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					       Part 2
 • Thyroid Nodular Diseases
 • Thyroid Cancers


What you need to know!
      Part 2
• Thyroid Nodular Diseases
• Thyroid Cancers


      Dr. Sima
      Conejo Medical Center
      Conejo Medical Center
      Diplomat American Board of
      Diplomat American Board of
      Internal Medicine & Fellow
      Internal Medicine & Fellow
      American Academy of
      American Academy of
      Cardiology (FAAC)
      Cardiology (FAAC)
                   health-for-everyone.com
           Major Endocrine Glands
                  Male   Female


                                  Pineal gland
Pituitary gland


                                    Parathyroid

Thyroid gland



                                        Thymus




Adrenal gland
                                        Pancreas




                                        Ovary



Testis
                Thyroid Anatomy
                            FOLLICLES:
                              Functional Units of the
                              Thyroid Gland




Follicles are the sites where
key Thyroid elements function:
 • Thyroglobulin (Tg)
 • Tyrosine
 • Iodine
 • Thyroxine (T4)
 • Triiodotyrosine (T3)
                          PHYSIOLOGY
                         Biosynthesis of T3 & T4
1) Dietary iodine (seafood, iodized, salt, dietary supplements as a trace
   mineral, dairy products)
    • Require 150 mcg / day
2) Transport and uptake of iodine by thyroid gland
3) Different chemical process (T4 and T3)
                               T4 (Thyroxin)
• All T4 comes from thyroid gland
• Is biologically inactive in the target tissues until converted to T3
                           T3 (Triiodotyrosine)
• Is the biologically active hormone and responsible for the majority of
  thyroid hormone effect
• 99% of circulating T4 and T3 is bound to plasma carrier proteins,
  mostly TBG
• Only free hormone has metabolic activity and physiological effect
     Hypothalamic-Pituitary-Thyroid Axis
     Hypothalamic-Pituitary-Thyroid Axis
               PHYSIOLOGY
               PHYSIOLOGY


       Hypothalamus
                               TRH




         Pituitary




                               TSH




T4                                                  Target
                                                   Tissues
         Thyroid Gland
                                                     Heart
T3

                                                     Liver
              T4                         T3


                                              TR
                                                     Bone

                          T4     T3
                         Liver, Muscle               CNS
Thyroid Hormone Actions
Growth and Development
        Dwarfism
         Thyroid Hormone Actions
              Growth and Development

• Cretinism  or
 Congenital Hypothyroidism
Thyroid Hormone Actions
         Metabolism
 HYPOthyroidism   HYPERthyroidism
       Thyroid Hormone Actions
             Affect on EYES




Puffy Eyes             Bulging Eyes
Thyroid Hormone Actions
 Affect on Thyroid Gland
         Goiter
        Thyroid Hormone Actions
          Affect on the Heart
        HYPOthyroidism    HYPERthyroidism




Heart                    Heart
                   Thyroid Hormone Actions
         Affect on the Reproductive System
                   HYPOthyroidism   HYPERthyroidism




Gastrointestinal
Thyroid Hormone Actions
Affect on the Skin




  pretibial myxedema
Thyroid Hormone Actions
Affect on the Hair
 Alopecia Areata
                            Thyroid Diseases

HYPOthyroidism            HYPERthyroidism   Thyroid Nodular Diseases         Thyroid Cancers

  Primary
  Secondary (or Central)

  Tertiary
   • Hypothalmic
     or Pituitary Stalk
                                             TSH         T4            T3

                      HYPOthyroid            High        Low           Low
                      HYPERthyroid
                                             Low         High          High
            Goiter and Thyroid Nodular Diseases
            Goiter is an enlarged thyroid gland
                                    Goiter
                 Diffuse Goiter              Nodular Goiter
                                    Nodules
   Hypo or Nonfunctioning Nodule               Hyperfunctioning Nodule
                (Cold Nodule)                        (Hot Nodule)


    Solid         Cyst    Mixed Cyst

 Benign Malignant Benign Benign Malignant

• Thyroid nodules are lumps which commonly arise within an otherwise
  normal thyroid gland
• More than 90% of thyroid nodules are benign
Goiter and Thyroid Nodule




Nodule

         Thyroid Gland
Diffuse Goiter
Diffuse Goiter
Multi-Nodular Goiter
Multi-Nodular Goiter
Goiter
Goiter
Goiter
    Benign Thyroid Nodules
       (more than 90%)

•   Colloid, hyperplastic
•   Hashimoto’s
•   Cystic
•   Follicular Adenoma
•   Hurthle Cell Lesion
            Thyroid Cancers
            (less than 10%)
• Papillary Carcinoma (most common)

• Follicular Carcinoma

• Medulary Carcinoma

• Anaplastic Carcinoma (rare & very aggressive)

• Primary Thyroid Lymphoma

• Metastatic Thyroid Cancer (from other sites)
Thyroid Cancer
Risk Factors for All Thyroid Diseases
 • Gender (women 6 to 8 times > than men)
 • Age >50
 • Family History
 • Iodine Deficiency
 • Iodine exposure or intake
 • Pregnancy
 • Thyroid surgery (neck trauma)
 • Radiation treatment
 • Autoimmune Diseases
 • Medications
 • Medical Tests
        More Concern:
Risk Factors for Thyroid Cancer
•Age less than 20 or more than 60
•Males
•Rapid growth, pain
•History of radiation therapy
•Family History of medullary thyroid cancer
•Hard, fixed lesion
•Lymphadenopathy
•Vocal cord paralysis
•Size of nodule (more than 4 cm)
•Dysphagia, stridor
            Diagnosis
• Physical Exam
• Blood Panel
   • CBC, Metabolic Panel, TSH, T3, T4,
     Thyroid Antibodies, Lipid Panel
• UA
• Chest X-ray
• EKG
• Thyroid Ultrasound
• Thyroid Scan
• FNA (Fine Needle Aspiration and Biopsy)
                            Thyroid Scans




Normal                                 Cold Nodule                   Hot Nodule

         Abnormally Decreased uptake

                                                Enlarged Goiter




                                                             Cold and Hot Nodule
              Abnormally Increased uptake
             Treatment
         Thyroid Nodules
• Cystic
   • Aspiration and observation
• Solid
   • Fine Needle Aspiration (FNA) and biopsy
        • Benign (observation)
        • Malignant (excision)
• Mixed Cyst (complex nodule)
   • Fine Needle Aspiration (FNA) and biopsy
        • Benign (observation)
        • Malignant (excision)

          Thyroid Cancers
Referral to:
• Endocrinologist, Head & Neck Surgeon,
  & Oncologist
“Have a peaceful, happy, and
healthy life”…from Dr. Sima!

        Dr. Sima
        Conejo Medical Center
        - Diplomat American Board of
          Internal Medicine and Fellow
        - American Academy of Cardiology
          (FAAC)