Transcript CLINICAL AND SONOGRAFIC APROACH TO THE THYROID NODULE
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Department of Internal Medicine and Gastroenterology University of Bologna L. Bolondi, L. Rasciti
Caso clinico
• Donna di 56 anni, sposata con 3 figli, in menopausa da 5 anni.
• Si accorge, guardandosi allo specchio, di lieve asimmetria della circonferenza del collo (modica tumefazione a sin); • Il medico palpa una formazione nodulare, di consistenza parenchimatosa, non dolente, verosimilmente riferibile al lobo tiroideo sin. Non rileva linfoadenopatie.
Caso clinico
• Funzione tiroidea (FT3, FT4, TSH) nella norma • Autoanticorpi (anti TG, antimicrosomiali) nella norma • Emocromocitometrico, GOT, GPT, Azotemia, Glicemia, Protidemia totale ed elettroforesi, VES, Es; urine nella norma • Viene inviata per esame ecografico
NODULO ISOECOGENO CON AREA LIQUIDA INTERNA. AL DOPPLER SEGNI DI VASCOLARIZZAZIONE PERIFERICA
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Key concepts
• Thyroid nodules are the most common endocrine disorder, they can be detected in an otherwise normal gland, especially in iodine-deficient areas. The frequency of thyroid nodules increases throughout life.
• Single nodules are about four times more common in women than in men.
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Key concepts
• Nodules are 10 times more frequent, in comparison to palpation, when the gland is examined at autopsy, during surgery, or by ultrasonography.
Prevalence of palpable thyroid nodules detected at autopsy or by ultrasonography (solid circle) or by palpation (open square) in subjects without radiation exposure or known thyroid disease.
E. Mazzaferri, NEJM 1993
TIROIDE NORMALE
NORMAL THYROID: Right lobe
TIROIDE: VASCOLARIZZAZIONE
ARTERIA TIROIDEA SUPERIORE
Small (<5mm) non palpable thyroid nodule in the left lobe (occasional finding)
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Key concepts
• Less than 1% of thyroid nodules detected at US prove to be malignant.
• Less than 5% of solitary nodules detected at US are malignant.
• A significant number of elderly patients have clinically silent thyroid cancers: up to 35% of thyroid glands at autopsy contain tiny (<1.0 cm), clinically unimportant papillary carcinomas.
• Among nodules removed surgically, an estimated 42 to 77 % are non-neoplastic colloid nodules, 15 to 40 % are adenomas, and 8 to 17 % are carcinomas.
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE CLASSIFICATION OF THYROID NODULES
Benign Nodules
a) Hyperplastic (colloid) nodule within goiter b) Follicular Adenoma i. Colloid variant ii. Hurthle cell variant c) Papillary Adenoma (suspect for malignancy) d) Teratoma
• •
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Hyperplastic and Colloid (adenomatous)
nodules are the dominant type of nodules, and can be single or multiple.
Most and aspirates are incompletely benign may hypofunctioning encapsulated.
and Cytologic studies usually reveal abundant colloid follicular cells, but hemorrhagic nodules or highly cellular be difficult differentiate from follicular cancer.
to
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
• A diagnosis of a follicular or Hürthle cell tumor requires further evaluation and management, since the cytologic features of benign follicular or Hürthle cell tumors and low-grade follicular or Hürthle cell cancer are similar.
• Benign from malignant nodules can only be distinguished by the presence or absence of capsular or vascular invasion on histologic examination of surgical specimens.
• Follicular FNAB .
and Hürthle cell tumors have respectively a malignancy rate of 10% to 20%, that cannot generally be assessed adequately at
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Malignant Nodules
a) Papillary Carcinoma (75-85%) i. Pure papillary ii. Mixed papillary and follicular carcinoma b) Follicular Carcinoma (20-25%) i. Malignant adenoma ii. Hurthle cell carcinoma or oxyphil carcinoma iii. Clear-cell carcinoma c) Medullary Carcinoma (5%) d) Anaplastic Carcinoma (<5%) e) Lymphoma f) Metastatic tumor
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Nodules with sonographic apparence of cysts
• Fifteen to 25 percent of all thyroid nodules are cystic.
• High-resolution ultrasound has shown that most of the nodules initially considered to be cystic are complex lesions (solid-cystic).
• Up to 15 percent are necrotic papillary cancers, and about 30 percent are hemorrhagic adenomas.
NODULE WITH CYSTIC APPEARANCE
HAEMORRHAGIC CYST
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Dectection of thyroid nodules
• By chance during routine physical examination • By chance during US of the neck performed for other problem (i.e. carotid arteries, lymphnodes etc.) • In symptomatic patiens: local pain tenderness swelling dysphagia dysphonia hoarseness
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Clinical challenge: to identify which nodules are malignant
• • • • • •
History and physical examination Laboratory evaluation Radionuclide scanning Ultrasonography FNA biopsy UG-FNA biopsy
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Clinical elements for differential diagnosis
Benign
• Family history of benign thyroid nodule or goiter or autoimmune thyroid disease.
• Symptoms of hypothyroidism or hyperthyroidism.
• Pain or tenderness associated with the nodule.
These factors do not exclude the presence of thyroid cancer .
Malignant
• A family history of medullary or papillary thyroid cancer or of familial polyposis (Gardner's syndrome).
• Age—the young (<20 years old) and the old (>70 years old) have the highest incidence of thyroid cancer.
• Rapid tumor growth.
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Clinical elements for differential diagnosis
Benign
• Soft, smooth, mobile nodule.
• Multinodular goiter without a dominant nodule.
Malignant
• Gender—the proportion of nodules that are malignant in males is double that in females.
• Nodule plus dysphagia or hoarseness.
• Firm, hard, irregular, and fixed nodule.
• Presence of cervical lymphadenopathy.
These factors do not exclude the presence of thyroid cancer.
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Clinical elements for differential diagnosis
Benign Malignant
• History of external neck irradiation during childhood or adolescence (this factor also increases the incidence of nonmalignant thyroid nodular disease) or exposure to nuclear fallout.
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Laboratory evaluation
• In patients with a thyroid nodule, a sensitive thyroid stimulating hormone (TSH) assay should be done, at a minimum, to determine the presence of hyperthyroidism or hypothyroidism.
• Serum calcitonin should be measured when medullary thyroid carcinoma or MEN II is suspected.
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
• Aim: Limits:
Radionuclide scanning
to identify hyperfunctioning nodules that are almost always benign.
lack of differentiating criteria for hypofunctioning nodules
Not all patients with thyroid nodules require nuclear imaging.
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Ultrasonography
• Widespread use of ultrasound for examining any neck pathology has resulted in frequent recognition of thyroid nodules, that are too small to be palpated on clinical examination.
• Usually, such nodules are < 1cm in largest diameter, they are typically asymptomatic, and are not associated with lymph nodes or other suggestions of malignancy.
• Often incidentally found, such nodules produce a problem because of the difficulty in achieving a specific diagnosis, which is desired by the patient.
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Ultrasonography
• In a recent metanalysis (Ann Intern Med, 126:226 31, 1997.), the risk for malignancy in US incidentalomas ranged betwen 0.45% and 13%.
• Large malignant nodules have been reported to be missed by palpation. The greatest size of malignant non palpable nodules was 2.1 cm.
• The existence of these nodules, detected by US exploration, suggests that a simple follow-up neck palpation, may not be the safest management strategy.
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Ultrasonography
• Currently no ultrasound suggestive for malignancy: criteria can distinguish benign from malignant thyroid nodules. However some features are a) Microcalcification b) Irregular or microlobulated margin c) Hypoechogenicity d) Intranodular blood flow pattern
NODULO ISOECOGENO CON AREA LIQUIDA INTERNA. AL DOPPLER SEGNI DI VASCOLARIZZAZIONE PERIFERICA
HYPERPLASTIC THYROID NODULE
TIROIDE: NODULO IPERPLASTICO
TIROIDE: NODULO IPERPLASTICO
TIROIDE: NODULO PARZIALMENTE CISTICO CON CALCIFICAZIONI
MEDULLARY CARCINOMA
PAPILLARY CARCINOMA Intranodular Vascularization
FOLLICULAR CARCINOMA
MORBO DI BASEDOW
TIROIDITE
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
FNA biopsy
• FNAB has become the initial test, after clinical and/or US examination, because it is safe and inexpensive and leads to a better selection of patients for surgery.
• FNAB is now believed to be the most effective method available for distinguishing between benign and malignant thyroid nodules.
• In this setting the FNAB sensitivity varies from 68 to 98% (mean, 83%) and specificity varies from 72 to 100% (mean, 92%).
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
FNA biopsy
• Provided that an adequate specimen is obtained, three cytologic results are possible: benign, malignant, indeterminate (or suspicious) findings.
and • A major problem diminishing the potential benefit of FNAB is the unskilled physician performing the biopsy or the inexperienced cytopathologist interpreting the specimens.
• Even in skilled hands, however, approximately 10% of biopsy findings are nondiagnostic.
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
FNA biopsy
• Repeated FNAB may be appropriate under several circumstances as follows: (1) when the lesion continues to enlarge; (2) when new clinical features develop that suggest possible malignancy; (3) when the previous cytologic diagnosis was indeterminate, or (4) when there is insufficient material for cytologic diagnosis.
• Routine repetitive FNAB of lesions that were previously shown to be benign is rarely indicated.
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
UG-FNA biopsy
• Ultrasound-guided FNAB (UG-FNAB) has emerged as an alternative to conventional FNAB for the diagnostic evaluation of nonpalpable nodules and for the repeat evaluation of nodules with previous nondiagnostic FNAB.
• It is also an excellent method for the evaluation of complex nodules by precisely positioning the needle in the solid portion of these nodules.
FNAB OF SOLID THYROID NODULE The arrow points to the needle
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
UG-FNA biopsy
• In the literature, the sensitivity and specificity of UG-FNAB amounted to 79% and 85%, respectively.
• UG-FNAB is possible for lesions smaller than 1 cm in size, but considering the probable benign nature of most of such lesions, a common alternative course is "observe" such lesions periodically.
• Due to the high prevalence of US thyroid nodules, a systematic UG-FNAB performed on all nonpalpable nodules is not advisable.
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE PALPABLE THYROID NODULE ULTRASONOGRAPHY NOT PALPABLE THYROID NODULE INCREASED RISK
YES NO
TSH < 0.03
YES NO
HOT NODULE
YES NO
BENIGN TREATMENT
YES
TSH < 0.03
TSH > 4.5
NO
FOLLOW UP US and LAB SINGLE NODULE
1 cm or DOMINANT NODULE
YES NO YES
CYST FNAB UG-FNAB
NO YES
INCREASED RISK
NO YES
US SIGNS FOR MALIGNANCY
NO
COLD NODULE
YES NO YES
DIAGNOSTIC
NO
SUSPICIOUS FOLLICULAR LESION CANCER INCREASED RISK SURGERY
NO YES
GOZZO COLLOIDOCISTICO TIROIDEO
IPERPLASIA NODULARE
TIROIDE: CA PAPILLIFERO
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Nodules with sonographic apparence of cysts
• Both benign and malignant lesions may yield bloody fluid; clear, amber fluid usually indicates a benign lesion.
• Cystic lesions often yield insufficient numbers of cells for diagnosis.
TIROIDE: CISTI EMORRAGICA
TIROIDE: VASCOLARIZZAZIONE
TIROIDITE DI HASHIMOTO
TIROIDITE DI HASHIMOTO
META TIROIDEE DI CA LARINGE
TIROIDE: NODULO IPERPLASTICO
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Benign Nodules
• Hyperplastic nodules (within goitre) • Follicular Adenoma • Colloid variant • Hurthle cell variant • • Papillary Adenoma (suspect for malignancy) Teratoma
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
• Papillary carcinoma is usually recognizable in specimens obtained by fine-needle aspiration biopsy. The smears tend to be cellular, and the cells have large nuclei with a pale ground-glass appearance.
• Follicular carcinoma is a tumor most reliably identified by invasion of the capsule or of vessels by malignant cells in surgical specimens (difficult diagnosis at fine-needle aspiration biopsy).
• Medullary
and
Anaplastic
carcinomas and Lymphomas (a particular risk in patients with Hashimoto's disease) can ordinarily be identified by fine-needle aspiration biopsy.
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
• A diagnosis of a follicular or Hürthle cell tumor requires further evaluation and management, since the cytologic features of benign follicular or Hürthle cell tumors and low-grade follicular or Hürthle cell cancer are similar.
• Benign from malignant nodules can only be distinguished by the presence or absence of capsular or vascular invasion on histologic examination of surgical specimens.
• Follicular and Hürthle cell tumors, diagnosed by using FNAB, have respectively a malignancy rate of 10% to 20%, that cannot generally be assesed at FNAB .
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
• Macrofollicular adenomas have no malignat potential • Although macrofollicular colloid adenomas have no malignant potential, about adenomas are follicular cancers.
5 percent of microfollicular adenomas, 5 percent of Hurthle cell adenomas, and 25 percent of embryonal
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
• A diagnosis of a follicular or Hürthle cell tumor requires further evaluation and management, since the cytologic features of benign follicular or Hürthle cell tumors and low-grade follicular or Hürthle cell cancer are similar.
• Benign from malignant nodules can only be distinguished by the presence or absence of capsular or vascular invasion on histologic examination of surgical specimens.
• Follicular and Hürthle cell tumors, diagnosed by using FNAB, have respectively a malignancy rate of 10% to 20%, that cannot generally be assesed at FNAB .
• •
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
Colloid (adenomatous) nodules are the dominant type of nodules, and can be single or multiple.
Most and aspirates are incompletely benign may hypofunctioning encapsulated.
and Cytologic studies usually reveal abundant colloid follicular cells, but hemorrhagic nodules or highly cellular be difficult differentiate from follicular cancer.
to
CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE
• Follicular adenomas, which are thought to be monoclonal tumors, tend to be single lesions with well-developed fibrous capsules and a uniform histologic structure distinct from the normal surrounding thyroid. They are classified according to the size or presence of follicles and the degree of cellularity.
• Although macrofollicular colloid adenomas have no malignant potential, about adenomas are follicular cancers.
5 percent of microfollicular adenomas, 5 percent of Hurthle cell adenomas, and 25 percent of embryonal