anatomy of thyroid
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Thyroid disease Libo Li MD Department of General Surgery Sir Run Run Shaw Hospital School of medicine, Zhejiang University. Anatomy of Thyroid. Anatomy of Thyroid. Thyroid disease. Nontoxic goiter Hyperthyroidism Thyroid Cancer Thyroiditis. Nontoxic Goiter. - PowerPoint PPT PresentationTRANSCRIPT
Thyroid diseaseThyroid disease
Libo Li MDLibo Li MDDepartment of General SurgeryDepartment of General Surgery
Sir Run Run Shaw HospitalSir Run Run Shaw HospitalSchool of medicine, Zhejiang UniversitySchool of medicine, Zhejiang University
Anatomy of ThyroidAnatomy of Thyroid
Anatomy of ThyroidAnatomy of Thyroid
Thyroid diseaseThyroid disease
Nontoxic goiterNontoxic goiter HyperthyroidismHyperthyroidism Thyroid CancerThyroid Cancer ThyroiditisThyroiditis
Nontoxic GoiterNontoxic Goiter
GoiterGoiter from the French from the French (goitre)(goitre) and Latin and Latin (guttur)(guttur), both meaning throat, both meaning throat
Defined as an enlargement of the thyroid gland Defined as an enlargement of the thyroid gland Endemic when it involves more than 10% of the Endemic when it involves more than 10% of the
populationpopulation The majority, secondary to iodine deficiencyThe majority, secondary to iodine deficiency Especially found in high mountain regions Especially found in high mountain regions
Nontoxic GoiterNontoxic Goiter
Clinical thinkingClinical thinking
Whether the patient has local symptoms Whether the patient has local symptoms Whether the goiter is toxic or nontoxicWhether the goiter is toxic or nontoxic Whether any of the nodules harbor a cancerWhether any of the nodules harbor a cancer The number and bilaterality of the nodules The number and bilaterality of the nodules TSH level, differential diagnosis of TSH level, differential diagnosis of
hypothyroidism or hyperthyroidismhypothyroidism or hyperthyroidism Appropriate treatment options for each particular Appropriate treatment options for each particular
patientpatient
Nontoxic GoiterNontoxic Goiter
Taking historyTaking history
Asymptomatic neck massAsymptomatic neck mass– A cough, shortness of breath, stridor, or hoarsenessA cough, shortness of breath, stridor, or hoarseness
– Choking or aspiration, dysphagia, or painChoking or aspiration, dysphagia, or pain
– Symptoms of hyperthyroidismSymptoms of hyperthyroidism
– Whether the patient has cosmetic concernsWhether the patient has cosmetic concerns From iodine deficiency regionFrom iodine deficiency region
Nontoxic GoiterNontoxic Goiter
Physical examinationPhysical examination
Whether the goiter is confined to the neck Whether the goiter is confined to the neck Whether it has a substernal componentWhether it has a substernal component Whether tracheal deviation is present Whether tracheal deviation is present The size and consistency of the goiter The size and consistency of the goiter The mobility of the vocal cords by either indirect The mobility of the vocal cords by either indirect
or direct laryngoscopyor direct laryngoscopy
Nontoxic Nontoxic
GoiterGoiter
Ultrasound Ultrasound – How many nodules?How many nodules?
– Bilateral?Bilateral?
– Ultrasound characteristicsUltrasound characteristics
Nontoxic GoiterNontoxic Goiter
CT scan CT scan – Neck and chest, especially substernal thyroidNeck and chest, especially substernal thyroid
– Rare intrathoracic or aberrant thyroidRare intrathoracic or aberrant thyroid
Nontoxic GoiterNontoxic Goiter
Fine needle aspiration (FNA) Fine needle aspiration (FNA) – Suspicious malignent goiterSuspicious malignent goiter
Nontoxic GoiterNontoxic Goiter
TreatmentTreatment
Iodine diet replacement (endemic goitor)Iodine diet replacement (endemic goitor) Surgical resectionSurgical resection
– SymptomsSymptoms Local compressionLocal compression Secondary hyperthyroidisimSecondary hyperthyroidisim
– Any suspicious or malignant lesionAny suspicious or malignant lesion– Cosmetic reasonsCosmetic reasons
Radioiodine therapy, high risk of ptsRadioiodine therapy, high risk of pts Thyroid hormone suppression (not for sporadic Thyroid hormone suppression (not for sporadic
goiter)goiter)
Sporadic Nontoxic GoiterSporadic Nontoxic Goiter
AsymptomaticAsymptomatic EuthyroidEuthyroid Most bilaterallyMost bilaterally No efficiency of thyroid hormone replacementNo efficiency of thyroid hormone replacement High recurrence postoperatively 30%~40%High recurrence postoperatively 30%~40%
Nontoxic GoiterNontoxic Goiter
History of Thyroid SurgeryHistory of Thyroid Surgery
First thyroidectomy, in Paris in 1791 by Pierre-First thyroidectomy, in Paris in 1791 by Pierre-Joseph DesaultJoseph Desault
Antisepsis, hemostasis, and general anesthesia in Antisepsis, hemostasis, and general anesthesia in the 1840s the 1840s – thyroid surgery became safethyroid surgery became safe
Theodore Kocher, a Nobel Prize in 1909Theodore Kocher, a Nobel Prize in 1909– From Bern, SwitzerlandFrom Bern, Switzerland
– His pioneering efforts in thyroid surgeryHis pioneering efforts in thyroid surgery
Primary HyperthyroidsimPrimary HyperthyroidsimGrave’s DiseaseGrave’s Disease
Clinical StatisticsClinical Statistics
Graves Disease is the most common cause of Graves Disease is the most common cause of hyperthyroidism (60-80%) of all caseshyperthyroidism (60-80%) of all cases
Females are affected more frequently than men Females are affected more frequently than men 10:1.510:1.5
Monozygotic twins show 50% concordance ratesMonozygotic twins show 50% concordance rates Incidence peaks from ages 20-40Incidence peaks from ages 20-40 Incidence is similar in whites and Asians, but is Incidence is similar in whites and Asians, but is
somewhat decreased for African Americanssomewhat decreased for African Americans
Graves' DiseaseGraves' Disease
Autoimmune systemic disorderAutoimmune systemic disorder Thyroid receptor antibody binding to and Thyroid receptor antibody binding to and
stimulating the TSH receptorstimulating the TSH receptor Excessive synthesis and secretion of thyroid Excessive synthesis and secretion of thyroid
hormonehormone Usually diffusely and symmetrically enlarged Usually diffusely and symmetrically enlarged
and firmand firm
Hyperthyroidism—uptakeHyperthyroidism—uptake
A. NormalA. Normal B. Graves’ DzB. Graves’ Dz C. Toxic Multinodular C. Toxic Multinodular
GoiterGoiter D. Toxic AdenomaD. Toxic Adenoma E. ThyroiditisE. Thyroiditis
HyperthyroidismHyperthyroidism
SymptomsSymptoms
Heat intolerance, sweating, palpitations, fatigueHeat intolerance, sweating, palpitations, fatigue Weight loss, diaphoresis, increased stool Weight loss, diaphoresis, increased stool
frequencyfrequency Muscle weakness, anxiety, insomnia Muscle weakness, anxiety, insomnia Nervousness or restlessness; irritability, Nervousness or restlessness; irritability,
emotional lability emotional lability In women, irregular mensesIn women, irregular menses
HyperthyroidismHyperthyroidism
Clinical findingsClinical findings
Tremor, tachycardia (A. fib), Tremor, tachycardia (A. fib), Goiter, lid lag, proptosis, periorbital edema, Goiter, lid lag, proptosis, periorbital edema,
exophthalmos; chemosis; hyperreflexiaexophthalmos; chemosis; hyperreflexia Warm, moist skin; dermopathy; and pretibial Warm, moist skin; dermopathy; and pretibial
edema,edema, osteoporosisosteoporosis
Exopthalamos in Graves Exopthalamos in Graves DiseaseDisease
Lid Lag in Graves Lid Lag in Graves DiseaseDisease
Hyperthyroidism—treatmentHyperthyroidism—treatment
Beta-blockers: control sxsBeta-blockers: control sxs– Propranolol decr peripheral T4 -> T3 conversionPropranolol decr peripheral T4 -> T3 conversion
Graves’ DzGraves’ Dz– PTU (safe in pregnancy) or methimazolePTU (safe in pregnancy) or methimazole
Rare side effect: agranulocytosisRare side effect: agranulocytosis– Radioactive iodineRadioactive iodine
75% of treated pts become hypothyroid75% of treated pts become hypothyroid– SurgerySurgery
Toxic Adenoma or TMNGToxic Adenoma or TMNG– RAI or surgeryRAI or surgery
HyperthroidismHyperthroidism
SurgerySurgery
Surgical approachSurgical approach– Bilateral near-total or total thyroidectomyBilateral near-total or total thyroidectomy
Indication of surgery (In China)Indication of surgery (In China)– Compressive symptomsCompressive symptoms
– Secondary or adenomaSecondary or adenoma
– Recurrence of medicine or iodine-131Recurrence of medicine or iodine-131
– No efficiency of medicineNo efficiency of medicine
– Second trimester of pregnancySecond trimester of pregnancy
Surgery for hyperthyroidismSurgery for hyperthyroidism
Preoperative preparationPreoperative preparation
Absolutely requiredAbsolutely required antithyroid drugs, for 3 to 6 weeks antithyroid drugs, for 3 to 6 weeks
– with a goal of nearly normalizing the T3 and T4 with a goal of nearly normalizing the T3 and T4 Propranolol or atenolol rapidly controls the Propranolol or atenolol rapidly controls the
adrenergic side effects of excess T4 and T3 adrenergic side effects of excess T4 and T3 – tachycardia, tremor, and diaphoresistachycardia, tremor, and diaphoresis
Lugol's solution rapidly but temporarily restores Lugol's solution rapidly but temporarily restores normal thyroid function and reduces thyroid normal thyroid function and reduces thyroid gland vascularitygland vascularity
Surgical complicationsSurgical complications
BleedingBleeding Recurrent Laryngeal Nerve DamageRecurrent Laryngeal Nerve Damage Hypoparathyroidism and HypocalcemiaHypoparathyroidism and Hypocalcemia Superior laryngeal nerve damageSuperior laryngeal nerve damage Thyroid stormThyroid storm
Thyroid cancerThyroid cancer
Thyroid cancerThyroid cancer
IntroductionIntroduction
The most common, 95% of all endocrine cancersThe most common, 95% of all endocrine cancers Increasing faster than any other cancer Increasing faster than any other cancer More than 90% , well differentiatedMore than 90% , well differentiated Good long-term prognosisGood long-term prognosis
Thyroid cancerThyroid cancer
Clinical PresentationClinical Presentation
Most, clinically with a palpable noduleMost, clinically with a palpable nodule Usually asymptomaticUsually asymptomatic Rare cases, with hoarseness, pain, dysphagia, Rare cases, with hoarseness, pain, dysphagia,
dyspnea, coughing, or choking spellsdyspnea, coughing, or choking spells PainPain ,, with the suspicion for with the suspicion for
– Medullary thyroid carcinoma Medullary thyroid carcinoma
– Anaplastic carcinomaAnaplastic carcinoma
– LymphomaLymphoma
Pertinent historical factors Pertinent historical factors predicting malignancypredicting malignancy
A history of head and neck irradiationA history of head and neck irradiation Total body irradiation for bone marrow transplantation Total body irradiation for bone marrow transplantation Exposure to fallout from the explosion of the Exposure to fallout from the explosion of the
Chernobyl nuclear power plant in 1986, especially in Chernobyl nuclear power plant in 1986, especially in children; children;
A family history of thyroid cancer; and rapid growth A family history of thyroid cancer; and rapid growth or hoarseness. or hoarseness.
Children, men, and adults older than 60 years have an Children, men, and adults older than 60 years have an increased risk of malignancyincreased risk of malignancy
Increase the risk of thyroid cancerIncrease the risk of thyroid cancer
Personal and family history of other endocrine Personal and family history of other endocrine disorders, disorders, – specifically hyperparathyroidism, pituitary adenomas, specifically hyperparathyroidism, pituitary adenomas,
pancreatic islet cell tumors, adrenal tumors, and pancreatic islet cell tumors, adrenal tumors, and
breast cancerbreast cancer. . A family history of papillary or medullary A family history of papillary or medullary
carcinoma (MEN syndromes), familial carcinoma (MEN syndromes), familial polyposis, Gardner's syndrome, and Cowden's polyposis, Gardner's syndrome, and Cowden's syndromesyndrome
Pertinent physical findings Pertinent physical findings Suggesting possible malignancy Suggesting possible malignancy
Gritty texture”(Gritty texture”( 颗粒样)颗粒样) of the thyroid noduleof the thyroid nodule Cervical lymphadenopathyCervical lymphadenopathy Vocal cord paralysisVocal cord paralysis Fixation of the nodule to surrounding tissueFixation of the nodule to surrounding tissue
Thyroid cancerThyroid cancer
DiagnosisDiagnosis
Ultrasound Ultrasound – Feature of malignancyFeature of malignancy
Irregular marginsIrregular margins Intranodular vascular patternIntranodular vascular pattern MicrocalcificationsMicrocalcifications
Fine needle aspiration (FNA)Fine needle aspiration (FNA)– The most reliable and cost-efficient methodThe most reliable and cost-efficient method
Thyroid cancer Thyroid cancer
DiagnosisDiagnosis
Thyroid function tests Thyroid function tests Serum markersSerum markers
– Thyroglobulin (TG) for well-differentiated thyroid Thyroglobulin (TG) for well-differentiated thyroid cancercancer
– Calcitonin and CEA for medullary thyroid cancerCalcitonin and CEA for medullary thyroid cancer All pts with medullary thyroid cancerAll pts with medullary thyroid cancer
– RET proto-oncogeneRET proto-oncogene
– pheochromocytoma and hyperparathyroidismpheochromocytoma and hyperparathyroidism
Management of thyroid cancer Management of thyroid cancer
The goals of therapy The goals of therapy
Removal of primary tumor, disease that extends beyond Removal of primary tumor, disease that extends beyond the thyroid capsule, and involved cervical lymph nodesthe thyroid capsule, and involved cervical lymph nodes
Minimization of treatment- and disease-related Minimization of treatment- and disease-related morbiditymorbidity
Accurate disease stagingAccurate disease staging Facilitation of postoperative treatment with radioiodine Facilitation of postoperative treatment with radioiodine
when appropriatewhen appropriate Accurate long-term surveillanceAccurate long-term surveillance Minimization of the risk of recurrent local and metastatic Minimization of the risk of recurrent local and metastatic
tumortumor
Well-Differentiated Thyroid CarcinomaWell-Differentiated Thyroid Carcinoma
Papillary Thyroid CarcinomaPapillary Thyroid Carcinoma
The most common endocrine The most common endocrine malignancymalignancy ,, approximately 80% of new cases approximately 80% of new cases
Associated with the best prognosisAssociated with the best prognosis At least twice as common in women as men At least twice as common in women as men A peak age of presentation of 38 to 45 yearsA peak age of presentation of 38 to 45 years 90% of radiation-induced90% of radiation-induced ,, familial in 5%familial in 5%
Papillary Thyroid CarcinomaPapillary Thyroid Carcinoma
Well-Differentiated Thyroid CarcinomaWell-Differentiated Thyroid Carcinoma
PrognosesPrognoses
The risk of death The risk of death – approximately 5% in the low-risk group approximately 5% in the low-risk group
– 40% in the high-risk group 40% in the high-risk group Fortunately, most pts (70%) in the low-risk Fortunately, most pts (70%) in the low-risk
groupgroup
Other histological factors Other histological factors
To predict the behavior of thyroid cancer To predict the behavior of thyroid cancer – Ploidy of the tumorPloidy of the tumor
– Adenylate cyclase response to thyroid stimulating Adenylate cyclase response to thyroid stimulating hormone (TSH)hormone (TSH)
– Radioiodine uptakeRadioiodine uptake
– A positive positron emission tomography scanA positive positron emission tomography scan
– Epidermal growth factor (EGF) receptor level and Epidermal growth factor (EGF) receptor level and various gene profilesvarious gene profiles
Papillary Thyroid CarcinomaPapillary Thyroid Carcinoma
The extent of surgical resection The extent of surgical resection
ControversialControversial American recommondationAmerican recommondation
– Total or near total thyroidectomyTotal or near total thyroidectomy complication rate of less than complication rate of less than 2%2%
– Selective nodal resection Selective nodal resection
– Postoperative treatment with iodine-131 Postoperative treatment with iodine-131 Low-risk pts less than 1 cmLow-risk pts less than 1 cm
– thyroid lobectomy and isthmectomy OKthyroid lobectomy and isthmectomy OK
– Reoperation Reoperation multifocal, with nodal metastases, or with local invasionmultifocal, with nodal metastases, or with local invasion
Benefits of total thyroidectomyBenefits of total thyroidectomy
Postoperative radioiodine scanning and ablative Postoperative radioiodine scanning and ablative therapy can be effectivetherapy can be effective
Serum thyroglobulin levels are rendered more Serum thyroglobulin levels are rendered more sensitive for detecting recurrent or persistent sensitive for detecting recurrent or persistent diseasedisease
Intrathyroidal cancer that is present in more than Intrathyroidal cancer that is present in more than 50% of patients is removed50% of patients is removed
The small risk of a differentiated thyroid cancer The small risk of a differentiated thyroid cancer becoming an undifferentiated cancer is decreased.becoming an undifferentiated cancer is decreased.
Papillary Thyroid CarcinomaPapillary Thyroid Carcinoma
The role of lymph node dissectionThe role of lymph node dissection
Also controversialAlso controversial Micrometastasis to cervical lymph nodes is Micrometastasis to cervical lymph nodes is
common (80%)common (80%) Prophylactic cervical lymph node dissection is Prophylactic cervical lymph node dissection is
not warranted not warranted Functional neck dissection and central neck Functional neck dissection and central neck
dissection should generally be performed dissection should generally be performed – only in pts with clinical or sonographic evidence of only in pts with clinical or sonographic evidence of
lymph node involvementlymph node involvement
Follicular Thyroid CarcinomaFollicular Thyroid Carcinoma
Approximately 10% of all thyroid malignanciesApproximately 10% of all thyroid malignancies Typically older than PTCTypically older than PTC Usually in the sixth decade of lifeUsually in the sixth decade of life The female-to-male ratio is between 2:1 and 5:1The female-to-male ratio is between 2:1 and 5:1 A slowly growing solitary thyroid noduleA slowly growing solitary thyroid nodule A tendency to spread hematogenouslyA tendency to spread hematogenously
– Rarely with symptoms of distant metastasis to the Rarely with symptoms of distant metastasis to the bone, lung, brain, and liver bone, lung, brain, and liver
Follicular Thyroid CarcinomaFollicular Thyroid Carcinoma
Less than 6% metastasize to the cervical lymph Less than 6% metastasize to the cervical lymph nodesnodes
Approximately 25% of pts have extrathyroidal Approximately 25% of pts have extrathyroidal invasioninvasion
10% to 33% have distant metastasis at the time 10% to 33% have distant metastasis at the time of initial diagnosisof initial diagnosis
The prognosis of follicular cancer The prognosis of follicular cancer
Slightly worse than that for papillary cancerSlightly worse than that for papillary cancer Overall survival ranges from 43% to 95% at 10 Overall survival ranges from 43% to 95% at 10
yearsyears Lifelong surveillance is not necessaryLifelong surveillance is not necessary
The prognosis of follicular cancer The prognosis of follicular cancer
The important prognostic factorsThe important prognostic factors– Presence of metastatic disease Presence of metastatic disease
– Older age (usually >40 years)Older age (usually >40 years)
– Degree of invasion (microcapsular vs. angioinvasion Degree of invasion (microcapsular vs. angioinvasion with or without capsular and widely invasive)with or without capsular and widely invasive)
– Degree of tumor differentiationDegree of tumor differentiation
Follicular Thyroid CarcinomaFollicular Thyroid Carcinoma
DiagnosisDiagnosis– The whole specimen must be evaluated for vascular The whole specimen must be evaluated for vascular
and capsular invasion.and capsular invasion.
– Diagnosis of follicular cancer cannot be made on Diagnosis of follicular cancer cannot be made on FNABFNAB
Follicular Thyroid CarcinomaFollicular Thyroid Carcinoma
TreatmentTreatment– The recommended initial operation is lobectomy and The recommended initial operation is lobectomy and
isthmectomyisthmectomy
– Lymph node dissection is rarely warranted because Lymph node dissection is rarely warranted because nodal metastases are uncommonnodal metastases are uncommon
Medullary Thyroid CarcinomaMedullary Thyroid Carcinoma
7% of thyroid cancers 7% of thyroid cancers 15% of all thyroid cancer–related deaths15% of all thyroid cancer–related deaths Approx 75% sporadicApprox 75% sporadic 零星的零星的 , 25% hereditary, 25% hereditary From c cells or parafollicular cells From c cells or parafollicular cells Located laterally at the junction of the upper two Located laterally at the junction of the upper two
thirds of the thyroid gland at approximately the thirds of the thyroid gland at approximately the level of the cricoid cartilagelevel of the cricoid cartilage
Medullary Thyroid CarcinomaMedullary Thyroid Carcinoma
In the sporadic formIn the sporadic form– Usually a single focus of malignancy Usually a single focus of malignancy – Unilateral disease in 85% of casesUnilateral disease in 85% of cases
In the hereditary formIn the hereditary form– Multifocal and bilateral in 90% of cases Multifocal and bilateral in 90% of cases – C-cell hyperplasiaC-cell hyperplasia
The hereditary forms of MTCThe hereditary forms of MTC
Medullary Thyroid CarcinomaMedullary Thyroid Carcinoma
Tumor markerTumor marker
Serum markers for calcitonin Serum markers for calcitonin – support the diagnosissupport the diagnosis
– correlate with tumor bulk, nodal, and distant correlate with tumor bulk, nodal, and distant metastasismetastasis
High CEA levels correlate with a poorer High CEA levels correlate with a poorer prognosisprognosis
Flushing and diarrhea also have a worse Flushing and diarrhea also have a worse prognosisprognosis
Medullary Thyroid CarcinomaMedullary Thyroid Carcinoma
Lymph node metastasesLymph node metastases
Positive in 70% of patients Positive in 70% of patients 81% of patients had central node disease81% of patients had central node disease 81% had ipsilateral cervical node disease81% had ipsilateral cervical node disease 44% had contralateral cervical nodal disease44% had contralateral cervical nodal disease
Prevention or cure of MTCPrevention or cure of MTC
By surgeryBy surgery– mainly dependent on the initial stage and the mainly dependent on the initial stage and the
adequacy of the initial operationadequacy of the initial operation
IndicationIndication– RET-positive patients with familial disease before the RET-positive patients with familial disease before the
age of possible malignant progressionage of possible malignant progression
– total thyroidectomy before age 6total thyroidectomy before age 6
Surgical management for MTC Surgical management for MTC
Depends on the presentation of the diseaseDepends on the presentation of the disease– Thyroidectomy and central node dissectionThyroidectomy and central node dissection
Central lymph node dissections increase Central lymph node dissections increase – the risk of recurrent laryngeal nerve injury and the risk of recurrent laryngeal nerve injury and
hypoparathyroidismhypoparathyroidism
Anaplastic Thyroid CarcinomaAnaplastic Thyroid Carcinoma
Rare, 1% to 2% of thyroid malignancies Rare, 1% to 2% of thyroid malignancies More than half of the deaths from thyroid cancerMore than half of the deaths from thyroid cancer Survival is measured in monthsSurvival is measured in months Commonly in patients older than 60 years Commonly in patients older than 60 years Usually presents as a rapidly expanding thyroid Usually presents as a rapidly expanding thyroid
mass mass
Anaplastic Thyroid CarcinomaAnaplastic Thyroid Carcinoma
Lymph node enlargement Lymph node enlargement – Frequent (84%) and earlyFrequent (84%) and early
Local tumor extension cause Local tumor extension cause – Fixation of the larynx, esophagus, and carotid vesselsFixation of the larynx, esophagus, and carotid vessels
Dysphagia, dysphonia, and dyspnea are commonDysphagia, dysphonia, and dyspnea are common Systemic metastases occur in 75% of pts, Systemic metastases occur in 75% of pts,
– Usually involving the lungs, bone, brain, and adrenal Usually involving the lungs, bone, brain, and adrenal glandsglands
Anaplastic Thyroid CarcinomaAnaplastic Thyroid Carcinoma
The diagnosis The diagnosis – Be established by FNABBe established by FNAB
– Differentiated from that of lymphoma and poorly Differentiated from that of lymphoma and poorly differentiated medullary carcinomadifferentiated medullary carcinoma
Anaplastic Thyroid CarcinomaAnaplastic Thyroid Carcinoma
SurgeySurgey
Usually not curative, with distant metastasesUsually not curative, with distant metastases Multimodality treatment, slightly improved Multimodality treatment, slightly improved
outcomesoutcomes– Indicate local control in 22% to 76% of ptsIndicate local control in 22% to 76% of pts
Median survival ranges from 2.5 to 9 months, Median survival ranges from 2.5 to 9 months, with 2-year survival of less than 20%with 2-year survival of less than 20%
Subacute ThyroiditisSubacute Thyroiditis
Painless ThyroiditisPainless Thyroiditis Painful ThyroiditisPainful Thyroiditis
– RareRare
Painless ThyroiditisPainless Thyroiditis
Also called lymphocytic thyroiditisAlso called lymphocytic thyroiditis Spontaneously resolving hyperthyroidismSpontaneously resolving hyperthyroidism An autoimmune disorderAn autoimmune disorder
– Typically elevated thyroid peroxidase antibody levels Typically elevated thyroid peroxidase antibody levels
– Lymphocytic infiltration of the thyroidLymphocytic infiltration of the thyroid
Painless ThyroiditisPainless Thyroiditis
Clinical PresentationClinical Presentation
Ages of 30 and 60 yearsAges of 30 and 60 years 40% pts with the classical a four-stage clinical 40% pts with the classical a four-stage clinical
coursecourse– (1)Destruction-induced thyrotoxicosis, (2) euthryoidism, (3) (1)Destruction-induced thyrotoxicosis, (2) euthryoidism, (3)
hypothyroidism, and (4) return to euthyroidismhypothyroidism, and (4) return to euthyroidism
Usually, firm gland and non-tender with Usually, firm gland and non-tender with symmetrical, modest enlargement symmetrical, modest enlargement
Nearly one third of pts, permanently hypothyroidNearly one third of pts, permanently hypothyroid
Painless ThyroiditisPainless Thyroiditis
Clinical ManagementClinical Management
Many patients do not require therapyMany patients do not require therapy Thyroidectomy is rarely indicated Thyroidectomy is rarely indicated
Painful ThyroiditisPainful Thyroiditis
Also called de Quervain's disease, Also called de Quervain's disease, granulomatous thyroiditis, granulomatous thyroiditis,
A viral etiologyA viral etiology Preceded by upper respiratory infectionPreceded by upper respiratory infection
Painful ThyroiditisPainful Thyroiditis
Clinical ManagementClinical Management
Usually self-limitedUsually self-limited Beta-blockade is indicated to treat the symptoms Beta-blockade is indicated to treat the symptoms
of hyperthyroidismof hyperthyroidism Nonsteroidal anti-inflammatory medications and Nonsteroidal anti-inflammatory medications and
prednisone may also be used for painprednisone may also be used for pain
Chronic ThyroiditisChronic Thyroiditis
Hashimoto's thyroiditisHashimoto's thyroiditis
The most common inflammatory diseaseThe most common inflammatory disease Autoimmune, chronic, progressive lymphocytic Autoimmune, chronic, progressive lymphocytic
thyroiditisthyroiditis Up to 95% of cases occur in womenUp to 95% of cases occur in women Elevated levels of circulating antibodies to Elevated levels of circulating antibodies to
thyroglobulin, thyroid peroxidase, and thyroglobulin, thyroid peroxidase, and thyrotropin receptorthyrotropin receptor
Hashimoto's thyroiditisHashimoto's thyroiditis
Clinical PresentationClinical Presentation
Usually asymptomaticUsually asymptomatic 20% with hypothyroidism20% with hypothyroidism
– The most common cause of hypothyroidism in USThe most common cause of hypothyroidism in US Usually symmetrical, firm glandUsually symmetrical, firm gland
Hashimoto's thyroiditisHashimoto's thyroiditis
ManagementManagement
Thyroid hormone replacement therapy Thyroid hormone replacement therapy – HypothyroidismHypothyroidism
– Elevated TSHElevated TSH
Hashimoto's thyroiditisHashimoto's thyroiditis
Indication of surgeyIndication of surgey
Malignancy is suspected from FNA biopsyMalignancy is suspected from FNA biopsy Compressive symptoms from a large goiter Compressive symptoms from a large goiter Cosmetic purposesCosmetic purposes
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