A Systematic Approach to Managing Goitre
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This document provides an overview of goitre (enlargement of the thyroid gland) including its definition, anatomy, functions, classifications, clinical features, investigations, and treatment options. It discusses the etiology, types and treatment of thyroid cancers. It also covers thyroiditis, imaging, histopathology, tests, and medical and surgical treatment approaches for hyperthyroidism and hypothyroidism including anti-thyroid drugs, thyroidectomy, and radioiodine therapy. The document emphasizes the importance of a systematic clinical approach and awareness of red flags when evaluating patients with goitre.
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A Systematic Approach to Managing Goitre
- 1. A Systematic Approach to Goitre Chea Chan Hooi MD, MS, FMAS, DMAS, CMIA, AMM Borneo Medical Centre (Miri) 23rd November 2019
- 2. Content • Definition • Anatomy • Function • Classification • Clinical features • Investigations • Treatment options • Medicine • Surgery • Radioiodine • Q&A
- 3. Definition • Goitre Enlargement of thyroid gland • Thyroxine (T4) Hormone produced by thyroid gland • Triiodotyronine (T3) The active form of thyroid hormone • Hypothyroidism Inadequate hormone • Hyperthyroidism Excessive hormone • Thyrotoxicosis Excessive hormone with fullblown symptoms
- 4. Anatomy • Butterfly shaped • 30 - 50% of population have pyramidal lobe
- 5. Function • Cardiac • Increase heart rate • Increase cardiac output • Respiratory • Increase respiration rate • Biochemical • Increase basal metabolic rate • Increase protein and carbohydrate metabolism • Nervous system • Potentiates brain development • Increase sympathetic activity • Reproductive • Increase endometrial thickness
- 6. Classification of thyroid disorders • Anatomical • Solitary nodule • Dominant nodule of MNG • Multinodular goitre (MNG) • Diffuse goitre • Functional • Hyperthyroidism (↑) • Hypothyroidism (↓) • Etiology • Infective • Neoplastic • Benign • Malignant • Degenerative • Inflamatory • Congenital • Autoimmune • Traumatic • Iatrogenic • Vascular • Endocrinopathy
- 7. Thyroid cancers • By histology • Follicular cells • Differentiated • Follicular • Papillary • Poorly differentiated • Undifferentiated (Anaplastic) • Non-follicular cells • Parafollicular - Medullary TC • Lymphatics - Lymphoma
- 8. PTC FTC Etiology Sporadic Endemic goitre Incidence Traditionally PTC < FTC but PTC incidence rising Age (y/o) 20 - 40 30 - 50 Diagnosis Goitre with lymph node mets Goitre with hematogenous mets Microscopy FNAC - Orphan Annie eye nuclei, Psammoma bodies HPE - Angioinvasion, capsular invasion Spread Lymphatic Hematogenous Recurrence rate 20% 30% Death from disease 10% 25%
- 9. Thyroiditis • Etiology • Infective Suppurative (rare) • Inflamatory Subacute granulomatous, radiation • Auto-immune Hashimoto, post-partum, subacute lymphocytic • Traumatic Direct trauma • Iatrogenic Amiodarone, interferon, lithium, radiotherapy, RAI (1%) • Idiopathic Riedel • Symptom • Painful > Painless • Hyper (3-6/52) --> hypo (3-6/12) --> euthyroid • Women > men
- 11. History • Compressive symptoms • Malignancy component • Risk factors • Red flags • Metastatic symptoms • Thyroid status • Hyper or hypothyroidism symptoms • Past thyroid or any neck surgery
- 12. Physical examination • Goitre? • Morphology • STN • MNG • Dominant nodule of MNG • Diffuse • Signs of malignancy • Thyroid function status • Eye signs • General thyrotoxicosis • Graves disease • Metastatic signs
- 17. Pemberton sign
- 18. Graves eye signs NO SPECS Class 0 None Class 1 Only signs (lid retraction ± lag) Class 2 Soft tissue (conjunctival & lids edema, injection) Class 3 Proptosis Class 4 Extraocular muscles involvement Class 5 Corneal involvement Class 6 Sight loss (usually CNII)
- 19. Imaging - Ultrasonography • The first investigation of choice • Role • Screening - exposed to neck radiation, FH of throid ca • Diagnostic & guide FNAC • Follow-up • Therapeutic in guiding RFA • TI-RADS score
- 21. Histopathology • FNAC • The standard • Image-guided to target solid component of lesion • Can be therapeutical for cyst fluid aspiration • Not applicable for follicular neoplasm • Core needle biopsy • Anaplastic or poorly differentiated TC • Seldom • Excision/Incision biopsy • Discrete lymph nodes • Cutaneous extension
- 23. Other tests • TFT • TSH • T4 • T3 • Iodine deficiency, in the earliest stages or relapse of thyrotoxicosis • T3:T4 ratio low in destruction- induced thyrotoxicosis (thyroiditis) vs high in Graves • Antibodies • Anti-TPO • Anti-Tg • Thyroglobulin • ECG • CXR • CT scan
- 24. Treatment options • Cancer • Surgery • Radioiodine • Hyperthyroidism • Medical • Radioiodine • Surgery • Thyroiditis • Medical • Less is more
- 25. Anti-thyroid drugs • Carbimazole is usually the first choice, more rapid control, option of OD dose, less tablet burden • PTU recommended in 1st trimester of pregnancy, less teratogenic, less secretion in breast milk, more hepatotoxic • Adverse effect • Altered taste sensation, rash (1:20), agranulocytosis (1: 1000 - 3000, 2PTU:CMZ) • Strategy • Titration • Block & replace • Higher risk for relapse • Men, <40 y/o, large goitre, eye involvment, high starting TSI level and drug dosage needed, previous relapse • Smoking
- 27. • By access • Open • Via collarneck incision • Endoscopic • Remote • Facelift incision approach • Breast-axillary approach • Locoregional • Transoral
- 44. Complications post thyroidectomy Early • Haemorrhage • RLN injury • SSI • Other adjacent organ injury • Surgical hypothyroidism • Surgical hypocalcaemia • Tracheomalacia Late • Chronic hypocalcaemia • Conscious about scar
- 45. Radioiodine therapy • I-131 • Thyroid cells will take up iodine from blood stream • Indications • Adjuvant post total thyroidectomy for DTC • Graves disease: 1st choice if younger, large goitre, very high T4, high TSI • Risk of precipitating thyroid storm: elderly, poorly controlled thyroid function • Absolute contraindication: pregnancy
- 46. Precautions • Stop ATDs 2/52 prior or administer rhTSH • Only in SGH, Kuching • Do not conceive, do not breast feed x 6/12 • Minimise contact with others, especially small children and pregnant women • Drink plenty of water • Clean the toilet thoroughly regularly and flush 3x after use
- 47. Conclusion • Goitre is common • Variety of morphologic presentation, etiologies • Beware of red flag symptoms that suggest malignancy • Anatomical, functional & diagnostic clinical assessment • Transoral thyroidectomy is the next frontier in thyroid surgery
- 48. TQ! Q&A?