Thyroids Diseases

Goiter

The thyroid gland is a butterfly-shaped organ located in the base of the neck. Diseases, as a result of which the thyroid gland increases, are called goiter. The cause of goiter may be formations, cysts, cancer or inflammation in the thyroid gland.

Goiter is the common name for many thyroid diseases. If there are nodules in the thyroid gland, it is called “Nodular goiter”, with increased thyroid function and excessive secretion of the thyroid hormone – “Toxic nodular goiter”, with an increase in the size of the thyroid gland – “Substernal goiter”, with the growth of the thyroid gland in the direction of the thorax – “Internal goiter”. Women more likely to have thyroid disease (goiter) than men. The incidence of the disease grows with age.

The goiter is usually harmless. On the other hand, every enlargement of the thyroid gland must necessarily be examined by a physician. Thyroid nodules, thyroid cancer, thyroid functional disease (hyperthyroid and hypothyroid), and inflammation of the thyroid gland (Hashimoto and other diseases) should be diagnosed, followed by monitoring or treatment.

Nodules of the thyroid gland

Nodular formations of the thyroid gland is one of thyroid gland diseases, which is often observed in clinics. The clinical significance of thyroid nodular formations is a possible risk of thyroid cancer with a probability of 5 to 15% in the presence of certain factors (age, sex, exposure to radiation, heredity). In the presence of all risk factors, this percentage may be higher than 15%.

Dimensions of nodular formations of the thyroid gland can vary greatly. Large nodules can be determined only by looking at the patient’s neck, small ones can not be determined manually and then ultrasound procedure is needed.

Ultrasound examination of the nodules provides us with important information. At half of patients one knot is found out, at other half – more. The likelihood of developing thyroid cancer is the same for patients with one nodule formation, and several. Typically this is 5%, but such factors as heredity, exposure to radiation, age can increase likelihood of developing thyroid cancer to 15%.

Knot formations in accordance with scintigraphy of the thyroid gland can be of 3 kinds: hot, cold and warm. Hot nodules are usually formations that contain in excess quantities the hormone of the thyroid gland (T4, T3). These patients typically have symptoms of hyperfunction of the thyroid gland called hyperthyroidism. Cold nodules do not affect the production of thyroid hormones. Warm ones work for the production of hormones as normal tissue of the thyroid gland. In hot nodule formations the probability of cancer is lower (up to 1%), while in cold ones it is higher. Approximately 80% of nodules are cold.

What nodule formations have a greater risk of cancer?

If there is an increase in nodules that were previously identified and controlled, especially if the growth was 15 – 25% or even more within 6 – 12 months, the risk of cancer should immediately be assumed. If there is an increase in the lymph nodes of the neck, a suspicious image is obtained on the ultrasound, a hard knot formation is felt by hand, which holds onto the surrounding tissue, and the probability of patient’s thyroid cancer should be considered.

Surveys, which are conducted for patients with nodular formations of the thyroid gland.

Hormonal and other biochemical tests:

Initially, TSH should be checked. At the same time free T3 and T4 can be checked. If TSH is low, there is a possibility of a low thyroid performance or it is this nodule that produces thyroid hormone in excessive amounts. This situation is called hyperthyroidism. If the TSH level is high, the nodular formation is likely to be cold and the patient has hypothyroidism. In both cases there is a chance for drug treatment of the patient. Another test is a thyroglobulin test. In most diseases of the thyroid gland, it can be elevated. Patients who have heredity for cancer, calcitonin levels should be checked. If it is high, there is a possibility of medullary thyroid cancer.

Ultrasound of the thyroid gland:

It is very important to measure the size of nodules. It is thus possible to determine the smallest nods up to 1 cm and nodules that have a risk of cancer, which can not be determined with hand. The following factors may indicate a high risk of cancer: uneven boundaries of nodules on ultrasound, the presence of small calcareous clusters called microcalcification, increased blood flow in the nodule, a darker color of the nodule compared with normal thyroid tissue, which is called hypoechoinality.

Aspiration biopsy of the thyroid gland with a fine needle:

The presence of cancer in the nodules can usually be determined with high accuracy. This can be done with each nodule larger than 1 cm. If on ultrasound some nodules measuring more than 5 mm will be regarded as having a high risk, then biopsy is performed. The percentage of making the correct diagnosis of pathology by this method is 95%.

Thyroid scintigraphy:

Shows whether the nodule formation is cold or hot. It is performed for patients with a low TSH level. If the formation is hot, the patient’s treatment may be changed. Sometimes in hyperthyroidism, the cause may be their cold nodular formations.

Treatment of nodular formations of the thyroid gland

If a patient has hypo- or hyperthyroidism, first of all it is treated. Especially if the level of TSH is high (hypothyroidism) in the case of cold nodules, nodules may grow. The decision is made on the basis of the size of the nodules and the results of aspiration biopsy with a fine needle. If there is thyroid cancer, the patient must be operated and, if necessary, given a radioactive iodine (the so-called “atomic treatment”). If, in the presence of hot nodules, it is not possible to take hyperthyroidism under control, the possibility of atomic treatment should be considered. If the dimensions of the hot nodule are large, the possibility of performing the surgery for the patient should be considered.

Surgical treatment of nodular thyroid formations

Surgery is the best option for patients who have cancer diagnosed by aspiration biopsy of nodular formations performed with a fine needle. Since thyroid cancer does not have an aggressive structure, the type of surgical treatment chosen may differ depending on the type of cancer, the size of the cancerous nodular tumors, and the spread of cancer to the lymph glands. For example, a nodule formation that has a diameter of 0.5 cm and is defined by us as a well-differentiated thyroid cancer does not require the removal of the entire thyroid tissue. And those who have cancer of the lymph nodes on the side of the neck, the thyroid gland should be completely removed and the lymph nodes are also included in the scope of the operation.

Knot formations that do not have risk of cancer, or biopsies do not show cancer, should be monitored. On the other hand, nodular formations can exert pressure on the esophagus or trachea, thereby leading to breathing, swallowing problems, sounds disturbing, or they can show a tendency to grow into the chest cavity, in this case, even if there is no cancer, surgery should be performed.

Finally, if as a result of two aspiration biopsies of the thyroid with a fine needle there is no suspicion of cancer or no possibility to diagnose, surgery is necessary. After the operation, some patients will need to undergo treatment with radioactive iodine, called “atomic therapy”. The decision on which patient to perform nuclear therapy is taken based on the characteristics of the patient and the pathology of the tumor.

Operation on the thyroid gland

Operation on the thyroid gland is performed through a 2 – 4 cm incision, which is done horizontally along the midline of the neck. The tissue of the thyroid gland, which looks like a butterfly, is partially or completely removed depending on the type of thyroid disease. In this operation, which requires a lot of attention, the nerves responsible for sound and parathyroid glands must be protected. Patients generally stay in the hospital for one day.

Types of thyroid cancer

Thyroid cancer is formed from the cells of the thyroid gland. It is usually formed from follicular cells of the thyroid gland or parafollicular cells (C cells). Usually well-differentiated and painless, occur in 80% of thyroid cancer. Many types of thyroid cancer are formed from the nodular formations of the thyroid gland. Along with this, in the important areas of the thyroid gland cancer is not formed. The decision about which nodule contains cancer is taken on the basis of a nodule examination, ultrasound examination, a fine needle biopsy. In children and women, thyroid cancer generally has a papillary structure. Medullary thyroid cancer is developing more rapidly if there had been a similar pathology in the family. Anaplastic thyroid cancer is quite aggressive and its treatment is very difficult.

The most important stage in the treatment of thyroid cancer is surgery. If these operations, which we call thyroidectomy, we do because of cancer, the thyroid gland is completely removed. This is called total thyroidectomy. The goal is to remove nodular formation or tissue with cancer, and to improve the effectiveness of subsequent treatments, all thyroid cells should be removed. In accordance with the pathological variety of cancer or in those who have been diagnosed with cancer of the lymph nodes of the neck, it may also be necessary to remove the lymph nodes of the neck.

If to look at kinds of a cancer of a thyroid gland in general, those which have well differentiated structure, as a rule have no negative influence on a life of patients with proper treatment. In other words, the majority with this disease continue a normal life, and can die only because of some other disease, not because of cancer of the thyroid gland. Medullary and anaplastic thyroid cancer, which form a small part of types of thyroid cancer, develop more rapidly. If a genetic structure will be established in medullary cancer, all adults and children, regardless of age, need to undergo a thyroid gland surgeries. Because they will definitely have cancer. Another pathological type of cancer – anaplastic – is rare. Unfortunately its treatment is rather difficult.

Hyperthyroidism (toxic goiter)

Graves’ disease

As a result of the uncontrolled production of the thyroid hormone (T4 and T3) in excessive amount for the TSH hormone secreted by the pituitary gland, excessive pressure is created, as a result of which the work of the immune system is disrupted. As a rule it is not genetically hereditary.

The TSH receptor antibody can be released in excessive amounts as a result of the malfunction of the immune system and this antibody constantly moves, like the TSH hormone, which is the reason for the constant and uncontrolled release of T4 and T3. A high level of this antibody and excessive function of the thyroid gland can cause symptoms in the eyes of the patient. Due to some substances that accumulate in the back of the eyes, one or two eyes (which is less common) begin to move forward. Smoking can enhance this symptom. Clinical manifestations of the disease are usually the following:

• Nervousness
• Excessive sweating
• Weight loss
• Diarrhea
• Increased fatigue and muscle pain
• Dry eyes and protrusion of eyeballs forward (Exophthalmia)
• Violation of the menstrual cycle
• Shiver
• Shaking hands (hand tremors)
• Hair loss
• Male breast enlargement

The diagnosis is made after the survey in the following order: physical examination, biochemical tests, hormonal tests, measurement of antibodies, ultrasound, the thyroid gland scintigraphy.

Option 1 for treatment – antithyroid drugs. Methimazole or Propylthiouracil can be used. For the purpose of lowering the rhythm of the heart and reducing the excessive sweating, Propranolol is used. Also, such patients keep to low iodine diet. If there is negative results of such treatment of patients who are monitored for 6 – 12 months, then treatment with radioactive iodine, called “atomic therapy” or surgical treatment (thyroid surgery), can be performed. Iodine-containing compounds are a variant of treatment that comes in addition to conventional treatments for patients who have suffered a thyroid storm or thyrotoxic crisis.

Hyperthyroidism due to Hashimoto’s disease:

This is a hyperthyroidism that is transmitted genetically, and is the result of rapid irritation of the thyroid tissue by thyroid antibodies (Anti-TPO and Anti-TG), the number of which is increased by the immune system. Signs, diagnosis, treatment is the same as treatment of Graves’ disease.

Hypothyroidism

This syndrome occurs as a result of a lack of thyroid hormones, manifested as a marked slowdown in all metabolic processes.

It may be a reason for growth, development and mental retardation of children and infants.

In adults, however, it can be a reason for slowing metabolism, slowing down the heart rate, reducing oxygen consumption, accumulating of substances called glycosaminoglycans (especially in the skin and muscles) in the cells, and other serious problems up to a coma called myxedema (very rarely in cases of long-term treatment absence).

The most important feature is the fact that if a patient undergoes treatment, full recovery is possible.

The diagnosis of hypothyroidism can be made laboratory-wise in the first stage as a result of the classical definition of a low level of free T4 and a high level of TSH.

Symptoms of hypothyroidism:

• Rapid fatigability, fatigue, weakness.
• Memory problems, slow thinking.
• Edema around the eyes and legs (due to the accumulation of substances called glycosaminoglycans in tissues)
• Myxedema (the absence of a thumbprint)
• Weight gain (slowing metabolism, accumulation of salt and water)
• Tendency to sleep and sleep apnea
• Slowing heartbeat (heart rate)
• Cold intolerance, a tendency to get warm
• Hoarseness and coarsening of the voice
• Reducing sweatiness
• Slow motion
• Thick, dry, rough and cold skin
• Hair loss, reduction and roughness of hairs
• Goiter
• Tingling all over the body
• Violation of menstruation cycle, inability to conceive, decreased sexual desire, erection problems
• Depression
• Hearing loss
• Slow reflexes
• Constipation, stomach bloating.
• Diagnosis of hypothyroidism

The diagnosis is made by measuring free T4 and TSH. Since primary hypothyroidism is most often detected, sT4 is low, and TSH is high. With secondary hypothyroidism, sT4 is low, and TSH is also low or within normal limits. With insensitivity of the thyroid hormone sT4, in spite of expectations it is high, and TSH is high or within normal limits.

Treatment

It is carried out with various doses of drugs containing Levothyroxine, depending on the patient’s condition. Also, depending on the situation of the patient, if necessary, drugs containing Triiodothyronine may be used in different doses.

Thyroiditis

Hashimoto’s disease

Hashimoto’s disease is a disease of the thyroid gland, which is much spoken about in the past 5 years and it is common occurrence. The Japanese surgeon Hakaru Hashimoto first diagnosed it in 1912 in Berlin. At that time, hardening of the thyroid gland and loss of functional characteristics was diagnosed as one disease.

In subsequent years it was found that the disease develops as a result of the attack of the body’s immune system against itself. The body increases the number of antibodies against the thyroid gland, which try to eliminate the gland, as if it is a harmful element for the body. For this reason, it is characterized as “an Autoimmune Disease or an Autoimmune Thyroiditis”.

Antibodies are protein substances that are produced by the immune system to protect the body from chemicals, bacteria or viruses. As a result, the thyroid gland is damaged, insufficiency starts and at the end hypothyroidism occurs, that is, insufficient work of the thyroid  gland.

Hashimoto’s disease can not be considered only as a kind of hypothyroidism. If the production of antibodies is excessive and the thyroid gland is severely damaged in a short time, thyroid hormones (T4 and T3), which in excessive amounts get into the blood from damaged cells, can become a cause of hyperthyroidism (excessive thyroid hormone production). Or if such an attack is very slow, there will be no changes in the level of thyroid hormones in the blood, and as a result, the thyroid function will look normal.

Hashimoto’s disease is most often observed in women, the mother, sister, children, mother-in-law and aunt of the patient should be examined. Women are diagnosed 15 – 20 times more often than men. 95% of the patients are women, which is 2% of the total. Occurs in about 10% of women whose age is 18 – 50 years. For this reason, it is defined as a mother-daughter disease. Genetically transmitted. The development of the disease is intensified by environmental factors.

The creation of the disease:

When Hashimoto’s disease, in the thyroid gland antibodies against thyroglobulin (TG) and thyroid peroxidase (TPO) are formed in the cells of the thyroid gland. The body for destruction of the thyroid tissue produces in large quantities anti-TPO and anti-TG antibodies. These antibodies were established in the 1980s, much later than the diagnosis of this disease.

These antibodies bind to the thyroid and cause damage to the cells of the thyroid gland. As the number of thyroid cells decreases as a result of damage, the characteristics and volume of the gland lose, the number of cells that produce the hormone decreases, resulting in a deficiency of the thyroid hormone. In fact, gland does not always decrease initially. At this time, some cells in the blood enter the thyroid gland and interfere with the functioning of follicular cells of the thyroid gland (areas containing the hormone of the thyroid gland). To compensate for this, some of the thyroid cells multiply.

As a result, the thyroid gland is enlarged and some follicles rupture. That is, there is a situation that looks like a goiter. As a result of the “repair” of broken follicles, a fibrous tissue forms in their place. After some time, the thyroid gland takes an irregular shape due to fibrous tissue and the proliferation of cells in various places. Over time, the fibrous tissue is enlarged, the volume of the gland decreases (atrophy of the thyroid gland)

Environmental factors that increase the likelihood of the disease:

First of all, this is an excessive use of iodine. After in Turkey in 1998 – 1999 the iodization of refined salt began, excessive consumption of salt occurred and the incidence of this disease also increased. In individuals with a genetic predisposition, excessive use of iodine can directly interfere with the synthesis of the thyroid hormone and is the cause of activation of the immune system and increased sensitivity of thyroglobulin molecule to anti-TG and anti-TPO antibodies. For this reason, damage significantly increases and destruction of the thyroid gland accelerates.

Other external factors are: stress, pregnancy, infection, smoking, hepatitis C, selenium deficiency. Especially selenium can protect the area in which damage is generated, due to the binding of autoantibodies in the cells of the thyroid (in spite of the fact that it is not completely covered). For this reason, patients with Hashimoto’s disease, especially those with normal thyroid hormone levels, should take selenium at a certain interval and restrict intake of iodine (HORMONES 2013, 12 (1): 12 – 18).

Complaints of patients with Hashimoto’s disease:

Most patients do not have obvious complaints. If there is hypothyroidism, it is possible to see the following manifestations: weakness, fatigue, exhaustion, weight gain, chills, rapid fatigability, dry skin, slowing intestinal motility, constipation, forgetfulness, depression. Women with hypothyroidism have higher discharge of blood during menstruation and it may last longer, but menstruation may be shorter. If a woman with hypothyroidism who has not been treated becomes pregnant, pregnancy may be terminated, but the condition can be improved by replacing the thyroid hormone.

With age, the incidence of hypothyroidism (thyroid insufficiency) in patients with Hashimoto’s disease is increasing. These patients have goiter, which hardness is comparable to rubber. Very rarely the thyroid gland can be firm, there are no pain or hypersensitivity in it. Very often the thyroid gland increases insensibly and there are no complaints. Usually people consult the doctor because of goitre or weakness, fatigue, lethargy, swelling on the eyelids, hands, face, legs, hoarseness, the cause of which is the lack of the hormone of the thyroid gland. If children have Hashimoto’s disease, this is expressed in the delay in development, slowing down the formation of bones, high cholesterol.

In the case of hyperthyroidism, such complaints as weight loss, diarrhea, excessive sweating, increased heart rate, loss of energy come to the fore. It may be that thyroid tests are normal, and the patient does not have any complaints, or there may be skin changes and hair loss. Women may have violation of the menstrual cycle. In that case, there may be complications in getting pregnant. For this reason, aim is to provide TSH below 2.5 micIU / mL at young women with Hashimoto’s disease.

How is the diagnosis made?

According to tests T3, T4 (especially free T3, free T4), TSH, anti-TPO and anti-TG. Ultrasound of the thyroid gland also greatly helps. Using ultrasound, the changes and the degree of damage to the gland can be detected.

When a member of the family has Hashimoto’s disease, other family members should also do a thyroid exam. Mother, daughters, sisters, aunts of women who were diagnosed with Hashimoto’s disease should be checked for this disease. Initially, the TSH test is performed.

Hashimoto’s disease can be either alone or together with Graves’ disease, nodular and multi-nodular goitre, thyroid cancer. On the basis of Hashimoto’s disease can develop any disease of the thyroid gland.

Treatment and control

Differ for each patient. If there is hypothyroidism, the thyroid hormones therapy started. If there is hyperthyroidism, anti-thyroid medications are given. If the hormones of the thyroid gland are normal, medication treatment can not be started. However, if young women and pregnant women need to have TSH below 2.5 micIU / mL, thyroid hormone therapy can be started faster. Selenium can be used without problems for women who are not pregnant. Iodine intake is limited for all but pregnant women. To ensure the reception of an ideal dose of the thyroid hormone, the patient should undergo a control every 6 months. With hyperthyroidism, the control period is shortened. If there is a nodular formation in the base, ultrasound is performed at a certain interval in accordance with the type of nodule.

Other thyroids

Inflammation of the thyroid gland can develop as a result of the reaction. Thyroid function can be normal. There may also be hyperthyroidism or hypothyroidism.

The subgroups are as follows:

Acute Thyroiditis: development of more than one infection in the thyroid gland. As a rule there is an abscess. Patients have a high temperature (fever) and pain in the neck. Hyperthyroidism usually occurs when a very large number of thyroid cells are destroyed and their hormones enter the blood stream. For the treatment antibiotics, anesthetics, antipyretics are taken. If the treatment is unsuccessful, the patient will undergo surgery.

Subacute Thyroiditis: Very severe inflammation of the thyroid gland, which usually develops as a result of the flu. At the initial stage, patients develop hyperthyroidism. The thyroid gland is very painful. Temperature is possible. For treatment, Aspirin, Non-steroidal anti-inflammatory drugs or Cortisone may be used.

De Quervain’s Thyroiditis

Riedel Thyroiditis

Radiation-induced Thyroiditis

Atrophic Thyroiditis