INCIDENTAL THYROID NODULES AND PROMINENT Incidental Thyroid...INCIDENTAL THYROID NODULES AND PROMINENT LYMPH NODES ON CHEST CT Richard M. Gore, MD ... Olavo Ribeiro RodriguesII; Roberto

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  • INCIDENTAL THYROID NODULES INCIDENTAL THYROID NODULES AND PROMINENT LYMPH NODESAND PROMINENT LYMPH NODES

    ON CHEST CTON CHEST CT

    Richard M. Gore, MDNorth Shore University Health System

    University of ChicagoEvanston, IL

    SCBT/MR 2010March 7, 2010

    15:50-16:10

  • MEDIASTINAL LYMPH MEDIASTINAL LYMPH NODESNODES

  • MEDIASTINAL LYMPH MEDIASTINAL LYMPH NODE SIZENODE SIZE

    Glazer AJR 144: 261Glazer AJR 144: 261--265, 1984265, 1984 Quint AJR 147: 469Quint AJR 147: 469--472, 1986472, 1986 Kiyono AJR 150: 771Kiyono AJR 150: 771--776, 1988 776, 1988

  • MEDIASTINAL LYMPH MEDIASTINAL LYMPH NODE SIZENODE SIZE

    Jornal Brasileiro de PneumologiaJornal Brasileiro de Pneumologia J bras pneumolJ bras pneumol 33:13333:133--140,140, 20072007 Mediastinal lymph node distribution, size and number: Mediastinal lymph node distribution, size and number:

    definitions based on an anatomical studydefinitions based on an anatomical study** Aurelino Fernandes Schmidt JAurelino Fernandes Schmidt JniorI; Olavo Ribeiro niorI; Olavo Ribeiro

    RodriguesII; Roberto Storte MatheusIII; Jorge Du Ub RodriguesII; Roberto Storte MatheusIII; Jorge Du Ub KimIV; FKimIV; Fbio Biscegli JateneVbio Biscegli JateneV

  • MEDIASTINAL LYMPH MEDIASTINAL LYMPH NODE SIZENODE SIZE

  • MEDIASTINAL LAD AND CHFMEDIASTINAL LAD AND CHF

    LAD present in 81% of patients with LAD present in 81% of patients with ejection fraction< 35%ejection fraction< 35%

    63% of enlarged nodes were pretracheal in 63% of enlarged nodes were pretracheal in location with a SAD of 1.3 cmlocation with a SAD of 1.3 cm

    Erly JCAT 27: 485Erly JCAT 27: 485--489, 2003489, 2003

  • MEDIASTINAL LAD AND CHFMEDIASTINAL LAD AND CHF

    42% of patients with left heart failure 42% of patients with left heart failure showed LAD. 62% showed regression with showed LAD. 62% showed regression with treatmenttreatment

    LAD group showed lower EF (34% vs LAD group showed lower EF (34% vs 43%), larger R superior pul vein, more 43%), larger R superior pul vein, more peribronchovascular thickeningperibronchovascular thickening

    Chabbert Eur Radiol 14: 481Chabbert Eur Radiol 14: 481--489, 2004489, 2004

  • MEDIASTINAL LAD AND CHRONIC MEDIASTINAL LAD AND CHRONIC INFILTRATIVE LUNG DISEASEINFILTRATIVE LUNG DISEASE

    67% with CILD had LAD67% with CILD had LAD UIP, IPF, CVD, BOOP, EAAUIP, IPF, CVD, BOOP, EAA

    Niimi JCAT 20: 305Niimi JCAT 20: 305--308, 1996308, 1996

  • MEDIASTINAL LAD AND PAHMEDIASTINAL LAD AND PAH

    44.7% with PAH had LAD44.7% with PAH had LAD Associated with pleural and pericardial Associated with pleural and pericardial

    effusionseffusions ? Due to increased lymphatic flow caused ? Due to increased lymphatic flow caused

    by right heart failureby right heart failure

    Bergin J Med Imag Rad Oncol 52:18Bergin J Med Imag Rad Oncol 52:18--23, 2008 23, 2008

  • PULMONARY ARTERYPULMONARY ARTERYHYPERTENSIONHYPERTENSION

    DyspneaDyspnea Fatigue Fatigue Dizziness Dizziness Chest painChest pain TachycardiaTachycardia PalpitationsPalpitations Syncope Syncope Lower extremity edema Lower extremity edema CyanosisCyanosis

  • THE THYROID NODULE THE THYROID NODULE PANDEMICPANDEMIC

    44--8% adults by palpation8% adults by palpation 41% adults by ultrasound41% adults by ultrasound 50% adults at autopsy50% adults at autopsy 25,690 new cases annually25,690 new cases annually 1,460 annual mortality1,460 annual mortality

  • INCIDENTAL THYROID LESIONS SEEN INCIDENTAL THYROID LESIONS SEEN ON NECK CT AND MRION NECK CT AND MRI

    16% incidence (6% prosp, 10% retrosp)16% incidence (6% prosp, 10% retrosp) Scintigraphy, sonography, TFT, FNA, Scintigraphy, sonography, TFT, FNA,

    lobectomylobectomy Mean cost of work up was $1,158Mean cost of work up was $1,158

    Yousem AJNR 18: 1423Yousem AJNR 18: 1423--1428, 19971428, 1997

  • THYROID NODULES FOUNDTHYROID NODULES FOUNDON CAROTID DOPPLERON CAROTID DOPPLER

    9.4% incidence of one or more thyroid 9.4% incidence of one or more thyroid nodulesnodules

    7.7% ultimately had thyroidectomy7.7% ultimately had thyroidectomy

    Steele Arch Surg 140: 981Steele Arch Surg 140: 981--985, 2005985, 2005

  • EPIDEMIC OF NODULAR EPIDEMIC OF NODULAR THYROID DISEASETHYROID DISEASE

    Assume a cost of Assume a cost of $1,500 for US$1,500 for US--guided FNA and guided FNA and cytologic analysiscytologic analysis

    Thyroid operations Thyroid operations cost $20,000 eachcost $20,000 each

  • THE STAGERING POTENTIALTHE STAGERING POTENTIALCOST OF THYROID NODULESCOST OF THYROID NODULES

    35,000,000 neck and chest CT 35,000,000 neck and chest CT performed annuallyperformed annually

    10% have thyroid nodules10% have thyroid nodules 3.5 million patients with nodules 3.5 million patients with nodules $1,500 X 3.5 million= $5,250,000,000$1,500 X 3.5 million= $5,250,000,000 $5,250,000,000/ 1,500= $3,500,000$5,250,000,000/ 1,500= $3,500,000

  • INCIDENTAL THYROIDINCIDENTAL THYROIDNODULES ON NECK CTNODULES ON NECK CT

    3.9% prevalence of malignant nodules3.9% prevalence of malignant nodules 7.4% prevalence of potentially malignant 7.4% prevalence of potentially malignant

    lesionslesions Patients Patients 35 y.o. have a significantly 35 y.o. have a significantly

    greater rate of malignancygreater rate of malignancy CT underestimates the number of nodules CT underestimates the number of nodules

    relative to sonographyrelative to sonography

    Shetty AJR 187: 1349Shetty AJR 187: 1349--1356, 20061356, 2006

  • INCIDENTAL THYROIDINCIDENTAL THYROIDNODULES ON NECK CTNODULES ON NECK CT

    No distinguishing features on CT could No distinguishing features on CT could confidently identify a lesion as malignantconfidently identify a lesion as malignant

    Features that warrant suspicion: punctate Features that warrant suspicion: punctate calcifications, larger size, younger patientcalcifications, larger size, younger patient

    Shetty AJR 187: 1349Shetty AJR 187: 1349--1356, 20061356, 2006

  • PATIENT LIFE EXPECTANCYPATIENT LIFE EXPECTANCYAND COMORBIDITIESAND COMORBIDITIES

    Defer evaluation unless patient Defer evaluation unless patient symptomatic or hyperthyroidsymptomatic or hyperthyroid

    For you who are about to die, we For you who are about to die, we salute yousalute you

  • Patient < 50 years oldPatient < 50 years old

  • ULTRASOUND EXAMULTRASOUND EXAM

    Document the number and size of nodulesDocument the number and size of nodules Marked hypoechogenicityMarked hypoechogenicity Intranodular vascularityIntranodular vascularity Incomplete peripheral haloIncomplete peripheral halo Irregular marginIrregular margin Central microcalcificationCentral microcalcification

  • WHAT ABOUT THE 75 MILLION OTHERS OF WHAT ABOUT THE 75 MILLION OTHERS OF US OLDER THAN 50 YEARS AND THE US OLDER THAN 50 YEARS AND THE

    12,000 BOOMERS REACHING 50 EACH DAY12,000 BOOMERS REACHING 50 EACH DAY

    No one ever got sued for recommending a No one ever got sued for recommending a thyroid ultrasound for an incidental thyroid thyroid ultrasound for an incidental thyroid nodule found on MDCTnodule found on MDCT

  • THYROID CANCER RISK THYROID CANCER RISK EVALUATIONEVALUATION

    History of radiationHistory of radiation Personal or FH of endocrine neoplasmsPersonal or FH of endocrine neoplasms Male genderMale gender Hoarseness or dysphagiaHoarseness or dysphagia AdenopathyAdenopathy Thyroid function testsThyroid function tests

  • NODULES < 8mm or 8NODULES < 8mm or 8--15 mm 15 mm without worrisome featureswithout worrisome features

    Risk factorsRisk factors AgeAge Life expectancy and Life expectancy and

    comorbiditiescomorbidities Patient counseling to Patient counseling to

    report any changereport any change Reevaluation with Reevaluation with

    ultrasound in 6 ultrasound in 6 monthsmonths

  • Wording of reportWording of report

    In an asymptomatic patient with normal In an asymptomatic patient with normal thyroid function, no history of radiation or thyroid function, no history of radiation or other thyroid cancer risk factors, this lesion other thyroid cancer risk factors, this lesion is statistically most likely benign.is statistically most likely benign.

  • NODULES 8NODULES 8--15 mm WITH 15 mm WITH 1 WORRISOME FEATURE1 WORRISOME FEATURE

    Mural thickeningMural thickening Mural nodularityMural nodularity CalcificationCalcification FNA with FNA with

    ultrasound ultrasound guidanceguidance

  • NODULES > 15 mmNODULES > 15 mm

    FNA with FNA with ultrasound ultrasound guidanceguidance

    MEDIASTINAL LYMPH NODESMEDIASTINAL LYMPH NODE SIZEMEDIASTINAL LYMPH NODE SIZEMEDIASTINAL LYMPH NODE SIZEMEDIASTINAL LAD AND CHFMEDIASTINAL LAD AND CHFMEDIASTINAL LAD AND CHRONIC INFILTRATIVE LUNG DISEASEMEDIASTINAL LAD AND PAHPULMONARY ARTERYHYPERTENSIONTHE THYROID NODULE PANDEMICINCIDENTAL THYROID LESIONS SEEN ON NECK CT AND MRITHYROID NODULES FOUNDON CAROTID DOPPLEREPIDEMIC OF NODULAR THYROID DISEASETHE STAGERING POTENTIALCOST OF THYROID NODULESINCIDENTAL THYROIDNODULES ON NECK CTINCIDENTAL THYROIDNODULES ON NECK CTPATIENT LIFE EXPECTANCYAND COMORBIDITIESPatient < 50 years oldULTRASOUND EXAMWHAT ABOUT THE 75 MILLION OTHERS OF US OLDER THAN 50 YEARS AND THE 12,000 BOOMERS REACHING 50 EACH DAYTHYROID CANCER RISK EVALUATIONNODULES < 8mm or 8-15 mm without worrisome featuresWording of reportNODULES 8-15 mm WITH 1 WORRISOME FEATURENODULES > 15 mm