All thyroid
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The document outlines the management of Graves' disease and thyroid nodules, detailing conditions like hyperthyroidism and thyrotoxicosis, their treatments which include radioactive iodine (i-131), antithyroid drugs, and surgery. It emphasizes the importance of biochemical evaluation, imaging, and follow-up protocols for assessing thyroid nodules and diagnosing thyroid cancer. Additionally, it discusses complications such as thyroid storm and provides guidelines for prevention and post-treatment monitoring.
All thyroid
- 1. Management of Graves’ Disease and Thyroid Nodules Facebook: Happy Friday Knight
- 3. Hyperthyroidism and Graves’ Disease
- 4. • Thyrotoxicosis: clinical state that results from inappropriately high thyroid hormone action in tissues generally due to inappropriately high tissue thyroid hormone levels • Hyperthyroidism: a form of thyrotoxicosis due to inappropriately high synthesis and secretion of thyroid hormone(s) by the thyroid
- 5. • Extra-thyroid sources of hormone: struma ovarii, metastatic DTC, factitious thyrotoxicosis • Most common causes are Graves’ disease (GD), toxic multinodular goiter (TMNG), and toxic adenoma (TA)
- 6. Etiology
- 7. • A radioactive iodine uptake should be performed when the clinical presentation of thyrotoxicosis is not diagnostic of GD • a thyroid scan should be added in the presence of thyroid nodularity
- 8. Biochemical Evaluation Condition T3 T4 TSH Overt hyperthyroidism Mild hyperthyroidism Subclinical hyperthyroidism
- 9. Treatment • Symptomatic: beta blocker • Specific – I-131 – Antithyroid drugs – surgery
- 11. Graves’ Disease • An autoimmune disorder • Thyrotropin receptor antibodies (TRAbs) stimulate TSH receptor increasing thyroid hormone production • Clinical: – symmetrical enlarged thyroid – Recent onset of ophthalmopathy – Moderate to severe hyperthyroidism
- 13. • Specific treatment – I-131 – Antithyroid drugs – Surgery: thyroidectomy Graves’ Disease
- 14. I-131 • Favorable factors – Females planning a pregnancy in the future (more than 4-6 months) – Ones that comorbidity increasing surgical risk – Patients with previously operated or externally irradiated neck – Contraindicated to ATD use – Lack of access to thyroid surgeon
- 15. I-131 • Contraindications – Pregnancy and lactation – Female planning a pregnancy in 4-6 moths – Coexisting or suspicious thyroid cancer – Individuals unable to comply with radiation safety guidelines
- 16. I-131 • Preparation for I-131 therapy – Beta blocker and methimazole are used for patients with high risk for worsening hyperthyroidism (FT4 2-3 time upper normal limit – For MMI: • Discontinue 3 -5 days before I-131 administration • Restarted 3 – 7 days later • Taper over 4-6 weeks as thyroid function normalized
- 17. I-131 • Administration – A single dose 10-15 mCi – Obtain pregnancy test within 48 hrs
- 18. I-131 • Follow up – Within 1 month with T3, T4 • If still thyrotoxic, monitor q4-6weeks • If euthyroidism, monitor q1year – When hyperthyroidism persists after 6 months following therapy, retreatment with I-131 is suggested
- 19. Antithyroid drugs • Favorable factors – High likelihood of remission (female, mild disease, small goiters, low titer TRAb) – Elderly – Patients with high surgical risk – Unable to follow safety guidelines – Previously operated or irradiated neck – Moderate to severe active Graves’ ophthalmopathy
- 20. Antithyroid drugs • Contraindications – Previous known major adverse reaction to ATDs – PTU: liver failure, hypersensitivity, agranulocytosis
- 21. Antithyroid drugs • Initiation – ATDs do not cure Graves’ hyperthyroidism – MMI > PTU except 1st trimester pregnancy – Before initiating, CBC and LFT should be obtained
- 22. Antithyroid drugs • Propylthiouracil (PTU): – 50-150 mg tid • Methimazole (MMI): – Single daily dose – Start with higher dose of 10-20 mg until euthyroid, then titrate to 5 mg
- 23. Antithyroid drugs • Monitoring – FT4 is obtained 4 weeks after initiation – When FT4 is normalized, T3 may be monitored – CBC should be obtained during febrile illness, routine monitoring is not recommended – LFT should be obtained when pruritic rash, jaundice, light-colored stool, dark urine, joint pain, abdominal pain, anorexia, nausea, or fatigue
- 24. Antithyroid drugs • Management of allergic reactions – Minor cutaneous reaction antihistamine without cessation – Persistent reaction cessation and switching to other ATDs, radioactive iodine, or surgery – Serious reaction switching ATDs not recommended
- 25. Antithyroid drugs • Duration – MMI 12-18 months with tapering and monitoring TSH until normal – Monitor TRAb level – If hyperthyroid after 18 months take it longer, radioactive iodine, surgery – Remission = normal TSH, FT4, T3 after 1 year of discontinuation
- 26. Surgery • Favorable factors: – Symptomatic compression – Large goiter (>80g) – Thyroid malignancy is suspected – High TRAbs – Moderate to severe active GO
- 27. Surgery • Contraindication – Serious comorbidity – Pregnancy
- 28. Surgery • Preparation – Euthyroid before surgery – Urgent: beta blocker and KI – KI: lugol solution (100mg/ml) 50 – 100 mg po tid x 10days
- 29. Surgery • Near-total or total thyroidectomy is a procedure of choice – Nearly 0% recurrence – Complications: hypocalcemia, recurrent or superior laryngeal nerve injury, bleeding • Refer to high-volume thyroid surgeon
- 30. Surgery • Postoperative care – Serum calcium or intact parathyroid hormone levels – As a result, calcium and calcitriol supplement can be given – Persistent hypocalcemia measure serum magnesium level
- 31. Surgery • Postoperative care: – Prophylaxis: CaCO3 1250-2500mg qid, tapering 500 mg q2days – Calcitriol 0.5 mcg daily, continue for 1-2 weeks – Elthroxin: daily dose 1.7 mcg/kg and serum TSH measured 6-8 weeks
- 32. Thyroid Storm
- 33. Definition • Thyrotoxicosis with any evidence of systemic decompensation • Life-threatening exacerbation of thyrotoxicosis • Typically associated with Graves’ Disease • High mortality rate if not immediately recognized and treated aggressively
- 35. • Precipitants: – Abrupt cessation of antithyroid drugs – Surgery under unrecognized or inadequately treated thyrotoxicosis – Acute illness – Rarely, following radioactive iodine therapy
- 36. Treatment • Beta-adrenergic blockade • Antithyroid drug therapy • Inorganic iodide • Corticosteroid therapy • Volume resuscitation • Aggressive cooling with paracetamol and cooling blankets • Respiratory support • Monitoring in an ICU
- 38. • PTU (50) 10 tabs po stat, then 5 tabs po q4hr • Methimazole (5) 12 tabs po, RS • Propranolol (40) 2 tabs po q4hr, titrate with HR • Lugol solution 250 mg po q6hr after starting ATD 1 hr x 5-7 days • Hydrocortisone 300 mg IV stat, then 100 mg IV q8hr x 3 days
- 39. Prevention • Euthyroid before surgery • In urgent surgery, iodide, beta blocker, and corticosteroid should be given • Iodide – Lugol solution: 50-100 mg po tid 10 days before surgery • Propanolol 40 mg po q8hr for 5 days • Betamethasone 0.5 mg po q6hr for 5 days
- 40. Management of Adult Patients with Thyroid Nodules
- 42. • The importance of thyroid nodule is to exclude thyroid cancer (7-15% of cases) • Non-palpable nodules detected on imaging is called incidentaloma • Nodules > 1cm should be evaluated • Nodules with symptoms or lymphadenopathy should also be evaluated despite of size < 1cm
- 43. Investigation • TSH • Thyroid sonography • FNA
- 44. TSH • If subnormal, a radionuclide thyroid scan should be performed • If normal or elevated, not perform
- 45. Thyroid sonography • Look at thyroid and cervical lymph node • Report: – Size in 3 dimensions – Location – Sonographic feature: • Composition calcification • Echogenicity shape if taller than wide • Margins vascularity
- 46. FNA • Most accurate and cost-effective method • US-guided FNA is preferred
- 48. 1 2 3
- 51. high suspicion > 70-90%
- 53. Low suspicion 5 – 10%
- 54. Very low suspicion <3%
- 55. Benign < 1%
- 58. Cytology • Nondiagnostic: repeat FNA with US guidance • Repeatedly nondiagnostic: close observation or surgical excision • Benign: no treatment (follow up) • Malignancy: surgery (Bethesda – near total thyroidectomy)
- 59. Cytology • Indeterminate (AUS/FLUS, FN, SUSP): – Molecular marker may be considered – BRAF, RAS, RET/PTC, PAX8/PPAR-gamma
- 60. Cytology – Total thyroidectomy when • Cytologically suspicious for malignancy • Known mutation specific for carcinoma • Sonographically suspicious • Large > 4cm • Familial thyroid caricoma • History of radiation exposure • Following lobectomy which is malignant • Bilateral nodular disease
- 61. Cytology • AUS/FLUS – If FNA and molecular marker not performed, surveillance or surgical excision (thyroid lobectomy) may be performed • FN: – Surgical excision (Bethesda-lobectomy) • Choices: lobectomy, near-total and total thyroidectomy
- 62. Cytology • Suspicious for malignancy cytology – Same as malignancy cytology – Bethesda – lobectomy or near-total thyroidectomy
- 63. Cytology • Multiple thyroid nodules ≥ 1 cm same as solitary thyroid nodule • Low TSH with multiple nodules radionuclide thyroid scan to determine functionality FNA in nodule ≥ 1cm with isofunctioning or nonfunctioning
- 64. Follow-up • Follow-up of nodules with benign cytology – High suspicious: repeat US-guide FNA within 12 months – Low to intermediate suspicion: repeat US within 12-24 months 20% increased 2 nodules dimension with a minimal increase of 2 mm or more than 50% change in volume or new suspicious one FNA
- 65. Follow-up • Follow-up of nodules with benign cytology – Very low suspicious: repeat US ≥ 24 months – Two benign FNA cytology results: US surveillance no longer indicated
- 66. Follow-up • For nodules that do not meet FNA criteria – High suspicion: repeat US in 6-12 months – Low to intermediate: repeat US in 12-24 months – Nodules > 1cm with very low suspicion and pure cyst: repeat US ≥ 24 months – Nodules ≤ 1cm with very low suspicion and pure cyst: no follow up
- 67. Role of Therapy for Benign Nodules • Routine TSH suppression in iodine sufficient populations is not recommended • If inadequate dietary intake, a daily supplement 150 mcg of iodine is recommended
- 68. Role of Therapy for Benign Nodules • Surgery may be considered in growing nodules if symptomatic (compressive or structural symptoms) • If asymptomatic: no surgery • No data to guide recommendation on thyroid hormone therapy
- 69. Thyroid Storm
- 71. Definition • Thyrotoxicosis with any evidence of systemic decompensation • Life-threatening exacerbation of thyrotoxicosis • Typically associated with Graves’ Disease • High mortality rate if not immediately recognized and treated aggressively
- 73. • Precipitants: – Abrupt cessation of antithyroid drugs – Surgery under unrecognized or inadequately treated thyrotoxicosis – Acute illness – Rarely, following radioactive iodine therapy
- 74. Treatment • Beta-adrenergic blockade • Antithyroid drug therapy • Inorganic iodide • Corticosteroid therapy • Volume resuscitation • Aggressive cooling with paracetamol and cooling blankets • Respiratory support • Monitoring in an ICU
- 76. • PTU (50) 10 tabs po stat, then 5 tabs po q4hr • Methimazole (5) 12 tabs po, RS • Propranolol (40) 2 tabs po q4hr, titrate with HR • Lugol solution (1 drop = 10 mg) 25 drops po q6hr after starting ATD 1 hr x 5-7 days • SSKI (1 drop = 50 mg) 5 drops po q6r after starting ATD 1 hr x 5-7 days • Hydrocortisone 300 mg IV stat, then 100 mg IV q8hr x 3 days
- 77. Prevention • Euthyroid before surgery • In urgent surgery, iodide, beta blocker, and corticosteroid should be given • Iodide – Lugol solution: 4 – 6 drops po tid – SSKI: 1 – 2 drops po tid 10 days before surgery • Propanolol 40 mg po q8hr for 5 days • Betamethasone 0.5 mg po q6hr for 5 days
- 78. References Bahn et al (Chair). Hyperthyroidism and Other Causes of Thyrotoxicosis: Management Guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. Vol 21, No. 6, (2011): p.593-646. A Baeza A, Aguayo J, Barria M, Pineda G 1991 Rapid preoperative preparation in hyperthyroidism. Clin Endocrinol (Oxf ) 35:439–442. วิทยา ศรีดามา บรรณาธิการ. Clinical Practice Guideline 2010 เล่มที่ 1. กรุงเทพฯ: โรง พิมพ์แห่งจุฬาลงกรณ์มหาวิทยาลัย, 2553
- 79. Thyroid: Update in Thyroid Cancer, Alternative Approach in Thyroid Surgery, and Difficult Thyroid Facebook: Happy Friday Knight 8th April 2016 Thailand
- 80. Update in Management of Thyroid Cancer
- 81. Goal of Treatment • Remove all of the primary tumor • Minimize recurrence risk • Facilitate postoperative treatment with RAI • Permit accurate staging and risk stratification • Permit accurate long term surveillance for disease recurrence • Minimize treatment-related mortality
- 83. 1 2 3
- 84. Investigations after Diagnosis DTC • Preoperative neck ultrasound • FNA of suspicious LN and Tg needle washout • CT and MRI • Vocal cord assessment
- 85. Preoperative Neck Ultrasound • DTC, especially PTC involves cervical LN metastases in 20-50% • Micrometastasis (< 2mm) may approach 90% • Sonographic features of pathological LN: – Enlargement (≥8-10mm) - cystic change – Loss of fatty hilum - calcification – Round shape - peripheral vascularity – hyperechogenicity
- 86. FNA of LN and FNA-Tg washout • FNA thyroglobulin washout = thyroglobulin concentration in washout fluid from fine- needle aspiration (FNA) – Suggestive cut-off Tg: 32 ng/ml • May be helpful in – Cystic node – Inadequate cytology – Discordance of cytology and imaging Pak et al. Endocrine. 2015; 49: 70-77.
- 87. Neck Imaging: CT and MRI • Appropriate in locally invasive DTC as adjunct – Progressive dysphagia – Respiratory compromise – Hemoptysis – Rapid tumor enlargement – Significant voice change or finding of vocal cord paralysis – Mass fixation to airway or neck structures – Substernal extension
- 88. Preoperative CT • Can perform with iodine IV contrast because it is generally cleared in 4-8 weeks
- 89. Vocal Cord Assessment • Symptoms: hoarseness • Re-do for completion thyroidectomy • Posterior extrathyroidal extension or extensive central node metastases
- 90. Operative Approach • Near-total and total thyroidectomy with gross removal of primary tumor – Clinical T4 (thyroid cancer > 4cm or gross extrathyroidal extension) – Clinical N1 (clinically node metastasis) – Clinical M1 (distant metastasis) – May choose total thyroidectomy to • Enable RAI • Enhance follow up • Patient preference
- 91. Operative Approach • Lobectomy alone – Thyroid cancer < 1cm – Without extrathyroidal extension – Clinical N0 – No prior head and neck radiation – No familial thyroid cancer
- 92. Operative Approach • Near-total and total thyroidectomy VS lobectomy – Thyroid cancer > 1cm and < 4cm – Without extrathyroidal extension – Clinical N0 – Lobectomy may be sufficient for low-risk PTC and FTC
- 93. Active Surveillance • Very low risk tumor • High surgical risk due to comorbid conditions • Relatively short life span • Concurrent medical or surgical issues that need to be addressed prior to thyroid surgery
- 94. Lymph Node Management • Therapeutic central-compartment neck dissection: clinically involved central nodes • Therapeutic lateral-compartment neck dissection: biopsy-proven metastatic LNpathy • Prophylactic central-compartment neck dissection: PTC + cN0 + T3/T4 or cN1b • Thyroidectomy without prophylactic neck dissection: T1/T2, noninvasive, cN0 PTC, most FTC
- 96. Postoperative Staging • AJCC/UICC staging is recommended for all patients with DTC • Provide prognostic information
- 101. BRAF mutation • Point mutation • 40-45% of PTC • 30% of poorly differentiated CA and ATC • Increased disease-specific mortality, higher risk of recurrence
- 102. Postoperative Tg & anti TgAb • Preoperative serum Tg and anti TgAb are not recommended to measure • Postoperative benefit: – Assess persistent disease – Assess the thyroid remnant – Predict potential future disease recurrence • Reach the nadir in 3 – 4 weeks post-op
- 103. Role of Postoperative Diagnostic Scanning • Including with I131 diagnostic imaging, SPECT-CT, RAI uptake measurement • Benefit – Identify thyroid remnant – Detect distant metastasis
- 104. Role of RAI Ablation After total thyroidectomy: • Should be considered =>ATA intermediate risk • Routinely recommended =>ATA high risk • Not recommended => – ATA low risk – Unifocal papillary microcarcinoma without other adverse features – Multifocal papillary microcarcinoma without other adverse features
- 105. Time to Perform RAI Ablation, • After total thyroidectomy and LT4 withdrawal for 3-4 weeks • TSH > 30 mIU/L • rhTSH in patients that may preclude thyroid hormone withdrawal: – Comorbidities – Inability to raise endogenous TSH
- 106. Posttherapy Whole Body Scan • Is recommended after RAI remnant ablation or treatment, to inform disease staging and document the RAI avidity of any structural disease
- 107. Role of TSH Initial Suppression • LT4 • ATA high risk: < 0.1 mU/L • ATA intermediate risk: 0.1 – 0.5 mU/L • ATA low risk: – With undetectable serum Tg: 0.5 – 2 mU/L – With low-lever serum Tg: 0.1 – 0.5 mU/L – Undergone lobectomy: 0.5 – 2 mU/L
- 109. Alternative Approach in Thyroid Surgery
- 110. • Open through Kocher incision • Endoscopic thyroid surgery
- 111. Classification of Endoscopic Thyroid Surgery • Approach – Direct midline – Regional – Remote – Transmucosal • Maintainance of Working Space – Gasless – Insufflation • Instrumental – Manual – robotic
- 112. Swanstrom LL and Sopher NJ. Mastery of endoscopic and laparoscopic surgery. 4th ed. Philadelphia: LIPPINCOTT WlLLIAMS & WILKINS, a WOLTERS KLUWER business, 2014
- 113. Swanstrom LL and Sopher NJ. Mastery of endoscopic and laparoscopic surgery. 4th ed. Philadelphia: LIPPINCOTT WlLLIAMS & WILKINS, a WOLTERS KLUWER business, 2014
- 114. Swanstrom LL and Sopher NJ. Mastery of endoscopic and laparoscopic surgery. 4th ed. Philadelphia: LIPPINCOTT WlLLIAMS & WILKINS, a WOLTERS KLUWER business, 2014
- 115. Clark JH, Kim HY, Richmon JD. Transoral robotic thyroid surgery. Gland Surg. 2015 Oct;4(5):429-34.
- 116. Clark JH, Kim HY, Richmon JD. Transoral robotic thyroid surgery. Gland Surg. 2015 Oct;4(5):429-34.
- 117. Clark JH, Kim HY, Richmon JD. Transoral robotic thyroid surgery. Gland Surg. 2015 Oct;4(5):429-34.
- 118. Difficult Thyroid
- 119. Concern of Thyroid Surgeons • Avoid unnecessary surgery • Avoid intraoperative unexpected conditions • Safe and low morbidity and mortality
- 120. • Difficult in diagnosis • Difficult in management • Difficult in surgery
- 121. Diificult in Diagnosis • Rapidly growing thyroid mass • Equivocal hyperthyroidism
- 122. Rapidly Growing Thyroid Mass • Anaplastic thyroid carcinoma • Hurthle cell carcinoma • DTC • Lymphoma • Bleeding thyroid adenoma • Bleeding nodular goiter • Soft tissue tumor, fibromatosis, sarcoma • Non-thyroidal mass: hemangioma or lymphangioma
- 123. • Clinical picture is the most important clue • FNA is not accurate • May need fast and accurate diagnosis • Probably need incision biopsy under GA with frozen section Rapidly Growing Thyroid Mass
- 124. Equivocal Hyperthyroidism • Graves’ disease with nodules • Thyroiditis • Toxic multinodular goiter • Different in treatment planning – Surgery or not – Extent of surgery
- 125. • Therapeutic diagnosis • Thyroid scan and FNA may not help to diagnose • Not an urgent condition that indicate surgery Equivocal Hyperthyroidism
- 126. Difficult in Management • Uncontrolled hyperthyroidism – Try step up ATD + beta blocker – Lugol’s solution – plasmapheresis
- 127. Difficult in Surgery • Completion thyroidectomy, recurrent disease • Organ invasion • Non recurrent laryngeal nerve • Substernal extension
- 128. Reoperation • Problems: – Scar – Anatomical distortion • Management: – Preoperative evaluation – Sharp dissection – meticulous
- 129. Organ Invasion • Management: – Preoperative evaluation of other organs involvement and resectability – Need imaging – Example: laryngeal and vascular involvement
- 131. References Swanstrom LL and Sopher NJ. Mastery of endoscopic and laparoscopic surgery. 4th ed. Philadelphia: LIPPINCOTT WlLLIAMS & WILKINS, a WOLTERS KLUWER business, 2014 Haugen BR et al. 2015 American thyroid association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2015: 26(1); 28-92. พุทธิพร เย็นบุตร. Update in management of thyroid cancer. April 2, 2016 ธัญวัจน์ ศาสนเกียรติกุล. Alternative approach in thyroid surgery. April 2, 2016 อดุลย์ รัตนวิจิตราศิลป์ . Difficult thyroid. April 2, 2016
Editor's Notes
- #106: rhTSH: recombinant human thyrotropin (thyrogen) ใส่เพื่อเพิ่ม serum TSH ให้สูงขึ้น