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Fayetteville VA Medical Center Grand Rounds January 16, 2015 Fayetteville, NC Thyroid Update Stanley A. Tan MD, MS, MPH, PhD, DTM&H, FACE, FACC, FCCP.

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Presentation on theme: "Fayetteville VA Medical Center Grand Rounds January 16, 2015 Fayetteville, NC Thyroid Update Stanley A. Tan MD, MS, MPH, PhD, DTM&H, FACE, FACC, FCCP."— Presentation transcript:

1 Fayetteville VA Medical Center Grand Rounds January 16, 2015 Fayetteville, NC Thyroid Update Stanley A. Tan MD, MS, MPH, PhD, DTM&H, FACE, FACC, FCCP

2 Disclosure Statement Nothing to disclose

3 Objectives After this grand rounds presentation, you should be able to: –1. Diagnose and manage hypothyroidism & hyperthyroidism –2. Evaluate and manage thyroid nodule(s) and goiters –3. Describe and manage thyroid cancers

4 Thyroid Anatomy Largest endocrine organ in body—20 g Right and left lobes Isthmus Pyramidal lobe Goiter = enlargement of thyroid –Diffuse –Nodular

5 Thyroid Physiology Iodide + tyrosine –MIT & DIT MIT + DIT = T 3 2 DIT = T 4 Thyroglobulin – storage Thyroid binding globulin – circulation Deiodinase –T4  T3

6 Thyroid Physiology Hypothalamic-Pituitary-Thyroid Axis –TRH (stimulates TSH & Prolactin) –TSH –T4 & T3 – Negative feedback Thyroid C-cell –Calcitonin –Thyroid Medullary Carcinoma (MEN type II)

7 Thyroid Diagnostic Evaluation TSH Free T4 –Old tests: T4, T3 uptake, FTI T3—Total & Free T3 Thyroid Peroxidase Antibody –Old test: Anti (thyroid) microsomal antibody Thyroglobulin Antibody Thyroglobulin

8 Thyroid Imaging Thyroid Ultrasound Scan –Anatomical RAI Thyroid Uptake & Scan –Physiologic & Anatomical –Uptake High: Graves’, Hashimoto Thyroiditis, Plummer’s Low: Hypothyroidism, exogenous thyroid or iodine, Subacute Thyroiditis –Scan Graves—Diffuse Hashimoto—Diffuse or patchy Plummer’s—Multi hot nodules Cold nodule—1-5 % malignancy

9 FNA Thyroid Biopsy Solitary Nodule “Cold” nodule –If negative, observe; repeat ultrasound scan 6 mo, rebiopsy if larger; continue observe if stable –If indeterminate, thyroid suppression; ultrasound 6 mo later, rebiopsy if larger or not shrinking

10 Hypothyroidism Symptoms –Weight gain, tired, sleepy, cold intolerance, constipation Signs –Myxedema facie, dry skin, scalp hair loss, brittle nail, periorbital edema, decreased DTR –Goiter Hashimoto thyroiditis, adenomatous No goiter: Idiopathic Primary Hypothyroidism

11 Hypothyroidism Diagnostic Studies –TSH, Free T4, Thyroid Peroxidase Antibody –Thyroid Ultrasound Scan Therapy –Levothyroxine –Dessicated Thyroid –Liothyronine

12 Hyperthyroidism Graves –Graves opthalmopathy –Goiter –Hyperthyroidism –Thyroid Stimulating Immunoglobulin (TSI) Hashimoto Thyrotoxicosis –Thyroid Peroxidase Antibody Plummer’s Disease –Hyperthyroid Multinodular Goiter

13 Hyperthyroidism Subacute Thyroiditis –Painful Goiter –Elevated Sed Rate –Decreased RAI Thyroid Uptake Acute Suppurative Thyroiditis Struma Ovarii Exogenous thyroid Secondary—TSH producing pituitary tumor

14 Goiter Diffuse –Hashimoto Thyroiditis –Graves’ Disease –Subacute Thyroiditis –Postpartum, Silent, Painless Thyroiditis –Adenomatous Goiter Multinodular –Plummer’s Disease –Adenomatous Multinodular Goiter Solitary Nodule

15 Evaluation of Thyroid Nodule FNA Thyroid Biopsy –Solitary Nodule –Dominant Nodule in a Multinodular Goiter –“Cold” Nodule If benign, observe, repeat ultrasound scan in 6 mo If indeterminate, suppress, repeat scan, rebiopsy if not shrinking or enlarging

16 Thyroiditis Hashimoto Thyroiditis Subacute Thyroiditis Postpartum, Silent, or Painless Thyroiditis Acute Infectious Thyroiditis Riedel’s thyroiditis

17 Hashimoto Thyroiditis Chronic lymphocytic thyroiditis Associated Polyglandular auto-immune disease (Schmidt’s Syndrome) Thyroid Peroxidase Antibody Transient hyperthyroidism (Hashimoto Thyrotoxicosis), euthyroidism, then hypothyroidism

18 Thyroid Cancer Thyroid Papillary Carcinoma Thyroid Follicular Carcinoma Thyroid Medullary Carcinoma Undifferentiated Thyroid Carcinoma Lymphoma

19 Thyroid Carcinoma Thyroidectomy High dose I-131 radiation therapy Synthroid suppression –Non-detectable TSH Yearly Thyroglobulin level RAI Total Body Scan –Year anniversary –Thyrogen stimulated

20 Thyroid Carcinoma Thyroid Papillary Carcinoma –Local lymph node invasion Thyroid Follicular Carcinoma –May be mixed with papillary –May be T4 producing—can cause hyperthyroidism with metastases –Hematogenous metastases to bone

21 Thyroid Medullary Carcinoma Thyroid C-Cells Calcitonin MEN Type II –Sipple Syndrome –Pheochromocytoma, Thyroid Medullary Carcinoma, Parathyroid Adenoma –Autosomal Dominant Surgery


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