Solitary thyroid nodule approach
Dept of Surgery
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Thyroiditis
? Inflammation of the thyroid gland
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? Acute illness? Severe thyroid pain
? Manifested primarily by thyroid dysfunction
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TypesAcute
? Streptococcus and anaerobes (70% Escherichia coli, Pseudomonas
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(Suppurative)
aeruginosa, Haemophilus influenzae, Eikenel a corrodens,
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ThyroiditisCorynebacterium, Coccidiomycosis species
? More common in children
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? Diagnosis : leukocytosis on blood tests and FNA biopsy for Gram's stain,
culture, and cytology
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? Treatment : parenteral antibiotics and drainage of abscessesSubacute
? Painful or painless
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Thyroiditis
? Post viral inflammatory response, Genetic predisposition, autoimmune
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? TSH is decreased, and thyroglobulin, T4 and T3 levels are elevated? beta blockers and thyroid hormone replacement (after hyperthyroid
phase)
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? Surgery for recurrent attacks
Chronic
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? Hashimoto'sThyroiditis
? Reidel's
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? De-quervain's
Hashimoto Thyroiditis
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? First described by hashimoto, in 1912, as strumalymphomatosa--
? Transformation of thyroid tissue to lymphoid tissue
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? Most common inflammatory disorder of the thyroid
? Leading cause of hypothyroidism
Etiology
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? Autoimmune process
? Increased intake of iodine
? Medications: interferon, lithium, and amiodarone
? Inherited predisposition
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? Chromosomal abnormalities : turner's syndrome anddown syndrome.
? Associations with hla-b8, dr3, and dr5 haplotypes
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Pathogenesis
Activation of CD4+T (helper) lymphocytes
T cells recruit cytotoxic CD8+T cells to the thyroid.
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Hypothyroidism results from:? destruction of thyrocytes by cytotoxic t cells
? autoantibodies, which lead to complement fixation and killing by natural
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killer cells or block the TSH receptorAntibodies are directed against the three main antigens
? Tg (60%)
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? TPO (95%)? TSH-R (60%)
? sodium/iodine symporter (25%)
Apoptosis (programmed cell death) also implicated
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Pathology
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? Gland is diffusely infiltrated by small
lymphocytes and plasma cells,
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occasionally shows well-developedgerminal centers
? Thyroid follicles are smaller than normal
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with reduced amounts of colloid and
increased interstitial connective tissue
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? Follicles are lined by h?rthle oraskanazy cel s, which are characterized
by abundant eosinophilic, granular
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cytoplasm.
Clinical Presentation
? Male: female ratio 1:10 to 20)
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? Ages of 30 and 50 years.? Minimal y or moderately enlarged firm gland
? 20% of patients present with hypothyroidism
? 5% present with hyperthyroidism ( hashitoxicosis)
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Diagnostic StudiesTSH T4 and T3 levels
Thyroid autoantibodies
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FNA biopsy if solitary suspicious nodule or a
rapidly enlarging goiter
Treatment
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Overtly hypothyroid:
? Thyroid hormone replacement therapy
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Subclinical hypothyroidism:? Male patients
? TSH greater than 10 mu/L
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? Euthyroid patients to shrink large goiters
? Surgery may occasional y be indicated for suspicion of malignancy
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or for goiters causing compressive symptoms or cosmeticdeformity
De Quervain's thyroiditis
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? First described in 1904
? Granulomatous thyroiditis
? Viral infections: Adenovirus, Coxsackievirus, Influenza
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virus, Epstein barr virus, Mumps, Echovirus & Enterovirus? Less common than Hashimoto's thyroiditis
? Gland swel s up is very painful and tender
? Patient becomes hyperthyroid but the gland cannot take
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up iodine so the radioactive iodine uptake is very low
? Absence of thyroid antibodies differentiates this
condition from autoimmune thyroiditis
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? Recovery is invariably complete and response to
prednisolone is so dramatic that it is almost diagnostic
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Riedel's Thyroiditis? Riedel's struma or invasive fibrous thyroiditis
? Replacement of al or part of the thyroid parenchyma by
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fibrous tissue
Etiology :
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? Autoimmune diseases, such as pernicious anemia andgraves' disease
? Mediastinal, retroperitoneal, periorbital, and retro-orbital
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fibrosis
? Sclerosing cholangitis
? Women between the ages of 30 and 60 years.
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Presentation:? Painless, hard anterior neck mass
? Dysphagia
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? Dyspnea
? Choking
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? Hoarseness? Symptoms of hypothyroidism & hypoparathyroidism
? Hard, "woody" thyroid gland
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Diagnosis:
? Open thyroid biopsy
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Treatment:? Surgery
? Thyroid hormone replacement
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? Corticosteroids and tamoxifen
Solitary Thyroid Nodule
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An isolated nodule in the thyroid glandBenign:
? Cysts
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? Adenoma-
? Papil ary
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? Fol icular? Hurthle cel type
? Toxic Adenoma- solitary hyper-functioning thyroid nodule
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? Non toxic Adenoma-solitary nonfunctioning thyroid nodule
Malignant:
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? Primary? Metastatic
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? Nodules common, whereas cancer relatively uncommon? Higher in women (1.2:1 4.3:1)
? Estimated 5-15% of nodules are cancerous
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? Although cancer more common in women, a nodule in a man
is more likely to be cancer
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Workup of a solitary thyroid noduleLaboratory Studies
Most patients with thyroid nodules are euthyroid
? Blood TSH level
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? Serum Tg levels? Serum calcitonin levels
? RET oncogene mutations
? 24-hour (urine) for vanillylmandelic acid (VMA),
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metanephrine, and catecholamineImaging
Ultrasound is helpful for:
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? detecting nonpalpable thyroid nodules
? differentiating solid from cystic nodules
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? identifying adjacent lymphadenopathy? Fol ow up of size of suspected benign nodules
CT and MRI are unnecessary in the routine evaluation
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of thyroid tumors, except for large, fixed, or substernal
lesions.
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Scanning the thyroid with 123I or 99mTc for evaluatingpatients for "hot" or autonomous thyroid nodules
Management
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? Malignant tumors are treated by thyroidectomy? Simple thyroid cysts: aspiration
If the cyst persists after three attempts at aspiration,
unilateral thyroid lobectomy is recommended.
? Lobectomy is also recommended for:
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? cysts greater than 4 cm in diameter
? complex cysts with solid and cystic components
Management
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? If a colloid nodule is diagnosed by FNA biopsy, patients should
still be observed with serial ultrasound and Tg measurements.
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? l-thyroxine in doses sufficient to maintain a serum TSH levelbetween 0.1 and 1.0 U/mL may also be administered.
? Thyroidectomy should be performed if:
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? Nodule enlarges on TSH suppression, compressive symptoms
? Cosmetic reasons
? H/o previous irradiation of the thyroid gland
? Family history of thyroid cancer
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