Transcript Evaluation of Thyroid Nodules

Evaluation of Thyroid Nodules
Michael L. Tuggy, MD
Swedish Family Medicine, Seattle, WA
Case 1
• 42 y.o. male with no active medical
problems. During your routine physical,
note a thyroid nodule. Told by ENT last
year not to worry about it.
• PE: 1 x 2cm R lower pole nodule.
What information do you want from the
patient?
Age as a Risk Factor
• Age
– young patients (<20 years of age)
– thyroid nodules are much more likely to be
malignant (40-50%).
– elderly (>60 years of age) -higher risk,
especially of more aggressive thyroid tumors.
Gender and Thyroid Nodules
• Gender
– male -higher risk if nodule present
– females
• have many more nodules
• less likely to be malignant.
• still have majority of thyroid cancers
Other major risks
• Radiation to head and neck.
– 40% risk of thyroid cancer usually 25 years
later.
– Exposed populations- Polynesian studies
• Family History of MEN II, Gardner’s
Syndrome, Cowden’s disease.
Historical Red Flags
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Recent growth
Soft tissue swelling
Vocal changes
Dysphagia
Signs of thyroid dysfunction
Case 2
• 26 y.o. Eritrean female with a 2-3 year
history of goiter. No symptoms but noted
enlargement on right for 1 year.
• P.E.: 3x4 cm Right sided thyroid mass,
firm, adherent to soft tissue.
What physical findings are worrisome?
How can you best clarify the nature of the
nodule?
Thyroid Exam
Physical Exam of the Thyroid
• Use both hands simultaneously to evaluate
for symmetry
• Patient upright - screening exam
• Patient supine with neck in extensiondetailed exam. Swallowing assists in
elevating gland.
• Evaluation of other neck structures.
• Voice changes (recurrent laryngeal nerve).
Thyroid Scans
• Purpose
– Determine function of the gland and/or a
nodule within the gland
• Hot nodules - usually independently
functioning nodules
– Rarely, rarely malignant
• Cold nodules - either adenoma or maligancy
– 15% chance of malignancy in adults.
Thyroid Ultrasound
• Can identify presence
of nodules.
• May be able to
characterize follicular
vs. solid.
• Not able to rule our
malignant nodule
• Aid in biopsy.
Thyroid
Case 3
• 30 y.o. WF with enlarging cold benign
thyroid adenoma (diagnosis from previous
FNA biopsy).
• PE: 4 x 5 cm mass on Right
What do you do now?
Fine-Needle Aspiration
• Best tool for determining pathology other
than surgical excision.
• Can be as high as 80 % sensitive and 95%
specific.
• Operator dependent in obtaining adequate
amount of tissue. 25 gauge needle is
optimal.
• Should not be relied on if negative in
patient with previous neck irradiation.
– Multifocal tumors common.
Interpreting the Biopsy Report
• What you get:
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–
–
–
benign
indeterminate
suspicious
inadequate specimen
• What it means:
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benign - 90-95% likelihood it is benign
indeterminate- who knows?
suspicious- it’s malignant.
inadequate specimen - do it again (and again)
Thyroid Malignancies- Papillary
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Most common
30% have node metastasis at diagnosis
Radiation related
Histologically, psammoma bodies
distinguish from benign adenoma.
Thyroid Malignancies-Follicular
• 20 % of malignancies
• Distinguished from normal follicular
adenomas by invasion of capsule or blood
vessels.
• May be difficult to determine on FNA
Thyroid MalignanciesMedullary
• 5-10% of cases
• arise from the C cells which produce
calcitonin
• diagnosis based on elevated thyrocalcitonin
levels and thyroid nodule (cold)
Thyroid MalignanciesAnaplastic
• < 10%
• Highly aggressive with local extension at
time of diagnosis.
• No suitable therapy
• Prognosis < 1 yr from diagnosis
Treatment
• For all malignancies, excision of the the
lobe (or if post-radiation the entire gland).
• XRT- very specific and well tolerated- I131
therapy.
• Anaplastic tumors - palliative radiation and
XRT.
What about those benign
nodules?
• No specific treatment is needed.
• Thyroid suppression may shrink size of
adenomas
• Not proven to be effective or necessary
• May hide malignancies - ? Periodic biopsies
or scans.
Case 4 - This weeks puzzler!
• 40 y.o. WF s/p I131 ablation for Grave’s Dz.
6 years ago.
• Persistant R thyroid nodule 2 x 1.5 cm in
size.
What is the likely diagnosis?
Outcomes
• Case 1. - Papillary cancer - 3 (+) nodes
– no metastasis at 1 year.
• Case 2. - Follicular cancer - 5 (+) nodes
– no metastasis at 1.5 years
• Case 3. - Large adenoma with incidental 1
cm papillary carcinoma superior to nodule.
– No recurrence at 5 years.
• Case 4. - Non-functional adenoma
Modified from: Castro, MR, Gharib, H. Endocr Pract 2003; 9:128.
Summary:
Solitary Nodule Evaluation
• TSH – if low – scan – if hot nodule, then observe.
• Normal TSH - Do I scan first or FNA first?– high risk - scan and FNA
• Is the nodule cold or hot?
• Cold - FNA biopsy
– low risk - FNA
• if indeterminate- scan and re-FNA or
excisional biopsy.
• Anti-perioxidase Antibody – helpful if low- TSH to
diagnose thyroiditis.
Never assume a solitary thyroid
nodule is benign. Prove it.