THYROID GLAND

PACTICAL ACTIVITY NO. 5

Morphofunctional investigations of the thyroid

1. In vitro methods: 1.1. Basal hormone determinations 1.2. Dinamic tests 1.3. Other specific laboratory findings
2. In vivo methods: 2.1. Radioactive iodine uptake: RAIU (thyroid Tc-uptake) 2.2. Thyroid scintigraphy: TSG 2.3. Thyroid ultrasound 2.4. Fine-needle aspiration biopsy: FNAB 3. Nonspecific investigations

During systemic illness normal or fT4 with TSH in the acute phase and in the recovery phase. Dopamine or glucocorticoid administration TSH , normal fT4 and fT3.

1. In vitro investigations
1.1. Basal hormonal assessments: TSH fT4, FT4 - free-T4; total T4 fT3, FT3 - free T3; total T3

A. Serum TSH: normal range: 0.5-4.5 mIU/L Diagnostical value (interpretation of pathological values): TSH : primary hypothyroidism (subclinical or overt form) TSH-secreting pituitary adenoma Refetoff syndrome (thyroid hormone resistance) TSH : hyperthyroidism central hypothyroidism systemic illness Dopamine or glucocorticoid administration

B. Serum free-T4 (fT4, FT4) normal range: 0.8-2 ng/dL or 0.7-2.5 ng/dL 9-30 pmol/L Diagnostical value (interpretation of pathological values): fT4 : overt hyperthyroidism TSH-secreting pituitary adenoma fT4 : overt hypothyroidism (primary or central) Refetoff syndrome

C.Serum T3 or free-T3: normal range: 0,5-1,5 ng/mL or 0,2 0,5 ng/dL 3-8 pmol/L Diagnostical value only in hyperthyroidism: fT3 and fT4 : overt hyperthyroidism fT3 and fT4 normal: overt hyperthyroidism with T3

Thyroid function testing algorithm

TSH low Normal, fT4 Normal euthyroid state high
Overt hyperthyroidism

high fT4

fT4 low
Central hypothyroidism

N
Subclin. hyperthyroidism

low
Overt primary hypothyroidism

N
Subclin. primary hypothyroidism

high
TSHsecreting pituitary adenoma/ Resitance to TH

1.2. Dinamic tests

A. TRH stimulation test B. TSH stimulation test (Queridos test) C. T3 suppression test (Werner s test)

A. TRH stimulation test - TRH 200-400 g iv. - TSH measure at 0, 20, 30, 60 Interpretation: - N: stimulated TSH 7mIU/L
- exaggerated response: I. hypothyroidism
exaggerated response, but tardive and prolonged: III hypothyr. low or absent response: II. hypothyroidism or high thyroid hormone levels: hyperthyroidism or exogenous thyroid hormones.

1.3. Other specific laboratory findings Antithyroid antibodies:

- TSH-receptor antibody: TRAb - anti-thyroid peroxidase antibody: ATPO - anti-thyroglobulin antibody: aTg

Thyroglobulin (TG): - to show the remnant thyroid tissue or recurrence (in thyroid bed or
metastases) in case of thyroid cancer after total thyroidectomy - differential diagnosis between hyperthyroidism (TG) and exogenous thyroid hormone in excess (TG ) - diagnostic value in congenital myxedema (TG )

Tumor markers:
- TG (in thyroid cancer, see above) - calcitonin: normal range < 1.5 ng/L, high in MTC - nonspecific tumormarker: ACE carcinoembryonic ag. (MTC)

2. In vivo investigations: 2.1. Radioactive iodine uptake: RAIU - determines the intrathyroidal iodine turnover - a jeun 10 Ci I131 or 40 Ci I123 - RIAU normal range:
I123 : 6h = 5-15% 24h= 8-30% I131 : 2h= 20 5% 24h= 40 5% 48h= lower with 5-15% to the value at 24h Tc99m: 0.5-3% RIAU : hyperthyroidism iodine deficient goiter RIAU : acompanying thyroiditis thyroid hormone administration iodine exposure hypothyroidism, lack of thyroid tissue

2.2. Thyroid scintigraphy: TSG

- morphofunctional investigation of the thyroid Indications: thyroid nodules, retrosternal goiter, ectopic thyroid tissue (ex. mediastinal), congenital malformations, postoperative recurrence

Terms: - thyroid nodules: - isofunctional nodule - hyperfunctional or hot nodule high uptake - hypofunctional or cold nodule low or absent uptake - compensated autonomous thyroid adenoma - decompensated autonomous thyroid adenoma Contraindications: - pregnancy, nursing mother - 6 months before conception - suckling, infancy - only for I131

TSG normal imagies

TSG with I131

TSG with Tc99m

TSG with I131 thyroid autonomy

Japanese flag aspect decompensated autonomous adenoma, hot nodule with a cold part, surrounded by the inhibited thyroid tissue

TSG with Tc99m - toxic thyroid adenoma

Hot nodul in right lobe, inhibited intact thyroid tissue decompensated autonomous adenoma aspect of Japanese flag

Compensated autonomous adenoma

T3 suppression test (Werner):

T3 75-100 g in divided doses daily for 5 days
it reduces the 24-hour RAIU by more than 50% the iodide uptake in the unaffected surrounding thyroid tissue will disappear

TSG with Tc99m

Multinodular toxic goiter

A. Norgmal TSG B. Cold nodule C. Hot nodule D. Multihetero-nodular goiter

2.3. Thyroid ultrasound Normal aspect: homogenous, isoechoic structure

Thyroid nodules

Hashimotos thyroiditis

PET CT

Elastography

2.4. FNAB Fine-needle aspiration biopsy

- elective method to differentiate benign and malignant thyroid nodules - in outpatient unit, without local anaesthesia - 25 G or 27G needle FNAB results:

- benign: about 70 % out of results; - malignant: 1- 5 %; - suspected, follicular lesion: 11-13%; - inadequate, non-diagnostic: 11-13%.
The sensibility and specificity is 90%.