ Most aggressive thyroid malignancy,with median survial only ~ 3 months. ✓ Iodine deficiency goitre is precursor . ✓ All patients are considered to have stage IV disease.
  67. 67. Thyroid Lymphoma ✓ Accounts for ~ 8 to 10 % of all Thyroid Ca ✓ Women > 70 yrs are usually affected. ✓ In 70 to 80 %, it arises in Preexisting Chronic Lymphocitic thyroditis with Subclinical or overt Hypothyroidism, in association with Hashimoto’s thyroiditis. ✓ Almost always Non-Hodgkin B-cell lymphoma ✓ Usually presents as Rapidly growing mass,with obstructive symptoms as dyspnea and dysphagia.
  68. 68. Thyroid Metastasis ✓ Usually Rare ✓ Common Primary sites are - 1. Skin – Melanoma ~39 % 2. Breast ~ 21% 3. Renal cell Ca ~ 10 % ✓ Usually Presents as Painless Lump with signs / symptoms of Primary. ✓ FNAC is Diagnostic
  69. 69. Recurrent Thyroid Ca ✓ Approximately 10% to 30% of patients after initial treatment ✓ 80% recur with disease in the neck ✓ 20% with Distant Recurrennce. ✓ Most common site of distant metastasis is the lung. ✓ Median time of Recurrence ~ 2.6 yrs ✓ Prognosis for clinically detectable recurrences is generally poor, regardless of cell type. ✓ Local and regional recurrences detected by I131 scan and not clinically apparent and have an excellent prognosis
  70. 70. Staging Of Thyroid Ca
  71. 71. Clinical Presentation ✓ Usual Presentation ✓ - A lump in the neck ✓ - Pain in the neck ✓ - Hoarseness ✓ - Trouble swallowing ✓ - Breathing problems ✓ Usual Presentation ✓ - Follicular Ca - ~1 % as Hyperthyroidism ✓ - Medullary Ca - ~ 2 – 4 % as Cushing Syn . Hypertension, Diarrhea ✓ - Papillary Ca – as LATERAL ABERRANT THYROID
  72. 72. Benign Vs Malignant Thyroid Swellings BENIGN MALIGNANT
  73. 73. Thyroid Carcinomas Investigations
  74. 74. Thyroid Carcinomas Pathology & Clinical Features
  75. 75. Thyroid Carcinomas Treatment

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