THYROID NODULES
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Transcript THYROID NODULES
THYROID
NODULES
LISA A. CICO, MSN, NP
UPSTATE MEDICAL UNIVERSITY
BREAST & ENDOCRINE SURGERY
COORDINATOR THYROID CANCER PROGRAM
SURGICAL COORDINATOR BREAST CANCER
PROGRAM
Comprehensive review of current
OBJECTIVES
Describe tools /
diagnostic testing for
assessment of the
patient with a thyroid
nodule(s)
*Utilize national
guidelines developed
for patients with
thyroid nodules
*Describe some of the
common symptoms of
patients with thyroid
nodules
diagnostic tools and imaging to
assess thyroid nodules
Review American Thyroid
Association, & National
Comprehensive Cancer Network
Guidelines for patients who
develop thyroid nodules
Review common symptoms of
patients with thyroid nodule
Obtaining appropriate
OBJECTIVES
Identify which patients
can safely be followed by
PCP
*Describe
imaging/diagnostic
modalities for following
the patient with thyroid
nodules
*Identify those patients
requiring referral to
specialty
*Identify which specialty
to make an appropriate
referral based on
diagnostic, objective and
symptomatic findings
imaging/diagnostic testing, and
frequency
Overview of ultrasonographic
thyroid terminology
Overview of Betheseda thyroid
nodule pathology terminology
Obtaining appropriate personal and
family history
Identify what patients require
referral and to endocrine or surgery?
Briefly discuss appropriate follow up
for the patient with thyroid cancer
Definition of Thyroid Nodule
“A discrete lesion within the thyroid gland that is
palpably and/or ultrasonographically distinct from
surrounding thyroid parenchyma”
*ATA Management Guidelines for Patients with Thyroid Nodules and Differentiated
Thyroid Cancer (2006 & 2009 Task Force)
Prevalence
Rallison et al. JAMA 1975
Hogan et al. J Surg Res 2009
60
50
40
Palpation
Autopsy
Ultrasound
30
20
10
0
10
20
30
40
50
60
70
“How was this nodule found?”
Palpation with a physical exam
Incidental finding on diagnostic work up
Self detection
Surveillance
Work up for symptoms of hyper/hypothyroidism
How was found is it clinically relevant?
Physical Examination of Thyroid Gland
Visual inspection
Palpation of thyroid, neck nodes, and supraclavicular
nodes
Fixed, mobile, soft, tender?
Reflexes why?
HR, BP, weight
Symptoms
Usually NONE!!
Occasionally painful, quick onset (cyst)
Difficulty swallowing
Hoarseness OR change in voice
Shortness of breath (or difficulty swallowing) usually
while supine OR hands raised over head
(Pemberton’s Sign)
Choking sensation
hyper/hypo thyroid
Symptoms?
Nodules
Hyper/Hypo thyroid
Difficulty swallowing
Hyper-functioning
nodule
Globus sensation
Hashimoto’s
Choking sensation
Pertinent History & PE in Evaluation of TNs
History
Physical Findings
Head & neck
Rapid growth
irradiation
Whole body irradiation
Nuclear fallout
Family history of
thyroid malignancy
Heredity
Hoarseness
Cervical /supraclavicular
lymphadenopathy
Fixation of nodule or
gland
> 4 cm
Solitary
Differential Diagnosis
Multinodular Goiter
Hashimoto’s Thyroiditis
Cancer
Lymphoma
Solitary Thyroid Nodule
Substernal Goiter
Family History
of
Hereditary Diseases
COWDEN’S SYNDROME
FAMILIAL POLYPOSIS
CARNEY COMPLEX
MEN 2
WERNER SYNDROME
THYROID MALIGNANCY
Substernal Goiters
Short neck
Stocky build
Usually incidental finding by CXR or CT
Many times treated unsuccessfully for asthma
Ultrasound: The Gold Standard
Anyone found to have,
OR is suspected of having a
nodule evaluate by
ultrasound!!
Pure cystic (relatively rare)
Spongiform appearance in >50% of
nodule volume (aggregration of
multiple microcystic components)
Multiple (?)
BENIGN
CHARACTERISTICS
BENIGN
Septated cyst
BENIGN
Cyst
BENIGN
US (a, transverse; b, longitudinal) scans in 51-year-old woman show 2.4-cm welldefined mixed-echoic hypoechoic nodule (arrows) in right lobe of thyroid gland. Initial
cytologic result was adenomatous hyperplasia, confirmed after 11 months at repeat
aspiration
High-risk history: History of thyroid cancer in one or
more first degree relatives; history of external beam
radiation as a child; exposure to ionizing radiation in
childhood or adolescence; prior hemithyroidectomy with
discovery of thyroid cancer, 18FDG avidity on PET
scanning; MEN2/FMTC-associated RET protooncogene
mutation, calcitonin >100 pg/mL. MEN, multiple
endocrine neoplasia; FMTC, familial medullary thyroid
cancer.
Suspicious features: microcalcifications; hypoechoic;
increased nodular vascularity; infiltrative margins; taller
than wide on transverse view.
FNA cytology may be obtained from the abnormal lymph
node in lieu of the thyroid nodule.
Sonographic monitoring without biopsy may be an
acceptable alternative
ULTRASOUND
CHARACTERISTIC
CONSIDERATIONS
Hypo-echogenicity compared to
SUSPICIOUS
CHARACTERISTICS
normal thyroid parenchyma
Increased intra-nodular vascularity
Irregular infiltrative margins
Presence of micro-calcifications
Absent halo
Shape taller than width in transverse
dimension
Nodules > 4 cm
Solitary
Difficulty swallowing
ATA Guidelines 2009
Suspicious
Hypoechoic
Suspicious
Increased vascularity
SUSPICIOUS
Increased vascularity
SUSPICIOUS
Calcifications
Poorly defined, irregular margins
SUSPICIOUS
Solid
Multiple Thyroid Nodules
FNA what nodule??
> 1 cm
Suspicious features
Dominant / largest one
FNA of Palpable Nodule
Palpation?
Ultrasound?
What nodule(s) do you
What nodule(s) do you
FNA?
FNA?
TN with suppressed TSH
UPTAKE SCAN to assess autonomous nodule
Compare to U/S what is the correlation with
Uptake
FNA consider in non - functioning or
isofunctioning with suspicious features
FNA
Only GOLD standard for proof of malignancy
without surgical pathology
FNA
False Negative
False Positive
false-negative rate of
??
up to 5% with FNA
which may be even
higher with nodules >4
cm
Is Size a Predictor of Malignancy?
< 1 cm
> 1 cm
NO
NO
ATA Guidelines 2009
FNA Results
Nondiagnostic
Benign
Atypia of Undetermined Significance (AUS)
Suspicious for a Follicular Neoplasm/Follicular
Neoplasm
Suspicious for Malignancy
Malignant
Bethesda System for Reporting Thyroid Cytopathology
Diagnostic Category
Risk of Malignancy
(%)
Nondiagnostic or
Unsatisfactory
Usual management
Repeat FNA with
ultrasound guidance
Benign
0-3
Clinical Follow up with
ultrasound 6 months
Atypia of Undetermined
significance or Follicular
lesion of Undetermined
significance
5-15
Repeat FNA 3 months; if
same, then lobectomy
Follicular Neoplasm or
suspicious for Follicular
neoplasm
15-30
Surgical Lobectomy
Suspicious for
Malignancy
60-75
Near total thyroidectomy
or surgical lobectomy
Malignant
97-99
Near total thyroidectomy
TSH
Lab Work
TSH
Free T4
Free T4
TPO in suspected thyroiditis
T4
T3
Free T3
TG tumor marker in PTC, FTC,
HTC
TPO
Thyroglobulin (TG)
Calcitonin
Calcitonin suspected MTC or in
follow up of MTC
Thyroid nodule
FNA
Benign
Exam/Sonogram
6-18 months
No Change
Repeat in 3-5 yrs
20% increase in
diameter in > 2
dimensions
(>2mm) or
volume
increase > 50%
Re-aspirate
Thyroid Nodule
TABLE 3. SONOGRAPHIC AND CLINICAL FEATURES OF THYROID NODULES AND RECOMMENDATIONS FOR FNA
Nodule sonographic or clinical features
Recommended nodule threshold size for FNA
High-risk historya
Nodule WITH suspicious sonographic featuresb
>5mm
Recommendation A
Nodule WITHOUT suspicious sonographic featuresb
>5mm
Recommendation I
Abnormal cervical lymph nodes
Allc
Recommendation A
Microcalcifications present in nodule
≥1cm
Recommendation B
AND hypoechoic
>1cm
Recommendation B
AND iso- or hyperechoic
≥1–1.5 cm
Recommendation C
WITH any suspicious ultrasound featuresb
≥1.5–2.0 cm
Recommendation B
WITHOUT suspicious ultrasound features
≥2.0 cm
Recommendation C
Spongiform nodule
≥2.0 cmd
Recommendation C
Purely cystic nodule
FNA not indicatede
Recommendation E
Solid nodule
Mixed cystic–solid nodule
RAI Uptake Scan
ONLY IN HYPERTHYROID
Cold Nodule - 10% incidence of being CA
Thyroid Cancers
From 2005 to 2009, incidence rates increased by
5.6% per year in men and 7.0% per year in women,
making thyroid cancer the fastest increasing cancer
in both men and women
Most common endocrine cancer
Projected Cases of Thyroid Cancer
60, 220 new cases are estimated for 2013
45, 310 female
14, 910 male
1,850 deaths projected for 2013
1,040 female
810 male
Death rate 0.5 per 100,000 in both male and females
AGE & INCIDENCE
AMCERICAN CANCER SOCIETY / NCCN/ SEER
Diagnosed at a younger age then most adult cancers
Median age at diagnosis was 50 years from 2005-2009
2 out of 3 cases are < 55 years old
Thyroid cancer in the pediatric population
Pediatric Incidence 2.0 per 1 million in children <15 yrs and
17.6 per 1 million in children 15-19 yrs
2% occur in children and teens
Surgery
TREATMENT
FOR
Radioactive Iodine Ablation
THYROID
CANCER
Levothyroxine
Monitor with WBS / ultrasound
CHILDREN
&
PREGNANT WOMEN
WHEN DO YOU OPERATE???
Complications of Thyroid Surgery
Recurrent laryngeal nerve injury
Hypo parathyroidism
Bleeding
Infection
COMPLICATIONS OF
SURGERY
Parathyroid glands
COMPLICATIONS OF
THYROID SURGERY
OR case
Surgery and TC
Low MORTALITY
Should be LOW
MORBIDITY too!!
Thyroid cancers LOW Mortality!!
Rod Stewart, Julie Andrews, Joe Piscopo
IF surgery is required, always refer to
someone who does at least > 50 / year
Always exceptions to the rules :
Roger Ebert, Supreme Court Justice
Reinquist
NO drains!!
NO RR tracks!!
Dermabond is ulgy on the neck, and often
opens a bit…
Summary
Refer to Endocrin0logy or
Surgery
Can safely follow with
ultrasound
Children
Nodule < 1 cm
Pregant women
Stable nodules with no change
Nodules > 1 cm with suspicious
Repeat in 6 months x 2, then
annually
features
Compressive symptoms
HT with globus symptoms
ULTRASOUND!! Even if
already had CT, carotid
doppler, etc
Monitor TFTs with U/S
Endocrine OR Surgery?
ENDOCRINE
Suspected/known
abnormal TFTs with
TNs
Pregnant
If FNA needed
Children
SURGERY
If suspect surgery is
indictated
Thank You
QUESTIONS?