Goiter and Malignant Thyroid Disease

Goiter & Malignant
Thyroid Disease
Dr. Thuraya AlSumai

Breast and Endocrine Surgical Oncology Fellow
Department of Surgery – KFSH&RC
Butterfly-shaped organ in front of the neck
Thyroid Anatomy
Blood supply
Histologically
Thyroid tissue is composed of spherical

thyroid follicular units.
Each follicular unit consists of a single
layer of cuboidal follicular cells
surrounding a lumen filled with colloid.
The thyroid also contains parafollicular C
cells which produce calcitonin.
Thyroid follicular units contain

thyroglobulin.
The thyroid gland stores > 90% of the

body’s iodine.
Thyroid Hormone Synthesis
• Transport of iodide to thyroid “Trapping”
• Oxidation of iodide into iodine
• Iodination of tyrosine (MIT/DIT) by TPO
• Coupling of 2 DIT to form T4 “Thyroxine”
• Coupling of 1 DIT and 1 MIT to form T3 “Thyronine”
Thyroid hormone synthesis and secretion are regulated

by the Hypothalamic-Pituitary-Thyroid axis.
What Does Your Thyroid
Gland Do for You?
• Thyroxine (T4) 90%
• Thyronine (T3) 10% Active form!
• Regulates several metabolic and

hemostatic functions so your cells can
function properly
• Affects every cell in the Body
Thyroid Hormone Affects
Many Organs and General Health
Eyes Lungs
Brain Heart
Kidney Liver
Skin GI Tract
Uterus
• Hyperthyroidism • Hypothyroidism
Signs and Symptoms of Hyperthyroidism
Hoarseness or
Nervousness Deepening of Voice
Persistent
Irritability
Sore or Dry Throat
Difficulty Sleeping Difficulty Swallowing
Rapid or Irregular Heartbeat
Bulging Eyes/Unblinking Stare
Swelling (Goiter) Infertility

Menstrual Irregularities or Weight Loss
Heat Intolerance
Light Period
Frequent Bowel Movements Increased Sweating
Warm, Moist Palms First-Trimester Miscarriage

Family History of
Excessive Vomiting in Pregnancy Thyroid Disease
or Diabetes
Signs and Symptoms of Hypothyroidism
Tiredness Puffy Eyes
Forgetfulness/Slower Thinking Swelling (Goiter)

Moodiness/ Irritability Hoarseness/
Depression Deepening of Voice

Persistent Dry or Sore Throat
Inability to Concentrate
Difficulty Swallowing
Thinning Hair or Hair Loss
Loss of Body Hair Slower Heartbeat
Menstrual Irregularities/
Dry, Patchy Skin Heavy Period
Weight Gain
Infertility
Cold Intolerance
Constipation
Elevated Cholesterol
Muscle Weakness or Cramps
GOITER
Goiter
Enlargement of thyroid gland.

Classification:
Simple (non-toxic) goiter
Toxic goiter
Neoplastic goiter
Inflammatory goiter
GOITERS
• Structure • Function
- Diffuse - Euthyroid
- Nodular - Hyperthyroid
- Hypothyroid
Simple (non-toxic) goiter
include:
Simple hyperplastic goiter (colloid goiter)
Cause: -physiological in pregnancy, puberty
-iodine deficiency.
Appearance: Large, smooth firm, non-tender goiter
Effect: euthyroid & pressure effect.
Tx: self-limiting, iodine supplementation.
Multinodular goiter (MNG)
Cause: the presence of areas of hyperplasia & areas
of hypoplasia in the gland. (asymmetric)
Appearance: Large, irregular, nodular goiter
Effect: euthyroid & pressure effect.
Tx: surgery for the pressure effect.
Toxic goiter
Grave’s disease (Diffuse Toxic Goiter)
Cause: Autoimmune disease characterized presence of
antibodies that stimulate TSH receptors in the gland.
Appearance: Diffuse, nodular, hyperemic gland.
Effect: Hyperthyroidism. Graves’ Ophthalmopathy (50%)
Tx: Anti-thyroid drugs, RIA 131, surgery.
Toxic Multinodular goiter (Plummer's

disease)
Cause: Toxic effect of longstanding MNG
Appearance: Large, irregular, nodular goiter.
Effect: Hyperthyroidism
Tx: Anti-thyroid drugs, RIA 131, surgery.
Inflammatory goiter
Rediel’s thyroiditis
Cause: Fibrosis of the thyroid. Invasive fibrous thyroiditis.
Appearance: Enlarged stony hard thyroid
Effect: Pressure effect
Tx: surgery (isthmectomy to relieve compression)
De quervain’s thyroiditis
Cause: Viral infection (preceded by URTI)
Appearance: Diffuse, firm, tender swelling
Effect: Mild hyperthyroidism. Self-limited
Tx: NSAIDs, steroids.
Hashimoto’s thyroiditis
Cause: Autoantibody against the thyroid gland. Lymphocytic thyroiditis.
Appearance: Diffuse, enlarged, rubbery, non-tender goiter
Effect: Hypothyroidism
Tx: thyroxine, surgery if suspicious nodules or compressive symptoms.
Neoplastic goiter
Include:
-Benign: adenoma
-Malignant: papillary, follicular, anaplastic, medullary
and lymphoma
Cause: -Longstanding MNG –Radiation –Hereditary
Appearance: Enlarged goiter associated with
lymphadenopathy
Effect:
-pressure effect
-euthyroid
-invasive effect
Tx: surgery
Investigation:
Laboratory investigation:
• T3 & T4 (free or total)
• TSH
• Calcitonin
• Thyroglobulin (Tg)
• Thyroid antibodies
• Anti-Tg, Anti-TPO, TSH-R antibody
Radiological investigation:
• US Neck
• American Thyroid Association sonographic
patterns and risk of malignancy.
• TIRAD system
• Iodine isotopes “Thyroid scan”
• By i.v injection of I123. Then, use gamma rays
to show hot and cold nodules.
• First line in nodules associated with
hyperthyroidism
• CT scan
• In case of compressive symptoms or
substernal extension
Fine Needle Aspiration
FNA is the single most important initial test to evaluate
thyroid masses (after TSH)
Indications:
-Cold nodule by thyroid scan
-Thyroid nodule with suspicious features on ultrasound
Approach to Thyroid Nodule

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Goiter and Malignant Thyroid Disease

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Goiter & Malignant

Dr. Thuraya AlSumai

Thyroid tissue is composed of spherical

Thyroid follicular units contain

The thyroid gland stores > 90% of the

Thyroid hormone synthesis and secretion are regulated

• Regulates several metabolic and

Swelling (Goiter) Infertility

Warm, Moist Palms First-Trimester Miscarriage

Excessive Vomiting in Pregnancy Thyroid Disease

Tiredness Puffy Eyes

Forgetfulness/Slower Thinking Swelling (Goiter)

Depression Deepening of Voice

Enlargement of thyroid gland.

Toxic Multinodular goiter (Plummer's

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