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24 Cards in this Set
- Front
- Back
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Arterial pressure diseases |
Graves’ disease or thyrotoxicosis= differential pressure Thyrotoxicosis= tachyarythmia Hypothyroidism= bradycardia Exophthalmos could be observed in any condition of thyrotoxicosis |
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Thyroid nodules |
Very frequent in general population Palpable ones are larger than 1cm Prevalence depends on diagnostic method Incidentalomas: nodules observed incidentally without any clinical signs/symptoms (most frequent thyroid nodules) 5% are malignant, 95% benign |
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Diagnostic work-up for thyroid nodules |
1. Thyroid hormonal evaluation: TSH, fT4= some conditions of thyrotoxicosis are caused by Plummer adenoma and hyper-functioning nodule 2. Calcitonin levels: biochemical marker of a specific type of thyroid neoplasms (medullary thyroid carcinoma) 3. Anti-TPO and anti-TG antibodies = check if concomitant thyroiditis in patients with Hashimoto thyroiditis there is a lower risk of developing thyroid nodules 4. Thyroid US= anatomic and morphological evaluation |
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Signs of malignancy in thyroid neoplasm nodules |
Increased diameter Absence of halo sign (benign sign if absent=suspected malignancy) Internal Vascularization Fine calcifications Margins ill-defined Hypeecogenecity |
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US suspicions of malignancy |
1. Very low suspicion 3% : spongey form, cystic (fluids), mixed colloidic nodules 2. Low suspicion 5-10% : isoecocic or hyper ecoic solid nodules, or mixes solid cystic nodules, with well defined margins, no fine calcifications 3. Intermediate suspicion 10-20% : hypoecoic solid nodules, with well defined margins and without fine calcifications 4. High suspicion 70-90% : hypoecocic solid nodules, ill-defined margins and/or fine calcification and/or capsule involvement |
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Thyroid scintigraphy |
Thyroid gland increased in size, dysmorphic due to dimensional prevalence of left lobe Uptake of tracer appears altered due to presence of area of relative hypo-uptakes in the lower third of left lobe Cold presentation at scintigraphy=malignancy |
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Fine needle aspiration cytology/ biopsy |
Characteristics to take into account: diameter and US nodule assessment Nodules more than 2cm: low suspicion on US Nodules more than 1,5cm: suspected low US Nodules more than 1cm: intermediate Nodule between 0,5 and 1 cm: high US suspicion Cytology gives only a % of the malignancy for the malignancy Definitive diagnosis of thyroid carcinoma is possible only with histological classification |
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Red flags for thyroid carcinoma |
Age more than 20 or more than 70: usually thyroid nodules are Moore frequent in older patients, the risk of thyroid carcinoma increases with age Male gender: thyroid nodules are more frequent in women Familiarity for neoplasm Compression signs and symptoms: cough, dysphasia, dysphonia Lymphadenopathies History of radiation therapy after neck radiation exposure: radiation therapy is a risk factor for increased risk of recurrence of thyroid carcinoma Fixed, hard, fast growing mass: usually thyroid nodules are completely asymptomatic |
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Thyroid neoplasms |
One of most frequent in general population Most common neoplasm of endocrine system Increased with age, plateau around 50 More common in females Increasing incidence in recent decades Increasing diagnoses Increasing risk factors (radiation exposure) In most cases tumors have good prognosis Thyroid neoplasms are defined as indolent tumors (type of slow growing cancer) Most frequent type is papillary carcinomas= 50-60% of thyroid carcinomas Most frequent neoplasms are with better prognosis |
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Follicular epithelium derivatives (90% of thyroid tumors excellent prognosis) |
Papillary carcinoma Follicular carcinoma Poorly differentiated: follicular variants, papillary variants, hurtle cell carcinoma |
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Undifferentiated (poor prognosis) |
Anaplastic carcinoma Medullary carcinoma |
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Non-epithelial tumors |
Primary thyroid lymphomas, sarcomas Metastasis |
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Follicular carcinoma second moist frequent (20-30%) |
Elderly patients 10 years survival: 70% Tendency to invade blood vessels= prod single distant metastasis Variants: Hurtle cell (oncocyte increased aggressiveness) Intervention needed |
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Medullary carcinoma |
5% thyroid neoplasms (undifferentiated form) Sporadic 80% cases Or hereditary in 20% cases (young patients) 5 years survival 50-70% Development from parafollicular cells or neuroendocrine C cells or thyroid Physiologically these cells produce calcitonin, that can be used as a biological marker Familial MEN2A and MEN2B syndromes: protooncogenic RET mutation, AD-transmission (autosomal dominant) THERE IS ANOTHER FORM MAN1 THAT DOESN’T PRESENT THIS MEDULLARY CARCINOMA |
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Ana-plastic carcinoma |
Worst, rare, thyroid neoplasm Undifferentiated, poor diagnoses, death 6 moths Characterized by a growing mass and invasion or surrounding structures, effects elderly Can be a transformation of papillary carcinoma or primary carcinoma, aggressive, rapid growth, possible but uncertain transformation form differentiated tumors |
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Lymphomas and metastasis |
Primary thyroid lymphoma Aggressive, rapid growing, non-movable tumor mass, Hashimoto thyroiditis is a possible risk factor Secondary lymphomas NHL, B cell lymphomas Metastasis from other primary tumors, mainly kidney and pulmonary (rare breast) |
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Treatment of thyroid nodules |
Thyroid surgery Hyper function nodule: first line treatment for Plummer/hyperfunctioning/toxic/autonomous adenoma is the surgical removal High risk nodules for malignancies and thyroid carcinoma Large diameter that can lead to compressive symptoms |
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Hemithyroidectomy |
Surgical removal of half of thyroid gland one lobe Patient affected by a single hyper-functioning lobule Low risk for thyroid carcinoma Very small thyroid carcinoma |
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Total thyroidectomy |
Performed in most patients with thyroid carcinoma Can be performed in addition to lymph node dissection Possible complications: -post-op hemorrhages and hematomas 0,5-2% -Transient 10-20% and permanent 2-3% hypoparathyroidism -Transient 7-10% and permanent 1,5-3% dysphonia (the nerve related is recurrent laryngeal nerve) The risk higher in total thyroidectomy |
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Risk assessment and relapses after surgical treatment of thyroid carcinoma |
In young patients less that 55 excellent prognosis In older patients prognosis depends on size of tumor and presence/ absence of lymph node metastasis and distant lesions Low risk: -small tumors, unifocal, no capsule or blood vessels invasion Intermediate risk: multi focal tumors, aggressive histology, foci of extra-thyroid extension lymph node involvement High risk: macroscopic extra thyroidal extension, incomplete tumor resection, distant metastasis |
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Adjuvant treatment after surgical treatment of thyroid carcinoma |
Radio-iodine treatment (RAI) with I131: administer iodine with cytotoxic agent=destroy any possible thyroid tissue residue. Should be considered in intermediate risk patients, recommended in high risk patients Suppression therapy with levotyroxine: treatment with high does of LT4 thyroid hormone =thyrotoxicosis and reduced and suppressed TSH levels and synthesis = reduction of potential TSH stimulation effect on residual thyroid cells to avoid proliferative effects Suppression therapy has Lowe effect in reducing risk of recurrence/relapse Targets TSH more than 0,1-0,5% mU/L |
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Patient risk classification therapy assessment |
High risk: radio-metabolic therapy then suppression Medium-low risk: only suppression therapy Very low risk: suppression therapy + replacement therapy |
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Replace my therapy of hypothyroidism |
Levothyroxine (eutirox)= method of intake: once a day in morning, fasting, waiting at lest 30-40min before breakfast or coffee Take into account potentially interfering drug therapy (PPI) BEFORE STARTING THERAPY IN AUTOIMMUNE/ OR CENTRAL FORMS IN THE SUSPICION OF ADRENAL INSUFFICIENCY MEASURE CORTISOLEMIA |
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Follow-ups after thyroid carcinomas surgery |
- yearly US of neck to evaluate possible appearance of local recurrences -6 month TSH reflex -calcitonin dosage used for medullary carcinomas -TG after total thyroidectomy= marker of recurrence -TG produced in thyroid and not secondarily secreted -TG increases in patients with total thyroidectomy -TG can bad in circulation in normal individuals but more often in patients with autoimmune disorders. It could be increased in patients affected by thyroiditis |
