THYROID NODULE

I.
II.
III.

IV.
V.
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BLOCK

XVII

Dr. F Hilado

MODULE

III

10/30/2015 3:00-5:00 PM

LECTURE

VII

OUTLINE
Thyroid Gland Anatomy
Thyroid Nodules
Diagnostic Evaluation Methods
- History and PE
- Laboratory Tests
- Investigative Procedures
Differential Diagnosis
Diagnostic Approach
Thyroid cancer

GOITER
refers to an enlarged thyroid gland
- Biosynthetic defects, iodine deficiency, autoimmune
disease, and nodular diseases can each lead to goiter,
although 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.

THYROID GLAND ANATOMY

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.
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 larynx
and over the 2nd and 3rd cricoid 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

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 <1 cm in diameter. Thyroid
nodules may be solitary or multiple, and
they may be functional or nonfunctional
Harrisons 19th edition
TYPES OF THYROID NODULES
UNINODULAR

Only one nodule

in the entire
thyroid gland

Page 1 of 11

Diagnostic evaluation:

This finding is consistent with the diagnosis of a

multinodular toxic thyroid. The patient underwent
surgery
Imaging In Endocrinology

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 ultrasound shows a solid hypoechoic nodule,
with microcalcifications
(b) Thyroid scintigraphy shows the cold nodule with no
detectable 99mTcO4 uptake. The patient underwent fine
needle cytology and the cytology was suspicious for
papillary carcinoma
Imaging In Endocrinology
MULTINODULAR

- more than 1 nodule

- it can be cystic,
complex, solid
- toxic, non-toxic and
euthyroid

Diagnostic evaluation:

A case of multinodular toxic thyroid. A hyperthyroid 46year-old woman with a palpable multinodular thyroid.
(a) Ultrasound scan shows 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.

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 TAKING
When we see a nodule, what are we going to do?
What are we going to ask?
HISTORY TAKING
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?

PHYSICAL EXAMINATION
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; and
a sudden increase in size of the nodule
with pain or tenderness, which suggests a cyst or
localized subacute thyroiditis
Malignancy
- include young age (<20 years) or older age (>60 years)
- male gender
- history of external neck irradiation during childhood or
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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
nodules
Nodule 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 reference
range, is associated with increased risk of
malignancy in a thyroid nodule
- indicates hypothyroidism and suggests Hashimoto
thyroiditis

Serum Thyroglobulin levels

- The measurement of serum thyroglobulin levels has
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 Endocrinology
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 uptake
throughout both lobes and sometimes even in the
isthmus
On the basis of tracer uptake:

NORMAL

Antithyroid Peroxidase Antibodies

- helpful in the diagnosis of chronic autoimmune
thyroiditis, especially if serum TSH is elevated

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Interpretation of nodule features in UTZ

Cold
Hypofunctioni
ng
Decreased
uptake

Warm
Indeterminate

Hot
Hyperfunctioning

Uptake similar
to surrounding
tissue

increased nodular
uptake with
suppression of uptake
in the surrounding
tissue
<5% of cases
autonomously
hyperfunctioning
adenomas
Focal thyroiditis

80-85%
Benign
adenoma,
thyroid cancer,
cyst

10 %
Cancer and
benign
nodules

GOOD
Anechoic/ Cystic
Spongy
Ring of vascularization

BAD
Hypoechoic/Solid
Well-vascularized
Microcalcifications
Irregular Margins

BENIGN CYST ON ULTRASOUND

Multinodular glands exhibit a heterogeneous patchy uptake,

with increased uptake suggestive of
toxic (Fig. C) or nontoxic (Fig. D) multinodular gland

BENIGN SPONGY CYST ON ULTRASOUND

ULTRASONOGRAPHY
- excellent method for detection of thyroid nodules as
small as 1 to 2 mm.
- Its sensitivity approaches 95%
- it has replaced radionuclide scanning as the
procedure of choice for imaging thyroid nodules.
It provides a precise and reproducible measurement
of nodule size and demonstrates whether a nodule is
cystic, solid, or mixed (complex)

SUSPICIOUS NODULE ON ULTRASOUND

Normal Thyroid UTZ

Ultrasonography is useful in confirming the presence of a

mass, determining whether it is of thyroidal or extrathyroidal
origin, assessing whether the lesion is single or multiple, and
guides FNA

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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
Papillary Thyroid Cancer
Cyst
Anaplastic Thyroid Cancer
Lymphocytic Thyroiditis
Medullary Thyroid Cancer
Granulomatous Thyroiditis Lymphoma
Metastatic cancer

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

Hyperthyroid
First 4-6 weeks
high T3, T4; low
TSH
We dont treat
this patient as
toxic goiter and
we cannot give
antithyroid drugs
Beta-blocker or
steroid given
(prednisone or
dexamethasone)
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)

3 Phases of Thyroiditis
Euthyroid
> 4-6 weeks
Normal Thyroid
Tests
will remain in this
phase or will
become
hypothyroid

Hypothyroid
2-3 months
low T3, T4; high
TSH
Give T4
(levothyroxine)
We can also
give T3
(liothyronine)
50-150 ug
depending on
blood test
Normal: we can
discontinue
medications
and 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 patchy
inflammatory 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 TSH
Destructive 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
Harrisons Internal Medicine 19th 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 but
develop 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.
Harrisons Internal Medicine 19th 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 the
thyroid gland. There is low TSH and high T3, T4
Thyroiditis in Hyperthyroid Stage vs Toxic Nodular Goiter
request for radio-iodine uptake

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:
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
o

Diffuse Toxic goiter: very dark (black)

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
Given this picture your
differentials would be
either Thyroiditis or
Thyroid cancer
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.

You can do TSH first but 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 of
the 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
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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 but

just 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

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 will
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

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

Subacute thyroiditis:
viral- give steroids- painless 4x a day for 2 weeks..
you can give for pain
Chronic give 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 suggested
for 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 presence
of 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

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 the
presence of marked vascular invasion

PAPILLARY THYROID CANCER

Harrisons Internal Medicine 19th edition
-

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)

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?

Page 9 of 11

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

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.
Harrisons Internal Medicine 19th edition

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 usually
negligible, 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 19th edition
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

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 Hashimotos
thyroiditis.
- 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 is
otherwise localized to the thyroid.
- If staging indicates disease outside of the thyroid,
treatment should follow guidelines used for other
forms of lymphoma
Harrisons Internal Medicine 19th edition
PLUMMERS NODULE/ TOXIC ADENOMA

- The background is light

- The iodineuptake is in
thenodule
sometimes patient dont become euthyroid right
away they can become hypothyroid. From toxic
to euthyroid then to hypothyroid

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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
Harrisons Internal Medicine 19th 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
Harrisons Internal Medicine 19th edition
COMPLICATIONS OF THYROIDECTOMY
- Bleeding
- Disappearance of voice
- Hypocalcemia

LALUMA LAMPREA LUCES MOLINA

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