Thyroid

Pierre G. Layson Click to edit Master

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Medical History

Medical History

General Data

A.D.L. 60 years old Female Filipino Married Catholic Pasay City Admitted in our institution last June 08, 2011

Chief Complaint

Anterior Neck Mass

History Of Present Illness

8 year history of slowly enlarging anterior neck mass

(-) difficulty in breathing (-) dysphagia (-) palpitations (-) weight loss (-) change in bowel habits (-) tremors (-) medications taken

Annual medical exam UTZ done

Past Medical History

(+) Hypertension Norvasc, Simvastatin (-) Diabetes mellitus (-) Asthma (-) Lung Disease/Tuberculosis (-) Allergies (+) Appendectomy 1965 (+) Excision of sinus polyp - 2006

Family Medical History

(+) Hypertension mother (+) Asthma - mother (-) Diabetes Mellitus (-) Cancer (-) Lung Disease

Personal & Social History

(-) Cigarette Smoking (-) Alcoholic Beverage Drinking (-) Allergies to food and drug

Review of Systems

General. (-) weakness, fatigue, fever Skin. (-) rashes, sores, pruritus HEENT. (-) headache, head injury, dizziness, abnormal vision, eye pain, redness, blurred vision, spots, specks, tinnitus, earaches, ear discharge, epistaxis, sore throat, hoarseness Neck. (-) stiff neck Breasts. (-) lumps, discharge, palpable mass

Review of Systems

Respiratory. (-) cough, hemoptysis CVS. (-) chest pain, othopnea, paroxysmal nocturnal dyspnea, edema GIT. (-) loss of appetite, nausea, change in bowel habits, rectal bleeding, hemorrhoids, abdominal pain, jaundice GUT. (-) dysuria, nocturia, hematuria, frequency, incontinence Neurologic. (-) fainting, seizures, weakness, tremors, numbness

Review of Systems

Hematologic. (-) easy bruising, past transfusion Endocrine. (-) excessive thirst, polyuria Psychiatric. (-) memory changes

Physical Examination

Vital Signs

BP = 120/70 PR = 84 RR = 20 Temp = 36.7 C

HEENT

Anicteric sclera Pink Palpebral conjunctiva (-) nasal discharge (-) ear discharge (-) CLAD 2x3 cm anterior neck mass, right, firm, non tender, moves with deglutition 1x1 cm anterior neck mass, left, firm non tender, moves with deglutition

Chest and Lungs

Symmetric Chest Expansion (-) intercostal retractions Clear Breath Sounds (-) rales / wheezing

Cardiovascular System

Adynamic Precordium Normal rate Regular rhythm (-) murmurs

Abdomen

Soft flat non-tender Normoactive bowel sounds (-) palpable mass

Extremities

Full and Equal Peripheral Pulses Pink nail beds (-) edema (-) cyanosis

Pertinent Findings

Subjective

60 year old, female Anterior neck mass (-) palpitations (-) tremors (-) weight changes (-) heat or cold intolerance (-) changes in bowel habits

Pertinent Findings

Objective

(-) CLAD 2x3 cm anterior neck mass, right, firm, non tender, moves with deglutition 1x1 cm anterior neck mass, left, firm non tender, moves with deglutition

Admitting Diagnosis

MultiNodular nontoxic goiter

Differential Diagnosis

Hashimoto Thyroiditis

Ruled in

Common in women Painless anterior neck mass No signs or symptoms of hypothyroidism

Ruled out

Differential Diagnosis

Riedel Thyroiditis

Ruled in

Common in women Painless anterior neck mass Hard woody neck mass Fixed Produce symptoms of compression including dysphagia, dyspnea, choking, and hoarseness

Ruled out

Course in the Ward

Patient was admitted at the ward. Patient underwent total thyroidectomy. Patient tolerated the procedure well.

Final Diagnosis

Multiple Colloid Adenomatous Goiter

CASE DISCUSSION

Goiter

Any enlargement of the thyroid gland is referred to as a goiter Enlarges in order to maintain the patient in a euthyroid state May be diffuse, uninodular, or multinodular

Presentation

asymptomatic, although patients often complain of a pressure sensation in the neck, particularly with motion. As the goiters become very large, compressive symptoms, such as dyspnea and dysphagia Pemberton's signfacial flushing and dilatation of cervical veins upon raising the arms above the head substernal goiter

Presentation

Physical examination may reveal a soft, diffusely enlarged gland (simple goiter) or nodules of various size and consistency in case of a multinodular goiter. Deviation of the trachea may be apparent.

Treatment

Most euthyroid patients with small, diffuse goiters do not require treatment Endemic goiters are treated by iodine administration

Treatment

Surgical resection is reserved for goiters that

continue to increase despite T4 suppression, cause obstructive symptoms, have substernal extension, are suspected to be malignant or are proven malignant by FNA biopsy, cosmetically unacceptable

Malignant Thyroid Diseases

RET proto-oncogene plays a significant role in the pathogenesis of thyroid cancers. It is located on chromosome 10 and encodes a receptor tyrosine kinase

Papillary Carcinoma

80% of all thyroid malignancies in iodine-sufficient areas and is the predominant thyroid cancer in children and individuals exposed to external radiation occurs more often in women, with a 2:1 female:male ratio the mean age at presentation is 30 to 40 years

Papillary Carcinoma

Lymph node metastases are common, especially in children and young adults, and may be the presenting complaint Diagnosis is established by FNA biopsy of the thyroid mass or lymph node

Papillary Carcinoma

Macroscopic calcification, necrosis, or cystic change may be apparent generally hard and whitish and remain flat on sectioning with a blade Histologically, papillary carcinomas may exhibit papillary projections, a mixed pattern of papillary and follicular structures, or a pure follicular pattern (follicular variant)

Papillary Carcinoma

Cells are cuboidal with pale, abundant cytoplasm, "grooving," crowded nuclei, and intranuclear cytoplasmic inclusions, Orphan Annie nuclei excellent prognosis with a greater than 95% 10-year survival rate Most authors agree that patients with high-risk tumors or bilateral tumors should undergo total or near-total thyroidectomy

Follicular Carcinoma

10% of thyroid cancers and occur more commonly in iodine-deficient areas Women have a higher incidence of follicular cancer, with a female:male ratio of 3:1, mean age at presentation of 50 years. present as solitary thyroid nodules, occasionally with a history of rapid size increase, and long-standing goiter. Pain is uncommon, unless hemorrhage into the nodule has occurred

Follicular Carcinoma

Histologically, follicles are present, but the lumen may be devoid of colloid. Malignancy is defined by the presence of capsular and vascular invasion Patients diagnosed by FNA biopsy as having a follicular lesion should undergo thyroid lobectomy

Follicular Carcinoma

Intraoperative frozen-section examination usually is not helpful, but should be performed when there is evidence of capsular or vascular invasion, or when adjacent lymphadenopathy is present. Total thyroidectomy should be performed when thyroid cancer is diagnosed.

Hrthle Cell Carcinoma

Like follicular cancers, Hrthle cell cancers are characterized by vascular or capsular invasion, and therefore cannot be diagnosed by FNA biopsy. more often multifocal and bilateral (approximately 30%), usually do not take up RAI (approximately 5%), more likely to metastasize to local nodes (25%) and distant sites, associated with a higher mortality rate

Medullary Carcinoma

5% of thyroid malignancies and arise from the parafollicular or C cells of the thyroid C cells secrete calcitonin, a 32-amino-acid polypeptide that functions to lower serum calcium levels typically unilateral (80%) in patients with sporadic disease, and multicentric in familial cases, with bilateral tumors occurring in up to 90% of familial patients

Medullary Carcinoma

Microscopically, tumors are composed of sheets of infiltrating neoplastic cells separated by collagen and amyloid Diagnosis is established by history, physical examination, raised serum calcitonin or CEA levels, and FNA cytology of the thyroid mass Total thyroidectomy

Anaplastic Carcinoma

approximately 1% of all thyroid malignancies majority of tumors present in the seventh and eighth decades of life typical patient has a long-standing neck mass, which rapidly enlarges and may be painful Lymph nodes usually are palpable at presentation Confirmed by FNA biopsy revealing characteristic giant and multinucleated cells.

Anaplastic Carcinoma

gross inspection, anaplastic tumors are firm and whitish in appearance Microscopically, sheets of cells with marked heterogeneity are seen. Cells may be spindle-shaped, polygonal, or large, multinucleated cells.

Anaplastic Carcinoma

gross inspection, anaplastic tumors are firm and whitish in appearance Microscopically, sheets of cells with marked heterogeneity are seen. Cells may be spindle-shaped, polygonal, or large, multinucleated cells. Tumor is one of the most aggressive thyroid malignancies, with few patients surviving 6 months beyond diagnosis

Lymphoma

less than 1% of thyroid malignancies and most are of the non-Hodgkin's B-cell type most thyroid lymphomas develop in patients with chronic lymphocytic thyroiditis rapidly enlarging neck mass often is painless diagnosis usually is suggested by FNA biopsy, although needle-core or open biopsy may be necessary for definitive diagnosis

Lymphoma

less than 1% of thyroid malignancies and most are of the non-Hodgkin's B-cell type most thyroid lymphomas develop in patients with chronic lymphocytic thyroiditis rapidly enlarging neck mass often is painless diagnosis usually is suggested by FNA biopsy, although needle-core or open biopsy may be necessary for definitive diagnosis

Lymphoma

Patients with thyroid lymphoma respond rapidly to chemotherapy (CHOP cyclophosphamide, doxorubicin, vincristine, and prednisone), which is also associated with improved survival. overall 5-year survival rate is about 50%

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