THYROID James Taclin C. Banez, M.D., FPSGS, FPCS.

THYROIDTHYROIDJames Taclin C. Banez, M.D., FPSGS, James Taclin C. Banez, M.D., FPSGS,

FPCSFPCS

ANATOMY:ANATOMY:• Location / PartsLocation / Parts• Arteries / Venous drainageArteries / Venous drainage• Nerve SupplyNerve Supply

• Sympathetic (Sympathetic (cervical cervical ganglionganglion))

• Parasympathetis (Parasympathetis (vagusvagus))• Histology:Histology:

• Thyroid follicle Thyroid follicle ((thyroglobulinthyroglobulin))

• C cells (C cells (neuroectoderm – 4neuroectoderm – 4thth and 5and 5thth ultimo brachial ultimo brachial bodiesbodies).).

PHYSIOLOGY:PHYSIOLOGY:• Synthesis & secrets Synthesis & secrets

thyroid hormone thyroid hormone (thyroid follicle)(thyroid follicle)

1.1. Iodide uptakeIodide uptake

2.2. Oxidation of iodide to Oxidation of iodide to iodineiodine

3.3. Organification Organification (thyroxin-iodine) MIT / (thyroxin-iodine) MIT / DITDIT

4.4. Coupling of inactive Coupling of inactive iodotyrosine T4 /T3iodotyrosine T4 /T3• Stored ----> released Stored ----> released

by protease / by protease / peptidasepeptidase

• Calcium LevelCalcium Level• Calcitonin Calcitonin (C cell)(C cell)

Evaluation of Thyroid Evaluation of Thyroid DiseasesDiseases

1.1. Clinical history and physical Clinical history and physical examinationexamination

2.2. Serum T3 & T4, Serum T3 & T4, TSHTSH determinationdetermination

3.3. Thyroid scanThyroid scan

4.4. Thyroid ultrasoundThyroid ultrasound

5.5. CT scan / MRICT scan / MRI

6.6. FNACFNAC

HYPERTHYROIDISM HYPERTHYROIDISM (Thyrotoxicosis)(Thyrotoxicosis)

A.A. With increase thyroid hormone With increase thyroid hormone secretionsecretion

1.1. Grave’s diseaseGrave’s disease2.2. Toxic nodular goiterToxic nodular goiter3.3. Toxic thyroid adenomaToxic thyroid adenoma

B.B. With out increased thyroid With out increased thyroid hormone secretionhormone secretion

1.1. Sub-acute thyroiditisSub-acute thyroiditis2.2. Functioning metastatic thyroid cancerFunctioning metastatic thyroid cancer3.3. Struma ovariiStruma ovarii

HYPERTHYROIDISMHYPERTHYROIDISMGRAVE’S Disease (Diffuse Thyroid GRAVE’S Disease (Diffuse Thyroid

Goiter)Goiter)• Most common form of thyrotoxicosisMost common form of thyrotoxicosis• AutoimmuneAutoimmune• Female > male; most prevalent 20-40 y/oFemale > male; most prevalent 20-40 y/o• Thyroid stimulating antibodyThyroid stimulating antibody

(immunoglobulin)(immunoglobulin)directed at the TSH receptor or the thyroid directed at the TSH receptor or the thyroid follicular cells.follicular cells.

• LATSLATS (long acting thyroid stimulating (long acting thyroid stimulating antibody)antibody)

• TRAb TRAb (thyroid receptor antibody)(thyroid receptor antibody)


Goiter)Goiter)• Manifestations:Manifestations:

• Signs/symptoms of thyrotoxicosis:Signs/symptoms of thyrotoxicosis:• heat intoleranceheat intolerance• sweatingsweating• weight loss, muscle wastingweight loss, muscle wasting• tachycardia/atrial fibrillationtachycardia/atrial fibrillation• fine tremorsfine tremors• easy fatigabilityeasy fatigability• hypoactive tendon reflexeshypoactive tendon reflexes• amenorrheaamenorrhea• decrease fertilitydecrease fertility• easy fatigability, agitation and excitabilityeasy fatigability, agitation and excitability• diarrheadiarrhea


Goiter)Goiter)• Triad:Triad:

• diffuse goiterdiffuse goiter• thyrotoxicosisthyrotoxicosis• exopthalmosexopthalmos

• Other:Other:• hair losshair loss• pretibial myxedemapretibial myxedema• gynecomastiagynecomastia• splenomegallysplenomegally

HYPERTHYROIDISMHYPERTHYROIDISMGRAVE’S Disease:GRAVE’S Disease:Exopthalmos:Exopthalmos:• Due to increase retro-bulbar Due to increase retro-bulbar

tissue:tissue:• Spasm of the upper eyelid, Spasm of the upper eyelid,

revealing the sclera above revealing the sclera above the corneoscleral limbus the corneoscleral limbus (Dalrymple’s sign)(Dalrymple’s sign)

• Lid lag Lid lag (von graefes sign)(von graefes sign)• External ophthalmoplegiaExternal ophthalmoplegia

(inability to move the (inability to move the eyeball)eyeball)

• Supra and infraorbital Supra and infraorbital swellingswelling

• Congestion and edema of the Congestion and edema of the conjunctiva and sclera conjunctiva and sclera (chemosis)(chemosis) ----> ----> ulcerationulceration

• Progression --> damage of Progression --> damage of optic nerve --> decreases optic nerve --> decreases visual acuity and impairment visual acuity and impairment of color vision (of color vision (malignant malignant exopthalmosexopthalmos) not corrected ) not corrected surgically --> surgically --> blindnessblindness

HYPERTHYROIDISMHYPERTHYROIDISM• Diagnosis:Diagnosis:

• Autonomous thyroid functionAutonomous thyroid function• Low TSHLow TSH• Elevated T3 / T4Elevated T3 / T4• Thyroid scan ---> diffuse elevated iodine uptakeThyroid scan ---> diffuse elevated iodine uptake

• Treatment:Treatment:• Choices:Choices:

1.1. Antithyroid drugsAntithyroid drugs2.2. Radioactive iodine therapyRadioactive iodine therapy3.3. SurgerySurgery

• Choice depends on:Choice depends on:1.1. AgeAge2.2. Severity of the diseaseSeverity of the disease3.3. Size of the glandSize of the gland4.4. Coexistent pathology (Ophthalmoplegia)Coexistent pathology (Ophthalmoplegia)5.5. Other factors:Other factors:

a.a. Patient’s preferencePatient’s preferenceb.b. PregnancyPregnancy

HYPERTHYROIDISMHYPERTHYROIDISMAntithyroid Drugs:Antithyroid Drugs:1.1. Propyl thiouracil (PTU)Propyl thiouracil (PTU) = 100-300mg TID= 100-300mg TID2.2. Methimazole (Tapazole)Methimazole (Tapazole) = 10-20 TID then OD= 10-20 TID then OD3.3. CarbimazoleCarbimazole = 40mg OD= 40mg OD

• Inhibits the organic binding of iodine and coupling Inhibits the organic binding of iodine and coupling of iodotyrosineof iodotyrosine

• PTU PTU can also lower conversion of T4 to T3; it can can also lower conversion of T4 to T3; it can also decrease thyroid autoantibody levelsalso decrease thyroid autoantibody levels

• Disadvantage of these drugs.Disadvantage of these drugs.a.a. Crosses the placenta --> inhibits fetal thyroid functionCrosses the placenta --> inhibits fetal thyroid functionb.b. Excreted in breast milkExcreted in breast milkc.c. Side effects:Side effects:

a.a. Skin rashesSkin rashesb.b. FeverFeverc.c. Peripheral neuritisPeripheral neuritisd.d. PolyarteritisPolyarteritise.e. Granulocytopenia (reversible)Granulocytopenia (reversible)f.f. Agranulocytosis / aplastic anemia (poor prognosis)Agranulocytosis / aplastic anemia (poor prognosis)

HYPERTHYROIDISMHYPERTHYROIDISM• Beta blockers (propranolol) – to Beta blockers (propranolol) – to

alleviate peripheral adrenergic effectsalleviate peripheral adrenergic effects

• Advised medical managementAdvised medical management• Small diffusely enlarge gland or larger glands Small diffusely enlarge gland or larger glands

that decreases in size due to antithyroid drugsthat decreases in size due to antithyroid drugs

• Toxic nodule goiters or large diffuse Toxic nodule goiters or large diffuse glands or hyperthyroidism when drug glands or hyperthyroidism when drug was discontinued ---> was discontinued ---> thyroidectomy / thyroidectomy / radioactive iodineradioactive iodine

HYPERTHYROIDISMHYPERTHYROIDISMRadioactive Iodine Therapy:Radioactive Iodine Therapy:Advantages:Advantages:

• Avoidance of surgery (no injury to nerve / parathyroid Avoidance of surgery (no injury to nerve / parathyroid gland)gland)

• Reduce cost & ease of treatmentReduce cost & ease of treatment

Disadvantages:Disadvantages:• Lifelong thyroxin replacement therapyLifelong thyroxin replacement therapy• Slower correction of hyperthyroidismSlower correction of hyperthyroidism• Higher relapse rateHigher relapse rate• Adverse effect of ophthalmopathyAdverse effect of ophthalmopathy

Suitable treatment:Suitable treatment:• Small or moderate size goiterSmall or moderate size goiter• Relapse after medical and surgical therapyRelapse after medical and surgical therapy• Antithyroid drug and surgery are contraindicatedAntithyroid drug and surgery are contraindicated

Contraindicated:Contraindicated:• Pregnant / breast feedingPregnant / breast feeding• Ophthalmopathy (progression of eye signs)Ophthalmopathy (progression of eye signs)• Isolated nodular goiter or toxic nodular goiterIsolated nodular goiter or toxic nodular goiter• Young age (children/adolescence ----> Infertility / Young age (children/adolescence ----> Infertility /

carcinomacarcinoma

HYPERTHYROIDISMHYPERTHYROIDISMRadioactive Iodine Therapy:Radioactive Iodine Therapy:Pt. is placed in euthyroid state with anti-Pt. is placed in euthyroid state with anti-

thyroid drugs. Then discontinue the thyroid drugs. Then discontinue the drugs for 2-3 wks before RAI tx is drugs for 2-3 wks before RAI tx is started (started (I 131 sodium iodideI 131 sodium iodide))

Complication of RAI tx:Complication of RAI tx:1.1. Exacerbations of thyrotoxicosis with Exacerbations of thyrotoxicosis with

arrhythmiaarrhythmia

2.2. Overt thyroid stormOvert thyroid storm

3.3. HypothyroidismHypothyroidism

4.4. Risk of fetal damageRisk of fetal damage

5.5. Worsening of eye signWorsening of eye sign

6.6. HyperparathyroidismHyperparathyroidism

HYPERTHYROIDISMHYPERTHYROIDISMThyroid Surgery:Thyroid Surgery:Indicated to:Indicated to:

1.1. Young patientYoung patient2.2. With Grave ophthalmopathyWith Grave ophthalmopathy3.3. PregnantPregnant4.4. With suspicious thyroid nodule in Grave’s glandWith suspicious thyroid nodule in Grave’s gland5.5. Large nodular toxic goiter w/ low level of radioactive iodine uptake.Large nodular toxic goiter w/ low level of radioactive iodine uptake.

Placed patient to euthyroid state prior to thyroid surgery:Placed patient to euthyroid state prior to thyroid surgery:1.1. Antithyroid drugsAntithyroid drugs2.2. Lugol’s iodine solution (3 drops BID)Lugol’s iodine solution (3 drops BID)3.3. PropranololPropranolol

Thyroidectomy:Thyroidectomy:1.1. Bilateral subtotal thyroidectomy Bilateral subtotal thyroidectomy 2.2. Total lobectomy & subtotal lobectomy contra-lateral (Hartley-Total lobectomy & subtotal lobectomy contra-lateral (Hartley-

Dunhill)Dunhill)3.3. Total thyroidectomyTotal thyroidectomy

Advantages over RAI:Advantages over RAI:1.1. Immediate cure of the diseaseImmediate cure of the disease2.2. Low incidence of hypothyroidismLow incidence of hypothyroidism3.3. Potential removal of coexisting thyroid carcinomaPotential removal of coexisting thyroid carcinoma

Disadvantages:Disadvantages:1.1. Complication ---> nerve injury (1%) and hypoparathyroidism (13% Complication ---> nerve injury (1%) and hypoparathyroidism (13%

transient/ 1% permanent).transient/ 1% permanent).2.2. HematomaHematoma3.3. Hypertrophic scar formationHypertrophic scar formation

HYPERTHYROIDISMHYPERTHYROIDISM• Recurrent thyrotoxicosis after Recurrent thyrotoxicosis after

surgery---> surgery---> RAIRAI

Treatment of Exopthalmos:Treatment of Exopthalmos:1.1. Tape eyelids at nightTape eyelids at night

2.2. Wear eyeglassesWear eyeglasses

3.3. Steroid eye drop / systemic steroid Steroid eye drop / systemic steroid (60mg prednisone OD) alleviate (60mg prednisone OD) alleviate chemosis.chemosis.

4.4. Lateral tarsorrhaphy to oppose eyelidsLateral tarsorrhaphy to oppose eyelids

5.5. Radio-orbital radiation or orbital Radio-orbital radiation or orbital decompressiondecompression

HYPERTHYROIDISMHYPERTHYROIDISMToxic Nodular Goiter (Plummers’ Toxic Nodular Goiter (Plummers’

disease):disease):• No extrathyroidal manifestationNo extrathyroidal manifestation• Milder than Grave’s diseaseMilder than Grave’s disease• Treatment:Treatment:

• PropranololPropranolol• Thyroidectomy (lobectomy with isthmectomy)Thyroidectomy (lobectomy with isthmectomy)

Toxic adenoma:Toxic adenoma:• Solitary toxic nodule (Follicular) tumorSolitary toxic nodule (Follicular) tumor• Thyrotoxicosis is uncommon unless it is 3 Thyrotoxicosis is uncommon unless it is 3

cm in size or more.cm in size or more.

Thyroid storm:Thyroid storm:• Life threateningLife threatening• Precipitated by:Precipitated by:

1.1. Infection (pharyngitis / pneumonitis)Infection (pharyngitis / pneumonitis)

2.2. Iodine 131 treatmentIodine 131 treatment

• Prophylactic treatment: --- Surgery in euthyroid Prophylactic treatment: --- Surgery in euthyroid statestate

• Treatment:Treatment:1.1. Fluid replacementFluid replacement

2.2. Antithyroid drugAntithyroid drug

3.3. Beta blockerBeta blocker

4.4. Lugol’s iodine solutionLugol’s iodine solution

5.5. HydrocortisoneHydrocortisone

6.6. Cooling blanketCooling blanket

7.7. SedationSedation

8.8. Extreme cases ----> peritoneal dialysis or hemofiltration to Extreme cases ----> peritoneal dialysis or hemofiltration to lowe T4&T3lowe T4&T3

• Avoid ASPIRIN ---> increases free thyroid hormone levelsAvoid ASPIRIN ---> increases free thyroid hormone levels

HYPOTHYROIDISMHYPOTHYROIDISMCauses:Causes:A.A. Primary:Primary:

1.1. Autoimmune thyroiditisAutoimmune thyroiditis• Hashimotos thyroiditisHashimotos thyroiditis• Primary myxedemaPrimary myxedema

2.2. IatrogenicIatrogenic• ThyroidectomyThyroidectomy• Iodine 131 txIodine 131 tx• Antithyroid drugsAntithyroid drugs

3.3. Congenital (Cretinism)Congenital (Cretinism)• Thyroid dysgenesisThyroid dysgenesis• DyshormonogenesisDyshormonogenesis

4.4. InflammatoryInflammatory• Subacute thyroiditisSubacute thyroiditis• Riedels thyroiditisRiedels thyroiditis

5.5. MetabolismMetabolism• Iodine deficiencyIodine deficiency

B.B. Secondary:Secondary:1.1. HypopituitarismHypopituitarism2.2. Hypothalamic hypothyroidismHypothalamic hypothyroidism3.3. Peripheral resistance to thyroid hormonePeripheral resistance to thyroid hormone

Treatment:Treatment:L-thyroxine (50-100ug)L-thyroxine (50-100ug)

THYROIDITISTHYROIDITISA.A. Acute Suppurative ThyroiditisAcute Suppurative Thyroiditis

• UncommonUncommon• Associated with URTIAssociated with URTI• Staphylococcuc, Streptococcus and Staphylococcuc, Streptococcus and

PneumococciPneumococci

E. ColiE. Coli• Sx:Sx: - acute thyroid pain- acute thyroid pain

- dysphagiadysphagia

- fever- fever• Dx:Dx: - FNA ----> smear and CS- FNA ----> smear and CS• Tx:Tx: - IV antibiotics / drain - IV antibiotics / drain

(abscess)(abscess)

THYROIDITISTHYROIDITISB.B. Nonsuppurative Thyroiditis:Nonsuppurative Thyroiditis:

1.1. Hashimotos diseaseHashimotos disease (Autoimmune lymphocytic (Autoimmune lymphocytic thyroiditis)thyroiditis)

• Most common form of chronic lymphocytic thyroiditisMost common form of chronic lymphocytic thyroiditis• Autoimmune disease:Autoimmune disease:

• Antithyroglobulin / antimicrosomal antibodiesAntithyroglobulin / antimicrosomal antibodies• 10 x more in females; 30 – 60y/o10 x more in females; 30 – 60y/o• Familial; 50% in first degree relativesFamilial; 50% in first degree relatives• Predisposing factors:Predisposing factors:

1.1. Down syndromeDown syndrome2.2. Familial Alzheimer’s diseaseFamilial Alzheimer’s disease3.3. Turner syndromeTurner syndrome

• Can co-exist with Can co-exist with papillary CApapillary CA• S/Sx: - Tightness in the throat (most common)S/Sx: - Tightness in the throat (most common)

- Painless, nontender enlargement of gland- Painless, nontender enlargement of gland• Dx:Dx: - Increase TSH, decrease T3 & T4- Increase TSH, decrease T3 & T4

- (+) Anti-thyroid antibodies- (+) Anti-thyroid antibodies- FNA ---> rule out CA (confirmatory)- FNA ---> rule out CA (confirmatory)

• Tx:Tx: - Medical if w/o compression ---->- Medical if w/o compression ---->thyroid hormonethyroid hormone

- Surgical:- Surgical: 1. Obstructive1. Obstructive2. Cosmetically unacceptable 2. Cosmetically unacceptable 3. Thyroid carcinoma coexist3. Thyroid carcinoma coexist


2.2. Subacute ThyroiditisSubacute Thyroiditis (De Quervans (De Quervans Thyroiditis / Giant Cell Thyroiditis)Thyroiditis / Giant Cell Thyroiditis)

• Exact cause unknownExact cause unknown• Female 5x more the malesFemale 5x more the males• 20 – 40 y/o20 – 40 y/o• S/Sx:S/Sx: - Tender enlargement of the - Tender enlargement of the

glandgland- Fever, malaise w/ - Fever, malaise w/

unilateral or bilateral unilateral or bilateral thyroid pain thyroid pain• Dx:Dx: - FNA- FNA

- ESR (increase)- ESR (increase)- Neutrophilia- Neutrophilia

• Tx:Tx: - NSAIDS- NSAIDS- Prednisone- Prednisone


3.3. Riedels’ Thyroiditis:Riedels’ Thyroiditis:• Marked dense invasive fibrosisMarked dense invasive fibrosis that may involve that may involve

surrounding structuressurrounding structures• Can cause hypoparathyroidismCan cause hypoparathyroidism• Unknown cause ( maybe part of fibrosclerosis – Unknown cause ( maybe part of fibrosclerosis –

retroperitoneum, mediastinum, lacrimal gland and bile retroperitoneum, mediastinum, lacrimal gland and bile duct)duct)

• S/Sx: - Compression symptomsS/Sx: - Compression symptoms

- Hoarseness - dyspnea- Hoarseness - dyspnea

- stridor- stridor - dysphagia - dysphagia

• Tx:Tx: - Tamoxifen - Tamoxifen

- Steroid- Steroid

- Isthmectomy – to relieve- Isthmectomy – to relieve

compression symptomcompression symptom

- Thyroxine replacement- Thyroxine replacement

GOITERGOITER• Enlargement of the thyroid gland in Enlargement of the thyroid gland in

a euthyroid pt a euthyroid pt not associatednot associated with neoplasm or inflammation:with neoplasm or inflammation:

1.1. Familial:Familial:• Inherited enzymatic defect Inherited enzymatic defect

(dyshormonogenesis)(dyshormonogenesis)• Autosomal recessiveAutosomal recessive• Hypothyroidism / euthyroidHypothyroidism / euthyroid

2.2. Endemic:Endemic:• Iodine deficiencyIodine deficiency

3.3. Sporadic:Sporadic:• No definite cause, excludes goiter caused No definite cause, excludes goiter caused

by thyroiditis and neoplasm as well as by thyroiditis and neoplasm as well as endemic goiterendemic goiter

GOITERGOITER

Pathology:Pathology:• May be diffusely May be diffusely

enlarged and smooth, enlarged and smooth, or enlarged markedly or enlarged markedly nodularnodular

• Nodules are filled w/ Nodules are filled w/ gelatinous, colloid rich gelatinous, colloid rich material and scattered material and scattered between areas of between areas of normal thyroid tissuesnormal thyroid tissues

• With areas of With areas of degeneration, degeneration, hemorrhage and hemorrhage and calcification.calcification.

GOITERGOITERS/Sx:S/Sx:• Asymptomatic usuallyAsymptomatic usually• Pressure symptoms Pressure symptoms

usually usually 1.1. DysphagiaDysphagia2.2. DyspneaDyspnea3.3. Paralysis of recurrent Paralysis of recurrent

laryngeal nervelaryngeal nerve4.4. Sudden pain associated Sudden pain associated

with rapid enlargement of with rapid enlargement of the gland ---> hemorrhage the gland ---> hemorrhage into a colloid nodule or into a colloid nodule or cystcyst

5.5. Superior mesenteric Superior mesenteric syndrome due retro-syndrome due retro-sternal extension causing sternal extension causing facial flushing that is facial flushing that is accentuated by raising his accentuated by raising his arm above the head arm above the head (Pemberton’s sign).(Pemberton’s sign).

GOITERGOITERDx:Dx:

• FNACFNAC ---> specially if one nodule predominates, ---> specially if one nodule predominates, or painful or has recently enlarged. or painful or has recently enlarged. To rule out To rule out CACA

• TSH, T3 & T4 ---> usually normalTSH, T3 & T4 ---> usually normal---> pts > 60y/o w/ long ---> pts > 60y/o w/ long

standing multinodular goiters (>17yrs) develops standing multinodular goiters (>17yrs) develops thyrotoxicosis (Plummer’s dse). Low TSH w/ thyrotoxicosis (Plummer’s dse). Low TSH w/ increased T3 but normal T4 (T3 toxicosis)increased T3 but normal T4 (T3 toxicosis)

Tx:Tx:• No tx for euthyroid, small, diffuse goiterNo tx for euthyroid, small, diffuse goiter• Thyroxine ---> for large diffuse goiter; to Thyroxine ---> for large diffuse goiter; to

depress TSH stimulation and reduce hyperplasiadepress TSH stimulation and reduce hyperplasia• Iodine ---> for endemic goiterIodine ---> for endemic goiter• Surgery:Surgery:

1.1. Cosmetically acceptableCosmetically acceptable2.2. Compression symptomsCompression symptoms3.3. Suspicion for malignancySuspicion for malignancy

Solitary or Dominant Thyroid Solitary or Dominant Thyroid NoduleNodule• Most are benign (colloid nodule/adenomas)Most are benign (colloid nodule/adenomas)

Physician should:Physician should:1.1. Perform an accurate clinical assessmentPerform an accurate clinical assessment2.2. Appreciate the risk factors for thyroid carcinomaAppreciate the risk factors for thyroid carcinoma3.3. Which pts would benefit from surgeryWhich pts would benefit from surgery

Risk factors for thyroid CA:Risk factors for thyroid CA:1.1. Low-dose radiation to head & neck (<2000 rad)Low-dose radiation to head & neck (<2000 rad)

- >2000rads causes destruction of thyroid gld.- >2000rads causes destruction of thyroid gld.- tends to be papillary type, multi-focal w/ higher incidence of LN - tends to be papillary type, multi-focal w/ higher incidence of LN metastases.metastases.

2.2. Family hx of thyroid CAFamily hx of thyroid CA- - Medullary CAMedullary CA – inherited as an autosomal dominanat trait – inherited as an autosomal dominanat trait- - PapillaryPapillary CA CA – 6% familial dse. – 6% familial dse.

3.3. AgeAge- thyroid nodule in - thyroid nodule in children and elderlychildren and elderly are more likely to be are more likely to be malignant.malignant.

4.4. SignsSignsa.a. Rapid enlargement of an old or new noduleRapid enlargement of an old or new noduleb.b. Symptoms of local invasion or compression symptomsSymptoms of local invasion or compression symptomsc.c. Consistency: Hard, gritty or fixed to surrounding structuresConsistency: Hard, gritty or fixed to surrounding structuresd.d. Palpable cervical lymphadenopathyPalpable cervical lymphadenopathye.e. A A cyst larger than 4 cmcyst larger than 4 cm in diameter or in ultrasound is complex has in diameter or in ultrasound is complex has

15% incidence of malignancy15% incidence of malignancy

Solitary or Dominant Thyroid Solitary or Dominant Thyroid NoduleNodule

Work up for Thyroid nodule:Work up for Thyroid nodule:

1.1. FNACFNAC – procedure of choice– procedure of choice

benignbenign -- 65%65% false (+) - 1%false (+) - 1%

malignantmalignant-- 5% 5% false (-) - 5%false (-) - 5%

SuspiciousSuspicious -- 15%15%

Non-diagnosticNon-diagnostic15%15%• Limitation of FNAC:Limitation of FNAC:

1.1. Follicular or Hurtle cell neoplasm (needs vascular and Follicular or Hurtle cell neoplasm (needs vascular and capsular invasion)capsular invasion)

2.2. Hx of head and neck radiation and family hx of thyroid CA Hx of head and neck radiation and family hx of thyroid CA usually has multifocal lesions.usually has multifocal lesions.

• If FNAC encountered a cyst ---> drain completely If FNAC encountered a cyst ---> drain completely 75% is curative; if cyst persist after 3 attempts 75% is curative; if cyst persist after 3 attempts ---> unilateral lobectomy ---> unilateral lobectomy


Work up for Thyroid nodule:Work up for Thyroid nodule:2.2. Thyroid ultrasonography:Thyroid ultrasonography:

• Use to a) follow up the size of suspected Use to a) follow up the size of suspected benign benign nodules diagnosed by FNACnodules diagnosed by FNAC

b) to detect presence of non-b) to detect presence of non-palpable palpable

nodules to locate and nodules to locate and differentiate it differentiate it for cyst or solidfor cyst or solid

3.3. MRI / CT scan:MRI / CT scan:• For large retro-sternal extensionFor large retro-sternal extension• For recurrent or persistent thyroid tumor For recurrent or persistent thyroid tumor

and to differentiate recurrence from and to differentiate recurrence from postoperative fibrosispostoperative fibrosis

• Detect the presence of invasion, sign of CA.Detect the presence of invasion, sign of CA.


Work up for Thyroid nodule:Work up for Thyroid nodule:4.4. Thyroid isotope imaging:Thyroid isotope imaging:

• Check the function and locate small lesionsCheck the function and locate small lesions• Cold -----------> 10 – 25% malignantCold -----------> 10 – 25% malignant• Hot -----------> 1% malignantHot -----------> 1% malignant

5.5. Laboratory:Laboratory:a.a. Thyroid function test:Thyroid function test:

• Not useful in assessing thyroid noduleNot useful in assessing thyroid nodule

b.b. Serum thyroglobulin level:Serum thyroglobulin level:• To detect presence of metastatic lesionsTo detect presence of metastatic lesions• Check completion of thyroidectomyCheck completion of thyroidectomy• Not used in medullary and anaplastic thyroid CANot used in medullary and anaplastic thyroid CA

c.c. Serum calcitonin:Serum calcitonin:• Follow up in Follow up in medullary CAmedullary CA

d.d. RET oncogensRET oncogens (+) pt should have 24 hrs urine (+) pt should have 24 hrs urine determination of VMA, metanephrine and determination of VMA, metanephrine and cathecolamine to rule out a coexisting cathecolamine to rule out a coexisting pheochromocytoma pheochromocytoma (for medullary CA)(for medullary CA)


Approach for Thyroid NoduleApproach for Thyroid Nodule

MALIGNANT THYROIDMALIGNANT THYROID• 90 – 95% are differentiated 90 – 95% are differentiated

tumor w/ follicular origintumor w/ follicular origin1.1. Papillary thyroid adenocarcinomaPapillary thyroid adenocarcinoma2.2. Follicular adenocarcinomaFollicular adenocarcinoma3.3. Hurtle cell carcinomaHurtle cell carcinoma

• 6% arise from parafollicular 6% arise from parafollicular cells:cells:

1.1. Medullary carcinoma of thyroidMedullary carcinoma of thyroid

• 1% poorly differentiated1% poorly differentiated1.1. Anaplastic thyroid carcinomaAnaplastic thyroid carcinoma

MALIGNANT THYROIDMALIGNANT THYROIDOncogene associated w/ Thyroid Oncogene associated w/ Thyroid

carcinoma:carcinoma:1.1. RET oncogene:RET oncogene:

• Seen in Seen in papillary and medullary thyroid papillary and medullary thyroid CACA

• Located in Located in chromosome 10chromosome 10

2.2. TRK – A:TRK – A:• Chromosome 1Chromosome 1

3.3. Mutated ras oncogenes:Mutated ras oncogenes:• Follicular thyroid carcinomaFollicular thyroid carcinoma, thyroid , thyroid

adenoma and multinodular goiteradenoma and multinodular goiter

4.4. Mutated p53 gene:Mutated p53 gene:• Anaplastic thyroid carcinomaAnaplastic thyroid carcinoma

MALIGNANT THYROIDMALIGNANT THYROIDPapillary Thyroid Carcinoma:Papillary Thyroid Carcinoma:

• Most common (80%)Most common (80%)• Predominant thyroid CA in children (75%)Predominant thyroid CA in children (75%)• Usually due to radiation exposure of the neck (85-90%)Usually due to radiation exposure of the neck (85-90%)• Multi-focal (30-88%); has LN spread (para-tracheal & Multi-focal (30-88%); has LN spread (para-tracheal &

cervical LN).cervical LN).• Can invade trachea, esophagus and recurrent Can invade trachea, esophagus and recurrent

laryngeal nerve; late hematogenous spread.laryngeal nerve; late hematogenous spread.• Mixed tumor (papillary & follicular):Mixed tumor (papillary & follicular): variant of variant of

papillary CA, but classified as papillary for it papillary CA, but classified as papillary for it biologically acts as papillary CA.biologically acts as papillary CA.

• Orphan Annie Nuclei:Orphan Annie Nuclei:• Characteristic cellular featureCharacteristic cellular feature• Abundant cytoplasm, crowded nuclei Abundant cytoplasm, crowded nuclei

and intra-nuclear cytoplasmic inclusionand intra-nuclear cytoplasmic inclusion

MALIGNANT THYROIDMALIGNANT THYROIDPapillary Thyroid Carcinoma:Papillary Thyroid Carcinoma:3 forms of papillary CA (based on size and 3 forms of papillary CA (based on size and

extent):extent):1.1. Minimal or occult / micro carcinomaMinimal or occult / micro carcinoma

• 1 cm or less, no capsular invasion1 cm or less, no capsular invasion• Non-palpable and usually an incidental finding Non-palpable and usually an incidental finding

intra-op or autopsyintra-op or autopsy• Recurrence rate ----> 7%Recurrence rate ----> 7%• Mortality ------------> 0.5%Mortality ------------> 0.5%

2.2. Intra-thyroidal Tumors:Intra-thyroidal Tumors:• > 1cm and confined to the thyroid gland> 1cm and confined to the thyroid gland• (-) extra thyroidal invasion(-) extra thyroidal invasion

3.3. Extra-thyroidal Tumors:Extra-thyroidal Tumors:• Locally advanced with invasion through the Locally advanced with invasion through the

thyroid capsule into adjacent structures.thyroid capsule into adjacent structures.• All types can be associated w/ LN metastases All types can be associated w/ LN metastases

and intra-thyroidal blood vessel invasion or and intra-thyroidal blood vessel invasion or occasionally metastasesoccasionally metastases

MALIGNANT THYROIDMALIGNANT THYROIDPapillary Thyroid Carcinoma:Papillary Thyroid Carcinoma:S/Sx:S/Sx:

• Euthyroid, slow growing painless massEuthyroid, slow growing painless mass• Signs of local invasions:Signs of local invasions:

• DysphagiaDysphagia• DyspneaDyspnea• Hoarseness of voiceHoarseness of voice

• Palpable cervical LN more apparent than primary Palpable cervical LN more apparent than primary lesion (lateral aberrant thyroid)lesion (lateral aberrant thyroid)

• Uncommon distant metastases (lung metastases Uncommon distant metastases (lung metastases in in childrenchildren))

Diagnosis:Diagnosis:• FNAC (specific and sensitive for papillary, FNAC (specific and sensitive for papillary,

medullary and anaplastic)medullary and anaplastic)• CT/MRI in pts w/ extensive local or sub-sternal CT/MRI in pts w/ extensive local or sub-sternal

extensionextension

MALIGNANT THYROIDMALIGNANT THYROIDPapillary Thyroid Carcinoma:Papillary Thyroid Carcinoma:Prognostic indicators: Prognostic indicators: (85% 10yrs (85% 10yrs

survival)survival)1.1. AGES scale:AGES scale:

A- ageA- age G- grade G- grade E- extentE- extent S- sizeS- size

2.2. MACIS scale:MACIS scale:

M- metastases A- age C- M- metastases A- age C- completeness of resection completeness of resection

I- extra thyroidal invasionI- extra thyroidal invasion S- size S- size

3.3. AMESAMES

4.4. TNMTNM

• Distant metastasesDistant metastases (bone): most (bone): most significant prognostic indicator overallsignificant prognostic indicator overall

MALIGNANT THYROIDMALIGNANT THYROIDPapillary Thyroid Carcinoma: Papillary Thyroid Carcinoma:

(SURGERY)(SURGERY)• Lobectomy with isthmectomyLobectomy with isthmectomy acceptable for acceptable for

minimal papillary thyroid CAminimal papillary thyroid CA• Total thyroidectomyTotal thyroidectomy (near total) if: (near total) if:

1.1. Size: if tumor > 3cmSize: if tumor > 3cm2.2. Age: male > 40y/oAge: male > 40y/o female > 50y/ofemale > 50y/o3.3. AngioinvasionAngioinvasion4.4. Distant metastasesDistant metastases

• Thyroidectomy w/ modified radical neck Thyroidectomy w/ modified radical neck dissectiondissection::

• If with clinically palpable cervical lymphadenopathyIf with clinically palpable cervical lymphadenopathy• Not done for prophylaxisNot done for prophylaxis

• Reasons for total thyroidectomy:Reasons for total thyroidectomy:1.1. 85% is multifocal85% is multifocal2.2. To decrease incidence of anaplasia in any residual tissueTo decrease incidence of anaplasia in any residual tissue3.3. Facilitate the diagnosis of unsuspected metastatic disease by Facilitate the diagnosis of unsuspected metastatic disease by

RAI scanning or treatmentRAI scanning or treatment4.4. Greater sensitivity of blood thyroglobulin level to predict Greater sensitivity of blood thyroglobulin level to predict

recurrent or persistent of the disease.recurrent or persistent of the disease.

MALIGNANT THYROIDMALIGNANT THYROIDFollicular Thyroid Carcinoma:Follicular Thyroid Carcinoma:• 10%; Female > Male (3:1), mean age= 50y/o10%; Female > Male (3:1), mean age= 50y/o• More frequent in Iodine deficiency areaMore frequent in Iodine deficiency area• Vascular invasion & hematogenous spread is more common Vascular invasion & hematogenous spread is more common

(bone, lung and liver).(bone, lung and liver).• Types:Types:

1.1. Minimally invasive tumor:Minimally invasive tumor:• Invasion into but not through the tumor capsuleInvasion into but not through the tumor capsule• Previously called atypical adenomaPreviously called atypical adenoma

2.2. Invasive tumors (capsular/vascular)Invasive tumors (capsular/vascular)• 1% thyrotoxic1% thyrotoxic• Dx / Tx:Dx / Tx:

• FNAC not helpful ----> lobectomy and isthmectomy (frozen section) FNAC not helpful ----> lobectomy and isthmectomy (frozen section) ----> (+) total thyroidectomy ----> iodine 131 to detect distant ----> (+) total thyroidectomy ----> iodine 131 to detect distant metastases and for ablation.metastases and for ablation.

• Prognosis: Prognosis: 1.1. Age over 50y/oAge over 50y/o2.2. > 4cm size> 4cm size3.3. Higher tumor gradeHigher tumor grade4.4. Marked vascular invasionMarked vascular invasion5.5. Marked extra-thyroidal invasionMarked extra-thyroidal invasion6.6. Distant metastasisDistant metastasis

• Mortality: 40 % ----> 10 yrsMortality: 40 % ----> 10 yrs

MALIGNANT THYROIDMALIGNANT THYROIDHURTLE CELL THYROID TUMOR:HURTLE CELL THYROID TUMOR:• 3 – 5%, intermediate, uni-focal3 – 5%, intermediate, uni-focal• Male : Female (2:1), spread by lymphaticsMale : Female (2:1), spread by lymphatics• Derived from oxyphilic cells of the thyroid gld.Derived from oxyphilic cells of the thyroid gld.• Possess TSH receptors and produces thyroglobulinPossess TSH receptors and produces thyroglobulin• Only 10% takes up iodine hence Only 10% takes up iodine hence thallium scanthallium scan is is

used to localize distant metastasisused to localize distant metastasis• Often multifocal and bilateralOften multifocal and bilateralDx:Dx: FNAC ----> 20% malignantFNAC ----> 20% malignantTx:Tx: - total thyroidectomy for RAI ablation usually - total thyroidectomy for RAI ablation usually

failsfails- mod radical neck dissection if with palpable - mod radical neck dissection if with palpable

cervical LNcervical LN- Thyroid suppression is suggested- Thyroid suppression is suggested

Prognosis:Prognosis: 60% ------> 5yr survival 60% ------> 5yr survival

MALIGNANT THYROIDMALIGNANT THYROIDMEDULLARY THYROID CARCINOMA:MEDULLARY THYROID CARCINOMA:• 5-7%; Aggressive tumor; 50-60y/o5-7%; Aggressive tumor; 50-60y/o• Arise from parafollicular or C cells of the thyroid Arise from parafollicular or C cells of the thyroid

(neuroectodermal-ultimobrachial bodies 4(neuroectodermal-ultimobrachial bodies 4thth &5 &5thth branchial pouches.branchial pouches.

• Secrets calcitonin (95%); 85% secrets Secrets calcitonin (95%); 85% secrets carcinoembryonic antigen (CEA)carcinoembryonic antigen (CEA)

• Sporadic 90%Sporadic 90%• unifocal, usually 45y/ounifocal, usually 45y/o• worse prognosisworse prognosis

• Familial 10%Familial 10%• Associated with:Associated with:

• MEN IIA or Sipples’ syndromeMEN IIA or Sipples’ syndrome (MTC, hyperplastic parathyroid (MTC, hyperplastic parathyroid and pheochromocytomaand pheochromocytoma

• MEN IIBMEN IIB (MTC, pheochromocytoma, ganglioneuromatosis and (MTC, pheochromocytoma, ganglioneuromatosis and Marfan,s syndrome)Marfan,s syndrome)

• Multifocal, usually 35 y/oMultifocal, usually 35 y/o• Better prognosisBetter prognosis

MALIGNANT THYROIDMALIGNANT THYROIDMEDULLARY THYROID CARCINOMA:MEDULLARY THYROID CARCINOMA:• Does not concentrate Iodine 131, Does not concentrate Iodine 131, Thallium scanThallium scan

is used to localized distal metastasis.is used to localized distal metastasis.• Spread:Spread:

• Lymphatics (neck and superior mediastinum)Lymphatics (neck and superior mediastinum)• Blood ---> liver, bone (osteoblastic) and lungBlood ---> liver, bone (osteoblastic) and lung• Local invasionLocal invasion

• Can secrets:Can secrets:• CalcitoninCalcitonin• HistamineHistamine• Serotinin (causes diarrhea)Serotinin (causes diarrhea)• ACTH 2-4% causing Cushing syndromeACTH 2-4% causing Cushing syndrome• CEACEA• Prostaglandin E2 and F2 alphaProstaglandin E2 and F2 alpha

Dx:Dx:• Hx ‘ PE; serum calcitonin, CEA, FNAC, Serum Hx ‘ PE; serum calcitonin, CEA, FNAC, Serum

calciumcalcium

MALIGNANT THYROIDMALIGNANT THYROIDTx:Tx:

• Total thyroidectomyTotal thyroidectomy• Radiotherapy and chemotherapy ---> failureRadiotherapy and chemotherapy ---> failure

• MRNDMRND is done for: is done for:• Palpable cervical LNPalpable cervical LN• >2cm tumor for 60% nodal metastasis>2cm tumor for 60% nodal metastasis

• Tumor debulking in cases of metastatic and local Tumor debulking in cases of metastatic and local recurrence should be done to ameliorate symptoms of recurrence should be done to ameliorate symptoms of flushing and diarrhea and help to decrease the risk of flushing and diarrhea and help to decrease the risk of death.death.

• All pt should be screen for pheochromocytoma (MEN II) All pt should be screen for pheochromocytoma (MEN II) w/c shoud be resected first.w/c shoud be resected first.

• Selective removal of the parathyroid shd be done if Selective removal of the parathyroid shd be done if preoperatively has hypercalcemia.preoperatively has hypercalcemia.

Follow up:Follow up: - serum calcium / CEA level- serum calcium / CEA levelPrognosis:Prognosis:

1.1. Localize -------> 80% 10 year survivalLocalize -------> 80% 10 year survival(+) LN --------> 45% 10 year survival(+) LN --------> 45% 10 year survival

2.2. Best ------------> Worst prognosisBest ------------> Worst prognosisFamilial non-MEN MTC -----> MEN IIA ----> Sporadic cases ------Familial non-MEN MTC -----> MEN IIA ----> Sporadic cases ------

> MEN IIB> MEN IIB

MALIGNANT THYROIDMALIGNANT THYROIDAnaplastic Thyroid Carcinoma:Anaplastic Thyroid Carcinoma:

• 1 – 3% most aggressive, few survive > 6 1 – 3% most aggressive, few survive > 6 monthsmonths

• Most arise from previous differentiated Most arise from previous differentiated thyroid CAthyroid CA

• Low incident could be due to low iodine Low incident could be due to low iodine deficiencydeficiency

• 70 – 80 y/o70 – 80 y/o

Treatment:Treatment:• Radiotherapy ----> doxorubicin ----> debulking Radiotherapy ----> doxorubicin ----> debulking

thyroidectomy ----> completion with radiotherapy and thyroidectomy ----> completion with radiotherapy and chemotherapychemotherapy

MALIGNANT THYROIDMALIGNANT THYROIDLYMPHOMA:LYMPHOMA:

• 1 – 5% non-Hodgkin B cell1 – 5% non-Hodgkin B cell• Usually develops in pts w/ chronic lymphocytic Usually develops in pts w/ chronic lymphocytic

thyroiditis (Hashimotos thyroiditis)thyroiditis (Hashimotos thyroiditis)• S/Sx similar with anaplastic CA, compression symptoms S/Sx similar with anaplastic CA, compression symptoms

is the most commonis the most common• Tx: Tx: ChemotherapyChemotherapy

• CyclophosphamideCyclophosphamide• DoxorubicinDoxorubicin• VincristineVincristine• PrednisonPrednison

RadiotherapyRadiotherapySurgery: - done for diagnosis and to alleviate Surgery: - done for diagnosis and to alleviate

compression compression symptomssymptoms• 80% survival if confined to the gland; 40% it had spread80% survival if confined to the gland; 40% it had spread

Metastatic Carcinoma:Metastatic Carcinoma:• Rare; hypernephroma is the most common primary siteRare; hypernephroma is the most common primary site

TThhaannkk yyoouu

THYROID James Taclin C. Banez, M.D., FPSGS, FPCS.

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Transcript of THYROID James Taclin C. Banez, M.D., FPSGS, FPCS.