Thyroid Biopsy

Follicular Adenoma
Benign neoplasms derived follicular cells
Usually Solitary
Painless Mass Dx'd at Physical Exam
Usually "Cold" But Can Be "Hot"
Can Use Ultrasound
Can Use Fine Needle Aspiration
Definitive Dx - Histologic Examination

Carcinoma of the Thyroid Pathogenesis

Ionizing Radiation - 2nd Decades
Head and Neck Lesions
Tonsils, Acne, Tinea Capitis
Hiroshima, Chernobyl, 3-Mile Island?
RET and PTC Concogene

Carcinoma of the Thyroid Generalizations

<1% of Cancer-Related Deaths
Most Occur in Adults
Adults; F > M; Estrogen Related
Childhood: Equally Related

Carcinoma of the Thyroid Subtypes

Papillary Carcinoma (75% to 85%)
Follicular Carcinoma (10%-20%)
Medullary Carcinoma (~5%)
Anaplastic Carcinoma (<5%)

Papillary Carcinoma

Most Common (80%)

Previous Ionizing Radiation
Neck Mass
May Have Local Lymph Node Involved
10 Year Survival - 85%

Follicular Carcinoma
Second Most Common (20%)
Older Age Group
I2 Deficiency (Goiters)

Solitary Cold Nodule

Tend to Metastasize (Lung, Bone, Liver)
Surgery and Thyroid Hormone

Medullary Carcinoma

Neuroendocrine from Parafollicular (C) Cells

Calcitonin Secretion
May Elaborate CEA, VIP, Serotonin
80% Solitary
20% MEN (IIa or IIb) - RET Proto-oncogenic
Maybe familial
50% - 5 year Survival

Anaplastic Carcinoma
Among the most aggressive Ca's
Elderly
Endemic Goiter
Death ~ 1 year

Incidence of Thyroid Abnormalities

1,500 Consecutive Patients
Abnormality
PT's w/Thyroid Disease
Nodular Goiter
Multinodular
Hot Nodule

Thyroiditis
Hypothyroidism
Cancer

No (% - Total)
90 (6%)
30 (2%)
13 (0.9%)
9 (0.6%)*
8 (0.5%)
6 (0.4%)
0 (0)
* 3 Adenomas, 1 Cyst

Common Symptoms of Thyroid Dysfunction

Hypothyroidism ( TSH/FT4 )
Fatigue
Weight Gain
Cold Intolerance
Dry Skin
Depression
Bradycardia

Thyroid Dysfunction - Associated

Abnormal Tests

Cholesterol
Anemia (NC/NC)
Na++
CPK/LDH
Alk Phos

Common Symptoms of Thyroid Dysfunction

Hyperthyroidism ( TSH/ T4/ T3)
Fatigue
Weight Loss
Heat Intolerance
Hyperhidrosis
Nervousness
Palpitations

Serum Thyroid Testing

Thyroid Stimulating Hormone (TSH)

Total T4 or Total T4
Free T4 or Free T3
Thyroid Antibodies
Thyroglobulin - Post Rx of Ca
Calcitonin - Medullary Carcinoma of Thyroid
(C-Cells)

Thyroid Disease - First Step

TSH - Single Most Important Test

Prevalence of Thyroid Dysfunction

Hypothyroidism

Prevalence

Lab

Subclinical

5-17%

TSH & FT4 - N

Hypothyroidism

2%

TSH & FT4 -

Prevalence of Thyroid Dysfunction

Hyperthyroidism
Subclinical
Hyperthyroidism

Prevalence
0.1-6.0%
0.2%

Hyperthyroidism Lab

Subclinical - TSH < 0.1

"Overt" - TSH < 0.1

FT4 - N & FT3 - N

FT4 - & FT3 -

American Thyroid Association

Thyroid Screening - TSH > 35y/o then q 5 years

Arch Int Med 16:1573-1575, 2000.

Parathyroids
Controlled by Level of Ionized Ca ++
Ca++
PTH
Ca++
PTH

PTH
Osteoclasts Activation---> Ca++
RT Absorption of Ca++
Vitamin D to di-OH-vit D
Urinary Phosphate Excretion
GI Calcium Absorption

PTH & Calcium & PTH

Adenoma
PTH ------------>
Ca++

Ca++ ---------> PTH

PTH---------> Ca++
RF

Ca++------------> PTH

Hyperparathyroidism - Clinical
Ionized Calcium
Total Calcium
PTH
"Painful bones, renal stones, abdominal groans, and &
psychic moans"
GI - Constipation, Peptic Ulcers, Pancreatitis
CNS - Depression, Lethargy, and Seizures
Neuromuscular - Weakness, Hypotonia
Polyuria and Polydipsia

Calcium - Three (3) Forms

Free - Calcium ~ 50% - Physiologic
Protein Bound Calcium ~ 40%
Calcium Complexes ~ 10%
Total Calcium = 100%

CA/P Equilibrium & PTH

[Ca++] x [ PO] = Constant
RF----------> Ca++ x PO------------> PTH
Cancer-------> Ca++ x PO------------> PTH
Adenoma------> PTH -----> Ca++ x PO

Ca++ then P
Hyper PTH

Malignancy,

Causes of Hypercalcemia

Malignancy - Metastatic Breast, Lung, Prostate,

& Multiple Myeloma
Primary Hyperparathyroidism
Drugs (Thiazides, etc.)
Acute and Chronic Renal Disease
Granulomatous Disease

Hypercalcemia in Different Malignancies

Multiple Myeloma - 50%

Head and Neck Cancer - 16% & 56%
Malignant Lymphoma - 30%
Breast - 10% to 25%
Lung - 20%

Hyperparathyroidism
Primary
Autonomous
Adenoma
Hyperplasia
Carcinoma (<1%)

Secondary
Chronic Renal Insufficiency
(BUN : CR )

Primary Parathyroid Hyperplasia

Usually sporadic, but may occur in MEN-I or
MEN-II
All 4 glands involved microscopically
Predominantly chief cells, sometimes only clear
cells, stromal fat decreased

Parathyroid Carcinoma
Rare, but aggressive
Usually presents as neck mass
Decrease fibrous bands and nodules
Invasion & nodal metastases (~50%)

Secondary Hyperparathyroidism

Chronic Renal Insufficiency - Most Common

Enlarged Parathyroid Glands
Chief (C) Cell Hyperplasia
Osteoporosis
Osteitis Fibrosa Cystica

Hyperparathyroidism Systemic Pathology

Bones: Osteoclastichyperplasia, reactive new
bone, osteoporosis, hemorrhage, fibrosis, cysts,
and osteoclast nodules
Kidneys: Stones,nephrocalcinosis
Pancreas: Ductal stones
Other Sites: Metastatic calcifications

Hypoparathyroidism
Surgical Removal of Thyroid (Whoops??)
Idiopathic/Autoimmune

Hypoparathyroidism - Clinical
PTH , Ca++ , P
Neuromuscular Sxs:
Chvostek's & Trousseau's Signs
Carpopedal Spasms
Seizures