STRUMA NODULUS NON

TOXIC
Dedy Rahmat Syahir C 111 10 174
Muh. Ikbal Lungge C 111 12 133

Case Report of Endocrin Metabolic Sub-Division

Internal Medicine Department
Faculty of Medicine Hasanuddin University
2017
PATIENT IDENTITY
Name : Ms. M
Age : 49 years old
Sex : Female
Religion : Moslem
Address : Barru
RM number : 741655
Day of admission : 16 – 12 – 2016
HISTORY TAKING
• Chief complaint : Swelling at the neck

• Patients come to the hospital with complaints swelling at the neck between right and left
especially at the right neck with length about 10 cm and a width about 15 cm had felt since
about 10 years ago and slow increasingly swelling. The mass is not pain especially on
swallowing, no hoarse, color like skin, flat and smooth surface, warm, solid consistency, no
fever, no shortness on breathing, no cough, no chest pain, no excessive sweating, no weight loss
and, defecation is normal once a day, solid and yellow, no history with black feces. Urinating is
normal, yellow clear color.

• There is a history with diabetes mellitus since one year ago and was treated with insulin
injections, history of hypertension since 5 years ago and no medical treatment, There is no
previous treatment history, and no family history of complaints for the same disease.
Physical Examination

• General Status : Moderate illness

• Nutritional status : Well nourished

• Consciousness : Compos mentis GCS 15 (E4M6V5)

Vital Sign
• Blood Pressure : 180/110 mmHg
• Heart Rate : 78 x/minutes
• Respiration Rate : 16 x/minutes (Thoracoabdominal)
• Temperature : 36,6˚C

• Weight : 59 Kg
• Height : 155 cm
• BMI : 24,5 kg/m2
PHYSICAL EXAMINATION
• Head : Within normal limit (WNL)
• Eyes : Icteric sclerae (-) Pupil φ2mm/2mm isochor
Anemic conjunctiva (-) Movement : WNL
• Ear : WNL
• Nose : WNL
• Mouth : Lips, teeth and gums WNL
Tonsil no hyperemia
Pharnyx no hyperemia
Tongue WNL (there’s no dirty tongue)
• Skin : Vasculitis (-), Petechie (-)
PHYSICAL EXAMINATION
• Neck :
- Thyroid gland :
Inspection: Nodule between on the right and left neck
especially on the right, length of 10 cm and a width of 15 cm,
not pain, skin like color, not move on swallowing
Palpation: solid consistency, flat surface, warm, not fixed, not
pain on pressure

- Lymphonodus enlargement (-)

- JVP R+2 cmH20
- Carotid artery WNL
PHYSICAL EXAMINATION
• Chest :
Inspection : right and left chest are move symmetrically and also
symmetric without movement. There is no abnormal mass.
The mammary gland is also WNL with her nipple pointing out.
Palpation : There is no crepitation, pain and abnormal mass. Vocal
fremitus is WNL. Apex cordis is palpated in 5th ICS of midaxillary
line sinistra
Percussion : Both side of chest is heard sonor. The hepato-pulmonary margin
is located in 6th ICS dextra and migrate 1 ICS inferiorly in the deep breath
Auscultation : Both side of chest is heard vesicular. There is no rales or wheezing. The
heart sound S1/S2 is regular without any murmur.
PHYSICAL EXAMINATION
• Abdominal :
Inspection : There is no abnormal mass
Auscultation : Peristaltic sound in normal limit
Palpation : There is no pain and abnormal mass.
Percussion : All regions of abdomen are heard
tympanic.
LABORATORY FINDINGS
(20 desember 2016
Test Result Reference Unit
WBC 7,8 4,00 – 10,00 10^3/Ul
RBC 4,69 4,00 – 6,00 10^6/Ul
HGB 12,9 12 – 16 gr/dl
HCT 37 37,0 – 48,0 %
PLT 282 150 – 400 10^3/Ul
Neut 52,1 52,0 – 75,0 %
Lymph 31,9 20,0 – 40,0 %
Monosit 9,6 2,0 – 8,0 10^3/Ul
Eosinofil 5,8 1,0 – 3,0 10^3/Ul
Basofil 0,6 0,00 – 0,10 10^3/Ul
PT/APTT 10,7/26,3 10 – 14/22 – 30 S
LABORATORY FINDINGS
(22 Desember 2016)
Test Result Reference Unit
Ureum 34 10 – 50 mg/dl
Kreatinin 0,6 F(<1,1) mg/dl
SGOT 23 <38 U/l
SGPT 23 <41 U/l

Examination Result Reference Unit

HBs Ag (ICT) Non Reactive Non Reactive

Anti HCV (ICT) Non Reactive Non Reactive

Na/K/Cl 141/3,9/102 136 – 145/3,5 – 5,1/97 – 111 mmol/L

LABORATORY FINDINGS
(4 january 2017)
Test Result Reference Unit
GDS 246 140 – 200 mg/dl

(20 Desember 2016)

Test result standart
FT4 1,41 0,932-1.71

TSHs 1,21 0,270-4.20

FNA TEST
(26 September 2016)

Result: Neoplasma folikullare nodule thyroid

RADIOLOGY FINDING
CT Thyroid/Neck (Without Contras) (9 November 2016)
Result: Thyroid mass Dextra (T3N0Mx)

Photo Thorax PA/AP (8 November 2016)

Result: - No metastasis sign
- Cardiomegaly with dilatatio aortae

USG Abdomen Upper and Lower (8 November 2016)

Result: - No metastasis sign
- Intra abdomen organs is normal
PROBLEM LIST
Problem Diagnose Therapy Plan

1.Nodule between on the right and • Struma Nodulus Non Toxic • Thyroidectomy
left neck especially on the right,
length of 10 cm and a width of 15
cm, not pain, not pain on
swallowing, no hoarse, skin like
color, not move on swallowing,
solid consistency, flat surface,
warm, not fixed, not pain on
pressure

FT4 1,41 (normal) TSHs 1,21

(normal).
FNA : Neoplasma Folikullare Nodul
Thyroid
CT Thyroid : Thyroid mass Dextra
(T3N0Mx)
PROBLEM LIST
Problem Diagnose Therapy Plan

2. BP = 180/100 mmHg, • Hipertensi grade II • ARB (Mycardis 80 mg/24 h/oral)

history of hypertension since 5 • Low salt diet
years ago

• Diabetes Melitus type II • Low sugar diet

3. GDS: 246 mg/dl, • Novorapid 6 unit/8 h/subcutan
history of diabetes since 1 year ago, • Levemir 10 unit/24 h/subcutan
family history with DM
DISCUSSION
Struma Nodulus Non Toxic
 DEFINITION
Struma or often called goiter is a swelling of the neck caused by
enlarged thyroid gland by effect of the thyroid gland malfunction or
changing in the composition and the morphology of the gland
Struma nodulus non toxic is enlarged thyroid gland consist of
nodules without hiperthyroidism or hipothyroidism

www.ncbi.nlm.nih.gov/pmc/articles/PMC4876491/
 ETIOLOGY
• Iodine deficiency
• Goitrogenic factor
• Iodine overage
• Genetic, etc
• Nutritions

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ANATOMY
PATOGENESIS OF STRUMA/GOITER
Iodine deficiency

Inhibit thyroid hormone Thyroid gland

Inhibit TSH Hipofisis Anterior

Increase TSH secreation Hipofisis

Thyroglobulin secretion into follicle

Swelling of gland

Struma/Goiter

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 Clinical Features
High Suspect Moderate Suspect Benign Nodule

• A family history of thyroid
carcinoma medulare
• Rapidly enlarge especially in
Levothyroxine therapy
• Dense and hard nodule
• Attached to the surrounding
tissue
• Paralysis of the vocal cord
• Regional Lymphadenopathy
• Distant metastasis
• Age under 20 years or up to 70
years old
• A history of radiaton on head
and neck
• Nodule > 4 cm or partially cystic
• Complain on pressure,
dysphagia, dysphonia, hoarse,
dyspnea, and cough
• A family history with benign
module
• Difuse struma or multinodosa
• Fixed amount
• FNA: Benign
• Simplex Cyst
• Warm or hot nodules
• Wane on Suppresive
Levothyroxine therapy

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 CLINICAL MANIFESTATION
• Often discovered incidentally in an asymptomatic patient
• The clinical manifestations caused by compression of vital structures in the neck or upper thoracic
cavity (trachea, esophagus, and neck veins)
• When tracheal narrowing becomes more severe, dyspnea and stridor develop, initially only on
exertion, but later also at rest
• Esophageal compression is less common than tracheal compression because the esophagus is
positioned more posteriorly in the neck
• Obstruction of the jugular or subclavian veins or the superior vena cava results in facial plethora
and dilated neck and upper thoracic veins
• Vocal cord paralysis, either transient or permanent, can occur because of stretching or
compression of a recurrent laryngeal nerve and results in hoarseness and dyspnea.

journals.lww.com/theendocrinologist/Fulltext/2003/01000/Nont
oxic,_Nodular_Goiter__New_Management_Paradigms.8.aspx
 TNM CLASSIFICATION
PRIMARY TUMOR (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor is found
T1 Tumor size ≤ 2 cm in greatest dimension and is limited to the thyroid
T1a Tumor ≤ 1 cm, limited to the thyroid
T1b Tumor > 1 cm but ≤ 2 cm in greatest dimension, limited to the thyroid
T2 Tumor size > 2 cm but ≤ 4 cm, limited to the thyroid.
T3 Tumor size >4 cm, limited to the thyroid or any tumor with minimal extrathyroidal extension (eg,
extension to sternothyroid muscle or perithyroid soft tissues)
T4a Moderately advanced disease; tumor of any size extending beyond the thyroid capsule to invade
subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve
T4b Very advanced disease; tumor invades prevertebral fascia or encases carotid artery or mediastinal
vessel

http://emedicine.medscape.com/article/2006643-overview
 STAGING
REGIONAL LYMPH NODES (N)
NX Regional nodes cannot be assessed
T0 No regional lymph node metastasis
N1 Regional lymph node metastasis
N1a Metastases to level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes)
N1b Metastases to unilateral, bilateral, or contralateral cervical (levels I, II, III, IV, or V) or
retropharyngeal or superior mediastinal lymph nodes (level VII)

DISTANT METASTASIS (M)

M0 No distant metastasis is found
M1 Distant metastasis is present

http://emedicine.medscape.com/article/2006643-overview
 STAGE GROUPING
PAPILLARY AND FOLLICULAR THYROID CANCER (AGE < 45Y)
STAGE T N M
I Any T Any N M0
II Any T Any N M1

PAPILLARY AND FOLLICULAR; DIFFERENTIATED (AGE ≥ 45Y)

STAGE T N M
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
T1-3 N1a M0
IVA
T4a N1b M0
IVB T4b Any N M0
IVC
http://emedicine.medscape.com/article/2006643-overview Any T Any N M1
 DIAGNOSTIC
• Anamnesis
• Physical examination
• Laboratory and Radiology diagnostic:
- FNA
- Scanning Thyroid
- USG Thyroid
- FT4 and TSHs

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 Nodul Tiroid

History of disease, phisical exam and

Low TSHs
TSHs

Normal TSHs or High Thyroid Scan

Suspect Cancer Evaluation Nodule function

Surgery FNA with USG Radioactive Iodium, Alternative:

Observation, Surgery, Ethanol
injection, Laser

Diagnostic Non Diagnostic

malignant Suspect Benign Repeat FNA with USG

Surgery Surgery Alternative: Observation, Non Diagnostic

surgery, therapy, Levothyroxin,
Ethanol injection, Laser

Surgery

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 TREATMENT
• Clinical Observation
• Suppressive Therapy with Levothyroxine
• Surgery
• Therapy with Radioiodine

www.ncbi.nlm.nih.gov/pmc/articles/PMC4876491/
Treatment Advantages Disadvantages
Levothyroxine Outpatient use Low efficacy
Low cost Main effect on perinodular volume
Prevent formation of other nodules? Continuous suppression of TSH, which leads
to side events associated with subclinical
hyperthyroidism, as well as unpredictable
bone and cardiac side effects
Surgery Substantial reduction in goiter size Not applicable to all individuals
Rapid relief of compression of vital cervical Post-surgical hemorrhage (1%)
structures Damage to the recurrent laryngeal nerve (1–
Allows pathological assessment 2%)
Temporary (0.5%) or definitive (0.6%)
hypoparathyroidism
Goiter recurrence depending on the extent of
resection
Post-surgical tracheomalacia (rare)
Increased morbidity in cases with large
goiters, intrathoracic extension or reoperation
Radioiodine Thyroid volume reduction by half in 1 year Gradual reduction in goiter size
Improves respiratory capacity in the long term The larger the goiter, the lower the effect
Frequent outpatient use Slight risk of short-term increase in goiter size
Can be successfully repeated 3% risk of thyroiditis
Few side effects 5% risk of development of Graves’ disease
15–20% risk of hypothyroidism at 12 months
Small risk of radiation-induced
ophthalmopathy
Requires retreatment in some cases
Risk of radiation-induced malignancy has not
been established
Comments
Declining due to adverse effects and lack of
efficacy
Standard treatment for large goiters or when
rapid decompression of cervical structures is
required
Total thyroidectomy should be considered the
preferred therapy to prevent goiter
recurrence
In some European countries, radioiodine has
become the standard therapy, replacing
surgery
May be considered in place of surgical
intervention in patients who refuse or are
unable to undergo surgery, or in those with
large goiters (except in cases that require
large radioiodine doses)
Can be preceded by rhTSH with lower
radioiodine dose
THANK YOU