Introduce:

Name
: Imam Sofii (Imam)
Born
: Pati, 11 Maret 1972 (39 yo)
Graduate : Med. Doctor (Undip, 1991)
General Surgeon (UGM, 2002)
Digestive Surgeon (Unpad, 2010)
Office
: Surgery Department, Sarjito General
Hospital/
Gadjah Mada Univ. Jogjakarta, Jl
Kesehatan no_
0274 851333, email:
imam_djawa@yahoo.com

THYROID NODULE

dr. Kunta Setiaji, Sp.B(K)Onk

Overview
Enlargement in the thyroid gland have
been collectively reffered to as goiters
Goiters may be diffuse or focal and may be
either smooth or noduler
They may be associated with normal
thyroid function or with thyroid
hyperfunction or hypofunction
Diffuse non-nodular goiters with normal or
decreased function are due to benign
causes.
Focal or nodular goiters with normal
function may be due to thyroid neoplasm

DIFFUSE THYROID
ENLARGEMENTS
A. Colloid and iodine-deficiency goiters
Clinical presentation. These are large,
bulky, soft enlargements of the thyroid,
which may grow to sizable proportions.
They occasionally produce compressive
symptoms.
Treatment
a. Compressive symptoms may require
surgery, but more often than not they are
removed for cosmetic reason
b. Other treatment is medical and
depends on the cause of the goiter.

DIFFUSE THYROID ENLARGEMENTS

B. Thyroiditis
1.

Inflammations of the thyroid can be acute, subacute,

or chronic
Acute thyroiditis is an uncommon disorder caused
by the hematogenous spread of microorganisms into
the thyroid gland.
Clinical presentation
The clinical picture is that of acute inflammation with
pain and tenderness, swelling, and redness over one
or both lobes.
The condition may occur in immuno-compromised
patient.
Staphylococci and streptococci have been
incriminated, but any organism can be causative.
Diagnosis is established by needle aspiration with
appropriate bacteriologic studies.
Treatment is by open drainage or localized resection
with administration of appropriate antibiotics.

2. SUBACUTE THYROIDITIS (Giant Cell, granulomatous, or de

Quervains thyroiditis)
is thought to be viral in origin and is often preceded by an
upper respiratory infection.
Clinical presentation
It is characterized by sore throat, enlargement of the gland
(which may be asymmetrical), and tenderness and
induration over the gland.
Patients may have symptoms of hyperthyroidism due the
release of thyroid hormone from the gland secondary to the
inflammation, but the radioiodine uptake is always
decreased, distinguishing it from Graves disease.
The disorder is self-limited, usually lasting from 2-6 months.
Occasonally, subacute thyroiditis is painless, causing
hyperthyroidism without symptoms of inflammation in the
gland, so that it may resemble Graves disease clinically.
This form is also distinguished from Graves disease by the
low radioiodine uptake. Painless thyroiditis not infrequently
occurs during the post partum period.
Treatment.

Symptoms are controlled with either aspirin or

corticosteroids.
Beta-adrenergic blockade may be used to relieve the
symptom of hyperthyroidism.
Antithyroid drugs are ineffective, since the
hyperthyroidism is not caused by increased thyroid
hormone synthesis.

3. Chronic Thyroiditis
occurs in two majors forms, Hashimotos and Riedels.
a. Hashimotos thyroiditis (Struma Lymphomatosa) is a
relatively common autoimmune disorder that occurs
predominantly in women. It is considered to be
autoimmune since it coexist with other autoimmune
conditions and is associated with the presence of
antithyroid antibodies in the serum.
Clinical presentation.
It should be considered in any woman who has a goiter
and hypothyroidism. The enlargement in the thyroid is
most commonly diffuse and less commonly nodular or
asymmetrical. There does not appear to be predilection
for thyroid cancer, but thyroid cancer should be
suspected when the thyroiditis is associated whit one or
more nodules.
Diagnosis. Thyroid function studies are usually normal.
Radioiodine uptake and scans show decreased uptake
with patchy distribution.
Treatment. This form of thyroiditis is ussually treated with
long-term thyroxine therapy. The gland will usually
regress in size unless there is considerable fibrosis.
Surgery is indicated when a dominant mass is not
suppressed by thyroxine therapy; when the gland
continous to enlarge despite thyroxine therapy; and when
the history and physical findings or the needle biopsy are
suggestive of thyroid malignancy.

b. Riedels (fibrosis thyroiditis) is a relatively

rare form of thyroiditis in which the
thyroid parenchyma is almost completely
replaced with dense fibrous tissue.
Clinical presentation. Usually occurs in
middle age and may cause pressure
symptom, such as cough, dyspnea, or
dysphagia. Because the gland is ussually
stony hard, the condition is difficult to
distinguish from thyroid malignancy.
Treatment. Surgery, namely resection of
the isthmus, is needed both to confirm
the diagnosis and to relieve the
symptoms.

NODULAR THYROID
ENLARGEMENT
Clinical presentation.
These goiters are caused by adenomatous hyperplasia of
the thyroid gland.
The thyroid enlargement is thought to be due to long
standing stimulation of the thyroid by TSH during a
period of suboptimal thyroid hormone production.
The progression to multinodularity occurs through a
process of cyclic changes of hyperplasia and colloid
formation.
Despite the relatively high incidence of adenomatous
hyperplasia, the presence of biologically active thyroid
cancer in multinodular goiters without clinical evidence of
malignancy occurs in fewer than 1% of cases.
Pathogenesis.
The nodules in the glands show a wide variety of
pathologic findings.
Some are filled with colloid, while others show evidence
of cystic degeneration. There may be focal calcification,
hemorrhage, or scarring

Diagnosis.
Most patients are asymptomatic, and the nodularityis
detected on routine physical examination.
Occasionally, attention may be drawn to the nodules
because of pain, difficulty in swallowing, or dyspnea if the
nodules enlarge either spontaneously or due to
hemorrhage.
Thyroid function studies are normal, as are the thyroid
antibodies. Radioiodine uptake is normal but scanning
shows variegated uptake of the radioiodine in the areas
of multinodularity.
Treatment.
If there are no clinical signs of malignancy and the gland
is not symptomatic, no treatment is necessary, and
simple observation is appropriate.
If the gland is cosmetically objectionable or if pressure
symptoms develop, then exogenous thyroid hormone
should be given. The purpose of thyroxine therapy is to
suppress endogenous TSH stimulation of the gland and
allow the gland to shrink. Lifelong suppresive therapy
with thyroxine should be given to minimize recurence.
Subtotal thyroidectomy is advisable if the glands are
large enough to produce compressive symptoms and do
not regress with thyroxine therapy.
If patients develop clinical signs of malignancy, this
should be confirmed by needle aspiration biopsy, and
appropriate surgery should be performed.

THYROID NEOPLASM
Overview. The commonest reason for thyroid surgery
today is to diagnose or treat a suspected thyroid
neoplasm that can not be diagnosed by
conventionals means. Not infrequently, a solitary or
prominent thyroid nodule is detected on physical
examination in an asymptomatic patient. The
concern is that the nodule will be malignant,
although most solitary thyroid nodules are benign.
Assesment of thyroid nodules.
a. Patients age
In children, 50% of thyroid nodules are malignant.
During the childbearing years, most nodules are
benign.
The incidence of cancer in nodules increases by
about 10% a decade after age 40 years.
b. Patients sex.
Thyroid cancer is commoner in women than in men
Benign thyroid nodules are also commoner in
women

c. Family history of thyroid malignancy.

Medullary carcinoma of the thyroid may
be transmitted as a mendelian dominant
trait, but other thyroid cancers are not
transmitted genetically.
d. History of radiation exposure.
Exposure of the head and neck region to
therapeutic x-rays has been found to
increase the incidence of thyroid cancer 5
to 10 fold. Radiation has been given for a
variety of disorders, such as an enlarged
thymus in infancy, enlarged tonsils and
adenoids during childhood, congenital
hemangiomas of the head and neck
region, acne vulgaris, and Hodgkins
disease.

e. Characteristics of the nodule.

Consistency.
Nodules that are firm in consistency suggest
malignancy; However, malignant nodules may
undergo cystic degeneration so that they may be
somewhat soft to palpation. Soft nodules are likely
to be benign; however, long-standing adenomatous
hyperplasi may be associated with calcification in
the nodule.
Infiltration
of the nodule into the surrounding thyroid or
overlying structures, such as the strap muscles or
trachea, suggest malignancy. However, malignant
nodules may have no sign of infiltration and may
mimic benign nodules.
Nodulation.
Solitary nodules have a 20% chance of being
malignant.
Growth patterns.
Nodules that suddenly appear or increase in size
should be suspected of being thyroid neoplasms.
Hemorrhage into a preexisting nodule, such as
adenomatous hyperplasia, can cause a sudden

Ipsilateral lymph node enlargement suggest

thyroid malignancy. In children, as many
as 50% of thyroid cancers are first
detected because of cervical lymph node
enlargement.
Mobility of the vocal cords should be
assessed preoperatively in all patients
undergoing thyroid operations.
Ipsilateral vocal cord paralysis in a patient
with thyroid nodule is almost always
diagnostic of a thyroid malignancy that
has infiltrated the reccurent laryngeal
nerve.
Since vocal cord paralysis may not be
associated with voice changes, the cords
should be examined by either indirect or
direct laryngoscopy or by nasal
pharyngoscopy.
Examination should be repeated

DIAGNOSTIC STUDIES
Although clinical evaluation is the mainstay in distinguishing
benign from malignant thyroid nodules, alone it may be
insufficient, and other diagnostic studies may be needed.
Thyroid function test are of little value in diagnosing thyroid
cancer. Nearly all thyroid cancer are nonfunctioning, as
are the nodules of adenomatous hyperplasia. Therefore
fewer than 1% of all thyroid malignancies will be
associated with hyperfunction.
Antithyroid antibodies may be elevated in patients with
Hashimotos thyroiditis, but thyroid cancer may coexist
with thyroiditis; thus, a positive antibody test does not
preclude the diagnosis of thyroid cancer.
Thyrocalcitonin assay will be elevated in patients with
medullary carcinoma of the thyroid.
Radioisotope scanning of the thyroid may be done with
radioiodine or with Technetium-99m pertechnetate.
Isotope tracers are taken up by normally functioning
thyroid tissue, which appears as a hot area on thyroid
scan; nodules that do not take up the tracers appear as
cold areas.
Approximately 20% of cold nodules will be malignant, and
approximately 40% of thyroid cancer will take up the
radioisotope tracer to some degree.

DIAGNOSTIC STUDIES
Ultrasonography.
Using an ultrasound probe, an image of of
the size and shape of the thyroid gland
and the nodules that is contains can be
mapped. Thyroid nodules, thus, can be
identified as either cystic, solid or
complex.
Ultrasonography is helpful in identifying
thyroid nodules that are not clinically
palpable and in directing a needle to a
non palpable nodule for biopsy.
Needle biopsy of the thyroid is designed to
obtain cells for histopathologic or
cytopathologic examination as an aid the

OPERATIVE APPROACH TO THE

THYROID NODULE
Operative removal is the mainstay of treatment for
thyroid carcinoma
The extent of the operation will depend upon the : Type
of thyroid cancer; Extent of the tumor as
determined from the preoperative findings. For a
solitary nodule confined to one lobe, the minimal
operation is total removal of that lobe and the
isthmus and removal of the anterior portion of the
opposite lobe.
Biologic aggressiveness of the tumor.
Lymph node resection is indicated when nodes appear
to be grossly involved.
The parathyroid glands and the reccurent laryngeal
nerve should be identified in all operations.

THANK YOU