Management of ThyroidManagement of Thyroid Nodules in ... Management of ThyroidManagement of Thyroid

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  • Management of ThyroidManagement of ThyroidManagement of Thyroid Management of Thyroid Nodules in theNodules in the 2121stst CenturyCenturyNodules in the Nodules in the 2121 CenturyCentury

    H h K ddH h K ddHesham KaddourHesham Kaddour Consultant ENT/Head& Neck SurgeonConsultant ENT/Head& Neck SurgeonConsultant ENT/Head& Neck SurgeonConsultant ENT/Head& Neck Surgeon

    Queen’s University Hospital Queen’s University Hospital –– UKUK

    2828thth International Laryngology International Laryngology ConferenceConference

    AlexAlex April April 20102010

    The most powerful tool hatThe most powerful tool hatThe most powerful tool hat The most powerful tool hat doctors have….doctors have….

    DIAGNOSISDIAGNOSISDIAGNOSISDIAGNOSIS

    BMJ BMJ 24 24 Feb. Feb. 20092009, , 338338

  • Thyroidectomy;Thyroidectomy; HISTORYHISTORY

    Bill th fi tBill th fi t•• Billroth first Billroth first thyroidectomy thyroidectomy 18501850

    Kocher modernKocher modern•• Kocher modern Kocher modern thyroidectomy thyroidectomy 1872187218721872

    •• Nobel Prize Nobel Prize 19121912

    • 1883

    Kocher’s performs a retrospective review • 5000 career thyroidectomies • Mortality rates decreased

    – 40% in 1850 (pre-Kocher & Bilroth) – 12.6% in 1870’s (Kocher begins practice)12.6% in 1870 s (Kocher begins practice) – 0.2% in 1898 (end of Kocher’s career)

    • Many patients developed cretinism or myxedema

    His conclusions ….

  • Thyroidectomy;Thyroidectomy; HISTORYHISTORY

    In presentation to the German Surgical In presentation to the German Surgical p gp g Congress …Congress …

    “ …the thyroid gland in“ …the thyroid gland in …the thyroid gland in …the thyroid gland in fact had a function….”fact had a function….”

    Theodor Kocher, Theodor Kocher, 18831883

    What is goitre?What is goitre?at s go t eat s go t e

    Thyroid gland enlargementThyroid gland enlargementThyroid gland enlargementThyroid gland enlargement

  • Types of goitreTypes of goitreTypes of goitreTypes of goitre EpidemiologicalEpidemiological •• EndemicEndemic •• SporadicSporadic MorphologicalMorphological •• MNMNMNMN •• SolitarySolitary FunctionalFunctionalFunctionalFunctional •• NonNon--toxictoxic

    T iT i•• ToxicToxic

    Thyroid Nodule; Thyroid Nodule; PathologyPathology

    •• Simple cystSimple cyst•• Simple cystSimple cyst •• Complex cystComplex cystp yp y •• Colloid noduleColloid nodule

    AdAd•• AdenomaAdenoma •• Hashimoto’s noduleHashimoto’s noduleHashimoto s noduleHashimoto s nodule •• Malignant noduleMalignant nodule

  • WHOWHO ClassificationClassification

    •• Grade Grade 00 NonNon--palpablepalpable goitregoitre

    Grade IGrade I PalpablePalpable goitregoitre•• Grade IGrade I PalpablePalpable goitregoitre

    •• Grade IIGrade II VisibleVisible goitregoitregg

    How Common?How Common?How Common?How Common?

    •• Palpable Thyroid NodulesPalpable Thyroid Nodules 55%%•• Palpable Thyroid Nodules Palpable Thyroid Nodules 55%% Deandrea et al Endocr.Pract.2002

    33 000000 000000•• In UKIn UK 33,,000000,,000000

  • How Common?How Common?How Common?How Common?

    •• HDUS ScanHDUS Scan 5050%%•• HDUS ScanHDUS Scan 5050%% Ezzat et al. Arch Intern Med 1994

    3030 000000 000000•• In UKIn UK 3030,,000000,,000000

    How Common?How Common?How Common?How Common? •• The annual incidence is The annual incidence is 00..11%% Gharib Thyroid Today 1997Gharib, Thyroid Today 1997

    •• U KU K 6060 000000 / year/ yearU KU K 6060,,000 000 / year/ year

  • The RealityThe RealityThe RealityThe Reality

    UKUK 77,,000 000 thyroidectomy/yearthyroidectomy/year

    DoH DoH 20042004

    The CostThe CostThe CostThe Cost •• ££33,,000000/ procedure / procedure BUPA 2009BUPA 2009

    •• The The currentcurrent cost;cost;

    UKUK ££2121 000000 000000 / year/ yearUKUK ££2121,,000000,,000000 / year/ year

  • The CostThe CostThe CostThe Cost

    ThTh P t ti lP t ti l C tC t•• The The PotentialPotential CostCost

    UKUK ££180180,,000000,,000000 / year/ yearUKUK ££180180,,000000,,000000 / year/ year

    Why Bothered?Why Bothered?

  • Malignant RiskMalignant RiskMalignant RiskMalignant Risk 1010 3030%%•• 10 10 –– 3030%%

    •• Solitary cold nodulesSolitary cold nodulesyy Kountakis et al Ear Nose Throat J 2002

    •• 55%% •• Any nodulesAny nodules Mazzaferri EL The New England Journal ofMazzaferri EL The New England Journal of

    Medicine 1993

    High Risk FactorsHigh Risk Factorsgg •• Past neck IrradiationPast neck Irradiation

    Hi h i t l di tiHi h i t l di ti•• High environmental radiationHigh environmental radiation •• Family history of Ca thyroidFamily history of Ca thyroid•• Family history of Ca thyroidFamily history of Ca thyroid •• Males > femalesMales > femalesMales > femalesMales > females •• Age > Age > 50 50 yearsyearsgg yy •• Children Children

  • Head & Neck CarcinomaHead & Neck Carcinoma

    • NICE 2004

    • IOG

    2 weeks referral guidelines2 weeks referral guidelines (NICE 2004)(NICE 2004)

    • Hoarseness persisting for more than six weeks. • Ulceration of oral mucosa persisting for more than three

    kweeks. • Oral swellings persisting for more than three weeks. • All red or red and white patches of the oral mucosa.All red or red and white patches of the oral mucosa. • Dysphagia persisting for more than three weeks. • Unilateral nasal obstruction, particularly when associated

    ith l t di hwith purulent discharge. • Unexplained tooth mobility not associated with periodontal

    disease.

    • Persistent neck mass > 3 weeks. • Cranial neuropathies.p • Orbital mass.

  • Neck Lump ClinicNeck Lump ClinicNeck Lump ClinicNeck Lump Clinic

    H&NH&N CytologistCytologistH&N H&N SurgeonSurgeon

    CytologistCytologist

    One Stop ClinicOne Stop Clinic

    CNSCNS RadiologistRadiologist

    IOGIOG 20042004IOG IOG 20042004 •• MDTMDT

    C U itC U it•• Cancer UnitCancer Unit •• Cancer CentreCancer CentreCancer CentreCancer Centre •• Cancer Net WorkCancer Net Work

    T mo r Ad isor BoardT mo r Ad isor Board•• Tumour Advisory BoardTumour Advisory Board •• Peers ReviewPeers Review •• Cancer TsarCancer Tsar

  • MMultiulti DDisciplinaryisciplinary TTeameamMMulti ulti DDisciplinary isciplinary TTeameam RadiologistRadiologist PathologistPathologist

    NuclearNuclear Thyroid SurgeonThyroid Surgeon

    EndocrinologistEndocrinologist

    NuclearNuclear MedicineMedicine PhysicianPhysician

    CNSCNS MDTMDT

    CoCo--ordinatorordinator

    1414//3131//6262 RulesRules1414//3131//6262 RulesRules

    GP ReferralGP Referral Lump ClinicLump Clinic DiagnosisDiagnosis

    MDTMDT TreatmentTreatment

    00 1414 3131 6262

    DAYSDAYS

  • British Thyroid AssociationBritish Thyroid Association 20072007

    EEvidencevidence BBasedased MMedicineedicineEEvidence vidence BBased ased MMedicineedicine II M t l i f RCTM t l i f RCT•• IaIa Meta analysis of RCTsMeta analysis of RCTs

    •• IbIb RCTRCT

    •• IIaIIa Controlled studiesControlled studies•• IIaIIa Controlled studiesControlled studies •• IIbIIb Experimental studiesExperimental studies

    •• IIIIII Non experimental studiesNon experimental studiesIIIIII Non experimental studiesNon experimental studies

    IVIV E t i iE t i i•• IVIV Expert opinionsExpert opinions

  • RecommendationsRecommendationsRecommendationsRecommendations •• AA Ia + IbIa + Ib

    •• BB IIa + IIb + IIIIIa + IIb + IIIBB IIa IIb IIIIIa IIb III

    •• CC IVIV

    Management of Thyroid NoduleManagement of Thyroid Nodule

    When to refer?When to refer?When to refer?When to refer?

    EmergencyEmergency RoutineRoutineUrgent Urgent 2 2 weeksweeksg yg y •Stridor ••AsymptomaticAsymptomatic

    ••22ndnd opinionopinion ••Patient requestPatient request

    gg •Change in size •Hoarseness L h d ••Patient requestPatient request•Lymph nodes

    BTA 2007

  • CCombinedombined TThyroidhyroid CCliniclinicCCombined ombined TThyroid hyroid CCliniclinic RadiologistRadiologist CytologistCytologist

    NuclearNuclear One Stop ClinicOne Stop Clinic

    EndocrinologistEndocrinologist

    NuclearNuclear MedicineMedicine PhysicianPhysician

    CNSCNS Thyroid Thyroid SurgeonSurgeon

    Neck Lump ClinicNeck Lump ClinicNeck Lump ClinicNeck Lump Clinic

    H&NH&N CytologistCytologistH&N H&N SurgeonSurgeon

    CytologistCytologist

    One Stop ClinicOne Stop Clinic

    CNSCNS RadiologistRadiologist

  • Neck Lump Clinic n=60

    30

    35 Unilateral Bilateral Parotid

    20

    25 Parotid Thyroid No Lump

    at ie

    nt s

    15

    20

    be r o

    f P a

    5

    10

    N um

    0 Unilateral Bilateral Parotid Thyroid No Lump

    Kaddour 2007

    Who should performWho should performWho should perform Who should perform thyroidectomy?thyroidectomy?thyroidectomy?thyroidectomy?

    •• General SurgeonGeneral Surgeongg •• Breast SurgeonBreast Surgeon ••