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 JúúniorI; Olavo Ribeiro niorI; Olavo Ribeiro

RodriguesII; Roberto Storte MatheusIII; Jorge Du Ub RodriguesII; Roberto Storte MatheusIII; Jorge Du Ub KimIV; FKimIV; Fáábio 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