Thyroid Nodules
- Imaging: US, Fine needle aspirate with cytology, I-scintiscan (will determine if hot or cold nodule). FNA is test of choice.
- Hot Nodule: Increased I uptake= functioning/hyperfunctioning nodule.
- Cold Nodule: Decreased I uptake= nonfunctioning nodule. More worrisome for being malignant.
- Surgical removal of the nodule if hx of radiation exposure.
Hyperthyroidism
-Most common cause is Grave’s Disease. Other causes are toxic adenoma and toxic multinodular goiter.
-Sx: nervous, irritable, palpitations, heat intolerance/increased sweating, tremor, wt loss or gain, diarrhea, dyspnea, sleep disturbance, menstrual disturbance, impaired fertility, photophobia/eye irritation/exopthalmous, fatigue/muscle weakness, pretibial myxedema
-Graves: autoimmune-Trabs stimulate TSH receptor which increase thyroid hormone production. Sx= exopthalmos, pretibial myxedema, and non pitting edema. TSH is low, T4 elevated, and Trabs present. Can be diagnosed with radioactive iodine uptake but not always necessary.
Tx= antithyroid drugs(PTU, methimazole), radioactive iodine, thyroidectomy.
Thyroid-Neoplastic disease
- Thyroid carcinoma: History= neck radiation, FH, young age, m>f. Signs= single nodule, cold nodule, increased calcitonin levels, lymphadenopathy, hard/immobile. Sx: voice change, dysphagia, discomfort, rapid enlargement.
- 5 types: papillary adenocarcinoma, follicular, medullary, hurthle cell, anaplastic/undifferentiated.
- Sx: mass, lymphadenopathy
- Workup: FNA, US, TSH level, Ca level
Hyperparathyroidism
- Increased secretion of PTH.
- Ca will be elevated, P will be low
- Primary= secretion by parathyroid. Most common cause is adenoma.
- Secondary= results from Ca wasting caused by renal failure or decreased GI Ca absorption.
- Tertiary= autonomous PTH secretion that is not responsive to the normal negative feedback
- Sx: kidney stones, bone pain, muscle pain/weakness, pancreatitis, gout, constipation, depression, wt loss, HTN, polydipsia/polyuria
- May see subperiosteal bone resorption - look at DEXA scan
- Tx: remove parathyroid gland-can implant into arm
Hypoparathyroidism
-Most common after thyroidectomy.
-Sx: tetany, muscle cramps, convulsions, tingling around the mouth/hands/feet, lethargy, personality changes, Chvostek sign (facial m. contraction on tapping of facial nerve), Trousseau phenomenon (carpal spasm), cataracts, thin/brittle nails, dry skin, alopecia, hyperactive DTRs.
Labs: Ca low, P high, PTH low.
Tx: Calcium, Vit D analogs(Calcitriol).
Adrenal-neoplastic disease
- Incidentaloma- found on CT. Most common cause is nonfunctioning adenoma. Resection indicated if solid and >6cm in diameter, if hormonally active, or enlarging cystic lesion.
- Adrenal adenoma or carcinoma can cause ACTH independent cushings syndrome. Need to use thin slice CT.
- Adrenal carcinoma= Necrosis, hemorrhage, and calcification.
Pheochromocytoma
- Tumor of the adrenal medulla
- Produces catecholamines (NE>epi)
- RFs= MEN-II, FH, von recklinghausen, von hippel lindau
- Sx: palpitations, HA, diaphoresis, HTN, pallor->flushing, anxiety, wt loss, tachycardia, hyperglycemia
- Dx: urine screen for VMA, serum epi/NE levels
- Imaging: CT, MRI, IMIBG(NE analog-will collect in the tumor), PET scan, Octreoscan
- Pre-op tx: alpha blocker FIRST (phenoxybenzamine, prazosin) to reduce catecholamine induced vasoconstriction (increases the intravascular volume). THEN do beta blocker!
- Will need tumor resection. (TOC)
Most common cause of thyroid enlargement?
-Multinodlular goiter-surgery for cosmetic reasons, compressive sx.
Papillary Adenocarcinoma
- most common thyroid cancer (80%)
- radiation exposure puts one at risk
- good prognosis
- Thyroidectomy if greater than 1.5cm, b/l, with cervical node metastasis. Remove involved lymph nodes.
- Post op= Synthroid
Follicular Adenocarcinoma
- Nodule is rubbery, encapsulated.
- good prognosis
- Tx= total thyroidectomy
- cannot be diagnosed by FNA-need tissue histology.
Medullary Carcinoma
- Associated with MEN-II (autosomal dominant)-if genetic it is always in both lobes.
- Secretes Calcitonin (tumor marker)
- Dx= FNA
- Poor I uptake (unlike papillary and follicular)
- poor prognosis if LN spread.
- Tx: total thyroidectomy and median LN dissection.
Anaplastic Carcinoma
- Histo findings= giant cells, spindle cells
- poor I uptake
- Dx= FNA
- Tx: Total thyroidectomy + chemo. Surgical resection is palliative airway relief.
- Very poor prognosis.
- Mostly older pts.
- Rapidly expanding
