Carcinoma of thyroid gland types causes diagnosis and treatment

Carcinoma of thyroid gland types causes diagnosis and treatment

Introduction

Thyroid gland is that gland which present in front of the neck which has two lobes one on each side connected together by an isthmus taken butter fly appearance

Thyroid gland is responsible for release of thyroid hormones such as tri-iodothyronine T3 tetra-iodiothyronine T4 and thyroid stimulating hormones TSH ,these hormones are responsible for the process of metabolism in the body if there is any disorders affect the release of these hormones are associated with diseases either in the form of increased secretion of thyroid hormones causing hyperthyroidism or decreased secretion of thyroid hormones causing hypothyroidism 

 

Thyroid cancer is a malignant tumor or neoplasm which arise from either follicular or parafollicular cells of the thyroid gland it is uncommon cancer which affect women more than men ,there are several types of thyroid cancer and different methods of treatment

 

What are the causes of cancer thyroid 

 There are certain factors which may associated with cancer thyroid such as

• Exposure to irradiation head and neck exposure to irradiation such as X rays during childhood for treated other diseases such as tuberculosis or TB of the lymph nodes which was done in the past these patients are more liable for development of cancer thyroid
• Endemic cancer such as the incidence of follicular carcinoma  is high in endemic areas possibly due to TSH stimulation
• Presence of benign thyroid lesions which may transformed to malignancy such as adenoma of the thyroid gland especially in male ,nodular goitre and Hashimotos thyroiditis
• Cancer thyroid may occur alone without previous causes DE Novo such as anaplastic carcinoma
• Hereditary causes may be found

What are the types of  thyroid cancer

 

There are several types of thyroid cancer as follow

• Papillary:it is the most common type of thyroid cancer account for more than 60% which can occur in young age begins in the follicular cells characterized by localized slowly growing nodule,can spread through lymphatic vessels to lymph nodes which is the main route of spread  it is hormonal dependency tumor and if diagnosed early and treated give good result and best prognosis
• Follicular : it is the second most common causes account for about 17% which also begins in the follicular cell of the thyroid gland can occur in young and old age characterized by slow rate of growth but more than papillary type ,can spread to through the blood to the lung and bones which is the main route of spread it is Iodine uptake tumor and if diagnosed early and treated can give better result but less than papillary type
• Anaplastic :it is least common type account for about 13% of thyroid cancer common in old age patient above 60 years ,begins also in follicular cells of thyroid gland , characterized by large rapid growing highly infiltrating mass ,can spread either by direct spread to surrounding organs which is the main route of spread or to the lymph nodes through lymphatic spread or to the lung bones liver and brain through blood spread,give temporary response to external irradiation has poor prognosis
• Medullary :less common type of thyroid cancer which arise from parafollicular cells called C- cells of thyroid gland which secreted calcitonin characterized by some tumors are familial runs in family and form part on multiple endocrine syndrome type II MEN type II or Sipples syndrome which has two forms MEN type IIa which consists of medullary carcinoma pheochromocytoma and hyerparathyyroidism ,MEN type IIb when the familial form is associated with prominent mucosal neuromas involving lips , tongue and eyelids can spread through lymphatic to the lymph nodes or through the blood to the lungs bone brain and liver which is the main route of spread the disease common associated with diarrhea due to 5 -hydroxy traptophan 5HT or prostaglandins produced by the tumor cells,calcitonin is a biomarker  it is non hormonal dependent can give good result after treatment without blood spread or metastases

What are the symptoms and signs of thyroid cancer

• The patient may complaining from mass or swelling in front of the neck
• The patient may not complaining and the thyroid mass or swelling is discovered incidentally by the physician during routine examination
• The patient may complaining from thyroid swelling of recent onset with rapid increased in size 
• The patient may complaining from pain either in front of the neck or in the ear earache due to Arnolds nerve infiltration by cancer cells this nerve is the auricular branch of the vagus nerve
• The patient may complaining from difficulty in swallowing dysphagia due to swelling compression on the esophagus
• The patient may complaining from change in his voice in the form hoarseness of voice due to recurrent laryngeal nerve infiltration by cancer cells
• The patient may complaining from shortening or difficulty in breathing dypsnea and cough either due to swelling compression effect or due to spread of cancer cells to the lungs
•    The doctor may showing by examination thyroid swelling which it is hard ,tender,irregular and fixed
• The doctor may show enlarged lymph nodes which hard and  mobile then become fixed
• The doctor may showing other signs of distant metastases or cancer spread such as loos of weight and jaundice in case of liver affection

When we can suspected thyroid cancer

 

Thyroid cancer can be suspected to be malignant in the following cases

• When there is thyroid swelling or goitre with previous history of head and neck exposure to irradiation
• When thyroid swelling present either in young or very old ages
• When thyroid swelling become increased in size and rapid growth
• When thyroid swelling associated with pain 
• When thyroid swelling become hard ,irregular and fixed or with limitation of it is mobility
• When there is blood or lymphatic metastases 

What are the investigations of cancer thyroid

 

Laboratory

 

Complete blood count

For anemia and fitness

   Liver function test

For elevation of liver enzymes in case of liver metasteses

Tumor markers

For detection of of thyrogobulin for differentiated carcinoma or calcitonin for medullary carcinoma

Tumor markers definition types and its aims

Thyroid function test

For T3,T4,TSH hormones of thyroid gland either elevated or decreased

Other according to the case

 

Radiological

 

Thyroid ultrasound

 

To differentiated between cystic from solid swelling

 

Thyroid scanning

 

By radioactive iodine to show the thyroid nodule which appear as

 

Cold nodule (inactive nodule)  a cold nodule it is the nodule which takes up no isotope such as in case of cancer  thyroid or common in cystic nodule

 

  Hot nodule or overactive nodule which takes up isotope while the surrounding thyroid tissue is inactive because the nodule is producing such high levels of thyroid hormones that TSH secretion is suppressed such as in case of hyperthyroidism

 

 Warm nodule or active nodule in which the warm nodule take isotope like normal thyroid tissue

 

X rays

For the neck ,chest,skull,spine and pelvis for detection cancer metastases

 

Laryngoscopy and bronchoscopy

For detection of recurrent laryngeal nerve or tracheal invasion by cancer cells

 

CT scanning of the head neck and chest and brain

MRI scanning of the head neck chest and brain

 

Whole body scanning

 

By using radioactive iodine which go through circulation to different body organs to detect cancer metastases

Other according to the case

 

Thyroid biopsy

 

Biopsy of thyroid gland it is essential for diagnosis of thyroid cancer which may be done by an open operation by surgical removal of the swelling or by needle fine needle aspiration cytology FNAC or by true cut needle biopsy which taken for histological examination under microscope for detection of cancer cells

If an enlarged lymph node is present it may be removed through a small incision directly over it and taken for microscopic examination for detection of cancer cells

 

What are the treatment of thyroid cancer

Treatment of thyroid cancer depend on many factors such as the type of the cancer the size of the cancer ,the age of the patient , there is distant metastases to other organs such as to the liver lungs bone brain lymph nodes or no the patient fit for operation or no

Treatment of thyroid cancer can be done by the following methods

Surgical

 

Surgical removal of thyroid gland by an operation called thyroidectomy

 

Radiotherapy

External irradiation indicated in case of some thyroid cancer which can not be treated by surgery or for recurrent cancer after it is removal or as palliative treatment to relieve pain or ulceration can be used in anaplastic cancer

 radiotherapy how it is work types and its complications

 

Hormonal therapy

 

    Some thyroid cancers are hormonal dependent and can respond to thyroid hormones like L-thyroxine such as papillary and follicular carcinoma

  Hormonal therapy how it is work types and its complications

Chemotherapy

 

Can be used in some thyroid cancer such as medullary carcinoma and analpastic cancer can be used also to relieve pain

Chemotherapy how it is work types and its complications

 

Radioactive iodine

 

Can be used in some thyroid cancer which its can uptake iodine such as follicular carcinoma by using sodium Iodide 131 which given by oral route then absorbed into the body and reach thyroid gland which trapped inside it which causes irradiation to the thyroid tissue and causing its damage so reduced secretion of thyroid hormones from thyroid gland  the half life of sodium Iodide 131 is eight days and can be retained in the body for several week and the excess Sodium Iodide are eliminated from the body through the kidney passing to the urine

tags:thyroid,cancer,malignancy,papillary,madullary

EXPLAINING OF CONN`S SYNDROME

EXPLAINING OF CONN`S SYNDROME OR HYPERALDOERONISM

Definition

Hyperaldosteronism means increased secretion of aldosterone hormone in the blood which may divided into primary (conn`s syndrome) which is the most commonly caused by an aldosterone - producing adenoma or carcinoma in the zona glomerulosa of the cortex of the adrenal gland or secondary hyperaldosteronism due to stimulation of the renin - angiotensin system from the renal artery stenosis and to low blood flow states such as congestive heart failure and liver cirrhosis

Cause of hyperaldosternisom

Primary hyperaldosternism

Results from autonomous aldosterone secretion which in trun leads to suppression of renin secretion

Most common age 30-50 years

• Most common  causes aldosterone producing adenoma or solitary functioning adrenal adenoma or very rare carcinoma in the zona glomerulosa causing conn`s syndrome  account for 70% of causes
• Adrenocortical hyperplasia may bilateral 25-30%
• Adrenal carcinoma  less than1%
• Ovarian carcinoma
• Familial causes
• Glucocorticoid suppressible hyperaldosteronism is an autosomal dominant form of hypertension in which aldosterone secretion is abnormally regulated by ACTH  this condition caused by recombinations between linked genes encoding closely related isozymes

Secondary aldosteronism

• Congestive heart failure
• Liver cirrhosis

Symptoms and signs

• Patient typically present with increased blood pressure  (hypertension) which is long standing moderate to severe hypertension and may be difficult to control despite the patient using multiple drug therapy due to water and sodium retention accounts for 1% in patient with essential hypertension
• Patient feel by headache
• Patient feel increased the frequency of micturation polyuria nocturia means at night and feel by thirsty or polydipsia
• Easy fatigue and weakness due to hypokalemia
• Muscle wasting and tirdness

Investigations and diagnosis

Laboratory

Blood tests

increased  plasma aldosterone concentration PAC  hyperaldosternism

Increased sodium NA hypernatremia

decreased potassium K hypokalemic acidosis

Decreased plasma renin activity PRA levels due to negative feedback caused by increased blood pressure and aldosterone

PAC :PRA ratio of 25 to 30 :1 is strongly suggestive of the diagnosis  but false positive results may occur in patient with chronic renal failure

Patients with primary hyperaldosternism fail to suppress aldosterone levels with sodium loading this test can be performed by 24 hours urine collection for cortisol , sodium , and aldosterone after 5 days of a high sodium diet or by giving the patient a load of 2 litre of saline solution while in supine position 2 to 3 days after being on a low sodium diet

Plasma aldosterone levels less than 8.5 ng|ml or a 24 hours urine aldosterone less than 14 ug after saline loading essentially for rules out primary hyperaldosternism

Radiological studies

CT and MRI scanning of the abdomen

To showing adrenal adenoma

Adrenal vein sampling

Selective venous catherization to localize aldosteronoma in which the adrenal vein is cannulated and blood samples for aldosterone and cortisol are obtained from both the adrenal veins and inferior vena cava after administration of the adrenocorticotrophic hormone ACTH but this procedure is invasive one and may lead to injury of the adrenal veins or ruptured it so this  may used in specific cases such as when the tumors can not be localized and in patients with bilateral adrenal enlarged to determine whether there is unilateral or bilateral increased secretion of aldosterone

Adrenal gland scintigraphy

Using NP-59 which is taken by the adrenal cortex and adrenal adenoma appear as hot nodules with suppressed contralateral uptake while hyperplastic glands show bilaterally increased uptake

Treatment

Treatment of hyperaldosteronism depend on the causes

Adrenal gland removal which can be done either by open surgical or laparoscopic adrenalectomy

Male patient more than 50 years and patients with multiple adrenal nodules may not benefit from adrenlectomy

Preoperative control of hypertension and adequate potassium supplementation are important

Patients are generally treated with diuretic drugs such as spironolactone an aldosterone antagonist

amiloride a potassium sparing diuretic that block sodium channels in the distal nephron of the kidney

   nifedipine a calcium channel blocker or captopril an angiotensin converting enzyme inhibitors ACE

Glucocorticoid - suppressible hyperaldosteronism

 Treated by administering exogenous dexamethasone at doses of .5 to 1 mg daily  also with spironolactone 

Postoperative

Some patient may suffer from transient hypoaldosteronism and need to give mineralocorticoids for up 3 months

tags:conn`s,explaining,syndrome

EXPLAINING OF ADDISON`S DISEASE

EXPLAINING OF ADDISON`S DISEASE OR ADRENOCORTICAL INSUFFICIENCY

Definition

Addison`s disease or adrenocortical insufficiency means inadequate secretion of corticosteroid hormones from the zona fasciculata of the adrenal cortex of the adrenal gland which may be primary resulting from adrenal disease or secondary as a result of a deficiency of adrenocorticotrophic hormone ACTH

Causes

Primary

• autoimmune disease such as addison`s disease

• Drugs such as ketoconazole rifampicin phenytoin aminoglutethemide metyrapone and mitotane
• Infection eg tuberculosis TB and HIV
• Spontaneous adrenal hemorrhage can occurs in patient with fulminate or acute meningococcal septicemia called Weterhouse-Friderichsen syndrome which associated with bilateral adrenal hemorrhage and infarction associated with disseminated intravascular coagulopathay (DIC) and may also occurs secondary to trauma severe stress infection and coagulopathies
• Inflitrative disorders such as sarcoidosis and amyloidosis and hemochromatosis
• Congenital adrenal hyperplasia
• Metatatic deposits from other cancer
• Pan hypopituitarism
• ACTH deficiency

Secondary

•  Exogenous glucocorticoid therapy with suppression of the adrenal glands is the most common cause of secondary adrenal insufficiency when the steroids are discontinued which the steroid therapy inhibits the production of ACTH  and leads to adrenal cortical atrophy 

• After removal of the adrenal gland post adrenalectomy
•  Pituiatery or hypothalamic tumors
• Pituitary hemorrhage such as postpartum Sheehan`s syndrome
• Trans-sphenoidal resection of pituitary gland

Symptoms and signs

• Acute adrenal insufficiency should be suspected in stressed patients with any risk factors
• Symptoms and signs may similar to sepsis or infection and present with fever nausea lethargy abdominal pain and severe hypotension hypoglcaemia dehydration and shock
• Chronic adrenal insufficiency such as occurring in patients with metastatic tumors may give symptoms such as fatigue salt craving weight loss nausea vomiting abdominal pain and diarrhea
• Hyper pigmentation of the skin and cirumoral pigmentation due to secretion of large amount of ACTH and  CRH with an increase in melanocyte stimulating hormones MSH
• Muscle wasting
• Postural decreased blood pressure( hyoptension )due to sodium and water loss

  Investigations and diagnosis

Laboratory

Hyponatremia decreased serum sodium NA+ and

Hyperkalemia increased serum potassium K+ and

Eosinophilia

Fasting or reactive hypoglycemia

Increased ACTH in primary causes and decreased in secondary causes

Decreased cortisol

ACTH stimulation test

ACTH 250 ug is infused intravenously and cortisol levels are measured at 0 , 30 , 60 minutes

Peak cortisol levels less than 20 ug|dl suggest adrenal insufficiency

ACTH  levels also enable one to distinguish primary from secondary causes

High ACTH levels with low plasma cortisol levels are diagnostic of primary adrenal insufficiency

 

Treatment

In patients with acute attack are treated by

Volume resuscitation with at least 2-3 litre of .9 saline solution or 5 % dextrose in saline solution

Blood should be obtained for electrolytes showing decreased NA+ and increased K+  blood glucose decreased and cortisol level decreased

ACTH increased in primary and decreased in secondary and eosinophilea

Drugs treatment give dexamethasone 4 mg intravenous

Hydrocortisone 100 mg intravenous every 6 hours after measure level of cortisol in the blood to avoid it is interference with it

After patient become stabilized the underlying causes should be known and treated

Maintenance doses of oral hydrocortisone 15-20 mg in the morning and 10 mg in the evening

Mineralocorticoids such as fludrocortisone .05-.1 mg daily may be required once the saline infusions are discontinued

 tags:addison`s,explaining,disease

EXPLAINING OF CUSHING SYNDROME

EXPLAINING OF CUSHING SYNDROME

Definition 

Cushing syndrome or hypercortisolism it is an endocrine or hormonal disorders which characterized by excessive or increased production of glucocorticoids or cortisol in the circulating blood which due to various causes such as iatrogenic steroids uses when the increased in the glucocorticoids is due to a pituitary tumor it is called cushing disease the cushing syndrome is more common in women than men

Causes of cushing syndrome

There are many causes which can be divided into

Causes related to adrenal gland and

 Causes not related to the adrenal gland

Causes related to adrenal gland

The adrenal gland is a small gland which lies above the kidney and there are two glands in the body one on each side above the kidney and  each gland consists of two parts outer cortex and inner medulla

The cortex of the adrenal gland responsible for production of the glucocorticoids or cortisol into the circulating blood these hormones are not stored in the adrenal cortex but they are released on demand which their secretion under negative feedback control as follow

Any stimulation such as stress fever or exercise to hypothalamus which is a part from the brain lead to release of corticotrophin releasing hormone (ACH) which stimulate the pituitary gland to release adrencorticotrophic hormone ACTH this hormone stimulate the zona fasiculata of the adrenal cortex which release cortisol into the blood so

 Causes of adrenal gland such as

•  Adrenal gland carcinoma which most common causes in children
• Adrenal gland adenoma
• Adrenal gland hyperplasia

Causes not related to the adrenal gland such as

• Iatrogenic causes by prolonged used of steroids drugs like predinsolone and predinsone for a long time such in cases of some chronic diseases like bronchial asthma collagen disease such as rheumatoid arthritis systemic lupus erythromatosis
•  Pituitary gland adenoma see here causing ACTH hypersecretion it is called cushing disease it is most common causes after an iatrogenic causes
• Ectopic ACTH  secretion in these cases there are tumors either benign or malignant away from the pituitary gland which secreted ACTH which in turn stimulate the adrenal gland to release cortisol such as

• Small cell or oat cell carcinoma of the lung
• Bronchial carcinoma
• Bronchial adenoma
• Thymic gland tumors
• Islt cell tumor of the pancrease
•  Medullary carcinoma of the thyroid gland

Familial cushing syndrome causes

Normally the cushing syndrome is not inherited disease but in rare case in some individual there is may inherited condition such as in multiple endocrine neoplasm MEN which has two known types

MEN type I( Werner syndrome) and MEN type II which has two types MEN IIa (Sipple syndrome ) and MEN II b

In MEN I syndrome  or Werner sundrome there are

• Parathyroid hyperplasia
• Pituitary adenoma which secreted ACTH
• Thyroid adenoma
• Adrenal adenoma or carcinoma
• Pancreatic and duodenal endocrine tumors
• For gut or mid gut carcinoid tumors
• Lipoma

What are the patient complaining in cushing syndrome or

Symptoms and signs and complications of cushing syndrome

Can be divided into the following items

General characters

• Truncal obesity in such case the patient suffer from obesity above the waste upper body obesity with thin legs and arms
• Buffalo hump increased fat deposition between the shoulder region
• Muscle wasting and weakness due to increased protein catabolsim
• Retarted growth rate in children
• Moon face the patient face become rounded red and full face
• Easy fatigue

Skin characters

• thin skin with easy bruising due to loss of collagen in capillary walls
• Skin striae or stretched or purple marks in the abdomen thigh and breast
• Acni and skin infection
• Skin pigmentation due to elevated ACTH levels stimulate melanocyte stimulating hormone which in turn stimulate melanin pigment release
• Poor wound healing cortisol inhibits fibroblasts and it is immunosuppressive agent

Effect on the bone

• Easy bone fractures like ribs and spine pathological fractures due to osteoporosis because cortisol inhibit the action of vitamin D which reduced calcium absorption from the intestine
• Back  and bone pain and tenderness
• Kyphosis due to osteoporosis

Effect on other hormones

• Diabetes melluites the cortisol has inhibitory effect on insulin also increased protein catabolism to glucose patient suffer from excessive urination and thirsty and dry tongue
• Hirsutism presence or hair distribution in abnormal site in women such as male as in chin face abdomen chest
• Amenorrhoea or menstrual cycle disturbances as the cortisol suppresses the pituitary gland gonadotrophin
• Imoptance in male and decreased libido or has no desire for sex
• Hypertension due to retention of sodium and water patient suffer from headache
• Edema or swelling of the lower legs due to retention of sodium and water

Effect on the brain

• Depression cortisol causes psychological disturbance
• Anxiety and behavior changes

Diagnosis and investigations of cushing syndrome

From symptoms and signs as above may helpful

Laboratory

Plasma cotisol measurements

Measured at morning and night the cortisol level become raised with loss of diurnal variation

Dexamethasone suppression test

In normal patient who taken 2 mg oral dexamethasone at midnight and plasma cortisol levels are measured at 8 AM at morning this inhibit ACTH production from pituitary gland and hence cortisol levels but in patient with cushing syndrome there is no decreased in the morning cortisol level is seen

False negative results may be seen in patients with mild disease 

False positive results also can be seen in patients  with chronic renal failure depression patients take medications like phenytoin drug 

The 24 hour urinary cortisol collection

Is very sensitive and specific test urinary free cortisol excretion of less than 100 ug|dl rules out hypercortisolism cortisol level elevated

Plasma ACTH levels

Checked to assess corticotrophin function levels of plasma ACTH by immunoradiometric assay  will be undetectable in primary adrenal tumors and the level will be suppressed after administration of CRH in cushing disease as in pituitary adenoma but not in an ectopic source

Salivary cortisol measurements

Using special kits highly sensitive test but they do not used as a routine

Radiological studies

CT and MRI scanning of the abdomen

They can be identified the adrenal tumors and also can help to distinguishing adrenal adenoma from cacinoma In which adrenal adenoma appear darker than the liver

And allowing for  assessment of vascular anatomy

CT and MRI scanning of the brain

To showing and assess the pituitary gland and if there is any tumors but CT and MRI scanning may not showing small microdenoma

Inferior petrosal sinus sampling for ACTH

Very effective to showing small microadenoma of pituitary gland

In this approach a catheter are placed in both internal jugular veins and peripheral veins and the ratio of petrosal to peripheral vein ACTH  level greater than 2 in the basal state and greater than 3 after CRH stimulation is diagnostic of pituitary tumor

CT and  MRI scanning of the chest and anterior mediastinum 

In case of ectopic tumors secreted ACTH ectopic ACTH  such as lung cancer bronchial cancer or adenoma

   

Radioscinitigraphic imaging of the adrenals gland

Using NP-59 to distinguish adrenal adenoma from adrenal hyperplasia  in adrenal adenoma show increased uptake on NP-59 with suppression of uptake in the contralateral or opposite gland  but the hyperplastic glands showing bilateral uptake

Bone density

   

Measured by dual X rays absorptiometery DEXAshowing bone osteoporosis

Treatment of cushing syndrome

Treatment of cushing syndrome depend on the causes such as

Cushing syndrome due to iatrogenic or prolonged  used of steroids

Steroid drugs should be gradually withdrawal or stopped by decreasing the dose of the steroids on several days in divided dose until completely stopped

But if the patient can not stopped it due to it is associated disease so these patients need for monitoring  their  blood sugar for glucose or diabetes and cholesterol level and bone density

Cushing syndrome due to adrenal tumors

Treated by removal of the tumors either by surgical or laparoscopic removal  by operation called adrenalectomy  which may be unilateral as in case of adrenal adenoma or bilateral adrenalectomy in case of bilateral adrenal hyperplasia

Cushing syndrome due to pituitary tumors

Pituitary adenoma is treated by transsphenoidal excision

Pituitary irradiation in case of persistent or recurrent disease after surgery

but it is has high rate of panhypopituitarism and some patients developed visual deficits

Sterotatic radiosurgery

Which uses CT guidance to deliver high doses of radiotherapy to the pituitary tumors to avoid the surgical complications as above

Medical treatment

Medical treatment are indicated in patient who fail to respond to other treatment

These treatment include the following drugs ketocoazole which it is antifungal drugs  also acts by inhibition of the adrenal gland secretion  metyrapone or aminoglutethimide drugs also inhibit adrenal gland secretion they acts as medical adrenalectomy

Cushing syndrome due to ectopic ACTH production

Treated by treatment the primary tumors like cancer lung bronchogenic carcinoma or adenoma cancer pancreas etc

Medical adrenalectomy by medical drugs such as metyrapone aminoglutethimide and mitotane

Bilateral surgical or laparoscopic adrenalectomy as palliative treatment and for unresectable tumors or for recurrent or persistent cushing disease also if the ectopic ACTH secreting tumor cannot be localized

 

tags:cushing.syndrome.explaining