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Anatomy
Embriology
Originates from foramen ceacum at the base of the tongue and descends into the neck, anterior to the hyoid bone, in front of the trachea. The tract left behind ( thyreoglossal tract) may persist and form a cyst (thyreoglossal cyst) The cyst may form a cutaneous fistula (thyreoglossal fistula)
Thyreoglossal cyst
Inflammation
Thyroiditis
Acute illness with pain
Infectious
Acute (Suppurative) Chronic
Autoimmune
Hashimoto (lymphocytic) thyroiditis
HASHIMOTO THYROIDITIS
Most common cause of hypothyroidism Autoimmune, non-Mendelian inheritance 45-65 years, F:M = 10-20:1 Painless symmetrical enlargement (minimally or moderately enlarged firm gland) 20% of patients present with hypothyroidism, and 5% present with hyperthyroidism (hashitoxicosis). Risk of developing
B-cell non-Hodgkins lymphoma Other concomitant autoimmune diseases
Endocrine and non-endocrine
Hashimoto Thyroiditis
Diffuse enlargement Firm or rubbery Pale, yellow-tan, firm & somewhat nodular cut surface
Hashimoto Thyroiditis
Massive lymphoplasmcytic infiltration with lymphoid follicles formation Destruction of thyroid follicles Remaining follicles are small and many are lined by Hurthle cells Increased interstitial connective tissue
Riedel's Thyroiditis
Riedel's struma or invasive fibrous thyroiditis
predominates in women between the ages of 30 and 60 years replacement of all or part of the thyroid parenchyma by fibrous tissue, which also invades into adjacent tissues "woody" thyroid gland with fixation to surrounding tissues associated with other focal sclerosing syndromes, including mediastinal, retroperitoneal, periorbital, and retro-orbital fibrosis, and sclerosing cholangitis, suggesting that it may in fact be a primary fibrotic disorder.
Functional Abnormality
Hyperfunction
in level of hormone toxic effects
Due to:
Diffuse hyperplasia Hyperfunctioning multinodular goiter Hyperfunctioning adenoma Subacute lymphocytic thyroiditis
Functional Abnormality
Hypofunction
in level of hormone impair development in infants and slowing of physical and mental ability in adults Due to: Postablation Surgery Radiation Autoimmune thyroiditis Drugs Dyshormonogenetic
Graves Disease
Most common cause of endogenous hyperthyroidism Autoimmune disease with genetic susceptibility associated with HLA-B8 and DR3 Female:Male = 5:1 Peak incidence between the ages 40 and 60 years Characterized by hyperthyroidism, symptoms of increased adrenergic stimulation include palpitations, nervousness, fatigue, emotional lability, hyperkinesis, and tremors Diffuse enlargement with audible bruit Ophthalmopathy with exophthalmos: Wide,staring gaze (fixed look) Lid lag, (von Graefe's sign) Spasm of the upper eyelid revealing the sclera above the corneoscleral limbus (Dalrymple's sign)
levels of free T4 & T3 and levels of TSH in blood uptake of radioactive iodine
Graves Disease
Graves Disease
Graves Disease
Graves Disease
Autoimmune disease with breakdown of helper-T-cell tolerance
Excessive production of TWO thyroid autoantibodies: 1) Thyroid-stimulating antibody (TSAb) & 2) Growth-stimulating antibody (GSAb)
Antibodies bind to the TSH receptor of the follicular cell Stimulation of the cell resulting in: Increased levels of thyroid hormones & Hyperplasia of the thyroid gland Hyperthyroidism and Thyroid gland enlargement
Graves Disease
Symmetrical enlargement of thyroid gland Cut-surface is homogenous, soft and appear meaty Hyperplasia and hypertrophy of follicular cells
Endemic Goiter
Low iodine content in drinking water & food (Himalayas, Alps, Andes, areas far from the sea) Prevalence decreasing due to prophylactic iodination of salt Iodine deficiency causes decreased hormone levels & consequent elevation in TSH
Sporadic Goiter
Commonest type of goiter Euthyroid, but may be hypo- or hyper Mostly idiopathic, but RARELY, may be caused by:
Drugs used in Rx of hyperthyroidism Goitrogens e.g. cauliflower, cabbage, cassava Suboptimal iodine intake Hereditary enzymatic defects
Multinodular goiter
Recurrent episodes of hyperplasia and involution leads to irregular enlargement All long standing diffuse endemic and sporadic goiter may eventually convert to multinodular goiter Causes most extreme enlargement and may be mistaken for neoplasm May arise due to variable response of follicular cells to external stimuli such as trophic hormones With uneven follicular hyperplasia, generation of new follicles and uneven accumulation of colloid rupture of follicle and vessels hemorrhage, scarring & calcification nodularity
Multinodular Goiter
Asymmetric enlargement Multinodular Haemorrhage Calcification Fibrosis Cystic degeneration
Multinodular Goiter
Multinodular Goiter
Numerous follicles varying in size Recent haemorrhage Haemosiderin Calcification Cystic degeneration +/- dominant nodule
Multinodular Goiter
Multinodular Goiter
Thyroid Neoplasms
I. Primary Tumours
Epithelial Malignant Lymphomas Mesenchymal tumours
II.
Metastatic Tumours
Malignant (carcinomas)
Follicular carcinoma (10-20%) Papillary carcinoma (75-85%) Undifferentiated (anaplastic) carcinoma (<5%)
Tumours of C-cells
Medullary thyroid carcinoma (MTC - 5%)
Follicular Adenoma
Benign, encapsulated tumor showing evidence of follicular differentiation Common Predominantly young to middle women Presents as solitary thyroid nodule Painless nodular mass, cold on isotopic scan
Follicular Adenoma
Solitary, Variably sized, encapsulated, wellcircumscribed with homogenous graywhite to red-brown cut-surface +/- degenerative changes
Follicular Carcinoma
Second most common form, 10-20% Females > Males, average age ~ 45 - 55 yr Rare in children Solitary nodule, painless, cold on isotopic scan Widely invasive Vs minimaly invasive 50% 10 yr survival Vs 90%10 yr survival Haematogenous route is preferred mode of spread
Follicular Carcinoma
Solitary round or oval nodule Thick capsule Composed of follicles Capsular invasion or vascular invasion within our outside capsular wall
Papillary Carcinoma
Commonest thyroid malignancy, 75-85% Female:Male = 2.5:1 Mean age at onset = 20 - 40 yr May affect children Prior head & neck radiation exposure Indolent, slow-growing painless mass cold on isotopic scan Cervical lymphadenopathy may be presenting feature
Papillary Carcinoma
Variable size (microscopic to several cm) Solid or cystic Infiltrative or encapsulated Solitary or multicentric (20%)
Papillary Carcinoma
Papillae or follicles Psammoma bodies NUCLEAR FEATURES***
Papillary Carcinoma
Nuclear Features
Optically clear (ground glass, Orphan Annie) nuclei Nuclear pseudoinclusions or nuclear grooves
Anaplastic Carcinoma
Rare; < 5% of thyroid carcinomas Highly malignant and generally fatal < 1yr. Elderly 65 yrs; females slightly > males Rapidly enlarging bulky neck mass Dysphagia, dyspnoea, hoarseness
Anaplastic Carcinoma
Large, firm, necrotic mass Frequently replaces entire thyroid gland Extends into adjacent soft tissue, trachea and oesophagus Highly anaplastic cell on histology with:
Giant, spindle,small or mix cell population
Anaplastic Carcinoma
Cellular pleomorphism +/- multinucleated giant cells High mitotic activity Necrosis
Anaplastic
Worst prognosis
Secondary Tumours
Direct extensions from: larynx, pharynx, oesophagus etc. Metastasis from: renal cell carcinoma, large intestinal carcinoma, malignant melanoma, lung carcinoma, breast carcinoma etc.