thyroid

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

FPCSFPCS

EmbryologyEmbryology Out pouching of the Out pouching of the

primitive foregut (3primitive foregut (3rdrd wk of gestation)wk of gestation)

1.1. Base of the tongue Base of the tongue (foramen cecum).(foramen cecum). Endoderm cells. Endoderm cells. Medial thyroid anlage Medial thyroid anlage – forms thyroid – forms thyroid follicular cellfollicular cell

2.2. 44thth branchial pouch branchial pouch – – forms lateral anlage. forms lateral anlage. Neuroectodermal Neuroectodermal origin (ultimobranchial origin (ultimobranchial bodies). Forms bodies). Forms parafollicular cells parafollicular cells located at located at superoposterior region superoposterior region

ANATOMY:ANATOMY:• Location / PartsLocation / Parts• Arteries / Venous Arteries / Venous

drainagedrainage• Nerve SupplyNerve Supply

• Sympathetic (Sympathetic (cervical cervical ganglionganglion))

• Parasympathetis Parasympathetis ((vagusvagus))

ANATOMY:ANATOMY:• Nerve SupplyNerve Supply

• Sympathetic (Sympathetic (cervical ganglioncervical ganglion))• Parasympathetis (Parasympathetis (vagusvagus))

ANATOMY:ANATOMY:Lymphatic Drainage:Lymphatic Drainage:

1.1. Central Central compartmentcompartment• Areas between the Areas between the

two carotid sheathstwo carotid sheaths

2.2. Lateral Lateral compartmentcompartment

Histology:Histology:• Thyroid follicle Thyroid follicle

((thyroglobulinthyroglobulin))• C cells C cells

((neuroectoderm – neuroectoderm – 44thth and 5 and 5thth ultimo ultimo brachial bodiesbrachial bodies).).

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 iodine and iodination of iodine and iodination of tyrosine in tyrosine in thyroglobulin to form thyroglobulin to form MIT / DITMIT / DIT

3.3. Coupling of inactive Coupling of inactive iodotyrosine to form iodotyrosine to form T4 /T3T4 /T3

4.4. Thryoglobulin is Thryoglobulin is hydrolized to free T3 hydrolized to free T3 and T4and T4

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

Evaluation of Thyroid Evaluation of Thyroid DiseasesDiseases

1.1. Clinical history and physical examinationClinical history and physical examination2.2. Thyroid Function TestThyroid Function Test

a.a. TSHTSH determination: determination: N = 0.5 to 5 uU/mlN = 0.5 to 5 uU/ml The only test necessary in most pts w/ thyroid The only test necessary in most pts w/ thyroid

nodules that clinically appears to be euthyroidnodules that clinically appears to be euthyroid The The most sensitive and specific test for the most sensitive and specific test for the

diagnosis of hyper and hypothyroidism diagnosis of hyper and hypothyroidism & for & for optimizing T4 replacement & suppressive therapyoptimizing T4 replacement & suppressive therapy

b.b. Total T4Total T4 ( ( 55 – 150nmol/L55 – 150nmol/L) and ) and Free T4Free T4 ( (12 12 to 28pmolto 28pmol) reflects the output from the ) reflects the output from the thyroid gland.thyroid gland.Total T3Total T3 ( (1.5 to 3.5 nmol/L1.5 to 3.5 nmol/L) ) Free T3Free T3 ( (3-3-9pmol9pmol) – confirming the diagnosis of early ) – confirming the diagnosis of early hyperhtyroidismhyperhtyroidism


c.c. Thyroid-releasing hormoneThyroid-releasing hormone:: Use to evaluate pituitary TSH secretory Use to evaluate pituitary TSH secretory

functionfunction Administer 500ug of TRH --> there shd be an Administer 500ug of TRH --> there shd be an

increase of 6uIU/ml from baselineincrease of 6uIU/ml from baseline

d.d. Thyroid antibodies:Thyroid antibodies: For Hashimoto’s thyroiditis & Graves’ dseFor Hashimoto’s thyroiditis & Graves’ dse

e.e. Serum thyroglobulinSerum thyroglobulin Normally not released but is noted in cases of Normally not released but is noted in cases of

thyroiditis & Graves’ dsethyroiditis & Graves’ dse It’s level is impt in monitoring recurrent It’s level is impt in monitoring recurrent

thyroid CA after total thyroidectomy and thyroid CA after total thyroidectomy and radioactive iodine ablationradioactive iodine ablation


3.3. Thyroid Imaging:Thyroid Imaging:a.a. Radioactive Radioactive

Imaging:Imaging: I I 123123 & I & I 131131

Mass and it’s activity:Mass and it’s activity: COLD COLD ((15 – 20% 15 – 20% malignant), HOT and malignant), HOT and WARM (<5% WARM (<5% malignant) nodulesmalignant) nodules

F-fluorodeoxyglucose F-fluorodeoxyglucose positron emissionpositron emission tomography – use to tomography – use to screen for metastases screen for metastases in thyroid CA if in thyroid CA if radioactive Iodine is radioactive Iodine is negativenegative..


3.3. Thyroid Imaging:Thyroid Imaging:b.b. Ultrasound:Ultrasound:

(-) radiation(-) radiation Cystic or solidCystic or solid Size and multicentricitySize and multicentricity Can assess cervical Can assess cervical

lymphadenopathylymphadenopathy To guide FNA biopsyTo guide FNA biopsy

c.c. CT/MRI scan:CT/MRI scan: Useful in evaluating Useful in evaluating

the extent of large, the extent of large, fixed or substernal fixed or substernal goiters & their goiters & their relationship to the relationship to the airway and vascular airway and vascular structuresstructures


4.4. Fine Needle Aspiration Biopsy:Fine Needle Aspiration Biopsy: Single most important test after Single most important test after

clinical history & PE in the evaluation clinical history & PE in the evaluation of thyroid masses.of thyroid masses.

w/ or w/o ultrasound guidancew/ or w/o ultrasound guidance

BENIGN THYROID BENIGN THYROID DISORDERSDISORDERS

HYPERTHYROIDISM (Thyrotoxicosis)HYPERTHYROIDISM (Thyrotoxicosis)

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

1.1. Grave’s diseaseGrave’s disease

2.2. Toxic nodular goiterToxic nodular goiter

3.3. Toxic thyroid adenomaToxic thyroid adenoma

B.B. With out increased thyroid hormone With out increased thyroid hormone secretionsecretion

1.1. Sub-acute thyroiditisSub-acute thyroiditis

2.2. Functioning metastatic thyroid cancerFunctioning metastatic thyroid cancer

3.3. 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 directed at the TSH receptor or the thyroid follicular cells.thyroid follicular cells.

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

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

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

Manifestations:Manifestations:• Signs/symptoms of thyrotoxicosisSigns/symptoms of thyrotoxicosis: : Inc. Body Inc. Body

MetabolismMetabolism• 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

HYPERTHYROIDISMHYPERTHYROIDISMGRAVE’S Disease GRAVE’S Disease

(Diffuse Thyroid (Diffuse Thyroid Goiter)Goiter)

• Triad:Triad:• diffuse goiterdiffuse goiter• thyrotoxicosisthyrotoxicosis• exopthalmosexopthalmos

• Other:Other:• hair losshair loss• pretibial pretibial

myxedemamyxedema• gynecomastiagynecomastia• splenomegallysplenomegally

(Glycosaminoglycans)

HYPERTHYROIDISMHYPERTHYROIDISMGRAVE’S GRAVE’S

Disease: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 the revealing the sclera above the corneoscleral limbus 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 eyeball)(inability to move the eyeball)• Supra and infraorbital swellingSupra and infraorbital swelling• 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

Orbital fibroblast & muscles share theA common antigen with thyrocytes

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• Thyroid ultrasoundThyroid ultrasound

• 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

HYPERTHYROIDISMHYPERTHYROIDISM

Antithyroid Drugs:Antithyroid Drugs:1.1. Propyl thiouracil (PTU)Propyl thiouracil (PTU) = 100-300mg TID = 100-300mg TID

2.2. Methimazole (Tapazole)Methimazole (Tapazole) = 10-20 TID = 10-20 TID then ODthen OD

3.3. CarbimazoleCarbimazole = 40mg OD= 40mg OD

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

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

HYPERTHYROIDISMHYPERTHYROIDISMDisadvantage of these drugs.Disadvantage of these drugs.

a.a. Crosses the placenta --> inhibits Crosses the placenta --> inhibits fetal thyroid functionfetal thyroid function

b.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 Agranulocytosis / aplastic anemia

(poor prognosis)(poor prognosis)

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

peripheral adrenergic effectsperipheral adrenergic effects

Advised medical managementAdvised medical management1.1. Small diffusely enlarge gland Small diffusely enlarge gland 2.2. larger glands that decreases in size due larger glands that decreases in size due

to antithyroid drugsto antithyroid drugs

Thyroidectomy / Radioactive Iodine Thyroidectomy / Radioactive Iodine AblationAblation

1.1. Toxic nodule goitersToxic nodule goiters2.2. Large diffuse glands Large diffuse glands 3.3. Hyperthyroidism recurs when drug was Hyperthyroidism recurs when drug was

discontinueddiscontinued

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

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

2.2. Reduce cost & ease of treatmentReduce cost & ease of treatment

Disadvantages:Disadvantages:1.1. Lifelong thyroxin replacement therapyLifelong thyroxin replacement therapy

2.2. Slower correction of hyperthyroidismSlower correction of hyperthyroidism

3.3. Higher relapse rateHigher relapse rate

4.4. Adverse effect of ophthalmopathyAdverse effect of ophthalmopathy

HYPERTHYROIDISMHYPERTHYROIDISMRadioactive Iodine Therapy:Radioactive Iodine Therapy:Suitable treatment:Suitable treatment:

1.1. Small or moderate size goiterSmall or moderate size goiter

2.2. Relapse after medical and surgical therapyRelapse after medical and surgical therapy

3.3. Antithyroid drug and surgery are Antithyroid drug and surgery are contraindicatedcontraindicated

Contraindicated:Contraindicated:1.1. Pregnant / breast feedingPregnant / breast feeding

2.2. Ophthalmopathy (progression of eye signs)Ophthalmopathy (progression of eye signs)

3.3. Isolated nodular goiter or toxic nodular Isolated nodular goiter or toxic nodular goitergoiter

4.4. Young age (children/adolescence) ----> Young age (children/adolescence) ----> Infertility / carcinomaInfertility / carcinoma

HYPERTHYROIDISMHYPERTHYROIDISMRadioactive Iodine Therapy:Radioactive Iodine Therapy:Complication of RAI tx:Complication of RAI tx:

1.1. Exacerbations of thyrotoxicosis with Exacerbations of thyrotoxicosis with arrhythmiaarrhythmia

2.2. Overt thyroid storm (sudden release of Overt thyroid storm (sudden release of TH)TH)

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 Large nodular toxic goiter w/ low level of

radioactive iodine uptake.radioactive iodine uptake.

Placed patient to euthyroid state prior to Placed patient to euthyroid state prior to thyroid surgery:thyroid surgery:

1.1. Antithyroid drugsAntithyroid drugs2.2. Lugol’s iodine solution (3 drops BID): SSKI Lugol’s iodine solution (3 drops BID): SSKI

supersaturated KIsupersaturated KI• Decrease vascularity of the gland / inhibit release of Decrease vascularity of the gland / inhibit release of

thyroid hormone hence reduce the risk of thyroid stormthyroid hormone hence reduce the risk of thyroid storm

3.3. PropranololPropranolol

HYPERTHYROIDISMHYPERTHYROIDISMThyroid Surgery:Thyroid Surgery:Thyroidectomy:Thyroidectomy:

1.1. Bilateral subtotal thyroidectomy Bilateral subtotal thyroidectomy 2.2. Total lobectomy & subtotal lobectomy contra-lateral Total lobectomy & subtotal lobectomy contra-lateral

(Hartley-Dunhill)(Hartley-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 Complication ---> nerve injury (1%) and

hypoparathyroidism (13% transient/ 1% permanent).hypoparathyroidism (13% transient/ 1% permanent).2.2. HematomaHematoma3.3. Hypertrophic scar formationHypertrophic scar formation

HYPERTHYROIDISMHYPERTHYROIDISMRecurrent 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 byPrecipitated by::

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

2.2. Iodine 131 treatmentIodine 131 treatment

3.3. Thyroid surgeryThyroid surgery

• Prophylactic treatment: --- Prophylactic treatment: --- Surgery in euthyroid stateSurgery in euthyroid state

Thyroid storm:Thyroid storm: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 Extreme cases ----> peritoneal dialysis or hemofiltration to lower T4&T3hemofiltration to lower T4&T3

Avoid ASPIRINAvoid ASPIRIN ---> increases free ---> increases free thyroid hormone levelsthyroid hormone levels

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

1.1. Autoimmune Autoimmune thyroiditisthyroiditis

• 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. HypopituitarismHypopituitarism

2.2. Hypothalamic Hypothalamic hypothyroidismhypothyroidism

3.3. Peripheral Peripheral resistance to resistance to thyroid hormone *thyroid hormone *

Treatment:Treatment:L-thyroxine (50-L-thyroxine (50-

100ug)100ug)• Will not work for *Will not work for *

THYROIDITISTHYROIDITISA.A. Acute Suppurative ThyroiditisAcute Suppurative Thyroiditis

• UncommonUncommon• Associated with URTIAssociated with URTI• Staphylococcus, Streptococcus and Staphylococcus, 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 (Autoimmune lymphocytic thyroiditis)lymphocytic thyroiditis)

• Most common form of chronic lymphocytic Most common form of chronic lymphocytic thyroiditisthyroiditis

• 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 syndrome

2.2. Familial Alzheimer’s diseaseFamilial Alzheimer’s disease

3.3. Turner syndromeTurner syndrome


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

• 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 - Painless, nontender enlargement of glandgland

• 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 thyroid

hormonehormone

- Surgical:- Surgical: 1. Obstructive1. Obstructive

2. Cosmetically 2. Cosmetically unacceptable unacceptable

3. Thyroid carcinoma coexist3. Thyroid carcinoma coexist

THYROIDITISTHYROIDITISB.B. Nonsuppurative Nonsuppurative

Thyroiditis:Thyroiditis:2. Riedels’ Thyroiditis2. Riedels’ Thyroiditis::

• Marked dense invasive Marked dense invasive fibrosisfibrosis that may involve that may involve surrounding structuressurrounding structures

• Can cause Can cause hypoparathyroidismhypoparathyroidism

• Unknown cause Unknown cause ( maybe part of ( maybe part of fibrosclerosis – fibrosclerosis – retroperitoneum, retroperitoneum, mediastinum, mediastinum, lacrimal gland and lacrimal gland and bile duct – sclerosing bile duct – sclerosing cholahgitis)cholahgitis)


3.3. Riedels’ Thyroiditis:Riedels’ Thyroiditis:• S/Sx: - painless woody hard anterior neck mass S/Sx: - painless woody hard anterior neck mass

w/c progresses causing compression symptomsw/c progresses causing compression symptoms

- Hoarseness - dyspnea- Hoarseness - dyspnea

- stridor- stridor - dysphagia - dysphagia• Dx: - open thyroid biopsy – frozen sectionDx: - open thyroid biopsy – frozen section

- FNA biopsy is inadequate- FNA biopsy is inadequate• Tx:Tx: - Isthmectomy – to relieve - Isthmectomy – to relieve

compression symptomcompression symptom

- Thyroxine replacement - Thyroxine replacement

- Tamoxifen- Tamoxifen

- Steroid- Steroid

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

GOITERGOITERPathology: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 gelatinous, colloid rich materialrich material and and scattered between scattered between areas of normal areas of normal thyroid tissuesthyroid 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

usuallyusually 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 cystinto a colloid nodule or cyst

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

• For diffuse – ultrasound to detect sub-clinical For diffuse – ultrasound to detect sub-clinical thyroid nodulethyroid nodule

• TSH, T3 & T4 ---> usually normalTSH, T3 & T4 ---> usually normal

Tx:Tx:1.1. No txNo tx for euthyroid, small, diffuse goiter for euthyroid, small, diffuse goiter2.2. Medical Tx:Medical Tx:

a.a. Thyroxine ---> for large diffuse goiter; to depress TSH Thyroxine ---> for large diffuse goiter; to depress TSH stimulation and reduce hyperplasiastimulation and reduce hyperplasia

b.b. Iodine ---> for endemic goiterIodine ---> for endemic goiter

3.3. Surgery:Surgery:a.a. Compression symptoms Compression symptoms b.b. Suspicion for malignancy Suspicion for malignancy c.c. Cosmetically acceptableCosmetically acceptable

Solitary or Dominant Thyroid Solitary or Dominant Thyroid NoduleNodule

Most are benign (colloid Most are benign (colloid nodule/adenomas)nodule/adenomas)

Risk factors for thyroid CA:Risk factors for thyroid CA:1.1. Low-dose radiation to head & neck Low-dose radiation to head & neck

(<2000 rad)(<2000 rad)

- >2000rads causes destruction of - >2000rads causes destruction of thyroid gld.thyroid gld.

- tends to be - tends to be papillary typepapillary type,, multi-focal multi-focal w/ higher incidence of LN metastasesw/ higher incidence of LN metastases..

2.2. Family hx of thyroid CAFamily hx of thyroid CA

- - Medullary CAMedullary CA – inherited as an – inherited as an autosomal dominanat traitautosomal dominanat trait

- - PapillaryPapillary CA CA – 6% familial dse. – 6% familial dse.

Solitary or Dominant Thyroid Solitary or Dominant Thyroid NoduleNodule

Risk factors for thyroid CA:Risk factors for thyroid CA:3.3. AgeAge

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

4.4. SignsSignsa.a. Rapid enlargement of an old or new noduleRapid enlargement of an old or new nodule

b.b. Symptoms of local invasion or compression Symptoms of local invasion or compression symptomssymptoms

c.c. Consistency: Hard, gritty or fixed to Consistency: Hard, gritty or fixed to surrounding structuressurrounding structures

d.d. Palpable cervical lymphadenopathyPalpable cervical lymphadenopathy

e.e. A A cyst larger than 4 cmcyst larger than 4 cm in diameter or in in diameter or in ultrasound is complex has 15% incidence of ultrasound is complex has 15% incidence of malignancymalignancy

Management of Solitary Thyroid Management of Solitary Thyroid NoduleNoduleexcept for pt w/hx of external radiation exposure or a except for pt w/hx of external radiation exposure or a family hx of thyroid CAfamily hx of thyroid CA

SOLITARY THYROID NODULESOLITARY THYROID NODULE

FNABFNAB

Non-diagnostic Benign Suspicious Non-diagnostic Benign Suspicious Malignant Malignant

Follicular lesionFollicular lesion Repeat FNAB Repeat FNAB

Thyroidectomy Thyroidectomy

Cyst Colloid Nodule RAI ScanCyst Colloid Nodule RAI Scan

aspirate Observe Hot Coldaspirate Observe Hot Cold

consider T4 tx.consider T4 tx.

reaccumulate continued growth RAI or reaccumulate continued growth RAI or Thyroidectomy Thyroidectomy

x 3 compressive symptom Thyroidectomyx 3 compressive symptom Thyroidectomy

ThyroidectomyThyroidectomy

MALIGNANT THYROIDMALIGNANT THYROID90 – 95% are differentiated tumor 90 – 95% are differentiated tumor

w/ follicular originw/ 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

Papillary Thyroid Papillary Thyroid Carcinoma:Carcinoma:3 forms of papillary CA (based on size and extent):3 forms of papillary CA (based on size and 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 intra-Non-palpable and usually an incidental finding intra-

op or autopsyop 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 thyroid Locally advanced with invasion through the thyroid

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

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

Papillary 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 lesion (lateral aberrant thyroid)(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

Papillary 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- size2.2. 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- size3.3. AMESAMES4.4. TNMTNM

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

TNM Classification of Thyroid TNM Classification of Thyroid TumorsTumorsPrimary tumor: (T)Primary tumor: (T)

TXTX – primary tumor not assessed – primary tumor not assessedT0T0 – no evidence of primary tumor – no evidence of primary tumorT1 T1 – tumor </= 2cm in diameter, limited to thyroid– tumor </= 2cm in diameter, limited to thyroidT2T2 – tumor > 2cm but < 4cm, limited to thyroid – tumor > 2cm but < 4cm, limited to thyroidT3 T3 – tumor >4cm, limited to thyroid, or any tumor w/ – tumor >4cm, limited to thyroid, or any tumor w/ minimal extra-thyroidal invasionminimal extra-thyroidal invasionT4aT4a – any size that extend beyond capsule invading – any size that extend beyond capsule invading subcutaneous soft tissue, larynx, trachea, subcutaneous soft tissue, larynx, trachea,

esophagus, esophagus, recurrent laryngeal nerve or recurrent laryngeal nerve or intrathyroidal intrathyroidal

anaplastic anaplastic cancer cancer T4bT4b – tumor invading prevertebral fascia or encasing – tumor invading prevertebral fascia or encasing

carotid carotid artery or mediastinal vessels or artery or mediastinal vessels or extrathyroidal extrathyroidal

anaplastic anaplastic cancercancer

TNM Classification of Thyroid TNM Classification of Thyroid TumorsTumors

Regional LN (N) – Regional LN (N) – include central, include central, lateral, cervical and mediastinal lateral, cervical and mediastinal LNLN

NXNX – regional LN cannot be assessed – regional LN cannot be assessed

N0 N0 – no regional LN metastasis– no regional LN metastasis

N1 N1 – regional LN metastasis– regional LN metastasisN1aN1a – metastases to level VI (pretracheal, – metastases to level VI (pretracheal,

paratracheal and paratracheal and prelaryngeal/Delphian LN)prelaryngeal/Delphian LN)

N1b N1b – metastases to unilateral, bilateral or – metastases to unilateral, bilateral or

contralateral cervical or superior contralateral cervical or superior mediastinal LNmediastinal LN


Distant Metastasis (M)Distant Metastasis (M)

MX – distant metastases cannot be MX – distant metastases cannot be assessedassessed

M0 – no distant metastasesM0 – no distant metastases

M1 – w/ distant metastasesM1 – w/ distant metastases


Papillary or Follicular Papillary or Follicular Tumors:Tumors:

STAGESTAGE TNMTNMYounger than age 45 y/oYounger than age 45 y/o

II any T, any N, M0 any T, any N, M0IIII any T, any N, M1 any T, any N, M1

Age 45 w/o and olderAge 45 w/o and older II T1, N0, M0 T1, N0, M0

IIII T2, N0, M0 T2, N0, M0 IIIIII T3, N0, M0; T1-3, N1a, M0 T3, N0, M0; T1-3, N1a, M0 IVAIVA T4a, N0-1a, M0;T1-4a, N1b, T4a, N0-1a, M0;T1-4a, N1b,

M0M0IVBIVB T4b, any N, M0 T4b, any N, M0IVCIVC any T, any N, M1 any T, any N, M1


Medullary Thyroid CancerMedullary Thyroid Cancer STAGESTAGE TNMTNM

II T1, N0, M0 T1, N0, M0 IIII T2-3, N0, M0 T2-3, N0, M0

IIIIII T1-3, N1a, M0 T1-3, N1a, M0 IVAIVA T4a, N0-1a, M0; T1-4a, T4a, N0-1a, M0; T1-4a, N1b, M0N1b, M0

IVBIVB T4b, any N, M0 T4b, any N, M0 IVCIVC any T, any N, M1 any T, any N, M1

Anaplastic CancerAnaplastic CancerSTAGESTAGE TNMTNM

IVAIVA T4a, any N, M0 T4a, any N, M0 IVBIVB T4b, Any N, M0 T4b, Any N, M0

IVCIVC Any T, any M, M1 Any T, any M, M1

Papillary Thyroid Carcinoma:Papillary Thyroid Carcinoma:Predict the risk of dying from Papillary Predict the risk of dying from Papillary

CACAA.A. Low Risk Patient:Low Risk Patient:

1.1. YoungYoung2.2. Well differentiated tumorWell differentiated tumor3.3. (-) metastasis(-) metastasis4.4. Small primary lesionSmall primary lesion

B.B. High Risk PatientHigh Risk Patient1.1. OlderOlder2.2. Poorly differentiated tumorPoorly differentiated tumor3.3. (+) local invasion(+) local invasion4.4. (+) Distant metastasis(+) Distant metastasis5.5. Large primary lesionLarge primary lesion

Papillary Thyroid Papillary Thyroid Carcinoma: (SURGERY)Carcinoma: (SURGERY)

1.1. For high risk tumors and For high risk tumors and bilateral tumors bilateral tumors - Total or near total - Total or near total

thyroidectomy:thyroidectomy:

2.2. For low risk patients, small For low risk patients, small & unilateral lesion& unilateral lesion

- ControversialControversial Total thyroidectomy vs. Total Total thyroidectomy vs. Total

lobectomy w/ Isthmectomylobectomy w/ Isthmectomy

Papillary Thyroid Carcinoma: Papillary Thyroid Carcinoma: (SURGERY)(SURGERY)

Proponent of Total Thyroidectomy:Proponent of Total Thyroidectomy:1.1. RAI can effectively detect and treat RAI can effectively detect and treat

residual thyroid tissue and metastatic residual thyroid tissue and metastatic lesions.lesions.

2.2. The serum Tg becomes more sensitive The serum Tg becomes more sensitive marker of recurrent or persistent diseasemarker of recurrent or persistent disease

3.3. Eliminates contralateral occult cancers as Eliminates contralateral occult cancers as sites of recurrence (85% are multifocal)sites of recurrence (85% are multifocal)

4.4. Reduces the risk of recurrence & improve Reduces the risk of recurrence & improve survivalsurvival

5.5. Decreases the 1% risk of progression to Decreases the 1% risk of progression to undifferentiated or anaplastic thyroid undifferentiated or anaplastic thyroid cancercancer

Papillary Thyroid Carcinoma: Papillary Thyroid Carcinoma: (SURGERY)(SURGERY)Proponent of Lobectomy:Proponent of Lobectomy:

1.1. Total thyroidectomy associated Total thyroidectomy associated w/ higher complication ratew/ higher complication rate

2.2. Recurrence in the remaining Recurrence in the remaining thyroid tissue is unusual (5%) thyroid tissue is unusual (5%) and most are curable by surgery.and most are curable by surgery.

3.3. Tumor multicentricity seems to Tumor multicentricity seems to have little prognostic have little prognostic significancesignificance

4.4. Have an excellent prognosisHave an excellent prognosis

Papillary Thyroid Carcinoma: Papillary Thyroid Carcinoma: (SURGERY)(SURGERY)Recommendation:Recommendation: Being recommended that Being recommended that

even low risk tumors should even low risk tumors should undergo total or near total undergo total or near total thyroidectomythyroidectomy

Follicular Thyroid Follicular Thyroid Carcinoma:Carcinoma:

• 10%; Female > Male (3:1), 10%; Female > Male (3:1), mean age= 50y/omean age= 50y/o

• More frequent in Iodine More frequent in Iodine deficiency areadeficiency area

• Vascular invasion & Vascular invasion & hematogenous spread is more hematogenous spread is more common (bone, lung and liver).common (bone, lung and liver).

• Types:Types:1.1. Minimally invasive tumor:Minimally invasive tumor:

• Invasion into but not through the Invasion into but not through the tumor capsuletumor capsule

• Previously called atypical adenomaPreviously called atypical adenoma

2.2. Invasive tumors Invasive tumors (capsular/vascular)(capsular/vascular)

• 1% thyrotoxic1% thyrotoxic

Follicular Thyroid Carcinoma:Follicular Thyroid Carcinoma:• Dx / Tx:Dx / Tx:

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

HURTLE 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 ----> is useless; have to demonstrate FNAC ----> is useless; have to demonstrate

vascular and vascular and capsular invasion. capsular invasion. Tx: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

MEDULLARY 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

MEDULLARY 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

MEDULLARY THYROID MEDULLARY THYROID

CARCINOMACARCINOMA::Tx: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

Anaplastic 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

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