The Thyroid: No mystery. Just need all the pieces to the puzzle.

The Thyroid: No mystery. Just need all the pieces to the puzzle. Todd Chennell, MS, RN ANP-C Endocrine surgery University of Rochester 2018 1 According to the American Thyroid Association, 12 percent of Americans will develop a thyroid condition at some point in their lives. Some estimates suggest up to 40 percent of the population suffers from at least some level of underactive thyroid. Women especially older women are the most susceptible group for developing hypothyroidism. Others at risk include the elderly or who have other existing autoimmune diseases like type 1 diabetes, rheumatoid arthritis and celiac disease. www.ata.org 2 Neck Anatomy www.ata.org 3 1

Basic Anatomy of the neck www.pyroenergen.com 4 Thyroid hormones: how it works The hypothalamus releases TRH (thyrotropin releasing hormone), which stimulates the release of TSH (thyroid stimulating hormone) from the pituitary gland. TSH makes its way to the thyroid and promotes its growth and development. The release of T3 and T4 is controlled by TSH. The liver in turn metabolizes the thyroid hormones and regulates their systemic endocrine effects. Regulates Metabolism so your cells function properly www.ata.org 5 6 2

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10 Common causes of Hypothyroidism Amiodarone Autoimmune/Hashimoto's thyroiditis Inadequate thyroid replacement Iodine deficiency I-131 treatment for thyroiditis/thyroid cancer Lithium Previous thyroid surgery Radiation Transient or postpartum thyroiditis Trauma to head/neck www.ata.org 11 Lab s for Hypothyroidism TSH, free T4 Anti thyroid antibodies anti-tpo S-CK, s-cholesterol, s-triglyceride Normochromic or macrocytic anemia ECG: Bradycardia www.ata.org 12 4

Hashimoto s disease Hashimoto s disease is the most common cause of hypothyroidism in the United States. Hashimoto s disease, also called chronic lymphocytic thyroiditis or autoimmune thyroiditis, is a form of chronic inflammation of the thyroid gland. The inflammation results in damage to the thyroid gland and reduced thyroid function or hypothyroidism, meaning the gland doesn t make enough thyroid hormone for the needs of the body. 13 Hashimoto s disease diagnosed Diagnosis begins with a physical examination and medical history. An enlarged thyroid gland may be detectable during a physical exam and symptoms may suggest hypothyroidism. We will then do several blood tests to confirm the diagnosis. Generally, a TSH reading above normal and a normal or elevated T4 means a person has hypothyroidism. Normal range of TSH is 0.45-4.25 14 Chronic Thyroid Disease Issues Goiter. Constant stimulation of your thyroid to release more hormones may cause the gland to become larger a condition known as a goiter. Heart problems. Hypothyroidism may also be associated with an increased risk of heart disease, primarily because high levels of lowdensity lipoprotein (LDL) cholesterol can occur in people with an underactive thyroid. Mental health issues. Depression may occur early in hypothyroidism and may become more severe over time. Hypothyroidism can also cause slowed mental functioning. 15 5

Chronic thyroid disease issues Peripheral neuropathy. Long-term uncontrolled hypothyroidism can cause damage to your peripheral nerves Myxedema. This rare, life-threatening condition is the result of long-term, undiagnosed hypothyroidism. Its signs and symptoms include intense cold intolerance and drowsiness followed by profound lethargy and unconsciousness. Infertility. Low levels of thyroid hormone can interfere with ovulation, which impairs fertility and birth defects 16 Thyroiditis Acute: due to suppurative infection of the thyroid Sub acute:also termed de Quervains thyroiditis/ granulomatous thyroiditis mostly viral origin Chronic thyroiditis: mostly autoimmune (Hashimoto s) 17 Acute Thyroiditis Bacterial Staph, Strep Fungal Aspergillus, Candida, Histoplasma, Pneumocystis Radiation thyroiditis Amiodarone (acute/ sub acute) Painful thyroid, ESR usually elevated, thyroid function normal 18 6

Starting replacement Hormone levothyroxin is the drug of choice for treatment of hypothyroidism The dosage, on a microgram per kilogram basis Most patients will require between 1.6 to 1.8 mcg of levothyroxin per kilogram of ideal body weight Its not perfect, its just a guide and will need to be adjusted!! It takes 6 weeks for full effect, followed by blood work every time you change doses 19 Natural thyroid hormone Desiccated porcine thyroid glands Contains T4 and T3 all natural Variable hormone content, efficacy across lots Some pigs are hyper/hypothyroid 20 Hyperthyroidism 21 7

Hyperthyroidism Symptoms Hyperactivity/ irritability/ dysphoria Heat intolerance and sweating Palpitations Fatigue and weakness Weight loss with increase of appetite Diarrhea Polyuria Oligomenorrhoea, loss of libido 22 Hyperthyroidism Signs continued Tachycardia (AF) Tremor Goiter Warm moist skin Proximal muscle weakness Lid retraction or lag Gynecomastia 23 24 8

Hyperthyroid causes Graves disease is the most common Toxic adenoma or Plummer's disease and toxic multinodular goiter (MNG) is the second in prevalence to Graves' disease. The prevalence of toxic nodular goiter increases with age and in the presence of iodine deficiency. Toxic adenoma or a toxic MNG is cause by the nodule or nodules autonomously producing thyroid hormone 25 Graves disease Graves disease, also known as toxic diffuse goiter, is the most common cause of hyperthyroidism in the United States. Hyperthyroidism is a disorder that occurs when the thyroid gland makes more thyroid hormone than the body needs. Graves disease is an autoimmune disorder, meaning the body s immune system acts against its own healthy cells and tissues. In Graves disease, the immune system makes antibodies called thyroid-stimulating immunoglobulin (TSI) that attach to thyroid cells. TSI mimics the action of TSH and stimulates the thyroid to make too much thyroid hormone. 26 How is Graves disease diagnosed We can sometimes diagnose Graves disease based only on a physical examination and a medical history. Laboratory tests confirm the diagnosis Ophthalmopathy: exophthalmos, lid lagophthalmoplegia Measuring TSH, T-4 and T-3 In making a diagnosis, we look for belownormal levels of TSH, normal to elevated levels of T4, and elevated levels of T3. 27 9

Graves disease continued, other testing The radioactive iodine uptake test measures the amount of iodine the thyroid collects from the bloodstream. High levels of iodine uptake can indicate Graves disease. A thyroid scan shows how and where iodine is distributed in the thyroid. In Graves disease, the entire thyroid gland is involved so the iodine shows up throughout the gland. The radioactive iodine test is also used for diagnosing toxic adenomas. 28 Diagnosis of Graves Disease Nuclear thyroid scintigraphy (I 123, Te 99 ) 29 Graves disease treatment options Thionamides inhibit central production of T3 and T4; immunosuppressive effect Methimazole starting dose 5-10mg a day can increase to BID-TID check TSH q-2 weeks. Do not use in pregnancy. Propylthiouracil- (PTU) 50 mg TID initially, can go up to 150 mg TID. Check TSH 2 weeks. preferred in pregnancy Side effects: hives, itching; agranulocytosis, hepatotoxicity, vasculitis Beta-blockade decrease CV effects 30 10

Graves treatment options continued Total thyroidectomy. The surgery is very similar to that for simple goiter, with the operation of total thyroidectomy it is the standard option. It is the only treatment that rapidly controls the thyrotoxicosis, and definitely is a permanent cure. Radioactive Iodine (131I) gives good results with a low dose, and can also be repeated if necessary. The risk of radioiodine-induced hypothyroidism after treatment is common. Radioactive iodine can not be used in patients with eye disease 31 Treatment for toxic nodules and toxic MNG Surgical excision for toxic adenomas and toxic MNG, in the form of a thyroid lobectomy. This is preferred as it works more quickly in controlling the thyrotoxicosis. Radioactive Iodine (131I) not as effective, and may need to be repeated. The risk of radioiodine-induced hypothyroidism after treatment is small, as the toxic nodule preferentially takes up the RAI, while suppressing uptake in the remaining thyroid, allowing it to be relatively protected. 32 Thyroid storm Thyroid storm or thyrotoxic crisis is a rare, but potentially life-threatening condition due to a massive release of thyroid hormones in patients with thyrotoxicosis. It is triggered by an episode of severe illness or physical stress in a toxic patient. The clinical features are dominated by a high fever, but other symptoms can occur such as tachycardia, hypertension, neurological symptoms (agitation, confusion, leading to coma) and gastrointestinal problems (vomiting & diarrhea). 33 11

Thyroid storm continued Hypertension may be followed by congestive heart failure, leading to hypotension and shock. Because thyroid storm is almost invariably fatal if left untreated, rapid diagnosis and aggressive treatment are critical. Once the diagnosis is suspected patients are best managed in an intensive care unit. Treatment is designed to: Reduce thyroid hormone secretion: antithyroid drugs and iodine Provide supportive therapy - external cooling, IV fluids, oxygen, steroids and beta-blockers 34 Thyroid Nodules work up 35 Thyroid nodules Thyroid nodules are solid or fluid-filled lumps that form within your thyroid Most thyroid nodules don't cause signs or symptoms. Occasionally, some nodules become so large that they can: Some can be felt Some can be seen, often as a swelling at the base of your neck Press on your windpipe or esophagus, causing shortness of breath, difficulty swallowing or changes in your voice 36 12

Overgrowth of normal thyroid tissue. Why this occurs isn't clear but such growth which is sometimes referred to as a thyroid adenoma Thyroid cyst. Fluid-filled cavities (cysts) in the thyroid most commonly result from degenerating thyroid adenomas Chronic inflammation of the thyroid (thyroiditis). Hashimoto's disease Multinodular goiter. "Goiter" is a term used to describe any enlargement of the thyroid gland Thyroid cancer. Although the chances that a nodule is malignant are small. Less than 5% 37 Thyroid Nodules continued A few thyroid nodules are cancerous but it's difficult to tell which nodules are malignant by symptoms alone. Although size isn't a predictor of whether a nodule is malignant or not, cancerous thyroid tumors are fixed masses that can grow quickly. Iodine deficiency. Lack of iodine in your diet can sometimes cause your thyroid gland to produce thyroid nodules. 38 Can I Make the Nodule Go Away by Taking Thyroid Hormone? Several studies reveal that suppression with thyroid hormone does not decrease the size of thyroid nodules. Therefore, unless a nodule is growing or becoming symptomatic, it is not necessary to suppress the nodule. In addition, suppression of a thyroid nodule would require long-term thyroidstimulating hormone (TSH) suppression, potentially increasing the risk of osteoporosis in these patients. 39 13

Thyroid fine needle aspiration (FNA) The FNA biopsy is the only non-surgical method that can differentiate malignant and benign nodules in most, but not all, cases. The needle is placed into the nodule several times and cells are aspirated in the needle by capillary action. The cells are placed on a microscope slide, stained, and examined by a pathologist. The nodule is then classified as nondiagnostic, benign, suspicious, or malignant. 40 Nodule on ultrasound 41 Biopsy 27g needle 42 14

Increased vascularity biopsy 43 Non-diagnostic indicates that there are an insufficient number of thyroid cells in the aspirate and no diagnosis is possible. Overall, 5 to 10% of biopsies are nondiagnostic Benign thyroid aspirations are the most common (as we would suspect since most nodules are benign) about 90% of the time. Malignant thyroid aspirations can diagnose the following thyroid cancer types: papillary, follicular variant of papillary, medullary, anaplastic, thyroid lymphoma, and metastases to the thyroid. 44 Thyroid Cancer Thyroid cancer arises when small tumors called thyroid nodules grow on the thyroid gland. Having a nodule on your thyroid is quite common, and 90% to 95% of thyroid nodules are noncancerous. However, those that are cancerous rarely spread through the body, or metastasize, and become life-threatening. higher risk if you have a family history of thyroid or other endocrine cancers 45 15

Thyroid Cancer continued Thyroid cancer often exhibits no thyroid disease symptoms, and is typically found during a routine examination. Malignant nodules tend to be firmer than benign nodules, so they can often be identified by touch. Testing includes a ultra sound and most often a fine needle aspirate (FNA) If FNA positive for cancer total thyroid is recommended. 46 Medullary thyroid cancer 47 PAPILLARY CANCER Most common, up to 80% of cases Found mostly in second & third decades and in the elderly Slow growing; metastasize via lymphatic's Best prognosis 48 16

Papillary thyroid cancer Stage 5-Year Relative Survival Rate I near 100% II near 100% III 93% IV 51 www.cancer.org 49 Follicular thyroid cancer Stage 5-Year Relative Survival Rate I near 100% II near 100% III 71% IV 50% www.cancer.org 50 Treatment for papillary Thyroid Cancer s Treatment is surgery in all cases. 90% cure/treatment is surgery I131 radio active iodine is only effective on papillary, follicular and Hurtle cell cancer I131 treatment is based on size of the cancer <1cm only surgery. The last piece of treatment is suppressive therapy with levothyroxin. <0.27 = running the patient hyperthyroid. 51 17

MEDULLARY CANCER Approximately 4% of thyroid cancers often multifocal Consider MEN type 2; screening of family members may be warranted More aggressive than papillary or follicular cancer 50% five-year survival if untreated Surgery only treatment 52 ANAPLASTIC CANCER Approximately 1% of thyroid cancers Most aggressive type of thyroid cancer Worst prognosis, with five-year survival less than 5% 53 Number of New Cases and Deaths per 100,000 The number of new cases of thyroid cancer was 14.2 per 100,000 men and women per year. The number of deaths was 0.5 per 100,000 men and women per year. These rates are age-adjusted and based on 2010-2014 cases and deaths. Lifetime Risk of Developing Cancer: Approximately 1.2 percent of men and women will be diagnosed with thyroid cancer at some point during their lifetime, based on 2012-2014 data. Prevalence of This Cancer: In 2014, there were an estimated 726,646 people living with thyroid cancer in the United States. http://seer.cancer.gov/statfacts 54 18

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