Adult Patients with Thyroid Nodules - Patients with Thyroid Nodules ... ATA 2015 Guideline ... Screening in people with familial DTC

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  • Adult Patients with Thyroid NodulesAmerican Thyroid Association 2015 Guideline

    Francis P. Baco, MD, FACP, FACE

    April 23, 2016

    1

    Nagasaki-1945

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    Disclosure:No Conflicts of Interest to Disclose

    This presentation is intended for educational purposes only and does not replace independent professional judgment.

    I am expressing my own views based on my reading, analysis and interpretation of the scientific information.

    I am a member of SPED and a Federal Government employeebut I am not speaking in representation of or presenting the views of the Veterans Administration, Puerto Rican Society of Endocrinology and Diabetes, State or Federal Government Agency or Department,

    other Professional Societies, Public or Private Corporation, or Pharmaceutical Company.

    2

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    Learning Objectives

    At the end of this lecture, participants will be able to:

    Outline how to manage a patient with a thyroid nodule

    Risk stratify thyroid nodules by ultrasonography characteristics

    Recognize when to proceed with a thyroid fine needle aspiration

    Appraise the cytology report and role of molecular markers in the evaluation and management of the patient with thyroid nodules.

    3

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    Thyroid NodulesATA 2015 Guideline

    The complete guideline has 133 pages, 92 of text, with more than 101 recommendations.

    Thyroid nodules part has ~34 recommendations

    25 Strong Recommendations

    4 High Evidence

    14 Moderate Evidence

    7 Low Evidence

    6 Weak Recommendations

    3 No Recommendations

    4

    Haugen BR, et al. Thyroid 2016;26:1-132

    How many have read the complete guideline?

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    Thyroid Cancer5

    http://seer.cancer.gov/statfacts/html/thyro.html

    64,300 Estimated New Cases in 2016

    1,980 Estimated Deaths in 2016

    98.1% Survival 2006-2012

    0.0

    2.0

    4.0

    6.0

    8.0

    10.0

    12.0

    14.0

    16.0

    19

    75

    19

    77

    19

    79

    19

    81

    19

    83

    19

    85

    19

    87

    19

    89

    19

    91

    19

    93

    19

    95

    19

    97

    19

    99

    20

    01

    20

    03

    20

    05

    20

    07

    20

    09

    20

    11

    20

    13

    Per

    10

    0,0

    00

    New Cases

    Deaths

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    Time Trends in Incidence of Thyroid Cancer for All Sizes and Those of 1 cm or Less

    6

    Morris LG JAMA Otolaryngol Head Neck Surg. Online April 14, 2016. doi:10.1001/jamaoto.2016.0230

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    Thyroid Cancer

    0%

    5%

    10%

    15%

    20%

    25%

    30%

    New Cases by Age Group

    New Cases by Age Group

    7

    http://seer.cancer.gov/statfacts/html/thyro.html

    Median Age at Diagnosis if 51 years

    0%

    5%

    10%

    15%

    20%

    25%

    30%

    Death by Age Group

    Death by Age Group

    Median Age at Death is 73 years

  • Thyroid Nodules

    8

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    No RecommendationNeither For or Against

    Screening in people with familial DTC

    Syndromes associated with DTC warrant screening as per syndrome

    Routine serum calcitonin

    Nodules >1cm with very low suspicion sonographic pattern or pure cyst surveillance.

    9

    Haugen BR, et al. Thyroid 2016;26:1-132

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    Not Recommended

    Thyroid scan if the TSH if normal or elevated

    Serum thyroglobulin for initial thyroid nodule evaluation

    Routine TSH suppression therapy for benign thyroid nodules in iodine sufficient populations.

    Potential harm outweighs benefit for most patients

    10

    Haugen BR, et al. Thyroid 2016;26:1-132

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    We Are Going To Be Talking About Common Garden Variety and Not Special Situations

    Special situations:

    Associated hoarseness or dysphagia

    History of rapid growing mass

    Personal history of head and neck or total body xRT

    Exposure to ionizing radiation

    Family history of thyroid cancer or syndrome associated to thyroid cancer

    Fixation to surrounding tissue

    Associated cervical lymphadenopathy

    11

    Haugen BR, et al. Thyroid 2016;26:1-132

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    Thyroid Nodule

    Radiological diagnosis

    discrete lesion within the thyroid gland that is radiologically distinct from the surrounding thyroid parenchyma.

    Non-Palpable nodules: incidentaloma

    12

    Haugen BR, et al. Thyroid 2016;26:1-132

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    Most Thyroid Nodules are Low Risk

    given the unfavorable cost/benefit considerations, attempts to

    diagnose and treat all such small thyroid cancers in an effort to

    prevent exceedingly rare outcomes is deemed to cause more harm

    than good.

    13

    Haugen BR, et al. Thyroid 2016;26:1-132

    Primum Non Nocere or Non-Maleficence Principle

  • Initial Evaluation

    14

    You suspect or palpate a lump in the thyroid. How do you proceed?

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    Serum TSH

    Normal or High TSH

    Thyroid sonography with survey of cervical lymph nodes

    Low TSH

    Radionuclide thyroid scan

    Thyroid ultrasound

    Hot nodule (s)

    Concordant with ultrasound do not require FNA

    Warm or Cold areas should be evaluated as having normal or high TSH

    15

    Haugen BR, et al. Thyroid 2016;26:1-132

  • If a nodule is identified in the ultrasound and

    the TSH is NOT low, then comes the determination if aspiration

    biopsy should be done or not.

    16

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    Thyroid Sonography

    Information looked:

    Is there truly a nodule?

    Specify size of the nodule

    US imaging characteristics

    Cystic component*

    Location of the nodule*

    Suspicious cervical lymphadenopathy

    Report should describe:

    Thyroid parenchyma & gland Size

    Nodule size (3 dimensions), location, composition, echogenicity, margins, presence and type of calcifications, shape and vascularity.

    Presence or absence of cervical lymph nodes in the central or lateral compartments

    17

    Haugen BR, et al. Thyroid 2016;26:1-132*Decrease the accuracy of FNA by palpation.

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    Ultrasonographic Risk Stratification18

    Haugen BR, et al. Thyroid 2016;26:1-132

  • MalignancyStratification

    US FeaturesMalignancy

    RiskCutoff

    For FNA

    HighRisk

    Irregular margins (Poorly defined margins)Microcalcifications (Bright Reflectors)Taller than wide in transverse viewRim Ca with extrusive soft tissue componentExtrathyroidal extension

    >70-90% > 1.0 cm

    Intermediate Hypoechoic without High Risk Features 10-20% > 1.0 cm

    Low Isoechoic, hyperechoic, or partially cystic with eccentric solid areas without High Risk Features

    5-10% > 1.5 cm

    Very Low Spongiform or partially cystic without HighRisk Features

    2.0 cmOr Observ.

    Benign Purely cystic

  • 20

    Haugen BR, et al. Thyroid 2016;26:1-132

    > 1.0 cm

    > 1.0 cm

    > 1.5 cm

    > 2.0 cmObserv.

    No FNA

  • Pte A

  • Pte A

    Presence of abundant follicular cells with focal architectural and cytologic atypia, giant multinucleated histiocytes, hemosiderin laden macrophages, Hurthle cells, mixed inflammatory cells, colloid andblood.

    Diagnosis:FNA, Right Thyorid Nodule: Follicular Neoplasm/Suspicious for a Follicular neoplasm.

  • Transverse grayscale images of histology-proven benign thyroid nodules from a 73-year-old woman with multinodular goiter. (A)

    This nodule has spongiform appearance and a hypoechoic halo. (B) This typical colloid nodule in the same patient is predominantly

    cystic with internal colloid (tiny echogenic foci with posterior comet tail artifacts).

    Junwei Zhang, Zhaojin Chen, Gopinathan Anil

    Ultrasound-guided thyroid nodule biopsy: outcomes and correlation with imaging features

    Clinical Imaging, Volume 39, Issue 2, 2015, 200206

    http://dx.doi.org/10.1016/j.clinimag.2014.10.019

  • 26

    Kim JY Ultrasonography 2015;34:304

  • 27

    How would you characterize this 2.7 x 1.9 x 1.3 cm nodule?

    A. High suspicionB. Intermediate suspicionC. Low suspicionD. Very low suspicionE. Benign

    FNTA was done:Adequate specimen.

    Hypercellular specimen consisting of follicular cells in sheets and aggregates showing architectural and focal cytologic atypia, stromal fragments, some dense colloid, RBC's and mixed inflammatory cells,mostly lymphocytes.

    Diagnosis:FNA, Right Thyroid Nodule: Suspicious for a Follicular neoplasm.

  • Presentation at SPED Convention April 23, 2016: Dr. F. P. Baco

    Report from a Well Respected Hospital PR30

    Ap