ENDOCRINE

竺可青

2013-5-29

CLASSICAL ALGORHYTHM

• PITUITARY– ANTERIOR– POSTERIOR

• THYROID• PARATHYROID• PANCREAS (endo.)• ADRENAL

– CORTEX– MEDULLA

• DEGENERATION (aka, “involution”)

• INFLAMMATION• NEOPLASM

– BENIGN– MALIGNANT

Homeostasis in the hypothalamus-pituitary-thyroid axis and

mechanism of action of thyroid hormones.

15-25 grams

• 1. Thyroiditis

• 2. Diffuse nontoxic goiter/simple goiter/endemic goiter

• 3. Graves Disease / diffuse toxic goiter / hyperthyroidism/ Basedow disease

• 4. Neoplasms of the Thyroid

HYPER-THYROIDISM

• aka, thyrotoxicosis• Diffuse (Graves disease)• Nodular• Adenoma• Carcinoma• Neonatal• Secondary to TSH pituitary adenoma

HYPER-THYROIDISM• HYPERMETABOLISM• Tachycardia, palpitations• Increased T3, T4• Goiter 甲状腺肿• Exophthalmos 突眼• Tremor• GI hypermotility• Thyroid “storm”, life threatening

HYPO-THYROIDISM• 1° Developmental • 1° Surgery, I-131, external radiation• 1° Auto-immune (i.e., Hashimoto’s)• 1° Iodine deficiency• 1° Li+, iodides 碘化物 , p-aminosalicylates• 2° (pituitary)• 3° (hypothalamic, rare)

HYPO-THYROIDISM

• Cretinism 呆小症– Severe retardation– CNS/Musc-skel– Short stature– Protruding tongue– Umbilical hernia – Maternal iodine defic.

• Myxedema 粘液水肿 (coma)– Sluggishness– Cool skin, ↑cholesterol

THYROIDITIS• Hashimoto (Auto-Immune) (Lymphoid follicles with

germinal centers), MOST COMMON cause of acquired hypothyroidism in USA

• Subacute Granulomatous (DeQuervain)

• Subacute Lymphocytic (just like Hashimoto’s but NO fibrosis and no germinal centers), often post-partum 产后

Subacute thyroiditis

The thyroid parenchyma contains a chronic inflammatory infiltrate with a multinucleate giant cell (above left) and a colloid follicle (bottom right).

Hashimoto thyroiditis 慢性淋巴细胞性甲状腺炎 / 桥本甲状腺炎

• 甲状腺实质广泛破坏萎缩，• 大量淋巴细胞浸润，• 纤维组织增生。

If the thyroid gland looks like a lymph node, the diagnosis is Hashimoto thyroiditis 。

甲状腺肿• 由于增生和胶质储存伴甲状腺激素不正常

分泌而产生的甲状腺肿大。• 非毒性甲状腺肿（结节性增生）• 毒性甲状腺肿

Diffuse nontoxic goiter/simple goiter/endemic goiter弥漫性非毒性甲状腺肿（结节性甲状腺肿）

• 缺碘 --- 使甲状腺分泌不足 --- 垂体促甲状腺 (TSH) 分泌增多 ---甲状腺滤泡上皮增生 --- 胶质堆积而使甲状腺肿大，一般不伴甲亢。

病因• 1 缺碘• 2 致甲状腺肿因子的作用• 3 高碘• 4 遗传与免疫

GOITERMost goiters worldwide are due to iodine deficiency.

The thyroid enlarges to try to trap more iodine, when serum levels are low.This is a adaptive response

• Diffuse hyperplastic goiter 增生期• Diffuse colloid goiter 胶质储积期• Nodular goiter 结节期 （结节性甲状腺肿

）

甲亢 Graves Disease / diffuse toxic goiter/ hyperthyroidism / Basedow disease

• Graves disease is the most common cause of endogenous hyperthyroidism.

• It is characterized by a triad of clinical findings: • Hyperthyroidism owing to hyperfunctional, diffuse enlargement of the thyroid

• Infiltrative ophthalmopathy with resultant exophthalmos

• Localized, infiltrative dermopathy, sometimes called pretibial myxedema, which is present in a minority of patients.

A patient with hyperthyroidism

Diffusely hyperplastic thyroid in a case of Graves disease

1 滤泡上皮增生呈高柱状 / 乳头状；2 腔内胶质稀薄见吸收空泡；

3 间质血管丰富淋巴组织增生。

SCALLOPING 扇贝

Podiatric case of the week. Myxedema is autoimmune edema.

Thyroid Neoplasms

• “Nodules” vs. true neoplasms

• Adenomas vs. Carcinomas

“NODULES”• Solitary vs. Multiple

• Younger vs. Older

• Male vs. Female

• Hx. neck radiation vs. NO Rx.

• “Cold” vs. HOT (really NOT-cold)

NEOPLASMS• ADENOMAS

– FOLLICULAR– HÜRTHLE

(oxyphilic)

• CARCINOMAS– FOLLICULAR– PAPILLARY– MEDULLARY

(AMYLOID)– ANAPLASTIC (worst)

结节性甲状腺肿 Nodular goiter. The gland is coarsely nodular and contains areas of fibrosis and cystic change.

Several clinical criteria might provide a clue to the nature of a given thyroid nodule:

• Solitary nodules, in general, are more likely to be neoplastic than are multiple nodules. • Nodules in younger patients are more likely to be neoplastic than are those in older

patients.

• Nodules in males are more likely to be neoplastic than are those in females.

• A history of radiation treatment to the head and neck region is associated with an increased incidence of thyroid malignancy.

• Nodules that take up radioactive iodine in imaging studies (hot nodules) are more likely to be benign than malignant.

ADENOMAS

胚胎性腺瘤胎儿型腺瘤单纯性腺瘤胶样腺瘤嗜酸粒细胞腺瘤非典型腺瘤

Follicular adenoma of the thyroid

Follicular adenoma. The photomicrograph shows well-

differentiated follicles resembling normal thyroid parenchyma

嗜酸粒细胞腺瘤 Hürthle cell tumor.

A high-power view showing that the tumor is composed of cells with

abundant eosinophilic cytoplasm and small regular nuclei.

甲状腺腺瘤

• 有完整的包膜；• 腺瘤内滤泡大小胶一致；• 腺瘤与周围甲状腺的实质不同• 压迫周围甲状腺组织

CARCINOMAS

• Papillary carcinoma (75% to 85% of cases) • Follicular carcinoma (10% to 20% of cases) • Medullary carcinoma (5% of cases)

• Anaplastic carcinoma (<5% of cases)

Papillary carcinoma 砂粒体 / 毛玻璃状核 of the thyroid.

Follicular carcinoma 滤泡性癌Cut surface of a follicular carcinoma with substantial replacement of the lobe of the thyroid. The tumor has a light-tan appearance and contains small foci of hemorrhage.

Follicular carcinoma of the thyroidA few of the glandular lumens contain recognizable colloid.

Capsular integrity in follicular neoplasmsEvaluating the integrity of the capsule is critical in distinguishing follicular adenomas from follicular carcinomas.In adenomas (A), a fibrous capsule, usually thin but occasionally more prominent, circumferentially surrounds the neoplastic follicles and no capsular invasion is seen (arrowheads); compressed normal thyroid parenchyma is usually present external to the capsule (top of the panel).

• In contrast, follicular carcinomas demonstrate capsular invasion (B, arrowheads) that may be minimal, as in this case, or widespread with extension into local structures of the neck.

• The presence of vascular invasion is another feature of follicular carcinomas.

Medullary carcinoma 髓样癌 of thyroid

These tumors typically show a solid pattern of growth and do not have connective tissue capsules.

Medullary carcinoma of the thyroid. These tumors typically contain amyloid 淀粉样物 , visible here as homogeneous extracellular material, derived from calcitonin molecules

secreted by the neoplastic cells （ C cell) .

小 结• 乳头状癌 最常见，青少年、女性多见，生长慢，恶性度较低，预后

较好。砂粒体 / 毛玻璃状核。

• 滤泡性癌 比乳头状癌恶性度高，预后差而少见，多见于 40 岁以上女性，早期易血道转移。注意包膜和血管侵犯。

• 髓样癌 滤泡旁细胞发生，属 APUD 瘤。间质常有淀粉样物沉着。降钙素 ( calcitonin ) 阳性。

• 未分化癌：恶性度高，预后差。可用 keratin\CEA\thyroglobulin 证实来自甲状腺上皮。

To make things simple,

let’s just say you can regard ALL papillary thyroid neoplasms as malignant!

ORPHAN ANNIE CELLS in PAPILLARY CARCINOMA

MEDULLARY CARCINOMA of the thyroid with “HYALINIZATION”, i.e.,

AMYLOID!!!

HYALINIZATION showing APPLE GREEN birefringence in CONGO RED stain, i.e., AMYLOID

BIOLOGIC BEHAVIOR• Papillary CA lymph nodes

• Follicular CA blood vessels, bone