Management and diagnosis of thyroid nodules

Management and diagnosis of thyroid nodules

Rebecca Rogers, MS IIIGillian Lieberman, MD

Rebecca Rogers, MS IIIGillian Lieberman, MD

AgendaAgendaReview thyroid anatomy and histologyLearn the differential diagnosis for a thyroid noduleBecome familiar with the management and follow-up for a patient with a thyroid noduleRecognize the various appearances of thyroid nodules on ultrasoundUnderstand the technique of ultrasound-guided Fine Needle Aspiration (FNA)Understand the use and results of radioactive iodine scans

Review thyroid anatomy and histologyLearn the differential diagnosis for a thyroid noduleBecome familiar with the management and follow-up for a patient with a thyroid noduleRecognize the various appearances of thyroid nodules on ultrasoundUnderstand the technique of ultrasound-guided Fine Needle Aspiration (FNA)Understand the use and results of radioactive iodine scans

Normal thyroid anatomyNormal thyroid anatomy

www.thaiclinic.com/images/thyroid_anatomy.jpg

www.fpnotebook.com/_media/ThyroidAnterior.gif

Internal jugular vein

Cricoid cartilage

Thyroid cartilage

Common carotid artery

Trachea

Normal Thyroid histologyNormal Thyroid histology

Follicular cells make thyroglobulinColloid stores thyroglobulinC cells make calcitonin

Follicular cells make thyroglobulinColloid stores thyroglobulinC cells make calcitonin

biology.clc.uc.edu/Fankhauser/Labs/Anatomy_&_Physiology/A&P202/ Endocrine_System/Endocrine_Histology.htm

Cuboidal follicular cells

colloid

Sinusoidal capillaries

Parafollicular cell (C cells)

Epidemiology of Thyroid Nodules - an “epidemic”? Epidemiology of Thyroid Nodules - an “epidemic”?

: detected by ultrasound/autopsy : detected by palpationMazzaferri,EL. N Engl J Med 1993;328:553

: detected by ultrasound/autopsy : detected by palpationMazzaferri,EL. N Engl J Med 1993;328:553

• By age 30, about 20% of the population has a thyroid nodule (women>men)

• Lifetime likelihood is around 60%

Modes of detection of thyroid nodules

Modes of detection of thyroid nodules

Incidentalomas on head/neck CTs and MRIs, carotid ultrasound, PET scans.Palpated by primary care physicianNoticed by patientWith symptoms of hypo/hyperthyroid

Incidentalomas on head/neck CTs and MRIs, carotid ultrasound, PET scans.Palpated by primary care physicianNoticed by patientWith symptoms of hypo/hyperthyroid

As more radiologic tests are done, more nodules are discovered

DDx for Thyroid NodulesDDx for Thyroid Nodules

Primary Thyroid cancer (5%)Benign adenomaColloid cystSimple thyroid cystMetastasis from distant site (rare)

Role of follow-up is to rule out cancer

Primary Thyroid cancer (5%)Benign adenomaColloid cystSimple thyroid cystMetastasis from distant site (rare)

Role of follow-up is to rule out cancer

Patients at Increased Risk for Thyroid Cancer Patients at Increased

Risk for Thyroid CancerFamily history of thyroid cancer or other endocrine cancers (MEN syndromes)Previous radiation to the neck (malignancy rates 20-50% in palpable nodules)Chernobyl fallout victims (age <14 at the time)Male sex (ie. if a nodule is present, it is more likely to be cancer)Age < 30, > 60Compressive symptoms (i.e. hoarseness, dysphagia)

Family history of thyroid cancer or other endocrine cancers (MEN syndromes)Previous radiation to the neck (malignancy rates 20-50% in palpable nodules)Chernobyl fallout victims (age <14 at the time)Male sex (ie. if a nodule is present, it is more likely to be cancer)Age < 30, > 60Compressive symptoms (i.e. hoarseness, dysphagia)

Algorithm for diagnosisAlgorithm for diagnosis

Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid Association Guidelines Taskforce. 2006.

Depending on the skill and comfort of the clinician, some obviously benign nodules may not receive FNA right away.

FNA = Fine Needle Aspiration

Our Patient JF: HistoryOur Patient JF: History

73-year-old femalePMH includes GERD, osteopenia, and palpitations.Noticed a mass in her neck, and a cervical lymph node was palpable.Referred for CT where a thyroid nodule was seen.

73-year-old femalePMH includes GERD, osteopenia, and palpitations.Noticed a mass in her neck, and a cervical lymph node was palpable.Referred for CT where a thyroid nodule was seen.

Our patient JF: additional historyOur patient JF: additional history

Received radiation to her face and neck for acne treatment when she was a teenager.Family history notable for a first cousin and aunt with thyroid cancer.

Received radiation to her face and neck for acne treatment when she was a teenager.Family history notable for a first cousin and aunt with thyroid cancer.

Our patient JF: WorkupOur patient JF: Workup

With her personal and family history, as well as her clinical symptoms of a noticeable mass, we have a high clinical suspicion for thyroid cancer.

Still, we start her workup the same way as everyone else’s - thyroid hormone functions.

With her personal and family history, as well as her clinical symptoms of a noticeable mass, we have a high clinical suspicion for thyroid cancer.

Still, we start her workup the same way as everyone else’s - thyroid hormone functions.

JF’s thyroid function JF’s thyroid function

TSH = 1.7 (0.5 - 5)

Free T4 = 1.4 (0.93 - 1.7)

Suggests normal thyroid function.

TSH = 1.7 (0.5 - 5)

Free T4 = 1.4 (0.93 - 1.7)

Suggests normal thyroid function.

Next step: thyroid imagining

Menu of Radiologic TestsMenu of Radiologic Tests

Radioactive Iodine ScansThyroid scintigraphy with I-123Whole-body I-123 scan

Thyroid Ultrasound, +/- fine needle aspiration (FNA)CT occasionally used to evaluate compressive symptoms and spread of thyroid cancer

Radioactive Iodine ScansThyroid scintigraphy with I-123Whole-body I-123 scan

Thyroid Ultrasound, +/- fine needle aspiration (FNA)CT occasionally used to evaluate compressive symptoms and spread of thyroid cancer

Thyroid ScintigraphyThyroid Scintigraphy

Scintigraphy determines thyroid activity by measuring uptake of radioactive iodine. Indicated only in patients who are hyperthyroid or have indeterminant FNA results.

Scintigraphy determines thyroid activity by measuring uptake of radioactive iodine. Indicated only in patients who are hyperthyroid or have indeterminant FNA results.

Comparison patient #1: Normal Thyroid Scintigraphy

Comparison patient #1: Normal Thyroid Scintigraphy

Equal uptake in both lobesNo focal areas of increased or decreased uptake

Equal uptake in both lobesNo focal areas of increased or decreased uptake

www.radiologyinfo.org/en/photocat/photos_pc.cfm?image=thyroid-nm5-nrml.jpg&pg=thyroiduptake

Anterior view of thyroid

Right lobe Left lobe

Comparison Patient # 2 : “Cold” Thyroid nodule on Scintigraphy

Comparison Patient # 2 : “Cold” Thyroid nodule on Scintigraphy

www.radiologyinfo.org/en/photocat/photos_pc.cfm?image=thyroid-nm5-nrml.jpg&pg=thyroiduptakewww.radiologyinfo.org/en/photocat/photos_pc.cfm?image=thyroid-nm5-nrml.jpg&pg=thyroiduptake

NORMAL scan

“Cold”/hypofunctioning nodule in left lobe (Pink arrow)

DDx for a “cold” nodule

• Thyroid cancer• Benign adenoma• Cyst (colloid or simple)

Comparison Patient #3: “Hot” Thyroid nodule on Scintigraphy

Comparison Patient #3: “Hot” Thyroid nodule on Scintigraphy

“Hot”/hyperfunctioning nodule in right lobe(Pink arrow)

www.endotext.org/aging/aging8/aging8.htm

NORMAL scan

DDx for a “Hot” Nodule

• Autonomous adenoma• Focal thyroiditis

NOTE: A hyperfunctioning nodule is always benign and is a “don’t touch” radiologic finding. May have malignant features on biopsy.

Our patient JF: recommended imaging

Our patient JF: recommended imaging

Ultrasound and Fine Needle Aspiration (FNA) is indicated as the next step.

NOTE: for some patient populations (i.e. middle aged women, no suggestive history), FNA would only be undertaken if the nodule looked suspicious on ultrasound, but due to her clinical history JF’s FNA will be done regardless of the features of the nodule.

Ultrasound and Fine Needle Aspiration (FNA) is indicated as the next step.

NOTE: for some patient populations (i.e. middle aged women, no suggestive history), FNA would only be undertaken if the nodule looked suspicious on ultrasound, but due to her clinical history JF’s FNA will be done regardless of the features of the nodule.

Comparison patient #4: Normal thyroid ultrasound

Comparison patient #4: Normal thyroid ultrasound

Thyroid tissue (yellow arrows) Internal Jugular Vein (blue arrow)Trachea (pink arrow) Common Carotid Artery (star)Thyroid tissue (yellow arrows) Internal Jugular Vein (blue arrow)Trachea (pink arrow) Common Carotid Artery (star)

www.chr.ab.ca/bins/image.asp?rim_id=746

Interpretation of nodule features on ultrasound (US)

Interpretation of nodule features on ultrasound (US)

GOODAnechoic/cystic“Spongy”Ring of vascularization

GOODAnechoic/cystic“Spongy”Ring of vascularization

BADHypoechoic/solidWell-vascularizedMicrocalcificationsIrregular margins

BADHypoechoic/solidWell-vascularizedMicrocalcificationsIrregular margins

Companion patient #5: Benign cyst on USCompanion patient #5: Benign cyst on USWell-defined anechoic/cystic mass, likely colloid (yellow arrows)

Hyperechoic dots with “comet-tailing” artifacts, suggested condensed colloid masses (pink arrows)

Internal jugular vein (blue arrow)

Common carotid artery (star)

Well-defined anechoic/cystic mass, likely colloid (yellow arrows)

Hyperechoic dots with “comet-tailing” artifacts, suggested condensed colloid masses (pink arrows)

Internal jugular vein (blue arrow)

Common carotid artery (star)K T Wong and Anil T Ahuja. Ultrasound of thyroid cancer. Cancer Imaging Vol 5, 2005 International Cancer Imaging Society

Companion patient #6: Benign “spongy” cyst on US

Companion patient #6: Benign “spongy” cyst on US

Well-defined nodule (yellow arrows)Several anechoic/cystic regions (pink triangles)Well demarcated by septations (blue arrows)

Well-defined nodule (yellow arrows)Several anechoic/cystic regions (pink triangles)Well demarcated by septations (blue arrows)

K T Wong and Anil T Ahuja. Ultrasound of thyroid cancer. Cancer Imaging Vol 5, 2005 International Cancer Imaging Society

Companion patient #7: Suspicious nodule on US

Companion patient #7: Suspicious nodule on US

Ill-defined border (yellow arrows)Hypoechoic, but non-cysticMany dense microcalcifications (pink triangles)

Ill-defined border (yellow arrows)Hypoechoic, but non-cysticMany dense microcalcifications (pink triangles)

K T Wong and Anil T Ahuja. Ultrasound of thyroid cancer. Cancer Imaging Vol 5, 2005 International Cancer Imaging Society

Our patient JF: Thyroid ultrasound

Our patient JF: Thyroid ultrasound

Two fairly well-defined nodules, > 1cm Rim calcification Hypoechoic texture No cystic areasTwo fairly well-defined nodules, > 1cm Rim calcification Hypoechoic texture No cystic areas

BIDMC PACS

Our patient JF: Thyroid ultrasound with doppler Our patient JF: Thyroid ultrasound with doppler

Nodule 1 shows some vascularity penetrating the nodule, nodule 2 shows rim vascularity. Nodule 1 shows some vascularity penetrating the nodule, nodule 2 shows rim vascularity.

#1

BIDMC PACSThyroid nodule #1 Thyroid nodule #2

Our patient JF: follow-up to ultrasound

Our patient JF: follow-up to ultrasound

Several suspicious features on ultrasound, plus older age, family history of thyroid cancer and history of radiation

Next step is a Fine Needle Aspiration (FNA) to collect cells from the nodules.

Several suspicious features on ultrasound, plus older age, family history of thyroid cancer and history of radiation

Next step is a Fine Needle Aspiration (FNA) to collect cells from the nodules.

Compainion patient #8: Method of FNACompainion patient #8: Method of FNA

A 25-27 gauge needle is used (yellow arrow), and several samples are collected until the pathologist has enough cellular material to examine.

A 25-27 gauge needle is used (yellow arrow), and several samples are collected until the pathologist has enough cellular material to examine.

www.annals.org/content/vol142/issue11/images/large/11FF1.jpeg

Method of FNA, continuedMethod of FNA, continued

Large, easily palpable nodules are sometimes done without ultrasound guidance.

Benefits of ultrasound guidance include being able to locate small and unpalpable nodules and targeting the solid area of cystic nodules.

Local anesthesia is used at the discretion of the practitioner and the patient.

Large, easily palpable nodules are sometimes done without ultrasound guidance.

Benefits of ultrasound guidance include being able to locate small and unpalpable nodules and targeting the solid area of cystic nodules.

Local anesthesia is used at the discretion of the practitioner and the patient.

Ultrasound guided FNAUltrasound guided FNA

Needle inserted perpendicular to the transducer is easiest to see, because more of the signal is bounced back and received by the transducer.

Needle inserted perpendicular to the transducer is easiest to see, because more of the signal is bounced back and received by the transducer.

www.annals.org/content/vol 142/issue11/images/large/1 1FF1.jpeg

Possible FNA resultsPossible FNA results

Pathology reports fall into 1 of 4 categories (incidences):

Non-diagnostic (15%)

Malignant (5%)

Indeterminant (10%)

Benign (70%)

Pathology reports fall into 1 of 4 categories (incidences):

Non-diagnostic (15%)

Malignant (5%)

Indeterminant (10%)

Benign (70%)

Repeat FNA

Lobectomy or or thyroidectomythyroidectomy

Close followClose follow--up or surgeryup or surgery

No followNo follow--up or repeat up or repeat ultrasound in 1 yearultrasound in 1 year

Our patient JF: FNA resultOur patient JF: FNA result

Indeterminant“Follicular cells with enlarged and crowded nuclei with rare nuclear grooves.”“There is slight nuclear membrane irregularity but no inclusions.”

Indeterminant“Follicular cells with enlarged and crowded nuclei with rare nuclear grooves.”“There is slight nuclear membrane irregularity but no inclusions.”

BIDMC cytology detail, careweb

*Suggestive of thyroid malignancy*

Our patient JF: TreatmentOur patient JF: Treatment

JF underwent a right lobectomy.Pathology results showed papillary thyroid carcinoma, follicular variant, with no lymph node involvement. JF underwent subsequent completion thyroidectomy 2 weeks later, which showed a small papillary carcinoma in the left lobe.

JF underwent a right lobectomy.Pathology results showed papillary thyroid carcinoma, follicular variant, with no lymph node involvement. JF underwent subsequent completion thyroidectomy 2 weeks later, which showed a small papillary carcinoma in the left lobe.

Our patient JF: Post-surgical follow-up

Our patient JF: Post-surgical follow-up

2 months later she underwent a total-body radioactive I-123 scan to look for remaining thyroid tissue.

Reminder: CT, MRI, or PET scans are notrecommended for following thyroid cancer, except CT to investigate compressive symptoms.

2 months later she underwent a total-body radioactive I-123 scan to look for remaining thyroid tissue.

Reminder: CT, MRI, or PET scans are notrecommended for following thyroid cancer, except CT to investigate compressive symptoms.

Radioactive I-123 ScanRadioactive I-123 Scan

Thyroid tissue takes up the radioactive iodine isotope, I-123. The radiation released does not damage the thyroid tissue and is picked up on film. Uses are to look for remaining thyroid tissue or exogenous uptake, indicating possible metastasis.Patient Preparation: patients must stop taking their thyroid replacement hormone for a week prior to the scan and eat a low iodine diet.

Thyroid tissue takes up the radioactive iodine isotope, I-123. The radiation released does not damage the thyroid tissue and is picked up on film. Uses are to look for remaining thyroid tissue or exogenous uptake, indicating possible metastasis.Patient Preparation: patients must stop taking their thyroid replacement hormone for a week prior to the scan and eat a low iodine diet.

Our patient JF: Results of I-123 scan

Our patient JF: Results of I-123 scan

No exogenous uptake on full body scan, suggests no spread of the cancer.Uptake in thyroid confirms remaining tissue and the need for radioactive ablation.

No exogenous uptake on full body scan, suggests no spread of the cancer.Uptake in thyroid confirms remaining tissue and the need for radioactive ablation.

BIDMC PACSWhole body Thyroid

I-131 Radioiodine ablationI-131 Radioiodine ablation

Radioactive iodine taken up by thyroid tissue. Short-distance beta emissions result in thyroid tissue damage.Minor amounts of long-distance gamma emissions require that patients are isolated for 24 hours after treatment.

Radioactive iodine taken up by thyroid tissue. Short-distance beta emissions result in thyroid tissue damage.Minor amounts of long-distance gamma emissions require that patients are isolated for 24 hours after treatment.

Our patient JF: 3 month post- ablation ultrasound

Our patient JF: 3 month post- ablation ultrasound

Post-throidectomy and ablation therapy ultrasound showed scar tissue with no recurrent nodules (yellow boxes) and no enlarged lymph nodes (not shown).

Post-throidectomy and ablation therapy ultrasound showed scar tissue with no recurrent nodules (yellow boxes) and no enlarged lymph nodes (not shown).

BIDMC PACS

AcknowledgementsAcknowledgements

Dr. Colin McArdleFor teaching me about thyroid ultrasound, FNA and care for patients with thyroid nodules.

Dr. Gillian LiebermanFor teaching and presentation guidance.

Maria LevantakisFor always being there when we need her.

Dr. Colin McArdleFor teaching me about thyroid ultrasound, FNA and care for patients with thyroid nodules.

Dr. Gillian LiebermanFor teaching and presentation guidance.

Maria LevantakisFor always being there when we need her.

ReferencesReferences

Mitchell J, Parangi S. The thyroid incidentaloma: an increasingly frequent consequence of radiologic imaging. Seminars in Ultrasound, CT and MR. 2005 Feb;26(1):37-46.Mazzaferri EL. Management of a solitary thyroid nodule.New England Journal of Medicine. 1993 Feb 25;328(8):553-9.Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid Association Guidelines Taskforce. THYROID. Volume 16, Number 2, 2006.

Mitchell J, Parangi S. The thyroid incidentaloma: an increasingly frequent consequence of radiologic imaging. Seminars in Ultrasound, CT and MR. 2005 Feb;26(1):37-46.Mazzaferri EL. Management of a solitary thyroid nodule.New England Journal of Medicine. 1993 Feb 25;328(8):553-9.Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid Association Guidelines Taskforce. THYROID. Volume 16, Number 2, 2006.