What Are the Different Types of Thyroid Treatment?

Goiter is divided into two types: simple goiter and nodular goiter.

Shao Tanglei

(Deputy Chief Physician)

Department of General Surgery, Shanghai Ruijin Hospital

Thyroid diseases are mainly divided into two categories: medically treated thyroid diseases and surgically treated thyroid diseases. Medically treated thyroid diseases include hyperthyroidism (commonly known as hyperthyroidism) and thyroid inflammation (including acute, subacute, and chronic thyroid inflammation). Surgical thyroid diseases include goiter and thyroid tumors. The main difference between the two is that the thyroid function tests for thyroid diseases that are medically treated are abnormal, while the thyroid function tests for thyroid diseases that are surgically treated are normal. But the two are not absolutely isolated, and the two can also transform each other. Especially medical thyroid diseases may also require surgical treatment. This article mainly introduces four types of thyroid diseases: goiter, hyperthyroidism (hyperthyroidism), thyroid inflammation, and thyroid tumors.

Western Medicine Name: Thyroid disease

Affiliated Department: Internal Medicine-Endocrinology
Disease site: thyroid

Goiter

Goiter is divided into two types: simple goiter and nodular goiter.

Simple goiter

The etiology of simple goiter is related to the lack of iodine in the diet (such as mountain areas) and in some cases (such as pregnancy, growth and development) the increased demand for iodine.

In patients with simple goiter, an enlarged thyroid gland can usually be found on the neck. Ultrasound can also confirm goiter, but there are no nodules in the thyroid. The thyroid function of patients with simple goiter is normal, which can be distinguished from goiter caused by hyperthyroidism and Hashimoto's thyroiditis.

Patients with simple goiter do not need surgery, they only need to add thyroxine preparations. Generally, the enlarged thyroid gland will subside after a period of medication. At present, there are mainly two types of thyroxine preparations used in China, one is thyroxine tablets, 40 mg / capsule; the other is levothyroxine nano tablets (such as Youjiale and Rettis), 50ug / cap or 100ug / cap . Thyroxine tablets are animal preparations extracted from the thyroid of pigs, which are relatively rough and not very high in purity; left thyroxine tablets are artificial preparations with relatively high purity.

Nodular goiter

Is the most common type of thyroid disease. Its etiology is not very clear, and may be related to endocrine disorders, high iodine diet, environmental factors, genetic factors and history of radiation exposure.

Patients with nodular goiter are usually found by physical examination or by themselves to find a neck mass. On examination, nodules above 1 cm can be felt. They are usually soft or tough, with smooth surfaces and clear boundaries. They can move up and down with swallowing. Thyroid function tests were all within the normal range. B-ultrasound showed normal or enlarged thyroid gland, and there may be single or multiple nodules on one or both sides of the thyroid. These nodules can be cystic, mixed, or substantial; they are oval in shape. Nodules may surround the nodules. The shape may be irregular; the boundary may be unclear; the blood supply may be rich; the substantial nodules may appear with coarse calcifications accompanied by sound shadows, but are generally not accompanied by microcalcifications.

Nodular goiter can only be cured by surgery, but not all nodular goiters require surgery. Generally, nodular goiters with a nodule of at least 20mm or suspected of malignancy or compression or located behind the sternum or secondary hyperthyroidism or affect aesthetics, work and life are considered surgery. If the above situation does not occur, it is recommended that B ultrasound follow-up every six months. The drug is not effective in treating nodular goiter. ^[1] ^[2] ^[3]

Thyroid disease hyperthyroidism

More common in young women. The clinical manifestations are mainly caused by excessive thyroid hormones in the circulation. The symptoms are irritability, irritability, insomnia, palpitations, fatigue, heat, sweating, weight loss, hyper appetite, increased stool frequency, or diarrhea. Women's menstruation is rare. On examination, most patients have varying degrees of goiter, which are diffuse, of medium texture, and without tenderness. Some patients have exophthalmos.

Thyroid function test blood T3, T4, FT3, FT4 increased, TSH decreased (generally <0.1mIU / L). Thyroid function test 131I uptake rate increased and the uptake peak moved forward. B-ultrasound revealed diffuse thyroid enlargement and increased blood supply; nodules were found in some patients' thyroid.

General treatment of hyperthyroidism includes paying attention to rest, adding enough calories and nutrition.

The treatment of hyperthyroidism mainly adopts the following three methods:

1. Antithyroid drugs (ATD). The main drugs are methimazole (MMI) and propylthiouracil (PTU). The side effects of antithyroid drugs are rash, itching of the skin, leukocytopenia, granulocytopenia, toxic liver disease and so on.

2.131 Iodine treatment. Indications include: adult Graves hyperthyroidism with goiter above degree; failure or allergy to ATD treatment; recurrence after hyperthyroidism surgery; hyperthyroid heart disease or heart disease with other causes of hyperthyroidism; Reduced blood cells; elderly hyperthyroidism; hyperthyroidism with diabetes; toxic multinodular goiter; autonomic functional thyroid nodules with hyperthyroidism. Contraindications are for pregnant and lactating women. The main complication after 131I treatment of hyperthyroidism is hypothyroidism. After hypothyroidism occurs, thyroid hormone preparations can be used instead of treatment to maintain normal thyroid function.

3. Surgery. The indications for surgical treatment are ineffective or ineffective in long-term drug treatment of moderate and severe hyperthyroidism; relapse after withdrawal, larger thyroid; nodular goiter with hyperthyroidism; compression of surrounding organs or retrosternal goiter; suspected and Patients with thyroid cancer coexist; children with hypothyroidism who are poorly treated with antithyroid drugs; those with poorly controlled hyperthyroidism drugs during pregnancy can be surgically treated in the second trimester (weeks 13-24) ^[1] ^[2] ^[4]

Thyroid disease thyroid inflammation

Subacute thyroiditis

Subacute thyroiditis is often secondary to upper respiratory tract infections, and often occurs in spring and autumn. Most of the subacute thyroiditis occurs in women aged 40-50 years. It is mainly manifested as neck pain, tenderness of the thyroid gland on one side, and systemic inflammation such as fever and joint pain. Hyperthyroidism may occur in some patients. On examination, most patients had tenderness on one side of the goiter.

In patients with subacute thyroiditis, the erythrocyte sedimentation rate increases, blood FT3 and FT4 are normal or slightly increased, and TSH is normal or slightly decreased. The serum TPOAb is often transiently increased. B-ultrasound showed that the thyroid volume increased, and the lesions within the gland showed low echo or uneven fusion, with unclear borders, irregular shapes, and localized calcifications.

Subacute thyroiditis is a self-limiting inflammation that usually resolves without special treatment. However, the patient should take a proper rest, and at the same time can be given prednisone or anti-inflammatory analgesics to reduce symptoms.

Chronic lymphocytic thyroiditis

Also known as Hashimoto's thyroiditis. More common in women, age 30-60 years old. The common symptom is general weakness, and most patients do not have neck discomfort, but a small number of patients will have local compression and neck pain. On physical examination, the thyroid gland was mostly bilaterally swollen, and the isthmus also increased. Tough texture, smooth or nodular surface. A few patients may be accompanied by cervical lymphadenopathy, but soft.

In thyroid function tests, blood T3, T4, FT3, FT4, and TSH are generally normal at the beginning of the disease, but as the disease progresses, TSH gradually increases, and finally T3, T4, FT3, and FT4 gradually decrease and hypothyroidism occurs. Thyroglobulin antibody (TGAb) or thyroid peroxidase antibody (TPOAb) is always elevated. B-ultrasound showed diffuse thyroid enlargement or nodular enlargement, uneven echo, and a grid-like or sheet-like echo change. Gland blood supply is generally rich.

The treatment of chronic lymphocytic thyroiditis is limited. Such as thyroid enlargement or hypothyroidism can be treated with thyroid hormone preparations. Selenium has been found to be effective in treating chronic lymphocytic thyroiditis, so selenium yeast tablets can also be used for treatment.

If chronic lymphocytic thyroiditis causes compression symptoms of goiter or nodules in the thyroid gland and nodules are highly suspected of malignancy, surgical treatment should be considered. ^[1] ^[2]

Thyroid disease thyroid tumor

Benign thyroid tumors

Benign thyroid tumors are mainly thyroid adenomas. Occurs in young adults. The clinical manifestations are mostly anterior neck masses, which grow slowly and have no subjective symptoms. Physical examination of the lump surface is smooth, soft or tough texture, clear boundaries, can move up and down with swallowing. Such as adenoma hemorrhage, the mass can grow rapidly with local pain, these symptoms usually disappear within 1-2 weeks.

General indicators of thyroid function tests are within the normal range, but for high-function adenomas, T3, T4, FT3, and FT4 can be increased, and TSH can be reduced. B-ultrasounds are mostly single nodules in the thyroid gland, but they can also be multiple. They are substantial or mixed, mostly oval, with clear boundaries and regular morphology.

Generally, thyroid adenomas with a diameter of less than 10mm are recommended to be observed and regularly followed up by ultrasound. Surgery may be considered if the adenoma has recently increased rapidly or appears to be oppressive or has a tendency to malignant change or is diagnosed as a high-functioning adenoma during follow-up.

Thyroid disease

1, disease classification: can be divided into differentiated thyroid cancer including papillary thyroid cancer and thyroid follicular cancer, poorly differentiated thyroid cancer such as myeloid cancer and undifferentiated thyroid cancer. At present, the incidence of thyroid cancer is increasing year by year.

2. Cause: The cause of thyroid cancer is not very clear. It may be related to dietary factors (high iodine or iodine-deficient diet), history of exposure to emission lines, increased estrogen secretion, genetic factors, or other benign thyroid diseases such as nodular goiter. , Hyperthyroidism, thyroid adenoma, especially chronic lymphocytic thyroiditis.

3. Clinical manifestations: differentiated thyroid cancer is more common in women, and the common age is 30-60 years. The development of differentiated thyroid cancer is slow. Patients can find a painless mass that gradually increases in the neck, which is unintentionally found by themselves or on a physical examination, or during an ultrasound examination. Physical examination of cancer is hard and hard, the surface may be smooth, and the border may be clear. If the cancer is localized in the thyroid, it can move up and down with swallowing; if it has invaded the trachea or adjacent tissues, it is more fixed.

4, auxiliary examination: thyroid function tests are mostly normal, but if it is transformed from other diseases such as hyperthyroidism or Hashimoto's thyroiditis, there is a corresponding abnormal thyroid function. B-ultrasound is very helpful for the diagnosis of differentiated thyroid cancer. Most of the differentiated thyroid cancers are solid masses in the B-ultrasound, but some of them can also be mixed masses that are mainly composed of solid components. Papillary thyroid carcinoma usually has low or very low echo in B-mode ultrasound, microcalcification can appear in the parenchyma, the shape of the mass can be abnormally vertical or upright, and the blood supply around the mass is abundant. Follicular carcinoma of the thyroid gland is usually a very homogeneous hyperechoic mass in the B-ultrasound, with abundant blood supply. The size of the mass, whether the boundary is clear, and whether the shape is regular are not important indicators for judging whether the mass is malignant. Fine-needle aspiration cytology (FNA) of a suspected malignant mass under B-ultrasound can now be used to further confirm the diagnosis of thyroid cancer.

Generally, differentiated thyroid cancer is cold nodules on isotopic scans. If there is suspicion of lymph node metastasis or invasion of surrounding organs such as the trachea and esophagus in differentiated thyroid cancer, CT examination can be used to understand the extent of lymph node metastasis and the extent of invasion of trachea, esophagus and other organs to facilitate the formulation of surgical plans.

5. Disease treatment:

Papillary thyroid carcinoma: Lymph node metastasis is the main cause. Lymph nodes in the neck can be divided into I-VI regions. Generally, lymph nodes in the II-VI region are related to thyroid cancer metastasis. Lymph nodes in the region VI are also commonly referred to as central group lymph nodes, including tracheoesophageal sulcus, pretracheal, and anterior laryngeal lymph nodes; region II-V lymph nodes are also referred to as cervical cervical lymph nodes, including lymph nodes around the large vessels in the neck and lymph nodes around the nerves. Lymph nodes in the central group are mostly located behind the thyroid gland and have a small diameter. Generally, cervical B-ultrasounds are difficult to find; while cervical lymph nodes can be found by B-ultrasound for metastases. In most cases, papillary thyroid carcinoma on one side often metastasizes to lymph nodes on the same side, but it can also metastasize to the lymph nodes on the opposite side. The way of lymph node metastasis is generally to the central group lymph nodes, and then to the cervical side lymph nodes; however, there are also some cancers, such as tumors located in the upper pole of the thyroid, which can first metastasize to the cervical nodes. The literature reports that, regardless of tumor size, the lymph node metastasis rate in the central group can usually reach about 50%. In view of this, the latest issue of China's guidelines for differentiated thyroid cancer emphasizes central group lymph node dissection. However, for the scope of thyroid resection, an individualized plan can be implemented according to the stage of the tumor, medical conditions in various places, and the degree of patient's awareness of the disease, but at least the cancerous gland lobe + isthmus must be removed.

Follicular carcinoma of the thyroid: Mostly metastasize to the lungs, bones, brains, and livers through the bloodstream. A more reasonable surgical procedure is to perform a bilateral full / near total resection of the thyroid gland and a lymph node dissection of the central group of the affected side. Iodine 131 treatment. However, because it is difficult to identify follicular carcinoma in frozen pathological sections during surgery, it is often necessary to perform another supplementary surgery.

According to foreign experience, because the prognosis of differentiated thyroid cancer is good, if the surgical resection is complete, supplemented with iodine 131 consolidation surgery. After the end of iodine treatment, taking thyroid hormone preparations for life and suppressing treatment can often achieve the curative effect. However, for differentiated thyroid cancer with a large amount of residual thyroid cancer after surgery, iodine treatment can not consolidate the effect of treatment. At the same time, stopping thyroid hormone preparations during repeated iodine treatment can cause tumor recurrence or dedifferentiation. For patients with more residual, it is recommended to take thyroxine preparations for suppression treatment. As for the dose of thyroxine inhibitory treatment, it depends on the stage of the tumor.

Medullary thyroid cancer: It is a moderate malignant tumor that occurs in thyroid C cells. Can be divided into hairspread, familial and MEN2 types. The patient's main manifestation was painless hard solid nodules of the thyroid gland and local lymphadenopathy. Sometimes lymphadenopathy becomes the first symptom. Some patients with medullary thyroid cancer may develop diarrhea, abdominal pain, and flushing. Physical examination of the goiter is hard, the border is unclear, and the surface is not smooth. Sporadic are mostly one-sided goiter, while familial and MEN2 types can be bilateral goiter.

Patients with medullary thyroid carcinoma have elevated serum calcitonin levels, and some patients have elevated carcinoembryonic antigen (CEA) levels. B-ultrasounds suggest that the mass is mostly located in the upper half of the thyroid gland, which can be single or multiple, with low echo. The center of the mass is mostly calcified, and the nodules are silent, and the blood supply is rich.

Medullary thyroid cancer can undergo lymphatic metastasis at an early stage, and distant metastasis can occur through the bloodstream, so the prognosis is worse than that of differentiated thyroid cancer. Because myeloid cancer has no effect on thyroid hormone preparations and iodine 131 treatment, only surgery is the most effective method for treating myeloid cancer. The scope of surgical resection should include bilateral total thyroidectomy and lymph node dissection in the central group of the cancerous side. If cervical lymph node metastasis is found before surgery, cervical dissection must be performed. However, for familial medullary carcinoma, even if no cervical lymph node metastasis is found, prophylactic cervical lymph node dissection can be performed. Due to the lack of thyroid function after medullary carcinoma, thyroid hormone preparations must be given replacement therapy.

Undifferentiated thyroid cancer: It is a highly malignant tumor and is more common in elderly patients. It is generally over 65 years old. The vast majority of patients present with a sudden neck mass, which is hard, with uneven surfaces, unclear borders, poor mobility, and rapidly increasing. May be accompanied by hoarseness, difficulty breathing and swallowing, and local lymphadenopathy. On the B-ultrasound, there are uneven clumps with unclear boundaries, which often involve the entire glandular lobes or glands. Necrotic zones can occur in most cases.

Due to the high malignancy of undifferentiated thyroid cancer, the disease progresses very quickly, and it is easy to invade surrounding organs and tissues such as the trachea, esophagus, and nerves and blood vessels of the neck. Therefore, it is often advanced at the time of consultation and cannot be surgically removed. Treatment and chemotherapy are performed only when the trachea is compressed or obstructed. In recent years, some people have suggested that early thyroid undifferentiated cancer, such as small primary lesions, can be performed with lobectomy or total thyroidectomy. Postoperative supplementary radiation and chemotherapy can also achieve good results. ^[1] ^[2] ^[3]