Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
Thyroid Nodules
ENDOCRINOLOGY DIVISION ENDOCRINOLOGY DIVISION
Dr. HAKIMI, SpAK
Dr. MELDA DELIANA, SpAK
Dr. SISKA MAYASARI LUBIS, SpA
Anatomical Considerations
The Thyroid Nodule
Congenital anomalies
� Thyroglossal duct cyst
Inflammatory lesions
� Inflammatory foci� Inflammatory foci
� Compensatory regenerative nodules (TSH,TGI)
Hyperplasia
Neoplasia
� Benign
� Malignant
Follicular epithelial neoplasms
� Follicular adenoma
� Differentiated: Papillary, Follicular Poorly Differentiated (Insular) Anaplastic
Parafollicular epithelial neoplasms
� Medullary carcinoma
� Mixed/composite carcinoma
Other primary epithelial neoplasms
Primary non-epithelial neoplasms
Secondary tumors
Incidence
� Occur in only 0,05-1,8% of children
� The most common form of cancer is papilary thyroid carcinoma
� Folicular adenomas & colloid cysts is majority of � Folicular adenomas & colloid cysts is majority of benign tyhroid nodules
The Approach to Investigationof the Thyroid Nodule
� Clinical examination
� Thyroid function tests
� Ultrasound
� Cytology of fine needle aspirate (FNAB)
Thyroid scan� Thyroid scan
� MRI
Clinical examination
� Painless nodules
� Firm or hard consistency
� Fixed to surrounding tissue
� Rapid growth
Cervical adenopathy, hoarseness, dysphagia� Cervical adenopathy, hoarseness, dysphagia
� Exposed to irradiation
� Family history of thyroid cancer or pheochromocytoma
� Other syndromes associated with nodular thyroid disease
Thyroid function tests� Anti TPO & anti Tg Abs
Abs (+) � underlying CLT, doesn’t exclude
thyroid cancer
� TSH, T4, T3� TSH, T4, T3
elevation T4 or/and T3 � functioning nodules
� Serum calcitonin
for familial case of thyroid cancer
� Genetic screening for mutation of RET proto-oncogen � suspected multiple endocrine
neoplasia type 2
Methods of Ret/PTC Analysis
DNA
� PCR analysis of ret/PTC gene rearrangements has been difficult due to variable break-point sites leading to heterogeneous tumor profiles
RNA
� RT-PCR for ret/PTC mRNA is the “gold standard”
� Variability of expression; not “all or none”
Protein
� Immunohistochemistry
Ret/PTC Gene Rearrangements
Ultrasonography
� Non invasive method
� Confirm & evaluate the morphological characteristic of thyroid nodules
� Cystic or homogeneously hyperechoic � lower
risk of malignancy
� Solid hypoechoic, calcifications, irreguler shape & absence of a halo � malignant nodules
The limitation :
� No reliably predict of malignancy
� Depend on individual experiences
Ultrasonography
YROIDYROID
ASS
Cytology of fine needle aspirate & biopsy (FNA)
� 20% of FNAB are insufficient or non diagnostic �
Repeat aspiration is ussually successful
� Identifiable on cytology by the presence of characteristic cell abnormalitiescharacteristic cell abnormalities
� In very young children, open excisional biopsy is suitable alternative
Fine Needle Aspiration Biopsy
Computed Tomography
� Distinguish cystic from solid
� Extent of lesion
� Vascularity (with contrast)
� Detection of unknown primary (metastatic)� Detection of unknown primary (metastatic)
� Pathologic node (lucent, >1.5cm, loss of shape)
� Avoid contrast in thyroid lesions
Computed Tomography
Magnetic Resonance Imaging
� Similar information as CT
� Better for upper neck and skull base
� Vascular delineation with infusion
Magnetic Resonance Imaging
Differential Diagnosis
Therapy
Excision for benign tumors & cysts
Malignant thyroid tumors �
� Total or near total thyroidectomy
Radioiodine ablation� Radioiodine ablation
� Monitoring for recurrence & disease progression
� Thyroid nodules < 1 cm or with benign cytology �
follow by serial ultrasound every 6-12 months
� Significant interval growth � repeated FNAB
Treatment of Thyroid Cancer � Papillary and follicular thyroid cancer
� Generally excellent prognosis
� Risk for recurrence for as long as 30 years
� Initial management
� Surgery and radioactive iodine� Surgery and radioactive iodine
� LT4 suppressive therapy
� Follow-up
� Physical examination
� Radioactive iodine scans
� Serum Tg
� TSH and T4
Standard Treatment of Thyroid Cancer
Total
Thyroidectomy
RAI
Whole Body Scan
Tg Assay
Suppression
Therapy1 Year
Ablation
Cohen EG, et al. Otolaryngol Clin North Am. 2003;36:129-157.
Mazzaferri EL, et al. J Clin Endocrinol Metab. 2003;88:1433-1441.
Sherman SI. Lancet. 2003;361:501-511.
Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463.
Mazzaferri EL, et al. Endocr Relat Cancer. 2002;9(4):227-247.
Thyroid Cancer Initial Treatment Strategy
Surgery Intermediate
and High RiskLow Risk
Diagnosis of Thyroid Cancer
RAI AblationPhysical Exam
Ultrasound
Total
Thyroidectomy
Lobectomy
Isthmusectomy
and High RiskLow Risk
Kinder BK. Curr Opin Oncol. 2003;15):71-77.
Sherman SI. Lancet. 2003;361:501-511.
Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463.
Radioactive Iodine
� Destroys remnants of normal thyroid tissue
� Destroys thyroid cancer cells
� Identifies distant metastases
� Maximizes sensitivity and specificity of serum thyroglobulin
Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463.
Cohen EG, et al. Otolaryngol Clin North Am. 2003;36:129-157.
TSH Suppression
Pituitary
TSH -
Pituitary
TSH -
Normal Thyroid Cancer Patients
Thyroid
T4
+Thyroid
T4
+
Minimum LT4 to
suppress TSH
without thyrotoxicosisBraverman LE, Utiger RD, eds. Werner & Ingbar’s The Thyroid: A Fundamental and
Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000.
Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463.
Sherman SI. Lancet. 2003;361:501-511.
Target TSH Suppression
<0.1 0.1 to 0.4 0.5 to 1
Low to
Undetectable
Suppressed but
Detectable Low Normal
TSH,
Optimal TSH
<0.1 0.1 to 0.4 0.5 to 1
• Most patients with
no evidence of
disease
• Persistent or recurrent
disease
• High-risk patients
• Very low-risk
patients
• Long-term
survivors
TSH,
mIU/L
Patients
Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463.
Sherman SI. Lancet. 2003;361:501-511.
Braverman LE, Utiger RD, eds. Werner & Ingbar’s The Thyroid: A Fundamental and Clinical Text.
8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000.