ENDOCRINE

CLASSICAL ALGORHYTHM PITUITARY DEGENERATION (aka, “involution”) ANTERIOR POSTERIOR THYROID PARATHYROID PANCREAS (endo.) ADRENAL CORTEX MEDULLA DEGENERATION (aka, “involution”) INFLAMMATION NEOPLASM BENIGN MALIGNANT Classical endocrine glands and classical disease categories

1 Diffuse nontoxic goiter/simple goiter/endemic goiter 弥漫性非毒性甲状腺肿 Endemic goiter occurs in geographic areas where the soil, water, and food supply contain only low levels of iodine. The lack of iodine leads to decreased synthesis of thyroid hormone and a compensatory increase in TSH, leading to follicular cell hypertrophy and hyperplasia and goitrous enlargement. With increasing dietary iodine supplementation, the frequency and severity of endemic goiter have declined significantly.

GOITERS 甲状腺肿 (aka, thyromegaly, diffuse or nodular) IODINE deficiency Increased TSH Goitrogens, e.g., cabbage卷心菜, Brussels sprouts, cauliflower 菜花, turnips, cassava 木薯) Associated with HYPO thyroidism eventually, NOT hyperthyroidism Decreased Iodine leads to decreased thyroid hormone, which leads to increased TSH which leads to increased growth of follicles. That’s how an iodine deficiency leads to a goiter. The probability of having a goiter is DIRECTLY proportional to how far you live from the ocean.

3 stages Diffuse hyperplastic goiter 增生期 Diffuse colloid goiter 胶质储积期 Nodular goiter 结节期

甲亢(hyperthyroidism) 广义上是指多种原因引起甲状腺合成和/或释放过多的甲状腺激素（thyroid hormone,TH）,而导致的以高代谢为主要表现的一组临床综合征，其中以自身免疫紊乱所导致的弥漫性甲状腺肿伴甲状腺功能亢进、即Graves病（GD)最为常见

甲状腺毒症病因 1.弥漫性毒性甲状腺肿（toxic diffuse goiter, Graves disease, Basedow disease） 2.桥本甲状腺毒症(Hashitoxicosis) 3.新生儿甲亢(neonatal hyperthyroidism) 4.多结节性毒性甲状腺肿(toxic multinodular goiter) 5.甲状腺自主高功能腺瘤（Plummer disease, toxic adenoma） 6.滤泡状甲状腺癌(Follicular thyroid cancer) 7.碘甲亢（IIH） 8.HCG相关甲亢 (绒毛膜癌、葡萄胎) 9.垂体性甲亢 (腺瘤或TSH细胞增生,甲状腺吸碘131率升高）

HYPER-THYROIDISM HYPERMETABOLISM Tachycardia, palpitations Increased T3, T4 Goiter 甲状腺肿 Exophthalmos 突眼 Tremor GI hypermotility Thyroid “storm”, life threatening Thyrotoxic crisis (or thyroid storm) is a rare but severe complication of hyperthyroidism, which may occur when a thyrotoxic patient becomes very sick or physically stressed. Its symptoms can include: an increase in body temperature to over 40 degrees Celsius (104 degrees Fahrenheit), tachycardia, arrhythmia, vomiting, diarrhea, dehydration, coma, and death.

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 2° (pituitary) 3° (hypothalamic, rare)

THYROIDITIS Hashimoto (Auto-Immune) (Lymphoid follicles with germinal centers), MOST COMMON cause of acquired hypothyroidism in USA Subacute Granulomatous Subacute Lymphocytic (just like Hashimoto’s but NO fibrosis and no germinal centers), often post-partum产后 Reidel’s struma = fibrosis from ANY cause.

GRAVES DISEASE (aka, diffuse toxic goiter) HYPERTHYROIDISM EXOPHTHALMOS PRE-TIBIAL MYXEDEMA Autoimmune, auto-antibodies to TSH receptors, thereby stimulating them

临床表现 （一）甲状腺毒症表现(甲状腺激素分泌过多) 1.高代谢症状群：产热和散热增多，蛋白质、脂肪和碳水化合物分解加速 2.神经精神系统兴奋表现 3.心血管系统：心动过速，房性心律失常，房颤，脉压增大，心脏病 4.消化系统：胃肠蠕动增快；肝功能异常 5.肌肉骨骼系统:周期性麻痹，急慢性甲亢肌病，骨质疏松 6.其他(生殖、血液） （二）甲状腺肿：弥漫性、质软、无压痛；动脉杂音

（三）突眼（25%～50%）包括： 1.非浸润性（单纯性、良性突眼） （1）上睑挛缩 （2）上睑迟滞（von Graefer征） （3）瞬目减少（Stellwag征） （4）双眼向上看时，前额皮肤不能皱起（Joffroy征） （5）辐辏不良（Mobius征） （6）一般突眼度≤18mm

*是Graves病的自身免疫反应在眼眶的表现 *可单侧突眼 *和甲亢的发生不同步,也可见于其他自身免疫性甲状腺疾病 *眼局部症状和体征明显 2.浸润性(恶性突眼): *是Graves病的自身免疫反应在眼眶的表现 *可单侧突眼 *和甲亢的发生不同步,也可见于其他自身免疫性甲状腺疾病 *眼局部症状和体征明显 *需要免疫抑制治疗

美国甲状腺协会Graves眼病的分级 (ATA, NOSPECS) 分级 眼部症状和体征 0 (N) 无症状和体征(No signs or symptoms) 1 (O) 仅有体征,无症状(Only signs, no symptoms) 2 (S) 软组织受累(Soft tissue involvement) (既有体征又有症状,signs and symptoms） 3 (P) 突眼(Proptosis,＞18mm) 4 (E) 眼外肌受累 Extaocular muscle involvement 5 (C） 角膜受累(Corneal involvement) 6 (S) 视力丧失Sight loss(optic nerve involvement）

（四）其他表现 1.局限性黏液性水肿（胫前黏液性水肿） 见于Graves病，病因不明 好发于胫前区，亦可见于足背、趾、踝 局部皮肤增厚，突出表面 无压痛，淡红色或淡紫色 毛孔粗，内陷明显，压之无凹陷切迹 2.指端粗厚

Thyroid Neoplasms “Nodules” vs. true neoplasms Adenomas vs. Carcinomas The differentiation between a “nodule” and a solitary neoplasm can be quite fuzzy, but it doesn’t matter.

“NODULES” Solitary vs. Multiple Younger vs. Older Male vs. Female Hx. neck radiation vs. NO Rx. “Cold” vs. HOT (really NOT-cold) Every type of thyroid disorder known is more common in females than males? Why? Ans: unknown What is the difference between a cold and a not-cold nodule isotopically?

NEOPLASMS FOLLICULAR PAPILLARY ADENOMAS CARCINOMAS FOLLICULAR HÜRTHLE (oxyphilic) CARCINOMAS FOLLICULAR PAPILLARY MEDULLARY (AMYLOID) ANAPLASTIC (worst) Did you ever know anybody who died from thyroid cancer? Why not? Thyroid neoplasms, like most endocrine neoplasms have TWO worrisome principles” Benign tumors often have extreme pleomorphism Malignant tumors may have NO pleomorphism For this reason follicular thyroid neoplasms are diagnosed benign or malignant often by its BEHAVIOR (e.g., capsular invasion), rather than by the appearance of the cells. Papillary thyroid neoplasms are EASY to diagnose benign vs. malignant because they are ALL malignant.

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

BIOLOGIC BEHAVIOR Papillary CA lymph nodes Follicular CA  blood vessels, bone This is just a generality, not a law. Most common thyroid carcinomas occur in younger, and most of them survive it!