Solitary Thyroid Nodule

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SOLITARY THYROID NODULE

Prepared by: Dr. Aisha M. Al-Zuhair

Supervised by: Dr. Naif Awad

KFHU – Khobar – Saudi Arabia

Jan 20, 2010

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INTRODUCTION

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In the general population, thyroid nodules are discovered by palpation in 3% to 7%, and by US in 20% to 76%

More common in women than men Prevalence increases linearly with

age, exposure to ionizing radiation, and iodine deficiency

Hegedus L.:  Clinical practice: the thyroid nodule.  N Engl J Med 351. (17): 1764-1771.2004

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HISTORY AND PHYSICAL

Most patients present with an asymptomatic mass discovered by a physician on routine neck palpation or by the patient during self-examination.

Newly diagnosed thyroid nodules should be evaleuated primarily to role out malignancy.

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WHEN TO SUSPECT MALIGNANCY

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History of childhood head/neck irradiation

Family history of PTC, MTC, or MEN2 Age <20 or >70 yearsMale sexEnlarging noduleAbnormal cervical adenopathyFixed nodule

Gharib H - Endocrinol Metab Clin North Am - 01-SEP-2007; 36(3): 707-35, vi

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EXPOSURE TO RADIATION

The risk is maximum 20 to 30 years after exposure.

Most thyroid carcinomas following radiation exposure are papillary (PTC).

There is a 40% chance that patients presenting with a thyroid nodule and a history of radiation to have thyroid cancer.

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COMMON CAUSES OF THYROID NODULES

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BenignColloid noduleHashimoto’s thyroiditisSimple or hemorrhagic cystFollicular adenomaSubacute thyroiditis

Ross D.M.:  Diagnostic approach to and treatment of thyroid nodules. I.   In: Rose B.D., ed. UpToDateWellesley (MA)2005

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Malignant – PrimaryFollicular cell-derived carcinoma:PTC, FTC, anaplastic thyroid carcinoma

C-cell–derived carcinoma:MTCThyroid lymphoma

Malignant – SecondaryMetastatic carcinoma

Ross D.M.:  Diagnostic approach to and treatment of thyroid nodules. I.   In: Rose B.D., ed. UpToDateWellesley (MA)2005

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MANAGEMENT:DIAGNOSTIC WORKUP

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IMAGING

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ULTRASONOGRAPHY

Most sensitive test to detect lesions in the thyroid

It is recommended that all patients who have a nodular thyroid, with a palpable solitary nodule or a multinodular goiter,be evaluated by US

Not indicated as screening test in general population

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ULTRASONOGRAPHY

Indicated in:Palpable noduleHistory of radiation to the neckAge<20 & >70Family history of MTC, MEN2, or PTCPresence of cervical

lymphadenopathy

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US PREDICTION OF MALIGNANCY

Solitary versus multiple nodulesSizeExtracapsular growthComplex or cystic lesionsNodule shapeSuspicious cervical adenopathy

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SOLITARY VS MULTIPLE NODULES

The risk of cancer is not significantly higher for solitary nodules than for glands with several nodules

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SIZE

Cancer is not less frequent in small nodules (diameter <10 mm)

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EXTRACAPSULAR GROWTH Hypoechoic nodules with irregular

borders, Extension beyond the thyroid

capsule,Invasion into perithyroid muscles,

andInfiltration of the recurrent laryngeal

nerve Are sonographic features suggestive

of malignancy

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COMPLEX OR CYSTIC NODULE

Complex thyroid nodules have solid and cystic components.

These are often benign.Some PTCs may be cystic.

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NODULE SHAPE

 A rounded appearance A more tall than wide shape of

the nodule A marked hypoechogenicity of a

solid lesion are newly described US patterns

suggestive of malignancy 

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CERVICAL L.N.

Enlarged rounded cervical L.N.No hilusCystic changes MicrocalcificationChaotic hypervacularity

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ULTRASONOGRAPHY

The sensitivity of each feature is around 85%

The predictive value of these US features for cancer is in part diminished by their low sensitivity

No US sign by itself can reliably predict malignancy

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Gharib H - Endocrinol Metab Clin North Am - 01-SEP-2007; 36(3): 707-35, vi

24Transverse ultrasonographic view of the right thyroid lobe showing a 1.2-cm hypoechoic nodule (N), which was benign by fine-needle aspiration biopsy. C, carotid artery; T, trachea.

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COLOR DOPPLER US

Evaluates nodule vascularity. Hypervascularity with chaotic

arrangement of blood vessels favors malignancy.

Peripheral flow indicates a benign nodule.

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US images of a left lobe thyroid nodule. (Lt) The 1.7 1.4-cm solid left lobe thyroid nodule was hypoechoic. (Rt) Color Doppler flow imaging shows hypervascularity. FNA biopsy showed papillary thyroid carcinoma, which was confirmed at surgery.

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OTHER IMAGING TECH

CT and MRI not as routine. Can asses size, retrosternal

extension, position and relation to the surrounding structure.

RAI scan: To differentiate hot from cold

nodulesMalignancy has been shown to occur

in 15% to 20% of cold nodules

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Images of a large, asymmetric multinodular goiter. (A) Chest radiography shows marked tracheal deviation to the right (arrow). (B) Chest CT confirmed the presence of a large substernal goiter on the left to the level of tracheal bifurcation.

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OTHER IMAGING TECHPET scan:

3-dimensional reconstruction imagesUse in detecting primary and

metastatic thyroid cancerThe clinical role of PET in pre-OP

investigation of thyroid nodules and in differentiating between benign and malignant lesions is controversial

Crippa F, Alessi A, Gerali A, et al: FDG-PET in thyroid cancer.  Tumori  2003; 89:540-543Urhan M - PET Clin - July, 2007; 2(3); 295-304.

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FNAC

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US GUIDED FNA

Indicated if:Palpation-guided FNA nondiagnosticComplex (solid/cystic) nodulePalpable small nodule (<1.5 cm)Impalpable noduleAbnormal cervical nodesNodule with suspicious US features

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FNAC SPECIMENS

70% Benign, 5% Malignant, 10% Suspicious, and 15% Unsatisfactory

Shwartz’s principles of surgery, 8th Ed

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FNAC RESULTS

Diagnostic / satisfactoryContains no less than six groups of

well-preserved thyroid epithelial cells consisting of at least 10 cells in each group

Nondiagnostic / unsatisfactoryInadequate number of cells result

from acellular cystic fluid, bloody smears, or poor techniques in preparing slides

34(A) Benign (colloid) nodule. (B) Hashimoto thyroiditis. (C) Papillary thyroid carcinoma. (D) Unsatisfactory (nondiagnostic) smear. 

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BENIGN (-VE) CYTOLOGY

Most common findingIndicative of:

Colloid noduleMacrofollicular adenomaLymphocystic thyroiditisGranulomatus thyroiditis Benign cyst

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MALIGNANT (+VE) CYTOLOGY

Commonest is PTC:Increased cellularity, Tumor cells arranged in sheets and

papillary cell groupsTypical nuclear abnormalities, which

include intranuclear holes and grooves

Others include:MTC, anaplastic carcinoma, and

high-grade metastatic cancers

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SUSPECIOUS CYTOLOGY

Diagnosis cannot be madeInculdes:

Follicular neoplasms, Hürthle cell neoplasms, Atypical PTC, or Lymphoma

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SUSPECIOUS CYTOLOGY

Follicular neoplasms are most common:Hypercellular with microfollicular

arrangement and Decreased or absent colloid

Hürthle cell neoplasm: Almost exclusively Hürthle cellsAbsent or scanty colloid lacking a lymphoid cell population

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Gharib H - Endocrinol Metab Clin North Am - 01-SEP-2007; 36(3): 707-35, vi

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Occasionally associated with a minor hematoma

No serious adverse effect of the FNA

No seeding of tumor cells in the needle tract has been reported

Because of 5% false –ve, repeat of biopsy is recommended in some situations

Gharib H - Endocrinol Metab Clin North Am - 01-SEP-2007; 36(3): 707-35, vi

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INDICATIONS FOR REPEAT BIOPSY

Follow-up of benign noduleEnlarging noduleRecurrent cystNodule >4 cmInitial FNA nondiagnosticNo nodule shrinkage after T4

therapy

 Castro M.R., Gharib H.:  Thyroid fine-needle aspiration biopsy: progress, practice, and pitfalls.  Endocr Pract 9. (2): 128-136.2003

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TG OF FNA OF CERVICAL L.N.

Thyroglobulin (Tg) can be measured in lymph node or nodule aspirates.

FNA-Tg levels were markedly elevated in metastatic lymph nodes

 FNA-Tg sensitivity was 84.0%The combination of cytology plus

FNA-Tg increased FNA sensitivity from 76% to 92.0%.Gharib H - Endocrinol Metab Clin North Am - 01-SEP-2007; 36(3): 707-35, vi

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IMMUNOHISTOCHEMICAL MARKERSSeveral molecular markers and

assaysHBME-1

monoclonal antibody stains papillary cancer positively but

does not stain benign follicular tumors

Galectin-3acts as a cell-death suppressordistinguish benign from malignant

thyroid follicular tumors

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Despite most studies showing markers to have high sensitivity or specificity, no markers have high sensitivity and specificity for correctly diagnosing thyroid cancer

Bartolazzi A., Gasbarri A., Papotti M.Thyroid Cancer Study Group, et al:  Application of an immunodiagnostic method for improving preoperative diagnosis of nodular thyroid lesions.  Lancet 357. (9269): 1644-1650.2001;  Segev D.L., Clark D.P., Zieger M.A., et al:  Beyond the suspicious thyroid fine needle aspirate: a review.  Acta Cytol 47. (5): 709-722.2003Castro M.R., Gharib H.:  Continuing controversies in the management of thyroid nodules.  Ann Intern Med 142. (11): 926-931.2005

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LABORATORY TEST

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TSH

To detect early or subtle thyroid dysfunction.

Inc in hashimoto thyroiditis and dec in subacute thyroiditis.

If TSH levels abnormal, free T3 & T4 should be measured to confirm the diagnosis.

American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules.  Endocr Pract 12. (1): 63-102.2006

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TPOAB

Thyroid peroxidase antibodyMeasured in pt with high TSH.High levels of TPOab suggest

autoimmune disease – hashimoto thyroiditis

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SERUM TG

Correlates with iodine intake and the size of the thyroid gland rather than with the nature or function of the nodule

Seldom used in nodule diagnosis Extremely elevated levels of Tg

may suggest thyroid metastasis.

American Association of Clinical Endocrinologists. Endocr Pract 12. (1): 63-102.2006Schwartz's Principles of Surgery; 8ed

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SERUM CALCITONINGood marker for C-cell disease

and correlates well with tumor burden

Prevalence of MTC ranging from 0.4% to 1.4% in patients who have nodular thyroid disease

Routine calcitonin measurement in all patients who have a nodular thyroid has been recommended by European studiesElisei R., Bottici V., Luchetti F., et al:  Impact of routine measurement of serum

calcitonin on the diagnosis and outcome of medullary thyroid cancer: experience in 10,864 patients with nodular thyroid disorders.  J Clin Endocrinol Metab 89. (1): 163-168.2004

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MANAGEMENT:TREATMENT

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Sabiston Textbook of Surgery, 18th ed

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FNAC +VE

Almost always surgical resectionIf malignancy is secondary,

further investigations needed to identify the primary

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THYROID OPERATIONS

Total thyroidectomy = 2 total lobectomy + isthemusectomy

Subtotal thyroidectomy =2 subtotal lobectomy +

isthemusectomyNear-total thyroidectomy =

Total lobectomy + subtotal lobectomy + isthemusectomy

Lobectomy Baily & love’s short practice of surgery; 24th ed

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SURGICAL MANAGEMENT

Lobectomy + isthemusectomy:In pt with low risk factors & Benign

nodulesNear-total or Total thyroidectomy:

In pt with high risk factors & Benign nodules

Malignant nodules

Gharib H - Endocrinol Metab Clin North Am - 01-SEP-2007; 36(3): 707-35, vi

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SURGICAL MANAGEMENT

Total thyroidectomy + cervical clearance:In MTCPTC and FTC with +ve L.N

Gharib H - Endocrinol Metab Clin North Am - 01-SEP-2007; 36(3): 707-35, vi

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FNAC -VE

Administration of T4 with TSH suppression:shrinking nodule size, arresting further nodule growth, and preventing the appearance of new

nodules 

Castro M.R., Caraballo P.J., Morris J.C.:  Effectiveness of thyroid hormone suppressive therapy in benign solitary thyroid nodules: a meta-analysis.  J Clin Endocrinol Metab 87. (9): 4154-4159.2002

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FNAC -VE

T4 therapy not recommended for:As routine For postmenopausal womenpatients with cardiac diseaseLarge nodule or MNG TSH <0.5 mIU/mL

Gharib H - Endocrinol Metab Clin North Am - 01-SEP-2007; 36(3): 707-35, vi

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FNAC -VE

Most thyroid nodules do not need specific treatment if malignancy and abnormal thyroid function have been excluded

Clinical and US follow-up should be performed every 1 to 2 years.

Cooper D.S., Doherty G.M., Haugen B.R.The American Thyroid Association Guidelines Taskforce, et al:  Management guidelines for patients with thyroid nodules and differentiated thyroid cancer.  Thyroid 16. 109-142.2006

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FNAC nondiagnostic Cyst: aspirate and follow up 3

months Recurrent cyst: surgical Large cyst >3-4cm: surgicalBenign nodule: surgical

Gharib H - Endocrinol Metab Clin North Am - 01-SEP-2007; 36(3): 707-35, vi

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THANK YOU

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REFERENCES Shwartz’s principles of surgery, 8th Ed Sabiston text book of surgery, 18th Ed Baily & love’s short practice of surgery; 24th ed

Gharib H - Endocrinol Metab Clin North Am - 01-SEP-2007; 36(3): 707-35, vi Cooper D.S., Doherty G.M., Haugen B.R.The American Thyroid

Association Guidelines Taskforce, et al:  Management guidelines for patients with thyroid nodules and differentiated thyroid cancer.  Thyroid 16. 109-142.2006

Castro M.R., Caraballo P.J., Morris J.C.:  Effectiveness of thyroid hormone suppressive therapy in benign solitary thyroid nodules: a meta-analysis.  J Clin Endocrinol Metab 87. (9): 4154-4159.2002

Elisei R., Bottici V., Luchetti F., et al:  Impact of routine measurement of serum calcitonin on the diagnosis and outcome of medullary thyroid cancer: experience in 10,864 patients with nodular thyroid disorders.  J Clin Endocrinol Metab 89. (1): 163-168.2004

American Association of Clinical Endocrinologists. Endocr Pract 12. (1): 63-102.2006