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MEDICAL SCIENCES
UDC 616.441-006.5-073.432.19
Nechyporch uk.A.A.,
4th year student of 21 group Bukovinian State Medical University;
Honcharuk L.M., PhD in Medical Sciences, Associate Professor Department of Internal Medicine Bukovinian State Medical University;
Aleksapolsky O. V.,
4th year student of 21 group Bukovinian State Medical University;
Turovych O.A.,
4th year student of 21 group Bukovinian State Medical University;
Savchyn D.M.,
4th year student of 21 group Bukovinian State Medical University;
Stander Y.O.
4th year student of 21 group Bukovinian State Medical University; DOI: 10.24412/2520-6990-2023-13172-23-25 BASIC ASPECTS OF DIAGNOSIS OF NODULAR FORMATIONS OF THE THYROID GLAND
Abstract.
The question of diagnosis and treatment ofpatients with the nodular form of goiter is one of the main problems of endocrinology. Over the pastfew years, there has been an increase in the number of thyroid diseases. Most often, clinically hidden thyroid nodules are diagnosed according to the results of ultrasound diagnostics in 87% of the population. Also, with the help ofpalpation, thyroid nodules were detected in 8%. Thyroid nodules are more common in the elderly (from 60 years old, they are found in 50%), but the high prevalence in old age allows us to consider nodular goiter as an age-related involution of the thyroid gland, which is considered the norm. There is a high risk of thyroid neoplasms in the population living in iodine-deficient regions and in those who have previously been exposed to radiation exposure. In the vast majority of cases, thyroid nodules do not have clinical manifestations. About 95% of thyroid neoplasms are diagnosed unexpectedly during ultrasound. To clarify the diagnosis, it is necessary to conduct laboratory tests, on the basis of which the treatment tactics will be decided. Its correct selection is one of the most important tasks for an endocrinologist.
Keywords: thyroid gland, nodular goiter, diagnostic methods.
A laboratory-instrumental examination is performed to obtain objective data on the size of the nodule, its structure, as well as the hormonal function of the thyroid gland, which are necessary for choosing a method of further treatment and dynamic monitoring. Laboratory-instrumental examination is the main part of the diagnostic process, the effectiveness of which depends on the optimal choice of methods and the correct interpretation of the obtained results.The following laboratory-instrumental examination methods are used for nodular formations of the thyroid gland: ultrasound examination, fine-needle aspiration biopsy with cyto-logical and cytochemical examination, determination of thyrotropin hormone (TTH), T4, T3, calcitonin, antibodies to thyroperoxidase (AT-TPO), AT-rTHG, lar-yngotracheoscopy, CT, MRI of the neck and mediastinum, scanning with 131I or 99mTs-pertechnetate or technetrile, intraoperative examination (during surgery) [1].
Ultrasound diagnostics. The best for ultrasound examination of the gland are sensors with a frequency of 7.5 and 10 MHz. Currently, color Doppler mapping
is used, which allows you to accurately assess the blood flow in the gland. The high resolution of ultrasound makes it possible to detect formations of small sizes in the thyroid gland, which are several millimeters in diameter. They are not palpable due to their small size or deep location in the tissue. The value of ultrasound lies in the ability to reliably determine the number of nodes, their localization, sizes, as well as the echogenicity of the identified formation: cystic, dense, mixed, blood flow rate, tissue structure around the node [2].
The following signs are characteristic of a colloid neoplasm: pronounced hypoechogenicity, the presence of a clear capsule, a hydrophilic halo ring (ring of low echogenicity) can be determined on the periphery with a width of 1-2 mm, located around the formation. At the same time, adenocarcinoma is characterized by unclear contours, a dense structure, reduced echogenicity with the presence of microcalcifications without an acoustic shadow in the formation and/or the absence or indistinctness of the capsule, intravascular blood flow, the predominance of the height of the node over the width. Enlarged regional lymph nodes in the form of
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MEDICAL SCIENCES / <«g©yL©(MUM~J©U©MaL» 2022
round or oval hypoechoic formations are often identified. In the presence of suspicious ultrasound signs, it is necessary to assess the mobility of the vocal folds. If it is impossible to visualize the vocal folds, fibrolaryn-goscopy is indicated. The most important diagnostic stage of ultrasound is the examination of regional lymph nodes, in which the following signs are assessed: size (it is necessary to assess the diameter or anteropos-terior size, and not the length for all cervical lymph nodes, except for the II level, the diameter is no more than 6 mm, for the II level - no more than 7-8 mm), the ratio of the long and short axis, the presence/absence of the gate, cystic changes, point hyperechoic inclusions (microcalcifications), the nature of vascularization (the gate or the entire lymph node), increased echogenicity of the lymph node (similarity to normal thyroid tis-sue).The most specific signs that make it possible to suspect a metastatic lesion of the lymph node are microcalcifications, a cystic component, peripheral vascularization, the similarity of the tissue of the lymph node with the tissue of the thyroid gland; less specific are the increase in size, the roundness of the contours, the absence of a gate. Ultrasonography is not recommended as a screening method for the general population, in patients with normal thyroid palpation data and a low clinical risk of thyroid cancer. Ultrasound examination is recommended in the following cases: patients at risk of thyroid malignancy, patients with palpable thyroid nodules or multinodular goiter, patients with lymphade-nopathy suspicious for malignancy, presence of a tumor on the neck, suspicion of a tumor [3].
Fine needle puncture aspiration biopsy (TAB). This manipulation is considered the main method of diagnosing thyroid neoplasms. Manipulation is simple, safe, relatively cheap and can be performed in an outpatient setting. Dissemination of the tumor along the course of the needle is not observed. Solid and hypoechoic nodes more than 1 cm in diameter are subject to puncture biopsy; nodes of any size with signs of invasive growth through the capsule or suspected cervical metastases; nodules of any size with indications for irradiation of the head and neck in the anamnesis, especially in childhood, in the presence of papillary thyroid cancer or MEN 2 syndrome in blood relatives; after previous operations for thyroid cancer; with an increased level of blood calcitonin; nodes less than 1 cm in the presence of ultrasound signs of malignancy. The combination of two or more criteria dramatically increases the probability of cancer in the node [3].
Radioisotope research (scanning) of the thyroid gland. As a rule, radioisotopes 99mTs-pertechnetate or iodine (123I, 131I) are used. The scan shows cold nodules (which do not accumulate the isotope), hot nodules (accumulate the isotope more than thyroid tissue) or nodules with intermediate inclusion of isotopes. Pre-operative thyroid scanning does not provide clear information about the nature of the node. Therefore, radioisotope scanning is performed in nodular goiter with subclinical or manifest thyrotoxicosis for the differential diagnosis of functional autonomy and other causes of thyrotoxicosis. It is not informative for the primary diagnosis of nodular goiter (to identify the nodes and assess their size), as well as for the primary diagnosis
of thyroid cancer. This method does not compete with TAB for determining the risk of thyroid nodule malignancy. The method of isotope scanning can be useful for the diagnosis of retrosternal goiter, metastases of highly differentiated thyroid cancer [4].
Laboratory diagnosis of diseases of the thyroid gland. Evaluation of the thyroid status of a patient with nodular forms of goiter is mandatory. Determining the concentration of thyroid hormones (free T4, free T3) and pituitary thyroid-stimulating hormone (TTH) makes it possible to detect hypo- and hyperthyroidism, which requires specific treatment. Thyrotoxicosis is observed in toxic thyroid adenoma, diffuse toxic goiter, and multinodular toxic goiter. Toxic adenoma, with rare exceptions, is a benign tumor. With diffuse toxic goiter, malignant neoplasms of the thyroid gland occur quite often. On the contrary, with multinodular toxic goiter, malignant neoplasms are found very rarely. It should also be remembered that multinodular toxic goiter occurs in 15-20% of cases in elderly patients. An increase in the content of thyroglobulin (TG) in the blood is observed in diseases of the thyroid gland that proceed with thyrotoxicosis. An increase in TG content is detected within 2-3 weeks after a puncture biopsy, as well as within 1-2 months after thyroid surgery. TG concentration is not a differential marker of benign and malignant tumors. Therefore, determining the level of TG before removing a thyroid neoplasm is not necessary. At the same time, the TG level is a highly informative indicator of the postoperative state of patients with differentiated forms of cancer (such cancers account for up to 90% of all thyroid malignancies); with the progression of the disease after non-radical surgery, relapses and metastasis, the content of thyroglobulin in the blood increases. TG is determined in parallel with antibodies to TG. Calcitonin (CT) is the most important marker of medullary (C-cell) thyroid cancer (MTC). An elevated level of CT in the serum very specifically indicates the presence of MTC, and when treatment is carried out, it indicates recurrence or metastasis. A cal-citonin study is mandatory in the presence of a family history or in the case of suspicion of medullary cancer or MEH 2 syndrome. In the preclinical stages of the tumor, the basal CT level may not exceed the normal range, in which case it is necessary to apply one of the stimulation tests:
pentagastrin test — pentagastrin is administered intravenously at the rate of 0.5 ^g/kg over 15 seconds; CT is determined before and after 2 and 5 min after administration;
calcium test — after taking blood from a vein to determine the level of basal CT, the patient is administered intravenously bolus calcium gluconate for 30 seconds at the rate of 2.5 mg (0.27 ml of a 10% solution) per 1 kg of body weight. If the patient's body weight is more than 70 kg, 20 ml of the solution is injected. The stimulated CT level is determined 2 and 5 min after the injection of the solution. An increase in the level of both basal and stimulated CT more than 100 pg/ml is highly suspicious for MDD, an increase in the level of stimulated CT less than 60 pg/ml should be considered a physiological response, an increase in the level of stimulated CT between 60 and 100 pg/ml requires dynamic
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monitoring (taking the test after 6-12 months), special attention should be paid to the multiplicity of the CT level increase during stimulation tests, it increases by 3-4 times [5].
Conclusion: Timely detection of thyroid gland formations and the correct choice of research method are the main criteria for further treatment of the patient and prevention of rapid complications. With the help of modern instrumental and laboratory research, medical professionals in their fields can interpret diagnoses of different complexity in patients. That is why the field of diagnostics in medicine is enriched with the latest technologies, which in the future will lead to progress in medicine and science as a whole.
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