Thyroid Tumors PDF

11/7/23, 2:12 PM Realizeit for Student Thyroid Tumors Tumors of the thyroid gland are classified on the basis of being benign or malignant, the presence or absence of associated thyrotoxicosis, and the diffuse or irregular quality of the glandular enlargement. If the enlargement is sufficient to c...

11/7/23, 2:12 PM Realizeit for Student Thyroid Tumors Tumors of the thyroid gland are classified on the basis of being benign or malignant, the presence or absence of associated thyrotoxicosis, and the diffuse or irregular quality of the glandular enlargement. If the enlargement is sufficient to cause a visible swelling in the neck, the tumor is referred to as a goiter. All grades of goiter are encountered, from those that are barely visible to those producing disfigurement. Some are symmetric and diffuse; others are nodular. Some are accompanied by hyperthyroidism, in which case they are described as toxic; others are associated with a euthyroid state and are referred to as nontoxic goiters. Endemic (Iodine-Deficient) Goiter The most common type of goiter that occurs when iodine intake is deficient is the simple or colloid goiter. In addition to being caused by an iodine deficiency, simple goiter may be caused by an intake of large quantities of goitrogenic substances in patients with unusually susceptible glands. These substances include excessive amounts of iodine. Lithium prescribed for the treatment of bipolar disorder has also been found to also have antithyroid actions (Singh & Clutter, 2019). Simple goiter is a compensatory hypertrophy of the thyroid gland, caused by stimulation by the pituitary gland. The pituitary gland produces thyrotropin or TSH, a hormone that controls the release of thyroid hormone from the thyroid gland. Its production increases if there is subnormal thyroid activity, as when insufficient iodine is available for production of the thyroid hormone. Such goiters usually cause no symptoms, except for the swelling in the neck, which may result in tracheal compression when excessive swelling is present. Many goiters of this type recede after the iodine imbalance is corrected. Supplementary iodine, such as SSKI, is prescribed to suppress the pituitary’s thyroid-stimulating activity. When surgery is indicated, the risk of postoperative complications is minimized by ensuring a preoperative euthyroid state through treatment with antithyroid medications and iodide to reduce the size and vascularity of the goiter. The introduction of iodized salt has been the single most effective means of preventing goiter in at-risk populations. Nodular Goiter https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZMyySaAjt8dTx3FnIrt15HOKniKu5nqplgCFS7%2bEIEJ2a… 1/6 11/7/23, 2:12 PM Realizeit for Student Some thyroid glands are nodular because of areas of hyperplasia (overgrowth). No symptoms may arise as a result of this condition, but not uncommonly these nodules slowly increase in size, with some descending into the thorax, where they cause local pressure symptoms. Some nodules become malignant, and some are associated with a hyperthyroid state. Therefore, the patient with many thyroid nodules may eventually require surgery. Thyroid Cancer Cancer of the thyroid is less prevalent than other forms of cancer; however, the incidence has tripled in the last 30 years (American Cancer Society [ACS], 2019) and accounts for 90% of endocrine malignancies. Although it has the fastest-growing cancer rate among both men and women, women are three times more likely to develop this cancer than men. In addition, thyroid cancer is more likely to develop in patients that are younger than 50 years (ACS, 2019; Yoo, Yu, & Choi, 2018). External radiation of the head, neck, or chest in infancy and childhood increases the risk of thyroid carcinoma. The incidence of thyroid cancer appears to increase 5 to 40 years after irradiation. Consequently, people who underwent radiation treatment or were otherwise exposed to radiation as children should consult their primary provider, request an isotope thyroid scan as part of the evaluation, follow recommended treatment of abnormalities of the gland, and continue with annual checkups. Additional risk factors that have been identified include smoking, low physical activity, unhealthy eating habits and high stress levels (Yoo et al., 2018). Assessment and Diagnostic Findings Lesions that are single, hard, and fixed on palpation or associated with cervical lymphadenopathy suggest malignancy. Thyroid function tests may be helpful in evaluating thyroid nodules and masses; however, results are rarely conclusive. An ultrasound-guided fine needle biopsy of the thyroid gland is the standard diagnostic procedure for evaluating thyroid nodules. It is performed as an outpatient procedure to make a diagnosis of thyroid cancer, to differentiate cancerous thyroid nodules from noncancerous nodules, and to stage the cancer if detected (Amdur & Dagan, 2019). The https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZMyySaAjt8dTx3FnIrt15HOKniKu5nqplgCFS7%2bEIEJ2a… 2/6 11/7/23, 2:12 PM Realizeit for Student procedure is safe and usually requires only a local anesthetic agent. Additional diagnostic studies include ultrasound, MRI, CT, thyroid scans, radioactive iodine uptake studies, and thyroid suppression tests. Medical Management The medical management depends on the classification of cell type found on biopsy. The three common groups include well-differentiated thyroid cancer (DTC), papillary thyroid carcinoma (PTC), and follicular thyroid carcinoma (FTC) (Amdur & Dagan, 2019). The treatment of choice for localized thyroid carcinoma is surgical removal (Amdur & Dagan, 2019). Total or near-total thyroidectomy is performed if possible (ACS, 2019). Modified neck dissection or more extensive radical neck dissection is performed if there is lymph node involvement. Efforts are made to spare parathyroid tissue to reduce the risk of postoperative hypocalcemia and tetany. After surgery, ablation procedures are carried out with radioactive iodine to eradicate residual microscopic disease (ACS, 2019). Radioactive iodine is also used for thyroid cancers with metastasis (ACS, 2019). After surgery, thyroid hormone is given to lower the levels of TSH to a euthyroid state (Bauerle & Riek, 2019). If the remaining thyroid tissue is inadequate to produce sufficient thyroid hormone, thyroxine is required permanently. Several routes are available for administering radiation to the thyroid or tissues of the neck, including oral administration of radioactive iodine (Bauerle & Riek, 2019) and external administration of radiation therapy. Administration of radioactive iodine for DTC is the most successful targeted therapy in oncology (Amdur & Dagan, 2019). Short-term side effects of radioactive iodine treatment may include neck soreness, nausea, and upset stomach; tender and swollen salivary glands; dry mouth; changes in taste; and, rarely, pain (Bauerle & Riek, 2019). The patient who receives external sources of radiation therapy is at risk for mucositis, dryness of the mouth, dysphagia, redness of the skin, anorexia, and fatigue. Chemotherapy is infrequently used to treat thyroid cancer. Patients whose thyroid cancer is detected early, who are younger than 50 years, and who are appropriately treated have a good prognosis (Amdur & Dagan, 2019). Patients who have had papillary cancer—the most common and least aggressive tumor—have the best prognosis of all thyroid cancers (ACS, 2019). Long-term survival is also common in follicular cancer, which is a more aggressive form of thyroid cancer (Bauerle https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZMyySaAjt8dTx3FnIrt15HOKniKu5nqplgCFS7%2bEIEJ2a… 3/6 11/7/23, 2:12 PM Realizeit for Student & Riek, 2019). However, continued thyroid hormone therapy and periodic follow-up and diagnostic testing are important to ensure the patient’s well-being. Later follow-up includes clinical assessment for recurrence of nodules or masses in the neck and signs of hoarseness, dysphagia, or dyspnea. The recommendations for longterm follow-up of patients with differentiated thyroid cancer are based on the stage of cancer and results of the follow-up examination 1 year following the initial treatment. The first year evaluation includes clinical examination, TSH and free thyroxine, and measurement of serum thyroglobulin within 6 months following the initial treatment, and a routine neck ultrasound with the first 6 to 12 months following initial treatment. Tests used to confirm sites of metastasis if there is clinical evidence of recurrence include radioiodine imaging, CT, MRI, skeletal x-rays, and skeletal radionucleotide imaging. Fluorodeoxyglucose (FDG) PET is useful to establish prognosis if there is evidence of distant metastases (ACS, 2019). Free T4, TSH, and serum calcium and phosphorus levels are monitored to determine whether the thyroid hormone supplementation is adequate and to note whether calcium balance is maintained. Patient education emphasizes the importance of taking prescribed medications and following recommendations for follow-up monitoring. The patient who is undergoing radiation therapy is also instructed in how to assess and manage side effects of treatment. Nursing Management Important preoperative goals are to prepare the patient for surgery and reduce anxiety. Often, the patient’s home life has become tense because of their restlessness, irritability, and nervousness secondary to hyperthyroidism. Efforts are necessary to protect the patient from tension and stress to avoid precipitating thyroid storm. Suggestions are made to limit stressful situations. Quiet and relaxing activities are encouraged. Providing Preoperative Care The nurse educates the patient about the importance of eating a diet high in carbohydrates and proteins. A high daily caloric intake is necessary because of the increased metabolic activity and rapid depletion of glycogen reserves. Supplementary vitamins, particularly thiamine and ascorbic acid, may be prescribed. The patient is reminded to avoid tea, coffee, cola, and other stimulants. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZMyySaAjt8dTx3FnIrt15HOKniKu5nqplgCFS7%2bEIEJ2a… 4/6 11/7/23, 2:12 PM Realizeit for Student The nurse also informs the patient about the purpose of preoperative tests, if they are to be performed, and explains what preoperative preparations to expect. This information should help to reduce the patient’s anxiety about the surgery. In addition, special efforts are made to ensure a good night’s rest before surgery. Preoperative education includes demonstrating to the patient how to support the neck with the hands after surgery to prevent stress on the incision. This involves raising the elbows and placing the hands behind the neck to provide support and reduce strain and tension on the neck muscles and the surgical incision. Providing Postoperative Care In the postoperative period, the priorities are to observe for any difficulty in breathing due to edema of the glottis, hematoma formation, or injury to the recurrent laryngeal nerve which requires the insertion of an airway, and to monitor the pulse and blood pressure for any indication of internal bleeding. The nurse must be alert for complaints of a sensation of pressure or fullness at the incision site which may indicate subcutaneous hemorrhage and hematoma formation and should be reported. In addition, the nurse periodically assesses the surgical dressings and reinforces as necessary. When the patient is in a recumbent position, the nurse observes the sides and the back of the neck as well as the anterior dressing for bleeding. A tracheostomy set is kept at the bedside at all times, and the surgeon is summoned at the first indication of respiratory distress. If the respiratory distress is caused by hematoma, surgical evacuation is required. The intensity of pain is assessed, and analgesic agents are given as prescribed for pain. The nurse should anticipate apprehension in the patient and should inform the patient that oxygen will assist breathing. When moving and turning the patient, the nurse carefully supports the patient’s head and avoids tension on the sutures. The most comfortable position is the semi-Fowler position, with the head elevated and supported by pillows. IV fluids are given during the immediate postoperative period. Water may be given by mouth as soon as nausea subsides and bowel sounds are present. Usually, there is a little difficulty in swallowing; initially, cold fluids and ice may be taken better than other fluids. Often, patients prefer a soft diet to a liquid diet in the immediate postoperative period. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZMyySaAjt8dTx3FnIrt15HOKniKu5nqplgCFS7%2bEIEJ2a… 5/6 11/7/23, 2:12 PM Realizeit for Student The patient is advised to talk as little as possible to reduce edema to the vocal cords; however, when the patient does speak, any voice changes are noted, indicating possible injury to the recurrent laryngeal nerve, which lies just behind the thyroid next to the trachea. An overbed table is provided for access to frequently used items so that the patient avoids turning their head. The table can also be used to support a humidifier when vapor-mist inhalations are prescribed for the relief of excessive mucous accumulation. The patient is encouraged to be out of bed as soon as possible and to eat foods that are easily swallowed. A high-calorie diet may be prescribed to promote weight gain. The incision may be closed using absorbable sutures, nonabsorbable sutures, and adhesive strips. Absorbable sutures dissolve within the body. If nonabsorbable sutures are used, the timeline for removal may vary; however, these types of sutures are usually removed 5 to 7 days following surgery. Adhesives will peel off spontaneously. The patient is usually discharged from the hospital on the day of surgery or soon afterward if the postoperative course is uncomplicated. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZMyySaAjt8dTx3FnIrt15HOKniKu5nqplgCFS7%2bEIEJ2a… 6/6