Download - 24.TIROIDA
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PATOLOGIA TIROIDEIPATOLOGIA TIROIDEI• ANATOMIE - 2 lobi - istm - lob piramidal
• ANATOMIE - 2 lobi - istm - lob piramidal
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FIZIOLOGIE
• Secretia - T3
- T4
• Regleaza metabolismul - glucozei - protidic - lipidic
• Influenteaza functia altor organe endocrine
- suprarenala - ovar - paratiroide - timus
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EXPLORAREA TIROIDEI
- Clinic
- Explorari functionale
- Ex. morfologice
- Alte explorari
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Examen clinic• Anamneza - debut
- cresterea de volum
- durere ±
- semne de hipo sau hipersecretie
- habitat
• Inspectie
• Palpare
• Auscultatie
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Explorari functionale
• Iodocaptare (I131) la 2h = 10-15% la 4h = 25-30% la 24h = 40-50% la 72h = 15-20%
• Clearance tiroidian de iod (I131) 8-40ml/min
• Dozarea iodului legat de proteine 4-8 mcg/ 100 ml
• Dozare T3 100 – 200 ng/ 100 ml
• Dozare T4 4-11 mcg/ 100 ml
• Anticorpi antitiroidieni
> Hipertiroidie
< Hipotiroidie
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Explorari morfologice (1)
• Scintigrafia tiriodiana
(I131)
• Rx. cervicala
• Rx. Toracica
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Explorari morfologice (2)
EcografiaTomografia computerizataRMNPunctie aspirativa
ex. citologic
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Alte explorari
• EKG
• Explorari pentru hipofiza
( Rx. Sa turceasca)
• Laringoscopie
• Scintigrafie osoasa
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Tiroiditele
Afectiuni inflamatorii ale tiroidei normale
• Acuta
• Subacuta
• Cronica
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Tiroidite acute (supurate)
Cauze• Germeni piogeni (septiemii, febra tifoida,
pneumonii, etc)• Virusuri (gripa, rujeola)
Infectia se poate transmite pe cale limfatica sau prin contiguitate
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Anatomie patologica
• Macroscopic - tiroida mare
- congestie
- aderenta la tesuturile vecine
- focare de necroza + supuratie
• Microscopic – infiltrat PMN
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Clinic
• Debut - febra
- frisoane
- dureri regiunea cervicala
- jena la deglutitie
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Perioada de stare
• Continua stare febrila
• Dureri exacerbate de miscarea capului,
deglutitie, tuse
• Tumefactia regiunii cervicale
• Glanda devine dura si foarte dureroasa
• Compresiune: traheala, esofagiana, recurentiala
• Tardiv → fluctuenta
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Evolutie
• Progresiva – complicatii si abcedare
- ruptura abcesului
- sindrom laringian
- tromboflebita jugulara externa
- sepsis
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Diagnostic
• Pozitiv - semne clinice
- punctie puroi
• Diferential - congestie tiroidiana de sarcina
- tiroidita subacuta
- hemoragii intrachistice
- debut neo tiroidian
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Tratament
• Medical - antibiotice + corticoterapie
- analgetice
- antiinflamatorii
• Chirurgical - incizia abcesului
- lobectomie
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Tiroidita (De Quervain) (granulomatoasa, pseudotuberculoasa,
cu celule gigante)
• Inflamatie subacuta, nesupurativa, autolimitata,
formarea unor foliculi pseudotuberculosi)
• Frecventa la femei > 30-50 ani
• Cauze – necunoscute (sunt incriminate infectia urliana si streptococica)
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ANATOMIE PATOLOGICA
• Macroscopic - Hipertofie, alb- galbuie, dura,
fara infiltrarea capsulei
• Microscopic - Folicul gigant (pseudoTBC), eozinofilie
- distrugerea foliculilor normali
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CLINIC
• Debut (ca o viroza)
- dureri cervicale, febra
• Local - durere > - deglutitie - miscarea capului - tuse
- glanda - marita de volum - dura - dureroasa - fara adenopatie - stare generala alterata
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PARACLINIC
• Iodocaptare 0
• Scaderea T3, T4
• Scintigrafie – fixare neomogena
• Punctie – prezenta foliculilor giganti + eozinofilie
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DIAGNOSTIC DIFERENTIAL
• Debutul virozelor
• Cancer tiroidian
• Toate tiroiditele acute sau cronice
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EVOLUTIE
• Vindecare 6 – 12 luni
• Cronicizare + recidive
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TRATAMENT
• Medical - corticoterapie 1- 2 luni
- substitutie T3 sau tiroida uscata
- radioterapie externa
• Chirurgical – Tiroidectomie
(cand persista nodulii)
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TIROIDITELE CRONICE
• TIROIDITA LIMFOMATOASA
(HASHIMOTO)
• TIROIDITA FIBROMATOASA
(RIEDEL)
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TIROIDITA LIMFOMATOASA
• Frecventa (0,3-1,2 %) - femei tinere
• Etiopatogenie - boala autoimuna
- factori genetici
- carenta vitamina A si D
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ANATOMIE PATOLOGICA
• Macroscopic - Hipertofie - ferma - asimetrica, - difuza
• Microscopic - Infiltrat limfocitar - Fibroza - Leziuni foliculare
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CLINIC
• Debut - insidios - hipertrofie ± disfunctie tiroidiana
• Stare - glanda marita asimetric - consistenta variabila - vagi dureri cervicale - displazie - dispnee - ± adenopatie
Stadii avansate
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PARACLINIC
• α2 proteine >
• Anticorpi antitiroidieni
• Iodocaptarea – de obicei crescuta
• Punctie
• Biopsie excizionalaDiagnostic pozitiv
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TRATAMENT
• Medical - substitutie hormonala
- corticoterapie
- imunosupresoare ±
- radioterapie
• Chirurgical - tiroidectomie - gusi compresive - suspiciune malignizare - adenopatii cervicale + gusa - gusa multinodulara - fara raspuns la tratament
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TIRIODITA FIBROASA
• Frecventa 0,3% - femei de varsta medie
• Etiologie – necunoscuta
• AP - macro: - glanda sau un lob transformat in tesut fibros dur, albicios
- micro: - foliculi sufocati de tesut fibros - infiltrat inflamator cronic ce se extinde la tesuturile vecine
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CLINIC
• Debut – insidios
• Stare – glanda dura - fara limite - fixa - semne de compresiune - stare generala buna - fara adenopatie
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PARACLINIC
• Iodocaptare - normala
- punctie (fibroza)
- hormoni tiroidieni scazuti
• Diagnostic diferentiat - tiroidita subacuta
- cancer tiroidian
- tiroidita Hashimoto
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EVOLUTIE
TRATAMENT
• 10-12 ani > compresia organelor din jur → asfixie
• Medical - hormonoterapie tiroidiana• Chirugical - lobectomie
- tiroidectomieEvita compresiunea
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GUSA ENDEMICA (DISTROFIE ENDEMICA TIREOPATA)
• Gusa – orice marire de volum a glandei, datorata unui proces hiperplazic de natura distrofica
localizat la foliculi sau in tesutul conjunctiv
• Sunt excluse - tumorile - inflamatiile
• Clasificare - eutiroidie - hipotiroidie - hipertiroidie
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• Congenitale
• Dobandite
• Endemice ( cand cuprind > de 10% din populatia
unei regiuni)
• Sporadice ( fiziologica)
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ETIOLOGIE
• Factori de mediu
- carenta de iod - apa, sol, alimente
- poluarea apelor - consum crescut de - varza, mazare, soia (alimente gusogene) - sfecla rosie - fasole, linte
- substante minerale (Ca, Mg, F, Cl)
- medicamente (PAS, sulfamide, corticoizi, fenilbutazona)
- iod in cantitate mare
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• Factori individuali
- ereditatea
- factori neuro-endocrini
- varsta (pubertatea, menopauza)
- tulburari de hormonogeneza
- pierderi cronice de iod - diaree cronica - alaptarea
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ANATOMIE PATOLOGICA
• Modificari polimorfe localizate sau interesand toata glanda
• FORME
- G. parenchimatoasa difuza (primul an sau pubertate)
Macro - elastica, omogena, neteda
Micro - arhitectura pastrata
- creste numarul de foliculi
- coloid crescut
- vascularizatie bogata
- hemoragii + scleroza interstitiala
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• G. coloida (cea mai frecventa in DET)
- macro: mare, consistenta moale
- micro: - coloid abundent - aplatizarea epiteliului folicular
• G. nodulara
- macro: - noduli mari, bine delimitati - evolueaza ca adenoame tiroidiene
- micro: - adenoame cu structuri diferite (folicular, trabecular, chistic, papilar)
- aplatizarea epiteliului folicular
- pot suferi transformari maligne
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• G.chistica
- Macro - chist unic sau multiplu
- prezenta de vegetatii in interior
- Micro - epiteliu folicular aplatizat
- proliferari endo chistice
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CLINIC• Anamneza - provine din regiune gusogena - ereditate - tratamente - obiceiuri alimentare - varsta
• Examen local - volum marit - mobila cu deglutitia - fara adenopatie cervicala - semne de compresiune - semne de hipo sau hiperfunctie
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PARACLINIC
• Rx cervical
• Scintigrafie
• Iodocaptare
• Test stimulare TSH
• T3, T4 - scazute sau normale
• Ecografie
• TC
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DIAGNOSTIC DIFERENTIAL
EVOLUTIE
• Tumori cervicale mediane• Tumori cervicale laterale• Adenopatii cervicale• Tiroidite• Cancer tiroidian
• Regresiune spontana• Persistenta• Crestere lenta sau in pusee
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COMPLICATII
• Functionale - hipo
- hiper
• Infectioase (strumite)
• Hemoragice - interstitiale
- intrachistice
• Mecanice - compresiuni
• Malignizare
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FORME CLINICE• Etiologice - endemice - sporadice - congenitale
• Topografice - mediastinale (plonjante) - cervicale laterale - linguale - intratraheala - esofagiana - ovariana (Sdr. Demons-Meigs) - ascita - tumora de ovar - hidrotorax • Evolutive - oligosmptomatica - endocrinopata - neuropata
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TRATAMENT
• Profilactic - chimioprofilaxia cu iod
- eliminarea alimentatiei gusogene
- ameliorarea conditiilor de viata
• Medical – indicatii - gusa oligosmptomatica
- gusa multinodulara
- gusa cu hipertiroidie
- hormonoterapie substitutiva
- solutie Lugol
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• Chirurgical
- indicatii - esecul tratamentului medical (dupa 4-6 luni) - gusi mari → cresc rapid - gusi nodulare reci - gusi hipertiroidizate - gusi ectopice - gusi compresive - gusi neuropate
- metode - tiroidectomie subtotala - lobectomie - enucleerea chistului tiroidian
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HIPOTIROIDIILE
• Stari de insuficienta functionala tiroidiana traduse clinic prin mixedem
• Cauze - gusile
- post tiroidite
- post tiroidectomii (totale sau subtotale)
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CLINIC• Tulburari trofice - edeme difuze - par friabil, rar - facies in luna plina
• Tulburari nervoase - bradipsihie, hipoacuzie - tulburari motorii si de vorbire
• Tulburari endocrine - hipogonadism, hipoinsulinism - insuficienta suprarenala si ovariana - tetanie
• Tulburari cardiovasculare – bradicardie, modificari EKG
• Tulburari digestive - atonii ale cailor biliare si ale tubului digestiv
• Tulburari metabolice - < scaderea metabolismului bazal proteic - tulburari de dezvoltare somatica
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TRATAMENT
• Forme clinice de mixedem - congenital → nanism + cretinism - juvenil → 3-6 ani - adult → post tiroidectomie - frust → astenie, adinamie, caderea parului,edeme
- substitutie hormonala - cresterea aportului de iod
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HIPERTIROIDIILE
• Afectiuni neuroendocrine caracterizate prin hipersecretie hormonala tiroidiana
• Etiologie Frecvent la femeile > de 50 de ani, pubertate, sarcina sau menopauza
• Factori favorizanti - profesie stresanta - surmenaj - sistem nervos central labil - leziuni tiroidiene
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• Factori determinanti
- traume psihice
- infectii de focar, viroze
- intoxicatii cu diverse toxine
- tumori tiroidiene
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PATOGENIE• Teoria cortico-diencefalo-hipofizara - Factorii etiologici actioneaza izolat sau simultan asupra reglarii neuroendocrine
• Teoria autoimuna - sub actiunea virusi, traume → circulatie → proteine foliculare → anticorpi antitiroidieni
• Teoria evolutiei stadiale - stadiul nevrotic – F.F. → cresterea secretiei TSH - stadiul neuro-endocrin – apar semne clinice - stadiul de visceralizare – coafectarea altor organe - stadiul marantic (casectizare) – depasirea mecanismelor neuroendocrine
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CLINIC• Debut – lent, rareoro brusc
• Stare
-Sindrom central (cortico-diencefalo-hipofizo-tiroidian)
- tulburari psihice - nervozitate - agitatie - insomnii - labilitate psihica - ideatie rapida
- tulburari - hipersudoratie palmara - dermografism (semn MARANON) - senzatie de constrictie toracica
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- tremor extremitati
- semne oculare - exoftalmie (20%) - privire stralucitoare - deficit de convergenta oculara - ochiul inchis clipeste frecvent - pigmentare periorbitara
- hipertrofia tiroidiana – apare tardiv, creste lent
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• Sindrom periferic (hipertiroidian)
- Tulburari vasculare – tahicardie
- palpitatii
- aritmie extrasistolica
- fibrilatie atriala
- insuficienta cardiaca
- Scadere ponderala - constanta, precoce si rapida
- Termofobie
- Tulburari trofice
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PARACLINIC
• EKG
• Colesterol scazut
• Iodocaptare ridicata
• Dozare T3, T4 crescuta
• Clereannce iod crescut
• Scintigrafie - hipercaptare neomogena
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FORME CLINICEa) Hipertiroidia pura primara (tireotoxicoza)
Hiperfunctie → Gusa – creste in special T3
T4 normal
b) Adenom toxic tiroidian (Plummer) - hipertiroidie pura primitiva (fara participare centrala) - adenom hipersecretant
Scintigrama:
nodul hipercaptant in glanda hipofunctionala
- fara exoftalmie
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c) Gusa exoftalmica (Basedow- Graves)
- hipertrofie ax talamo-hipofizar
d) Gusa hipertiroidizata (boala Basedow)
- hipertiroidie secundara
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DIAGNOSTIC• Dg pozitiv - semne clinice - paraclinic - crestere nivel tiroidian - scintigrama cu hipercaptare - iodocaptare initial crescuta, descrestere rapida
• Dg diferential – nevrozele - para Basedow-ul pubertatii - tahicardia paroxistica - delirium tremens - sdr tiroidian paraneoplazic - tiroiditele - cancer pulmonar - cancer tiroidian - feocromocitom
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• Evolutie – crestere in pusee cu agravare progresiva
• Complicatii - cardiopatia hipertensiva
(rezistenta la cardiotonice)
- hepatoza tireotoxica
- diabet tiroidian
- TBC pulmonar
• Prognostic - bun sub tratament
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TRATAMENT
• Medical
- iod
- antitiroidiene de sinteza
(carbimazol, metil tiouracil)
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• Chirugical - Indicatii absolute - hipertiroidie cu suspiciune de malignizare
- hipertiroidie cu adenom unic sau multiplu
- hipertiroidie cu compresiuni - hipertiroidie cu semne de visceralizare
- Indicatii relative - restul hipertiroidiilor
- Contraindicatii - formele centrale - forme asociate unor boli grave - sub 16 ani - formele fara gusa - formele cu tulburari psihice
OPERATIA – pregatire preoperatorie - tiroidectomie subtotala
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CANCERUL TIROIDIAN
• Frecventa: 2-5% din afectiunile tiroidiene
0,5% din totalul cancerelor
• Etiopatogenie - carenta de iod
- antitiroidiene de sinteza
- iradieri la varste tinere
- leziuni nodulare sau adenom tiroidian
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ANATOMIE PATOLOGICA
• Carcinoame -vezicular - folicular - nodular (solid) - spino-celular - anaplazic
• Sarcoame - fibrosarcoame - limfom malign - limfo-sarcom
• Mixte - carcino-sarcom - teratom mailgn
• Metastaze
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CLINIC
• Debut - lent (de obicei)
- zgomotos (rar – la tineri)
• Local - gusa care creste rapid
- dura, fixa
- adenopatie
- piele infiltrata
• Sistemic – minime, nespecifice si tardive
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PARACLINIC
DIAGNOSTIC DIFERENTIAL
• Scintigrafic• Ecografic• TC• Laringoscopie• Biopsie
• Tiroiditele cronice• Gusi nodulare• Tumori cervicale• Tiroidita subacuta
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• FORME CLINICE
- acute - lente - schiroase - aberante
• COMPLICATII - asfixie - metastaze la distanta - invazia locala - tromboza vene jugulare
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CLASIFICARE CLINICA
• Tumora primara
Tx - tumora primara nu poate fi evaluata
T0 - tumora primara nedecelabila
T1 - < 1cm, limitata la tiroida
T2 - intre 1 si 4 cm, limitata la tiroida
T3 - > 4cm, limitata la tiroida
T4 - orice dimensiune, dar care a depasit capsula glandei
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CLASIFICARE CLINICA
• Adenopatii regionale
Nx - adenopatiile nu pot fi evaluate
N0 - absenta adenopatiei regionale
N1- adenopatii regionale metastatice
N1a - cervicala homolaterala
N1b - cervicala bilaterala, mediana
- contro-laterala
- mediastinala
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TRATAMENT
• Complex - CHIMIOTERAPIE
- CHIRURGICAL
- RADIOTERAPIE
- RADIOTERAPIE METABOLICA
iod radioactiv