Benign Thyroid Disease: Sarah Rodriguez, MD Francis Quinn, MD

Benign Thyroid Disease
Sarah Rodriguez, MD Francis Quinn, MD
Benign Thyroid Disease
Benign Nontoxic Conditions
Benign Toxic Conditions
Diffuse and Nodular Goiter Toxic Multinodular Goiter Graves Disease Toxic Adenoma
Inflammatory Conditions

Chronic (Hashimotos) Thyroiditis Subacute (De Quervains) Thyroiditis Riedels Thyroiditis
Anatomy
Anatomy
Histology
Thyroid Hormone Synthesis

1. Iodide trapping 2. Oxidation of iodide and iodination of thyroglobulin 3. Coupling of iodotyrosine molecules within thyroglobulin (formation of T3 and T4) 4. Proteolysis of thyroglobulin 5. Deiodination of iodotyrosines 6. Intrathyroidal deiodination of T4 to T3
Hypothalamic Pituitary Axis
Effects of Thyroid Hormone
Fetal brain and skeletal maturation Increase in basal metabolic rate Inotropic and chronotropic effects on heart Increases sensitivity to catecholamines Stimulates gut motility Increase bone turnover Increase in serum glucose, decrease in serum cholesterol
Goitrogenesis
Iodine deficiency results in hypothyroidism Increasing TSH causes hypertrophy of thyroid (diffuse nontoxic goiter) Follicles may become autonomous; certain follicles will have greater intrinsic growth and functional capability (multinodular goiter) Follicles continue to grow and function despite decreasing TSH (toxic multinodular goiter) Sporadic vs. endemic goiter
Presentation
Usually picked up on routine physical exam or as incidental finding Patients may have clinical or subclinical thyrotoxicosis Patients may have compressive symptoms: tracheal, vascular, esophageal, recurrent laryngeal nerve
Flow-Volume Loop
Tracheal Compression
Gross and Microscopic Pathology Multinodular Goiter
Treatment of Diffuse or Multinodular Goiter
Suppressive Therapy Antithyroid Medications: Propylthiouracil and Methimazole I-131 Surgical Therapy
Graves Disease
Most common form of thyrotoxicosis Autoimmune etiology with familial predisposition Thyroid receptor stimulating antibody unique to Graves disease; other autoantibodies present (TgAb, TPOAb) Affects females five times more often than males
Presentation of Graves Disease
Thyrotoxicosis: palpitations, nervousness, easy fatigability, diarrhea, excessive sweating, intolerance to heat, weight loss Eye signs Diffuse goiter
Graves Ophthalmopathy

Class one: spasm of upper lids with thyrotoxicosis Class two: periorbital edema and chemosis Class three: proptosis Class four: extraocular muscle involvement Class five: corneal involvement Class six: loss of vision due to optic nerve involvement
Graves Gross and Microscopic Pathology
Treatment
Antithyroid Drugs
May require prolonged therapy
Radioactive iodine
May worsen ophthalmopathy unless followed by steroids

Make patient euthyroid prior to surgery Potassium iodide two weeks prior to surgery can decrease the vascularity of the gland
Surgery

Thyrotoxicosis and Thyroid Storm
Acute thyrotoxicosis: beta-blockers, barbiturates, cholestyramine Thyroid storm: manage aggressively with beta-blockers, calcium channel blockers, PTU, methimazole, sodium iodide, digitalis or diuretics for heart failure, fluid and electrolyte management
Toxic Adenoma
Autonomously functioning thyroid nodule hypersecreting T3 and T4 resulting in thyrotoxicosis (Plummers disease) Almost never malignant Manage with antithyroid drugs followed by either I-131 or surgery
Chronic Thyroiditis
Also known as Hashimotos disease Probably the most common cause of hypothyroidism in United States Autoantibodies include: thyroglobulin antibody, thyroid peroxidase antibody, TSH receptor blocking antibody
Gross and Microscopic Pathology of Chronic Thyroiditis
Presentation and Course
Painless goiter in a patient who is either euthyroid or mildly hypothyroid Low incidence of permanent hypothyroidism May have periods of thyrotoxicosis Treat with levothyroxine
Subacute Thyroiditis
Also known as De Quervain's thyroiditis Most common cause of thyroid pain and tenderness Acute inflammatory disease most likely due to viral infection Transient hyperthyroidism followed by transient hypothyroidism; permanent hypothyroidism or relapses are uncommon
Treatment of Subacute Thyroiditis
Symptomatic: NSAIDS or a glucocorticoid Beta-blockers indicated if there are signs of thyrotoxicosis Levothyroxine may be given during hypothyroid phase
Histopathology of Subacute Thyroiditis
Riedels Thyroiditis
Rare disorder usually affecting middleaged women Likely autoimmune etiology Fibrous tissue replaces thyroid gland Patients present with a rapidly enlarging hard neck mass
Histopathology of Riedels Thyroiditis
Sources (photographs and figures)

Netter FH. Atlas of Human Anatomy 2nd ed. Novartis 1997. Plate 68 and 70. Braverman LE and Utiger RD. Werner and Ingbars The Thyroid A Fundamental and Clinical Text. 8th ed. Lippincott Williams and Wilkins 2000. Fig 76.1, Fig 76.2, Fig 29.16 Damjanov I and Linder J. Pathology A Color Atlas. Mosby 2000. Fig 10-12, Fig 10-13, Fig 10-14, Fig 10-16, Fig 10-17, Fig 10-19 Burkitt HG, Young B and Heath JW. Wheaters Functional Histology A Text and Color Atlas. Churchill Livingstone 1993. Fig 17.7 Greenspan FS and Gardner DG. Basic and Clinical Endocrinology 6th ed. Lange 2001. Fig 7-5, Fig 7-21

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Benign Thyroid Disease: Sarah Rodriguez, MD Francis Quinn, MD

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Benign Thyroid Disease

Sarah Rodriguez, MD Francis Quinn, MD

Benign Thyroid Disease

Benign Nontoxic Conditions

Benign Toxic Conditions

Chronic (Hashimotos) Thyroiditis Subacute (De Quervains) Thyroiditis Riedels Thyroiditis

Thyroid Hormone Synthesis

Hypothalamic Pituitary Axis

Effects of Thyroid Hormone

Gross and Microscopic Pathology Multinodular Goiter

Treatment of Diffuse or Multinodular Goiter

Presentation of Graves Disease

Graves Gross and Microscopic Pathology

May require prolonged therapy

May worsen ophthalmopathy unless followed by steroids

Thyrotoxicosis and Thyroid Storm

Gross and Microscopic Pathology of Chronic Thyroiditis

Presentation and Course

Treatment of Subacute Thyroiditis

Histopathology of Subacute Thyroiditis

Histopathology of Riedels Thyroiditis

Sources (photographs and figures)

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