THYROID MODULE

SYED MOHAMMAD USMAN

SAEED
18-0679-153
GROUP 1, BLOCK 1
 ANATOMY

 Arises as an outpouching of the primitive foregut around the third

week of gestation

 Thyroid follicles are initially apparent by 8 weeks of gestation

 Colloid formation begins by the 11th week of gestation

 The adult thyroid gland is brown in color and firm in consistency

 The normal thyroid gland weighs approximately 20g

 Located posterior to the strap muscles

 ANATOMY

 Thyroid lobes

 Adjacent to the thyroid cartilage

 Extend to the midthyroid cartilage
superiorly
 Lie adjacent to the carotid sheaths and
sternocleidomastoid muscles laterally
 Isthmus

 Connects the two thyroid lobes at the

midline
 Located just inferior to the cricoid
cartilage
 A pyramidal lobe is present in about 50% of
patients
 ARTERIAL SUPPLY

• The superior thyroid arteries arise from the

ipsilateral external carotid arteries and divide
into anterior and posterior branches at the
apices of the thyroid lobes.
• The inferior thyroid arteries arise from the
thyrocervical trunk shortly after their origin
from the subclavian arteries.
• The inferior thyroid arteries travel upward in
the neck posterior to the carotid sheath to
enter the thyroid lobes at their midpoint.
• The inferior thyroid artery crosses the
recurrent laryngeal nerve (RLN),
necessitating identification of the RLN before
the arterial branches can be ligated.
 VENOUS SUPPLY

• The venous drainage of the thyroid

gland occurs via multiple small surface
veins, which coalesce to form three
sets of veins—the superior, middle, and
inferior thyroid veins.
• The superior thyroid veins run with the
superior thyroid arteries bilaterally.
• The superior and middle veins drain
directly into the internal jugular veins.
• The inferior veins often form a plexus,
which drains into the brachiocephalic
veins.
 NERVE SUPPLY

• The left RLN arises from the vagus nerve where it crosses the aortic

arch, loops around the ligamentum arteriosum, and ascends

medially in the neck

• Along their course in the neck, the RLNs may branch, and pass

anterior, posterior, or interdigitate with branches of the inferior

thyroid artery.

• The RLNs innervate all the intrinsic muscles of the larynx, except

the cricothyroid muscles, which are innervated by the external

laryngeal nerves.
• Sympathetic innervation of the thyroid gland is provided by fibers
from the superior and middle cervical sympathetic ganglia.
• Parasympathetic fibers are derived from the vagus nerve and
reach the gland via branches of the laryngeal nerves.
 LYMPHATIC SYSTEM

• Regional lymph nodes include

pretracheal, paratracheal, perithyroidal,
superior mediastinal, retropharyngeal,
esophageal, and upper, middle, and
lower jugular chain nodes.
• Thyroid cancers may metastasize to any
of these regions, although metas-tases to
submaxillary nodes (level I) are rare
(<1%). There also can be “skip”
metastases to nodes in the lateral
ipsilateral neck without central neck
nodes.
 THYROID HISTOLOGY
• Microscopically, the thyroid is divided into
lobules that contain 20 to 40 follicles.
• The follicles are spherical and are lined by
cuboidal epithelial cells and contains a
central store of colloid secreted from the
epithelial cells under the influence of the
pituitary hormone TSH.
• The second group of thyroid secretory
cells is the C cells or parafollicular cells,
which contain and secrete the hormone
calcitonin
 PHYSIOLOGY OF THYROID

• Iodine metabolism :

• The average daily iodine requirement is 0.1 mg, which can be

derived from foods.
• In the stomach and jejunum, iodine is rapidly converted to iodide
and absorbed into the bloodstream, and from there it is
distributed uniformly throughout the extracellular space.
• Iodide is actively transported into the thyroid follicular cells by an
adenosine triphosphate (ATP)–dependent process.
• The thyroid is the storage site of >90% of the body’s iodine
content
• The remaining plasma iodine is cleared via renal excretion
 PHYSIOLOGY OF THYROID

• Thyroid Hormone Synthesis, Secretion, and Transport:

• Iodide trapping - involves active transport of iodide across the

basement membrane of the thyrocyte via the sodium/ iodide (Na+ /I–

) symporter

• Oxidation of iodide to iodine and iodination of tyrosine

residues on Tg, to form monoiodotyrosines (MIT) and

diiodotyrosines (DIT)

• Both processes are catalyzed by thyroid peroxidase (TPO)

 PHYSIOLOGY OF THYROID

• Coupling of two DIT molecules to form tetra-iodothyronine or

thyroxine (T4 ), and one DIT molecule with one MIT molecule to

form 3,5,3′-triiodothyronine (T3 ) or 3,3′,5′-triiodothyronine reverse

(rT3).

• Tg is hydrolyzed to release free iodothyronines (T3 and T4 )

and mono- and diiodotyrosines.

 PHYSIOLOGY OF THYROID

• The secretion of thyroid hormone is controlled by the

hypothalamic-pituitary-thyroid axis.

• The hypothalamus produces a peptide, the

thyrotropin-releasing hormone (TRH), which

stimulates the pituitary to release TSH or thyrotropin.

• TSH secretion by the anterior pituitary is also

regulated via a negative feedback loop by T4.

PHYSIOLOGY OF THYROID
 EVALUATION OF PATIENTS WITH
THYROID DISEASE

• TSH is the only test necessary in most patients with thyroid nodules

that clinically appear to be euthyroid.

• Serum Thyroid-Stimulating Hormone (Normal 0.5–5 μU/mL)

• The most sensitive and specific test for the diagnosis of hyper- and

hypo-thyroidism and for optimizing T4 therapy

 EVALUATION OF PATIENTS WITH
THYROID DISEASE
• Total T4 (Reference Range 55–150 nmol/L) and T3 (Reference Range 1.5–3.5
nmol/L)
• Total T4 levels reflect the output from the thyroid gland and are increased not
only in hyperthyroid patients, but also in those with elevated Tg levels
secondary to pregnancy, estrogen/progesterone use, or congenital diseases.
• Similarly, total T4 levels decrease in hypothyroidism and in patients with
decreased Tg levels due to anabolic steroid use and protein-losing disorders
like nephrotic syndrome.
• Measurement of total T3 levels is important in clinically hyperthyroid patients
with normal T4 levels, who may have T3 thyrotoxicosis.
• Total T3 levels often are increased in early hypothyroidism.
 EVALUATION OF PATIENTS WITH
THYROID DISEASE

• Free T4 (reference range 12–28 pmol/L) and free T3(3–9 pmol/L)

• Most useful in confirming the diagnosis of early

hyperthyroidism, in which levels of free T4 and free T3 rise

before total T4 and T3.

 EVALUATION OF PATIENTS WITH
THYROID DISEASE

• Thyrotropin-Releasing Hormone
• This test is useful to evaluate pituitary TSH secretory function and is
performed by administering 500 μg of TRH intravenously and measuring
TSH levels after 30 and 60 minutes. In a normal individual, TSH levels
should increase at least 6 μIU/mL from the baseline.

• Thyroid Antibodies
• Thyroid antibodies include anti-Tg, anti-microsomal, or anti-TPO and
thyroid-stimulating immuno-globulin (TSI).
• Anti-Tg and anti-TPO antibody levels indicate the underlying disorder,
usually an autoimmune thyroiditis.
• About 80% of patients with Hashimoto’s thyroiditis have elevated
thyroid anti-body levels
 EVALUATION OF PATIENTS WITH
THYROID DISEASE

• Serum Thyroglobulin

• The most important use for serum Tg levels is in monitoring patients

with differentiated thyroid cancer for recurrence, particularly after

total thyroidectomy and RAI ablation.

• Serum Calcitonin (0–4 pg/mL Basal)

• This 32-amino-acid polypeptide is secreted by the C cells and

functions to lower serum calcium levels, although in humans, it has

only minimal physiologic effects.

• It is also a sensitive marker of MTC.

 EVALUATION OF PATIENTS WITH
THYROID DISEASE
• Radionuclide Imaging

• Both iodine-123 (123I) and iodine-131 (131I) are used to image

the thyroid gland.
• 123I is used to image lingual thyroids or goiters

• 131I is used to screen and treat patients with differentiated

thyroid cancers for metastatic disease.
• The images obtained by these studies provide information not
only about the size and shape of the gland, but also the
distribution of functional activity.
 EVALUATION OF PATIENTS WITH
THYROID DISEASE
• Radionuclide Imaging

• Technetium Tc 99m pertechnetate (99mTc) is taken up by the

thyroid gland and is increasingly being used for thyroid
evaluation.
• More recently, 18F-fluorodeoxyglucose (FDG) positron emission
tomography (PET) combined with computed tomography (CT) is
being increasingly used to screen for metastases in patients
with thyroid cancer in whom other imaging studies are
negative.
 EVALUATION OF PATIENTS WITH
THYROID DISEASE
• Ultrasound

• Advantage of no radiation exposure

• It is helpful in the evaluation of thyroid nodules,

distinguishing solid from cystic ones
• In addition, characteristics such as shape,
borders and presence of calcifications, and
vascularity can provide useful information
regarding risk of malignancy.
• Ultrasound is also especially helpful for
assessing cervical lymphadenopathy and to
guide FNAB.
 EVALUATION OF PATIENTS WITH
THYROID DISEASE

• Computed Tomography/Magnetic Resonance Imaging Scan

• Useful in evaluating the extent of large, fixed, or substernal

goiters and their relationship to the airway and vascular

structures.

• Noncontrast CT scans should be obtained for patients who are

likely to require subsequent RAI therapy.

• If contrast is necessary, therapy needs to be delayed by several

months.
 BENIGN THYROID DISORDERS

HYPERTHYROIDISM
 HYPERTHYROIDISM

Diffuse Toxic Goiter (Graves’ Disease)

• Autoimmune disease, female preponderance (5:1), and peak

incidence between the ages of 40 and 60 years

• Graves’ disease is characterized by thyrotoxicosis, diffuse

goiter, and extrathyroidal conditions including ophthalmopathy,

dermopathy, thyroid acropachy, gynecomastia

 HYPERTHYROIDISM

• Clinical Features–

• Lid lag (von Graefe’s sign)

• Spasm of the upper eyelid revealing the sclera above the

corneoscleral limbus (Dalrymple’s sign)
• Prominent stare

• Periorbital edema

• Conjunctival swelling and congestion, proptosis

• Limitation of upward and lateral gaze

• Gynecomastia, thyroid acropachy and onycholysis is also seen

HYPERTHYROIDISM

Ophthalmopathy

Thyroid acropachy
 HYPERTHYROIDISM

• Diagnosis:
• Suppressed TSH with or without an
elevated free T4 or T3 level.
• (+) eye signs
• 123I uptake and scan - An elevated
uptake, with a diffusely enlarged gland,
confirms the diagnosis of Graves’
disease
• Anti-Tg, Anti-TPO elevated in upto 75%
• Treatment:
• Antithyroid drugs - propylthiouracil
(100-300mg 3 times a day) and
methimazole (10-30mg 3 times a day)
• thyroid ablation with radioactive 131I
• thyroidectomy
 HYPERTHYROIDISM

Toxic Multinodular Goiter

• Symptoms and signs
• similar to Graves’ disease, but
extrathyroidal manifestations are absent.
• Diagnostic Studies
• Suppressed TSH level and elevated free
T4 or T3 levels.
• RAI uptake also is increased, showing
multiple nodules with increased uptake
and suppression of the remaining gland.
• Treatment.
• RAI and surgical resection may be used
for treatment; When surgery is performed
near-total or total thyroidectomy is
recommended
 HYPERTHYROIDISM
Toxic Adenoma
• Hyperthyroidism from a single
hyperfunctioning nodule
• Characterized by somatic mutations in the
TSH-R gene
• Most nodules have attained a size of at least 3
cm before hyperthyroidism occur
• P/E - solitary thyroid nodule without palpable
thyroid tissue on the contralateral side.
• Diagnosis - RAI scanning shows a “hot” nodule
with suppression of the rest of the thyroid
gland
• Treatment
• Smaller nodules antithyroid medications
and RAI.
• Larger nodules lobectomy and
isthmusectomy is preferred to treat young
patients and those with larger nodules.
 HYPERTHYROIDISM

Thyroid Storm
• Condition of hyperthyroidism accompanied by fever, agitation or
depression, and cardiovascular and GI dysfunction, including
hepatic failure
• Precipitated by abrupt cessation of antithyroid medications,
infection, thyroid or nonthyroid surgery, and trauma in patients
with untreated thyrotoxicosis
• Treatment
• Oxygen supplementation and hemodynamic support should
be instituted.
• Acetaminophen for pyrexia
• Lugol’s iodine or sodium ipodate (intravenously) should be
administered to decrease iodine uptake and thyroid hormone
secretion.
• PTU therapy
• Corticosteroids
 HYPOTHYROIDISM

o Clinical Features

o In Neonates: Cretinism and characteristic facies similar to those

of children with Down syndrome and dwarfism.
o Failure to thrive and severe mental retardation often are present

o In childhood or adolescence: delayed development and may

also lead to abdominal distention, umbilical hernia, and rectal
prolapse.
o In adults: tiredness, weight gain, cold intolerance, constipation,
and menorrhagia.
o Patients with severe hypothyroidism or myxedema develop
facial and periorbital puffiness
 HYPOTHYROIDISM

• The skin becomes rough and dry and often develops a yellowish
hue
• Hair becomes dry and brittle, and severe hair loss may occur,
loss of the outer two thirds of the eyebrows
• Enlarged tongue, nonspecific abdominal pain accompanied by
distention and constipation.
• Libido and fertility are impaired.
• Laboratory Findings
• low circulating levels of T4 and T3 .
• Raised TSH levels are found in primary thyroid failure
• Secondary hypothyroidism - low TSH levels that do not increase
following TRH stimulation.
• Thyroid autoantibodies are highest in patients with autoimmune
disease
• Treatment
• T4 is the treatment of choice
HYPOTHYROIDISM
 THYROIDITIS
Acute (Suppurative) Thyroiditis
• More common in children ; often is preceded by an URI or otitis media
• Streptococcus and anaerobes account for about 70% of cases

• Symptoms

• Severe neck pain radiating to the jaws or ear, fever, chills,

odynophagia, and hoarseness
• Diagnosis

• leukocytosis on blood tests

• FNAB for Gram’s stain, culture, and cytology

• Treatment

• Parenteral antibiotics and drainage of abscesses.

• Thyroidectomy may be needed for persistent abscesses

 THYROIDITIS

Subacute Thyroiditis
• Painful thyroiditis:

• viral in origin or result from a postviral inflammatory response

• 30- to 40-year-old women

• Symptoms - characterized by the sudden or gradual onset of

neck pain, which may radiate toward the mandible or ear.
• History of a preceding upper respiratory tract infection often
can be elicited.
• P/E - The gland is enlarged, exquisitely tender, and firm
 THYROIDITIS

Subacute Thyroiditis
• Painful thyroiditis:

• Diagnosis

• (in early stage)TSH is decreased, and Tg, T4 , and T3 levels are

elevated
• The ESR >100 mm/h

• RAIU also is decreased

• Treatment

• Painful thyroiditis is self-limited, and therefore, treatment is

primarily symptomatic
 THYROIDITIS

• Painless thyroiditis

• Autoimmune in origin

• More common in women; 30 and 60 years of age.

• P/E - demonstrates a normal sized or minimally enlarged,

slightly firm, non tender gland.
• Diagnosis - Labs and RAIU are similar to those in painful
thyroiditis, except for a normal erythrocyte sedimentation rate.
• Treatment - β-blockers and thyroid hormone replacement.
Thyroidectomy or RAI ablation is only for recurrent, disabling
episodes of thyroiditis.
 THYROIDITIS

Chronic Thyroiditis
• Lymphocytic (Hashimoto’s) Thyroiditis
• most common inflammatory disorder of the thyroid; leading
cause of hypothyroidism
• male-to-female ratio is 1:10 to 20; 30 and 50 years old.
• Clinical Presentation
• minimally or moderately enlarged firm gland
• painless anterior neck mass
• Diagnostic Studies
• elevated TSH and the presence of thyroid autoantibodies
• Treatment
• Thyroid hormone replacement therapy is indicated in overtly
hypothyroid patients
 THYROIDITIS

Riedel’s Thyroiditis
• characterized by the replacement of all or part of the thyroid
parenchyma by fibrous tissue
• predominantly in women between the ages of 30 and 60 years
old
• Clinical presentation
• painless, hard anterior neck mass, which progresses over
weeks to years
• produce symptoms of compression, including dysphagia,
dyspnea, choking, and hoarseness
• Patients may present with symptoms of hypothyroidism and
hypoparathyroidism as the gland is replaced by fibrous tissue
• P/E reveals a hard, “woody” thyroid gland with fixation to
surrounding tissues
• Diagnosis needs to be confirmed by open thyroid biopsy
• Surgery is the mainstay of the treatment
 GOITER

• Any enlargement of the thyroid gland is referred to as a goiter

• Clinical Features

• Asymptomatic

• Pressure sensation in the neck is possible

• When goiter becomes very large, compressive symptoms such

as dyspnea and dysphagia may occur
• Physical examination may reveal a soft, diffusely enlarged gland
(simple goiter) or nodules of various size and consistency in
case of a multinodular goiter
 GOITER

• Diagnostic Tests

• Patients usually are euthyroid with normal TSH and low-normal

or normal free T4 levels.
• RAIU - areas of hot and cold nodules

• Treatment

• Most euthyroid patients with small, diffuse goiters do not

require treatment.
• Endemic goiters are treated by iodine administration
DIFFERENTIAL DIANOSIS OF THYROID
DISEASES

• Diffuse Toxic Goiter (Graves’ Disease)

• Toxic Multinodular Goiter

• Toxic Adenoma

• Thyroid Storm

• Acute (Suppurative) Thyroiditis

• Subacute Thyroiditis

• Chronic Thyroiditis

• Riedel’s Thyroiditis
 RISK FACTOR FOR MALIGNANCY

• Young age

• Female sex

• Radiation exposure

• Obesity

• Iodine deficiency

• Family history of thyroid cancer or goiters

• Personal history of goiter

• Genetic conditions like familial adenomatous polyposis

SOLITARY THYROID NODULE
 THYROID MALIGNANCY

• Papillary Carcinoma (80%)

• Follicular Carcinoma (10%)

• Hürthle Cell Carcinoma (3%)

• Medullary Carcinoma (5%)

• Anaplastic Carcinoma (1%)

• Lymphoma (<1%)
 THYROID MALIGNANCY

• Most common Presentation:

• palpable swelling in the neck

• The RET proto-oncogene plays a significant role in the

pathogenesis of thyroid cancers

 PAPILLARY CARCINOMA

• It is the predominant thyroid cancer in children and individuals

exposed to external radiation
• 2:1 female-to-male ratio; mean age at presentation is 30 to 40
years.
• Presentation:

• Slow-growing painless mass in the neck

• Dysphagia, dyspnea, and dysphonia usually in locally advanced

invasive disease.
• Lymph node metastases are common

• Diagnosis
• FNAB of the thyroid mass or lymph node

• Neck ultrasound
 PAPILLARY CARCINOMA

• Pathology

• On gross examination, PTCs generally are hard and whitish and

remain flat on sectioning with a blade
• Macroscopic calcification or necrosis may be apparent
 PAPILLARY CARCINOMA

• Histologically:

• Cells are cuboidal with pale, abundant cytoplasm

• Crowded nuclei that may demonstrate “grooving”

• Intranuclear cytoplasmic inclusions (Orphan Annie nuclei)

• Psammoma bodies may be present

PAPILLARY CARCINOMA
PAPILLARY CARCINOMA
PAPILLARY CARCINOMA
 PAPILLARY CARCINOMA

• Treatment
• Patients with high-risk tumors or bilateral tumors should
undergo total or near-total thyroidectomy

• Prognosis
• In general, patients with PTC have an excellent prognosis
with a >95% 10-year survival rate.
 FOLLICULAR CARCINOMA

• Female-to-male ratio of 3:1, and a mean age at presentation of 50

years old
• Presentation

• As solitary thyroid nodules, rapid size increase, and long-

standing goiter
• occasionally with a history of Pain and cervical
lymphadenopathy(5%)
• distant metastases may be present

• Diagnosis

• FNAB– not very reliable

• molecular markers: BRAF, Ras, RET/PTC, and PAX/PPAR
 FOLLICULAR CARCINOMA

• Pathology.

• Follicular carcinomas usually are solitary lesions, and the

majority are surrounded by a capsule
• Follicles are present, but the lumen may be devoid of colloid

• Surgical Treatment

• Any follicular lesion - thyroid lobectomy

• Total thyroidectomy is recommended by some surgeons in older

patients with follicular lesions >4 cm
• Prognosis

• Mortality from follicular thyroid cancer is approximately 15% at

10 years and 30% at 20 years
 HÜRTHLE CELL CARCINOMA

• Subtype of follicular thyroid cancer

• Pathology

• characterized by vascular or capsular invasion and, therefore,

cannot be diagnosed by FNAB.
• Tumors contain sheets of eosinophils

• Treatment

• Unilateral - lobectomy and isthmusectomy

• Invasive - total thyroidectomy

• modified radical neck dissection when lateral neck nodes are

palpable or identified by ultrasonography
 MEDULLARY CARCINOMA

• Arises from the parafollicular or C cells of the thyroid

• Usually develops superolaterally in the thyroid lobes

• Associated with familial MTC, MEN2A, and MEN2B.

• female-to-male ratio is 1.5:1; 50 and 60 years old

• Presentation

• Neck mass that may be associated with palpable cervical

LAD(15% to 20%)
• Pain or aching

• local invasion - dysphagia, dyspnea, or dysphonia

 MEDULLARY CARCINOMA

• Pathology
• Sheets of infiltrating neoplastic cells separated by collagen and
amyloid
• The presence of amyloid is a diagnostic finding
MEDULLARY CARCINOMA
 MEDULLARY CARCINOMA

• Diagnosis
• Raised serum calcitonin and CEA levels
• The presence of amyloid
• Stain positively for CEA and calcitonin gene–related peptide
• Treatment
• Total thyroidectomy is the treatment of choice for MTC
• Postoperative Follow-Up and Prognosis
• annual measurements of calcitonin and CEA levels
• The 10-year survival rate is approximately 80% but
decreases to 45% in patients with lymph node involvement.
 ANAPLASTIC CARCINOMA

• Female predominance; Mean age- 60-70yr

• One of the most aggressive thyroid malignancies
• Presentation
• long-standing neck mass, which rapidly enlarges and may be
painful
• dysphonia, dysphagia, and dyspnea are common.
• tumor is large and may be fixed to surrounding structures or may
be ulcerated with areas of necrosis
• LAD usually present
• Diagnosis
• FNAB revealing characteristic giant and multinucleated cells
• Core or incisional biopsy for confirmation
ANAPLASTIC CARCINOMA
 ANAPLASTIC CARCINOMA

• Pathology.
• Grossly, firm and whitish in appearance.
• Three main histologic growth patterns: spindle cell,
squamoid, and pleomorphic giant cell.
 ANAPLASTIC CARCINOMA

• Management
• Imaging to assess resectability.
• Preoperative laryngoscopy to assess the status of the
vocal cords.
• A total or near-total thyroidectomy with therapeutic
lymph node dissection is recommended for patients
with an intrathyroidal mass
• If extrathyroidal extension is present, an en bloc
resection is recommended
• Adjuvant radiation and Chemotherapy is associated
with prolonged survival
• Prognosis
• Few patients survive 6 months beyond diagnosis
 LYMPHOMA

• Presentation
• rapidly enlarging neck mass often
painless
• Symptoms similar to anaplastic
carcinoma
• Diagnosis
• Ultrasound for early diagnosis - well-
defined hypoechoic mass.
• needle core or open biopsy may be
necessary for definitive diagnosis
• Treatment and Prognosis.
• chemotherapy (CHOP—
cyclophosphamide, doxorubicin,
vincristine, and prednisone),
• Thyroidectomy and nodal resection if
airway obstruction
• The overall 5-year survival rate is
about 50%
COMPLICATIONS OF THYROID SURGERY

• Nerves, parathyroids, and surrounding structures are all at risk of injury

during thyroidectomy.

• Injury to the RLN

• 20% risk of injury to the external branches of the superior laryngeal nerve

• The cervical sympathetic trunk is at risk of injury in invasive thyroid

cancers and retroesophageal goiters and may result in Horner’s syndrome.

• Transient hypocalcemia (from surgical injury or inadvertent removal of

parathyroid tissue) 50% of cases, but permanent hypoparathyroidism
occurs <2% of the time

• Postoperative hematomas or bleeding

• Bilateral vocal cord dysfunction

• Wound cellulitis and infection

Written Report

Block 9 Group 2
NB is a 69 year old female, born on December 10, 1943. She
is a Roman Catholic, lives in Rizal, and is not employed.
Patient was admitted for surgical management of an
anterior neck mass.
Make a history and physical examination framework of patient with anterior
neck mass
General data
• Name: NB
• Age: 69
• Sex: Female
• Address: Rizal
• Religion: Roman Catholic

Chief Complaint: Anterior neck mass

History of Present Illness

• 6 years prior to admission, the patient noted a 3x3 cm mass on her anterior neck.

• The mass was not painful or tender.

• The patient denied any symptoms such as hoarseness, dysphagia, or difficulty of

breathing.
• She also denied symptoms such as easy fatigability, generalized weakness, dry
skin, cold intolerance, hair loss, difficulty concentrating and poor
memory, constipation, unexplained weight gain, paresthesias, or impaired
hearing.

• The patient also denied symptoms of hyperactivity, irritability, heat intolerance

and sweating, palpitations, unexplained weight loss, diarrhea, and polyuria.

• The patient did not seek any medical consult and did not take any medications
nor herbal or traditional remedies.

• In the interim, the patient noted a gradual enlargement of the neck mass, but
denied any symptoms.

• 1 year prior to consult, the patient noted hoarseness and decreased hearing, but
still did not seek medical advice or take any medications or remedies.

• Few hours prior to admission, the patient noted hemoptysis, described as reddish
expectorated sputum which prompted consult at the East Avenue Medical Center
Emergency Room, hence the admission.
Past Medical History

The patient has no hypertension, asthma, diabetes, cardiovascular disease,

seizures, previous operations or trauma, no known allergies.

Family History

No family history of hypertension, diabetes mellitus, allergies, stroke, malignancy,

arthritis, CV, and kidney diseases, PTB or UTI.

Personal/Social History

The patient has no vices, is married, an elementary graduate, and is unemployed.

Review of Systems

Systemic
No fever, malaise, dizziness, anorexia, headache

HEENT
No blurring of vision, no deafness, no speech difficulties

Respiratory
No orthopnea, tachypnea, shortness of breath

CVS
No chest tightness, no chest pain

Abdomen
No constipation, no abdominal pain
Physical Exam

Patient is awake, alert coherent and not in cardiorespiratory distress. No pallor or

cyanosis.

Vital signs
BP: 130/80 mm Hg, PR: 72 bpm, RR: 20/min, Temp: 36.3 C

Dermatologic
No skin lesions, no hair lesions or thinning of hair

HEENT
• (+) impacted cerumen on the right ear, intact tympanic membranes on both ears
• No nasal congestion or masses
• No tonsillopharyngeal hypertrophy, absent teeth, (+) use of dentures
• Indirect laryngoscopy showed right side deviation of airway, left vocal cord
paralysis, with the right vocal cord fully mobile, and a patent airway
• L anterior neck mass which moves with deglutition, hard, non tender and fixed
Cardiovascular
Adynamic precordium, distinct heart
sounds, normal rate, regular rhythm, no
murmurs

Pulmonary
Equal chest expansion, (+) wheezing on
bilateral upper and mid lung fields

Abdomen
Soft, flabby abdomen, no pain or
tenderness
Questions pertaining to her visit to the hospital:

What brings you to the hospital today?

 When did you notice the swelling for the first time? How long has the mass been present?
 Has it changed? If so, over what time frame?
 Is it painful? On the scale of 1-10, 1 being the lowest and 10 being highest, how would you rate the
pain?
 Does talking or eating make the pain worse? Is there anything which makes the pain go away?
 Are there symptoms of recent infection of nearby structures (cough, cold, sore throat, earache,
toothache, skin problems, head lice, bites)? Has there been a fever?
 When did you had your menopause?
 Do have any of the symptoms that I’m going to mention, if yes, would you tell me from when you
started to notice such symptoms like: Hair fall, Dry skin, Getting Irritated easily, Weight loss, Sensitivity,
cold, Tremors, Feeling hot, Forgetfulness, Fatigue, Diarrhea.
 Do you smoke?
 Do you have difficulty breathing or any change in voice?
 You told you coughed up blood. How much blood came? A spoon or a streak?
 How many times has this happened?
 Apart from all these, do you suffer from any of the conditions like DM, HTN, BA, seizures or thyroid?
Is there anyone in the family who was diagnosed with a thyroid disorder? Is he/she a first degree relative?

Physical examination
Physical examination consists of - Inspection, Palpation, Percussion, Auscultation

Wash your hands and guide your patient about the different tests you are going to perform.

Inspection
Check the behavior - notice the level of activity.
Check the hands for dry skin, increased sweating, acropachy and for peripheral tremor.
Pulse - rate and rhythm.
Face - for sweating, dry skin and loss of eyebrows.
Eyes - check for exophthalmos, lid retraction and eye movements. Lid lag tested.
Neck - scars /incisions, masses, lymph node enlargement
Trachea - for any deviation from the midline
Inspection of thyroid gland at the midline of neck. If mass noted, tell patient to swallow some water
Patient is asked to protrude the tongue to rule out thyroglossal duct cyst.
Look at the tibia for pretibial myxedema.

Palpation
Ask for permission before examining, if he/ she agreed then move to the procedure

Lymph nodes - Palpate with pads of 2 digits in a circular motion

Palpate all these 10 lymph nodes:
1. Preauricular
2. Postauricular
3. Suboccipital
4. Tonsillar
5. Submandibular
6. Submental
7. Anterior cervical
8. Posterior cervical
9. Deep cervical
10. Supraclavicular and infraclavicular

Thyroid gland is palpated using 3 fingers of each hand along the midline of the neck. Each lobe is palpated by
moving fingers laterally from the isthmus.
Ask the patient to sip and swallow water.
Look for size, symmetry, consistency, masses and palpable thrill.
Then assess mass, it’s position, shape, tenderness, consistency and mobility.
Palpate the suprasternal notch to see the extent of the mass

Auscultation - look for bruits

Thank the patient. Wash hands and summarize findings.

Enumerate and explain your
differential diagnosis

RULE IN RULE OUT

Goiter Age (-) Symptoms of

(+) Anterior neck mass Hyper/hypothyroidism
(+) Painless neck mass
(+) Hoarseness
Thyroglossal cyst (+) Painless mass Age (0.6% chances are there
(+) Neck mass moves with to present)
swallowing
Papillary thyroid Gender (-) Palpable lateral cervical
carcinoma (+) Hoarseness lymph node
(+) Hemoptysis
(+) Hard and nontender
(+) Slow growing painless lump
(+) Moves freely with deglutition
Follicular carcinoma Age and Gender Symptoms of thyrotoxicosis
(+) Painless unless hemorrhage Long standing goiter
enter into nodule Rapidly size increasing
Enumerate and explain the tests needed to reach a correct final diagnosis

CBC: to determine if there is any ongoing infection or inflammation. And might help in
rule in of any infectious cause of the mass like abscess.

Fine Needle Aspiration Biopsy : It is considered the best first-line diagnostic

procedure for a thyroid nodule. The accuracy of FNAB results is better than any other
test for detecting papillary thyroid carcinoma

Thyroid Function Test: Helps determining if the mass affecting thyroid function.

Thyroid Ultrasound: It is Standard Procedure to evaluate the thyroid masses.

Ultrasound evaluation can identify features of a nodule that increase the risk of
malignancy, such as fine stippled calcification and enlarged regional nodes. Ultrasound
elastography is used to evaluate tissue stiffness non-invasively. This technique takes
advantage of the fact that malignant nodules tend to be harder than benign nodules.
Chest X Ray: Since our patient has experienced hemoptysis and physical examination
suggests that there is wheezing, it will help in determine any other pathology and also
help to determine if there is any metastasis. If needed we can do CT scan with contrast
or MRI to determine the invasiveness and metastasis of the mass.

PET scan: This diagnostic test is helpful if the thyroid cancer does not take up iodine.

Radionuclide Imaging
Iodine-123 (123 I) emits a low dose radiation, has a half-life of 12 to 14 hours, and is
used to image lingual thyroids or goiters.

The images obtained by these studies provide information not only about the size and
shape of the gland, but also the distribution of functional activity.

Areas that trap less radioactivity than the surrounding gland are termed cold, whereas
areas that demonstrate increased activity are termed hot. The risk of malignancy is
higher in “cold” lesions (20%) compared to “hot” or “warm” lesions (<5%).
Explain the risk factors and causes

• Women are diagnosed with 3 of every 4 thyroid cancers

• Age
• Genetics
• Radiation exposure
• Diet low in iodine
• Breast cancer
• Family history of thyroid cancer
• Personal or family history of goiters
• Whole body radiation for bone marrow treatment
• Exposure to high levels of radiation caused by nuclear accidents or weapons testing
• Certain genetic conditions like familial adenomatous polyposis (FAP), Gardener
syndrome, Cowden disease
Explain the pathophysiology

The first oncogenic events identified in papillary thyroid carcinoma were chromosomal
rearrangements involving the rearranged during transfection (RET) proto-oncogene, which
arises from a paracentric inversion of chromosome 10.

RET fusion proteins (the RET/PTC family) appear to play an oncogenic role in
approximately 20% of papillary thyroid carcinomas, with RET/PTC1, RET/PTC2, and
RET/PTC3 accounting for most cases. In addition, the NTRK1 and the MET proto-oncogene
may be overexpressed and/or amplified.

Evidence also suggests that some molecules that physiologically regulate the growth of
the thyrocytes, such as interleukin-1 and interleukin-8, or other cytokines (eg, insulinlike
growth factor 1, transforming growth factor beta, epidermal growth factor) could play a
role in the pathogenesis of this cancer.
Mutation in the BRAF gene resulting in the BRAF V60E protein is prominent in
papillary thyroid carcinoma. The BRAF V600E mutation is associated with
aggressive clinicopathological characteristics of papillary thyroid carcinoma,
including lymph node metastasis, extrathyroidal invasion, and loss of radioiodine
avidity, which may lead to failure of radioiodine treatment and disease
recurrence.

There is also a clear association between radiation exposure (from radiotherapy

or fallout) and incidence of papillary thyroid carcinoma.
Treatment options and prognosis

Surgery

A lobectomy is an option for unifocal tumors smaller than 4 cm with no evidence of

extrathyroidal extension or lymph node metastasis. For patients with PTC > 4 cm, or
with gross extra-thyroidal extension (clinical T4), or clinically apparent metastatic
disease to nodes (clinical N1) or distant sites (clinical M1), the initial surgical procedure
should include a near-total or total thyroidectomy and gross removal of all primary
tumor unless there are contraindications to this procedure.

If surgery is chosen for patients with thyroid cancer < 1 cm without extra-thyroidal
extension and cN0, the initial surgical procedure should be a thyroid lobectomy unless
there are clear indications to remove the contralateral lobe.

Thyroid lobectomy alone is sufficient treatment for small, unifocal, intrathyroidal

carcinomas in the absence of prior head and neck radiation, familial thyroid carcinoma,
or clinically detectable cervical nodal metastases.
Prophylactic central-compartment neck dissection (ipsilateral or bilateral) should be a
consideration in patients with PTC with clinically uninvolved central neck lymph nodes
(cN0) who have advanced primary tumors (T3 or T4) or clinically involved lateral neck
nodes (cN1b), or if the information will be used to plan further steps in therapy.

Adjuvant Radioiodine Therapy

After thyroidectomy, radioiodine is the therapy of choice in patients with PTC to ablate
residual normal thyroid tissue.

Radioiodine therapy is indicated in the following cases:

• Patients with tumor >2 cm and one of the following risk factors: gross extra-thyroidal
extension, age >45 years, lymph node and distant metastases
• Patients with tumor <2 cm and distant metastasis
• Radioactive iodine therapy is given 4-6 weeks after surgery. Prior to treatment, a
hypothyroid state is induced by stopping thyroid hormone replacement treatment.
The therapy is continued until no more radioactive iodine uptake is seen.
Thyroid Hormone Treatment

After thyroidectomy, patients require lifelong thyroid hormone therapy, usually as

monotherapy with levothyroxine (LT4).

Since TSH can promote the growth of remaining PTC cells, the dosage of LT4 should
initially be high enough to achieve suppression of thyrotropin.

The thyroid function should be checked after 6 to 8 weeks.

Depending on the result, the dosage should be adjusted; the use of TSH suppressive
therapy should merit careful consideration since it carries an increased risk of
complications.
THANK YOU