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BENIGN THYROID DISORDERS

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Title: BENIGN THYROID DISORDERS


1
BENIGN THYROID DISORDERS
  • Regional SpR Teaching
  • Woo-Young Yang
  • ST5

2
CLASSIFICATION
  • Simple Non-Toxic
  • Toxic
  • Inflammatory
  • Neoplastic
  • Rare

3
CLASSIFICATION
  • Simple Non-Toxic
  • Iodine Difficiency
  • Multinodular Goitre
  • Solitary Nodule
  • Physiological
  • Toxic
  • Graves Disease
  • Plummers Disease
  • Inflammatory
  • Hashimotos Thyroiditis
  • De Quervains Thyroiditis
  • Riedels Thyroiditis
  • Neoplastic
  • Follicular
  • Papillary
  • Medullary
  • Anaplastic
  • Lymphoma
  • Metastatic
  • Rare
  • Infective
  • Iatrogenic

4
IODINE DIFFICIENCY
  • Epidemiology
  • Commonest cause of goitre and hypothyroidism
    world wide
  • Not common in the western world
  • Pathophysiology
  • Insufficient iodination of thyroglobulin
  • Decrease in Thyroid Hormone
  • Increase in TSH
  • Diffuse hyperplasia(/- multinodular appearance)
  • Pregnancy
  • Increased demand on maternal iodine
  • Worsening features with subsequent pregnancies
  • Treatment
  • Iodine Replacement

5
EUTHYROID MNG
  • Epidemiology
  • Incidence by Palpation 10
  • Incidence by Imaging up to 50
  • Aetiology
  • Benign
  • Colloid cyst
  • Simple cyst
  • Adenoma
  • Infection
  • Malignant

6
INVESTIGATIONS
  • Serological
  • TFT
  • Serum Calcitonin?
  • FNAC
  • USS ((useful in looking for malignant features
    such as microcalcification and capsular
    invasion/increased vascularity))
  • CT/MRI for retrosternal component
  • Tc99/I123 Scintigraphy NOT useful in MNG/SN
    ((BTA and ATA, incidence of cancer 10 in cold
    nodules))

7
TREATMENT
  • Surgery
  • Cosmetic
  • Compressive symptom
  • Suspicion for cancer
  • Radioiodine
  • Indicated if unfit for surgery
  • Regression of the goitre size

8
SOLITARY NODULES
  • Mx is broadly similar to MNG
  • Cystic nodules
  • Many resolve spontaneously
  • Larger cysts tend to recur
  • Treatment
  • Simple aspiration and expectant approach with
    small cysts(lt3ml)
  • Surgery for the larger ones(10 cancer risk)

9
CLASSIFICATION
  • Simple Non-Toxic
  • Iodine Difficiency
  • Multinodular Goitre
  • Solitary Nodule
  • Physiological
  • Toxic
  • Graves Disease
  • Plummers Disease
  • Inflammatory
  • Hashimotos Thyroiditis
  • De Quervains Thyroiditis
  • Riedels Thyroiditis
  • Neoplastic
  • Follicular
  • Papillary
  • Medullary
  • Anaplastic
  • Lymphoma
  • Rare
  • Infective
  • Iatrogenic

10
HYPERTHYROIDISM CLINICAL FEATURES
  • Cardiac
  • Tachycardia, AF
  • High output congestive heart failure
  • Thermoregulatory
  • Heat intolerance
  • Metabolic
  • Weight loss
  • Increased appetite
  • GI
  • Diarrhoea
  • Neuopsychiatric
  • Irritability
  • Anxiety
  • Dermatological
  • Hair loss and brittle nails
  • Hormonal
  • Irregular menstruation
  • Misc
  • Fine tremor
  • Thyroid bruit

11
HYPOTHYROIDISM CLINICAL FEATURES
  • Cardiac
  • Bradycardia
  • Thermoregulatory
  • Cold intolerance
  • Metabolic
  • Weight gain
  • Decreased appetite
  • Glucose intolerance
  • GI
  • Constipation
  • Neuopsychiatric
  • Depression
  • Mental impairment
  • Dermatological
  • Dry skin
  • Myxoedema
  • Hormonal
  • Irregular menstruation
  • Misc
  • Hoarseness

12
GRAVES DISEASE
  • Epidemiology
  • Commonest cause of hyperthyroidism(60)
  • UK incidence 80/100,000
  • Pathophysiology
  • Autoantibodies against TSH receptor
  • Stimulation of thyroid gland hyperplasia
  • Autonomous production of T3 and T4
  • Association with other organ-specific autoimmune
    diseases
  • Pernicious anaemia, DM, Addison Disease,
    Myesthenia Gravis
  • HLA-DR3, B8

13
GRAVES DISEASE CLINICAL PRESENTATION
  • Thyroid Manifestations
  • Diffuse symmetrical goitre /- bruits
  • Hyperthyroidism
  • Extrathyroid Manifestations
  • Acropachy
  • Myxoedema
  • Graves ophthalmopathy

14
GRAVES OPHTHALMOPATHY
  • Pathophysiology
  • Lymphocytic infiltration and glycosaminoglycan
    deposition
  • Extraocular muscle swelling
  • Periorbital fat proliferation

15
GRAVES OPHTHALMOPATHY
  • Clinical Features
  • Proptosis greater than 22 mm
  • Lid retraction and lid lag
  • Conjunctival oedema and corneal ulceration
  • Oculomotor problem
  • Decreasing visual acuity
  • Rx options
  • High dose steroids
  • Radiotherapy
  • Surgical alignment/decompression

16
TOXIC MULTINODULAR GOITRE
  • Epidemiology
  • Commonly found in the elderly
  • Pathophysiology
  • Jod-Baselow Phenomenon ((exact mechanism is
    obscure. Background iodine deficiency, followed
    by iodine Xs, leading to unmasking
    hyperthyroidism. Normal follicular architecture
    becomes disrupted, leading to inefficient iodine
    trapping))
  • T3 toxicosis subclinical hyperthyroidism
    ((importance of T3 measurement))

17
TOXIC ADENOMA
  • Plummers Disease
  • Epidemiology
  • Rare 2 of hyperthyroidism
  • Younger than Toxic MNG
  • Pathophysiology
  • Somatic, non-inherited TSH receptor mutation
  • Autonomous TSHR activation and

18
TOXIC GOITRE - INVESTIGATIONS
  • TFT
  • Thyroid Autoantibodies
  • TPO ((actually the most senstive marker of
    graves disease 45 for TSH R))
  • Thyroglobulin
  • TSH receptor
  • Scintigraphy
  • Distinction between toxic nodule and Graves
    disease

19
TOXIC GOITRE - TREATMENT
  • Difference between Graves disease and Toxic
    MNG/Adenoma
  • Graves disease may go into remission(30)
  • Toxic MNG/Adenoma does not go into remission
  • Treatment Options
  • Antithyroid Drugs
  • Radioiodine
  • Surgery

20
ANTITHYROID DRUGS
  • Thionamides
  • Carbimazole, Methimazole, Popylthiouracile(PTU)
  • Pharmacophysiology
  • Inhibition of the organification and oxidation of
    iodine
  • T4/T3 synthesis inhibition
  • ? Immunomodulation effect for Graves disease?
  • Side effects
  • Deranged LFT - rarely drug-induced hepatitis
  • Agranulocytosis(1/1,000)

21
OTHER DRUGS
  • Beta-blocker
  • Propranolol
  • Anticoagulants
  • AF management

22
RADIOIODINE 131
  • First treatment of choice for Graves Disease and
    MNG
  • PO administration
  • Pharmacophysiology
  • Beta radiation DNA damage and apoptosis
  • (different from I 123, which emits gamma rays)
  • Dose
  • ? Titration
  • 400 600 MBq sufficient for both Graves and
    Toxic MNG

23
RADIOIODINE 131
  • Side effect
  • Hypothyroidism
  • Thyroiditis
  • Safety?
  • Outpatient treatment
  • Avoid contact with children ((sleep alone/no
    sharing utensils))
  • Contraindication
  • Pregnancy
  • Breast feeding

24
TOXIC GOITRE - SURGERY
  • Indications
  • Refractory to radioiodine
  • Patients rejection of radioiodine
  • Severe ophthalmopathy
  • Pregnancy with uncontrolled disease
  • Cosmetic
  • Pre-op Preparation
  • Antithyroid treatment
  • Potassium Iodide if antithyroid drug not
    tolerated ((saturates the thyroid with iodine,
    then the gland turns off the absorption
    mechanism))

25
TOXIC GOITRE - SURGERY
  • Graves Disease
  • Total thyroidectomy
  • Toxic Adenoma
  • Thyroid Lobectomy
  • Toxic SMG
  • ? Subtotal thyroidectomy

26
HYPERTHYROIDISM IN PREGNANCY
  • Graves Disease
  • Thionamides are safe in pregnancy
  • PTU is preferred as less drug is delivered to
    foetus
  • Intra-partum Transient Hyperthyroidism of
    hyperemesis gravidarum ((betaHCG and TSH share
    the same subunit))
  • Post-partum Thyroiditis ((distinction by autoAb,
    clinical signs, iodine uptake(postpartum)))

27
INFLAMMATORY GOITRES - HASHIMOTOS THYROIDITIS
  • Anti-TPO/Thyroglobulin/TSHR autoAb
  • Initial transient hyperthyroidism due to cellular
    destruction and release of the preformed thyroid
    hormones
  • Subsequent hypothyroidism
  • Rubbery diffuse thyroid enlargement
  • Treatment
  • Thyroid replacement
  • Surgery if necessary

28
INFAMMATORY GOITRES DE QUERVAINS SUBACUTE
THYROIDITIS
  • Granulomatous inflammation of the thyroid gland ?
    2y to viral infection
  • Subacute course over weeks/months
  • Tender symmetrical diffusely enlarged goitre
  • Phases
  • hyperthyroid hypothyroid euthyroid(recovery)
  • Treatment
  • Thyroid status control
  • NSAIDs

29
INFLAMMATORY GOITRES RIEDELS FIBROSING
THYROIDITIS
  • Chronic Inflammation and Fibrosis of Thyroid
    Gland
  • Very rare 1.6/100,000
  • Uncertain Pathophysiology
  • ? Autoimmune
  • ? Part of systemic fibrosis
  • Spread of the fibrosis outside the thyroid gland
    can cause RLN dysfunction/tracheal
    compression/hypoparathyroidism

30
RIEDELS FIBROSING THYROIDITIS
  • Clinical features
  • Extent of hypothyroidism depends on extent of
    fibrosis of the gland
  • Hard wooden goitre WITHOUT cervical
    lymphadenopathy
  • May have extra-cervical involvements
    retroperitoneal fibrosis/mediastinal fibrosis
  • Investigation
  • Neither FNAC nor Imaging can reliably distinguish
    Riedels Fibrosing Thyroiditis from malignancy
  • ? PET-CT?
  • Open surgical biopsy is required by wedge
    resection

31
RIEDELS THYROIDITIS
  • Medical Treatment
  • Steroid
  • Tamoxifen ((not by oe inhibition but by grow
    factor level decrease therefore fibroblasts
    down))
  • Thyroid hormone replacement
  • Surgical Treatment
  • Wedge Resection
  • Further surgical Rx not recommended due to the
    extensive fibrosis
  • Prognosis
  • self-limiting, good prognosis

32
THANK YOU
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