R. A.

Sulaiman , MD, FCAP

Medical Director of Laboratories
Avera McKennan Hospital &University Health Center
Physicians Laboratory Ltd.
Learning objectives
 Recognize the location, cell types, and size of
thyroid gland
 List hormones and functions produced by the
thyroid gland
 Recognize mechanisms of thyroid hormone
production
 Recognize assays used to diagnose thyroid
disorders
 Evaluate data to determine which thyroid disease
is most likely
 Embryology
Anatomy
Histology
Physiology
Thyroid Function Tests
& Pathology
Thyroid Gland
Embryology and
development
 First endocrine gland to appear in
embryonic development
 begins to develop ~24 days in the
thyroid diverticulum
 descends into the neck and passes
anteriorly to hyoid and laryngeal
cartilages
 for a time is connected to tongue by
thyroglossal duct
 assumes definitive shape and final
location by 7 weeks gestation, and
the thyroglossal duct disappears
 initially consists of solid mass of
endodermal cells, which are broken
up into network of epithelial cords by
invasion of surrounding vascular
mesenchyme  lumen forms 
colloid forms by 11th week and
thyroid follicles are formed, and
synthesis of hormones commences
Thyroid Gland
Anatomy
 Single, bi-lobed gland in the neck
 Largest of all endocrine glands
 Produces hormones
 thyroxine (T4) and tri-iodothyronine (T3) are
dependent on iodine and regulate basal metabolic rate
 calcitonin which has a role in regulating blood
calcium levels
 Unique among human endocrine glands – it
stores large amount of inactive hormone within
extracellular follicles
Anatomy
 Brown-red and soft
 Usually weighs about 25-30g (larger in women)
 Surrounded by a thin, fibrous capsule of
connective tissue
 External to this is a “false capsule” formed by
pretracheal fascia
 Right and left lobes
 United by a narrow isthmus, which extends across
the trachea anterior to second and third tracheal
cartilages
 In some people a third “pyramidal lobe” exists,
ascending from the isthmus towards hyoid bone
Anatomy
 Clasps anterior and lateral surface of pharynx,
larynx, oesophagus and trachea “like a shield”
 Lies deep to sternothyroid and sternohyoid
muscles
 Parathyroid glands usually lie between
posterior border of thyroid gland and its sheath
(usually 2 on each side of the thyroid), often
just lateral to anastomosis between vessel
joining superior and inferior thyroid arteries
 Internal jugular vein and common carotid
artery lie postero-lateral to thyroid
Anatomy
 Each lobe
 pear-shaped and ~5cm long
 extends inferiorly on each
side of trachea (and
oesophagus), often to level
of 6th tracheal cartilage
 Attached to arch of cricoid
cartilage and to oblique
line of thyroid cartilage
 moves up and down with
swallowing and oscillates
during speaking
Blood supply
 highly vascular
 main supply from
superior and inferior
thyroid arteries
 usually 3 pairs of
veins drain venous
plexus on anterior
surface of thyroid
Lymphatic drainage
 lymphatics run in the
interlobular
connective tissue,
often around arteries
 pass to prelaryngeal
LN’s → pretracheal
and paratracheal
LN’s
Thyroid Gland
Histology
 Functional units are
follicles – responsible for
synthesis and secretion of
T3 and T4
 Occasional scattered “clear
cells”/parafollicular cells/“C
cells” produce and secrete
calcitonin
 Colloid is the secretory
product of follicular cells
 Extra-cellular proteinaceous
substance composed of
thyroid hormones linked
together with protein
(“thyroglobulin”)
Histology
Thyroid Gland
Thyroid hormones –
structure
 2 principal thyroid hormones
 thyroxine (T4 or tetraiodothyronine)
 triiodotyronine (T3)
Physiology
 Produce T4 and T3
 Hypothalamus releases thyroid
releasing factor (TRF) to pituitary, which
releases thyroid stimulating hormone
(TSH) into blood
 Follicular cells normally synthesize
thyroglobulin and secrete it into the
follicular lumen
Physiology
 Thyroid peroxidase, found in apical
membrane of thyroid follicular cells,
catalyzes iodination of tyrosine residues
on thyroglobulin molecule and coupling
of iodotyrosyl residues to form T4
(thyroxine) and T3, which are still bound
to thyroglobulin, making them inactive;
they are then stored as colloid
Physiology
 In response to TSH, follicular cells
pinocytose colloid, release the
thyroglobulin, and secrete now active T4
and T3 into bloodstream
 Body needs 100 mg of iodide per day
from diet to synthesize adequate T4
 Most T4/T3 is reversibly bound to
thyroid binding globulin
Physiology
 Free T4/T3 enters cells, binds to nuclear
receptors, increases basal metabolic
rate
 Decreased serum T4/T3 stimulates
release of TRF and TSH via negative
feedback regulation; elevated levels
have opposite effect
Thyroid regulation
Thyroid hormones –
structure
 Thyroid hormones stored conjugated to thyroglobulin, but are
cleaved by pinocytosis before being released into circulation
 Majority of the thyroid hormone secreted is T4 (90%), but T3 is
the considerably more active hormone
 Although some T3 is also secreted, most is derived by
deiodination of T4 in peripheral tissues, especially liver and
kidney
 Deiodination of T4 also yields reverse T3 (no known metabolic
activity)
 Both are poorly water soluble
 99% of circulating thyroid hormone is bound to carrier protein
(mostly thyroxine-binding globulin, but also transthyrein and
albumin)
 Provides a stable pool from which unbound/free hormone is released
for uptake by target organs
Thyroid hormones –
function
 Likely that all cells express thyroid hormone
receptors
 Metabolism
 Increases basal metabolic rate
 Increases carbohydrate and lipid metabolism
 Normal growth
 Normal development
 Especially CNS
 Other systems
 CVS – increases heart rate, cardiac output
 CNS – mental acuity
 Reproduction – fertility requires normal thyroid function
Calcitonin – function
 Minor role in regulating (reducing) blood
calcium concentration
 Suppresses osteoclastic bone resorption
 Inhibits renal tubular reabsorption of calcium
and phosphorus
Effects of TSH on thyroid gland
 Increased thyroglobulin proteolysis →
increased circulating thyroid hormones
 Increased activity of “iodide pump” -
increases cellular iodine uptake
 Increased iodination of tyrosine and
coupling
 Increased size and secretory activity of
thyroid cells
 Increased number of thyroid cells, plus
change from cuboidal to columnar
epithelial structure
Thyroid Gland
Hypothyroidism
 Deficiency in thyroid hormone secretion
and action
 Common, 2-15%
 Clinical symptoms:
 Obvious: lethargy, fatigue, cold intolerance
 Subtle
 Primary: impaired synthesis of T4 & T3
 Secondary: decreased in TRH, TSH
Hypothyroidism

Cause Hormone concentrations Goitre

Primary failure of
↓T3 and T4, ↑ TSH Yes
thyroid gland

Secondary to
hypothalamic or ↓T3 and T4, ↓ TSH and/or ↓ TRH No
pituitary failure

Dietary iodine
↓T3 and T4, ↑ TSH Yes
deficiency
Hyperthyroidism
 Hypermetabolic condition caused by
excessive production of thyroid
hormones
 Most common
 Grave’s Disease
Grave’s disease
 Most important cause of hyperthyroidism
 Autoimmune thyroiditis
 Diffuse thyroid enlargement and
exophthalmos
 Follicular cells stimulated by IgG antibody
(LATS) that causes constant thyroid
hormone production, independent of TSH
 Large, fleshy thyroid gland with large
follicles lined by active cells
Hyperthyroidism
Cause Hormone concentrations Goitre
Abnormal thyroid-
stimulating
immunoglobulin ↑ T3 and T4, ↓ TSH Yes
(eg. Grave’s
disease)
Secondary to
excess
↑ T3 and T4, ↑ TSH and/or ↑ TRH Yes
hypothalamic or
pituitary secretion

Hypersecreting
↑ T3 and T4, ↓ TSH No
thyroid tumour
Thyroid Gland
Thyroid regulation
TSH
 In most reference laboratories, the normal
range for is 0.45 to 4.5 mIU/L
 very reliable assays with a wide dynamic
range
 integrated measure of thyroid hormone
action
 the response of TSH to changing thyroid
hormone levels is greatly amplified
 it’s not affected by any binding protein
changes
TSH
 an indirect measure of thyroid function
 there is some delay in responses to
acute changes in peripheral thyroid
hormone levels
 in a very rare case (pituitary or hypothalamic disease, or
thyroid hormone resistance) the TSH measurement

alone can be misleading

Total T4
 Normal range for total T4 is 5.5 to 12.5
microgram/dL (206 to 309 nanomol/L)
 pretty reliable
 good measure of thyroid gland output
 changes occur fast when thyroid gland
activity changes
Total T4
 Concentration is highly variable, and
highly dependent on the variable thyroid
hormone-binding globulin concentrations
 a small fraction is free and that’s actually
the biologically active fraction
 the assays have limitation of being all
competitive assays and suffering from a
limited dynamic range
Total T3
 normal range for total T3 is 60 to 180
nanograms/dL (0.92 to 2.76 nanomol/L)
 reliable assays
 represents the active thyroid hormone
 changes occur fast with changes in
thyroid gland activity
 selectively overproduced in
thyrotoxicosis
Total T3
 concentration is linked to the highly
variable thyroid hormone-binding
globulin concentrations
 only a small free fraction is biologically
active
 majority of T3 is manufactured in
peripheral tissues on demand
 competitive assays with limited dynamic
range
FreeT4
 Typical normal range for FT4 is 0.9 to
2.3 nanograms/dL (12 to 30 picomol/L)
 reasonable reliable
 give a good measure of the thyroid
gland hormone output
 change fast with thyroid gland activity
 and, most importantly, are independent
of TBG concentrations
FreeT4
 it is a pro-hormone—the active hormone
is T3, and levels can occasionally
fluctuate with non-thyroidal illness
 standard assays have a very limited
dynamic range and at some ranges of
binding protein concentrations, they may
be unreliable
Free T3
 Normal range for FT3 is 230 to 420
picograms/dL (2 to 7 picomol/L)
 the same advantages, more or less, as
free T4 and very similar disadvantages.
 the major disadvantages
 all current free T3 assays have serious
shortcomings and generally are not
recommended
Free T3
 Free thyroxine concentrations are
already only a few percent of the total
thyroxin concentrations
 Free T3 concentrations are only a few
percent of the total T3 concentrations
 the total T3 concentrations are never more
then 20% of the total thyroxin concentration
 Low picomolar concentrations, which causes
a lot of analytical problems
Balancing It All Up
For initial diagnosis
 TSH
 It is equally useful for hypo- and
hyperthyroidism
 has the highest sensitivity and specificity for
initial diagnosis
 and is least likely to be disturbed by non-
thyroidal illness or drugs
For initial diagnosis
 TSH
 Free T4:
 free T4 measurements are often used when
either the TSH alone is not clearly diagnostic
(ie, borderline measurements)
 or when there is some need to gauge the
severity of hypo- or hyperthyroidism
For initial diagnosis
 TSH
 Free T4
 Total T3:
 those cases where both TSH and FT4
measurements are on the fence, or not
clearly diagnostic
Follow up patients
 Acute & sub-acute conditions:
 Graves’ disease or sub-acute thyroiditis
○ measure FT4 because the changes in thyroid
hormones can occur very rapidly and the TSH
levels may lag a few days or even weeks
behind
○ TSH
○ Total T3
Follow up patients
 Chronic or slowly progressive
conditions:
 permanent hyperthyroidism and NG:
○ TSH is the main stay
○ Occasionally supplemented by Free T4
○ Rarely by Total T3
Thyroid Gland
Thyroid regulation
Low TSH –
with a high FT4 and/or FT3

 Suggestive of hyperthyroidism
 Subacute or granulomatous thyroiditis
 Other causes include factitious
thyrotoxicosis (caused by excessive use
of thyroid hormone medication)
Low TSH –
with a low FT4 and/or FT3

 secondary (central) hypothyroidism

 nonthyroid illness (sick euthyroid
syndrome)
 in the second and third trimesters of
pregnancy
Low TSH –
with a normal FT4 and/or FT3
 suggest subclinical (mild) hyperthyroidism
 nonthyroid illness
 the following drugs:
 dopamine, dopaminergic agonists,
glucocorticoids, cytokines, or octreotide
 recent treatment of hyperthyroidism with
antithyroid medication
 in the first trimester of pregnancy
High TSH –
with a high FT4 and/or FT3
 assay artifact/laboratory error
 TSH-secreting pituitary tumor
 resistance to thyroid hormonehyper- or
hyposecretion of other pituitary
hormones
 thyroid hormone resistance syndrome
 Thyroxine replacement therapy
 acute psychiatric disorders
High TSH –
with a low FT4 and/or FT3
 suggests primary hypothyroidism.
 autoimmune thyroiditis (Hashimoto disease),
○ the most common cause of primary
hypothyroidism.
○ More than 90% have positive TPOAb

 thyroidectomy or radioactive iodine

treatment of the thyroid without
adequate thyroid hormone replacement
High TSH –
with a normal FT4 and/or FT3
 subclinical (mild) hypothyroidism
 recovery from nonthyroid illness
 poor adherence to thyroxine replacement
therapy or its malabsorption
 medication that promotes increased
metabolism of thyroid hormone
 problems with assay procedures
 (e.g., interference of abnormal antibodies in
serum) can cause false elevation in TSH
Normal TSH –
with a low FT4 and/or FT3

 secondary (central) hypothyroidism

 drug use (e.g., phenytoin, rifampin,
carbamazepine, barbiturates)
 and assay error when interfering
substances are present.
 Sensitive serum TSH

TSH

Undetectable Subnormal Normal Elevated

Hyperthyroid Borderline status No further tests hypothyroid

Free T4,
Free T4 & free T3 Free T4
T3 if FT4 is NL

TRH test
Auxiliary Testing
 Antithyroperoxidase autoantibodies
 Amtithyroglobulin autoantibodies
 Anti-TSH-receptor autoantibodies
 Thyroid hormone-binding protein
 Molecular analysis of thyroid hormone
receptors
Summary - thyroid
 Major endocrine gland
 Located in the neck
 Closely related to parathyroid glands,
thyroid cartilage, trachea, important nerves
(recurrent laryngeal) and vessels
 Important role in metabolic regulation via
thyroid hormones
 T3 and T4
 Stored extracellularly in inactive form
Summary
 Regulated by feedback loop involving
hypothalamus (TRH), pituitary (TSH) and
thyroid hormones themselves
 Hypo- and hyperthyroidism are common
conditions
 Benign and malignant pathology
 Grave’s disease
 Hashimoto’s disease
 Papillary/follicular/anaplastic carcinoma
 Medullary carcinoma
Thyroid Gland
Thyroid pathology
 Thyroid enlargement may be diffuse or nodular
 Irregular multinodular enlargement (goitre) of the
entire gland is common, especially in the elderly
 Focal nodular enlargement may be due to a tumour
 Symmetrical slightly nodular (‘bosselated’) firm
enlargement of the whole gland is characteristic of
Hashimoto’s disease
 Symmetrical diffuse enlargement is usually
associated with hyperthyroidism (eg. Grave’s
disease)
 Most thyroid enlargement (except
Hashimoto’s) results from hyperplasia of
thyroid follicles and their cells
Multinodular goitre
 Common in the elderly
 Often undetected
 May present for cosmetic reasons (neck
swelling) or compression symptoms (eg.
trachea)
 Usually have normal thyroid function
 Cause uncertain
 ? Uneven response of thyroid tissue to
fluctuating TSH levels over many years
Thyroiditis
 Viral
 De Quervain’s thyroiditis
○ Affects younger/middle-aged women
○ Slight diffuse, tender swollen gland
○ Transient febrile illness, often viral origin (eg. mums
with kids who have mumps/measles etc)
○ Inflammatory destruction of follicular cells

 Autoimmune
 Grave’s disease
 Hashimoto’s disease
Thyroiditis
 Viral
 De Quervain’s thyroiditis
○ Affects younger/middle-aged women
○ Slight diffuse, tender swollen gland
○ Transient febrile illness, often viral origin (eg. mums
with kids who have mumps/measles etc)
○ Inflammatory destruction of follicular cells

 Autoimmune
 Grave’s disease
 Hashimoto’s disease
Grave’s disease
 Most important cause of hyperthyroidism
 Autoimmune thyroiditis
 Diffuse thyroid enlargement and
exophthalmos
 Follicular cells stimulated by IgG antibody
(LATS) that causes constant thyroid
hormone production, independent of TSH
 Large, fleshy thyroid gland with large
follicles lined by active cells
Hashimoto’s disease
 Destructive autoimmune thyroiditis
 Common in middle age, women > men
 Most common auto-antibodies are anti-
microsomal Ab and anti-thyroglobulin Ab
 Diffusely enlarged thyroid, symmetrical
and firm
Thyroid malignancies
 Follicular cell origin
 Papillary carcinoma - 70%
 Follicular carcinoma - 25%
 Anaplastic carcinoma - rare
 Parafollicular ‘C’ cell origin
 Medullary carcinoma - 5%
Papillary carcinoma
 Follicular cell origin
 Well-differentiated
 Arises mostly in young adults
 Often multifocal
 Metastasises via lymphatics to neck nodes
 Slow-growing
 Excellent prognosis
 Treatment
 Surgery - lobectomy/thyroidectomy
 Iodine-131
 ± EBRT
Follicular carcinoma
 Follicular cell origin
 Most common in middle age
 Metastasises via blood stream
 Characteristically spreads to bone, lung
 Good prognosis
 Treatment
 Surgery
 Iodine-131
 ± EBRT
Anaplastic carcinoma
 Follicular cell origin
 Occurs exclusively in the elderly
 Poorly differentiated
 Rapidly progressive with direct invasion of
adjacent structures
 Very poor prognosis
 Treatment - poor response
 Surgery?
 EBRT?
 (Iodine-131?)
Medullary carcinoma
 Arises in parafollicular ‘C’ cells
 Sporadic or part of MEN syndrome
 Small cells containing neuro-endocrine granules
 Occurs in middle-aged and elderly
 Slow-growing
 Metastasises to lymph nodes
 Secretes calcitonin (blood test)
 Treatment
 Surgery
 EBRT (but relatively radio-resistant)
 Low uptake of iodine-131 - limited role