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Stanley A. Tan MD, MS, MPH, PhD, DTM&H, FACE, FACC, FCCP

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Presentation on theme: "Stanley A. Tan MD, MS, MPH, PhD, DTM&H, FACE, FACC, FCCP"— Presentation transcript:

1 Stanley A. Tan MD, MS, MPH, PhD, DTM&H, FACE, FACC, FCCP
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 = T3 2 DIT = T4
Thyroglobulin – storage Thyroid binding globulin – circulation Deiodinase T4  T3

6 Thyroid Physiology Hypothalamic-Pituitary-Thyroid Axis Thyroid C-cell
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 RAI Thyroid Uptake & 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 Signs
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 Therapy
TSH, Free T4, Thyroid Peroxidase Antibody Thyroid Ultrasound Scan Therapy Levothyroxine Dessicated Thyroid Liothyronine

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

13 Hyperthyroidism Subacute Thyroiditis Acute Suppurative 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 Multinodular Solitary Nodule 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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