2. Heterotropic Thyroid Tissue
• Found anywhere along the course of the
thyroiglossal duct ( Midline )
• Frequently Base of the tongue
• Difficulty in swallowing
• Respiratory obstruction
• 70% with (+) gross lingual thyroid
Develop hypothyroidism after it’s
removal
7. The immune response is not self-
perpetuating, so the process is limited.
Viral antigen or thyroid antigen is
released
Antigen w/in macrophages stimulates
the formation of cytotoxic T lymphocytes,
which then damage thyroid follicular
cells.
Granulomatous Thyroiditis de Quervain’s
8. DESCRIPTION
Middle age Women (3 to 5:1) M< W
30-40’s
Unknown Etiology
Believed to be a postviral inflammatory
process
9. CLINICAL MANIFESTATION
Acute Symptoms
Sorethroat, Painful swallowing, Fever,
Malaise
Marked Tenderness on the thyroid
Thyroid inflammation and hyperthyroidism are
transient, usually diminishing in 2 to 6 weeks, even
if the patient is not treated.
10. Transient Hperthyroidism is
Due to:
Due to disruption of thyroid follicles and
release of excessive thyroid hormone
Nearly all patients have high serum T4 and
T3 and low serum TSH levels.
Radioactive iodine uptake is low because of
suppression of TSH
Unlike hyperthyroid state
( Graves ) – RAI uptake is INCREASED
11. Later followed by
Transient, usually asymptomatic hypothyroidism
lasting from 2 to 8 weeks,
Recovery is virtually always complete
Repaired by Fibrosis
Advanced Stage Firm Thyroid
gland
Granulomatous Thyroiditis de
Quervain’s
12. Morphology:
Assymetric gland enlargement :
Usually 2x normal
On cut section, the involved areas are
firm and yellow-white and stand out
from the more rubbery, normal brown
thyroid substance
Micro: Marked inflam + Giant cell
Granulomas about damaged follicles
15. Type Microscopic
All show extensive
lymphocytic infiltration of
the glands with germinal
centers
Lymphocytic
Thyroiditis
Intervening follicles are
relatively Normal
Hashimoto’s
Thyroiditis
Follicles are lined by
oncocytic cells
Grave’s
Disease
Hyperplastic intervening
follicles
17. DESCRIPTION:
Most common cause of
hypothyroidism in areas of the world
where iodine levels are sufficient.
Women Over 40y/o
W>M 10:1 to 20:1
Patients with Hashimoto disease are
at increased risk for the development
of B-cell lymphomas.
18. Diffuse thyroid Enlargement
◦ Firm / Painless
◦ Tracheal & Esophageal
Compression
◦ Not Adherent to surrounding
structure
Initial Mild Hyperthroidism
◦ High FT3, FT4, Low TSH , Low
RAIU
Later Hypothyroidism
DESCRIPTION:
19. Pathogenesis:
Both cellular and humoral
factors contribute to thyroid
injury
This disease is believed to be
caused primarily by a defect in
T cells.
20. (1 ) They interact with B cells and stimulate
the secretion of a variety of antithyroid
antibodies, which may activate antibody-
dependent cytotoxicity mechanisms
Anti- Thyroglobulin & Thyroid peroxidase
Anti-TSH receptor
Anti- Iodine Transporter
(2) Helper T cells may induce the formation
of CD8+ cells, which can be cytotoxic to
thyroid cells.
(3) Cytokine –mediated cell death: CD4 T
cell IFN macrophage recruit
Activated T cells have two roles in the
disease
21. Gross:
◦ Diffusely enlarged or Localized
enlargement.
◦ The capsule is intact, and the
gland is well demarcated from
adjacent structures.
◦ The cut surface is pale, gray-tan,
firm, and somewhat nodular
25. MANAGEMENT:
Treatment :
1. No therapy
2. Subtotal Thyroidectomy 2o large
lesions or pressure
or confused as Ca.
Complications:
◦ Evolve Gradually
Malignant Lymphoma
Leukemia
Hurthle cell Ca
36. Grave’s Disease
Young Adult Females
20-0 y/o
Genetic factors – imp’t etiology
HLA-B8 and DR3
37. Triad of Clinical Findings
Hyperthyroidism
Muscle Weakness , Weight Loss
Increase SNS
Infiltrative Ophthalmopathy
Exopthalmus
Localized, infiltrative dermopathy
Pretibial Edema – minority of cases
Shin area – scaly thickening and induration
38. Laboratory
Elevated free T3 T4
Increased RAI uptake in the presence of
TSH < 0.1mU/L
Due to stimulation of follicles by TSI
Depressed TSH levels
39. MORPHOLOGY
Gross
Symmetric enlargement
Reddish , Succulent
Microscopic
Markedly Hyperplastic Follicles
Prominent Papillary formation
Some glands grow outside into the skeletalmuscle
1-9% incidence of malignant transformation
42. PATHOGENESIS
TSH is NOT involved in pathogenesis
IgG against TSH receptor
TSI IMMUNOGLOBULIN
TBII THYROTROPIN-BINDING INHIBITOR
IMMUNOGLOBULIN
Increased Incidence after Irradiation to
neck lesions
Also caused by Amiodarone – associated
Thyrotoxicosis ( 37% iodine )
46. Nodular Hyperplasia
Most Common Thyroid disease
Some Cases Associated w/
Hashimoto’s
Types of Simple Goiter ( Diffuse
NonToxic Goiter)
Endemic Goiter
Sporadic Goiter
47. Endemic Goiter
Due to low Iodine
Lead to Decreased synthesis of
Thyroid Hormones
Compensatory Increase TSH
secretion Goiter
Initially Hyperactive thyroid
Later Follicular atrophy
Goitrous Hypothyroidism
48. Sporadic (Nodular) Goiter
Less frequent than endemic
Female Preponderance
Puberty or Young adult
Pathogenesis- Unknown
Features
Mild Dietary Deficiency of iodine
Slight Hormonal Impairment
Increase Renal Clearance of iodide
49. Simple Goiter
Gross
Diffusely enlarged thyroid
gland
Rarely exceeds 100-150
grams
Clinical Manifestation
Euthyroid – majority
Mass effect
T3,T4 normal
TSH usually elevated or
upper range
58. Clues to nature of given
nodule Solitary nodules tend to be Neoplastic
than are multiple nodules
Nodules in young patients are likely
Neoplastic than in older patients
Nodules in males are more likely
neoplastic than females
History of radiation to Head/Neck is
associated with Increased incidence of
Thyroid Malignancy
Hot Nodules in scan are more likely
Benign
70. DESCRIPTION:
Most common type of thyroid
Malignancy
Any age, Usually 40 y/o
Account for >90% of thyroid
malignancy in children
5-10% has History of Irradiation
to Head/Neck
83. Follicular Variant
◦ Composed almost entirely of follicles
◦ Ground glass nuclei
◦ Scalloped edges
◦ Behavior similar to conventional
papillary Ca
High Nodal Mets
Mets usually exhinit papillary type
Variants :
84. Spread & Metastasis :
¼ show extension to tissues of the
neck
Lymphatic mets > Blood
Cervical mets
◦ Very Common
◦ Usually young patient
◦ May be the !st sign
Lungs
◦ most common Blood Mets
◦ CT scan
85. Prognosis :
Prognosis
◦ General Excellent Prognosis
Prognosis decreases with:
◦ Age Male
◦ Tall Variant Size
◦ Multicentricity Distant Mets
◦ Reactivity EMA , LeuMI
◦ Aneuploidy
86. Factors that NOT generally
correlate w/ Prognosis
◦ Proportion of papillae to follicles
◦ Psammoma bdies
◦ Cervical node Mets
◦ Fibrosis
Prognosis :
91. PROGNOSIS
Minimally Invasive
Grossly encapsulated
Solid, Fleshy
Full thickness capsular invasion and expand like
mushroom
Vascular Invasion
Venous invasion w/in capsule
Must contain one or more clusters of tumor attched to
the wall
Mets <5%
95. DESCRIPTION :
Composed of C ( parafolliculaar ) cells
Mostly located in Midportion or Upper
Half of the gland
Immunohistochemical stain
◦ Reactive Keratin, Calcitonin CEA, NSE
◦ ACTH, Cakcitonin gene related peptide
◦ Generally Negative for Thyroglobulin
100. MICROSCOPIC:
◦ Solid proliferation of round to
polygonal cells
◦ Granular amphophilic
cytoplasm
◦ Medium nucleus
◦ Highly vascular stroma
◦ Coarse calcification
101. MEDULLARY CARCINOMA
Treatment
Total Thyroidectomy + Cervical
Lympadenectomy
5 year survival rate about 35%
Not particularly responsive to RAI ,
external radiation or chemotx
102. PROGNOSIS:
Good Prognostic factor
Young age, female, familial , confined
lesion
Poor Prognostic factor
Sporadic cases ( older age affected )
High mitosis
Small cell type
Poor Staining for Calcitonin & Increased
Reactivity for CEA
Calcitonin production related to differentiation
103. STAGING OF THYROID TUMORS
for Papillary & Follicular
UNDER 45 YEARS OLD
STAGE I ANY T
ANY N
M0
STAGE II ANY T
ANY N
M1
104. STAGING OF THYROID TUMORS
for Papillary & Follicular
45 YEARS OLD AND OVER
STAGE I T1N0M0
STAGE II T2N0M0
T3N0M0
STAGE IIII T4N0M0
ANY T , N1 , M0
STAGE IV ANY T ,
ANY N
M1
105. STAGING OF THYROID TUMORS
for Medullary
STAGE I T1 N0 M0
STAGE II T2
T3
T4
N0 M0
STAGE III ANY T N1 M0
STAGE IV ANY T ANY N M1
106. STAGING OF THYROID TUMORS
for Undifferentiated Tumor
ALL CASES ARE STAGE IV
STAGE IV ANY T ANY N ANY M
107. STAGING OF THYROID TUMORS
PRIMARY TUMOR-Solitary or Multifocal
Measure the largest for classfication
TX Primary tumor cannot be assesses
TO No evidence of primary tumor
T1 Tumor 1 cm or less in greatest dimension limited to the
thyroid
T2 Tumor > 1cm but not more than 4cm
T3 Tumor > 4cm in greatest dimension limited to the thyroid
T4 Tumor of any size extending beyond the thyroid capsule
108. STAGING OF THYROID TUMORS
LYMPH NODE – Regional nodes are the Cervical and
Upper Mediastinal LN
NX Regional LN cannot be assesses
N0 No regional LN metastasis
N1 Regional LN metastasis
N1a Metastasis in Ipsilateral Cervical LN
N1b Metastasis in Bilateral , Midline, or Contralateral
Cervical or Mediastinal LN
109. STAGING OF THYROID TUMORS
DISTANT METASTASIS
MX Presence of Distant Metastasis cannot be
Assesed
M0 No distant metastasis
M1 Distant metastasis