management of thyroid disease: too many, too little, masses€¦ · treatment, sp thyroid cancer...

Management of Thyroid Disease: Too many, too little, masses

Presented by:Vanessa Pomarico-Denino,

EdD, FNP-BC, FAANPFaculty

Fitzgerald Health Education Associates,North Andover, MA

Northeast Medical Group (NEMG) APRNAdjunct faculty for Southern CT State University

and Quinnipiac University

Developed by:Margaret A. Fitzgerald,

DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAPPresident,

Fitzgerald Health Education Associates, North Andover, MA

Disclosure

• No real or potential conflict of interest to disclose.

• No off-label, experimental or investigational use of drugs or devices will be presented.

Fitzgerald Health Education Associates 2

Objectives


• Having completed the learning activities, the participant will be able to:– Discuss the pathophysiology of common

thyroid disorders. – Identify expected laboratory findings in

common thyroid disorders including TSH, free T4, total T4, T3, and antithyroid antibodies.

Objectives (continued)


• Having completed the learning activities the participant will be able to: (cont.)– Discuss treatment options for the person

with select thyroid disorders including thyroid masses.

References held within and at the end of the presentation.


Thyroid Disorders



Fitzgerald Health Education Associates. All rights reserved. Reproduction is prohibited. Prior permission required for use of questions or course content.

1

Key Concepts in Thyroid Disease

• The thyroid produces two hormones, thyroxine (T4) and triiodothyronine (T3). These hormones act as cellular energy release catalysts and influence the function and health of every cell in the body.


Hypothyroidism Clinical Presentation:Reduced Systemic Cellular Energy Release

All signs, symptoms reversible with treatment

MOM’S SO TIRED MnemonicMost Common Thyroid Disorder

Encountered in Primary Care


In Hypothyroidism Clinical Presentation: MOM’S SO TIRED Mnemonic

Memory lossObesity (modest weight gain, mostly fluid, usually <10 lbs [4.5 kg])MenorrhagiaSlowness (mentally and physically)Skin and hair drynessOnset gradualTirednessIntolerance to coldRaised BPEnergy levels fallDepression/Delayed relaxation phase of all reflexes, especially patellar, Achilles


Condition CommentHashimoto thyroiditis Most common hypothyroid cause,

most often in women age >50 years. Autoimmune in origin, discovered once thyroid is largely destroyed and nonfunctional.

Post-radioactive iodine (RAI) treatment

Status post (SP) Graves’ disease treatment, SP thyroid cancer treatment with thyroid ablation and resulting hypothyroidism

Select medication use Lithium, amiodarone, interferon, others

Hypothyroidism: Common Etiology

Most often found in middle-aged women


Hashimoto thyroiditis• Most common hypothyroid cause,










Post-radioactive iodine (RAI) treatment• Status post (SP) Graves’ disease

treatment, SP thyroid cancer treatment with thyroid ablation and resulting hypothyroidism









Select medication use• Lithium, amiodarone, interferon, others



2

Hyperthyroidism Clinical Presentation:

Excessive Cellular Energy Release

All signs, symptoms reversible with treatment

SWEATING Mnemonic


Hyperthyroidism Clinical Presentation: SWEATING Mnemonic


SweatingWeight loss (~10 lb [4.5 kg] average, muscle as well as fat)Emotional lability, “mind racing,” memory alterationAppetite increased, but losing weightTremor/tachycardiaIntolerance of heat, irregular menstruation, irritabilityNervousnessGoiter, GI problems (frequent, low volume, loose stools)

Condition Comment Graves’ disease Most common hyperthyroid etiology, most often found in women age

30‒50 yAutoimmune in nature, seen with other autoimmune conditions such as RA, lupus, vitiligo, celiac disease, T1DM

Typical hyperthyroidism presentation as well as exophthalmus and goiterToxic adenoma Benign (nonmalignant), metabolically-active thyroid nodule

Typical hyperthyroid presentation with palpable unilateral thyroid mass but without exophthalmus

Thyroiditis Usually transient. Etiology‒ Viral or autoimmune, postpartum, drug-induced in origin Typical milder hyperthyroidism presentation with thyroid tenderness but without exophthalmus

Select medication use

Amiodarone (also hypothyroidism), interferon (also hypothyroidism), othersTypical milder hyperthyroid presentation without goiter or exophthalmus

Hyperthyroidism:Common Etiology


Graves’ diseaseMost common hyperthyroid etiology, most often found in women age 30‒50 yAutoimmune in nature, seen with other autoimmune conditions such as RA, lupus, vitiligo, celiac disease, T1DMTypical hyperthyroidism presentation as well as exophthalmus and goiter










Toxic adenomaBenign (nonmalignant), metabolically-active thyroid nodule Typical hyperthyroid presentation with palpable unilateral thyroid mass but without exophthalmus










ThyroiditisUsually transient. Etiology‒ Viral or autoimmune, postpartum, drug-induced in origin Typical milder hyperthyroidism presentation with thyroid tenderness but without exophthalmus










Select medication useAmiodarone (also hypothyroidism), interferon (also hypothyroidism), othersTypical milder hyperthyroid presentation without goiter or exophthalmus



3

Thyroid TestTest Evaluates Comment

Thyroid-stimulating hormone (TSH)NL=0.4-4.0 mIU/LTrue population distribution=0.5-1.5 mIU/L range with M=1.18 mIU/L

Hypothalamic-pituitary-thyroid axis function, reflects anterior pituitary lobe’s ability to detect amount of circulating free thyroxine (TSH, also known as thyrotropin), TSH receptors found in thyroid follicular cells, receptor stimulation increases T3 and T4 production, secretion

Single most reliable test to diagnose all common forms of hypo- and hyperthyroidism, particularly in the ambulatory setting. Given TSH’s high sensitivity and specificity, when TSH results are WNL, thyroid disease has been ruled out.

Free T4 (FT4, free thyroxine)NL=10-27 pmol/L

Unbound, metabolically active portion of thyroxine

About 0.025% of all T4

Total T4 (Total thyroxine)NL=4.5-12.0 mcg/dL (57.91-154.44 nmol/L)Rarely indicated test

Reflects the total of the protein-bound and free thyroxine.

Often altered (increased or decreased) in the absence of thyroid disease but with the use of select medications (exogenous estrogen [HT, OC], methadone) and presence of clinical conditions, such as pregnancy, chronic hepatitis

Free T3

NL=3.5-7.7 pmol/L (0.2-0.5 ng/dL)Rarely indicated test

Unbound, metabolically active portion of triiodothyronine (T3) When compared to T4, T3 is about 4 x more metabolically active.

About 20% of circulating (T3) is from the thyroid, rest as a result of conversion of T4 to T3

Total T3

NL=95-190 ng/dL (1.5-2.9 pmol/L)Rarely indicated test

Reflects the total of the protein-bound and free triiodothyronine

See comments on total T4

Antiperoxidase (antimicrosomal, antithyroid, thyroperoxidase [TPO]) antibodyNL=Depends on lab method, either numeric value or titer

A test to help detect autoimmune thyroid disease

Measures an antibody against peroxidase, an enzyme held within the thyroid


EvaluatesHypothalamic-pituitary-thyroid axis function, reflects anterior pituitary lobe’s ability to detect amount of circulating free thyroxine (TSH, also known as thyrotropin), TSH receptors found in thyroid follicular cells, receptor stimulation increases T3 and T4 production, secretion

TestThyroid-stimulating hormone (TSH)NL=0.4–4.0 mIU/LTrue population distribution=0.5–1.5 mIU/L range with M=1.18 mIU/L

Test Evaluates CommentThyroid-stimulating hormone (TSH)NL=0.4-4.0 mIU/LTrue population distribution=0.5-1.5 mIU/L range with M=1.18 mIU/L









Free T3




Total T3







Thyroid Test


TestThyroid-stimulating hormone (TSH)(cont.)

CommentSingle most reliable test to diagnose all common forms of hypo- and hyperthyroidism, particularly in the ambulatory setting. Given TSH’s high sensitivity and specificity, when TSH results are WNL, thyroid disease has been ruled out.










Free T3




Total T3







Thyroid Test


TestFree T4 (FT4, free thyroxine)NL=10–27 pmol/L

EvaluatesUnbound, metabolically active portion of thyroxine

CommentAbout 0.025% of all T4










Free T3




Total T3







Thyroid Test


TestTotal T4 (Total thyroxine)NL=4.5–12.0 mcg/dL (57.91–154.44 nmol/L)Rarely indicated test

EvaluatesReflects the total of the protein-bound and free thyroxine.










Free T3




Total T3







CommentOften altered (increased or decreased) in the absence of thyroid disease but with the use of select medications (exogenous estrogen [HT, COC], methadone, others) and presence of clinical conditions, such as pregnancy, chronic hepatitis

Thyroid Test











Free T3




Total T3







Thyroid Test


TestFree T3NL=3.5–7.7 pmol/L (0.2–0.5 ng/dL)Rarely indicated test

EvaluatesUnbound, metabolically active portion of triiodothyronine (T3) When compared to T4, T3 is about 4 × more metabolically active.



4










Free T3




Total T3







Thyroid Test


CommentAbout 20% of circulating (T3) is from the thyroid, rest as a result of conversion of T4 to T3










Free T3




Total T3







Thyroid Test


TestTotal T3NL=95–190 ng/dL (1.5–2.9 pmol/L)Rarely indicated test

EvaluatesReflects the total of the protein-bound and free triiodothyronine

CommentSee comments on total T4










Free T3




Total T3







Thyroid Test


TestAntiperoxidase (antimicrosomal, antithyroid, thyroperoxidase [TPO]) antibodyNL=Depends on lab method, either numeric value or titer

EvaluatesA test to help detect autoimmune thyroid disease










Free T3




Total T3







Thyroid Test


CommentMeasures an antibody against peroxidase, an enzyme held within the thyroid

Measuring TSH and FT4?

• “When thyroid status is stable and hypothalamic-pituitary function is intact, serum TSH measurement is more sensitive than free T4 (FT4) for detecting mild (subclinical) thyroid hormone excess or deficiency.”


Measuring TSH and FT4? (continued)


• “The superior diagnostic sensitivity of serum TSH reflects the log/linear relationship between TSH and FT4and the exquisite sensitivity of the pituitary to sense free T4 abnormalities relative to the individual’s genetic free T4 set-point.”

– Source: https://www.aace.com/disease-state-resources/thyroid/guidelines



5

Measuring TSH and FT4? (continued)


• “Serum FT4 measurement is a more reliable indicator of thyroid status than TSH when thyroid status is unstable, such as during the first2‒3 months of treatment for hypo- or hyperthyroidism.”

– Source: www.aacc.org/sitecollectiondocuments/nacb/lmpg/thyroid/thyroid-fullversion.pdf

True or false?

• TSH levels peak in the evening and are lowest in the afternoon.

• TSH varies with physiologic conditions such as illness, psychiatric disorders and low energy intake.


Clinical Utility of Reverse T3

• What is reverse T3? – Biologically inactive

form of T3

– Produced in body particularly during periods of stress

– Normally eliminated from body quickly


Clinical Utility of Reverse T3(continued)

• Clinical utility • Not in standard thyroid care

– Likely helpful in evaluation of sick euthyroid syndrome where active T3 is within normal range and rT3 is elevated


Euthyroid Sick Syndrome

• Most common setting– Acute starvation– Any critical illness

• Laboratory diagnosis– NL free T4

– NL TSH – Low total and free T3

– Source: https://emedicine.medscape.com/article/118651-overview


Thyroid Test ResultsLow Thyroxine (FT4)=High TSH

• Example– TSH=84 mIU/L (0.4‒4.0 mIU/L)– Free T4=3 pmol/L (10‒27 pmol/L)

• Etiology– Untreated hypothyroidism– Inadequate thyroxine dose




6

From Levothyroxine PI

• “Synthetic T4 is identical to that produced in the human thyroid gland. Levothyroxine (T4) sodium has an empirical formula of C15H10I4N NaO4 • H2O, molecular weight of 798.86 g/mol (anhydrous)….”


From Levothyroxine PI(continued)

• T½

– In hypothyroid state=9‒10 d– In euthyroid state=7 d– In hyperthyroid state=3‒4 d

• How many T½ to reach steady state? Eliminate drug from the body?


Intervention in Hypothyroidism

• Calculating anticipated levothyroxine dose– 1.6 mcg/kg/day in adults– 1.0 mcg/kg/day in elderly– 4.0 mcg/kg/day in children–≥50% increase during pregnancy

• Increase levothyroxine dose by ≥33% as soon as pregnancy is confirmed


True or false?

• When calculating the levothyroxine dose for a patient, ideal body weight (IBW) should be used for the person who is overweight or obese.

• For the person who is underweight, actual body weight should be used.


True

True

Therapy is usually initiated in patients under the age of 50 years with full replacement. • For those patients who are older than

age 50 years or in younger patients with a history of cardiac disease, a lower initial dosage is indicated, starting with 0.025 to 0.05 mg of levothyroxine daily, with clinical and biochemical reevaluations at 6‒ to 8‒week intervals until the serum TSH concentration is normalized.


What about desiccated porcine or bovine thyroid preparations?

Source: American Thyroid Association Treatment Guidelines for Patients with

Hypothyroidism, available at https://www.aace.com/disease-state-

resources/thyroid/guidelines



7

T4/T3 Combinations

• Desiccated thyroid preparations (T4/T3 combination, porcine or bovine origin such as Armour Thyroid®, Nature-Throid®, Bio-Throid®, Westhroid®)– 1 grain=60‒65 mg thyroid USP=100 mcg

levothyroxine– Thyroid USP 60‒120 mg per day for typical

adult daily dose


Per American Thyroid Association (ATA)

• “Biological and synthetic thyroid hormone preparations containing both T4 and T3 are also not currently recommended for therapy since they produce fluctuating and often elevated T3 concentrations, although their use is not necessarily contraindicated.”


Monitoring Thyroxine Therapy

• TSH– No sooner than

6‒8 (AACE) or 8‒12 (ATA) weeks • ~8 weeks covers

both guidelines• Long T½

• TSH too high– Dose too low– Adherence– Drug interaction

• TSH too low– Excessive use– Dose too high


Thyroid Test ResultsHigh Thyroxine (FT4)=Low TSH

• Example– TSH <0.15 mIU/L (0.4‒4.0 mIU/L)– Free T4=79 pmol/L (10‒27 pmol/L)

• Etiology– Hyperthyroidism– Excessive thyroxine dose


Intervention in Hyperthyroidism at the Time of Diagnosis

• Beta adrenergic antagonist– β1, β2 blockade if possible

• Propranolol, nadolol

• Antithyroid medication– PTU, methimazole

• Radioactive iodine (RAI)– Thyroid ablation


Etiology, test results

Intervention Comment

Untreated hypothyroidism Low FT4=High TSHTSH=84 mIU/L (NL=0.4–4.0 mIU/L)

Free T4=3 pmol/L (NL=10–27 pmol/L)

•Prescribing levothyroxine (Synthroid®, Levoxyl®, generic, a bioidentical replacement hormone) dose, using ideal body weight in obesity, actual body weight in healthy weight, underweight

–1.6 mcg/kg/d in adults–1.0 mcg/kg/d in elderly–4.0 mcg/kg/d in children–≥50% increase during pregnancy

•Increase levothyroxine dose by ≥33% as soon as pregnancy is confirmed.

•T4/T3 porcine thyroid combination (Armour® Thyroid). 1 grain=60–65 mg thyroid USP=100 mcg levothyroxine. Thyroid USP 60–120 mg/d for typical adult daily dose. Use not recommended by AACE due to variable pharmacokinetics.

•Check TSH after approximately 8 weeks of therapeutic levothyroxine therapy.

–Checking sooner leads to errors in clinical decision-making.

–Drug interaction• Levothyroxine should be taken with water

on an empty stomach, same time every day.

• Should not be taken within 2 hours of cation, such as calcium, iron, aluminum, magnesium, others

Untreated hyperthyroidism/ thyroidoxicosisHigh FT4=Low TSHExample:TSH<0.15 mIU/L (NL=0.4–4.0 mIU/L)Free T4=79 pmol/L (NL=10–27 pmol/L)

• At time of diagnosis –Beta-adrenergic antagonist with β1-, β2-blockade (propranolol, nadolol), if not contraindicated, to counteract tachycardia, tremor

• Hyperthyroidism treatment–PO methimazole (Tapazole®), or PTI to reduce thyroxine production to become euthyroid.

–Once euthyroid from antithyroid medications, radioactive iodine (RAI) use. Therapeutic goal= Thyroid ablation with resulting hypothyroidism.

• Methimazole and PTU use carries acute hepatic failure warning even in the absence of liver disease risk factors.

• Hyperthyroidism is usually treated in conjunction with endocrinology consultation.

Subclinical hypothyroidism Elevated TSH with NL free T4Example:TSH=8.9 mIU/L (NL=0.4–4.0 mIU/L)Free T4=15 pmol/L (NL) (NL=10–27 pmol)TPO Ab=76 IU/mL (NL<35 IU/mL)

• Recommended treatment with levothyroxine with TSH>5 mIU/L if: –Presence of goiter or TPO antibodies. –Presence of symptoms compatible with hypothyroidism, infertility, pregnancy, or imminent pregnancy would also favor treatment.

Follow up as with hypothyroidism

Assessment and Intervention of Common Thyroid Diseases


Etiology, test results

Untreated hyperthyroidism

Intervention

• At time of diagnosis –Beta-adrenergic antagonist with β1-, β2-blockade (propranolol, nadolol), if not contraindicated, to counteract tachycardia, tremor

• Hyperthyroidism treatment–PO methimazole (Tapazole®), or PTU to reduce thyroxine production to become euthyroid



8

True or false?

Methimazole and PTU use carries acute hepatic failure warning even in the absence

of liver disease risk factors.

Fitzgerald Health Education Associates, LLC 49

True, FDA boxed warning

Clinical Example

• You see a 38-year-old woman with hypothyroidism who is currently taking levothyroxine 75 mcg daily with excellent adherence. She is feeling well. Results of today’s laboratory testing include a TSH=4.5 μIU/mL. The next best step in her care is to:


A. Continue on the same levothyroxine dose and obtain a repeat TSH in 1 year.

B. Decrease the levothyroxine dose by 25 mcg/d and repeat a TSH in 1 month.

C. Increase the levothyroxine dose by 25 mcg/d and repeat a TSH in 2 months.

D. Check antiperoxidase antibodies and have the patient return in 1 month for followup.


Clinical Example (continued)

Primary Hypothyroidism Treatment Algorithm

TSH >4 μIU/mL TSH <0.5 μIU/mL

Initial levothyroxine dose influenced by ideal or actual body weight, overall health status.

Increaselevothyroxine

dose by12.5 to 25 mcg/d

TSH test

Approximately 8 Weeks

TSH 0.5‒2.0 μIU/mLSymptoms resolved

Measure TSH at 6 months, then annually or

when symptomatic

Continue dose

Decreaselevothyroxine


Singer PA, et al.. JAMA.;273:808‒812. Demers LM, Spencer CA, eds. The National Academy of Clinical Biochemistry Web site.

Available at: http://www.nacb.org/lmpg/thyroid_lmpg.stm


Samantha, 47-year-old Woman

• Last year’s results– TSH=1.2 mIU/L

• 0.35‒4.0 mIU/L

– FT4=14 pmol/L• 10‒27 pmol/L

• This year’s results– TSH=6.4 mIU/L– FT4=6 pmol/L

• Long-standing hypothyroidism

• States continues to take her levothyroxine “every day, justlike clockwork”


Samantha – Interim History

• Since last visit with you, saw gyn for heavy menstrual bleeding

• Underwent endometrial ablation procedure and is quite pleased with the results




9

Iron Ingestion and Levothyroxine Therapy

Ferrous sulfate effect on TSH levels in patients with hypothyroidism

Source: Campbell NR, et al. Ann Intern Med. 1992;117:1010‒1013.

P<0.001

0123456

TSH

Lev

el, μ

IU/m

L

Before Ingestion After Ingestion


LT4 Interactions

• Iron•Calcium•Aluminum antacids•Sucralfate•Soy milk

• Formation of inactive drug compound– Separate ≥2h– Empty stomach


Medications Increasing Metabolism of Thyroid Hormone

• Phenytoin• Phenobarbital• Carbamazepine• Rifampin


NTI with Many Drug-drug, Drug-nutrient Interactions

• Take your levothyroxine– Always at the same time of day– Empty stomach, ≥½ h before or ≥2 h

after meal – Separate from other meds including

OTC, minerals, vitamins by ≥2 h


Generic or brand?Per AACE Statement

• “Patients should be maintained on the same brand name levothyroxine product. If the brand of levothyroxine medication is changed, either from one brand to another brand, from a brand to a generic product, or from a generic product to another generic product, patients should be retested by measuring serum TSH in six (6) weeks, and the drug reiterated as needed.”…


Generic or brand?Per AACE Statement

(continued)

• …“Since small changes in levothyroxine administration can cause significant changes in TSH serum concentrations, precise and accurate TSH control is necessary to avoid potential adverse iatrogenic effects.”

– Source: https://www.endocrine.org/~/media/endosociety/Files/Advocacy%20and%20Outreach/Position%20Statements/Other%20Statements/Joint_Statement_LevothyroxineThyroxine.pdf




10

Continued Fatigue

• With NL TSH and free T4– Consider checking free T3

• T4– ~40% converted in peripheral tissue to T3


Should we also give T3?

• Triiodothyronine (T3) – About 4 × as active

as T4

– Possibly importantto brain function


T4 and Liothyronine Sodium (Cytomel®)?

• Add to T4? – Liothyronine sodium, LT3 (Cytomel®) usual

dose=12.5 mcg• Short T½

• Usual daily dose 25‒75 mcg per day– Reduce T4 dose by 50 mcg

• Inconclusive study in effectiveness but anecdotal, patient-by-patient reports


T3 Replacement Per ATA

• “After taking a tablet of liothyronine sodium (Cytomel®) there are very high levels of T3 for a short time, and then the levels fall off very rapidly. This means that T3 has to be taken several times each day and even doing this does not smooth out the T3 levels properly.”

– Source: http://www.thyroid.org/thyroid-hormone-treatment/


Cost of Thyroid Medications Per GoodRx, Per 90 Tabs

• Brand name Synthroid®

– ~$120• Generic levothyroxine

– ~$12• Brand name Cytomel®

– ~$75• Armour Thyroid®

– ~$45


Subclinical HypothyroidismElevated TSH, NL Free T4

• Example– TSH=8.9 mIU/L (0.4‒4.0 mIU/L)– Free T4=15 pmol/L (10‒27 pmol/L)– Antithyroid antibodies=1:1,800

(<1:1,000)




11

Per AACE GuidelinesSubclinical Hypothyroidism

• AACE guidelines recommend treatment of patients with TSH >5 mIU/L if the patient has a goiter or if thyroid antibodies are present.

• The presence of symptoms compatible with hypothyroidism, infertility, pregnancy or imminent pregnancy would also favor treatment.

– Source: https://www.aace.com/disease-state-resources/thyroid/guidelines


Sonia35-year-old woman w CC “sore throat and earache both sides for the past two weeks”

• Afebrile• Pharynx and TM benign• Hyperreflexia• Tender, slightly enlarged thyroid


Sonia describes where her throat and ears hurt.

70Fitzgerald Health Education Associates

Sonia35-year-old Woman

(continued)

• TSH <0.15 mIU/L (0.15–4.0)• Free T4=33 pmol/L (10–27)• ESR=66 mm/hr (<15 mm/hr)


Thyroiditis Subacute (Granulomatous) Thyroiditis

• In hyperthyroid phase– Neck pain, a tender, diffuse goiter, and

elevated T4 and/or T3

• Caused by damage to thyroid follicular cells and breakdown of stored thyroglobulin, leading to unregulated release of thyroxine (T4) and triiodothyronine (T3)



(continued)• Duration of hyperthyroid phase

– Lasts 2–6 weeks until T4 and T3 stores are depleted• Low TSH minimizes thyroid

follicular stimulation

– Hypothyroidism often follows,usually transient




12


(continued)• Etiology

– Likely viral infection trigger• Common report of recent URI symptoms• Multiple case reports post Coxsackievirus

outbreaks

– Also strong association with HLA-B35• ?Viral trigger with genetic basis


Additional More Common Thyroiditis Forms

• Subacute lymphocytic thyroiditis– Most common form of

postpartum thyroiditis • Often presents with nervousness, poor sleep,

painless thyroid, in first year postpartum, most often around month 3 after birth

– Lasts 1–2 months with self-resolution


Thyroiditis Testing

• Additional evaluation– Check anti-TPO antibodies

• More commonly positive in postpartum thyroiditis, rarely positive ingranulomatous thyroiditis

• Consider thyroid scanning– Generally increased uptake in Graves’

disease, low uptake in thyroiditis


Evaluation of a Solitary Thyroid Nodule


What is a thyroid nodule?

Palpable thyroid mass, not a term specific to any diagnosis.

What is the risk of a palpable thyroid nodule being a malignant lesion?

Presentation of benign and malignant thyroid lesions typically the same. Risk that any thyroid nodule is malignant=about 5%.

What are the findings most consistent with a malignant thyroid nodule?

History of head or neck irradiationSize larger than 4 cm in size Firmness, nontender on palpationRelatively fixed position (nonmobile)Persistent non tender cervical lymphadenopathyDysphoniaHemoptysis


Palpable thyroid mass, not a term specific to any diagnosis, generally >1 cm in diameter.










Presentation of benign and malignant thyroid lesions typically the same. Risk that any thyroid nodule is malignant=About 5%










History of head or neck irradiationSize larger than 4 cm Firmness, nontender on palpationRelatively fixed position (nonmobile)Persistent nontender cervical lymphadenopathyDysphoniaHemoptysis



13

Clinically evident (palpable, usually >1 cm)

thyroid nodule

Thyroid-stimulating hormone level (TSH)

Thyroid ultrasound to determine size, location, characteristics

TSH suppressed (Metabolically active

lesion)

Nuclear medicine thyroid scan

(Determines function and structure)

"Hot" nodule

(Metabolically active lesion)

Radioiodine ablation or surgery

Nodule not "hot"

(Metabolically inactive lesion)

Fine-needle aspiration biopsy

TSH not suppressed (Metabolically inactive

lesion)

A) Normal thyroid, B) Graves’ disease – Diffuse increased uptake in both thyroid lobes, C) Toxic

multinodular goiter, D) Toxic adenoma, E) Thyroiditis


Source: https://upload.wikimedia.org/wikipedia/commons/0/0a/Thyroid_scintigraphy.jpg

Conclusion


End of PresentationThank you for your time and attention.

Vanessa Pomarico-Denino, EdD, FNP-BC, FAANP

www.fhea.com [email protected]


References

• American Association of Clinical Endocrinologist Medical Guidelines for Clinical Practice: Hyperthyroidism and Hypothyroidism, available at https://www.aace.com/disease-state-resources/thyroid/guidelines


References (continued)

• Fitzgerald, M. (2017) Nurse Practitioner Examination and Practice Preparation. 5th edition, Philadelphia: F. A. Davis, available at fhea.com

• Fitzgerald, M., Miller, S. Comprehensive Clinical Pharmacology Course, available at fhea.com

• Fitzgerald, M., Miller, S., Pathophysiology for Advanced Practice Course, available at fhea.com




14

• Images/Illustrations: Unless otherwise noted, all images/illustrations are from open sources, such as the CDC or Wikipedia or property of FHEA or author.

• All websites listed active at the time of publication.


Copyright Notice

Copyright by Fitzgerald Health Education AssociatesAll rights reserved. No part of this publication may be reproduced or transmitted

in any form or by any means, electronic or mechanical, including photocopy, recording or any information storage and retrieval system, without permission

from Fitzgerald Health Education Associates

Requests for permission to make copies of any part of the work should be mailed to:

Fitzgerald Health Education Associates85 Flagship Drive

North Andover, MA 01845-6184


Statement of Liability

• The information in this program has been thoroughly researched and checked for accuracy. However, clinical practice and techniques are a dynamic process and new information becomes available daily. Prudent practice dictates that the clinician consult further sources prior to applying information obtained from this program, whether in printed, visual or verbal form.

• Fitzgerald Health Education Associates disclaims any liability, loss, injury or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this presentation.


Fitzgerald Health Education Associates

85 Flagship Drive

North Andover, MA 01845-6154978.794.8366 Fax-978.794.2455

Website: fhea.com

Learning & Testing Center: fhea.com/npexpert

www.facebook.com/fitzgeraldhealth

@npcert




15

Primary Hypothyroidism Treatment Algorithm

TSH >4 μIU/mL TSH <0.5 μIU/mL

Initial levothyroxine dose influenced by ideal or actual body weight, overall health status.

Increaselevothyroxine


TSH test

Approximately 8 Weeks

TSH 0.5‒2.0 μIU/mLSymptoms resolved

Measure TSH at 6 months, then annually or

when symptomatic

Continue dose

Decreaselevothyroxine


Singer PA, et al.. JAMA.;273:808‒812. Demers LM, Spencer CA, eds. The National Academy of Clinical Biochemistry Web site.

Available at: http://www.nacb.org/lmpg/thyroid_lmpg.stm




16

management of thyroid disease: too many, too little, masses€¦ · treatment, sp thyroid cancer...

Documents