Tyroid and Struma

7/30/2019 Tyroid and Struma

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Ihsanil husna


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Terletak dileher tengah, seperti kupu-kupu

Terdiri dari 2 lobus kiri& kanan yg dihubungkan

oleh isthmus N: sebesar ibu jari, berat 20 gr.

MProduksi hormon tiroid T3(iodotironin ) dan T4 (tiroksin)


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: mengatur metabolisme tubuh

Proses pembentukan tiroid diatur oleh hormon TSH (thyroitropin stimulating hormone) yg dihasilkan olehkelenjar pituitaria (hipofise) mll mekanisma umpan

balik

TSH sendiri bekerja dibawah pengaruh hormonTyrotropin releasing hormone ( TRH)di hipothalamus

Bila hormon tiroid rendah, TSH merangsang tiroid umemproduksi hormon tiroid ( Tiroksin daniodotironin)


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Untuk membentuk hormon tiroid dibutuhkanbahan mikronutrien yg berasal dari makanan.Antara lain iodium

WHO : kebutuhan iodium:

0-59 bln= 90 mcg 6-12 thn = 120 mcg

Dewasa = 150 mcg

Ibu hamil = 200 mcg

GAKY= Kekurangan Yodium


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Pembesaran kelenjar tiroid

Gangguan fungsi tiroid

Karsinoma

GAKY


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STRUMA=GONDOK;

Pembengkakan di leher (di bawah jakun ataularynx) karena kelenjar thyroid yang

membesar.

Didaerah non endemik sering ditemukan simple

diffusegoiter(pembesaran rata) ataustruma nodosa/multinodosa


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1. hipertiroid = produksi hormon tiroidyang berlebihan

2. hipotiroid = produksi hormon tiroidkurang


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Etiologi: auto imun , terkait dg genetik

Wanita : pria =4:1

Tubuh membentuk zat anti thd sel-seltiroid. Bila zat anti tsb merangsang(stimulator) menyebabkan produksi hormon

tiroid meningkat & kadar TSH tertekan seperti pada Graves dissease


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Struma nodosa toksik

Struma multinodosa toksik

tiroiditis


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Berdebar-debar = palpitasi

Keringat banyak

Lemas, makan banyak tapi BB menurun

Kulit hangat,halus dan lembab

Tremor,Oftalmopati, takikardi

Refleks fisiologis meningkat


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Struma

Bruit, eksoptalmus, proptosis,

Refleks fisiologi meningkat, periodikparalisis

Krisis tiroid

laboratorium TsH rendah ( sgt rendah)

T4 / fT4 dan T3 meningkat


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Kadar hormaon tiroid ( T3,fT4, T4 danTsH & TsHs)

USG tiroid Sidik tiroid ( scan tiroid & Tc 99 dan I

131)

Ro toraks (tiroid retrosternal) EKG ( Atrium fibrilasi )


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Medikamentosa : Propiltiourasil,Metimazol

Prinsip terapi :dosis tinggi bertahap

diturunkan sesuai respons klinis danlaboratorium

operatif

Radiasi internal dg I 131


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Etiologi:

autoimun= Hoshimoto

Pasca ablasi tiroid

Tiroiditis

Kelainan kongenital


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Keluhan: bervariasi dari samar sampai jelastergantung kaar hormon dan lama prosespenyakitnya

Cepat cape,Mengantuk,tidakbergairah,Depresi

Ggn konsentrasi, ggn mental, tidak tahandingin, suara parau, BB meningkat, nafsumakan kurang, sulit BAB, ggn menstruasi nyerisendi dan kesemutan


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Kulit kering,lamban, bicara lambat, suaraserak, sulit konsentrasi, sembab,reflekslamban dan menurun.

Dapat menaikkan kadar lemak darah danfc risiko untuk penyakit jantung koronerdan stroke


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Etiologi: ggn fgs kelenjar tiroid

ibu menderita kekurangan iodium

Klinis:

- Ggn pertumbuhan fisik ( cebol )

- Ggn tingkat kecerdasan

- Keterbelakangan mental


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bila diketahui sedini mungkin diberikanterpai hormon tiroid ( tiroksin ) seumur

hidup


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Terdiri atas:

Ca tiroid berdiferensiasi sedang

Ca Tirod medullare Ca tiroid tidak berdifferensiasi (anaplastik)

Ca jenis lainnya


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Nodul di kelenjar tiroid membesar danmendesak jaringan sekitarnya

Terjadi ggn menelan, suara serak

Diserta pembesaran kelenjar getah beningleher,stadium lanjut menyebar ke tulang, otak,paru-paru

Ca tiroid anaplastik paling ganas Ca tiroid berdifferensiasi relatif jinak


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ETIOLOGI:

Kekurangan asupan yodium saat dikandungan danbalita

Gejala klinis:ggn pertumbuhan fisik dan mental,

IQ rendah, infertilitas Daerah kantong endemis :

Dieng ( Jateng)

Tengger (Jateng )

Bukit Barisan ( Gayo/ aceh dan Sumbar)


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Kadar hormon tiroid ( TsH dan TsHs):

Bila kadar rendah lanjutkan dgnpemeriksaan kadar hormon tiroid

T3 dan T4 atau fT4. Kadar fT4 lebihspesifik karena tidak dipengaruhi olehprotein yang disebut dengan thyroxine

binding globulin (TBG ) Kusus pada wanita hamil dgn TBG tinggi

HARUS diperiksa fT4


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Hipertiroid: Tsh/TsHs rendah dan T3 & fT4 (hormon tiroid ) tinggi

Hipertiroid subklinik: Hormon tiroid normal, tapi TsH/TsHs rendah

Hipotiroid: Tsh/TsHs tinggi dan hormon tiroid rendah

Hipotoroid subklinis :

TsHs tinggi dan hormon tiroid normal


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Usg: nodul soliter, multinodul, nodul kistik padatatau campuran.

Hipervaskularisasi:menggambarkan,hiperfungsi

kelenjar tiroid

Batas tegas/ tidak. Kalsifikasi/tidak.

Scan tiroid I131:cold/warm nodul 10 -15% cold nodul adalah ca Tiroid


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Biopsi aspirasi jarum halus

Penting untuk diagnostik keganasan nodultiroid

Menggunakan jarum halus untuk mengambilsedikit jaringan tiroid


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Menggunakan yodium radioaktif I131,I123 Atau Tc99m pertechnetate)

Dapat ditentukan apakah high uptake(graves diseasses) atau low uptake(iatrogenic hypertiroidsm/ tyroiditis)

Menentukan dosis terapi I131


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Ultrasonography

Ultrasonography can accurately detect nonpalpable nodules, estimate thesize of the nodule and the volume of the goiter, and differentiate simple

cysts, which have a low risk of being malignant, from solid nodules orfrom mixed cystic and solid nodules, which have a 5 percent risk of beingmalignant (Figure 3). Ultrasonography also provides guidance fordiagnostic procedures (e.g., fine-needle aspiration biopsy) as well astherapeutic procedures (e.g., cyst aspiration, ethanol injection, or lasertherapy) and facilitates the monitoring of the effects of treatment.9 In one

study, among patients who had been referred for evaluation of a palpablethyroid abnormality, ultrasonography altered the clinical management intwo thirds of cases,14 mainly by identifying nodules that were smallerthan 1 cm (which were not considered to require further evaluation) in 20percent of the patients and by discovering additional nodules (whichrequired biopsy) in 24 percent of the patients. Characteristics revealed by

ultrasonography

such as hypoechogenicity, microcalcifications,irregular margins, increased nodular flow visualized by Doppler, and,especially, the evidence of invasion or regional lymphadenopathy areassociated with an increased risk of cancer; however, sonographicfindings cannot reliably distinguish between benign and cancerouslesions.9

Other Methods


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Other Methods

Computed tomography (CT) and magnetic resonance imaging also cannot reliably differentiate betweenmalignant and benign nodules. These tests are rarely indicated in the evaluation of a nodule. An exception is inthe diagnosis and evaluation of substernal goiters, since these imaging techniques can assess the extent of thegoiter more precisely than can other techniques and can evaluate tracheal compression.3,15 Evaluation ofglucose metabolism by positron-emission tomography using fludeoxyglucose (fluorodeoxyglucose) F 18 mayhelp in distinguishing benign from malignant nodules, but its use is limited by cost and accessibility16 and it

cannot replace biopsy.

Fine-Needle Aspiration Biopsy

Independent of morphology, fine-needle aspiration provides the most direct and specific information about athyroid nodule. It is performed on an outpatient basis,1,4,5 is relatively inexpensive, and is easy to learn.Complications are rare and primarily involve local discomfort. The use of anticoagulants or salicylates does notpreclude biopsy. In centers with experience in fine-needle aspiration, the use of this technique has beenestimated to reduce the number of thyroidectomies by approximately 50 percent, to roughly double the

surgical confirmation of carcinoma, and to reduce the overall cost of medical care by 25 percent,17 ascompared with surgery performed on the basis of clinical findings alone.

Fine-needle aspiration has diagnostically useful results in about 80 percent of cases,18 typically with two tofour passes of the needle. The number of cases in which sufficient samples are obtained increases if aspirationis guided by ultrasonography, especially in nodules that are partly cystic, and repeated biopsy reduces by halfthe rate of insufficient samples (to about 10 percent).19,20 The diagnostic accuracy of fine-needle aspirationdepends on the way in which suspicious lesions are handled. Viewing them as "positive" increases sensitivity(rate of false negative results, 1 percent), but decreases specificity.21 If fine-needle aspiration reveals a

follicular neoplasm (which occurs in approximately 15 percent of nodules, of which only 20 percent turn out tobe malignant), radionuclide scanning should be performed.1,2,3 If such scanning shows a functioning nodulewith or without complete suppression of the rest of the thyroid, surgery can be avoided, since the risk of canceris negligible.17 In a cystic lesion or one that is a mixture of cystic and solid components, fine-needle aspirationof a possible solid component should be performed, since the risk of cancer is the same as that for a solidnonfunctioning nodule.2,20,21 With the exception of calcitonin immunostaining for medullary carcinoma,there are no reliable immunohistologic or molecular tests for distinguishing between benign and malignantnodules.3

Treatment of the Solitary Thyroid Nodule


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Surgery

The main indications for surgery are clinical orcytologic features suggestive of cancer orsymptoms due to the nodule (Table 1).4,5 Ifpreoperative cytology suggests a benign lesion,hemithyroidectomy is generally preferred.4,5,18

Postoperative administration of levothyroxine isindicated only in cases of hypothyroidism.34When surgery is performed by a specialist, theincidence of complications is low (i.e.,postoperative hypoparathyroidism in 1 percent ofcases and injuries to the recurrent laryngeal nervein about 1 percent), but the complication rate ishigher for less experienced surgeons and thosewithout special training.35


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Radioiodine

Radioiodine is an option for treatment of a functioning nodule,with or without biochemical hyperthyroidism. It iscontraindicated in pregnant and breast-feeding women.Normalization of the results of thyroid radionuclide scanning andthe serum thyrotropin level (often referred to as a "cure") isachieved in 75 percent of patients, and thyroid volume is reducedan average of 40 percent, after a single dose of iodine-131 aiming

at a level of 100 Gy, independent of pretreatment thyroidfunction.36,37 The main side effect is hypothyroidism, whichoccurs in approximately 10 percent of patients within five yearsafter treatment and increases in frequency over time. This risk isunrelated to dose but is greater in patients with thyroidperoxidase antibodies and with iodine uptake in extranodular

thyroid tissue.36,37 Most nodules do not disappear afterradioiodine therapy but may become harder on palpation andmay reveal unusual cytologic features as a result of irradiation.Thyroid function should be checked regularly during the first yearand yearly thereafter in order to detect hypothyroidism. Nodulesare unlikely to grow after radioiodine therapy, but if growthoccurs, a biopsy may be warranted.


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Areas of Uncertainty

There are no data from studies comparing the

outcome and cost-effectiveness of variousstrategies of evaluating a nodule (e.g., usingradionuclide imaging and ultrasonographicguidance for fine-needle aspiration). There arealso insufficient data comparing the outcome(including quality of life) of variousmanagement approaches in the absence ofcancer.


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Guidelines from Professional Societies

Clinical-practice guidelines were published in 1996 by the

American Thyroid Association1(www.thyroid.org/professionals/publications/guidelines.html) and the American Association of ClinicalEndocrinologists46(www.aace.com/clin/guidelines/thyroid_nodules.pdf). Therecommendations of both organizations correspond with

those provided here. Radionuclide scanning is not routinelyrecommended, but it is advocated in the case of asuppressed level of serum thyrotropin or the finding offollicular neoplasia with the use of fine-needle aspiration.Thyroid ultrasonography is recommended to guide fine-needle aspiration, especially in nodules that are small and

incidental or are partly cystic or from which primary fine-needle aspiration has yielded insufficient material. Fine-needle biopsy of all possibly malignant nodules (which arenot defined in the guidelines) is advocated. If the cytology isbenign, repeated biopsy is seldom indicated.


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In the case of a benign nodule, periodic lifelong follow-up every 6 to 24months (including measurement of serum thyrotropin levels, neckpalpation, and fine-needle aspiration in case of growth or othersuspicious signs) is recommended. For a functioning benign nodule,iodine-131 is considered the treatment of choice, with surgery as analternative, especially if the nodule is very large or partly cystic or if thepatient is young; treatment is more strongly recommended if the serum

thyrotropin level is decreased or overt hyperthyroidism is present,because of adverse effects on bone and the cardiovascular system. For anonfunctional benign nodule, there is no clear recommendation on theuse of levothyroxine, although this therapy is considered contraindicatedwhen the serum thyrotropin level is suppressed, in patients more than 60years old, and in postmenopausal women. If levothyroxine therapy isused, regular reassessment (the interval is not defined in the guidelines)

is recommended, with monitoring of serum thyrotropin levels, whichshould be subnormal but measurable. The guidelines do not addressethanol injection and laser therapy.


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Conclusions and Recommendations

For the patient who presents with a nodule, as in the case described in the vignette, the main concern is to exclude thepossibility of thyroid cancer, even though the vast majority of nodules are benign (Figure 1). The initial evaluationshould include measurement of the serum thyrotropin level and a fine-needle aspiration, preferably guided byultrasonography. If the patient has a family history of medullary thyroid carcinoma or multiple endocrine neoplasia type2, the serum calcitonin level should also be checked. If the thyrotropin level is suppressed, radionuclide scanning shouldbe performed. In patients less than 20 years old, and in the case of a high clinical suspicion for cancer (e.g., follicularneoplasia as diagnosed by fine-needle aspiration and a nonfunctioning nodule revealed on scanning), the patient shouldbe offered hemithyroidectomy regardless of the results of fine-needle aspiration.

In the case of a functioning benign nodule, iodine-131 is generally the therapy of choice, independent of concomitanthyperthyroidism. For nonfunctioning cystic nodules, aspiration and ethanol injection therapy may be considered, andethanol injection or laser therapy if the nodules are solid, but data to support the use of these therapies are limited. Myusual approach after documenting benign cytology is to follow the patient yearly with neck palpation and measurementof the serum thyrotropin level, with repeated ultrasonography and fine-needle aspiration if there is evidence of growthof the nodule. I do not recommend levothyroxine therapy to shrink or prevent growth of benign nodules because of thedrug's low efficacy and potential side effects.

Dr. Hegeds reports having received grants from the Agnes and Knut Mrk Foundation, the Novo Nordisk Foundation,and the A.P. Mller Relief Foundation.

I am indebted to Dr. Steen J. Bonnema and Dr. Finn N. Bennedbk for their helpful comments.


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Suatu keadaan emergensi (life threatening)Angka kematian 10 %Etiologi:

1.Peningkatan hormon tiroidmendadak.Penghentian obat-obat tiroid tiba-tiba, radiasi, palpasi tiroid secara kasar danakibat penggunaan iodium radioaktif

2 Keadaan diluar penyakit tiroid spt stressemosional,KAD atau hipoglikemi, stroke,infark atau emboli paru


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Demam tinggi

Takikardi

Ggn kesadaran

Ggn sal cerna ( mual, muntah nyeri abdomen,diare dan ikterus)

Gagal jantung


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Atasi fc pencetus Suportif cairan ,elektrolit,oksigen dan kompres

dingin

PTU 200-250 mg/4 jam kl perlu pasang ngt Yodida 1 jam stlh PTU. Berupa larutan lugol 8

tts tiap 8 jam atau potassium yodida 2x0,5-1 g Hidrokortison 100 mg/8 jam

Beta bloker: propanolol 60-120 mg/jam Plasmafareses Digoksin dan diuretik bila ada gagal jantung


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Idealnya penderita graves disease tidakhamil sampai kondisi eutiroid

Graves disease gejala klinik bisa mirip

dengan kehamilan Prevalensi 0,2 %

Sering terjadi remisi pada kehamilan tm ke3, tapi relaps kembali pasca persalinan (3-6bln kmdn)


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Hipertiroid mirip kehamilan shg hipertiroidpada kehamilan sering sulit terdeteksi

Pada kehamilan terjadi peningkatan klirensyodium oleh ginjal shg kadar yodiuminorganik diplasma turun sehingga kelenjartiroid hipeertropi dan hiperplasi untukmenangkap yodium lebih banyak.

Pada kehamilan juga terjadi peningkatanhormon estrogen sehingga kadar TBG ( tiroidbinding globulin) , T4 dan T3 total meningkat,shg hrs diperiksa FT4.

H


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Bila tidak terjadi kadar eutiroid bisa timbulkrisis tiroid, toksemia, partus prematurus,solusio plasenta dan gagal jantung.

Anak beresiko untuk menjadi BBLR dan fetaldeath.

Sebaliknya bila over treatment bisa terjadihipotiroid.


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PTU : dosis 3x50-150 mg

Efek samping bisa terjadi hipotiroid padajanin, ggn mental/intelektual janin ok PTU

bisa melewati BBB Trimester ke III kehamilan dosis harus

dikurangi 100-200 mg/hari

Begitu janin lahir harus dicek kadar hormontiroid janin untuk menghindari terjadinyakrisis tiroid


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Bila janin hipotiroid diberikan Ltiroksin(INUTERO)

Bila janin hipertiroid bisa diberikan PTU

dosis 10 mg/kgBB dibagi 3-4perlu PTU dosisbesar pada TM ! Atau alergi dengan PTU,struma makin besar atau pasien tidak bisamakan obat kalai pemberian

Larutan lugol 3x1 tts Remisi bisa terjadi dalam 1-6 bulan

Operasi dilakukan bila pasien


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BILA PASIEN ALERGI PTU

BUTUH DOSIS BESAR,

STRUMA MAKIN BESAR

Dilakukan pada TM 2 kehamilan

Tyroid and Struma

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