Thyroid gland

Anatomy 

     

Bi-lobed gland over second and third tracheal ring piramidal lobe : 40 ± 50 % Weight : 20 ± 30 gr Epithelium lined follicle Colloid : glycoprotein ( thyroglobulin ) Vascular stroma True connective tissue capsule

It is important to ligate the superior thyroid artery close to the gland to avoid injury to the nerve during thyroidectomy

Inferior thyroid artery
Inferior thyroid artery : Thyrocervical trunk Absent in up to 6%  Thyroidea ima : directly from aorta , innominate artery or right common carotid artery  Present in up to 12%   

 

Superior thyroid vein : IJV or common facial vein Inferior jugular vein : innominate vein or IJV Middle thyroid vein : IJV Lymphatic paratracheal nodes superior mediastinum & middle deep cervical node and lateral the neck

Embryology 

Median endodermal derivative that migrates from the tongue base to its normal position in the neck by 7th week . The distal portion of this thyroglossal duct forms the thyroid gland 

Physiology 
   

Concentrate iodine 20 ± 30 % is store in thyroid Small percentage in hormone and nonthyroid tissue All tyrosine compounds are bound to thyroglubulin and store in thyroid follicles as colloid The unbound thyroid hormone is responsible for influencing metabolism .

Thyroglossal duct anomaly   

7% of the population has remnants of the thyroglossal duct Cyst : anywhere along the length of duct 60% infrahyoid , 24% suprahyoid , 1% intralingual 1-2 cm cystic mass that is mobile on swallowing & protruding of the tongue 

    

60% contain thyroid tissue Malignancy is rare Acute infection Contain mucus like clear fluid If it is become symptomatic it must be removed Sistrunk operation

Lingual thyroid 
  

Failure of thyroglossal duct to descend A mass at the foramen cecum Aysmptomatic or present with airway obstruction May be the only thyroid tissue

Ectopic thyroid tissue 

Anywhere along the migratory route of the thyroid Mediastinum , larynx , trachea , pericardium or esophagus 

Congenital intrathyroid cysts

Present in children persistent ultimobranchial bodies or an intrathyroidal thyroglossal duct cyst

Infectious and inflammatory disorder

Acute suppurative thyroiditis
M=F Preceded by an upper respiratory tract infection Staph. The most common organism Painful enlargement of the gland Fever Abscess formation 

    

Painless thyroiditis

Sporadic form 

   

More common in female Difuse thyroid enlarement Without pain or thyroid enlargement Temporary hyperthyroidism 50% become hypothyroid which resolves in 6 month

Postpartum thyroiditis 

  

Initial hypothyroidism is mild Lymphocytic infiltration and follicle disruption Self-limiting disease Steroid may be of value

Subacute thyroiditis ( De Quervain´thyroiditis ) 

     

At all age most common at 5th decade F>M May be viral Painful thyroiditis Defuse thyroid enlargement Malaise and fever thyrotoxic

Endocrine phases 

  

Hyperthyroidism : 1-3 month Euthyroid : 1-3 weeks Hypothyroid : 2-6 month Recovery which is complete 

Lymphocyte , monoycyte and giant cell infiltration . Treatment consist of analgesic steroid and antiinflammatory agents . 

Hashimoto´s thyroiditis 
  

 

Common Affecting 2 population 95 % in female Autoimmune etiology with strong genetic predisposition Diffusely enlarge with nodularity firm Disrupted follicle with lymphocyte and plasma cell infiltration and variable fibrosis Residual hypothyroidism

A thyroid scan demonstrated a salt and pepper pattern  



Anti thyroglobulin and antimicrosomsal ab are present up to 90% FNA is diagnostic Increased risk for developing B ± cell lymphoma

Riedelµs thyroiditis 
     

Uncommon F>M Older patient May be mediastinal & retroperitoneal fibrosis Fixed rock-hard thyroid enlargement Gland replaced with fibrosisAirway obstruction and dysphagia Palliative surgery to relieve obstruction

Hyperthyroidism

Gravesµ Disease 
  

 

3th and 4th decade F/M : 7/1 Autoimmune etiology : abnormal Ig that fix on TSH receptor of thyroid epithelial cell Diffuse toxic goiter ophthalmopathy 55% Dermophathy 5%

Cont. 

 

T3 , T4 , T3RU Thionamide , sympathetic blocker , iodine Radioactive iodine

Pregnant women should not be treated with this modility

Surgical indication 

 

Refuse radioactive therapy Thyroid nodules suspicious for malignancy Must be rendered euthyroid prior to surgery

Subtotal thyroidectomy leaving 7-8 gr of nodule free tissue is recommended however , total thyroidectomy is proposed by many

Toxic multinodular goiter  



Older patient no ophthalmopathy or dermophathy Total thyroidectomy Radioactive iodine but not successfully as surgery

Toxic adenoma 



Younger patient Quite large ( 2.5 ± 3 cm ) Surgical excision

Multinodular nontoxic goiter 

 

Compensatory response Common in female Secondary to dietry deficiency Symptom and sign of pressure

A small percentage (1-2%) may harbor a malignancy

Treatment
Thyroid suppression  Surgery: cosmetic deformity pressure symptom refractory to suppression Fear of malignancy Development of toxicity 

Neoplasm & Cyst

Benign adenoma 
 



Encapsulated tumor Glandular epithelium with intratumoral degenerative changes ( hemorrhage , fibrosis , calcification ) Rare thyrotoxicosis Type : follicular,colloid , embryonal, fetal , Hurthle ???

Malignant

Papillary carcinoma 60 ± 65 % 

   

Third ± 5th decade F/M : 2/1 Indolent with overall excellent prognosis May arise from benign adenoma Low-dose and high dose external RT

Macroscopic pattern 

 

Occult ; <1.5 cm Intrathyroid ( 70% ) Extrathyroid : infiltrate larynx , trachea , strap muscle , great vessel

Microscopic pattern 

  

Purely papillary Some may have area of follicular Anaplastic transformation is rar Venous invasion in 10%

Intraglandular lymphatic invasion results in high incidence of multicentricity

Neither multicentricity nor regional LN metastasis have any prognostic significance

Negative prognostic indicator 

  

Advance age Male gender extrathyroid extension Distant metastasis

Cont. 

 

Dedifferentiation Vascular invasion Atypical variants ( tall cell, columnar , sclerosing ) may have negative prognostic significance

Follicular carcinoma 15% 
   

Vascular invasion Metastasis to bone brain and liver Anaplastic transformation is more common Overtly invasive : infiltrate surrounding structure ( MR 20-50%) Minimally invasive : microscopically has capsular invasion (MR 5%)

Definitive diagnosis can often be established only on permanent section

Poor prognostic indicator 

   

Advanced age Male gender extrathyroid extension Distant metastasis Vascular invasion anaplastic transformation trabecular growth pattern

Hurthle cell carcinoma 5% 



As a variant of follicular tumors Overtly invasive :higher mortality rate Higher LN metastasis Minimally invasive 

Not all nodule containing Hurthle cell are neoplastic .The vast majority are Hurtule cell changes in benign follicular adenomatous nodules or thyroiditis

Medullary carcinoma 3-5% 

    

10 ± 20 % familial Sporadic : in 5th decade Multicentric ,lateral upper 2/3 of gland Encapsulated , diffuse infiltrative 50% nodal metastasis 15-25% distant metastasis

MEN type 2A 
   

Medullary thyroid cancer C-cell hyperplasia Adrenal pheochromocytoma Adrenal medullary hyperplasia Parathyroid hyperplasia

MEN type 2B

In addition :  Mucosal neuromas  GI ganglioneuroma  Musculoskeletal abnormality

Poor prognostic indicator 

    

MEN type 2B Nodal & distant metastasis Extrathyroid extension Small cell tumor pleomorphism Poor calcitonin staining High CEA

Anaplastic carcinoma 1-5% 
   



Rare tumor Arise in well-differentiated tumor Older women Advance stage early infiltration of surrounding structure Small cell , giant cell Extremely poor prognosis

Lymphoma 1-3.5% 
      

Primarily in the thyroid As a part of systemic disease Arises in a gland with Hashimoto´s thyroiditis Elderly women Diffusely enlarged gland or nodule Hypothyroidism Diffuse large cell lymphoma Good prognosis

Miscellaneous 

  

Sarcoma Mucoepidermoid carcinoma SCC Kidney , colon , melanoma are the most common distant site

Clinical presentation

Thyroid enlargement 
 

Smooth and diffuse ( usually benign ) Nodular Multinodular goiter may harbor a neoplasm( 10-15% ) : 90% benign 10 % malignent

Overall incidence of malignancy in a multinodular goiter is only 1-2%

Symptom & sign of pressure   



Dysphagia ( discomfort on swallowing obstruction ) Mild to moderate stridor chondromalacia airway obstruction TVC edema & RLN paralysis hoarseness Retrosternal extension tracheal deviation & SVC

Symptom & sign of infiltration 
    

Stridor and hemoptysis Rapid increasing in mass RLN paralysis Dysphagia & odynophagia Brachial plexus infiltration Painful enlargement

Evidence of regional and distant metastasis  

 

It is the only obvious clinical evidence of thyroid cancer Papillary metastasis may be cystic ( 20%) Follicular carcinoma : distant metastasis Medullary and anaplastic : extracapsular extension

Evidence of endocrine dysfunction 

  

Most patients are euthyroid Occasionally : hypothyroid Rarely : hyperthyroid Medullary : calcitonin , ACTH , PG secretion

Evaluation of a thyroid mass

Neck X-ray 

Patchy calcification : Benign thyroid disease Well ±differentiated carcinoma Medullary carcinoma

Chest X-Ray 

  

Retrosternal extension Tracheal deviation Mediastinal nodal involvement Pulmonary metastasis

CXR should always be done

Esophagogram  

It should be done if the patient complains of significant dysphagia It differentiate thyroid from nonthyroid causes of dysphagia

Radionuclide scan 

 

Determine the functional status of gland Differentiate diffusely enlarge from nodular Differentiate single nodule from multinodular goiter

Tc-99 
   

Low cost Ready available Short ± half life Optimal imaging Only trapped , not organified

Radioactive Iodine 



It is able to determine function ¹²³I is the best but is expensive and have very short half life

Thallium 201 

Detecting : lymph node metastasis retrosrernal extension recurrent disease functioning nodule within suppressed gland

Octreotide scintigraphy is useful for detecting metastatic medullary and Hurthle cell carcinoma

Radionuclide scan no longer used as a first line imaging study

Ultrasonography

High ± resolution real time US enable the radiologist to detect nodule as small as 3mm

US usage 
     

Screening high risk patient ( prior RT ) Differentiating single nodule from multiple Cystic or solid status Facilitating FNA Monitoring medically treated patient Evaluating clinically negative neck for metastasis Recurrent disease after surgery

CT scaning & MRI 

  

Extrathyroidal extension Retrosternal involvement Metastatic disease Unnecessary in the evaluation of a routine thyroid mass

Metastatic workup 

 

Bone scan CT scan of abdomen and chest Octreotide study

Blood test
T3 T4 TSH Thyroid Ab for Hashimoto thyroiditis Serum thyroglobulin Serum calcitonin in medullary carcinoma especially if there is a family history 

    

These level may increases after FNA and should be performed prior to it

Postoperative serum thyroglobulin levels under 10 ng/ml in patients under supression therapy are indicative of cancer control

FNA biopsy 

  

Obtain satisfactory specimen from nodule it is of no value in microinvasive follicular If the report is suspicious the patient should probably proceed to surgery Inadequate specimen repeat FNA

FNA biopsy 



The best results obtains from periphery Multiple aspirates are frequently necessary

A negative FNA should never preclude surgical exploration in a patient with highly suspicious lesion

Large bore needle aspiration  

A portion of capsule and surrounding tissue can be included It is rarely indicated

Surgical exploration indication

Obvious malignancy 
  

Clinical or radiographic evidence of infiltration Clinical or radiographic evidence of regional or distant metastasis FNA positive for malignancy ( papillary , medullary , anaplastic ) Thyroid mass with raised serum level of calcitonin

Suspicion of malignancy 
    

Suspicious fine ± needle aspiration Nodule refractory to suppression Solitary thyroid nodule with raised serum thyroglobulin level Recurrent cyst refractory to two aspirations and thyroid suppression Nodule going wrong , a solitary nodule increasing in size and associated with pain True single nodule in males elderly women children , or in any patient with a history of prior RT

Management of thyroid Tumor

Every patient undergoing a thyroid exploration should sign a very specific detail and inform that should include the possibility of performing throidectomy

Total thyroidectomy    

Better oncologic operation in the case of multicentric disease Difficult residual thyroid suppression and anaplastic transformation risk Good postoperative scanning and radioactive ablation Postoperative thyroglobulin titrage

Subtotal thyroidectomy 

 

Simpler & time ±consuming Lower morbidity Not affected the prognosis of well differentiated tumor

Extrathyroid extension 



Well-differentiated tumor : 9-16% If gross tumor would be left using the shaving technique wild field resection should be performed .  

RLN enveloped & paralyzed it should be sacrificed . If it is the only functioning nerve and the tumor and the tumor can be dissected off this should be done

Superficial invasion can be shaved but direct extension into the lumen : sleeve or wedge resection and primary anastomosis 

  

Superficial thyroid cartilage : shave resection Hemilarynx : vertical partial laryngectomy Anterior larynx : hemilaryngectomy And reconstruction Cricoid and bilateral laryngeal involvement : total laryngectomy

Postoperative RT and iodine is indicated

Regional lymph node  

In all patient : pericapsular and paratracheal node need to be removed routinely Overt node in these area : sup. Mediastimun and lateral neck exploration

Papillary carcinoma 

  

Clinical node : 20-25% Pathological node : 30-79% It has no adverse effect on prognosis Extracapsular extension does not appear to have an ominous prognosis

Follicular carcinoma  

Very rare < 10% clinically & 20% pathologically Neck dissection are performed only for overt metastasis

Hurthle cell carcinoma 



30% lymphatic metastasis Functional neck dissection should be performed when disease is encountered

Medullary carcinoma 

 

Metastasis : 50 ± 63 % Prophylactic paratracheal , superior mediastinal and lateral neck dissection Or : positive node in mediastinum and lateral neck dissection is performed

Follow -up

Well-differentiated tumor 
   

Become hypothyroid and after 4-6 week radioiodine scan Any residual tissue : I ablation In overt local or regional remnant & distant metastasis should be used Further 6 and 12 months scan and then every 2 year Serum thyroglobulin every 6 months

Medullary carcinoma  

 

Calcitonin level : every 3 months ( in first year ) Every six months there after High calcitonin level : full metastatic work up CT & MRI of the neck and octreotide scan No overt disease : neck dissection and if it done before RT to neck

Postoperative RT  

  

Residual and inoperable disease or cancer that has undergone anaplastic transformation 50 Gy RT appears more effective than radioactive iodine in treating local recurrence in WD cancer I radioactive is the treatment of choice for distant metastasis RT is the treatment of choice in anaplastic carcinoma

Role of chemotherapy

Most disappointing results

Postoperative thyroid hormone 



Total thyroid ablation : T4 supplement It is useful in controlling any microscopic residual WD thyroid cancer that may have been left locally , regionally or distantly

Prognosis 

  



Low risk patient : 1-2 % MR High risk patient : 40 ± 50 % Hereditary & sporadic cancer have similar survival ( 82% at 5 year ) Anaplastic cancer has a dismal survival Early stage medullary : good prognosis

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