Goitre + Thyroid nodules Flashcards
What is a goitre?
Goitre = thyroid enlargement
=> may be psychological or pathological
Who does a goitre commonly occur in?
Women > men
What are the clinical features of a goitre?
Majority are painless
Large goitres => dysphagia and difficulty breathing => oesophageal or tracheal compression
Small goitres => more visible on swallowing than on palpation
What are the important aspects to record during a clinical examination of a goitre?
Size ; shape ; consistency ; mobility of a gland
Whether lower margins can be demarcated => absence of retrosternal extension?
Bruit
Assoc. lymph nodes assessed
Trachea position
Iodine containing meds or exposure to radiation => goitre
What can cause a painful goitre?
Thyroiditis
Bleeding into a cyst
Thyroid tumour
The 4 major aspects which determines a goitre is:
- Pathological nature
- Compressive symptoms
- Patient’s thyroid status
- Cosmetic concerns
INFO CARD
There are two types of goitre: Diffuse or Nodular.
What are the causes of a diffuse goitre?
- Simple diffuse goitre i.e. puberty, pregnancy (physiological)
- Autoimmune i.e. Graves’, Hashimoto’s disease
- Thyroiditis i.e. de Quervain’s thyroiditis
- Iodine deficiency
- Dyshormonogenesis
There are two types of goitre: Diffuse or Nodular.
What are the causes of a nodular goitre?
- Multinodular goitre
- Solitary nodular
- Fibrotic (Riedel’s thyroiditis)
- Cysts
What are some other causes of goitre formation?
Tumours i.e. adenomas, carcinomas, lymphomas
Sarcoidosis
Tuberculosis
Excessive doses of carbimazole or PTU induces goitre
Describe diffuse goitres:
i. Simple goitre
ii. Autoimmune thyroid disease
iii. Thyroiditis
i. Simple diffuse goitre : smooth & soft
ii. Autoimmune thyroid disease :
=> firm diffuse goitre of variable size seen in Hashimoto’s thyroiditis & Graves’ disease thyrotoxicosis
=> a bruit present in thyrotoxicosis
iii. Thyroiditis : diffuse swelling with acute tenderness ± severe pain
=> suggestive of acute viral thyroiditis => de Quervain’s
Describe nodular goitres:
i. Multinodular goitre
Multinodular goitre:
=> classic multi nodular goitre easily apparent clinically
=> most common type of nodular goitre esp in elderly
=> usually euthyroid but can have clinical hyperthyroidism
=> most common cause of trachea or oesophageal compression
=> laryngeal nerve palsy
Describe nodular goitres:
i. Solitary nodular goitre
Solitary nodular goitre:
=> Majority are benign or cysts but can be malignancy
=> solitary toxic nodules rare ; assoc. with T3 toxicosis
=> important but challenging to differentiate between small minority of malignant solitary nodules amongst majority being benign nodules
=> Hx of rapid enlargement, assoc. lymph nodes or pain suggestive of aggressive malignancy
- but most thyroid cancers are painless & slow growing
- risk factors for malignancy = iodine deficiency, radiation
Describe nodular goitres:
i. Fibrotic goitre (Riedel’s thyroiditis)
Fibrotic goitre:
=> rare
=> woody gland ; irregular & hard
=> difficult to distinguish from carcinomas
Nodular goitres can also be a sign of malignancy i.e.
thyroid carcinomas or
origin of lymphomas or
metastatic deposit
INFO CARD
Which tests are carried out in order to investigate a goitre?
- Thyroid function test : TSH, free T3, T4
- Thyroid antibodies to exclude autoimmune aetiology
- Ultrasound : high resolution
- Fine needle aspirate : using ultrasound to guide in cystic lesions
* cystic lesions can be malignant ; solitary or dominant nodule in multinodular goitre = 5% of malignancy - Thyroid isotope scan : distinguishes between functioning (hot) or non-functioning (cold) nodules.
=> hot nodule = rarely malignant
=> cold nodule = malignant in 10%
*fine needle aspirate replaced thyroid isotope scan
How do you manage a goitre?
Surgery if:
=> possible malignancy : positive FNA = surgery mandatory
=> compressed trachea or oesophagus
=> cosmetic reasons even if goitre benign = increased anxiety in patient
*most of the time goitres are small with no symptoms => monitor
Thyroid carcinoma is not common. It commonly affects women and presents 90% of the time as a thyroid nodule.
What are the 5 types of thyroid carcinomas?
- Papillary carcinoma (70%)
=> Derived from thyroid epithelium
=> Young people
=> Local
=> Good prognosis
- Follicular carcinoma (20%)
=> Derived from thyroid epithelium ; differentiated
=> Females
=> Metastases to lungs & bone
=> Good prognosis
- Medullary carcinoma (5%)
=> Derived from calcitonin-producing C cells (neuroendocrine tumour)
=> Assoc. with MEN2 (multiple endocrine neoplasia)
=> Familial
=> Local & metastases
=> Poor prognosis
- Anaplastic carcinoma (<5%)
=> Derived from thyroid epithelium ; undifferentiated
=> Familial
=> Locally invasive
=> Very poor prognosis
- Lymphoma (2%)
How do you treat thyroid carcinomas?
Total or near total thyroidectomy surgery
What are thyroid adenomas?
Overgrowth of normal thyroid tissue = thyroid adenoma.
=> not cancerous
=> serious if it causes compressive symptoms
What are thyroid cysts?
Fluid-filled cavities (cysts) in the thyroid = from degenerating thyroid adenomas.
=> solid components mixed with fluid in thyroid cysts
=> noncancerous but occasionally contain cancerous solid components
