Endocrine Disorder

1. Tumors of:
Thyroid Gland
Parathyroid Gland
Adrenal Gland
1Prof. RS Mehta

2. Thyroid Tumors
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3. Anatomy
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4. Introduction
• Infrequent cancer -1% of all cancers
• Benign diseases common
• 1200 pts die annually
• Requires multidisciplinary approach
• Cancer of the thyroid is much less prevalent
than other forms of cancer; however, it
accounts for 90% of endocrine malignancies.
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5. • 17,000 cases diagnosed annually.
• Women 3 times more than men.
• Peak incidence 30-40s.
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6. Etiology/Risk Factors
• Arise from the two cell types in the gland.
• Follicular cells make papillary, follicular, and
anaplastic.
• C-cells produce medullary.
• Radiation exposure (papillary).
• Populations with low dietary iodine have a
higher proportion of follicular and anaplastic
cancers.
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7. Classification of thyroid cancer:
1. pappillary adenocarcinoma
 Incidence70%
 Most common and least aggressive
 Asymptomatic nodule in a normal gland
 Starts in childhood or early adult life,remains localised
 Metastasises along the lymphatics if untreated
 More aggressive in the elderly
2.follicular adenocarcinoma
 Incidence15%
 Appears after 40 yrs of age
 encapsulated;feels elastic or rubbery on palpitation
 Spreads through the bllod stream to bone,liver and lung
 Prognosis is not as favourable as for pappilary adenocarcinoma
7Prof. RS Mehta

8. 3. medullary carcinoma:
 Incidence5%
 Apppears after 50 yrs of age
 Occurs as a part of multiple endocrine neoplasia
 Hormone producing tumor causing endocrine dysfunction symptoms
 Metastsise by lymphatics and blood stream
 Moderate survival rate
4. analastic carcinoma
 Incidence5%
 50% occur in patients older than60 yrs
 Hard, irregular mass that griws quickly and spreads by direct invasion to
adjacent tissues
 May be painful and tender
 Survival for patients with anaplastic cancer is usually less than 6 month
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9. 5. thyroid lymphoma:
• Incidene 5%
• Appears after age 40 yrs
• May have history of goitre ,hoarseness.dyspnea,pain and pressure
• Good pronosis
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10. 10Prof. RS Mehta

11. History/Symptoms:
• Painless, palpable solitary nodule.
• Nodules are present in 4-7% of population.
• Most are benign
• 5% are malignant
• Age at presentation (>60 and <30)
• Rapid growth
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12. Contd:
• Malignant nodules usually painless
• Sudden onset pain usually benign.
• Hoarseness suggests malignancy, nerve
involvement.
• Dysphagia
• Heat intolerance, palpitations suggest
autonomously functioning nodules.
• Family history (medullary).
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13. Contd:
• Symptoms
• The most common presentation of a thyroid nodule,
benign or malignant, is a painless mass in the region
of the thyroid gland.
• Symptoms consistent with malignancy
• Pain
• dysphagia
• Stridor
• hemoptysis
• rapid enlargement
• hoarseness
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14. Risk factors:
• Thyroid exposure to irradiation
• Age and Sex: common in female
• Family History
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15. ASSESMENT :
• Lesions that are single,hard and fixed on
palpitation or associated with cervical
lymphadenopathy suggest malignancy
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16. DIAGNOSTIC TEST:
• Thyroid function test
• Needle biopsy ie FNAC
• Ultrasound
• MRI
• CT
• Thyroid scans
• Radioactive iodine uptake studies
• Throid suppression test
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17. Treatment:
• Surgical excision whenever possible.
• Total thyroidectomy has been mainstay (all
apparent thyroid tissue removed).
Complications include nerve damage
bilaterally, parathyroid injury bilaterally.
• After, get radioiodine scan, ablation if residual
disease or recurrence.
17Prof. RS Mehta

18. Contd:
• Over the years, modification to procedure to
reduce the above complications.
• Subtotal thyroidectomy( small portion of
thyroid tissue opposite the side of malignancy
is left in place) and postop ablation.
• Thyroid lobectomy and isthmectomy also a
viable option with small tumors
18Prof. RS Mehta

19. Prognosis:
• Age: at diagnosis. Cancer relate death more
common if patient is older than 40 years.
• Recurrences common in patients diagnosed
when they were less than 20 years or older
than 60 years.
• Men are twice more likely as women to die.
• Tumors greater than 4 cm have higher
recurrence, death.
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20. Contd:
 Histology:papillary has 30 year cancer related death
rate of 6%. Follicular has a 30 year cancer related
death rate of 15%.
 Local invasion predicts poorer prognosis.
 LN metastases not important for prognosis.
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21. Complications:
• Hemorrhage
• hematoma formation
• Edema of glottis
• Injury to the recurrent laryngeal nerve
• Injury to the parathyroid glands
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22. Tumors of parathyroid gland
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23. Introduction
Parathyroid tumor appear on one or
more of a person's parathyroid glands.
 Tumors cause the parathyroid gland to
make more parathyroid hormone than
the body needs, a condition called
primary hyperparathyroidism.
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24. Intro…
Too much parathyroid hormone upsets the
body's normal calcium balance, which increases
the amount of calcium in the blood stream.
Women are twice as likely to develop
parathyroid adenomas as men, and often after
menopause.
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25. Etiology
• The cause of most parathyroid tumor is
unknown.
• about 10 percent are thought to be hereditary.
• Radiation exposure of the head and neck also
may increase the risk of tumors
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26. Pathophysiology
• The normal function of PTH is to increase bone
resorption, thereby maintaining proper balance of
calcium and phosphorous in the blood
• excessive circulating PTH leads to bone damage,
hypercalcemia and kidney damage
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27. Clinical features
Many people have no symptoms.
Symptoms that may occur include:
• Kidney stones
• Bone and joint pain
• General aches and pains from no obvious cause
• Constipation, nausea or decreased appetite
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28. Contd…
• Depression of neuromuscular function:
droping objects, general fatigue, lose memory for
recent events, confusion, emotional instability,
changes in level of consciousness
• Constipation, nausea or decreased appetite
• Cardiac arrhythmias
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29. Diagnostic evaluation
• Blood tests: to check the levels of parathyroid
hormone, calcium, phosphorus, and vitamin D.
• A 24-hour urine test : to check for increased calcium in the urine.
• Bone density test: DEXA scan
• Kidney x-rays, ultrasound or CT scan - may show kidney stones)
• Neck ultrasound
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30. treatment
• Surgery is the most common treatment, and it
often cures the condition.
• Medical treatments include minimising calcium
and vitamin D supplements.
• Postmenopausal women are treated with
estrogen therapy
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31. Medical management
Hydration therapy
 Serum calcium levels are lowered by hydration and
calciuria
 Influsion of normal saline is the fluid of choice as it acts
on kidney to inhibit the resorption of calcium
• A loop diuretic: furosemide may be also be used to
promote calciuria after rehydration
• biphosphonates: Pamidronate or etidronate disodium
and calcitonin are effective in treating hypercalcemia
by inhibiting bone resorption.
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32. Management contd…
• Dietary calcium is restricted, and all drugs that
might cause hypercalcemia (thiazides, vitamin
D) are discontinued.
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33. 33Prof. RS Mehta

34. Adrenal tumor:
Tumors of adrenal cortex
Adrenocortical adenoma
Adrenocortical carcinoma
Tumors of adrenal medulla
Neuroblastoma
Pheochromocytoma
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35. Adrenocortical adenomas are encapsulated, well-
circumscribed, solitary tumors.
They are benign tumors which are extremely
common
Most of the adrenocortical adenomas are less than
2 cm in greatest dimension and less than 50 gram in
weight
It is uncommon in younger than 30 years old, and
have equal incidence in both sexes.
Adrenocortical adenoma.
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36. Adrenocortical carcinoma
They frequently invade large vessels,
such as the renal vein and inferior
venacava as well as metastasizing via
the lymphatic and through the blood to
the lungs and other organs.
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37. Neuroblastoma
It is malignant tumour of immature neuroblastic cells
and most common pediatric cancers.
Approx 90% presents before 5 yrs of age and 50%
within the 1st 2 yrs of age.
Common sites for tumours are adrenal gland ( 30%),
paravertebral retroperitoneum (28%), posterior
mediastinum (15%) , pelvis (5%) and cervical areas
37Prof. RS Mehta

38. Pheochromocytoma
• A tumor of the adrenal medulla that produces
excess catecholamines.
• It is usually benign.
• The mean age at diagnosis is about 40 years
• Affects men and women equally
• about 10% are bilateral, 10% are extraadrenal
(near the aorta, ovaries, spleen) and 10% are
malignant
• About 0.1% of hypertensive patients harbor a
pheochromocytoma.
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39. Etiology
• The exact cause is unknown
• About 25% of patients have an inherited condition
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40. Pathophysiology
• Pheochromocytoma is composed of chromaffin
cells
• so named because these cells stain brownish
yellow with chromic salts.
• Because of excessive amount of epinephrine and
norepinephrine they secrete, they can produce
severe menifestations and even death.
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41. Clinical features
Excess secretion of nor epinephrine and epinephrine
leads to
Hypertension
Hyper metabolism
Hyperglycemia
Hypertension may be associated with paroxismal or
persistent pounding headache, diaphoresis and
palpitations are common.
Hyper metabolic and hyperglycemic effects produce
tremor, pallor or face flushing, nervousness, polyuria,
nausea, vomiting, diarrhea, abdominal pain
41Prof. RS Mehta

42. Diagnosis
History and physical examinations
blood anlysis: raised plasma catecholamines
level
24 hours urine samples: to assess excess VMA
and metanephrines in the urine.
CT scan and MRI - to localise tumor.
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43. Management
Surgical management:
Complete removal of tumor
Adrenalectomy: removal of one or both adrenal glands
Medication therpy is required to prepare the patient
for surgery, preferably for a minimum of 6 weeks to
control BP and allow restoration of normal plasma
volume
Phenoxybenzamine,(the α- adrenergic blocking agents)
5-10 mg orally 6-8-hourly and increased as tolerated
every few days with a typical final dose of 20–30 mg
three times per day
43Prof. RS Mehta

44. • Before surgery, the blood pressure should be
consistently below 160/90 mmHg.
• Beta blockers (10 mg propranolol three to four
times per day) can be added after starting alpha
blockers, and increased as needed, if tachycardia
persists.
• Other antihypertensives, such as calcium-
channel blockers or angiotensin-converting
enzyme inhibitors, have also been used when
blood pressure is difficult to control with
phenoxybenzamine alone.
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45. NURSING MANAGEMENT:
• GOALS:
• To gain patient confidence and reduce anxiety
• To protect patient from tension and stress to
avoid precipitating thyroid storm
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46. Nursing diagnosis:
• Pain related to surgical procedure
• High risk for infection related to surgical
wound and exposure to microorganisms
• Altered to nutrition less than body
requirement related to difficulty in swallowing
• Knowledge deficit related to disease process
46Prof. RS Mehta

47. Preoperative care:
• Instruct the patient about the importance of
eating a diet rich in carbohydrates and protein
• Supplementary vitamins particularly thymine
and ascorbic acid may be prescribed
• Pt is reminded to avoid tea,coffee,cola and
other stimulants
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48. • Inform the patient about the purpose of
preoperative test if they are to be perform
and explain the preoperative preparation
• Ensure a good night rest before surgery
• Demonstrate the pt how to support the neck
with the hands after surgery to prevent stress
on the incision
48Prof. RS Mehta

49. POSTOPERATIVE CARE:
• Periodically assess the surgical dressings and
reinforce them if necessary
• Assess for difficulty in respiration
• Assess for the intensity of pain
• Administer iv fluids during the immediate post
operative period
• The patient is advice to talk as little as possible
to reduce edema to vocal cords
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50. • The patient is usually permitted out of bed as
soon as possible and is encouraged to eat
foods that are easily swallowed
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51. Nursing management:
Parathyroid Tumors
Closely observe for signs of dehydration, immobility,
and diet therapy
Closely monitors the patient to detect symptoms of
tetany (which may be an early postoperative
complication).
• The nurse reminds the patient and family about the
importance of follow-up to ensure return of serum
calcium levels to normal
• Assess for ca levels
• Assess for signs of osteoporosis
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52. 52Prof. RS Mehta

53. •Thank you
THANK YOU 53Prof. RS Mehta