Pembesaran Tiroid 24 Juni 2009
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Transcript of Pembesaran Tiroid 24 Juni 2009
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Bambang Sugeng
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• Thyroidea thyros = perisai• Endoderm, tonjolan bakal pharynx dari foramen
sekum (pangkal lidah) turun ke caudal (ke leher) pd garis tengah
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KELAINAN KONGENITAL
TIROID EKTOPIK
• Tiroid lingual
• Lateral aberrant thyroid
• Median ectopic thyroid
THYROGLOSSAL CYST = Kista duktus tiroglosus
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• Berat 20 – 25 gram• Lobus kanan-kiri, lobus piramidalis• Paratiroid• Aa Vv thyrodea superior dan inferior yang
ber-anastomosis dengan pembuluh darah trakhea dan oesophagus
• Limfe : juxtathyroid, pre-tracheal, para-tracheal
• N laringeus superior dan inferior / recurrens
MAKROSKOPIS
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MIKROSKOPIS
• Lobulus terdiri dari 24 – 40 folikel
• Folikel berbentuk sferis dan berdiameter 30 μm
• Folikel berisi koloid yg dihasilkan sel epitel untuk menyimpan tiroglobulin
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• Penghasil hormon tiroid
• Iodine inorganik oksidasi iodine
• Iodine + thyrosine iodothyrosine
• MIT dan DIT T3 dan T4
• Dlm sirkulasi terikat pada TBG
• Diatur oleh TSH yg dihasilkan oleh lobus anterior kel hipofisis dan TRH yg dihasilkan oleh hipotalamus
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PEMERIKSAAN THYROID
• Anamnesis
• Pemeriksaan Fisik
• Uji metabolisme : BMR
• Pemeriksaan Laboratorium : fungsi kelenjar thyroid
• Pemeriksaan radiologi / sidik radioaktif / thyro-scan
• Pemeriksaan sitologi / patologi
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• Normal : kel tiroid tidak terlihat dan sukar diraba
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Inspeksi dari depan
Palpasi dari depan
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Test fungsi tiroid
Thyroid functional state
TSH
0.3-3.3.mU L-1
Free T4
10-30 nmol L-1
Free T3
3.5-7.5 µmol L-1
Euthyroid Normal Normal Normal
Thyrotoxic Undetectable High High
Myxoedema High Low Low
Suppresive T4 therapy Undetectable High High
T3 toxicity Low/undetect-able
Normal High
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Simple goiter (euthyroid)
Diffuse Hyperplastic Physiological Pubertal Pregnancy
Multinodular
Toxic
Diffuse : Grave’s diseaseMultinodularToxic adenoma
Neoplastic
BenignMalignant
Inflammatory
Autoimmune : HashimotoGranulomatous : de Quervain’sFibrosing : Riedel’s thyroiditisInfective : acute / chronicOther : amyloid
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• Goitre (guttur = tenggorokan) : pembesaran kelenjar tiroid = struma
• Sebagai akibat rendahnya kadar hormon tiroid dalam darah
• Kebutuhan jodium : 0.1 – 0.15 mg perhari
• Rendahnya kadar tiroid : 1. Rendah pemasukan jodium
2. Kegagalan sintesis
3. Goitrogens : kol, obat-obatan
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Struma difusa
Stimulasi
Diffuse hyperplastic goitre
HiperplasiLobus diisi folikel aktif
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Struma Nodosa
Lobus aktif perlu vaskularisasi
perdarahan dannekrosis
necrotic lobulesbersatu diisi koloidNODUL
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Pemeriksaan Fisik Struma
• Terlihat benjolan leher depan
• Warna sama dg kulit sekitarnya
• Licin, kenyal-padat (tidak keras)
• Ikut bergerak sewaktu menelan (kecil)
• Tidak nyeri dan pada perabaan suhu sama dg sekitarnya
• Tidak ada tanda toksis
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Pemeriksaan PenunjangStruma
• Serum TSH dan hormon tiroid dlm batas normal
• USG dpt membedakan dg kista
• Radiologi : deviasi trakhea, retrosternal
• Bila curiga keganasan perlu mencari diagnosis adanya keganasan
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Komplikasi• Secondary thyrotoxicosis
(30%)• Obstruksi trakhea • Trakheomalacia• Berubah ganas : Ca -
follikular• Retrosternal : bendungan
sesak, pelebaran vena leher, trakheo-malacia
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Penanganan Struma
• Bila masih difus, mungkin masih reversibel
• Setelah terbentuk nodul tidak dapat dipengaruhi terapi jodium
• Sering tidak mengganggu tidak dilakukan operasi
• Nodul yg mengganggu (penekanan, kosmetik) dilakukan operasi
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Etiologi
• Seperti keganasan lain, etiologi yg pasti belum dapat ditentukan
• Pada anak yg mendapat terapi radiasi pada tiroid, diketahui akan timbul keganasan pada tiroid
• Karsinoma folikuler banyak didapati di daerah endemis struma stimulasi TSH?
• Auto-immun?
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Pemeriksaan penunjang
• Fungsi tiroid (TSH, T3,T4 dll)
• Sitologi : FNAB (fine needle aspiration biopsy)
• Radiologi : USG, foto thoraks penekanan, kalsifikasi, metastasis
• Pemeriksaan radioaktif / thyro-scan : Iodium 131 (131 I) atau Tc99m (99mTc)
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USG
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Cold Nodule pada thyroscan ganas?
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Hot Nodule
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Benign : Follicular adenoma
Malignant 1. Primary Follicular epithelium – differentiated Follicular Papillary Follicular epithelium – undifferentiated Anaplastic Parafollicular cells Medullary Lymphoid cells Lymphoma 2. Secondary : metastatic
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KARSINOMA PAPILER
• Paling sering didapati (60-80%)
• Insidens wanita : laki-laki = 2 : 1
• Umur penderita rata-rata 35 tahun
• Teraba sebagai benjolan padat sampai keras
• Sering didapati kalsifikasi
• Fungsi tiroid normal / euthyroid
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KARSINOMA PAPILER
• Penanganan berupa tindakan operasi
• Bila kecil cukup dengan lobektomi dan isthmectomy
• Bila besar dilakukan total atau “near total” thyroidectomy
• Prognosis : relatif baik
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Karsinoma papiler
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KARSINOMA FOLIKULER
• Didapati 10-20% dari keganasan tiroid
• Wanita : laki-laki = 3 : 1
• Umur penderita rata-rata 50 tahun
• Penyebaran sering hematogen ke tulang, paru-paru dan hepar
• Penanganan : operasi
• Prognosis : lebih jelek dibanding papiler
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Karsinoma folikuler
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KARSINOMA MEDULER
• 5% dari keganasan tiroid
• Berasal dari C cells / para follicular cells (penghasil kalsitonin)
• Disertai nyeri, disfagi, dispnea dan disfoni
• Wanita : laki-laki = 1.5 : 1
• Umur penderita sekitar 50 – 60 tahun
• Operasi pilihan : total thyroidectomy
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Karsinoma meduler
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KARSINOMA ANAPLASTIK
• Paling ganas dari keganasan tiroid
• Tumbuh cepat, dapat merupakan perubahan dari yang berdiferensiasi
• Disertai nyeri, disfoni dan dispnoe
• Jarang yg dapat hidup 6 bulan sesudah diagnosis, umumnya 3 bulan sudah meninggal
• Tidak ada modalitas terapi yg memuaskan
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Relative incidence %
Papillary Ca 60
Follicular Ca 20
Anaplastic Ca 10
Medullary Ca 5
Malignant lymphoma 5
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Papillary
%
Follicular
%
Male incidence 22 35
Lymph node metastasis 35 13
Blood vessel invasion 40 60
Recurrence rate 19 29
Overall mortality rate 11 24
Perbedaan Ca papiler dan Folikuler
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TINDAKAN INDIKASI
Biopsi insisi Struma difusa (utk diagnosis)
Biopsi eksisi Tumor/nodul terbatas (diagnosis)
Tiroidektomi Hipertiroidi / Graves
Subtotal tiroidektomi Struma nodosa
Hemitiroidektomi Adenoma unilateral
Tiroidektomi total Keganasan
Tirodektomi radikal Keganasan dgn metastasis
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KOMPLIKASI
• Perdarahan
• Hematoma
• Tracheomalacia
• Edema laring
• “Thyroid storm” / krisis tiroid
• Terpotongnya N recurrens
• Terangkatnya paratiroid
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QUESTIONS
?
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• Pembesaran kel tiroid umumnya jinak, berupa struma
• Struma diffusa masih reversibel
• Struma nodosa bila ada keluhan dan curiga ganas operasi
• Keganasan yang berdiferensiasi baik prognosisnya baik, terutama karsinoma papiler
• Karsinoma anaplastik prognosisnya paling buruk
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• Tindakan bedah untuk hipertirodi, tiroiditis diperlukan bila medikamentosa tidak memuaskan