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Solitary thyroid nodule
By: Yehia Matter EL-ashcker
any thyroid disese may present itself as STN:
1.Clinically apparent solitary nodule on top of MNG2.Simple nodule eg colloid nodule3. Autonomous toxic nodule4. Focal thyroiditis( Hashimoto_De Quervain_Riedel)5.Cyst eg haemorrghic6.adenomas eg follicular7.carcinoma (papillary-follicular-anaplastic-lymphoma)
Clinical picture:• symptom:
1.Neck swelling2. Painful swelling: in case of *hae *thyroiditis *malignancy3. Toxic manifestation :in toxic nodules4.Criteria of malignany:in malignant nodules
• signs:1. Usually in lower pole.
2. Firm ,hard or cystic. 3.moves up and down with deglutition
investigation:
1.Thyroid scan.2.US.3. Thyroid function test.4.Biopsy:FNAC-true cut needle- excision.
treatment schemea.Multiple :subtotal thyroiddectomyb.Solitary :*cystic ->Aspiration :simple cyst " no further ttt" ->suspicious of malignancy if : Haemorrhagic aspirate Incomplete disapperance "i.e residual mass" +ve cytological exam Rapidly reaccumulating: Managed according to type and operability
*Solid: I123 scana.Warm nodules : hemi-thyroidectomy & biopsyb.Hot nodules :toxic nodules : before 45 =hemi-thyroidectomy & after 45 =1st therapyc.Cold nodules : biopsy : benign = hemi-thyroidectomy & malignant = according to type an operability
1.clinically apparent solitary nodule on top of MNG:Clinically: STNUS: MNGpathology :NE :STN MP : dormant nodule (fibrous tissue capsule with necrotic tissue, area of Haemorrhage & destroyed thyroid follicles) complications & ttt :as MNG
2-colloid nodule • female 20-30 years complaining of STN• MP: fibrous tissue with capsule surrounding inactive thyroid
follicles filled with colloid • ttt: with compression manifestations, retrosternal extension,
bad cosmosis -> hemithyroidectomy
3- thyroid cyst• NE :STN with +ve pajet test• MP : Fibrous tissue capsule containing serous fluid, colloid
material or blood• US :cyst• ttt: Aspiration up to 3 times if simple cyst• suspicious of malignancy (Haemorrhagic aspirate, residual
tissue mass, rapidly reaccumulating, +ve cytology) -> hemithyroidectomy or total thyroidectomy according to pathology
4-autonomous toxic nodule "ATN" • Etiology: autonomous activity of solitary nodule "with no thyroid Ab.) • pathology :• NE : STN + toxic manifestations • ME : over activity nodule surrounded by suppressed thyroid tissue • this over active nodule consists of autonomously active thyroid follicles
surrounded by fibrous tissue • Investigation :increase in T3,T4 & decrease in TSH,• U. S :Solitary solid nodule• thyroid scan -> hot nodule• ttt : <45yrs - >hemi-thyroidectomy, >45yrs - >radioactive I131
5.Thyroiditis A- autoimmune (Hashimoto) thyroiditis :• 30 - 50 yrs, may give a family history of thyroiditis • NE :STN +/- Pain & tenderness , rubbery or firm in consistency. Initially - > toxic
manifestations, later on - > manifestations if hypothyroidism • MP : infiltration of the thyroid gland in the affected area by lymphocytes & plasma cells. • Complications : Hypothyroidism , Malignant change (malignant lymphoma) - > 70 fold
increase in the risk O (papillary carcinoma) • Investigation :• Thytoid function tests : initial hyperthyroidism then hypothyroidism ( increas in TSH &
decrease in T3 & T4)• Thyroid Antibodies : anti microsomal Ab. , anti thyroglobulin Ab. • Thyroid biopsy • TTT : hemi-thyroidectomy with retrosternal extension, compression manifestations or
suspicious of malignancy
B-subacute thyroiditis (Granulomatous - de Quervain's thyroiditis) :• Female 30-40 years, history of URTI 2 weeks ago, followed by neck
pain & toxic manifestations • NE:tender STN• MP : degeneration of thyroid follicles that become surrounded by
giant cs forming granuloma• Investigation : increase in Esr, T3,T4 & decrease in TSH, radio
active iodine uptake• TTT: the disease is self-limited so ttt is primarily symptomatic
(Prednisolone & NSAID)
C- Riedel's thyroiditis ( fibrosing or woody) :• Female with history of collagen disease complaining STN - >
hard, fixed with compression manifestations • MP :replacement of thyroid tissue by fibrous tissue, which
also invades the adjacent tissue • Investigation : tissue biopsy, normal thyroid functions,
thyroid scan - > normal uptake but not appear on the scan • TTT : with sever compression manifestations - > isthmectomy
to decompress the trachea
6- follicular adenoma• NE :Solitary thyroid nodule which is firm & well encapsulated • ME :several histological variants (embryonal, fetal, follicular
& microfollicular) • C/P: STN ( may be functioning) • Investigations : tisse biopsy - >no anglo capsular invasion • Thyroid scan - > warm nodules (if functioning) • TTT :hemi-thyroidectomy
7-Malignant STN• usually - > papillary, follicular or medullary thyroid carcinoma • Rarely - > lymphoma or anaplaatic carcinoma A -Papillary thyroid carcinoma • 15-40yrs complaining of STN with malignant criteria :• Rapidly growing & associated with dysphagia & hoarseness of voice• Hard, >1cm, fixed to the skin or sternomastoid wit enlarged Cx. LNs & +ve berr's
sign• MP : papillary projections formed of C. T core covered by a malignant cuboidal
epithelium with a characteristic pale empty nuclei - > orphan Annie nuclei + nuclear drooves & pseudo-inclusion + psammoma bodies.
• Investigations :increasw in S.thyroglobulin thyroid scan - > cold nodule, neck U/S, CT&MRI, indirect larygoscope & FNAC + metastatic work up
B. follicular carcinoma
• female 40-60yrs complaining of STN with malignant criteria
• MP : thyroid follicles with variable degree of differentiation (solid sheets of malignant cells may be present).
• angiocapsular invasion is a characteristic feature & according to its degree, follicular carcinoma may be :
• non-invasive : if angiocapsular invasion is minimal
• invasive :if angio capsular is moderate or marked
• spread mainly by blood, differentiated tumour & may be functioning
• investigations :
• increase in S.thyroglobulin , Thyroid scan - >cold nodule , Neck U/S, CT&MRI
• Indirect larygoscope & trucut or open surgical biopsy + metastatic work up•
ttt of differentiated thyroid carcinoma (papillary & follicular) • 1- total (in high risk group) or near total thyroidectomy (in low risk group) to
avoid injury of parathyroids & RLN at least on one side• 2- Lymphadectomy : for involved Cx. LNs -> cherry picking or modified 🍒
block dissection "spare sternomastoid, accessory nerve & Internal jugular vein"
• 3-thyroid tissue suppression :post operative thyroxin in a full suppressive dose (making TSH < 1 micro micro /L) as tge tumour is TSH dependant
• 4-radiactive iodin scanning and ablation : post operative whole body scan using radioactive I131 to detect metastasis (done after stoppage of T4 for 6 weeks in order to permit a high stimulating level of TSH on the metastasis) - > if metastasis is found - >theraputic dosses of radio active iodine (I131)
c. Medullary thyroid carcinoma • ♀ 40-60yrs complaining of STN with malignant criteria • MP : aheets of malignant cs " spindlr shaped or polygonal)
separated by collagen & amyloid (amyloid is a diagnostic finding) • +ve immunohistocemistry for calcitonin • metastasize early - > 50% of patients have neck LNs at time of
diagnosis • , functioning tumour - >secretes calcitonin, CEA, PGs& serotonin &
doses not taje up radioactive I
TTT : • 1-ttt pheochromocytoma 1st if present • 2- MTC is ttt by :• Total thyroidectomy • lymphadenectomy ( routine central neck clearance + ipsilateral
modified radical block dissection if tumor > 1.5 cm) • adjuvent radio & chemotherapy • 3- prophylactic total thyroidectomy for family member proved to
have RET gene mutation
Thank you