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Thyroid diseases

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Benign and malignant disease of thyroid gland, surgical anatomy of thyroid, Hyperthyroidism, Thyrotoxicosis, Thyroid nodule, Hypothyroidism, Myxoedema, Thyroidectomy, Antithyroid drugs, carcinoma of thyroid, Papillary carcinoma, Follicular carcinoma, Medullary carcinoma, Anaplastic carcinoma, MEN-1, MEN-2a, MEN-2b, Thyroidectomy

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Thyroid diseases

  1. 1. THYROID DISEASES By Dr. Abdul Qadeer MBBS; FCPS; FICS Assistant Professor in General Surgery King Faisal University College of Medicine Kingdom of Saudi Arabia
  2. 2. OBJECTIVES 1. Embryology & related diseases 2. Anatomy of thyroid 3. Physiology of thyroid hormones 4. Benign thyroid disorders & their management 5. Goiter & Solitary thyroid nodule & management 6. Thyroid malignancy & management 7. MEN 1 and MEN 2
  3. 3. 1. EMBRYOLOGY OF THYROID  Follicular cells: Thyroglossal duct as median bud in the pharynx  Foramen cecum: at the base of tongue is its remnant  Parafollicular (C) cells: from ultimobronchial body (neural crest)  Inferior parathyroid: from 3rd pharyngeal pouch  Superior parathyroid: from 4th pharyngeal pouch  Thymus: from 3rd pharyngeal pouch
  4. 4. DISEASES OF EMBRYOLOGICAL MALDEVELOPMENT  Ectopic thyroid  Ectopic parathyroid  Thyroglossal cyst
  5. 5. 2. SURGICAL ANATOMY OF THYROID  Normal weight = 20-25 g  Lobule: is the functional unit supplied by single arteriole  Lobule is made up of 24-40 follicles with cuboidal epithelium  Follicle contains colloid material in which thyroglobulin is stored  Blood supply: rich supply by superior & inferior thyroid arteries + tracheal & esophageal arteries
  6. 6. SURGICAL ANATOMY OF THYROID  Extensive lymphatic drainage by different groups of lymph nodes i.e. a. Subcapsular lymph nodes b. Paratracheal nodes c. Nodes on superior & inferior thyroid veins (Level VI) d. Deep cervical nodes (Level II, III, IV, V) e. Mediastinal nodes (Level VII)
  7. 7. RELATIONS OF THYROID GLAND  Recurrent laryngeal nerves  Superior laryngeal nerves  Thyroid arteries: superior & inferior  Thyroid veins: superior, middle & inferior  IJVs  Carotid arteries  Parathyroid glands  Thymus  Lymph nodes
  8. 8. 3. PHYSIOLOGY OF THYROID HORMONES  Tri-iodothyronine (T3) and Thyroxine (T4) are formed by:  Iodide trapping  Oxidation of iodide to iodine  Binding of iodine to tyrosine = monoiodotyrosine  MIT + MIT = DIT  MIT + DIT = T3  DIT + DIT = T4
  9. 9. SERUM TRANSPORT PROTEINS 1. Albumin 2. Thyroxine-binding globulin (TBG) 3. Thyroxine-binding prealbumin (TBPA)  Small amounts of free (unbound) hormones are biologically active  Free T4 = 0.03% of total circulating hormone  Free T3 = 0.3% of total circulating hormone  T3 (& RT3) is quick acting (within few hours)  T4 is slow acting (4-14 days)
  10. 10. PARATHYROID HORMONE (PTH)  Secreted by parathyroid glands  Released in response to low serum calcium or high serum magnesium level  Functions include: 1. Activates osteoclasts to reabsorb bone 2. Increases Ca++ reabsorption from urine 3. Renal activation of vitamin D 4. Increases gut absorption of Ca++ 5. Increases renal excretion of phosphate
  11. 11. THE PITUITARY THYROID AXIS  Thyrotrophin releasing hormone (TRH) is secreted by hypothalamus. It stimulates TSH  Thyroid stimulating hormone (TSH) is secreted by anterior pituitary, depends upon the circulating level of thyroid hormones  TSH is controlled by negative feedback mechanism
  12. 12. TREATMENT BY THYROID HORMONES  T4 replacement dose = 0.15 mg OD  T4 suppressive dose = 0.2 mg OD  T3 suppressive dose = 20µg TDS  TSH (recombinant human) is used to maximize radioactive iodine uptake as an alternative to thyroid hormone withdrawal
  13. 13. 4. BENIGN THYROID DISORDERS & THEIR MANAGEMENT  Benign thyroid disorders include: 1. Hypothyroidism: Infantile (cretinism) and adult (myxedema and dyshormonogenesis) 2. Goitre (Thyroid enlargement) 3. Hyperthyroidism
  14. 14. FETAL/INFANTILE HYPOTHYROIDISM (CRETINISM)  Inadequate thyroid hormone production during fetal & neonatal development a. Endemic cretinism: due to dietary iodine deficiency b. Sporadic cretinism: may be due to (i). An inborn error of thyroid metabolism (ii). Complete or partial agenesis of the gland
  15. 15. CLINICAL FEATURES OF CRETINISM  Hoarse cry  Macroglossia  Umbilical hernia
  16. 16. MANAGEMENT OF CRETINISM a. Immediate diagnosis & treatment with thyroxine is must to prevent physical & mental under-development b. Iodized salt in sporadic cases c. Biochemical screening of neonates using TSH & T4 assays on a heel-prick blood sample d. Monitoring of anti-thyroid drugs in women under treatment e. No radioactive iodine in pregnancy
  17. 17. ADULT HYPOTHYROIDISM  SIGNS: 1. Bradycardia 2. Cold extremities 3. Dry skin & hair 4. Periorbital puffiness 5. Hoarse voice 6. Bradykinesis, slow movements 7. Delayed relaxation phase of ankle jerk  SYMPTOMS: 1. Tiredness 2. Mental lethargy 3. Cold intolerance 4. Weight gain 5. Constipation 6. Menstrual disturbance 7. Carpal tunnel syndrome  Myxoedema = Severe thyroid failure
  18. 18. TREATMENT OF ADULT HYPOTHYROIDISM  Low T3 & T4 levels  High TSH level  High serum level of TPO antibodies: autoimmune disease  Oral thyroxine 0.10 – 0.20 mg /day is curative  0.05 mg / day replacement dose  T3 20 µg three times a day for rapid response
  19. 19. MYXOEDEMA  Severe hypothyroidism  S/S: 1. Typical facial appearance 2. Supraclavicular puffiness 3. Malar flush 4. Yellow tinge of the skin
  20. 20. MYXOEDEMA COMA  Characterized by: a) Altered mental state b) Hypothermia c) Precipitating medical condition e.g. cardiac failure or infection d) High mortality  Treatment:  Bolus of 0.50 mg of T4 or 10 µg of T3 i/v or orally every 4-6 hours  Slow warming of the patient  Antibiotics  Hydrocortisone
  21. 21. PRIMARY OR ATROPHIC MYXOEDEMA  An autoimmune disease like Hoshimoto’s thyroiditis, but without goitre formation
  22. 22. DYSHORMONOGENESIS  Genetic deficiencies in the enzymes controlling the synthesis of the thyroid hormones e.g. TPO  Usually autosomal recessive pattern  Pendred syndrome: a) TPO deficiency leads to goitre b) associated with severe sensorineural hearing impairment and c) abnormality of bony labyrinth observed on
  23. 23. 5. GOITER & SOLITARY THYROID NODULE & MANAGEMENT  Generalized enlargement of the thyroid gland  Discrete swelling (nodule) in one lobe or  Dominant swelling
  24. 24. CLASSIFICATION OF THYROID SWELLINGS No Simple (Euthyroid) Toxic Neoplastic Inflammatory 1 Diffuse hyperplastic i. Physiological ii. Pubertal iii. Pregnancy Diffuse (Graves’ disease) Benign Autoimmune a) Chronic lymphocytic b) Hoshimoto’s disease 2 Multinodular Multinodula r Malignant Granulomatous i.e. De Quervain’s thyroididtis 3 Toxic adenoma Fibrosing i.e. Riedel’s thyroididtis 4 Infective i.e. i. Acute (Bacterial, viral ii. Subacute iii. Chronic (TB, Syphilis) 5 Other i.e. amyloid
  25. 25. SIMPLE GOITRE  Simple goiter may develop by the stimulation of thyroid gland by TSH. This stimulation may be by: i. Microadenoma in the anterior pituitary ii. Chronically low circulating thyroid hormones iii. Dietary deficiency of iodine (endemic). Daily iodine requirement is 0.1–0.15 mg iv. Defective hormone synthesis  Other factors include growth factors and immunoglobulins
  26. 26. GOITROGENS  Vegetables e.g. cabbage, kale, rape, which contain thiocyanate  Drugs e.g. para-aminosalicylic acid (PAS), anti-thyroid drugs  Large quantities of iodides
  27. 27. INVESTIGATIONS  Thyroid function tests  X-ray thoracic inlet & chest  USS  CT scan  FNAC
  28. 28. COMPLICATIONS  Tracheal compression = acute respiratory obstruction  Secondary thyrotoxicosis  Carcinoma
  29. 29. RETROSTERNAL GOITRE  It may remain symptomless  May lead to complications e.g. A. Dyspnea B. Dysphagia C. Engorgement of facial, neck and superficial chest wall veins D. RL nerve paralysis
  30. 30. PREVENTION & TREATMENT OF SIMPLE GOITRE  Dietary iodized salt  Thyroxine 0.15-2.0 mg daily for few months may regress the goiter  Surgery due to: i. Cosmetic grounds ii. Pressure symptoms iii. Patient anxiety iv. Retrostrenal goitre
  31. 31. SURGERY OF GOITRE  The choice of surgical treatment in multinodular goiter may be: i. Total thyroidectomy ii. Subtotal thyroidectomy leaving up to 8 g of normal tissue iii. Near-total thyroidectomy leaving up to 2 g (Dunhill procedure) iv. Lobectomy with isthmusectomy
  32. 32. MANAGEMENT OF CLINICALLY DISCRETE SWELLING  Clinically discrete swelling may be: i. Isolated or solitary (70%) ii. Dominant (30%)  15% of isolated swellings prove to be malignant  30-40% are follicular adenomas  Remaining are cysts, thyroididtis or colloid degeneration
  33. 33. INVESTIGATIONS  TSH & free T3, T4  Autoantibodies  Isotope scan (if there is toxicity & nodularity). It may show hot (overactive), warm (active) or cold (inactive) areas  USS: shows subclinical nodularity & cysts  May show signs of neoplasia e.g. i. Microcalcification ii. Increased vascularity iii. Macroscopic capsular breach iv. Nodal involvement
  34. 34. FNAC  Following conditions can be diagnosed by FNAC: i. Colloid nodules ii. Thyroiditis iii. Papillary carcinoma iv. Medullary carcinoma v. Anaplastic carcinoma vi. Lymphoma Note: FNAC cannot distinguish between a benign follicular adenoma & follicular carcinoma (i.e. by capsular & vascular invasion)
  35. 35. FNAC
  36. 36. Classification of FNAC reports Non-diagnosticThy 1 Non-diagnostic cysticThy 1c Non-neoplasticThy 2 FollicularThy 3 Suspicious of malignancyThy 4 MalignantThy 5
  37. 37. RADIOLOGY & OTHER  Chest and thoracic inlet x-rays  CTS  MRI  PET, to localize disease which does not take up radioiodine  Laryngoscopy: vocal cords (medicolegal)  Core biopsy: may cause pain, bleeding, tracheal damage, RL nerve damage  Serum calcium estimation
  38. 38. CORE BIOPSY NEEDLE
  39. 39. HYPERTHYROIDISM / THYROTOXICOSIS  Clinical types are: 1) Diffuse toxic goiter (Graves’ disease) 2) Toxic nodular goiter 3) Toxic nodule 4) Hyperthyroidism due to rare causes
  40. 40. HYPERTHYROIDISM / THYROTOXICOSIS  SYMPTOMS: i. Tiredness ii. Emotional lability iii. Heat intolerance iv. Weight loss v. Excessive appetite vi. Palpitations  SIGNS: i. Tachycardia ii. Hot, moist palms iii. Exophthalmos iv. Eyelid lag/retraction v. Agitation vi. Goitre with bruit
  41. 41. DIFFUSE TOXIC GOITER (GRAVES’ DISEASE)  Primary thyrotoxicosis  The goiter is diffuse & vascular  Affects younger women usually  Family history in 50% cases  Autoimmune disease  Abnormal thyroid stimulating antibodies (TSH-RAb) that bind to TSH receptor sites & produce a disproportionate
  42. 42. TOXIC NODULAR GOITER & TOXIC ADENOMA  Secondary thyrotoxicosis  The goiter is nodular  A simple nodular goiter is present for a long time before the hyperthyroidism  The nodules are inactive & the internodular thyroid tissue is overactive  If a nodule becomes overactive, it is toxic adenoma (autonomous)  Toxic adenoma hypertrophy and hyperplasia is not due to TSH-Rab
  43. 43. SYMPTOMATOLOGY OF TOXIC GOITRE  Primary thyrotoxicosis: i. Goitre diffuse & vascular ii. Onset is abrupt iii. Associated signs include orbital proptosis, ophthalmoplegia, pretibial myxedema  Secondary thyrotoxicosis: i. Goitre is nodular ii. Onset is insidious iii. Cardiac signs are frequent e.g. cardiac failure or atrial fibrillations A fast heart rate, which persists during sleep is characteristic
  44. 44. HISTOLOGY OF NORMAL GLAND & TOXIC GOITRE  Normal gland: acini lined with flattened cuboidal epithelium and filled with homogeneous colloid  Hyperthyroidism: hyperplasia of acini, lined by high columnar epithelium
  45. 45. TREATMENT OF THYROTOXICOSIS A. Antithyroid drugs B. Surgery C. Radioiodine
  46. 46. ANTITHYROID DRUGS  Carbimazole 10 mg TDS to QID  Propylthiouracil  β-adrenergic blockers e.g. propranolol (40 mg TDS), nadolol (160 mg OD)  Iodides  Advantages: No surgery, no radioactive material  Disadvantages: prolonged treatment, 50% failure rate, dangerous drug reactions e.g. agranulocytosis or aplastic anemia
  47. 47. THYROID SURGERY  Advantages: i. Goiter is removed ii. Cure is rapid and high  Disadvantages: i. Recurrent of thyrotoxicosis (5%) in subtotal thyroidectomy ii. Hypoparathyroidism iii. Nerve injury iv. Scar v. Thyroid failure
  48. 48. RADIOIODINE THERAPY  Advantages: i. No surgery ii. No prolonged drug therapy  Disadvantages: i. Availability of isotope facility ii. Avoid pregnancy (Absolute contraindication) iii. Avoid close physical contact especially children (Relative contraindication) iv. Eye signs may be aggravated
  49. 49. POSTHYROIDECTOMY COMPLICATIONS  Hemorrhage i. Tension hematoma ii. Subcutaneous hematoma  Respiratory obstruction (Tracheomalacia)  RL nerve paralysis & voice change  Thyroid insufficiency  Parathyroid insufficiency  Toxic crisis (storm)  Wound infection  Hypertrophic or keloid scar  Stitch granuloma
  50. 50. 6. THYROID MALIGNANCY & MANAGEMENT  Tumors of thyroid may be benign or malignant
  51. 51. CLASSIFICATION OF THYROID NEOPLASMS Benign Malignant Follicular adenoma Primary i. Follicular (20%) ii.Papillary (60%) iii.Anaplastic (10%) iv.Medullary (5%) v.Lymphoma (5%) Secondary i. Metastatic ii.Local infiltration
  52. 52. PAPILLARY CARCINOMA  Most common among the carcinomas of thyroid  May be multifocal in one lobe or both  Lymphatic spread is common  Blood-borne spread unusual  May infiltrate to esophagus, trachea or sternothyroid muscle  Orphan Annie-eyed nuclei: characteristic pale, empty nuclei visible histologically as papillary projections  Occult carcinoma (microcarcinoma)
  53. 53. HISTOLOGY OF PAPILLARY CARCINOMA
  54. 54. FOLLICULAR CARCINOMA  Macroscopically encapsulated but microscopically invades the capsule and the vascular spaces  Rarely multifocal  Lymph node involvement is less common  Blood-borne metastasis is more common  Mortality rate is twice as compared with the papillary carcinoma
  55. 55. FOLLICULAR CARCINOMA (VASCULAR INVASION)
  56. 56. HURTHLE CELL TUMOR  Variant of follicular carcinoma  Contain Hurthle/Askanazy cells histologically  Poor prognosis
  57. 57. TREATMENT OF DTC  Treatment of differentiated thyroid cancer (DTC) depends upon: I. Preoperative diagnosis or II. After diagnostic lobectomy 1. Total thyroidectomy 2. ±Node dissection 3. Radioiodine to detect and ablate metastases 4. Thyroglobulin monitoring 5. Thyroxine 0.1-0.2 mg daily to suppress endogenous TSH
  58. 58. THYROGLOBULIN AS TUMOR MARKER  Very important in the follow-up and detection of metastatic disease after surgery of DTC  Endogenous TSH production must be suppressed by T4  Surgery or therapeutic radioiodine is then indicated  Presence of antithyroglobulin antibodies interferes with and invalidates thyroglobulin as serum marker for recurrence  Careful clinical palpation of neck is important in such cases
  59. 59. UNDIFFERENTIATED (ANAPLASTIC) CARCINOMA  Occurs mainly in elderly women  Local infiltration is early feature  Lymphatic & blood-borne spread is common  Extremely lethal tumor & survival is calculated in months  Usually needs palliative treatment by surgery or radiotherapy. Chemotherapy is ineffective  Surgery for complications e.g. tracheal decompression
  60. 60. MEDULLARY CARCINOMA  Tumor of parafollicular (C cells)  10-20 % are familial, (affects children & young)  Resembling carcinoid tumor  Has characteristic amyloid stroma  Levels of calcitonin & CEA are usually high
  61. 61. MEDULLARY CARCINOMA  Diarrhea occurs (30% cases) due to 5-HT and prostaglandins produced by the tumor cells  May occur as part of MEN-2A or MEN-2B  Calcitonin is its tumor marker  Tumors are not TSH dependent, don’t take up radioiodine
  62. 62. TREATMENT OF MEDULLARY CARCINOMA  Total thyroidectomy  Prophylactic or therapeutic resection of cervical lymph nodes  Preoperatively, pheochromocytoma must be excluded by measuring urinary catecholamines
  63. 63. LYMPHOMA OF THYROID  May be isolated tumor of thyroid or part of widespread malignant lymphoma disease  May cause tracheal compression, managed by isthmusectomy  Very good response to radiotherapy in local disease  Worse prognosis as part of generalized lymphoma disease
  64. 64. 7. MEN-1 AND MEN-2  Multiple endocrine neoplasia are inherited syndromes  Characterized by a combination of benign & malignant tumors in different endocrine glands  Two types i.e. MEN-1 and MEN-2
  65. 65. MULTIPLE ENDOCRINE NEOPLASIA TYPE 1  Also called Wermer’s syndrome  Characterized by triad of tumors 1. Tumor of anterior pituitary gland (prolactinomas) 2. Hyperplasia of parathyroid causing primary hyperparathyroidism (pHPT) 3. Pancreatico-duodenal endocrine tumors e.g. gastrinoma, insulinoma, VIPoma, glucagonoma, somatostatinoma
  66. 66. MULTIPLE ENDOCRINE NEOPLASIA TYPE 2  Three subtypes 1. Familial medullary thyroid carcinoma (FMTC) 2. MEN-2a and 3. MEN-2b
  67. 67. MULTIPLE ENDOCRINE NEOPLASIA TYPE 2  MEN-2a (Sipple’s syndrome): characterized by the combination of: i. MTC ii. pHPT iii. Pheochromocytoma (Bilateral)  MEN-2b: characterized by i. MTC, ii. pHPT, iii. Pheochromocytoma iv. Neuromas of lips, tongue, eyelids v. Marfanoid habitus
  68. 68. REFERENCE  Bailey & Love’s short practice of surgery, 26th edition, chapter 51: pages 741-777
  69. 69. The end

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