Management of Solitary Cold Thyroid Nodule

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    Management of SolitaryManagement of SolitaryCold Thyroid NoduleCold Thyroid Nodule

    ((A RetroA Retro-- & Prospective Study)& Prospective Study)ByBy

    Abdullah MohamedAbdullah MohamedEzzatEzzatFakhrFakhrElEl--DinDin

    SupervisorsSupervisors

    Prof. Dr.Prof. Dr. MohamedMohamed KadryKadry MohamedMohamed KadryKadryProfessor of General SurgeryProfessor of General Surgery

    Prof. Dr.Prof. Dr. MagdiMagdi HassanHassan ElEl--ShahawiShahawiProfessor of Surgical OncologyProfessor of Surgical Oncology

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    The solitary thyroid nodule isThe solitary thyroid nodule is

    defined as a discrete palpabledefined as a discrete palpable

    swelling in an otherwise impalpableswelling in an otherwise impalpablegland.gland.

    It is a clinical diagnosis. Many ofIt is a clinical diagnosis. Many ofthese cases prove to be multithese cases prove to be multi--

    nodular but presenting as a singlenodular but presenting as a single

    thyroid nodule.thyroid nodule.

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    The incidence of solitary thyroid nodule isThe incidence of solitary thyroid nodule is

    about 4%about 4%

    Females are more affected than males (4:1)Females are more affected than males (4:1)Commonest in the age group between 21Commonest in the age group between 21--4040

    yearsyears

    Malignancy is found in about 8Malignancy is found in about 8--10% of these10% of thesenodulesnodules

    The chance of malignancy in the solitary coldThe chance of malignancy in the solitary cold

    thyroid nodule is 15thyroid nodule is 15--20%20%

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    AnatomyAnatomy

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    Anatomy ofthe thyroid

    gland

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    Simple (colloid) noduleSimple (colloid) nodule

    Autonomous (toxic) noduleAutonomous (toxic) nodule

    Inflammatory nodule:Inflammatory nodule:AcuteAcute thyroiditisthyroiditis

    GranulomatousGranulomatous thyroiditisthyroiditis

    AutoimmuneAutoimmune thyroiditisthyroiditis

    RiedelRiedelss thyroiditisthyroiditis

    CystsCysts

    Pathology of the Solitary Thyroid Nodule:Pathology of the Solitary Thyroid Nodule:

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    NeoplasticNeoplastic nodule:nodule:

    Epithelial tumors:Epithelial tumors:Follicular adenomaFollicular adenoma

    Papillary carcinomaPapillary carcinoma

    Follicular carcinomaFollicular carcinomaHHrthlerthle cell (cell (oncocyticoncocytic) tumors) tumors

    Clear cell tumorClear cell tumor

    Squamous cell,Squamous cell,

    mucinousmucinous

    and related tumorsand related tumors

    Poorly differentiated carcinomaPoorly differentiated carcinoma

    Undifferentiated carcinomaUndifferentiated carcinoma

    Medullary carcinomaMedullary carcinoma

    Lymphoid tumors and tumor likeLymphoid tumors and tumor likeconditionsconditions

    Metastatic tumorsMetastatic tumors

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    Clinical examinationClinical examinationLaboratory studiesLaboratory studies

    Radiological studies:Radiological studies:

    Neck ultrasonographyNeck ultrasonographyIsotope scanning of the thyroidIsotope scanning of the thyroid

    CT scanCT scan

    Histopathological studies:Histopathological studies:

    Fine needle aspiration cytologyFine needle aspiration cytology

    Frozen sectionFrozen section

    Final histopathological examinationFinal histopathological examination

    Diagnostic Tools of Solitary Thyroid NoduleDiagnostic Tools of Solitary Thyroid Nodule

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    Benefits:Benefits:

    Detection ofDetection of multinodularitymultinodularityDifferentiates texture of the nodule (cysticDifferentiates texture of the nodule (cystic vsvs solid andsolid andhomogenoushomogenous vsvs heterogeneous)heterogeneous)

    Detects and follows the size of the noduleDetects and follows the size of the nodule

    Detection of thyroid calcificationDetection of thyroid calcification

    Exploration of the neck for enlarged lymph nodesExploration of the neck for enlarged lymph nodesGuidance of FNAGuidance of FNA

    Color Doppler sonography in malignancy predictionColor Doppler sonography in malignancy prediction

    Disadvantages:Disadvantages:Operator dependentOperator dependentDoes not clearly delineate anatomy between thyroidDoes not clearly delineate anatomy between thyroidand adjacent structuresand adjacent structures

    Cannot diagnose malignancyCannot diagnose malignancy

    Thyroid UltrasonographyThyroid Ultrasonography

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    Appearance of thyroid carcinoma onAppearance of thyroid carcinoma onthyroid scan:thyroid scan:

    No change.No change.

    Enlargement of the lobe without alterationEnlargement of the lobe without alterationin the apparent activity.in the apparent activity.

    Encroachment on the edge of the lobeEncroachment on the edge of the lobe

    (benign lesion tend to displace rather than(benign lesion tend to displace rather thanencroach on the lobe).encroach on the lobe).

    Presents as cold area within the lobe.Presents as cold area within the lobe.

    Isotope Scanning of the Thyroid GlandIsotope Scanning of the Thyroid Gland

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    Disadvantages:Disadvantages:

    Radiation exposureRadiation exposure

    Difficult to detect lesions in theDifficult to detect lesions in the

    periphery orperiphery or isthumusisthumus

    Normal tissue over nonfunctioningNormal tissue over nonfunctioning

    nodule may mask findingsnodule may mask findingsCannot diagnose malignancyCannot diagnose malignancy

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    Fine Needle Aspiration and CytologyFine Needle Aspiration and Cytology

    Benefits:Benefits:

    Simple, safe, painless, well toleratedSimple, safe, painless, well tolerated

    procedure and can be repeated manyprocedure and can be repeated manytimes when neededtimes when needed

    Enables definite diagnosis ofEnables definite diagnosis of

    malignancymalignancy

    Diagnostic accuracy is more than 90%Diagnostic accuracy is more than 90%

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    Limitations:Limitations:

    Technical difficulties including samplingTechnical difficulties including samplingerror, inadequate preparation of theerror, inadequate preparation of the

    aspirate, and interpretation errorsaspirate, and interpretation errors

    False positive resultsFalse positive results

    False negative resultsFalse negative results

    Less reliable for cystic lesionsLess reliable for cystic lesions

    Differentiation between follicular adenomaDifferentiation between follicular adenoma

    and well differentiated carcinomaand well differentiated carcinoma

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    Cytological InterpretationCytological Interpretation

    Positive malignancy: Malignant cells arePositive malignancy: Malignant cells are

    presentpresent

    Suspicious: In presence of nuclearSuspicious: In presence of nuclear atypiaatypiaandand hypercellularityhypercellularity

    Negative: No evidence of malignant cellsNegative: No evidence of malignant cells

    Unsatisfactory: Inadequate specimen forUnsatisfactory: Inadequate specimen for

    interpretationinterpretation

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    Indications of surgical resection ofIndications of surgical resection of

    thyroid nodule influenced by FNACthyroid nodule influenced by FNACAll proven malignant nodulesAll proven malignant nodules

    AllAll cytologicallycytologically diagnosed folliculardiagnosed follicular

    neoplasmsneoplasmsAll lesions exhibiting an atypical but nonAll lesions exhibiting an atypical but non--diagnostic cellular pattern on cytologydiagnostic cellular pattern on cytology

    Cystic nodules which recur followingCystic nodules which recur followingaspirationaspiration

    When on clinical grounds, suspicion ofWhen on clinical grounds, suspicion of

    malignancy is high even if the cytologymalignancy is high even if the cytologyreport suggests benign diseasereport suggests benign disease

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    Findings that may increase risk ofFindings that may increase risk of

    malignancy in thyroid nodulesmalignancy in thyroid nodules

    Solitary cold noduleSolitary cold nodule

    Male sex, age >40 yearsMale sex, age >40 years

    Rapidly enlargingRapidly enlargingHoarseness orHoarseness or dysphagiadysphagia

    History of neck irradiation, family history of thyroidHistory of neck irradiation, family history of thyroidcarcinomacarcinoma

    Inherited tumor syndromes e.g. MEN type IIInherited tumor syndromes e.g. MEN type II

    Irregular, hard, fixed, ill defined marginsIrregular, hard, fixed, ill defined margins

    IpsilateralIpsilateral lymphadenopathy or distant metastaseslymphadenopathy or distant metastases

    HypoechoicHypoechoic nodule or cyst >4