Sei sulla pagina 1di 7

Goiter and Thyroid Cancer Authors: Stephanie Lee, M.D.,Ph.D., Anastassios G. Pittas, M.D.

Color Key Important key words or phrases. Important concepts or main ideas.

1. Goal
To understand the causes of thyroid enlargement and the clinical evaluation of this condition.

2. Learning Objectives

To understand the etiology, pathophysiology, symptoms and management of non-toxic goiter and thyroid nodules. To understand the etiologies, evaluation and management of solitary thyroid nodule To understand the cell of origin, pathophysiology, risk factors and management of thyroid carcinoma including: papillary, follicular, lymphoma, anaplastic, and medullary.

Please note: This lecture is tightly linked to the pathology lecture on Thyroid Cancer

3. Non-Toxic Goiter
A non-toxic goiter is any enlargement of the thyroid gland that does not result from an inflammatory or neoplastic process and is not associated with hypothyroidism or hyperthyroidism. Endemic goiter is defined as thyroid enlargement in more than 10% of the population while sporadic goiter is a result of factors that do not affect the general population. Nontoxic goiter is more common in women than men.

3.1. Etiology
There are various possible etiologies for a non-toxic goiter including: 1. Iodine deficiency (defined as intake < 50 mcg per day). This is not uncommon in the US, as about 1 in 4 women over 40 years old may have moderate iodide deficiency. 2. Iodine excess in glands with pre-existing inflammation 3. Goitrogens are substances that can cause a goiter. Goitrogens can be divided into: o Drugs such as lithium (inhibits release of thyroid hormone causing hypothyroidism and secondary goiter) or amiodarone (high iodide content may cause inhibition of thyroid hormone synthesis. Amiodarone may also induce inflammatory destruction of the thyroid)

Foods such as the Brassica family of vegetables, soy bean and cassava 4. Dyshormonogenesis: inherited defect in the thyroid hormone biosynthetic pathway will cause a secondary (compensatory) goiter. 5. Radiation. Exposure to radiation at a young age increases risk for goiter, nodules and cancer as well as hypothyroidism. Abnormal thyroid structure and function may appear many years (10-20) after exposure to radiation. 6. Unknown. In most cases of goiter, a readily identifiable cause is not found. It is believed that genetic predisposition under the influence of unknown environmental factors may lead to formation of goiter.

3.2. Pathophysiology
The histopathology varies with the etiology and duration of the goiter. Initially, there is a uniform hyperplasia but as the disorder persists, the thyroid architecture loses its uniformity with development of areas of involution or fibrosis interspersed with areas of focal hyperplasia resulting in multiple nodules and the formation of a multinodular goiter (MNG). Many diffusely enlarged goiters are composed of multiple soft nodules which cannot be palpated individually. Accumulation of colloid may also contribute to the nodularity of the goiter. Hemorrhage or cystic degeneration of a hyperplastic nodule can result in a sudden focal increase in size of a goiter. In areas of growth, regression and hemorrhage, irregular calcifications can occur. The evolution of this multinodular stage is accompanied by the development of "hot" (hyperfunctioning) and "cold" (non-functional) nodules on thyroid nuclear scan (Technicium 99m pertechnetate or I-123 radioiodine) with functional autonomy (see Figure 1). Figure 1

Nodules within a MNG are due to a combination of monoclonal and polyclonal expansion. The natural history for goiters is a continuous accumulation of multiple autonomously functioning, or "hot" nodules leading to mild thyrotoxicosis after several decades (developing into a toxic multinodular goiter, see section on thyrotoxicosis).

3.3. Clinical Findings


Initially a small goiter is usually asymptomatic. As the goiter enlarges the patient may develop structural or functional problems:

3.3.1. Structural
The patient may notice a pressure on the lower portion of the anterior trachea and esophagus causing a cough, dyspnea, or dysphagia. Dysphonia (hoarseness) may occur due to compression of the recurrent laryngeal nerve. This is uncommon and when present, a malignant process should be suspected. Sudden enlargement due to hemorrhage into a pre-existing nodule or cystic degeneration of a nodule can cause pain and/ or obstructive symptoms. Superior mediastinal obstruction may occur. This can also be induced when the patients' arms are raised above the head resulting in suffusion of the face, filling of the external jugular veins and, rarely, syncope (Pemberton's sign).

3.3.2. Functional
As the thyroid enlarges, areas of autonomy may lead to thyrotoxicosis (see Hyperthyroidism lecture). In long-standing goiter with areas of autonomy, excess iodine intake, often medically given in the form of an iodinated contrast CT or amiodarone, may result in the development of thyrotoxicosis (Jodbasedow phenomenon). Hypothyroidism may also be seen (e.g. iodine deficiency, dyshormonogenesis).

3.4. Laboratory and Imaging Evaluation


To evaluate thyroid function (hypothyroidism or hyperthyroidism), TSH is measured. Thyroid autoantibodies (anti-Thyroid Peroxidase or anti-TPO) are often checked to determine risk for autoimmune thyroid disease. If a dominant nodule or a history of head and neck radiation is obtained, the patient should be evaluated for thyroid cancer (see below). To evaluate structure, often physical examination by an experienced thyroidologist is adequate. Occasionally, thyroid imaging, most often with an ultrasound, is done to define the size and nodularity of the goiter.

3.5. Treatment
Factors that are obviously linked with the goiter such as iodine deficiency should be treated.. If thyrotoxicosis or hypothyroidism are present, they need to be treated. Surgery is usually recommended if there is a suspicion of malignancy, local obstructive symptoms or for cosmetic reasons.

Surgical Instruments List


for the Thyroidectomy procedure: (Quantity recommended is in parentheses)

(1) nylon needle holder (4) short needle holders (6) large towel clips (2) straight mayo scissors (1) baby Metzenbaum scissors (1) regular Metzenbaum scissors (1) nurses scissors (1) fine iris scissors (4) #3 knife handles (1Calibrated) (1) #7 knife handle (6) #10 blades (4) #15 blades (1) short plain forceps (1) short multitoothed forceps (2) vascular forceps (1) fine Cushing forceps (2) regular Cushing forceps (1) Freer elevator (2) Kelly clamps (2) Ochners (36) Criles (12) curved mosquito clamps (6) straight mosquito clamps (2) Babcock clamps (2) Senn rakes (2) pairs of double skin hooks (1) pair of single skin hooks (1) pair vein retraction (1) adenoid suction (1) pair Green retractors (1) double-ended medium-small Richardson retractors

(1) McCabe nerve dissector (5) bullets (peanuts) (2) army-navy retractors (1) fiberoptic headlight unit (1) bipolar cautery unit (1) K1 Gardlok dissector (1) Penrose drain (1) pack Steri Strips (1) pack I-Meds The above are the essential surgical instruments recommended. Other standard surgical supplies are typically in use during thyroidectomies and other procedures, such as these: (the list is not all-inclusive) (1) Jobst arthrombic pump (1) Narkomed Anesthetic machine, with appropriate vaporizer for the gas utilized. (1) set of volatile general anesthesia bottles: Choice of several typically used in thyroidectomies: Enflurane (Ethraneused in my operation on 2-10-92); halothane, sevoflurane(desflurane), isoflurane, and methoxyflurane. There may be additional agents used I have not come across in textbooks :) (1) Endotracheal Tube assembly, Hilo cuff (1) Datascope and Pulse Oximeter unit (1) Brethaid Humivent

(1) O2 cannula delivery system (1) angiocath set (1) Heart monitor with gel pads (1) pulse oximeter (1) Norcuron-OR (1) Webril (1) Esophageal Stehoscope (1) box laparotomy sponges (1) stat temp fever detector (1) surgical incision marking pen (1) surgical prep razor (1) complete set of Kerlix fluffs, gauzes, and abdomenal surg pads (1) complete set of sutures for all layers of fascia (1) Foley catheter and drainage container (1) pack Intravenous starter kit and IV tubing (1) pack IV extension kit (1) Code Blue defibrillation unit (1) rack of extra surgical forceps (all sizes and shapes) Back to Thyroidectomy technique summary page

Potrebbero piacerti anche