3. Nodul Tiroid Tiroiditis CA Tiroid-2
description
Transcript of 3. Nodul Tiroid Tiroiditis CA Tiroid-2
Thyroid Abnormalities
Himawan Sanusi
THE THYROID GLAND
Pyramidal lobe
Left lobe
Right lobeIsthmus
Internal jugular vein
Thyroid cartilago
External carored arteri
22
Basic elements in regulation of thyroid function
THYROID
TISSUE
TRH
HYPOTHALAMUS
PORTAL SYSTEM
TSH
ANTERIORPITUITARY
“FREE”
T3
T3
T4
T4
I
I
_
T4
+
T3
+
Usually Complain thyroid disease
Complications of a Spesific form hyperthyroidism: Graves’ disease which may present which prominence of the eyes or exophthalmos and Thickening of the skin over the lower legs (rare) or thyroid dermopathy
Diffuse goiter• Simple diffus goiter• Hypertiroidism• Hashimoto thyroiditis
Nodular goiter 1. Thyroid nodul 2. Thyroid cyst
3. Adenomatosa goiter 4. Subacut /chronis thyroiditis 5. Plummer thyroiditis
Definition• Thyroiditis heterogenous group of
inflamatory disorders the thyroid gland• Etiologies range from autoimmune to
infectious origins• Clinical course Acute, subacute, or
chronic. Can be euthyroid, transient phase thyrotoxicosis and / or hypothyroidism. Painless or painfull
I. Autoimmune thyroiditisChronic autoimune thyroiditis
Hashimoto’s thyroiditisAtrophic thyroiditisFocal thyroiditisJuvenile thyroiditis
Silent thyroiditis / Postpartum thyroiditis II. Subacute thyroiditis III. Acute suppurative thyroiditisIV. Riedel’s thyroiditis
Classification of thyroiditis
Classification of thyroiditisHystologic classification
Chronic lymphocytic
Subacute lymphocyticGranulomatous
Microbial inflamatory
Invasive fibrosis
Synonims
Chronic lymphocytic thyroiditis,Hashimoto’s thyroiditisSubacute lymphocytic thyroiditis,Postpartum thyroiditis,Sporadic painless thyroiditisSubacut granulomatous thyroiditisDe Quervains thyroiditisSuppurative thyroiditisAcut thyroiditis
Riedel’s strumaRiedel’s thyroiditis
Terminology for Thyroiditis.
Type Synonim
Hashimoto’s thyroiditis Chronic lymphocytic thyroiditis Chronic autoimmune
thyroiditis Lymphadenoid goiter
Painlesspostpartum thyroiditis Postpartum thyroiditis Subacute lymphocytic thyroiditis
Painless sporadic thyroiditis Silent sporadic thyroiditis Subacute lymphocytic thyroiditis
Painful subacute thyroiditis Subacute thyroiditis de Quervain’s thyroiditis
Giant-cell thyroiditis Subacute granulomatous
thyroiditis Pseudogranulomatous thyroiditis
Terminology for Thyroiditis.
Type Synonim
Suppurative thyroiditis Infectious thyroiditis Acute suppurative thyroiditis Pyogenic thyroiditis
Bacterial thyroiditis
Drug-induced thyroiditis - (amiodarone, lithium, interferon alfa, interleukin-2)
Riedel’s thyroiditis Fibrous thyroiditis
Hakaru Hashimoto (1912) 4 patients chronic disorder of the thyroid diffuse lymphocytic infiltration, fibrosis, parenchymal atrophy, and eosinophilic change in some acinar cells
Hashimoto’s thyroiditis(Chronic thyroiditis)
Dr Hakaru Hashimoto
Hashimoto thyroiditisis the most common
cause of hypothyroidism & goiter
in the United States
Hashimoto’s thyroiditis
Statosky J et al. Am Acad of Family physicians 2000;61:1054
Hashimoto’s thyroiditisEtiology & pathogenesis
HT is immunologic disorder which lymphocytes become sensitized to thyroidal antigens and autoantibodies are performed.Thyroid antibodies in HT are:1. Thyroglobulin antibody (Tg Ab)2. Thyroid peroxidase antibody (TPO Ab) =
( Microsomal antibody) 3. TSH Receptor blocking antibody ( TSH - R Ab block)
CELL CELL STIMULATION BLOCKADE
Antagonist Antibody
Agonist Antibody
TSHR-Ab
TSHRTSHR
Davies TR. Graves’ disease in Werner & Ingbar’s : The thyroid ; 2000 ;520
Autoimmune thyroiditis
Clinical Manifestation Clinical Manifestation Hashimoto’s ThyroiditisHashimoto’s Thyroiditis
Symptom & SignsHT usually presents with goiter , euthyroid or mild hypothyroidism.
Sex distribution : F/M 4:1
Painless & patients may be anware of the goiter
Laboratory findingsLaboratory findings
• T4 N/ low, TSH will be elevated. RAIU may be high, normal or low
• Tg Ab & TPO Ab positif• Fine needle aspiration biopsy large infiltration lymphocytes Hurttle cells
Diagnostic procedures• Test of thyroid autoimmunity:
TPOAb 95% + in HT & 90% Atrophic thyroiditis
TgAb less frequently + Diagnostic specificity of thyroid antibody tests is not absolute.
• Test for thyroid function TSH, fT4• RAIU : normal, low or high.• USG : diffusely reduced echogenecity• FNAB not necessary,excep. rapidly
enlarging goiter
Diffuse goiter
Anti microsomal (or TPO) antibody Anti-thyroglobulin antibody Positive
Hashimoto’s thyroiditis
PositiveUS Biopsy
Other diseases*Negative
Negative
Sign symptom of hypothyroidism
*Simple goiter, adenomatous goiter etc
Diagnosis of Hashimoto’s thyroiditis
Treatment Hashimoto’s thyroiditis
TreatmentTreatment• Goiter small & asymptomatic not
require therapy• Levo-thyroxine is given over
hypothyroidism to supress TSH & decreased serum thyroid antibody. Levo-thyroxine in euthyroid, still controversial
TreatmentTreatment•Corticosteroids : regression
pain, reduction in size of the goiter, thyroid antibody, not recommended in benign disease.
•Surgery indicated pain, cosmetic, or pressure symptoms after levothyroxine and corticosteroid therapy.
Riedel’s thyroiditis
• Rare 1,06/100.000, middle age or elderly women
• Etiology unknown (autoimmune process or primary fibrotic disorder)
• Characterized fibrosis replaces normal thyroid parenchyma,1/3 cases multifocal fibrosclerosis
Riedel’s thyroiditis
• Thyroid fibrosis (stony hard,woody), painless, progressive anterior neck mass,
• Generalized fibrosing (1/3 patients), pressure symptoms laryngeal nerve paralysis or hypoparathyroidism (rare)
• Usually euthyroidism, hypothyroidism (30%)• Laboratorium : non spesific• USG/CT-Scan inconclusive• Difinitive diagnosis open Biopsy
Riedel’s thyroiditis• Treatment:
Corticosteroids medical treatment of choice Tamoxipen, methotrexate inhibitor fibroblast
proliferation ( early stages) Levothyroxine hypothyroidism
Surgical care diagnosis, relieving tracheal compression
• Mortality asphyxia (6-10%), extrathyroidal fibrotic lesions may complicate the prognosis
Subacute thyroiditis• Cause unknown ( viral infection
(?) preceded URT infection, coincidence viral disease (mumps, measles, Echo virus, adeno virus, epst. Barr virus, influenza)
• Women : Men (3-5:1)• Onset: 20-60 yr• Summer
Subacute thyroiditis• Palpation thyroid: enlarged, asymetrical,
nodul, firm, tender & painful.• Thyrotoxicosis during inflamatory phase
euthyroidism hypothyroidism euthyroidism (4th phases)
• Laboratorium: ESR increase, leukocyt N/ increase, fT4,,TSH, RAIU
• Recovery 4-6 months, spontaneous remitting
20
0
15
10
5
1Eu Hypo EuHyper4 11 -
Phase :Weeks:
0
30
20
10
40
24-hour 131 I
uptake %T4
ug/dL
T4
131 I
Changes in serum T4 & Radiactive iodine uptake in patients with subacute Thyroiditis
Woolf PD, Daly R :Am J Med 197;60:73
Laboratory findings during different phases of subacute thyroiditis
Phase
Thyrotoxicosis
Hypothyroid
Recovery
T4 &/T3 Level
High
Low
Normal
TSH level
Low
Normal,or high
High to normal
RAIU value
<5%
Normal to high
High to normal
Treatment Subacute thyroiditis
• Symptomatic: Acetaminophen 4X 0,5g, NSAID or glucocorticoid (prednison 3 X 20 mg (7-10 days)
• Betablockers symptoms of thyrotoxicosis• L-thyroxine 0.1-0.15 mg /daily hypothyroid
phase. Long-term L-thyroxine permanent hypothyroidism (10%)
• Antibioticsno value• Thyroidectomy rarely
NECK PAIN
RAIU
PRESENTING SYMPTOMS
YES N0
INCREASED
RAIU
SUBACUTE GRANULOMATOUS
THYROIDITIS
MICROBIAL INFLAMMATORY
THYROIDITIS
HYPERTHYROIDISMDECREASED HYPOTHYROIDISM
CHRONIC LYMPHOCYTIC THYROIDITIS
GRAVES DISEASE SUBACUT LYMPHOCYTIC THYROIDITIS
Clinical Differentiating of the Subtype Thyroiditis
Statosky J et al. Am Acad of Family physicians 2000;61:1054
Acute suppurative thyroiditisAcute suppurative thyroiditis
• Rare, serious, bacterial inflamatory disease, children, 20-40 yr, sex ratio 1:1
• Etiologi: Infectious: Staph. aureus, strep.pyogenes, strep. pneumonia, esch.coli, pseudomonas aeruginosa
• Infection by hematogenous, direct trauma
Symptoms and Signs :• Neck pain, warm, tenderness, the
neck unable to extend• Dysphagia, dysphonia, referred to
ear, mandibula, lymphadenopathy• Systemic manifestation: fever,
chills, tachycardia, malaise• Palpation: unilateral, erythematous
Acute suppurative thyroiditisAcute suppurative thyroiditis
• Thyroid function : Euthyroidism• Laboratorium : TPO antibodies
absent, ESR high, PMN leukocytosis
• 24-hour 123I uptake normal• FNA Biopsy : purulent material•Treatment : antibiotics or
surgical drainage
Acute suppurative Acute suppurative thyroiditisthyroiditis
Chronic-pyogenic Chronic-pyogenic thyroiditisthyroiditis
Etiology : • Salmonellatyphosa, syphilis,
tuberculosis, echinococcus, actinomyces
Symptoms : Suppurative, non suppurative
Treatment : antibiotic, drainage
Thyroid nodules & Thyroid nodules &
Thyroid cancerThyroid cancer
Thyroid nodules - prevalence• Thyroid nodules commonThyroid nodules common, increase , increase
with agewith age
• 30-60%30-60% of thyroids have nodules at of thyroids have nodules at autopsyautopsy
• Palpation: Palpation: 5-20% (>1cm)5-20% (>1cm)
• U/S: U/S: 15-50% (>2mm)15-50% (>2mm)
Thyroid nodules & Thyroid cancerThyroid nodules & Thyroid cancer• In 95% of cases , thyroid cancer
presents as a nodule or lump in the thyroid nodul thyroid.
• Thyroid nodule extremely common, particularly women. Prevelance in USA 4% in adult population. F:M ratio 4:1.
• Thyroid cancer rare. Incidence 0.004% per year
Benign thyroid adenomaEtiology :
Focal thyroiditis Multinodular goiter Post surgical remnant hyperplasiaBenign adenoma : Follicular Rare: Teratoma, lipoma, hemangioma
Differentiation benign & Malignant lesions
• History : Family history of goiter suggests benign disease, endemic goiter
• Physical characteristics: Benign : older age, woman, soft nodule, multi nodular goiter. Malignant : Children, young, male, solitary, firm nodule, vocal cord paralysis, firm lymph nodes, distant metastasis
• Serum factors : Benign : high titer of antibody Malignant : calcitonin
• Scanning : Benign: Hot nodule Malignant: Cold nodule
• Biopsy (needle)
Differentiation benign & Malignant lesions
Malignant thyroid Malignant thyroid CarcinomaCarcinoma
• Papillary Carcinoma 75 %• Folliculare Carcinoma 16 %• Medullary Carcinoma 5 %• Anaplastic Carcinoma 3 %• Lymphoma 5 -10 %
Diagnostic approach• Fine Needle Aspiration (FNA)
10-20% risk of suspicious cytology, therefore thyroid surgery95% of histology will be benign, and surgery “unnecessary
• Isotop Scann(CT)rarely used for evaluation 80% of nodules are “cold”small cold nodules may be missed
• Ultrasonography (USG)
Diagnostic approach - ultrasound
Identifies solid v. cystic nodules
Identifies MNG
May aid FNA
Does not exclude malignancy
Diagnostic approach - other tests
Calcitoninvery high results diagnostic for MTCrisk of borderline false positivesnot for routine use
Thyroglobulinnot helpful for exclusion of carcinoma : overlap with benign diseasebest for follow-up after thyroidectomy
Thyroid noduleThyroid nodule
MixedMixed
FNACFNAC
L-T4 L-T4 Follow upFollow up Surgery Surgery
BenignBenign SuspeciousSuspecious
EchographyEchography
Malignant Malignant
Follow-upFollow-up
Echography Echography ScanScan
Normal TSHNormal TSH Low TSHLow TSH
Hot Hot Cold Cold
131131 I /surgery I /surgery
Cystic Cystic Solid Solid
Evacuation Evacuation
Management of the solitary nodule
N o
W atch ?
B en ig n
S u rg ery
M a lig n an t
In d ete rm in ate
S u rg ery
R ep eat F N A C
In d ete rm in ate
S u rg ery
F o llicu la r
F N A C
Y es
Tru e s o lita ry n od u le?
TreatmentTreatment• Thyroidectomi• Jodium 131Radioactive• Thyroxine supression