Disorders of Thyroid

- Hyperthyroidism

- Hypothyroidism

- Thyroiditis

-.Diffuse multinodular Goiter

- .Neoplasms – adenoma/carcinoma

-.Congenital – Thyroglossal cyst/duct

Goiter
.It is a diffuse or focal enlargement of the thyroid gland

.Caused by: 1- Colloid goiter. 2- Grave’s disease. 3- Thyroiditis. 4- Tumors

Colloid goiter
most cases start as diffuse enlargement with nodularity development at later
They represent compensatory hyperplasia of follicular epithelium .stages
.secondary to decreased thyroid hormone production

Diffuse-Multinodular goiter
Pathophysiology:

- Endemic & sporadic types

.- Endemic: Cassava – thiocyanate – iodide transport

- Sporadic: rare, females, young and usually of unclear cause. (may be

.)associated mild defect, iodine deficiency and physiological needs

- When there is low T3 and T4 there will be an increase of TRH & TSH that
induce secretion of thyroid hs associated with enlargement of thyroid gland by
hypertrophy and hyperplasia of follicular epithelium at earlier stages diffuse and
.by time nodular

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Stages:

- .Hyperplastic stage & Colloid stage

- due to uneven hyperplasia and accumulation

of colloid as a result of tension and stress that lead to rupture of follicles

CLINICALLY:

1-Huge size result in dysphagia, airway obstruction, chocking sensation and

stridor. SITE as retrosternal extension causing superior vena cava syndrome with
.vein enlargement, tachycardia and heart failure

.2- Rarely toxic hyperthyroidism plummer syndrome

3- Mass effect and misdiagnosed as tumor need US, isotope scanning, FNAC, CT
.scan and MRI

Morphology:

Grossly: at early stages symmetric and diffusely enlarges the thyroid gland
and in late stages there is multiple nodules on cut surfaces. Some nodules
show cystic degeneration, hemorrhage, fibrosis, and calcification.

Microscopy: show randomly sized colloid filled follicles lined by flattened cells
due to pressure of colloid with focal areas of hyperplasia, fibrosis, cystic
changes, necrosis & hemorrhage present as hemosiderin laden macrophages

Hyperthyroidism
Thyrotoxicosis it is a hypermetabolic state encountered much more often in
females caused by High free T3/T4 in the blood.

CAUSES: COMMON:

1- Diffuse toxic hyperplasia (Graves)

2- Toxic multinodular goiter

3- Toxic adenoma.

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UNCOMMON CAUSES:

1- Thyroiditis

2- Functioning thyroid carcinoma

3- TSH secreting pituitary adenoma

4- Iatrogenic.

5- Struma ovarii.

6- Choriocarcinoma and hydatidiform mole.

Clinical features:

- Nervousness, palpitations, rapid pulse, fatigability, muscular weakness, weight

loss with good appetite, diarrhea, heat intolerance, warm skin, excessive
perspiration, emotional liability, menstrual changes, fine tremor of the hand,
.eye changes and enlargement of the thyroid gland

- Cardiac manifestations: tachycardia, arrhythmias, especially fibrillation or SVT,

cause is obscure but more prone to occur in old age group

Graves Disease
- Common (2%F)

Females, 20-40y, Autoimmune, associated with other autoimmune diseases

-

- HLA B8 and DR3.

- Triad of clinical features, -

Hyperthyroidism

Exopthalmos and retraction of the upper eyelid.

Pretibial myxedema.

- Ab to TSH receptor – thyroid stimulating antibody, thyrotropin binding

inhibitor immunoglobulin are responsible for hyperfunction.
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- Thyroid growth immunoglobulin responsible for hyperplasia.

- Micro: Diffuse hyperplasia, tall columnar cells, papillary folds

& Scalloped, pale, scanty colloid.

Hypothyroidism
Cretinism / Myxedema – Low T3/T4, High TSH

Causes:

- Hashimoto’s thyroiditis – autoimmune

- Iodine deficiency

- Drugs – PAS, iodides, lithium

- Developmental – Atrophy, hypoplasia Pituitary disorders

- Radiation/Surgery

Cretinism (child):

- Impaired CNS & bone growth

- Mental retardation

- Short stature

- Coarse facial features

- Protruding tongue

- Umbilical hernia

Myxedema (adult)

- Slow physical and mental activity

- Cold intolerance

- Over weight
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- Low cardiac output

- Constipation and decreased sweating

- Cool pale thick skin

Thyroiditis
- Some are ill defined as interstitial th.

- Some are rare as palpation th. And suppurative (always blood borne).

- Reidel’s fibrous thyroiditis of unknown etiology manifested as atrophy and

hypothyroidism with fibrous adhesions.

Common types are

1- Hashimoto’s thyroiditis,

2- subacute lymphocytic thyroiditis

3- subacute granulomatous

Hashimoto Thyroiditis
- Common non endemic goitre.

- females more common 45-65y.

- Autoimmune disease with genetic basis HLA-DR5, DR3.

( defect in thyroid specific suppressor T cells lead to emergence of T helper

cells against specific thyroid antigens which cooperate with B cells lead to
formation of auto-antibodies as Ab to thyroid peroxidases formerly known
as antimicrosomal Abs & Anti- thyroglobulin antibody)

- Initial hyperthyroidism and in long standing cases hypothyroidism.

- High risk of B cell lymphoma.

Grossly: Firm diffuse goiter.

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Microscopy: Follicle atrophy with lymphocytic infiltration.

Hürthle cells – eosinophilic cells.

Fibrosis & destruction of follicular tissue.

Granulomatous Thyroiditis:
- Subacute or DeQuervain thyroiditis.

- Less common, Females, 30-60 years

- Pain, fever, fatigue, myalgia.

- Post viral syndrome.

- Genetic association - HLA B35

- Patchy microabscess, granulomas with giant cells.

- Hyperthyroidism.

- Heals with normal thyroid function.

Subacute lymphocytic thyroiditis

- Foci of lymphocytic infiltration with mild fibrosis.

-Obscure origin but may be an autoimmune in origin.

Thyroid Cancer
Classification:

1- Epithelial cell tumors

Differentiated

Papillary (75- 80%)

Follicular (10-20%)
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Undifferentiated

Anaplastic (3-5%)

2- Parafollicular (C- cell) tumors

Medullary ( 5%)

Lymphoma (1-2%)

3- Others

Neoplasms of Thyroid

Adenoma – Follicular adenoma – hot

Papillary Carcinoma – 75-80%

Follicular carcinoma - 10-20%

Medullary carcinoma – 5%

Anaplastic carcinoma - <5%

- Neoplasms of Thyroid:
Usually solitary, benign.

Good prognosis - <1% cancer mort.

May be functional – hot nodule.

Malignancy - Infiltration – fixation, hoarseness, recurrent laryngeal nerve

damage.

Clinical Presentation:

- Thyroid nodule (most common)

- Cervical lymph node(s)

- Local compressive symptoms

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- Distant metastasis

- Thyroid dysfunction

Thyroid Nodules:
- Prevalence: Physical Exam 4-7% Ultrasound
30%
- 50% Autopsy

- Incidence increases with age

Thyroid Nodules
)Cont’d(:

Most thyroid nodules are BENIGN

A thyroid nodule has 5-12% malignancy rate

History of radiation increases the chance of malignancy to 30-50%

Evaluation:
History

Physical Examination

Laboratory Evaluation

TSH and FNAC

Imaging Studies

NOT VERY HELPFUL

HISTORY:
Age < 20 or > 50

Head or neck irradiation

Family history
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Male sex

Recent growth

Pressure symptoms

PHYSICAL EXAMINATION:

Hard non tender nodule

Nodule of different consistency within MNG

Fixed nodule

Cervical lymphadenopathy

Immobile vocal cord

Ultrasonography:
Generally has a minor role in the evaluation of thyroid nodules

Palpable nodules do not need ultrasound

Small non-palpable nodules (<1cm) are generally unimportant even if

malignant

Cystic nodules can be malignant

FNA:

The most important test in the evaluation of a thyroid nodule

Has an overall sensitivity of 83-98% and specificity of 92-100%

Complications are very rare and usually minor

Radionucleotide Scans:

Most thyroid nodules are cold (95%)

Most cold nodules are benign (80-85%)

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Hot nodules are usually functioning and can be detected by TSH (suppressed)

Warm nodules can be malignan

Radioactive iodine:

is concentrated from the blood by thyroid follicular cells, allowing correlation of

anatomic features with thyroid function. Decay of radioactive iodine is detected
as dark spots on the scan. A normal thyroid gland shows diffuse moderate
iodine uptake in the right and left lobes and isthmus. Graves disease is
characterized by diffuse increased uptake. Multinodular goiter most often
shows patchy, irregular uptake with some nodules hyperfunctional compared to
normal (dark, or "warm," on scan) and other nodules hypofunctional (pale, or
"cold"). The focal rounded defect lacking uptake (cold nodule) is characteristic
of thyroid neoplasms and cysts. A focal rounded area of increased uptake that
suppresses the remaining thyroid gland (hot nodule, not pictured) is most often
.a hyperfunctional follicular adenoma or goiter nodule

Evaluation (Summary):

Most thyroid nodules are benign

TSH determines the thyroid functional status

Thyroid scanning and U/S are generally not helpful

FNA is the most useful diagnostic procedure

Adenoma
Follicular common, rarely Papillary

Compact follicles (large in MNG)

Solitary, rarely Functional or hot.

Centre may show necrosis/hem.

Well capsulated.

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Compressed normal gland.

Thyroid Carcinoma
Uncommon – child – elderly.

Common - Papillary adenocarcinoma.

Associated with radiation exposure, especially during the first 2 decades.

Type Age Spread Prognosis

Papillary Young <45y Lymph Excellent

Follicular Middle age B.V. Good

Anaplastic Elderly Local Poor

Medullary Elderly All variable

Familial

Papillary Carcinoma
Most common cancer – 75-80%

Idiopathic, Radiation, Gardner & Cowden syndromes.

Papillary folds, Psammoma bodies, Orphan-Anne nucleus.

98% 10 year survival when localized.

Conclusions:
- Hyperthyroidism

Graves, thyrotoxicosis, LATS

Hypermetabolism, high T3/T4, low TSH

- Thyrotoxicosis
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 Antithyroglobulin, anti microsomal

. Hypometabolism, Low T3/T4, high TSH

- Multinodular goitre – low iodine

- Neoplasms

Follicular adenoma – capsulated, single

Carcinoma: Papillary follicular, medullary, anaplastic

.

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