1) The document discusses the evaluation and management of different types of anterior neck masses, including thyroid nodules, thyroglossal cysts, carotid body tumors, cervical lymphadenitis, and branchial cysts.
2) It provides guidance on the questions to ask patients about neck lumps, associated symptoms, and examination findings. It also outlines the appropriate tests and workup depending on the suspected diagnosis.
3) The key points are that thyroid status must be determined, thyroid nodules in euthyroid patients should be referred to a surgeon for FNA, and different surgical procedures or treatments are used depending on the specific diagnosis.
A 32-year-old male presents with worsening symptoms of dysphagia, hoarseness, neck pain, and trouble breathing over recent weeks. He has a history of goiter. Physical exam and ultrasound are planned to evaluate for thyroid cancer. Thyroid cancer accounts for 400 deaths annually in the UK and occurs most often in women, usually presenting as a thyroid nodule but sometimes with lymph node involvement or metastases. Different types include papillary, follicular, anaplastic, and medullary carcinomas.
This document discusses 6 cases involving thyroid disorders. Case 1 involves a 56-year-old woman with fatigue, weight gain, and constipation diagnosed with Hashimoto's thyroiditis and hypothyroidism. Case 2 involves a 34-year-old woman with tremors, hot flushes, and weight loss diagnosed with silent lymphocytic thyroiditis. Case 3 involves a 40-year-old man with a thyroid nodule found on exam who should undergo fine-needle aspiration biopsy. Case 4 involves management of levothyroxine dosage for a pregnant woman with hypothyroidism. Case 5 involves a 75-year-old woman with fatigue and subclinical hypothyroidism who should repeat thyroid testing
How would you approach a patient with thyroidMuhammad Habib
Physical examination and laboratory tests would be used to investigate a patient with thyroid swelling. Laboratory tests would include thyroid hormones (T4 and T3), TSH, and thyroid autoantibodies to check for hyperthyroidism, hypothyroidism, or an autoimmune cause. Radiological tests such as radioactive iodine uptake quantification and thyroid scintiscanning could further identify areas of abnormal thyroid activity that may indicate conditions like Graves' disease, multinodular goiter, or thyroid cancer. Together these examinations would help arrive at a diagnosis for the patient's thyroid condition.
This document summarizes management of hyperthyroidism. It discusses the epidemiology, causes, symptoms, complications, and treatment options for hyperthyroidism including radioactive iodine, surgery, antithyroid medications, and their adverse effects. It also reviews guidelines for diagnosing and treating thyroid disorders during pregnancy, the prevalence of thyroid cancer in hyperthyroidism patients, and literature on managing hyperthyroidism in Asia and Saudi Arabia.
This document provides information on the classification, etiology, natural history, clinical features, investigations, and management of different thyroid swellings. Simple goiter includes diffuse hyperplastic goiter and multinodular goiter (MNG). MNG forms due to discordant nodule growth and can be toxic or non-toxic. Discrete thyroid swellings have a higher risk of malignancy compared to other swellings. Ultrasound with FNAC is important for evaluating nodules. Treatment depends on diagnosis and may include surgery such as subtotal thyroidectomy or total thyroidectomy. Retrosternal goiters extending into the mediastinum can compress airways and may require transcervical or open sternotomy surgery
This document summarizes thyroid diseases and evaluation of thyroid nodules. It discusses the peripheral action of thyroid hormones, thyroiditis conditions including Hashimoto's, subacute, and Riedel's, hyperthyroidism including Graves' disease and toxic nodular goiter, evaluation of thyroid nodules including risk factors and initial workup, and treatment options for hyperthyroidism such as antithyroid medications, radioactive iodine, and surgery.
The role of nuclear medicine in differentiated thyroid cancer (DTC)Herbert Klein
PowerPoint: Guidelines for the management of differentiated thyroid cancer are discussed with special reference to the use of radioiodine imaging and therapy.
A 32-year-old male presents with worsening symptoms of dysphagia, hoarseness, neck pain, and trouble breathing over recent weeks. He has a history of goiter. Physical exam and ultrasound are planned to evaluate for thyroid cancer. Thyroid cancer accounts for 400 deaths annually in the UK and occurs most often in women, usually presenting as a thyroid nodule but sometimes with lymph node involvement or metastases. Different types include papillary, follicular, anaplastic, and medullary carcinomas.
This document discusses 6 cases involving thyroid disorders. Case 1 involves a 56-year-old woman with fatigue, weight gain, and constipation diagnosed with Hashimoto's thyroiditis and hypothyroidism. Case 2 involves a 34-year-old woman with tremors, hot flushes, and weight loss diagnosed with silent lymphocytic thyroiditis. Case 3 involves a 40-year-old man with a thyroid nodule found on exam who should undergo fine-needle aspiration biopsy. Case 4 involves management of levothyroxine dosage for a pregnant woman with hypothyroidism. Case 5 involves a 75-year-old woman with fatigue and subclinical hypothyroidism who should repeat thyroid testing
How would you approach a patient with thyroidMuhammad Habib
Physical examination and laboratory tests would be used to investigate a patient with thyroid swelling. Laboratory tests would include thyroid hormones (T4 and T3), TSH, and thyroid autoantibodies to check for hyperthyroidism, hypothyroidism, or an autoimmune cause. Radiological tests such as radioactive iodine uptake quantification and thyroid scintiscanning could further identify areas of abnormal thyroid activity that may indicate conditions like Graves' disease, multinodular goiter, or thyroid cancer. Together these examinations would help arrive at a diagnosis for the patient's thyroid condition.
This document summarizes management of hyperthyroidism. It discusses the epidemiology, causes, symptoms, complications, and treatment options for hyperthyroidism including radioactive iodine, surgery, antithyroid medications, and their adverse effects. It also reviews guidelines for diagnosing and treating thyroid disorders during pregnancy, the prevalence of thyroid cancer in hyperthyroidism patients, and literature on managing hyperthyroidism in Asia and Saudi Arabia.
This document provides information on the classification, etiology, natural history, clinical features, investigations, and management of different thyroid swellings. Simple goiter includes diffuse hyperplastic goiter and multinodular goiter (MNG). MNG forms due to discordant nodule growth and can be toxic or non-toxic. Discrete thyroid swellings have a higher risk of malignancy compared to other swellings. Ultrasound with FNAC is important for evaluating nodules. Treatment depends on diagnosis and may include surgery such as subtotal thyroidectomy or total thyroidectomy. Retrosternal goiters extending into the mediastinum can compress airways and may require transcervical or open sternotomy surgery
This document summarizes thyroid diseases and evaluation of thyroid nodules. It discusses the peripheral action of thyroid hormones, thyroiditis conditions including Hashimoto's, subacute, and Riedel's, hyperthyroidism including Graves' disease and toxic nodular goiter, evaluation of thyroid nodules including risk factors and initial workup, and treatment options for hyperthyroidism such as antithyroid medications, radioactive iodine, and surgery.
The role of nuclear medicine in differentiated thyroid cancer (DTC)Herbert Klein
PowerPoint: Guidelines for the management of differentiated thyroid cancer are discussed with special reference to the use of radioiodine imaging and therapy.
The thyroid gland is located in the lower neck and produces thyroid hormones which regulate metabolism. A goiter is an enlargement of the thyroid gland. Simple goiters are non-toxic enlargements that are usually asymptomatic. Toxic goiters secrete excess thyroid hormones and can be either diffuse or nodular. Thyroid nodules are common and evaluating them involves tests like ultrasound, biopsy, and scans to determine if they are benign or malignant. Surgery is the main treatment and complications can include bleeding, nerve damage, and hypocalcemia.
The thyroid gland develops from the median bud of the pharynx and descends during development. The parathyroid glands develop from the third and fourth pharyngeal pouches. The thymus also develops from the third pouch. Fine needle aspiration cytology is the preferred investigation for evaluating discrete thyroid swellings due to its accuracy, simplicity, and ability to be repeated as needed with ultrasound guidance. Isotope scanning can help differentiate a toxic nodule from toxic multinodular goitre by localizing areas of overactivity in the thyroid gland.
2012 Clinical Practice guidelines for hypothyroidism in adults: American Asso...Jibran Mohsin
This is presentation format of 2012 Clinical Practice guidelines for hypothyroidism in adults: American Association of Clinical Endocrinologists (AACE) / American Thyroid Association (ATA)
Hashimoto's thyroiditis is a chronic autoimmune thyroid disorder characterized by the presence of goiter and hypothyroidism. It is caused by antibodies attacking the thyroid and impairing its function. The main symptoms are those of hypothyroidism like fatigue and weight gain. Treatment involves lifelong thyroid hormone replacement therapy via levothyroxine to manage hypothyroidism. Surgery may be indicated for large goiters causing obstruction, suspicious nodules, symptoms refractory to medication, or cosmetic reasons. Fine needle aspiration is important to screen for thyroid cancer.
This document discusses the anatomy, physiology, pathology, staging, diagnosis, and treatment of thyroid cancer. Some key points:
- The thyroid gland is located in the neck and produces thyroid hormones which regulate metabolism. Thyroid cancers are classified based on their level of differentiation.
- Diagnostic evaluation includes laboratory tests, ultrasound of the thyroid, and fine needle aspiration if a nodule is detected. Prognostic factors like histology, stage, and tumor size help determine a patient's risk level.
- Surgical treatment typically involves total thyroidectomy. Lymph node dissection may also be performed. Postoperative radioactive iodine remnant ablation is recommended for intermediate- and high-risk
This document provides an overview of thyroid cancer, including the anatomy and physiology of the thyroid gland, epidemiology, risk factors, clinical presentation, diagnostic evaluation, staging, surgical management, and role of radioactive iodine treatment. Key points include that thyroid cancer is most commonly diagnosed through incidental finding of a thyroid nodule, surgical removal of the thyroid (total thyroidectomy) is the primary treatment, and radioactive iodine ablation may be used post-operatively depending on risk level. Prognostic factors include histologic classification and cancer stage at diagnosis.
General surgery thyroid disorders lecture .pptxIssaAbuzeid1
The document discusses the thyroid gland, including its embryology, anatomy, physiology, and various diseases and disorders. It begins by outlining the objectives of understanding thyroid development, function, investigations, and treatments. It then describes the gland's embryological origin and migration path. Subsequent sections cover anatomy, histology, physiology, evaluation methods, benign and malignant disorders, and their treatments.
thyrotoxicosis in special situation the let.pptHamedRashad1
how thyroid hyperfunction affects children and elderly , when to suspect and how to treat Summary of clinical manifestations and how to peck and diagnose and methods of treatment
This document provides case studies and discussions on various endocrine topics. Case 1 describes a patient presenting with adrenal crisis who is treated with IV hydrocortisone and fluid resuscitation. Case 2 involves an incidental adrenal nodule found on imaging requiring hormonal evaluation. Case 3 presents a patient with Graves' disease, confirmed by positive TRAb, who is started on beta blockers and methimazole. The document also reviews thyroid storm, its presentation and treatment including beta blockers, antithyroid medications, iodine, glucocorticoids and supportive care.
The document discusses the thyroid gland and various thyroid conditions. It begins by describing the location of the thyroid gland and possible enlargements or nodules. It then discusses the main functions of the thyroid gland and the hormones it secretes. Various thyroid conditions are summarized such as hyperthyroidism, hypothyroidism, thyroiditis, thyroid cancer, and dental management considerations for patients with thyroid disease.
TFT and imaging tests are used to evaluate thyroid function and diagnose thyroid disorders. TSH, T4, and T3 tests evaluate thyroid status, with TSH being the most sensitive and reliable. Antibodies, enzymes, and ultrasound can help determine the cause, such as autoimmune disease. Imaging like ultrasound and CT scan can assess the thyroid gland and detect nodules. Isotope scanning and PET scans have limited use but can help identify recurrent thyroid cancer when iodine uptake is reduced.
A 69-year-old female presented with an itchy throat and a family history of thyroid cancer. An ultrasound revealed an 8mm nodule in her left thyroid lobe. Further investigations would include a fine needle aspiration biopsy of the nodule. The doctor would explain to the patient that the small nodule size is reassuring but not completely benign, and recommend follow up ultrasound scans. If the nodule was larger, such as 15mm or 30mm, the risk of cancer would be higher and surgery may be considered.
- Fine-needle aspiration cytology (FNAC) is the most important diagnostic tool for evaluating a solitary thyroid nodule, as it is safe, cost-effective, and reliable for differentiating between benign and malignant diseases of the thyroid. Ultrasound-guided FNAC is more accurate than palpation-guided.
- Thyroid imaging with ultrasound and radioactive iodine uptake scans can identify high-risk features that increase the likelihood of malignancy, such as hypoechogenicity, microcalcifications, irregular shape, and lack of iodine uptake in the nodule.
- Cytology results are categorized using the Bethesda or THY classification systems. Suspicious or malignant results
The document describes several cases of thyrotoxicosis and discusses potential causes. It outlines cases of three patients, two children and one infant, who presented with thyrotoxicosis. The potential causes discussed include Graves' disease, toxic multinodular goiter, toxic adenoma, neonatal Graves' disease, activated TSH receptor, excess TSH, thyroiditis, and thyrotoxicosis resulting from excess iodine or medications like amiodarone.
Thyroid nodules are common, especially in women and older adults. While most are benign, thyroid cancer occurs in 5-15% of nodules. Risk factors for cancer include age under 18 or over 60, male sex, family history, rapid growth, fixation, hoarseness, lymphadenopathy, and radiation exposure. Tests include thyroid function tests, ultrasound, and fine needle aspiration. Ultrasound features such as hypoechogenicity, irregular borders, microcalcifications, and taller-than-wide shape indicate higher cancer risk. Guidelines from the American Thyroid Association and other groups provide recommendations on evaluation and management of thyroid nodules and cancer.
Thyroid carcinoma is the most common endocrine malignancy, with an annual incidence of 3.5 per 100,000 in the UK. Differentiated thyroid carcinomas have high 10-year survival rates of 80-90% for middle-aged adults, but recurrence rates of 10-15% are possible. Diagnosis is usually via fine needle aspiration biopsy of thyroid nodules, with surgery the main treatment depending on tumor size, involvement of lymph nodes, and histological subtype. Long-term monitoring of serum thyroglobulin levels and thyroid-stimulating hormone levels is important for screening for recurrence.
Hyperthyroidism is often caused by Graves' disease, which results from autoimmune production of thyroid stimulating hormone (TSH) receptor antibodies. This leads to excessive thyroid hormone production and symptoms of hyperthyroidism. Graves' disease is the most common cause of childhood hyperthyroidism. Treatment options include antithyroid medications, radioactive iodine therapy, or surgery, with the choice individualized for each patient.
This document discusses an approach to a person with an abnormal thyroid stimulating hormone (TSH) level. It begins by introducing the thyroid gland and hormones T4 and T3, which are regulated by TSH. Several conditions can cause high or low TSH, including hypothyroidism, hyperthyroidism, thyroid hormone resistance, and TSH-secreting pituitary adenomas. Specific thyroid conditions discussed in detail include Hashimoto's thyroiditis, iodine deficiency, acute/subacute/silent/chronic thyroiditis, and subclinical hypothyroidism. Treatment depends on the underlying condition but may include levothyroxine, glucocorticoids, surgery, or radiation therapy.
This document outlines the anatomy, epidemiology, risk factors, diagnosis, and management of thyroid cancer. It discusses the different histological subtypes including papillary, follicular, hurthle cell, anaplastic, and medullary carcinomas. Total thyroidectomy is the primary treatment for localized disease. Radioactive iodine is commonly used as adjuvant therapy for differentiated cancers. External beam radiation therapy may be used for residual or unresectable neck disease. Long term monitoring with serum thyroglobulin is important for recurrence detection.
This document discusses neck masses and thyroid disorders. It provides information on evaluating neck masses, including obtaining a history and physical exam. Congenital masses and infections are more common in young adults, while neoplasms are more likely in older adults. Fine needle aspiration and CT scans can help evaluate masses. It also discusses thyroid nodules, hypothyroidism, hyperthyroidism, causes like Graves' disease and thyroiditis, and treatments like beta blockers or radioactive iodine.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
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The thyroid gland is located in the lower neck and produces thyroid hormones which regulate metabolism. A goiter is an enlargement of the thyroid gland. Simple goiters are non-toxic enlargements that are usually asymptomatic. Toxic goiters secrete excess thyroid hormones and can be either diffuse or nodular. Thyroid nodules are common and evaluating them involves tests like ultrasound, biopsy, and scans to determine if they are benign or malignant. Surgery is the main treatment and complications can include bleeding, nerve damage, and hypocalcemia.
The thyroid gland develops from the median bud of the pharynx and descends during development. The parathyroid glands develop from the third and fourth pharyngeal pouches. The thymus also develops from the third pouch. Fine needle aspiration cytology is the preferred investigation for evaluating discrete thyroid swellings due to its accuracy, simplicity, and ability to be repeated as needed with ultrasound guidance. Isotope scanning can help differentiate a toxic nodule from toxic multinodular goitre by localizing areas of overactivity in the thyroid gland.
2012 Clinical Practice guidelines for hypothyroidism in adults: American Asso...Jibran Mohsin
This is presentation format of 2012 Clinical Practice guidelines for hypothyroidism in adults: American Association of Clinical Endocrinologists (AACE) / American Thyroid Association (ATA)
Hashimoto's thyroiditis is a chronic autoimmune thyroid disorder characterized by the presence of goiter and hypothyroidism. It is caused by antibodies attacking the thyroid and impairing its function. The main symptoms are those of hypothyroidism like fatigue and weight gain. Treatment involves lifelong thyroid hormone replacement therapy via levothyroxine to manage hypothyroidism. Surgery may be indicated for large goiters causing obstruction, suspicious nodules, symptoms refractory to medication, or cosmetic reasons. Fine needle aspiration is important to screen for thyroid cancer.
This document discusses the anatomy, physiology, pathology, staging, diagnosis, and treatment of thyroid cancer. Some key points:
- The thyroid gland is located in the neck and produces thyroid hormones which regulate metabolism. Thyroid cancers are classified based on their level of differentiation.
- Diagnostic evaluation includes laboratory tests, ultrasound of the thyroid, and fine needle aspiration if a nodule is detected. Prognostic factors like histology, stage, and tumor size help determine a patient's risk level.
- Surgical treatment typically involves total thyroidectomy. Lymph node dissection may also be performed. Postoperative radioactive iodine remnant ablation is recommended for intermediate- and high-risk
This document provides an overview of thyroid cancer, including the anatomy and physiology of the thyroid gland, epidemiology, risk factors, clinical presentation, diagnostic evaluation, staging, surgical management, and role of radioactive iodine treatment. Key points include that thyroid cancer is most commonly diagnosed through incidental finding of a thyroid nodule, surgical removal of the thyroid (total thyroidectomy) is the primary treatment, and radioactive iodine ablation may be used post-operatively depending on risk level. Prognostic factors include histologic classification and cancer stage at diagnosis.
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The document discusses the thyroid gland, including its embryology, anatomy, physiology, and various diseases and disorders. It begins by outlining the objectives of understanding thyroid development, function, investigations, and treatments. It then describes the gland's embryological origin and migration path. Subsequent sections cover anatomy, histology, physiology, evaluation methods, benign and malignant disorders, and their treatments.
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This document provides case studies and discussions on various endocrine topics. Case 1 describes a patient presenting with adrenal crisis who is treated with IV hydrocortisone and fluid resuscitation. Case 2 involves an incidental adrenal nodule found on imaging requiring hormonal evaluation. Case 3 presents a patient with Graves' disease, confirmed by positive TRAb, who is started on beta blockers and methimazole. The document also reviews thyroid storm, its presentation and treatment including beta blockers, antithyroid medications, iodine, glucocorticoids and supportive care.
The document discusses the thyroid gland and various thyroid conditions. It begins by describing the location of the thyroid gland and possible enlargements or nodules. It then discusses the main functions of the thyroid gland and the hormones it secretes. Various thyroid conditions are summarized such as hyperthyroidism, hypothyroidism, thyroiditis, thyroid cancer, and dental management considerations for patients with thyroid disease.
TFT and imaging tests are used to evaluate thyroid function and diagnose thyroid disorders. TSH, T4, and T3 tests evaluate thyroid status, with TSH being the most sensitive and reliable. Antibodies, enzymes, and ultrasound can help determine the cause, such as autoimmune disease. Imaging like ultrasound and CT scan can assess the thyroid gland and detect nodules. Isotope scanning and PET scans have limited use but can help identify recurrent thyroid cancer when iodine uptake is reduced.
A 69-year-old female presented with an itchy throat and a family history of thyroid cancer. An ultrasound revealed an 8mm nodule in her left thyroid lobe. Further investigations would include a fine needle aspiration biopsy of the nodule. The doctor would explain to the patient that the small nodule size is reassuring but not completely benign, and recommend follow up ultrasound scans. If the nodule was larger, such as 15mm or 30mm, the risk of cancer would be higher and surgery may be considered.
- Fine-needle aspiration cytology (FNAC) is the most important diagnostic tool for evaluating a solitary thyroid nodule, as it is safe, cost-effective, and reliable for differentiating between benign and malignant diseases of the thyroid. Ultrasound-guided FNAC is more accurate than palpation-guided.
- Thyroid imaging with ultrasound and radioactive iodine uptake scans can identify high-risk features that increase the likelihood of malignancy, such as hypoechogenicity, microcalcifications, irregular shape, and lack of iodine uptake in the nodule.
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The document describes several cases of thyrotoxicosis and discusses potential causes. It outlines cases of three patients, two children and one infant, who presented with thyrotoxicosis. The potential causes discussed include Graves' disease, toxic multinodular goiter, toxic adenoma, neonatal Graves' disease, activated TSH receptor, excess TSH, thyroiditis, and thyrotoxicosis resulting from excess iodine or medications like amiodarone.
Thyroid nodules are common, especially in women and older adults. While most are benign, thyroid cancer occurs in 5-15% of nodules. Risk factors for cancer include age under 18 or over 60, male sex, family history, rapid growth, fixation, hoarseness, lymphadenopathy, and radiation exposure. Tests include thyroid function tests, ultrasound, and fine needle aspiration. Ultrasound features such as hypoechogenicity, irregular borders, microcalcifications, and taller-than-wide shape indicate higher cancer risk. Guidelines from the American Thyroid Association and other groups provide recommendations on evaluation and management of thyroid nodules and cancer.
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This document discusses an approach to a person with an abnormal thyroid stimulating hormone (TSH) level. It begins by introducing the thyroid gland and hormones T4 and T3, which are regulated by TSH. Several conditions can cause high or low TSH, including hypothyroidism, hyperthyroidism, thyroid hormone resistance, and TSH-secreting pituitary adenomas. Specific thyroid conditions discussed in detail include Hashimoto's thyroiditis, iodine deficiency, acute/subacute/silent/chronic thyroiditis, and subclinical hypothyroidism. Treatment depends on the underlying condition but may include levothyroxine, glucocorticoids, surgery, or radiation therapy.
This document outlines the anatomy, epidemiology, risk factors, diagnosis, and management of thyroid cancer. It discusses the different histological subtypes including papillary, follicular, hurthle cell, anaplastic, and medullary carcinomas. Total thyroidectomy is the primary treatment for localized disease. Radioactive iodine is commonly used as adjuvant therapy for differentiated cancers. External beam radiation therapy may be used for residual or unresectable neck disease. Long term monitoring with serum thyroglobulin is important for recurrence detection.
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Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
4. Which questions should the GP ask about the
lump itself?
The key when assessing a midline neck lump is to determine whether
the lump is of thyroid origin and, if so, whether it is malignant.
• How long has the lump been there?
• Has the lump got bigger, smaller, or stayed the same size?
• Is the lump painful?
• Are there any other lumps?
5. Which associated symptoms should the GP ask
about?
• Are there any symptoms suggestive of hyper- or hypothyroidism?
• Are there any symptoms suggestive of compression or invasion?
• Are there symptoms suggestive of infection?
6. Past medical history:
• Any autoimmune disorders?
• Known risk factors for thyroid malignancy?
Family history:
• Autoimmune disease?
• Hereditary forms of thyroid carcinoma?
7.
8. • Location:
Superficial lump? Lipoma, epidermal cyst, dermoid cyst or abscess.
Deep lump? Thyroid gland.
• Relationship to other structures:
Moves on swallowing? Thyroid gland (attached to pre-tracheal fascia)
Moves on tongue protrusion (i.e. deglutition)? Thyroglossal cyst
(attached to hyoid bone)
Tethered to neighboring muscle or skin? Malignancy or Riedel’s
thyroiditis
9. • Character of the lump:
Diffuse, smooth enlargement? Physiological goiter, Graves’,
Hashimoto’s, or de Quervain’s thyroiditis. In the latter it is also tender
Solitary, solid nodule? Malignancy more likely.
Solitary, cystic nodule? Thyroglossal, epidermal, dermoid, or thyroid
cysts.
Multiple nodules? Multinodular goiter (focal hyperplasia) more likely
10. What else should the GP examine?
• Is there any cervical lymphadenopathy?
• What is the extent of any thyroid swelling?
• Are there any signs of hyper- or hypothyroidism
11.
12.
13.
14. Clinical examination has poor sensitivity for thyroid status and thus the
GP should request biochemical tests of thyroid function.
Mrs. Luther’s thyroid status will have a considerable influence upon her
further investigation and management.
Firstly, note that the presence of a goiter says nothing of a patient’s
thyroid status – they could be hyper-, hypo-, or euthyroid, and thus you
must confirm their status in order to manage them appropriately.
Secondly, thyroid status is critically important when considering thyroid
nodules because patients with malignancy are almost always euthyroid
– hence a diagnosis of hyperthyroidism in a patient with a thyroid
nodule should be seen as a ‘good’ sign.
15. As a first step, the GP should request:
• Thyroid-stimulating hormone (TSH)
− if TSH is low request free tri-iodothyronine (T3 ) and free thyroxine
(T4 )
− if TSH is high request thyroid peroxidase antibodies (Hashimoto’s).
• Serum calcitonin: only if there is a signifi cant family history of
thyroid cancer.
16. The GP requests a serum TSH, which is later
reported as 3.9 mU/L.
Should Mrs. Luther be referred to an endocrine surgeon or
endocrinologist?
Broadly speaking, if a patient has evidence of altered thyroid function
they should be referred to an endocrinologist as thyroid cancer is very
rare in this group.
By contrast, euthyroid patients with thyroid nodules (either solitary
nodules or dominant nodules in multinodular goiters) should be
referred to an endocrine surgeon in the first instance.
Thus, Mrs. Luther should be referred to an endocrine surgeon.
17. What further investigation(s) is the surgeon
likely to request?
• The first-line test for the investigation of thyroid nodules is FNA.
Ultrasound may be used to guide aspirations, and can provide an
estimate of nodule size and an assessment of whether the nodule is
solid, cystic, or mixed (solid and mixed nodules have a higher
likelihood of malignancy).
• There is relatively little indication for radionuclide scanning nowadays.
These scans use isotopes (99Tc or 123I) to indicate whether a nodule is
functioning or not. Nodules are thus reported as either being ‘hot’
(functioning) or ‘cold’ (non-functioning). Hot nodules are almost
always benign, whereas about 5–20% of cold nodules are malignant.
18. • There is also little indication for computed tomography (CT) scanning
or magnetic resonance imaging (MRI) in the majority of cases. The
exceptions include retrosternal extension of a goiter, invasive tumors,
and hemoptysis.
19.
20. There are a number of potential outcomes for FNA of a thyroid nodule:
• Insufficient aspirate to make a diagnosis = Thy1
• Benign (e.g. thyroiditis) = Thy2
• Follicular lesion/suspected follicular neoplasm = Thy3
• Suspicious of malignancy = Thy4
• Diagnostic of malignancy = Thy5
Unfortunately, FNA cannot distinguish between a benign follicular
adenoma and a malignant follicular carcinoma.
Thus it is not possible to say whether Mrs. Luther has cancer or not
21. Stages of subsequent management:
1) Surgery- Low-risk follicular carcinoma may be treated by thyroid
lobectomy whereas high-risk patients are usually offered total or
near-total thyroidectomy
There are various features that are used to allocate patients with
differentiated thyroid cancer to either high-risk or low-risk groups. The
principal factors contributing to high risk are
older age, male gender, poorly differentiated histological features,
tumor size (>4 cm), extrathyroidal invasion, and metastatic spread (but
not lymph node involvement, unlike in many other cancers).
22. 2) T3 replacement- The patient must have replacement thyroid
hormone as their thyroid gland has now been removed.
However, TSH levels need to be high (hence the patient is hypothyroid)
at the time of administration of subsequent radio-iodine, because the
high TSH stimulates uptake of radio-iodine.
We therefore need to stop the administration of exogenous thyroid
hormone prior to radio-iodine therapy, so that TSH is released from
negative feedback and levels have time to rise.
23. T3 has a half-life of about 2.5 days and thus can be stopped 2 weeks
before radio-iodine therapy.
By contrast, if T4 (which has a half-life of 7–10 days) was used to
replace the patient’s thyroid hormone, it would need to be stopped
about 6 weeks prior to radio-iodine therapy, and the patient would
spend longer in an unpleasant hypothyroid state.
24. 3) 131 I Ablation- The radioactive iodine is selectively taken up by
thyroid cells, which are then destroyed by the radiation.
This is done for all patients who have undergone total or near-total
thyroidectomy as a way of eliminating any malignant cells left behind
after surgery.
T3 suppression is stopped 2 weeks before treatment so that any
remaining thyroid cells take up the 131I.
Some countries are investigating an alternative strategy whereby
thyroid hormone replacement does not need to be stopped prior to 131I
ablation, and patients are given recombinant TSH to stimulate radio-
iodine uptake.
25. 4) T4 suppression- Give a dose sufficient to suppress TSH secretion
completely (as TSH will stimulate any remaining, potentially malignant,
thyroid tissue to regrow).
If thyroglobulin (TG) levels then rise above zero in the presence of T4
suppression, it suggests a return of the malignant thyroid cells.
5) Follow-up- This is usually annual clinical examination with
measurement of serum TSH and TG.
26. Fortunately the prognosis for most differentiated thyroid cancer
(follicular or papillary) is very good, and the overall 10-year survival rate
is approximately 80–90%.
28. An upper midline cystic lesion that is attached to the hyoid bone
(hence rises when the tongue is protruded) is consistent with a
thyroglossal cyst
Treatment is by surgical resection of the cyst ± the mid-portion of the
hyoid bone (Sistrunk’s procedure).
There are three reasons for excision:
1) Eliminating the chance of further infection
2) Eliminating the (small) chance of carcinoma in the cyst
3) Cosmesis
30. The examination findings suggest that Mrs. Slocock has a carotid body
tumor (also known as a chemodectoma).
Carotid body tumors are a type of glomus tumor or paraganglioma
(glomus cells are specialized chemoreceptor cells). They are typically
slow growing, but large tumors may exert pressure effects resulting in
complications such as cranial nerve palsies or Horner’s syndrome.
Carotid body tumors require imaging to determine their precise
location. Suitable modalities include duplex ultrasound, angiography,
and CT/MRI.
Treatment in the majority of patients is surgical excision
32. The fact that they are tender and coexisting with an acute febrile illness
makes it highly likely that this is cervical lymphadenitis.
The combination of sore throat, lymphadenopathy, fever, tonsillar
enlargement, and (most importantly) splenomegaly are characteristic
of glandular fever, caused by Epstein–Barr virus (EBV).
Toxoplasmosis and acute cytomegalovirus (CMV) can also cause
lymphadenopathy and splenomegaly, but would not account for the
sore throat and swollen tonsils.
33. The GP could order the following blood tests
• Full blood count: looking for leukocytosis and lymphocytosis.
• Heterophil antibody tests:
• Blood film: looking for lymphocytosis and atypical T-lymphocytes
(large with irregular nuclei).
EBV yields a positive result in all three of the above blood tests (as will
acute CMV and toxoplasmosis). A more specific test is to detect IgM
towards the EBV viral capsid antigen.
34. The GP should not prescribe amoxycillin or ampicillin for Miss. Banfi ’s
sore throat as both of these antibiotics can precipitate a severe rash in
patients with acute EBV infection.
There is no specific management for glandular fever, although Miss
Banfi should avoid any contact sports for a few months as there is a risk
of damage to the enlarged and delicate spleen.
Miss Banfi may, however, derive symptomatic benefit from analgesics
and throat lozenges.