Neoplastic Thyroid Nodules Goiter and Thyroid Cancer

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    Thomas Repas D.O.

    Diabetes, Endocrinology and Nutrition Center, Affinity Medical Group, Neenah, Wisconsin

    Member, Diabetes Advisory Group, Wisconsin Diabetes Prevention and Control ProgramMember, Inpatient Diabetes Management Committee, St. Elizabeths Hospital, Appleton, WI

    Chairman, Diabetes Steering Committee, AMG/NHP, Appleton, WI

    Tuesday March 15, 2005

    Website: www.endocrinology-online.com

    Neoplastic Thyroid Disease:Thyroid Nodules, Goiter, and Thyroid

    Cancer

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    Neoplastic Thyroid Disease

    Thyroid Nodules

    Goiter

    Multinodular

    Diffuse

    Endemic

    Thyroid Cancer

    Well differentiated and poorly differentiated

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    Thyroid Nodular Disease

    Thyroid gland nodules are common in the

    general population

    Palpable nodules occur in approximately 5%of the US population, mainly in women

    Most thyroid nodules are benign

    Less than 5% are malignant Only 8% to 10% of patients with thyroid nodules

    have thyroid cancer

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    Multinodular Goiter (MNG)

    MNG is an enlarged thyroid gland containing

    multiple nodules

    The thyroid gland becomes more nodular with

    increasing age In MNG, nodules typically vary in size

    Most MNGs are asymptomatic

    MNG may be toxic or nontoxic

    Toxic MNG occurs when multiple sites of autonomousnodule hyperfunction develop, resulting in

    thyrotoxicosis

    Toxic MNG is more common in the elderly

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    Endemic Goiter

    No longer a problemin the US and thedeveloped world

    Still a serious healthconcern in parts ofthe world with iodinedeficiency includingmountainous areasor areas with highrainfall/flooding

    Kaplan, E. et al. Thyro id Disease ManagerSurgery of the Thyroid Gland Chapter 21, May 99

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    Thyroid Carcinoma

    Incidence Thyroid carcinoma occurs relatively infrequently compared to the

    common occurrence of benign thyroid disease

    Thyroid cancers account for only 0.74% of cancers among men, and2.3% of cancers in women in the US

    The annual rate has increased nearly 50% since 1973 toapproximately 18 000 cases

    Thyroid carcinomas (percentage of all US cases) Papillary (80%)

    Follicular (about 10%)

    Medullary thyroid (5%-10%)

    Anaplastic carcinoma (1%-2%)

    Primary thyroid lymphomas (rare)

    Metastatic from other primary sites (rare)

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    Initial Evaluation of a Thyroid

    Nodule/Mass

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    Risk factors for Malignancy

    Solitary thyroid nodules in patients >60

    or 3 or 4 cm)

    Growth of nodule

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    Evaluating Thyroid Nodules

    TSH measurement

    Ultrasound of the thyroid

    Fine needle aspiration

    Radioactive iodine imaging

    Kim N, et al. Otolaryngol Clin North Am. 2003;36:17-33.

    Braverman LE, Utiger RD, eds. Werner & IngbarsThe Thyroid: A Fundamental and

    Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000.Castro MR, et al. Endocr Pract. 2003;9:128-136.

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    Thyroid Ultrasonography

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    Thyroid Ultrasonography

    Excellent for

    characterizing size and

    other features of nodule Useful in localizing

    nodule for FNA

    Cannot distinguish

    between benign vs.

    malignant

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    Thyroid Ultrasonography

    Certain features may suggest greater risk of cancer:

    Irregular or poorly defined borders of nodule

    Lack of a "halo

    Hypo-echogenicity

    Evidence of microcalcifications Increased blood flow

    Growth and interval change on serial

    ultrasounds

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    RAI imaging

    Formerly had been used extensively in the initial

    work up of nodular thyroid disease

    FNA is now considered the gold standard

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    RAI imaging

    The problem:

    Although hot nodules are usually

    never cancer, only 5% of all nodulesare hyperfunctioning

    The remaining 90-95% that are warm

    or cold could be cancer and thusrequire FNA

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    RAI imaging

    Circumstances where RAI imaging may be

    useful and indicated:

    Suppressed TSH (more likely to have a

    autonomously functioning nodule)

    Multiple nodules, none dominant Other

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    Thyroid FNA

    Now considered the

    most cost effective and

    sensitive/specific

    diagnostic test of thyroidnodules

    The use of US has

    expanded the role of

    FNA in evaluatingnodules and improved

    the validity of the results

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    Thyroid FNA

    Possible FNA Results

    Benign: 70 -75 %

    Malignant: Up to 5%

    Suspicious: About 10%

    Nondiagnostic: About 10 - 20%

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    Thyroid FNA

    Limitations

    False negatives: (< 5% of FNA) more likely in large (>4cm)

    or small (

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    Management and Follow up

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    Management of Thyroid Nodules

    Depends on FNA results (see algorithm)

    Benign:

    False negatives rare, but be cautious in large(>4cm) or small nodules (

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    Suspicious FNA

    About 10% of all FNA results

    CANNOT distinguish benign vs malignant

    of hypercellular nodules (follicular/Hurthle

    cell) by FNA alone

    ALWAYS require surgical resection for dx

    Up to 10 30% of these will be malignant

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    Non-diagnostic FNA

    About 15% of all FNA results

    NEVER consider equivalent to benignFNA

    Up to 10% of ND FNA will contain CA onresection

    Be very cautious of a pathology report:

    consistent with benign colloid nodule; iflimited/no follicular epithelial cells noted,then this is a ND FNA rather than benign

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    Non-diagnostic FNA contd

    Three options:

    Repeat FNA now- may get valid FNA onrepeat up to 30 50% of the time

    Follow-up US in 6 months, repeat FNA orresect then if any interval change

    Surgical resection now- usually reserved

    only for patients with history suggestive ofincreased risk or patients who are veryanxious and do not want to wait

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    LT4 Suppression of Thyroid

    Nodules

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    LT4 Suppression of Nodules

    Although once more commonly used, it hasbegun to fall out of favor

    Some endocrinologists still recommend LT4suppression for a TSH between 0.1 0.5

    However, studies demonstrate lack of efficacy orimproved outcome

    There is significant risks associated with longterm iatrogenic hyperthyroidism (loss of bonedensity, arrhythmias in the elderly, etc.)

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    LT4 Suppression of Goiter

    Patients with a MNG especially could laterdevelop an autonomously functioning nodulewith subsequent thyrotoxicosis if not followed

    closely

    Is useful for goiter suppression in patientswith subclinical or overt hypothyroidism

    May also have a role in goiter patients withTSHs in the upper limits of normal (>3.0) whoalso have + thyroid autoantibodies(controversial)

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    Thyroid Carcinoma

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    Typical Presentation of

    Thyroid Cancer

    Painless lump

    Normal thyroid function tests

    Found