b17m03l08 Thyroid Nodules

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THYROID NODULE BLOCK XV

Dr. F Hilado MODULE III10/30/2015 3:00-5:00 PM LECTURE VI

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OUTLINE

I. Thyroid Gland Anatomy

II. Thyroid Nodules

III.

Diagnostic Evaluation Methods- History and PE

- Laboratory Tests

- Investigative Procedures

IV. Differential Diagnosis

V. Diagnostic Approach

VI. Thyroid cancer

THYROID GLAND ANATOMY

Largest endocrine gland in the body and is tasked with

regulating the metabolism of most of the bodys cells

Butterfly-shaped organ located inferior to the larynxand over the 2

ndand 3

rdcricoid cartilage.

It has two pyramidal-shaped lateral lobes,

approximately 5 cm long, joined by the narrow

isthmus anterior to the trachea

Pretracheal fascia

- Attaches the thyroid to the trachea so that

it moves with the trachea and larynx when

swallowing but not when the tongue is

protruded

THYROID NODULES

Goiter- Is an enlarged thyroid gland by palpation,

ultrasound, or thyroid scan

It is not about the blood tests. This will only tell you

the function, whether it is hypothyroid, hyperthyroid,

or euthyroid

GOITER

- refers to an enlarged thyroid gland

- Biosynthetic defects, iodine deficiency, autoimmune

disease, and nodular diseases can each lead to goiteralthough by different mechanisms

Biosynthetic defects and iodine deficiency

- reduced efficiency of thyroid hormone synthesis,

leading to increased TSH, which stimulates thyroid

growth as a compensatory mechanism to overcome the

block in hormone synthesis.

Graves disease

-the goiter results mainly from the TSH-Rmediated

effects of TSI

Hashimotos thyroiditis

-

occurs because of acquired defects in hormone

synthesis, leading to elevated levels of TSH and its

consequent growth effects.

- Lymphocytic infiltration and immune systeminduced

growth factors also contribute to thyroid enlargement

in Hashimotos thyroiditis.

NODULAR DISEASE

- is characterized by the disordered growth of thyroid

cells, often combined with the gradual development of

fibrosis- occurring in about 37% of adults when assessed by

physical examination

Ultrasound: nodules are present in up to 50% of adults,

with the majority being


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Diagnostic evaluation:

A case of single thyroid nodule. A 25-year-old patient with

incidental ultrasound finding of a thyroid nodule in the left

lobe

(a) Thyroid ultrasoundshows a solid hypoechoic nodule,

with microcalcifications

(b) Thyroid scintigraphyshows the cold nodule with no

detectable 99mTcO4 uptake. The patient underwent fine

needle cytology and the cytology was suspicious forpapillary carcinoma

Imaging In Endocrinology

MULTINODULAR

Diagnostic evaluation:

A case of multinodular toxic thyroid. A hyperthyroid 46-

year-old woman with a palpable multinodular thyroid.

(a) Ultrasound scanshows an enlarged thyroid with

multiple nodules in both right and left lobe. The gland

seems to extend in the mediastinum

(b) Thyroid scintigraphy.The scan shows intense uptake in

the glandular parenchyma with multiple cold areas in

correspondence to the major nodules seen at ultrasound.

This finding is consistent with the diagnosis of a

multinodular toxic thyroid. The patient underwent

surgery

Imaging In Endocrinology

Nodular, non-toxic goiter

- 1 nodule, blood tests are normal

Nodular, toxic goiter:- 1 nodule with abnormal blood tests

- TSH low with T3 and T4 that is high

Diffuse goiter:

- enlarged thyroid but no nodules

Multinodular:

- >2 nodules either toxic or non-toxic

There is no nodular hypothyroid or multinodular

hypothyroid, we call that non-toxic hypothyroid

DIAGNOSTIC EVALUATION METHODS

HISTORY TAKINGWhen we see a nodule, what are we going to do?

What are we going to ask?

HISTORY TAKING PHYSICAL EXAMINATION

Is it painful?

History of fever, cough,

nasal congestion, fluids

one month ago?

Does it go with

swallowing?

For how long did he

notice the nodule?

Family history of

thyroid nodule or

thyroid cancer?

Weight loss/gain?

Sleeping patterns?

Tremors?

Palpitations?

Inspection:

Allow to swallow (does it

follow?)

Palpation:

Tender? How many? Size?

Auscultation:

bruit (present in Graves

disease, but not in nodules)

History

Benign disease

- Family history of Hashimotos thyroiditis, benign

thyroid nodule, or goiter

-

Symptoms of hypothyroidism or hyperthyroidism; an

a sudden increase in size of the nodule

with pain or tenderness, which suggests a cyst or

localized subacute thyroiditis

Malignancy

- include young age (60 years

- male gender

- history of external neck irradiation during childhood

- more than 1 nodule

- it can be cystic,

complex, solid

-

toxic, non-toxic and

euthyroid


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adolescence

- rapid growth

- recent changes in speaking, breathing, or swallowing;

and a family history of

thyroid cancer or multiple endocrine neoplasia type 2

(MEN2)

Physical Examination

Malignancy- firm consistency of the nodule

- irregular shape

- fixation to underlying or overlying tissues

- vocal cord paralysis

- Suspicious regional lymphadenopathy

Nodule Size < 4 cm

- not predictive of malignancy

-

the incidence of cancer in incidentally identified or

nonpalpable thyroid nodules is the same as in patients

with palpable

nodulesNodule Size >4 cm

- the incidence of carcinoma may be higher

Williams Textbook of Endocrinology

Laboratory Tests

Serum TSH

- first-line screening test,

- may be measured with a highly sensitive immunometric

assay and combined with a single measurement of free

thyroid hormone concentrations

Low or undetectable serum TSH

- associated with normal thyroid hormones suggest

possibility of toxic, autonomously functioning

nodular areas in the goiter and should lead to

thyroid scintigraphy

- indicates the need to monitor the patient for the

possible development of hyperthyroidism and

indicates that there is no point in attempting further

suppression of TSH with thyroxine therapy

High serum TSH value

- Patients with thyroid cancer

-

even if it is within the upper part of the referencerange, is associated with increased risk of

malignancy in a thyroid nodule

- indicates hypothyroidism and suggests Hashimoto

thyroiditis

Antithyroid Peroxidase Antibodies

- helpful in the diagnosis of chronic autoimmune

thyroiditis, especially if serum TSH is elevated

Serum Thyroglobulin levels

- The measurement of serum thyroglobulin levels h

historically not been recommended in the

evaluation of solitary thyroid nodule because it is

also elevated in benign thyroid disorders

- There is more recent data to suggest that elevated

serum thyroglobulin, thyroglobulin antibody, and

thyroid-stimulating hormone (TSH) levels may be

associated with a higher risk of malignancy

Williams Textbook of Endocrinolo

Investigative Procedures

A number of investigative techniques identify possible

malignancy of the nodule, including imaging with

radionuclide, ultrasound examination, and fine needle

biopsy

RADIOISOTOPE SCANNING

Scintigraphy

- is the standard method for functional imaging of the

thyroid.

- The two isotopes most commonly used are 123I and

99mTc pertechnetate, the latter being the agent of

choice, because of lower cost and greater availability

Interpretation

- Scanning provides a measure of the iodine-trapping

function in a nodule compared

with the surrounding thyroid tissue.

-

Normally, there is uniform tracer uptakethroughout both lobes and sometimes even in the

isthmus

On the basis of tracer uptake:

NORMAL


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Cold Warm Hot

Hypofunctioni

ng

Indeterminate Hyperfunctioning

Decreased

uptake

Uptake similar

to surrounding

tissue

increased nodular

uptake with

suppression of uptake

in the surrounding

tissue80-85% 10 %


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CT SCAN AND MRI

- Limited role in the initial evaluation of solitary thyroid

nodule

- Indications for these imaging techniques include

suspected tracheal involvement, either by invasion or

compression, extension into the mediastinum, or

recurrent disease

FNA BIOPSY- This procedure represents a major advance in the

diagnosis and management of thyroid nodules

- now considered the most effective test currently

available to distinguish benign from malignant thyroid

nodules

- diagnostic accuracy that approaches 95%

FNA BIOPSY RESULT

Benign Diagnosis Malignant Diagnosis

Colloid Nodule

Cyst

Lymphocytic ThyroiditisGranulomatous Thyroiditis

Papillary Thyroid Cancer

Anaplastic Thyroid Cancer

Medullary Thyroid CancerLymphoma

Metastatic cancer

Handbook of diagnostic endocrinology

Management and Diagnosis of Thyroid Nodules

DIFFERENTIAL DIAGNOSIS

THYROID ABSCESS or ACUTE THYROIDITIS

(+) tenderness, Fever, Soft

Redness on the side of the thyroid gland

ACUTE THYROIDITIS:

- caused by bacteria (staph or strep, or opportunistic

bacteria)

- aspiration, culture and sensitivity

- antibiotics, incision and drainage

ACUTE THYROIDITIS

- rare and due to suppurative infection of the thyroid.

In children and young adults,

- the most common cause is the presence of a

piriform sinus, a remnant of the fourth branchial

pouch that connects the oropharynx with the thyroid- A long-standing goiter and degeneration in a thyroid

malignancy are risk factors in the elderly

- The patient presents with thyroid pain, often

referred to the throat or ears, and a small, tender

goiter that may be asymmetric.

- Fever, dysphagia, and erythema over the thyroid are

common, as are systemic symptoms of a febrile

illness and lymphadenopathy

Harrisons Internal Medicine 19th

edition

SUBACUTE THYROIDITIS:- caused by virus (coxsackie, adenovirus, mumps virus,

echovirus, influenzae, epstein-barr)

- low-grade fever, like trangkaso, flu-like symptoms

-

patient then feels that it is tender, cold upon

palpation

3 Phases of Thyroiditis

Hyperthyroid Euthyroid Hypothyroid

First 4-6 weeks > 4-6 weeks 2-3 months

high T3, T4; low

TSH

Normal Thyroid

Tests

low T3, T4; high

TSH

We dont treat

this patient as

toxic goiter and

we cannot give

antithyroid drugs

Beta-blocker or

steroid given

(prednisone or

dexamethasone)

will remain in this

phase or will

become

hypothyroid

Give T4

(levothyroxine)

We can also

give T3

(liothyronine)

50-150 ug

depending on

blood test

Normal: we can

discontinue

medicationsand give blood

test after 2-3

weeks

SUBACUTE THYROIDITIS

- De Quervains thyroiditis, Granulomatous thyroiditis,

- Many viruses have been implicated, including

mumps, coxsackie, influenza, adenoviruses, and

echoviruses, but attempts to identify the virus in an

individual patient are often unsuccessful and do not


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influence management.

- The diagnosis of subacute thyroiditis is often

overlooked because the symptoms can mimic

pharyngitis

- The peak incidence occurs at 3050 years, and women

are affected three times more frequently than men

Pathophysiology

-

The thyroid shows a characteristic patchyinflammatory infiltrate with disruption of the

thyroid follicles and multinucleated giant cells

within some follicles.

- The follicular changes progress to granulomas

accompanied by fibrosis. Finally, the thyroid

returns to normal, usually several months after

onset

Initial phase of follicular destruction

- there is release of Tg and thyroid hormones,

leading to increased circulating T4 and T3 and

suppression of TSHDestructive phase

- radioactive iodine uptake is low or undetectable

Hypothyroid phase

- After several weeks, the thyroid is depleted

of stored thyroid hormone and a phase of

hypothyroidism typically

occurs

- with low unbound T4 (and sometimes T3) and

moderately increased TSH level

Radioactive iodine uptake returns to normal or is

even increased as a result of the rise in TSH. Finally,thyroid hormone and TSH levels return to normal as the

disease subsides


edition

CHRONIC OR PAINLESS THYROIDITIS AND SUBACUTE

LYMPHOCYTIC THYROIDITIS:

- these are autoimmune

- antimicrosomal antibodies are very low

- some are also post-partum (6wks-3mos after

delivery)

-

clinical features: no nodule before pregnancy butdevelop a painless nodule

- Give steroids

- Clinical course is same as subacute thyroiditis

(some become hypothyroid for life but others

return to normal function and nodule disappears

THYROIDITIS: after 2 wks of prednisone or

dexamethasone, the thyroid nodule disappears.

CHRONIC THYROIDITIS

HASHIMOTOS THYROIDITIS

- hard on palpations

- sometimes painless

- sometimes feel cancer-like

- patients are hypothyroid: give levothyroxine

- also involves immune system destroying the

thyroid gland itself

REIDELS TRAUMA

- cancerous type based on palpation but they are

just benign

- cant be treated with steroids

- sometimes we think it is cancer so we recommend

surgery

Whatevers deficient, you fill up. Whatevers in excess,

you reduce

Chronic Thyroiditis

- Focal thyroiditis is present in 2040% of euthyroid

autopsy cases and is associated with serologic

evidence of autoimmunity, particularly the presence

of TPO antibodies

Hashimotos thyroiditis

- The most common clinically apparent cause of chronic

thyroiditis

- an autoimmune disorder that often presents as a firm

or hard goiter of variable size

Riedels thyroiditis

- is a rare disorder that typically occurs in

middle-aged women.

- It presents with an insidious, painless goiter with

local symptoms due to compression of the

esophagus, trachea, neck veins, or recurrent

laryngeal nerves.

- Dense fibrosis disrupts normal gland architecture

and can extend outside the thyroid capsule.

- Despite these extensive histologic changes,

thyroid dysfunction is uncommon.

-

The goiter is hard, nontender, often asymmetric,and fixed, leading to suspicion of a malignancy.

- Diagnosis requires open biopsy as FNA

biopsy is usually inadequate.

- Treatment is directed to surgical relief of

compressive symptoms. Tamoxifen may also be

beneficial.


edition


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DIAGNOSTIC APPROACH FOR THYROID NODULE

Thyroiditis in Hyperthyroid Stage vs Thyroid cancer

- Radio-iodine uptake

To differentiate Thyroiditis from Thyroid cancer during

the first stage of thyroiditis when there is hyperthyroid

and your TSH is low

In Primary hyperthyroidism, the problem is in thethyroid gland. There is low TSH and high T3, T4

Thyroiditis in Hyperthyroid Stage vs Toxic Nodular Goiter

request for radio-iodine uptake

Radioiodine uptake is low in thyroiditis while it is high

in hyperthyroid (toxic goiter)

In ultrasound: Both will appear as solid nodule

In thyroid scan:

o Diffuse Toxic goiter: very dark (black)

o Warm thyroid: not that dark, lighter compared to

diffuse toxic goiter

Normally: right gland is bigger than the left.

Cold nodule: 3 ddx: cystic, thyroiditis or carcinoma

Uninodule + flu-like symptoms: thyroiditis

o We dont usually do thyroid scan on thyroiditis

(not routine), we use radio-iodine uptake if we

want to make a diagnosis of thyroiditis which we

can make by history and PE.

Acute bleeding or trauma in the thyroid gland can also

give you pain kung wala sila ya flu-like symptoms

This patient of mine has Thyroid Cancer.

o Cystic: will also appear in thyroid scan but in

thyroid ultrasound it will appear as a solid nodule

(black). Cancer or thyroiditis appear as solid

nodule

o

UTZ: Solid: white; Complex: black and white

You should know how to read the ultrasound and

thyroid scan. Do not rely on the technicians and

radiologists. Review and Correlate your imaging results

to the history and PE.

UTZ solid thyroid nodule UTZ cystic thyroid nodule

FLOW CHART IN DIAGNOSING THYROID NODULE

When you see a nodule, there are three methods:

You can do TSH firstbut personally I dont do this since

clinically you can diagnose a px whether toxic or not.

But if you are not sure then you can do this

Low TSH: When it is low, do thyroid scan. If the result ofthe thyroid scan is warm, either observe or do radioactive

uptake. If it is hot or toxic, you treat medically first and

make sure the blood tests are normal hen do radioactive

iodine uptake (10-15 mg)

Normal TSH: do ultrasound or fine needle biopsy. In

ultrasound, if cystic I aspirate and biopsy. On the other

hand, if it is solid you do FNAB. If the result is colloid or

benign you give Levothyroxine because it suppresses TSH

which stimulates the thyroid gland to increase in size

Given this picture your

differentials would be

either Thyroiditis orThyroid cancer


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Ill try the patient for 6 months to one year. If the

thyroid gland increase in size despite the presence of

levothyroxine then it is malignant despite negative

FNAB. This is because FNAB is not a definitive diagnosis

for thyroid cancer. It is just a screening because you

cant demonstrate breakage in cytoplasm

If it decreases in size then continue with T4 butjust be careful especially with our levothyroxine ..

because in elderly it will cause arrhythmia and also they

said they can make your bones thin

If the FNAB result is papillary carcinoma then I will

recommend patient for total thyroidectomy

If you see follicular in FNAB then probably it is just

adenoma because you cant say if it is cancerous by just

FNAB. You should do cytology studies and look for

breakage in cytoplasm to confirm if it is malignant

Proceed immediately to FNAB. If FNAB is cysticit is

usually benign. So its either you treat, observe, or

follow-up your patient. There are cystic that if they

return to you after 1 month, the nodule is no longer

there. There are also some cases that they return if

they kept on scratching and touching your nodule the

cyst there will return. If it is solid colloid then benign so

Ill just treat with T4. But if it is follicular, either I refer

for thyroidectomy or I do thyroid scan. If the result of

thyroid scan is cold then I do surgery if warm then just

give T4

Do Thyroid scan first. If it is cold nodule then do

FNAB and UTZ. UTZ can be cystic or solid. Cystic

aspirate. Solid either treat or FNAB. In FNAB it wil

appear follicular then do surgery if colloid then

give T4

If dont want to spend a lot do direct FNAB

UTZ, FNAB, Thyroid Scan

Straight FNAB

Depends on psychology and state of care and what the

patient like (comfort to convince to FNAB less expensive

and more direct)

SUMMARY

Acute thyroiditis: bacteria- treatI will give aspirate or antibiotics

Hyperthyroid phase- beta blockers-- popropanol

Subacute thyroiditis:

viral- give steroids- painless 4x a day for 2 weeks..

you can give for pain

Chronicgive only thyroid hormones

THYROID CANCER


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Cystic and Hyperthyroid Nodules

- are usually Benign but not all of them are benign

Multinodular

- most likely are benign but not all are benign

- I have patient once when she had her frozen

section biopsy it is multinodular. The surgeon told

the patient it is benign. However doc suggestedfor a total thyroidectomy because she is

suspecting it is cancer since the goiter increased in

size despite the management. When the gross

pathology came out it is positive for papillary

thyroid cancer. The smallest nodule which is corn

size is the one that is cancerous

Moral Lesson:

DONT TELL YOUR PATIENT RIGHT AWAY THAT IT IS

BENIGN BASED ON THE FROZEN SECTION. YOU SHOULD

WAIT FOR A GROSSPATHOLOGY!

Thyroid cancer is more common in men but goiter is

more common in women

Goiter is common in women because of the hormones

that stimulate TSH

History and Physical Examination

- it is hard, tender, hoarseness of voice

- common in iodine deficient area

- sometimes tracheal deviation

- Very strong family history

Total Thyroidectomy is done to confirm the presenceof malignancy

TYPES OF THYROID CANCER

Papillary Thyroid Cancer

- most benign

- The spread is regionalistic lymph node

- If there is recurrence you do node picking

- responsive to thyroid hormone

- Lobectomy, then suppress with hormone or TT +

thyroid hormone replacement

-

Good prognosis

PAPILLARY THYROID CANCER

- most common type of thyroid cancer

- Accounting for 7090% of well-differentiated

thyroid malignancies.

- Microscopic PTC is present in up to 25% of

thyroid glands at autopsy, but most of

these lesions are very small (several millimeters)

and are not clinically

significant

Characteristic cytologic features of PTC help make the

diagnosis by FNA or after surgical resection

- Psammoma bodies

- cleaved nuclei with an orphan-Annie

appearance caused bylarge nucleol

-

formation of papillary structures.- PTC tends to be multifocal and to invade locally

within the thyroid gland as well as through the

thyroid capsule and into adjacent structures in the

neck. It has a propensity to spread via the

lymphatic system but can metastasize

hematogenously as well, particularly to bone and

lung.

Because of the relatively slow growth of the tumor, a

significant burden of pulmonary metastases may

accumulate, sometimes with emarkably few symptoms.

The prognostic implication of lymph node

Harrisons Inernal Medicine 19th

edition

Follicular

- systemic

- responsive to radioactive iodine

-

good prognosis

FOLLICULAR THYROID CANCER

- incidence of FTC varies widely in different parts of

the world; it is more common in iodine-deficient

regions.- accounts for only about 5% of all thyroid cancers

- FTC is difficult to diagnose by FNA because the

distinction between benign and malignant

follicular neoplasms rests largely on evidence of

invasion into vessels, nerves, or adjacent

structures.

- FTC tends to spread by hematogenous routes

leading to bone, lung, and central nervous system

metastases.

- Poor prognostic features

- include distant metastases, age >50 years, primary

tumor size >4 cm, Hrthle cell histology, and thepresence of marked vascular invasion


edition

There is no pure papillary. It can be mixed with

follicular. That is why we need a low dose

radioactive Iodine 30-50

Why total thyroidectomy?


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o Because of what you called multicentric

experience wherein you can have a tumor in

the normal side which cannot be seen by naked

eye or palapte. That means it is microscopic so

we have to remove the other side and do

radioactive iodine therapy. We cant do

Radioactive iodine if there still thyroid gland

left because the RaI will just stay there and not

go to metastatic area

Is there really total thryoidectomy?

o No it is a near total thyroidectomy. No matter

how experienced the surgeon is, you cant

totally remove everything

o You can have hypocalcemia and hoarsness of

voice as complications

Undifferentiated Thyroid Cancer

- common in 60years and above

-

very poor prognosis- live for 1 month

- palliative: NGT, tracheostomy at most 3 mo

- rapid growth 6 month

- debulking in 1 month re appear so better dont

touch it

ANAPLASTIC THYROID CANCER

- poorly differentiated and aggressive cancer

- The prognosis is poor, and most patients

die within 6 months of diagnosis.

- Because of the undifferentiated state of these

tumors, the uptake of radioiodine is usuallynegligible, but it

can be used therapeutically if there is residual

uptake.

- Chemotherapy has been attempted with multiple

agents, including anthracyclines and paclitaxel,

but it is usually ineffective.

- External beam radiation therapy

can be attempted and continued if tumors are

responsive

Harrisons Internal Medicine 19

thedition

Medullary Cancer

- There is no cure

- Do total thyroidectomy the radiation and

chemotherapy

MEDULLARY THYROID CANCER

- can be sporadic or familial

- Accounts for about 5% of thyroid

cancers

- There are three familial forms of MTC: MEN 2A,

MEN 2B,and familial MTC without other features

of MEN

- In general, MTC is more aggressive in MEN 2B

than in MEN 2A, and familial MTC is more

aggressive than sporadic MTC.

- Elevated serum calcitonin provides a marker of

residual or recurrent disease.


edition

Lymphoma

- very poor prognosis

Papillary and Follicular have good prognosis

Medullary and Undifferentiate have poor prognosis

Cancerthryoidectomy, radioactive iodine

LYMPHOMA

-

often arises in the background of Hashimotosthyroiditis.

- A rapidly expanding thyroid mass suggests the

possibility of this diagnosis.

- Diffuse large-cell lymphoma is the most common

type in the thyroid.

- Biopsies reveal sheets of lymphoid cells that can

be difficult to distinguish from small-cell

lung cancer or ATC.

- These tumors are often highly sensitive to

external radiation.

- Surgical resection should be avoided as initial

therapy because it may spread disease that isotherwise localized to the thyroid.

- If staging indicates disease outside of the thyroid,

treatment should follow guidelines used for other

forms of lymphoma


edition

PLUMMERS NODULE/ TOXIC ADENOMA

sometimes patient dont become euthyroid right

away they can become hypothyroid. From toxic

to euthyroid then to hypothyroid

- The background is light

- The iodineuptake is in

thenodule


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TOXIC ADENOMA

- A solitary, autonomously functioning thyroid

nodule

- Thyrotoxicosis is usually mild

- The disorder is suggested by a subnormal TSH level;

the presence of the thyroid nodule, which is

generally large enough to be palpable; and the

absence of clinical features suggestive of Graves

disease or other causes of thyrotoxicosis.- A thyroid scan provides a definitive diagnostic test,

demonstrating focal uptake in the hyperfunctioning

nodule and diminished uptake in the remainder of

the gland, as activity of the normal thyroid is

suppressed


edition

NONTOXIC MULTINODULAR GOITER

NONTOXIC MULTINODULAR GOITER

- The thyroid architecture is distorted, and

multiple nodules of varying size can be

appreciated.

- Because many nodules are deeply embedded in

thyroid tissue or reside in posterior or substernal

locations, it is not possible to palpate all nodules


edition

COMPLICATIONS OF THYROIDECTOMY

- Bleeding

- Disappearance of voice

- Hypocalcemia

LALUMA LAMPREA LUCES MOLINA

b17m03l08 Thyroid Nodules

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