THYROID GLAND

PACTICAL ACTIVITY NO. 5

Morphofunctional investigations of the thyroid

1. In vitro methods:
1.1. Basal hormone determinations
1.2. Dinamic tests
1.3. Other specific laboratory findings
2. In vivo methods:
2.1. Radioactive iodine uptake: RAIU
(thyroid Tc-uptake)
2.2. Thyroid scintigraphy: TSG
2.3. Thyroid ultrasound
2.4. Fine-needle aspiration biopsy: FNAB
3. Nonspecific investigations

During systemic illness normal or fT4 with TSH in the acute phase and in the recovery phase.
Dopamine or glucocorticoid administration TSH , normal fT4 and fT3.

1. In vitro investigations
1.1. Basal hormonal assessments:
TSH
fT4, FT4 - free-T4; total T4
fT3, FT3 - free T3; total T3
A. Serum TSH: normal range: 0.5-4.5 mIU/L
Diagnostical value (interpretation of pathological values):
TSH : primary hypothyroidism (subclinical or overt form)
TSH-secreting pituitary adenoma
Refetoff syndrome (thyroid hormone resistance)
TSH : hyperthyroidism
central hypothyroidism
systemic illness
Dopamine or glucocorticoid administration

B. Serum free-T4 (fT4, FT4)

normal range: 0.8-2 ng/dL or 0.7-2.5 ng/dL
9-30 pmol/L
Diagnostical value (interpretation of pathological values):
fT4 : overt hyperthyroidism
TSH-secreting pituitary adenoma
fT4 : overt hypothyroidism (primary or central)
Refetoff syndrome
C. Serum T3 or free-T3:
normal range: 0,5-1,5 ng/mL or 0,2 0,5 ng/dL
3-8 pmol/L
Diagnostical value only in hyperthyroidism:
fT3 and fT4 : overt hyperthyroidism
fT3 and fT4 normal: overt hyperthyroidism with T3

Thyroid function testing

algorithm
TSH
low
fT4
low
Central
hypothyroidism

N
Subclin.
hyperthyroidis
m

high

Normal,
fT4
normal
euthyroid
state
high
Overt
hyperthyroidis
m

fT4
low

Overt
primary
hypothyroidis
m

N
Subclin.
primary
hypothyroidis
m

high
TSHsecretin
g
pituitary
adenom
a/
Resitanc

1.2. Dinamic tests

A. TRH stimulation test

B. TSH stimulation test (Queridos test)
C. T3 suppression test (Werners test)
A. TRH stimulation test
- TRH 200-400 g iv.
- TSH measure at 0, 20, 30, 60
Interpretation:
- N: stimulated TSH 7mIU/L
-

exaggerated response: I. hypothyroidism

- exaggerated response, but tardive and prolonged: III hypothyr.
- low or absent response: II. hypothyroidism or high thyroid hormone
levels: hyperthyroidism or exogenous thyroid hormones.

1.3. Other specific laboratory findings

Antithyroid antibodies:
- TSH-receptor antibody: TRAb
- anti-thyroid peroxidase antibody: ATPO
- anti-thyroglobulin antibody: aTg

Thyroglobulin (TG):
- to show the remnant thyroid tissue or recurrence (in thyroid bed
or metastases) in case of thyroid cancer after total thyroidectomy
- differential diagnosis between hyperthyroidism (TG) and
exogenous thyroid hormone in excess (TG )
- diagnostic value in congenital myxedema (TG )

Tumor markers:
- TG (in thyroid cancer, see above)
- calcitonin: normal range < 1.5 ng/L, high in MTC
- nonspecific tumormarker: ACE carcinoembryonic ag. (MTC)

2. In vivo investigations:
2.1. Radioactive iodine uptake: RAIU
- determines the intrathyroidal iodine turnover
- a jeun 10 Ci I131 or 40 Ci I123
- RIAU normal range:
I123 : 6h = 5-15%
24h= 8-30%
I131 : 2h= 20 5%
24h= 40 5%
48h= lower with 5-15% to the value at 24h
Tc99m: 0.5-3%
RIAU : hyperthyroidism
iodine-deficient goiter
RIAU : acompanying thyroiditis
thyroid hormone administration
iodine exposure
hypothyroidism,
lack of thyroid tissue

2.2. Thyroid scintigraphy: TSG

- morphofunctional investigation of the thyroid
Indications: thyroid nodules, retrosternal goiter, ectopic thyroid tissue
(ex. mediastinal), congenital malformations, postoperative recurrence
Terms:
- thyroid nodules:
- isofunctional nodule
- hyperfunctional or hot nodule high uptake
- hypofunctional or cold nodule low or absent uptake
- compensated autonomous thyroid adenoma
- decompensated autonomous thyroid adenoma
Contraindications:
- pregnancy, nursing mother
- 6 months before conception
- suckling, infancy - only for I131

TSG
normal imagies

TSG with I131

TSG with Tc99m

TSG with I131 thyroid autonomy

Japanese flag aspect decompensated autonomous adenoma,

hot nodule with a cold part, surrounded by the inhibited thyroid tissue

TSG with Tc99m - toxic thyroid adenoma

Hot nodul in the right lobe, inhibited intact thyroid tissue

decompensated autonomous adenoma
aspect of Japanese flag

Compensated autonomous adenoma

T3 suppression test (Werner):

T3 75-100 g in divided doses daily for 5 days
it reduces the 24-hour RAIU by more than 50%
the iodide uptake in the unaffected surrounding thyroid tissue will disappear

TSG with Tc99m

Multinodular toxic goiter

A. Norgmal TSG
B. Cold nodule
C. Hot nodule
D. Multihetero-nodular goiter

2.3. Thyroid ultrasound

Normal aspect: homogenous, isoechoic structure

Thyroid nodules

Hashimotos thyroiditis

PET CT

Elastography

2.4. FNAB Fine-needle aspiration biopsy

- elective method to differentiate benign and malignant thyroid
nodules
- in outpatient unit, without local anaesthesia
- 25 G or 27G needle
FNAB results:
- benign: about 70 % out of results;
- malignant: 1- 5 %;
- suspected, follicular lesion: 11-13%;
- inadequate, non-diagnostic: 11-13%.
The sensibility and specificity is 90%.