«confirm» on methodical meeting of endocrinology department a chief of endocrinology department, prof. Vlasenko M. V. “ 31 ” august 2012 y methodological recomмendations icon

«confirm» on methodical meeting of endocrinology department a chief of endocrinology department, prof. Vlasenko M. V. “ 31 ” august 2012 y methodological recomмendations




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MINISTRY OF HEALTH PROTECTION OF UKRAINE

Vynnitsa national medical university named after M.I.Pyrogov





«CONFIRM»

on methodical meeting of endocrinology department

A chief of endocrinology department, prof. Vlasenko M.V.


_________________

“_31_”_august___ 2012 y



METHODOLOGICAL RECOMМENDATIONS

for independent work of students

by preparation for practical classes



Scientific discipline

Internal medicine

Мodule № 1

^ Basis of Internal medicine

substantial module №1

Diagnostic, treatment and prophylactic basis of main endocrinology diseases”


Topic

^ Topic №13: Iodine deficiency diseases of thyroid gland. Signs of the endemic region. Clinics, diagnostics, prophylactic, treatment. Tumors of thyroid gland.

Course

4

Faculty

Medical № 1



Vynnitsa – 2012


^ METHODOLOGICAL RECOMМENDATIONS

for the students of 4-th course of medical faculty for preparation to the practical classes from endocrinology


1.Тopic №13: Iodine deficiency disease of thyroid gland. Signs of the endemic region. Clinics, diagnostics, prophylactic, treatment. Tumor of thyroid gland.


^ 2. Relevance of topic: Iodine-defcit disease is one of the most widespread non-infectious hu­man pathologies. In a world iodine insuffciency is felt by 2 billion of per­sons, including 740 millions of people with enlargement of thyroid gland (endemic goiter), and 45 millions – with the expressed mental retardation as a result of iodine insuffciency (WHO, 2003). In the same time in Ukraine the defcit of iodine feels about 70 % population – 34 millions of people. During last years there is the increase of the amount of regions, in which the goiterous endemy is fxed, and its complication rises. The spectrum of iodine-defcit diseases is very wide and well known. Among them a goiter is most widespread, and in a social plan the reproductive function disorders in women and innate mental abilities disorders in children are most mean­ingful. It requires to take most drastic measures for liquidation of iodine endemy in a country. One of principal reasons, that determines the neces­sity of rapid and reliable liquidation of goiter endemy, is aspiration to the improvement of health of population in these regions, that is to the removal of iodine-defcit diseases.

Last years in the structure of endocrine diseases greater part is taken by diseases of thyroid gland. Benign and malignant tumors of thyroid gland are distinguished. Adenoma belongs to benign one, and cancer of thyroid gland - to malignant. Adenoma of thyroid gland can be nontoxic (hormonal -nonactive) and toxic (hormonal-active). The presence of nodes formation in a thyroid gland is the main clinical manifestation of adenoma, and for hormonal-active one – still symptoms of thyreotoxicosis.

During last years in Ukraine there is steady growth of goiter morbidity caused by Chernobyl accident. Increasing frequency of thyroid gland cancer also has direct connection with the Chernobyl catastrophe. High-differenti­ated and low-differentiated forms of cancer are distinguished. The fatal con­sequences which are observed after ill-timed diagnostics and treatment of thyroid gland cancer require the careful study of this disease and knowledge of medical tactic for any stages of thyroid gland cancer.


^ 3. Aim of lesson:

  • To know the spectrum of iodine-defcit diseases.

  • To master the method of palpation of thyroid gland.

  • To be able to distinguish by palpation nodular goiter from diffuse one and to palpate regional lymphatic nodes.

  • To be able to use international goiter classifcation in practice.

  • To estimate the functional condition of thyroid gland.

  • To be able to set a diagnosis and conduct differential diagnostics of en­demic and sporadic goiter

  • To defne the treatment tactic of diffuse and nodular nontoxic goiter.

  • To be able to use the method of conducting of individual, group and mass prophylaxis of iodine-defcit diseases.

  • To master the practical skills in diagnostics of thyroid gland enlargement, in presence of nodular formation in it.

  • To estimate the functional state of thyroid gland.

  • To know the diseases which are accompanied by nodular formation in thyroid gland.

  • To be able to carry out differential diagnostics of adenoma and thyroid gland cancer.

  • To be able to use international classifcation of thyroid gland cancer in practice.

  • To defne the volume of necessary additional examinations in presence of nodular formations in a thyroid gland.

  • To estimate the results of ultrasonic examination, scanning of thyroid gland, information of cytological and histological investigation.

  • To defne treatment tactic for different forms of thyroid gland cancer.

  • To know the features of thyroid gland cancer in children.

  • To carry out the clinical supervision of patients with thyroid gland cancer.



4. References

4.1. Main literature

  1. Endocrinology. Textbook/Study Guide for the Practical Classes. Ed. By Petro M. Bodnar: - Vinnytsya: Nova Knyha Publishers, 2008.-496 p.

  2. Basіc & Clіnіcal Endocrіnology. Seventh edіtіon. Edіted by Francіs S. Greenspan, Davіd G. Gardner. – Mc Grew – Hіll Companіes, USA, 2004. – 976p.

  3. Harrison‘s Endocrinology. Edited J.Larry Jameson. Mc Grew – Hill, USA,2006. – 563p.

  4. Endocrinology. 6th edition by Mac Hadley, Jon E. Levine Benjamin Cummings.2006. – 608p.

  5. Oxford Handbook of Endocrinology and Diabetes. Edited by Helen E. Turner, John A. H. Wass. Oxford, University press,2006. – 1005p.

4.2. Additional literature

  1. Endocrinology (A Logical Approach for Clinicians (Second Edition)). William Jubiz.-New York: WC Graw-Hill Book, 1985. - P. 232-236. Pediatric Endocrinology. 5th edition. – 2006. – 536p.

  2. Thyroid Disordes (Aclevelend Clinic Guide) by Mario Skugor, Jesse Bryant Wilder Clevelend Press,2006. – 224p.



Basic Level.

The structure of thyroid gland

Mechanisms of biosynthesis of thyroidic hormones

Etiology and pathogeny of endemic goiter

Clinical manifestations of endemic goiter

Medicaments of thyroidic hormones and iodine


Students’ Independent Study Program.

You should prepare for the practical class using the existing text books and lectures. Special attention should be paid to the following:

  1. Epidemiology of iodine-defcit diseases.

  2. Etiology and pathogenesis of endemic goiter.

  3. Infuencing of zoogenic factors of environment and technogenic catas­trophes on the atomic energy objects on the state of thyroid gland and spreading of its pathology.

  4. International classifcation of goiter.

  5. Diffuse and nodular nontoxic goiter, diagnostics, treatment.

  6. Infuence of iodine insuffciency on development of children.

  7. Iodine prophylaxis: mass, group, individual.

  8. Signifcance of the use of iodine salt in the prophylactic of iodine-defcit diseases

  9. Nodular forms of goiter. Monitoring of patients with nodes in a thyroid

  10. gland.

  11. Pathomorphological classifcation of thyroid gland tumors.

  12. Etiology, pathogenesis of adenoma and cancer of thyroid gland.

  13. Role of Chernobyl catastrophe in increasing of thyroid gland cancer

  14. morbidity.

  15. Clinical features of adenoma and different forms of thyroid gland cancer.

  16. Clinical classifcation of thyroid gland cancer.

  17. Diagnostics and differential diagnostics of adenoma and thyroid gland cancer.

  18. Modern scheme of treatment, rehabilitation and clinical supervision of patients with thyroid gland cancer.



Short content of theme

Iodine-defcit disease of thyroid gland:

– a diffuse euthyroidic (nontoxic) goiter is the diffuse enlargement ofthyroid gland without its disfunction;

– nodular euthyroid (colloid) goiter;

– functional autonomy of thyroid gland and thyrotoxic adenoma; – iodine-defcit hypothyrodism (at the sharply expressed iodine defcit).


^ Day’s necessity in an iodine (WHO, 2005)



Age group or physiological state

Necessity in iodine, mkg per day

Neonates (from 0 to 1 year)

50

Children of young age (from 1 to 5 years)

90

Children of school age (from 6 to 12 years)

120

Adults

150

Pregnant and breast-feeding women

200

A goiter is the pathological enlargement of thyroid gland without clari-fcation of its functional state. The size of thyroid gland is determined by its examining, palpation and measuring a volume by ultrasonic investigation (USI). By international norms, in the case of using of USI in adults (over 18 years) a goiter is diagnosed, if volume of gland is more than 18 ml in women, and more than 25 ml in men.

^ Algorithm of conducting of palpation of thyroid gland

Task Sequence of implementation Remark



To acquire skill of palpation of thyroid gland

1. Reference palpation: disposing hands on a neck
and asking a patient to do swallowing motion, to
fnd the place of location of thyroid gland.

2. Detailed palpation: to defne mobility, pain-
fulness, consistency, state of capsule of thyroid
gland, degree of its enlargement.

3. To estimate the state of regional lymph nodes
(nodules).

To pay atten­tion to low, retrosternal location of thyroid gland

^ Classifcation of goiter (WHO, 2001)

0 There is no goiter (the sizes of parts do not exceed the sizes of distal phalanx of large fnger of the inspected person)

1 A goiter is palpated, but is not visible at normal head position. Nodular formations which do not cause the enlargement of the gland belong to this class

2 A goiter is palpated and is visible at normal head position

Formula for the calculation of thyroid gland volume by the data of USI

Volume = [(Tl × Wl × Ll) + (Td × Wd × Ld)] × 0,479 The volume of every part is counted up by multiplying of thickness (Т), width (W) and length (L) with the coeffcient of correction on the ellipse structure of part (0,479). The volume of all gland consists of volumes of its parts; the volume of the isthmus is disregarded usually.

The normal thyroid gland volume in children and teenagers (97-percentil; from data of USI) [WHO, 2001]



ABS (m2)

0,8

0,9

1,0

1,1

1,2

1,3

1,4

1,5

1,6

1,7

Girl

3,4

4,2

5,0

5,9

6,7

7,6

8,4

9,3

10,2

11,1

Boys

3,3

3,8

4,2

5,0

5,7

6,6

7,6

8,6

9,9

11,2

ABS is the area of body surface which is calculated by the nomogram or by a formula (M is body mass in kilograms, H is height in centimetres):

ABS = М0,425 × H0,725 × 71,84 × 10 - 4

Epidemiological criteria of estimation (assessment) of iodine-defcit degree



Criteria

Population

Degree of iodine-defcit







Easy

Middle

Heavy

Frequency of goiter (%) by the data of palpation

schoolboys

5,0–19,9 %

20,0–29,9 %

> 30,0 %

Frequency of goiter (%) increase of volume of gland from data of USI

schoolboys

5,0–19,9 %

20,0–29,9 %

> 30,0 %

Concentration of iodine in urine (median, mkg/l)

schoolboys

50–99

20–49

< 20

Frequency of the TSH level > 5 mIU/ml at neonatal screenning

babies

3,0–19,9 %

20,0–39,9 %

> 40,0 %

Level of thyroglobulinum in a blood (median, ng/ml)

children adult

10,0–19,9

20,0–39,9 %

> 40,0



Spectrum of iodine-deficiency pathology (WHO, 2001)



Age periods

Iodine-defcit pathology

Inwardly-uterine period

• Abortions

• Stillborn

• Innate anomalies

• Increasing of perynatal death rate

• Increasing of child’s death rate

• Neurological cretinism:

mental backwardness

deaf-and-dumb

squint

• Mixedemic cretinism:

mental backwardness undersized (low height) hypothyroidism

• psycho-motor violations

New-born

• hypothyroidism neonatal

Children and teenagers

• Violation of mental and physical development

Adults

• Goiter and its complication

• Iodine-inducted thyrotoxicosis

For any age

• Goiter

• hypothyroidism

• Cognitive function disorders

• Increase of absorption of radio-active iodine at
nuclear catastrophes


^ Methods of prophylaxis of iodine-defcit diseases

– a mass iodine prophylaxis is a prophylaxis in the scale of population; it is carried out by addition of iodine in the most widespread food stuff (kitchen salt);

– a group iodine prophylaxis is a prophylaxis in the scale of certain groups of the high risk of the IDD development: children, teenagers, preg­nant and breast-feeding women. It is carried out by the regular prolonged reception of medicaments which contain the physiological doses of iodine;

– an individual iodine prophylaxis is the prophylaxis of individuals by the prolonged reception of medicaments which contain the physiological doses of iodine.

Histological classifcation of thyroid gland tumors (WHO, 1988)

1. Epithelial tumors 1.1. Benign tumors

1.1.1 Follicular adenoma:

  • normofollicullar

  • macrofollicular

  • microfollicullar

  • trabecullar solid

1.1.2 Others
1.2 Malignant

1.2.1 Follicular carcinoma:

  • minimum invasive

  • wide invasive

oxyfphilic cellular variant light cellular variant

  1. Papillary carcinoma: papillar microcarcinoma encapsulated variant follicular variant diffuse-sclerosis variant oxyphilic cellular variant

  2. Medullary carcinoma:

mixed medullar-follicular carcinoma

  1. Undifferentiated (anaplastic) carcinoma

  2. Other carcinomas

2. Unepithelial tumors:

thyroid sarcoma

malignant hemangiothelioma

  1. Malignant lymphoma

  2. Mixed tumors

  3. Secondary tumors

  4. Unclassifed tumors

List of diseases with the single nodules of thyroid gland

which is necessary to differentiate

Primary thyroid gland damage Non thyroidic damage



Adenoma

Lymphadenopathy

Carcinoma

Adenoma or prothyreoid cyst

Cyst

Cyst-like hygroma

Thyroiditis autoimmune

Carotid aneurism

Lymphoma

Metastases

Previous hemithyroidectomy




Cyst of thyroid-tongue duct




Thyroid hemiagenesy





^ Clinical classifcation of thyroid gland cancer

TNM – classifcation of differentiated thyroid gland cancer

(actual since 01.01.2003)

T – primary tumor

Тх – conclusion about a primary tumor is impossible;

T0- primary tumor is not found;

Т1 – tumor size is to 2 cm, localized in a gland;

Т2 – tumor size is more than 2 cm and to 4 cm, limited by the gland cap­sule;

Т3 – tumor size over 4 cm, localized only in a thyroid gland, or tumor of any size with minimum extrathyroid spreading (by an invasion in M. sternohyoіdales or in parathyroid muscles and cellular tissue);

Т4а – tumor spreads outside the thyroid gland capsule with the invasion in one or a few of such anatomic structures: hypodermic cellular tissue, trachea, throat, gullet, recurrence nerve

T4b – tumor infltrate paravertebral fascia, vessels of mediastinum and sur­rounds a carotid artery

* multifocal tumors not depending on their histological analysis must be marked by the letter of “m”, thus the gradation “Т” is determined by the tumor of most size.

N – regional lymphatic nodules (lymphatic nodules of neck and mediasti­num) (LN)

Nх – conclusion about the regional LN damage is impossible;

N0 – metastases in regional LN is not found;

N1 – metastases in regional LN;

N1а – damage of pretracheal, paratracheal, laryngeal LN;

N1b – damage of other neck LN uni- or bilateral, contralateral on both sides or only on opposite and/or superior LN of mediastinum.

** pT, pN, pM categories which specify on morphological confrmation of the Т, N, M factors.

*** pN0 – is proposed after conducting of selective lymphadenectomy and histological investigation usually from 6 LN and more. In case if in investigated LN is not determined metastatic process, but their amount does not arrive at 6, pN0-stage have to be appropriated.

М – distant metastases

Мх – conclusion about distant metastases is impossible;

М0 – distant metastases are not determined;

М1 – there are distant metastases.

^ Ultrasonic signs of nodular formation in thyroid gland



True cyst

Clear limited, spherical, echo-negative, non-echogenic format­ion of regular shape with even and thin walls, with homogene­ous incorporations, has a capsule

Nodes with focal There is a node in thyroid lobule with presence of hypoecho-cystic changes genic areas, in which blood fow is absent at coloured echodo-plerography. Has a clear capsule

Colloid node

Nodes formation in thyroid gland with expressed hypoecho-genic, has a clear capsule, on periphery hydrophillic halo-rim can be determined (rim is low echogenic, width 1–2 mm, loca­ted around the formation)

Adenoma

Nodes formation of round form with clear contours, encapsula­ted, of decreased echogenic

Adenocarcinoma

Thyroid gland formation with unclear contours, dense struc­ture, of decreased echogenic with the presence of microcal-cinats in formation and (or) absence or unclear capsule. A suspicious node does not change during pressure on it by an ultrasonic sensor. Enlarged regional lymphatic nodes as hypoechogenic formations of round or oval form are often determined



^ Tests and Assignments for Self-assessment.


Multiple Choice.

Choose the correct answer/statement:

1. The patient is 30, lives in Carpathians, appealed with com­plaints about the increase of thyroid. From the inspections the diffuse in­crease of thyroid is exposed to 1a grade, function is not violate. What type of prophylaxis of endemic goiter will you advise?

  1. Potassium iodide 150 mkg per day

  2. Antistruminum 1 tab. 2 times per a week

  3. L-thyroxinum 25 mkg per day

  4. L-thyroxinum 50 mkg per day

  5. Mercazozilum 20 mg per day

2. Habitant of the Ivano-Francovsk region of age of 23 years, complains of unmaturing of pregnancy. In marriage 5 years, there were a few pregnancies and all ended by fetal loss. During a review the goiter of 2 grade is determined, thyroid gland is soft. Clinically signs of violation of function of parathyroid gland is not determined. During the inspection of plasma of blood, the level of thyroxine is 66 nmol/l, threeiodthyronine -2.78 nmol/l, TSH - 4.0 MU/l. Middle iodineuria at the habitants of this re­gion is 4 mkg/100 ml. What is possible cause of patient’s sufferings?

  1. Iodine defcit state

  2. Low level of thyroxine in plasma of blood

  3. High level of triiodothyronine in plasma of blood

  4. Growth of TSH in plasma of blood

  5. Presence of goiter

3. The sick 40 years is observed at endocrinology concerning the increase of thyroid of 1 grade. It is known that she arrived from an en-

demic district. What recommendations on the prophylaxis of development of goiter at?

  1. Potassium iodide 150 mkg per day

  2. Consumption of meal rich in iodine

  3. Waiver of smoking

  4. To avoid supercooling

  5. Regular reviews of doctor

4. A sick woman 60 years which during a few decades lived in Carpathian region complains of a presence about 20 years “tumors” on a neck which could be seen at a review and is displaced at swallowing. A “tumors” causes no unpleasant feelings and no disorders of organs of neck. At research of sick including punctional biopsy the exposed mixed (diffuse nodular) bilateral goiter of 2 grade with signs of subclinical hypothyoidism is determined. What treatment does the sick require?

  1. Conservative (by thyroid hormones)

  2. Operation of goiter removal (resection of gland)

  3. Radioiodine therapy

  4. X-Ray therapy

  5. Diet, rich in iodine

5. At a patient 32 years during medical survey a nodule is exposed in the right lobe of thyroid. Complaints are not present. Objectively: from the side of internal organs without deviations from a norm. The nodule is 25 mm in a diameter palpated in the right lobe of thy­roid, dense, not painful, mobile. Neck lymphatic nodules are not enlarged. What research is most informing for clarifcation of diagnosis?

  1. Aspirational biopsy of thyroid

  2. Ultrasonic research of thyroid

  3. Computer tomografa of thyroid

  4. Scyntygrafa of thyroid

  5. Termografa of thyroid

6. At a woman 40 years at the palpation of thyroid gland a nod­ule is exposed in a left lobe, compacted, moderately painful during palpa­tion, “cold” at scyntygrafa with I131. What inspection is most expedient for clarifcation of diagnosis?

  1. Aspirational biopsy

  2. Determination of the TSH level in a blood

  3. Refexometria

  4. Determination of excression of iodine with urine

  5. Thermografa of thyroid gland

7. The sick 39 years complains of the presence of tumor on the front surface of neck. Became ill 2 years ago. A tumor was enlarged in sizes, the timbre of voice changed, feeling of pressure appeared. Objectively: in the left lobe of thyroid a nodule is palpated 3 sm in a diameter, painless. The functional state of thyroid is not changed. What is the diagnosis?

  1. Cancer of thyroid

  2. Nodular euthyreoid goiter

  3. Nodular hyperthyroid goiter

  4. Chronic lymphomatous Hashimoto thyroiditis

  5. Chronic fbrous Ridel’s thyroiditis

Answer: 1 – A. 2 – A. 3 – A. 4 – A. 5 – A. 6 – A. 7 – A.


Students Practical Activities.


Work 1 : Students’ group is divided into 2 sub-groups, that work near the patients’ bed: ask the patients on organs and systems, take anamnesis of the disease , anamnesis of life, make objective exam. With the teacher’s presence. In the class-room they discuss the patients, learn data of laboratory and instrumental exam. of these patients.

1.To group the symptoms into the syndromes.

2.To find out the leading syndrome and make differential diagnosis.

3.To formulate the diagnosis.

4.To make a plan of treatment.


Methodological recommendation prepared assistant, c.m.s. Chernobrova O.I.

It is discussed and confirm on endocrinology department meeting

" 31 " august 2012 y. Protocol № 1.

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