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MIDS 227 (module 1 + 2) > Ch 3 Thyroid Pathology > Flashcards

Ch 3 Thyroid Pathology Flashcards

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1
Q

Role of u/s in imaging thyroid pathology?

A

-Locate nodules (intra/extra thyroidal)
-Describe appearance
-Determine other involvement (muscular, vasculature, lymph nodes, etc)
-Guide FNA/biopsy
-Follow up nodules for growth, new nodules, recurrence, post surgical, etc

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2
Q

What causes diffuse pathology of the thyroid gland?

A

-Inflammation/infection
-Thyroiditis (acute + chronic)
-Autoimmune (grave’s disease + hashimoto’s)
-Goiters

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3
Q

What causes focal nodules of the thyroid gland?

A

-Hyperplasia
-Adenoma
-Carcinoma
-Lymphoma
-Metastases

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4
Q

SF of focal nodules?

A

Variable
-Single or multiple
-Unilateral or bilateral

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5
Q

What procedure provides the diagnosis of benign vs malignant?

A

FNA cytology

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6
Q

Differentiate euthyroid, hyperthyroid + hypothyroid?

A

Euthyroid: normal functioning thyroid gland
Hyperthyroid: increased function
Hypothyroid: decreased function

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7
Q

What is the m/c thyroid function disorder?

A

Hypothyroidism (decrease in thyroid hormone production)

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8
Q

Differentiate b/w primary + secondary causes of hypothyroidism? Which is more common?

A

Primary:
-M/c
-Abnormality of the gland itself
-Decrease in T3/T4 = compensatory increased TSH

Secondary:
-Pituitary or hypothalamus failing to stimulate the normal thyroid function
-Decrease in TSH = decreased T3/T4

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9
Q

What is the m/c cause of primary hypothyroidism?

A

Worldwide: iodine

In iodine sufficient areas: hashimoto thyroiditis (aka chronic autoimmune thyroiditis)

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10
Q

Who m/c has primary hypothyroidism?

A

-Females, aged 45-65

-Associated with genetic predisposition, high iodine intake, selenium deficiency, smoking, chronic hepatitis C + other autoimmune diseases (such as sjogren syndrome, lupus + rhumatoid arthritis)

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11
Q

How is primary hypothyroidism diagnosed?

A

With bloodwork

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12
Q

What are the clinical manifestations/symptoms of hypothyroidism?

A

Depends on the severity (ranging from asymptomatic to myxedema coma)

M/c symptoms:
-Weakness/fatigue, dry skin, cold intolerance, hoarseness, weight gain, constipation, menstrual irregularities + decreased sweating

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13
Q

General SF of hashimotos thyroiditis

A

-Similar to Graves disease
-M/c diffusely abnormal echotexture*
-Hypervascular in early stage

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14
Q

SF of hashimotos thyroiditis in early, late + end stages?

A

Early:
-Increased size
-Coarse echotexture
-Hypo to normal echogenicity

Late:
-Fibrotic strands causing lobulations

End:
-Multinodular + fibrotic
-ill defined + heterogeneous
-Atrophic

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15
Q

An isthmus greater than how many cm AP indicates diffuse enlargement of the thyroid?

A

> 1cm AP

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16
Q

What causes thyrotoxicosis / hyperthyroidism?

A

Elevated levels of free T3 + T4 (this causes a hypermetabolic state)

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17
Q

Differentiate b/w primary + secondary hyperthyroidism?

A

Primary:
-Excess thyroid hormone is synthesized + secreted by the thyroid (ex. graves disease)

Secondary:
-Rare
-Due to an outside source (ex. TSH secreting pituitary adenoma)

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18
Q

What is the m/c cause of thyrotoxicosis?

A

Hyperthyroidism

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19
Q

What is the m/c cause of hyperthyroidism?

A

Graves disease

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20
Q

What is graves disease?

A

Autoimmune disease

(m/c in women of child bearing age)

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21
Q

Causes of graves disease?

A

-Hereditary
-Immune system
-Age
-Gender
-Stress

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22
Q

Pt’s with graves disease must present with 1 or more of the following symptoms:

A

-Hyperthyroidism
-Diffuse thyroid enlargement (goiter)
-Ophthalamopathy (protrusion of eyes)
-Graves dermopathy (pretibial myxedema)

(note: the general term myxedema refers to hypothyroidism, so we must be careful not to mix these terms up)

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23
Q

Clinical symptoms of hyperthyroidism/graves disease in adults?

A

-Severe wight loss
-Excessive sweating
-Heat intolerance
-Ophthalmopathy (bulging eyes)
-Enlarged thyroid (goiter)
-Tachycardia at rest
-Mood changes
-Dyspnea
-Nervous/anxiety
-Hand tremors/muscular weakness
-Menstrual irregularities (oligo or amenorrhea)

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24
Q

What happens if hyperthyroidism/graves disease gets left untreated?

A

-Can become severe + life threatening
-Complications include a “thyroid storm”

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25
Clinical symptoms of hyperthyroidism/graves disease in children?
-Accelerated growth spurts -Advanced bone age -Emotional lability (mood swings) -Hyperactivity -Difficulty concentrating -Occasionally failure to thrive
26
SF of hyperthyroidism/graves disease?
-Normal or enlarged thyroid -Heterogeneous when enlarged -Hypervascularity (aka thyroid inferno) -Spectral doppler shows peak velocities exceeding 70 cm/sec -Isthmus >1cm indicates diffuse enlargement
27
What is thyroiditis?
Term that includes multiple different types of disorders that involve some form of thyroid gland inflammation
28
What is the m/c presentation of thyroiditis?
Hypothyroidism (then thyrotoxicosis)
29
Acute vs acute suppurative symptoms of thyroiditis?
Acute: -low grade fever -sore neck Acute suppurative (pus forming): -bacterial + rare -m/c in peds -may see an abscess on u/s
30
Other names for subacute thyroiditis?
-De Quervain disease -Granulomatous thyroiditis
31
Who m/c gets subacute thyroiditis?
-Female aged 30-50 -Possibly related to a viral cause
32
Clinical presentation of subacute thyroiditis?
-History of recent viral infection -Neck pain (can radiate to upper jaw, throat or ears) which is associated with symptoms of inflammation like fever, tenderness, fatigue, anorexia, etc. -Unilateral or bilateral enlargement of gland (usually temporary + resolves in 2-6 weeks) -Spontaneous recovery of thyroid function in 6-8 weeks -Good recovery (may have some residual fibrosis)
33
SF of acute or subacute thyroiditis?
-Enlargement -Hypoechoic -Normal or decreased vascularity -Nodularity
34
What is goiters?
Enlargement of thyroid gland (m/c in women)
35
SF of goiters?
-Variable sizes (can get huge, especially in multi-nodular goiters) -Isthmus >1cm (diffuse enlargement) -Toxic or non-toxic -Simple or multinodular
36
Symptoms of goiters?
Symptoms present when thyroid becomes enlarged + causes compression on the adjacent anatomy -Dysphagia (from compression on esophagus) -Inspiratory stridor (high pitched sound) -Venous congestion (pressure on adjacent neck veins) -Hoarseness (compression on laryngeal nerve)
37
Explain endemic non-toxic goiters?
Endemic: disease that is constantly present in a certain geographic area or in a certain group of people -Due to deficiency in food, water + soil -Hypothyroid causes a decrease in iodine + T3/T4, with an increase in TSH
38
Explain sporadic non-toxic goiters?
-These occur spontaneously in euthyroid pt's in iodine sufficient areas -M/c occurs b/w 35-60 years old -Cause is unknown
39
Do non-toxic goiters cause the thyroid to have normal or abnormal function?
Normal, typically euthyroid
40
Explain toxic goiters?
-M/c multinodular -Can cause hyperthyroidism / thyrotoxicosis / graves disease (toxic meaning it produces T3 + T4)
41
What are multinodular goiters?
-Appears multi-lobulated + asymmetric enlargement of the thyroid -Can involve 1 or both lobes + can extend below the clavicle/sternum (aka plunging goiter) -Can be toxic or non-toxic
42
SF of multinodular goiters?
-Heterogeneous -Lobulated + multinodular -Possible calcifications (must look for other discrete nodules within the goiter, as neoplasms + cancers can exist within a goiter too)
43
What causes thyroid disease in pregnancy?
Hormonal + physiological changes
44
What is 1 common presentation of thyroid disease in pregnancy?
Increase in thyroid size (due to reduction in plasma iodine), returns to normal size post-partum
45
What is the m/c condition after abortion, miscarriage or delivery?
Postpartum thyroiditis (PPT)
46
Classic presentation of PPT?
Thyrotoxicosis followed by hypothyroidism
47
SF of PPT?
-Decreased echogenicity -Diffuse enlargement of thyroid (must do bloodwork to determine PPT b/c the sono appearance is very non-specific)
48
15-25% of solitary thyroid nodules are what?
Cystic or mostly cystic (due to hemorrhage or degeneration)
49
Treatment of thyroid cysts?
Benign (only if symptomatic): -Percutaneous ethanol injection Malignant (rare): -Surgery
50
What 2 types of thyroid cysts are there?
-Simple -Complex (colloid + hemorrhagic cysts)
51
SF of simple thyroid cysts?
-Circular/oval -Distinct margins -No internal echoes -Posterior enhancement
52
What are colloid cysts?
-Very common -Irregularly enlarged follicles containing abundant colloid -Can have calcifications -Can have multiple echogenic foci (colloid crystals) with comet tail artifact (not microcalcifications)
53
What are hemorrhagic cysts?
-May contain blood + debris -May have complex internal echoes, septations + debris
54
What are thyroid nodules?
-Term for a variety of different lesions (benign, malignant, etc.) -Very common to have -M/c in women -Increased frequency with age + with decreased iodine intake
55
Differentiate b/w hot vs cold nodules?
Hot: -Hyper functioning -Area of dense collection of activity on nuclear med image -Only 5-10% of nodules are hot (implies benignity) Cold (m/c): -Non functioning -Area of decreased/absent activity on nuclear med image -Majority of nodules are cold (10-15% are malignant)
56
Are hot or cold nodules m/c?
Cold (non-functioning)
57
The differentiation b/w hot + cold nodules is based on what?
Tc-99m (technetium-99m) nuclear medicine scintigraphy examination, this tracts how much iodine is absorbed into the nodules
58
What is the m/c cause of the majority of nodular diseases?
Hyperplasia
59
What causes hyperplasia?
-Iodine deficiency or under utilization -If thyroid increases in size, can develop into a goiter -M/c in females aged 35-50
60
SF of hyperplasia?
Variable: -M/c isoechoic -Echogenic (as thyroid increases in size) -Peripheral halo -Cystic degeneration (common) -Perinodular vascularity
61
What is a thyroid adenoma?
Benign, neoplastic, slow growing nodule (all adenomas are nodules + they make up 5-10% of nodules)
62
SF of thyroid adenomas?
M/c solitary, well-circumscribed + oval/circular!! -Fibrous capsule -Can be cystic, complex, solid, etc. -Rim calcifications -Halo (hypoechoic rim surrounding nodule, can be complete or incomplete) -Spoke + wheel CD appearance
63
Are adenomas m/c in males or females?
7x more likely in females, aged 50-60
64
Most adenomas are derived from what subtype?
Follicular cells
65
Are most adenomas functioning or non-functioning?
Non-functioning
66
Rarely adenomas will produce what?
Thyroid hormones + cause hyperthyroidism (aka a toxic adenoma / hot nodule)
67
Follicular adenomas is indistinguishable from what other pathology?
Follicular carcinoma (can't be distinguished on u/s or with an FNA)
68
What are the 2 m/c types of thyroid cancer?
1: papillary carcinoma 2: follicular carcinoma (only 5-15% of nodules are malignant)
69
Incidence of thyroid carcinoma is m/c in what pt's?
Pt's with previous radiation exposure, but must have an FNA/biopsy done to confirm malignancy
70
SF of thyroid carcinomas?
-M/c solid + hypoechoic -M/c feature specific to malignancy is microcalcifications (<2mm + appears as hyperechoic foci w/o shadowing) -Taller than wide -Tumor invasion or lymph node metastasis is very suspicious for thyroid malignancy (hyperechoic = benign, hypoechoic = malignancy)
71
Differentiate the SFs b/w low + high thyroid risk of cancer?
Low: -hyperechoic or isoechoic -cystic -large calcifications -perinodular (peripheral) hypervascularity or avascular nodule High: -hypoechoic -solid -microcalcifications -intrinsic (center) hypervascularity -ill defined margins + shape is tall > wide -local invasion + lymphadenopathy (refer to table 15-4 in slides for full list)
72
Explain papillary cancer?
-M/c type of thyroid cancer -Least aggressive + great prognosis/survival rate -Spreads via the lymphatics
73
Who m/c gets papillary cancer?
Females aged 20-50 (but is more aggressive in men)
74
Clinical presentation of papillary cancer?
-Painless palpable lump -Palpable nodule with enlarged cervical lymph nodes -Enlarged cervical lymph nodes w/o palpable thyroid nodule (must check for enlarged lymph nodes)
75
How can we diagnose + treat papillary cancer?
Diagnosis: with an FNA biopsy, as it is most accurate Treatment: total/partial thyroidectomy or radical neck dissection, usually followed by suppressive therapy
76
SF of papillary cancer?
-Hypoechoic -Microcalcifications -Hypervascularity -Punctate microcalcifications can appear in the affected lymph nodes if metastasis is present
77
Explain follicular cancer?
-2nd m/c -M/c in females aged 40-50, with an increased incidence in areas of dietary iodine deficiency -Is spread via the blood (hematological spread) -Rarely spreads to neck nodes
78
Clinical presentation of follicular cancer?
-Slow growing + painless nodule -Mets to bone, lungs or liver is seen
79
What is the diagnosis + treatment of follicular cancer?
Diagnosis: only made histologically (FNA is not effective) Treatment: lobectomy or thyroidectomy, along with radioactive iodine treatment with widely invasive tumors
80
SF of follicular cancer?
Similar to follicular adenomas: -irregular margins -thick irregular halo -chaotic vascularity (rarely has specific features of malignancy)
81
List the types of thyroid cancers from most to least common?
-Papillary -Follicular -Medullary -Anaplastic -Hurthle cell -Lymphoma
82
Explain medullary carcinoma?
-Is derived from parafollicular cells (aka c-cells) which secrete calcitonin -Increases serum calcitonin -M/c in females
83
Medullary carcinoma is associated with what syndrome?
MEN syndrome
84
Which type of thyroid cancer is aggressive + does not respond to chemo or radiation therapy?
Medullary cancer
85
Clinical presentation of medullary cancer?
-Mass in neck -Other symptoms related to endocrine secretion (including carcinoid syndrome (serotonin) + cushing syndrome)
86
SF of medullary cancer?
Similar to papillary cancer: -note that local invasion + mets to cervical lymph nodes is more common with medullary cancer
87
Explain anaplastic cancer?
-M/c in females over 60, with an increased incidence in endemic goiter areas -Most aggressive thyroid cancer with a poor prognosis -Invades nearby vasculature + muscles, widespread mets -No effective treatments
88
Which form of thyroid cancer is the most aggressive with a poor prognosis?
Anaplastic cancer (no effective treatments, pt's often only last about 5 years)
89
Clinical presentation of anaplastic cancer?
Rapidly enlarging neck mass with symptoms relating to the destruction of local structures (such as dyspnea, dysphagia, hoarseness, cough)
90
SF of anaplastic cancer?
-Large, solid, hypoechoic mass with encasing or invading blood vessels -Possibly invasion of other nearby structures as well -Hard to assess due to size (CT or MRI is better)
91
Explain hurthle cell cancer?
-Has thyroglobulin producing cells -Classified as either a benign or malignant hurthel cell adenoma based on histology -Is aggressive -M/c in males with advanced age
92
Diagnosis + treatment of hurthle cell cancer?
Diagnosis: histology (FNA not effective) Treatment: total thyroidectomy (clinical presentation + SF are variable)
93
Thyroid cancers are generally m/c in males or females?
Females, hurthle cell cancer is the only one m/c in males
94
Clinical presentation of thyroid lymphoma?
-M/c arise from chronic thyroiditis (hashimoto) -Rapidly growing mass -Symptoms of airway obstruction (dyspnea, dysphagia)
95
Diagnosis + treatment of lymphoma?
Diagnosis: -surgery often done to diagnose it -accuracy of FNA biopsy in diagnosing thyroid lymphoma is being researched Treatment: -radiation therapy + chemo
96
Which 2 thyroid cancers have no treatment?
-Medullary -Anaplastic
97
SF of lymphoma?
-M/c large, solid, hypoechoic mass -Infiltration of thyroid parenchyma + encasement of neck vessels (CCA, IJV) -Cystic necrosis -Doppler will be hypovascular or show chaotic blood vessel distribution
98
Is it common for cancer to metastasize to they thyroid?
-No! Very uncommon -Occurs in late disease progression to another primary cancer
99
Thyroid mets is m/c spread by blood or lymphatics?
Blood
100
M/c mets to thyroid are from what?
Melanoma, breast, lung, RCC
101
SF of thyroid mets?
-Non specific -M/c hypoechoic
102
T/F: Heat intolerance is a symptom of hypothyroidism?
False, is a symptom of hyperthyroidism (cold = hypothyroidism, hot = hyperthyroidism)
103
What is the m/c cause of primary hypothyroidism?
Hashimotos or iodine insufficiency worldwide
104
What is the m/c form of thyroid cancer?
Papillary
105
Thyroid inferno is a common sonographic feature in which condition?
Graves disease / hyperthyroidism
106
Serum calcitonin can be used as a tumor marker for which type of thyroid carcinoma?
Medullary (from the c-cells, which secrete calcitonin)
107
Based on Tc-99m, hot nodules are usually ____?
Benign

MIDS 227 (module 1 + 2) (14 decks)

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