do a I'm going to talk to you about clinical
aspect of thyroid disease.
So you all know that the thyroid gland is a
hormonal endocrine gland based at the front part of the
neck.
There's a little diagram of how it fits, uh, compared
to the thyroid cartilage and the cricoid cartilage.
Um, and we know that the thyroid gland secretes thyroid
hormones as T4 and T3.
So predominantly the thyroid hormone secretes T4, but peripherally T4
is converted to T3.
And T3 is the hormone that has the predominant physiological
um action.
And as you know, thyroid hormone controls your metabolism.
And so you get this situation of stimulation by the
hypothalamus and the pituitary gland to induce the thyroid gland
to produce some thyroid hormone.
And that is the this this is a this is
the system, as you know.
So uh, the hypothalamus produces TR and that stimulates the
pituitary to produce TSH.
And that stimulates the thyroid gland to produce its hormones
T4 and T3.
And they act by negative feedback to control the system.
So you you know, all about negative feedback is sort
of mechanism of homeostasis.
I think it comes up to a certain extent in
GCSE and A-level biology, where one talks about maintaining the
the the temperature of the body, you you get a
set point.
Essentially there's a set point where the body kind of
wants, if you like uh, the T4 levels to be
at a certain level and if it's if it's too
low, they will stimulate more production of the hormones, and
if the levels are too high, they will inhibit the
production so that that's how the whole system is controlled
to keep the TSH and the T4 kind of in
the normal level and to keep the metabolism, you know,
on track.
So if the pituitary gland is working normally, you can
kind of imagine or you can see even a graph
of TSH versus T4.
And you get the idea that that is kind of
how the relationship would be represented.
If the I may have a pointer, I may not
I don't know if this.
Yeah.
So if you're, shall we say if your T4 levels
drop for whatever reason your body will produce more loads
more TSH to try and get the normal working pituitary
to restore things back to this area, which is the
normal range.
And if you produce extra T4, then if your pituitary
is working normally, it will essentially stop producing TSH and
silence itself because you've already got too too much T4
around so it doesn't want to.
It doesn't want to stimulate any more.
So this is this is the normal normal range for
both T4 and TSH.
Um, so that's how the system is supposed to work.
So the prob the clinical problems we would talk about
are hypothyroidism and hypothyroidism and also nodules and lumps.
All of endocrinology is having too much or too little
of hormones pretty much.
Also tumours of endocrine glands.
So that's kind of a model for a lot of
clinical endocrinology.
Um, so if we start with hypothyroidism, not having enough
thyroid hormone that has lots of clinical symptoms, it's a
slowing of your metabolic processes.
So people pretend to be tired or cold, possibly with
weight gain, thin hair, dry skin, low mood, constipation and
bradycardia.
Those are the some of the symptoms.
And there's also a diagram there that might include some
other things.
It says heavy periods and infertility on the diagram as
opposed to the list I've got there.
And it also says I think depression and forgetfulness.
So a few other features.
But but it's it's quite broad.
It affects lots of different systems.
So if you imagine a kind of case study, you
might have a lady who's 69 years old she comes
in with to hospital with confusion and exhaustion, and somebody
does blood tests showing a TSH is 84 and a
free T4 is four.
Now I realise I haven't showed you previously the normal
ranges of these hormones, but in our labs the normal
ranges are kind of given in this.
So you want your T4 to be somewhere between, shall
we say ten and 20, although actually the exact numbers
given they're a little bit different and you want your
T3 to be somewhere between 3 and 6, and you
want your TSH to be somewhere between .0.4 and five,
shall we say.
So?
I mean, you know, the exact numbers are given.
They're a bit different.
So you can see that she's hypothyroid.
Her TSH is way too high and her T4 is
very low.
So it's this is clearly primary hypothyroidism a kind of
very obvious case.
And hypothyroidism gives the symptoms we described on the previous
slide.
Um, you can get this coarsening of hair puffiness of
the face because of depositions of things called glucosamine or
glycans in the soft tissues and in the tongue and
various places.
This is quite an extreme example.
They've put on the caption gross clinical hypothyroidism.
I mean, maybe that's not the nicest way of expressing
it, but it is a severe case.
She has lots and lots.
She's very she's very puffy.
She's got, um, uh, and you can imagine that the,
the in the enlarged tongue you can't see and the
hoarseness of voice.
These are other features of we keep ticking on.
Maybe that's why we find it might.
Um.
So hypothyroidism has a variety of causes.
Um, the two commonest causes are iatrogenic.
So us doing a treatment that renders the thyroid not
working, that would be an operation to remove the whole
of the thyroid.
That's one way you end up hypothyroid.
If you give radio iodine treatment to the to for
for a for a for an overactive thyroid, you're very
likely to end up with an underactive thyroid.
So I think is the top of that list.
And the other really common reason why the thyroid becomes
underactive is a chronic autoimmune disease.
Um, so autoimmunity where the thyroid is attacked and stops
functioning.
Um, it can be atrophic where the thyroid is, you
know, uh, it essentially becomes, uh, shrunken, or it can
be Hashimoto's where it becomes nodular.
Um, so whether the thyroid is big or little doesn't
tell you so much about what's going on in terms
of function, but that those are the two most common
causes.
And and so this is an extension of the previous
slide where you've got the two common causes at the
top.
But there are a bunch of other, uh, rarer causes
of an underactive thyroid that I thought we would touch
upon.
So one is thyroiditis.
Thyroiditis is a kind of, um, a broad term.
It just means inflammation in the thyroid.
And there's lots of different types.
Um, but but a viral thyroiditis or the other types
of thyroiditis are listed there.
All types of thyroiditis can make the thyroid go underactive,
either temporarily or permanently.
And iodine has bizarre effects on the thyroid, but a
severe iodine deficiency can make your thyroid very underactive.
Actually, excess iodine can also cause the thyroid to be
stunned.
And it can be you can be hypothyroid with excess
iodine as well.
But that's a that's a detail.
But that is another cause.
And then some drugs and some diseases that infiltrate the
thyroid.
Um, so there's a list of drugs there that I
think we won't go into in great detail, but also,
um, the infiltrated disease of the thyroid, strange things like,
um, uh, sarcoidosis or lymphoma, these are quite rare, but
but, but, but but things that will, will infiltrate and
stop the thyroid from working.
So the treatment for hypothyroidism is really simple.
People get given levothyroxine, which is essentially T4.
And I mentioned to you that T4 needs to be
converted to T3 peripherally by these diagnose enzymes, but that
that is supposed to be a system that works in
the majority of people normally.
Um, I don't want to go too far into controversial
area, but some people believe that T4 isn't converted that
well to T3 in some people.
And so there is a movement, uh, afoot, um, mostly
driven by patient groups who feel that they would like
to be given T3 instead of T4, which is much
more expensive.
But that's something that that's again, that's a sort of
detail.
The the top line information about being having an underactive
thyroid is that you've given levothyroxine and you get given
about 100 micrograms a day.
Um, I put 75 to 125 on the slide.
Some people do it by weight.
They say 1.6 micrograms per kilogram.
That would tend to give you a bit more, wouldn't
it?
I mean, but but you might end up with it.
Some people would end up on a dose of 150
or more.
Um, and the way in which you check that your
thyroid is, um, adequately treated as you do blood tests
to check that the TSH is normal.
And so if your TSH is in the normal range,
you that.
And if your pituitary gland is working normally, then you're
on the right dose of levothyroxine.
That's the that's the kind of conventional mantra.
Um, so blood tests to check the TSH.
Um, you can check the T4 as well, but TSH
is a more kind of bankable, um, stable thing to
monitor.
So if we go to a second case, this is
a 25 year old patient who's tired, and so they
have a TSH that's as shown.
And a T4 and T3, uh, measured there.
And so the point about those blood tests is that
they're all in the normal range.
And so this person doesn't have a thyroid problem.
And I suppose the point I wanted to make there
is that the symptoms of hypothyroidism are incredibly non-specific.
Loads of us gain weight and we don't want to
gain weight.
Loads of us are tired.
You know, loads of people maybe have more hair thinning
than they want or have, you know, whatever those things.
So lots of people think they've got thyroid problems.
But we tend to trust the biochemistry.
And so you will I guess you just The point
is you need to do the tests to, to check.
Um, having symptoms that are potentially consistent with hypothyroidism is
really common.
So if someone says, I think I'm hypothyroid, but my
blood tests are normal, the blood tests must be wrong.
We tend to argue the other way and say no,
we actually would trust the blood test in that stage
situation, and it's not thought that you would benefit from
thyroid hormone if you're not properly hypothyroid despite symptoms.
Um, some people believe differently, but that's the conventional idea
that I think you should have taken at least as
your top line information.
Um, thyroid antibodies, um, are very common.
Uh, and they do indicate that you might have a
predisposition to become, to develop a thyroid dysfunction in the
course of your life.
But it is very common to have thyroid.
There are different types of thyroid antibody, but the most
common one is the TPO antibody.
And I get a really lot of GP's writing to
me saying, you know, this patient, they're tired, their thyroid
function is normal, but their TPO antibody is positive.
So would you like to see them in clinic because
you know you can make them better.
And I'm in a nice, positive way.
I have to be like, no, I can't make them
better.
You know, TPO antibodies are positive and 12% of the
female population of the UK and tiredness with normal thyroid
function, we don't really have a treatment for uh so
that's not not a pathology.
It's not an endocrine pathology.
Um but, but it is something that we, we, we,
we, we hear about a lot.
If the only thing that's wrong is the antibodies and
the, um, if the only thing is wrong is the
antibodies and the and there are symptoms, but the thyroid
function is normal, but that's not regarded as thyroid pathology.
Um, and all you would do there is say it's
sensible for the patient to keep having their thyroid checked
every year or so to check because they might develop
hypothyroidism, as in biochemical hypothyroidism in the future.
Okay.
So now we're going to move to an overactive thyroid.
So this is a case of a 30 year old
female patient anxious shaky pulses going along at 100.
The biochemistry shown there you can see the TSH is
suppressed.
And the T4 and T3 are both high.
So we recognise that to be hypothyroidism overactive thyroid.
We use the term thyroid toxic doses as well.
Um, I actually use the term thyroid psychosis and hypothyroidism
fairly interchangeably.
There is a technical difference, um, which maybe we won't
go into.
I mean, don't worry about it.
Uh, but, uh, but but but essentially thyroid psychosis is,
is the is the is the clinical term the correct
clinical term for having an overactive sort of having, uh,
having too much thyroid hormone and the clinical effects from
it.
Um, so, so, uh, people who are thyroid toxic will
get mood and behavioural changes.
They'll get restlessness, shaking, sweating, palpitations, breathlessness, diarrhoea, muscle weakness
sometimes.
Um, so, uh, some of the clinical signs you might
see with someone who an overactive thyroid is that you
get little attack traction because of over sympathetic stimulation to
the eyelids.
So you can see with this, uh, his left eye,
uh, you can see that you can see the white
of the eye above the iris.
Uh, one shouldn't be able to do that.
That's, uh, that's, you know, uh, lid retraction, um, lid
lag is the idea that if you have a if
you ask a patient to, um, if you move something
in an arc from high up to low down and
ask the patient to follow it with their eyes, that
their, their eyelids will, will, will be they will follow
it with their eyes, but their eyelids will remain retracted,
um, in a more pronounced way.
And so the eyelids would follow slowly.
Um, and so you can sort of see in a
dynamic way the lid retraction.
Um, so the main causes of thyroid psychosis are graves
disease and a nodule in the thyroid that's producing too
much thyroid hormone.
Not all nodules in the thyroid produce too much thyroid
hormone.
But some do.
Uh, we'll come back to thyroid nodules in a second.
Um, so graves disease is Autoimmunity.
I think there's going to be a further slide on
it.
So it's an autoimmune disease where you produce the TSH
receptor antibody and that stimulates the thyroid to be overactive.
Um a thyroid nodule.
Again we'll come back to you.
But but some nodules produce additional thyroid hormone in a
toxic in a in a in a in an autonomous
way.
Um there are some rarer causes of thyroid toxicities listed
um, uh, in black on this slide.
So if you have a pituitary tumour that's making too
much, uh, tsh, um, too much thyroid hormone, then that
will in turn make the thyroid produce too much thyroid
hormone.
And that is one reason why you might get thyroid
psychosis.
That's really rare.
So TSH is one of the rarer types of pituitary
tumour.
And pituitary tumours aren't that common anyway.
So um so that's to bear in mind.
But but you will probably not see one of those,
uh, in su to start doing a job like like
mine.
Uh, hCG stimulated hypothyroidism is the idea that pregnancy can
make your thyroid toxic because beta hCG, as you know,
is the hormone of early pregnancy.
So, um, women in the first trimester of pregnancy sometimes
are a little bit thyroid toxic, and that's normally just
settles by itself.
It's not too bad if you have a clinical stage
where you produce a lot of hCG, you can have
quite significant thyroiditis with this.
That's more common if you have a molar pregnancy or
if you have very bad hyperemesis gravidarum.
So a women who are getting lots of vomiting in
early pregnancy or with twins you get more HCG.
So anyway there there can be um hCG mediated hypothyroidism
is perhaps more of a physiological cause, but um, it's
definitely something we see if you're taking thyroid hormone and
you take too much of it, then that is a
cause of, um, uh, that was obviously a cause having
too much hormone and thyroiditis.
Um, thyroiditis.
There are several types which I think will come to,
but thyroiditis can generate extra thyroid hormone as well as
potentially making you have underactive thyroid.
Um, I said I wouldn't go into the difference between
thyroid psychosis and hypothyroidism, but since I'm on this slide,
I mean, I think the the point is that thyroid
toxicities, where is any condition where you have too much
thyroid hormone.
So everything on this slide is thyroid causes hypothyroidism is
when the thyroid gland is making the extra thyroid hormone.
Um, and so uh, so for example, if you think
about excess or excess excess thyroid hormone medication that that
is an example of your thyroid toxic.
But you don't have hypothyroidism because the, the because the
the reason your thyroid hormone is too high is not
because the thyroid hormone, the thyroid gland is making too
much.
It's just it's coming from another source.
So that's a, um, that that's a detail.
Um, but I would use the terms interchangeably.
And so if we go to somebody with graves disease,
this is somebody an example of primary hypothyroidism is grave
disease.
It's an autoimmune disease where you make an antibody.
The antibody binds to the TSH receptor and stimulates it.
Um, these patients, yes, they have an overactive thyroid.
They can also have thyroid disease.
And they can also have a swollen thyroid gland.
So this lady is, um, got, um, you can see
her little retraction.
We she we can believe she's thyroid toxic.
She looks a bit stressed.
Um, her thyroid gland looks a little bit enlarged.
Um, thyroid eye disease is only about 20% of people
who have graves disease get thyroid disease as well.
And it classically gives you itching and watering of the
eyes.
And it makes the whites of the eyes go red
and you get irritation.
Um, it can produce a bulging of the eyes, It's
the thalamus, where the eyes are further forward in the
skull than they should be.
And potentially it can give you double vision and sight
threatening.
I mean, that's quite rare.
So most people, most people with graves disease don't have
thyroiditis at all.
And those that do, they mostly get symptoms which are
very unpleasant, uh, to have itchy eyes that water and
have tearing.
So they're often very unhappy about having this illness.
But, um, the idea that, you know, but you have
to have really quite a severe case for it to
be sight threatening or cause double vision so that those
problems are rare.
But, um, but but thyroid disease itself is actually is
actually, you know, not not a nice thing to have
and takes a while to settle down.
Um, so if you have graves disease, you can have
these other manifestations.
So we've mentioned thyroid eye disease.
That's relatively common because it's about 1 in 5.
It's about 20%.
The other manifestations of graves disease that you some see
are really rare.
So you can get this thyroid, which is the is
basically like clubbing, but it's very, very rare.
But it is one of the many causes of clubbing
where it gives you this, you know, this the the
drumstick, the swelling of the, of the distal part of
the fingers.
And you can get a dermal pathy a skin disease
related to Graves's.
Again, it's very rare.
It's a sort of orange peel type appearance.
And this is one slide of it.
But you know that again, that is that is not
a common manifestation of graves.
These are rare things that we sometimes sometimes see.
Um, but the most, most people, graves disease will have
an overactive thyroid, a swollen thyroid gland.
And they may or may not have thyroid disease.
So the tests one would do would be that you
need to have, um, thyroid function, blood tests, obviously, as
we've said.
And then you check for this TSH receptor antibody.
Um, that's a different antibody to the TPO antibody I
mentioned.
T they're both antibodies for the thyroid, and they both
are markers of an autoimmunity, uh, in the thyroid.
But the TPO antibody is, um, more, more associated with
an underactive thyroid.
And it's also quite common in the population in general.
As I said, uh, the TSH receptor antibody, which we
call trap is um, is a more specific marker of
autoimmunity causing graves.
And it is basically the diagnostic tests for graves, the
tribe antibody.
Um, so if someone's overactive got an overactive thyroid, you
might check their antibody because if it's positive, they've almost
certainly got graves disease and you got your diagnosis, um,
if they don't have a positive antibody, then it's more
uncertain what's going on.
And you would in that situation do a thyroid uptake
scan, which is a nuclear medicine scan where they use
they use they can use a variety of things, but
they use technetium normally to see if the thyroid gland
itself is taking up, take the ECM or and therefore
functioning um, in the whole gland.
And so that helps you to determine if you have
a toxic nodule.
So I mentioned one of the common, uh, causes of
an overactive thyroid is that you might have a nodule
in the thyroid that is autonomous, that's producing too much
thyroid hormone.
And a thyroid uptake scan would give you that diagnosis.
Um, and the other investigation you might consider is an
ultrasound that's less specific.
I mean, an ultrasound is a good way to image
the thyroid in general.
It's not going to tell you whether you have a
nodule that's over functioning or definitively tell you you've got
graves disease or thyroiditis, but it is sometimes a useful
test to have a, a better understanding in a sort
of global sense of what's happening with the thyroid.
So those are the investigations for hypothyroidism and then treatments.
Um, yeah.
I mean, so people with hypothyroidism, thyroid psychosis are often
have lots of symptoms.
And so you might give them beta blockers because they're
going to work quickly to suppress and control the symptoms.
So beta blockers stop you being from shaky.
Uh, they make you less anxious, less tremulous, less tachycardic.
Um, and so starting beta blockers is one way to
get someone who has Start-Up psychosis to feel a bit
better today.
And that's so that's that's a good thing.
And that would be something you would use.
You're then going to use a medical treatment to make
their thyroid hormone levels come down.
Those medications are much slower.
So you might start them on carbon muscle or uracil.
Carbon muscle is the drug of choice that you use.
Um, and proper thyroid uracil is only mostly only really
used uh, in a situation of either pregnancy or anticipate,
you know, either planned pregnancy or actually being pregnant because
it's a bit safer in pregnancy.
Um, but otherwise it's not such a good drug as
carbamazepine.
Um, so those are the two medical drugs, but they
don't work straight away.
So if you see someone in clinic who's thyroid toxic
and you start them on a beta blocker, that will
help their symptoms straight away, but it won't treat the
underlying problem, you can give them carbine resolve to treat
the underlying problem, but it'll take a few weeks to
kind of fully normalised the numbers, the the thyroid hormone
levels.
Um, if those things don't work or can't be used
or whatever, what we call definitive treatment for graves disease
is you can give radio iodine.
So that's where the patients, um, they eat or they
swallow a, should we say a capsule of radio labelled
iodine.
And then because it's iodine, it finds its way to
the thyroid and because it's radio labelled it will destroy
the overactive thyroid cells.
Um, and so that would stop them being overactive with
their thyroid.
Um, or you can do surgery, you can do an
operation to remove the thyroid.
And in that situation you would remove the whole of
the thyroid normally.
Because if you're trying to treat graves disease with an
operation, you kind of need to remove the whole of
the thyroid so that the graves doesn't come back.
Um, that is the the current belief they used to
always do, like subtotal thyroid surgery to try and take
the most of the graves disease away, but leave some
thyroid tissue But now, if you're doing an operation for
graves disease, the belief is that you should probably just
remove the whole of the thyroid and kind of cure
the patient from being thyroid toxic hypothyroid.
So, um, that is supposed to be a diagram about
a toxic nodule, as I mentioned already.
But, um, it's just it's not really.
It's not it's not a diagram.
It's.
Well, it's a yeah.
So the idea is that within the thyroid, you could
have a nodule or a lump, uh, of, of thyroid
tissue, um, that could be overactive and producing too much
thyroid hormone.
So, you know, classically it might just be a centimetre
or two in size.
The way you would find that out is firstly, the
patient would have be they'd be thyroid toxic.
So they might have symptoms and their blood tests would
tell you they were hypothyroid thyroid toxic.
And then when you do an uptake scan the nuclear
medicine scan uptake scan, which I said was also known
as a technician scan, that would show you that this
area was working way too hard and that the rest
of the thyroid was perhaps not working so hard.
And that way you would know that that's a toxic
nodule, and that although you can control that with tablets
temporarily, that's going to be better treated with radio iodine
or surgery, because that's a those are those are definitive
treatments for that for this condition.
So I mentioned thyroiditis I think thyroid disease is quite
a confusing word.
Obviously it just means inflammation of the thyroid.
That's kind of obvious.
But there's loads of different types and they're not that
similar to each other.
So it's a hotchpotch of weird things, but you can
divide it into painless and painful types, which are sort
of useful.
Um, so, um, people who have a painless form of
thyroiditis will often just become hypothyroid, uh, insidiously.
So lymphocytic thyroiditis or a postpartum thyroiditis or Hashimoto's thyroiditis,
these patients will often become hypothyroid with an underactive thyroid.
They might go through a phase of being thyroid toxic
before they become hypothyroid.
Um, and which we'll see, I think on the next
slide.
And similarly, these are, these are painful forms of, uh,
thyroiditis, uh, radiation used and this, this granulomatous thyroiditis, which
we used to call declare veins thyroiditis.
So, um, uh, and when I say painful, I mean,
in the, in the thyroid.
So if you have a.
Oh, yes.
So the next slide kind of tells us the kind
of cadence of these things.
So if you have an episode of thyroiditis, you'll often
be hypothyroid for a bit.
And then you'll go through being your thyroid and then
you'll become hypothyroid.
And then sometimes.
So I guess what you ask you to look at
is the red and the blue lines, because those are
the T3 and T4 hormones, and those are the ones
that are how much thyroid hormone you actually have.
Um, and though people who have thyroiditis will often go
hypothyroid and then hypothyroid and then either go back to
normal or sometimes this diagram doesn't really show it, but
sometimes they can just remain hypothyroid.
And um I guess I just put the graph up
to, uh, to indicate to you that thyroiditis is a
bit complicated and your thyroid can be overall or underactive,
or it can be changing with thyroiditis, but it can
present with a very painful anterior neck.
Or it can be painless.
Of course, if you have a completely painless form of
thyroiditis, you may not really notice that you're you're briefly
hypothyroid.
So people with lymphocytic thyroiditis sometimes just end up hypothyroid.
Um, uh, and they sort of don't notice the, uh,
the thyroid toxic phase.
Um, but but thyroiditis is a bit confusing, but it
is a condition of inflammation of the thyroid, often where
the thyroid will go high and low and then stay
there or high and low and recover briefly.
Yeah.
So that's what I was going to say about thyroid
psychosis and hypothyroidism.
I think we should just talk about thyroid nodules, which
is the third of the three kind of clinical areas
we talked about.
So if you saw a patient who was, um, comes
and tells you they've got a nodule in their front
part of their neck that they've noticed, that's not a
particularly, you know, it's a reasonably common presentation.
Um, this is quite a quick history.
They've just noticed it in the last couple of weeks.
Um, so in that situation, you would do some thyroid
function blood tests so that you're kind of expecting them
to be normal, but you would just check because it
could be a toxic nodule, uh, an overactive nodule, which
you would see that in the thyroid function, if the
person's thyroid function is normal.
The next tests for a thyroid nodule to do an
ultrasound scan, and often for a needle to be put
in to get a sample of cells, we call that
fine needle aspiration.
So it's a bit like a biopsy, but it it's
but it gives you a cytology sample.
So it's a bit it's a bit less invasive than
a biopsy.
And also a biopsy would give you, you know, histology.
It would give you a 3D uh, structure of, of
a bit of a lump of tissue.
Whereas a final aspiration only gives you cells, it gives
you cytology.
So it's analysed slightly differently Um, so I guess the
point about thyroid nodules is 90% of them are benign.
So when people come and see us with thyroid nodules,
we try and reassure them that it's very likely to
be nothing to worry about.
But it does need to be assessed.
Some nodules are thought to be low risk, so if
they have ultrasound appearances that are benign, uh, if the
cytology is benign, these are very reassuring things.
Uh, the, the ultrasound are graded on this weird you
scale where you two is benign and you five is
malignant.
You four is I think it's malignant, but I'm not
certain you one is essentially doesn't really exist.
I guess it's to have a completely normal thyroid where
you don't even have a nodule, so that's fine.
But no one really talks about U1 because it's not
clinically relevant.
So you two is a benign nodule.
And if it's something is you 4 or 5, you're
already thinking this is probably a malignant lesion.
It's going to have to come out with an operation.
Um, the cytology, you know, when they put the needle
in for the fine needle aspiration, you may get suspicious
or diagnostic of malignancy cells.
The management of this is this surgery, and the extent
of surgery would depend a bit on how big the
nodule and how bad it looks.
If it's a small nodule, you might end up with
just the nodule being removed.
A sort of Lubeck to me, where one lobe of
the thyroid is removed.
But often you'd have a total thyroidectomy if you've got
thyroid cancer or a strong suspicion of thyroid cancer.
That's kind of how we would look at thyroid nodules
in general.
Um, so thyroid cancer is um, is a cancer that
has several different types.
Um, the vast majority is papillary thyroid cancer.
And then there are other types of follicular, medullary, anaplastic.
And sometimes you can get lymphoma in the thyroid.
Uh slightly different thing.
But but that that is another malignancy that you'd see
in the thyroid.
Um, both um papillary thyroid cancer and follicular thyroid cancer
have really good prognosis.
I mean, it's still a really big deal to be
told you have thyroid cancer and it needs to be
worked up and people have to have an operation and
they have to have follow up.
So I'm not trying to belittle the experience, but actually
the the five year, the ten year prognosis is really,
really good.
And so these people notwithstanding that it's disruptive to have
an operation and have that diagnosis, uh, you know, a
very it's not a life limiting condition or it's very,
very unusual, very rarely.
Medullary thyroid carcinoma is linked with multi endocrine neoplastic syndrome
type two.
And the tumour marker is calcitonin.
So that's a bit more it's a bit more aggressive.
It has a slightly less good prognosis.
And it has this interesting genetic link with other other
tumours for example for a chromosome as we were going
to do today.
Um anaplastic thyroid cancer is is very rare, but it's
extremely aggressive.
And it um and it, it increases in size very
fast and it is not responsive to very many treatments.
So, um, so the vast majority of thyroid cancer has
an excellent prognosis, but you have to be a little
bit careful about saying that, because of course an anaplastic
thyroid cancer has a terrible prognosis.
So that's a it's often just that's the small print.
But but one needs to be aware that there is
this spectrum.
And I've said at the bottom there that the prognosis
for papillary thyroid carcinoma is excellent, with a five year
survival of more than 89, sorry, 98%.
So, so, so, so very good compared to other types
of cancer.
So I mean, in summary from the talk we've we've
talked about hypothyroidism, underactive thyroid and hypothyroidism, uh, which is
classically graves disease.
But there are some other forms.
And then we've done we've touched upon thyroid nodules and
thyroid cancer.
Um, I had a few kind of questions just to
go through briefly to just, um, emphasise some of those
things.
So this is the question.
One is there's a Polish lady who's referred to your
clinic for an assessment of a thyroid nodule.
Uh, so it's a two centimetre thyroid nodule.
It's palpable, soft, mobile.
And she's got normal thyroid function.
So I guess one question they could ask you is
what would be the following management strategies.
Um, and so what about those are rather wordy answers
aren't they.
But I've said ultrasound is not required because it's soft
and you think it's clinically low risk.
That's not really quite right.
Uh, because you still need to assess these nodules.
The B says ultrasound should be, uh, performed with an
F and a C says you should do, um, ultrasound
and an FNA, uh, regardless of the findings.
And D says you should do an operation on the
thyroid.
Um, so actually B is correct.
I haven't really emphasised that in the talk, but if
you have, um, if you do an ultrasound, you do
put a needle in if there's any suspicion on the
ultrasound, if the ultrasound says it's completely benign, then the
guidelines say it's not a brilliant idea to put a
needle in.
Because if you do an FNA and you get cytology,
the cytology can be a bit misleading sometimes.
Uh, so, um, you kind of then start to worry
about a nodule that you weren't worried about, which which
makes everything kind of more difficult.
So you're supposed to trust your ultrasound.
If an ultrasound says it's benign.
That's the end of the matter.
If the ultrasound says there's a question to answer, a
fine needle aspiration is the next test.
So that's one example of how you'd work up a
nodule and and a question about it.
Um, the next case is a 25 year old lady
she presents with tiredness and weight gain.
She's got those, um, blood tests and TPO antibody positive.
So it just asks you for an interpretation.
So we kind of touched upon this earlier.
The point about this is that she has normal thyroid
function.
And so she's not got a thyroid pathology.
She might think she has.
But but she doesn't have a thyroid pathology, at least
not one that's kind of active at the moment.
She does have TPO antibodies that are positive, and we're
not unsympathetic to the fact that she's got tiredness and
weight gain, and I suppose she could be in the
process of developing an overactive and underactive thyroid.
So it's not unreasonable to recheck her thyroid function.
Maybe in a few months, but I think we'd have
to tell her.
At the moment, a thyroid is working normally and that
we don't really have a treatment to offer her.
And if you said, well, you anticipate her thyroid becoming
underactive in the future, couldn't you give her something to
kind of prevent that?
There isn't really a treatment that does that at the
moment in the thyroid world.
Um, if you want to prevent someone developing an autoimmune
disease, you sometimes can immunosuppressed them in in other walks
of, you know, in other and other fields of medicine.
But we wouldn't immunosuppressed someone to avoid them.
Developing hypothyroidism because hypothyroidism is quite easy to treat.
And immunosuppression is not a trivial thing.
So you don't you don't, at least not under current
medical practice.
You're going to you're going to note that the TPO
antibodies are positive, and therefore note that there might be
a predisposition to develop hypothyroidism at some future point, but
you're just going to monitor and offer her treatment, you
know, if and when it was an active issue at
some point in the future.
Um, so question three is that there's a lady who's
feeling hot with a racing heart, anxious, breathless, weight loss.
And you can see her blood test show that she's
clearly thyroid toxic, and she has a lab antibody that
is elevated.
So we've asked you just for the diagnosis.
So again that's that's relatively easy.
This is grave disease because the tribe antibody is the
is the marker of graves disease.
So it could have been any of the other as
well.
Papillary thyroid cancer doesn't really give you thyroid tox cases.
And autoimmune hypothyroidism makes you hypothyroid as the name suggests.
So that would be um, uh, those would be the.
Yeah.
So, so whereas toxic nodule and how she talks closest
are both reasonable suggestions for the clinical presentation.
But the tribe antibody makes this graves.
Um, I didn't put a question in about this.
I was going to but then.
But I think that if they were going to ask
you a question about treatment of hypothyroidism, I think that
what they might ask you and I haven't mentioned it,
but perhaps I should, is that carbon muscle has a
well-known and important side effect, not side effect, but, well,
potential side effect, which is that it can make you
pant out to panic.
What am I doing here?
I was trying to.
Yeah.
Okay.
That slide.
Yeah.
So, um, carbon is all and all but but but
these anti thyroid medicines, they can give you a side
opinion um or neutropenia shall we say.
So you can have um, uh low white cells.
And that is something that you're kind of told to
watch out for.
And I didn't put it on the slide.
But I think that if any of you ended up
in general practice and you were seeing kind of thyroid
patients and they were taking carbon muscle, when you start
someone on carbon muscle, you were expected to kind of
warn them that there is a small risk that they
develop a, uh, they develop, um, uh, leukaemia.
So low, low white cell counts.
Um, uh, when they're on carbon result, the risk is
really small.
It's quantified as three in every thousand patients that take
carbon muscle.
So it's less than 1%.
But it is quite important because the patients who develop
um, uh, what they call a granular psychosis, don't they?
But but low white cell counts, uh, on carbon muscle
can, um, you can become really sick with that because
your immune system is not functioning weirdly.
It can present with any type of infection, I suppose,
because if you're a white cells very low, you could
develop an infection.
Um, but classically it always presents with or at least
in the series of it.
When they describe like a series of 20 cases, everybody
seems to get a very, very bad pharyngitis, like a
really, really bad sore throat, uh, which is associated with
the immune suppression of their, uh, of them having, of
having a granulosa ptosis.
So patients with Covid mas all are usually warned if
they develop an extremely bad sore throat, uh, they should
have a blood test to check their white cell levels
are still okay.
And that is I think that's an important sort of
general medical point that although not in the slides, I
thought that you should know that.
And it's a rare side effect of carbon muzzle, and
it wouldn't be unreasonable to ask question about that, I
guess, although, yeah, because it is an important thing to
know.
So.
So Cuban missile can give a granular status, low white
cells.
And although that could present with any infection for some
reason, it is a very bad sore throat.
That is the kind of classic clinical presentation of this
which people are asked to look out for.
Um, and so they're asked to just make sure they
get a blood test to check their white cells are
okay.
And I think that if they were going to ask
you a question, a clinical question on the thyroid, they
might ask you about, you know, the, you know, what
should patients on Cuban missile look out for in terms
of severe side effects?
Um, so that that would be a question for if
it were written, but it's only for, um, only for
you listening, uh, because it's not on the slide.
Um, that is kind of the end of this section.
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