2. outline
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2
ď‚— Thyroid anatomy
ď‚— Thyroid physiology
ď‚— Evaluation of patients with thyroid diseases
ď‚— Management of simple goiters
ď‚— Management of toxic goiters
ď‚— References
3. Thyroid anatomy
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ď‚— two lobes connected by an isthmus
ď‚— 20 grams
ď‚— posterior to strap muscles in the anterior neck
ď‚— lobules that contain 20 to 40 follicles each
ď‚— 3 million follicles exist in the adult male
5. Thyroid physiology
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ď‚— Thyroid hormone synthesis
ď‚— Iodide trapping
ď‚— Oxidation of iodide & iodination of tyrosine by
thyroid peroxidase
ď‚— Coupling of MIT and DIT to form T4 and T3
ď‚— Hydrolysis of thyroglobulin to release free T3 and T4
7. Thyroid physiology cont…
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ď‚— All of T4 is produced in the thyroid while only 20%
of T3.
ď‚— T3&T4 are transported bound TBG,TBPA and TBA
 Hypothalamo – pituitary – thyroid axis controls
secretion
9. Effects of thyroid hormones
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ď‚— Affects almost every system in the body
ď‚— Fetal brain &skeletal development
ď‚— Increase O2 consumption,BMR& heat production
ď‚— Positive inotropic and chronotropic on heart
ď‚— Increased GI motility,etc.
10. Evaluation of patients with thyroid
disease
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ď‚— TFT
 Serum TSH – most sensitive test for
diagnosis of hypo and hyperthyroidism
ď‚— Free T3&T4- for diagnosis of early
hyperthyroidism
ď‚— Total T3&T4-are not good for screening,
can be affected by factors other than
thyroid function
ď‚—Calcitonin
11. Evaluation cont…
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ď‚— TRH test-to asses pituitary TSH
secretion
ď‚— Thyroid antibodies(anti Tg,anti TPO and
TSI)
ď‚— elevated in autoimmune thyroid
d.(Graves d/Hashimoto’s thyroiditis)
Don’t indicate thyroid function
ď‚— Serum thyroglobulin
ď‚— for monitoring recurrent/metastatic
thyroid ca.
12. Evaluation cont…
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ď‚— Thyroid imaging
ď‚— Radionuclide imaging
ď‚— Size, shape & function of gland assessed
 Increased uptake=“hot", less risk of
malignancy,<5%
 Decreased uptake=“cold" higher risk of
malignancy (15-20%)
ď‚— Ultrasound
ď‚— CT/ MRI good for assessment of
retrosternal extension
14. Evaluation cont…
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ď‚— FNAC
ď‚—The best investigative modality for
detecting malignancy
ď‚—When guided by ultrasound has high
sensitivity and specificity
ď‚—Reduced thyroidectomies by 50%
ď‚— Biopsy
16. Simple goiters cont…
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ď‚— Race = no racial predilection
ď‚— Sex= female to male ratio 4:1
ď‚— Spectrum of illness
ď‚—Diffuse
ď‚—Uninodular(Solitary Nodule)
ď‚—Multinodular
ď‚—Cystic enlargement
17. Diagnosis
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ď‚— Most are asymptomatic
ď‚— If symptomatic
ď‚—Neck mass
ď‚—Compression symptoms mainly in
intrathoracic extension
ď‚—Hoarseness of voice
ď‚— FNAC is important to exclude
malignancy
18. Treatment of simple goiters
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I. Multinodular goiters
ď‚— no ideal treatment
ď‚—Options are
A. Iodine supplementation-not
effective on nodular goiter,
abandoned
B.L thyroxine suppression therapy
15 – 40 % reduction in size in 3
months
ď‚— More effective on small diffuse
goiters
19. Treatment cont…
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C . Surgery
ď‚—The preferred modality
ď‚—Indicated for:
-large goiters with compression
symptoms, -in suspicion of
malignancy &
-cosmosis
ď‚—Advantages
ď‚— Significant goiter reduction with prompt relief of
symptoms
ď‚— Definitive tissue diagnosis
20. Treatment cont…
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ď‚—Disadvantages
ď‚— Many complications
 Recurrence in 15 – 40%
ď‚— Long term risk of
hypothyroidism(10-20%)
D.Radioiodine therapy(I131)
ď‚—Not effective in larger goiters, with
higher recurrence
ď‚—40- 60% reduction in size in 1 to 2
years
ď‚—Small Goiters:-Recurrence is low(8%
21. Management of goiters,sep.2010
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II.Solitary nodule
A.Small sized(1-1.5 cm) no treatment,
followed regularly with FNAC(3-6% risk of
malignancy)
B.Solitary cold nodule
 T4 therapy – helps to shrink the nodule
ď‚— Surgery( lobectomy or isthmusectomy)
ď‚— In malignant or suspicious cytology
ď‚— Cosmetic
ď‚— Pressure symptoms
ď‚— Percutaneous ethanol injection therapy
Treatment cont…
22. Treatment cont…
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III. Solitary cyst –accounts for 15-25% of
thyroid nodules
ď‚— FNAC needed always to exclude
malignancy
ď‚— If small (<2-3cm) and benign should be left
untreated
 If large(>2-3cm) – aspiration is effective
 Surgery –in suspicious or non diagnostic
cytology & recurrence after aspiration
 PEIT – good success(61-95% reduction in
size)
24. Toxic goiters cont…
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I . Grave’s disease
ď‚—Most common cause of
hyperthyroidism
ď‚—Prevalence of 3per 1000 in the USA
ď‚—an autoimmune disease of unknown
etiology
ď‚—M:F ratio 1:5 and peak age of 20 - 40
years
ď‚—Mediated by thyroid stimulating
antibodies
ď‚—The gland is diffusely & smoothly
25. Toxic goiters (Grave’s) cont…
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ď‚— Clinical presentations
ď‚— Triad:-
Goiter,thyrotoxicosis,exophthalmos
ď‚—Symptoms and signs of increased
thyroid hormone activity
ď‚—Some specific manifestations
ď‚—Graves ophtalmopaty (50%)
ď‚—Dermopathy (1-2%)
ď‚—Acropathy
ď‚—Gynecomastia in men
26. Toxic goiters (Grave’s) cont…
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ď‚— Diagnosis
ď‚—Decreased TSH
with or without
increased free
T3&T4
ď‚—Diffuse increase
in RAI uptake
ď‚—Increased
TsAb,TSH
receptor Ab
27. Toxic goiters (Grave’s) cont…
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 Treatment –focuses on hyperthyroidism,
not the autoimmunity
ď‚—Antithyroid drugs
ď‚— radioiodine ablation
ď‚—Surgery
ď‚— Choice depends on
ď‚—Age, previous therapy,cost,size of
goiter,asscociated
ophtalmopathy,availability,patients
preference etc…
28. Toxic goiters (Grave’s) cont…
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A . Antithyroid drugs
ď‚—PTU and methimazole are used
ď‚—Both act by inhibiting thyroid
peroxidase enzyme
ď‚—First line treatment in children,
adolescents
ď‚—In preparation for radiotherapy and
surgery
29. Toxic goiters (Grave’s) cont…
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ď‚—Disadvantages
ď‚—Both cross the placenta
ď‚—Side effects e.g. agranulocytosis
ď‚—Associated with high relapse rate(40-
80% in 2 years)
ď‚—Most patients improve in 2 weeks
,become euthyroid in 6 weeks
 β blockers can be used together
30. Toxic goiters (Grave’s) cont…
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B . Radioiodine therapy (I 131)
ď‚— Is the mainstay of therapy in the developed
world
ď‚— Advantages
 Avoidance of surgery and it’s risks
ď‚— Reduced cost and ease of treatment
ď‚— Disadvantages
ď‚— High chance of hypothyroidism(70% at 11
years)
ď‚— Progression of ophtalmopathy (33%)
ď‚— Fetal damage
31. Toxic goiters (Grave’s) cont…
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ď‚—Indications
ď‚—Older patients with small or moderate
sized goiters
ď‚—Relapse after medical or surgical
treatment
ď‚—Patients with contraindication for
drugs and surgery
ď‚—Contraindications
ď‚—Pregnancy and breast feeding
ď‚—Young patients
ď‚—Patients with ophtalmopathy
32. Toxic goiters (Grave’s) cont…
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C . Surgery
ď‚—Goal is complete and permanent
control
ď‚—Indications
ď‚—Young patients
ď‚—Patients with cancer or suspicious
nodule
ď‚—Allergy to antithyroid drugs
ď‚—Large goiters
ď‚—Pregnant and those with desire to
conceive soon
33. Toxic goiters (Grave’s) cont…
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ď‚— Preoperatively
ď‚—Patient should be rendered euthyroid
Lugol’s iodine (for 10 days,3 drops
BID) to decease vascularity of the
gland
ď‚— Extent of surgery
ď‚—Depend on desired outcome
(recurrence vs. euthyroidism) and
surgeons experience
34. Toxic goiters (Grave’s) cont…
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ď‚— Options
ď‚—Total or near total thyroidectomy
ď‚—Coexisting cancer
ď‚—Refusal to RAI
ď‚—Severe ophtalmopathy
ď‚—Severe reaction to drugs
ď‚—Subtotal thyroidectomy
ď‚—For all the remaining patients
35. Toxic goiters (Grave’s) cont…
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ď‚— If recurrence occurs =RAI
ď‚— Patients need long term follow up with
yearly TSH measurement
36. Toxic goiters cont…
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II.Toxic MNG
ď‚—Has slow onset and subtle symptoms,
with no extra thyroidal manifestations
ď‚—Usually in older age(>50 years) ,with
previous non toxic MNG, because of
autonomous nodules
ď‚—Diagnosis =similar to graves
ď‚—RAI-multiple nodules with increased
uptake
37. Scan in a patient with a toxic
multinodular goiter
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38. Toxic goiters (TMNG) cont…
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ď‚— Treatment
ď‚—Surgery (subtotal thyroidectomy)
ď‚—Is the preferred mode of treatment
ď‚—RAI
ď‚—Larger doses are needed
ď‚—High recurrence rate
ď‚—Only for elderly poor operative risks
ď‚—Provided no cancer or airway
compression exists
39. Toxic goiters (TMNG) cont…
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ď‚—Antithyroid drugs
ď‚—As preparation for surgery or
radiotherapy
ď‚—Not effective as long term therapy
ď‚—High recurrence rate
40. Toxic goiters cont…
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III.Toxic adenoma (Plummer's disease)
ď‚—Is hyperthyroidism from a single hyper-
functioning nodule( at least 3 cm
diameter )
ď‚—Mainly in young patients
ď‚—Thyrotoxicosis is usually mild
ď‚—Diagnosis
ď‚—Palpable nodule and symptoms of
thyrotoxicosis
ď‚—RAI = hot nodule
41. Iodine (I 123) scan in a patient with a
palpable nodule
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42. Toxic goiters cont…
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ď‚— Treatment
ď‚—Antithyroid drugs as preparation for
RAI or surgery
ď‚—RAI effective for small nodules
ď‚—Surgery( lobectomy and
isthmusectomy)
ď‚—Good for larger nodules
ď‚—PEIT (ethanol injection)
44. References
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ď‚— Stephanie L Lee, e medicine, July 2006
ď‚— John L Floyd ,e medicine, march 2006
 Schwartz’s ,principles of surgery,8th ed,2005
ď‚— Laszlo Hegedus ,NEJM.2004;351;1764-1771
ď‚— Laszlo Hegedus et al,Endocrine
reviews.2003; 24(1):102-132
ď‚— Ad R.Hermus,NEJM.1998,338;1438-1447