Thyroid disease - geriatrics.otn.cageriatrics.otn.ca/pluginfile.php/91/mod_resource/content/0/Thyroid... · 4 Presented by: Ontario’s Geriatric Steering Committee Thyroid nodule

Presented by: Ontario’s Geriatric Steering Committee

Thyroid disease Maria Wolfs MD MHSc FRCPC

Presented by: Ontario’s Geriatric Steering Committee 2

Thyroid nodules

Subclinical hypothyroidism

Subclinical hyperthyroidism

Outline

Presented by: Ontario’s Geriatric Steering Committee 3 Presented by: Ontario’s Geriatric Steering Committee

Thyroid Nodules


Thyroid nodule - prevalence

Prevalence on palpation: – in iodine sufficient parts of the world

– 5% in women – 1% in men

Prevalence on ultrasound: – 19-67% of randomly selected patients

Risk of cancer in thyroid nodule: – 5-10 %

Cooper DS et al. Thyroid 2009;19(11)


Investigating a thyroid nodule


Investigating a thyroid nodule

LOW TSH N/HIGH TSH


Investigating a nodule

LOW TSH

Hyperfunctioning

nodules = very low

risk for malignancy




N/HIGH TSH

Thyroid Ultrasound


Suspicious ultrasound features

Microcalcifications

Hypoechoic

Increased nodular vascularity

Infiltrative margins

Taller than wide on transverse view




? Fine needle aspiration biopsy

N/HIGH TSH

Thyroid Ultrasound



Who needs a biopsy? > 0.7 cm nodule

High-risk history + nodule WITH suspicious sonographic features

Abnormal cervical lymph nodes

≥ 1 cm nodule

Solid nodule AND hypoechoic

Microcalcifications present in nodule

≥1-1.5 cm nodule

Solid nodule AND iso- or hyperechoic

≥1.5-2.0cm nodule

Mixed cystic–solid nodule WITH any suspicious ultrasound features

> 2.0cm nodule

Mixed cystic–solid nodule WITHOUT suspicious ultrasound features

Spongiform nodule



Who needs a biopsy?

> 0.7 cm nodule

High-risk history + nodule WITH suspicious sonographic features

Abnormal cervical lymph nodes

≥ 1 cm nodule

Solid nodule AND hypoechoic

Microcalcifications present in nodule

≥1-1.5 cm nodule

Solid nodule AND iso- or hyperechoic

≥1.5-2.0cm nodule

Mixed cystic–solid nodule WITH any suspicious ultrasound features

> 2.0cm nodule

Mixed cystic–solid nodule WITHOUT suspicious ultrasound features

Spongiform nodule


•≥ 1 cm Solid

•≥ 2 cm Mixed solid-cystic


Fine-needle biopsy

Benign

Non-diagnostic

Malignant

Suspicious (indeterminate) for neoplasm

Follicular lesion


Fine-needle biopsy

Benign

–5% false-negative rate of FNA

–Higher in larger nodules (> 4cm)

Non-diagnostic

Malignant


Follicular lesion


Follow-up benign nodules

Yearly physical exam

Follow up ultrasound – in 6-18 months after initial FNA

If stable – next follow up 3-5 years later

If evidence of growth – 20% increase in two nodule dimensions with minimal increase of 2

mm in two dimensions on ultrasound – Repeat FNA – Refer to endocrine

LT4 suppression therapy is not recommended




Follow up ultrasound – in 6-18 months after initial FNA

If stable – next follow up 3-5 years later

If evidence of growth – 20% increase in two nodule dimensions with minimal

increase of 2 mm in two dimensions on ultrasound

– Repeat FNA

– Refer to endocrine





Follow up ultrasound

– in 6-18 months after initial FNA

If stable

– next follow up 3-5 years later

If evidence of growth

– 20% increase in two nodule dimensions with minimal increase of 2 mm in two dimensions on ultrasound

– Repeat FNA

– Refer to endocrine



Fine-needle biopsy

Benign

Non-diagnostic

–Repeat FNA

Malignant


Follicular lesion


Fine-needle biopsy

Benign

Non-diagnostic

Malignant – 95% risk of malignancy

Suspicious (indeterminate) for neoplasm – 50-75% risk of malignancy

Follicular lesion – 5-15% risk of malignancy

Refer to endocrine or ENT


Indications for thyroid surgery

Malignant or suspicious pathology

Family history of familial medullary thyroid cancer Recurrent cystic nodule with benign FNA

Compressive symptoms

Increasing in size

Size > 4 cm

Patient preference


Thyroid Nodules

Take home message


Thyroid nodule - summary

N/HIGH TSH

Thyroid Ultrasound

LOW TSH

Thyroid Uptake and Scan



Fine needle aspiration biopsy if:

• ≥ 1 cm Solid

• ≥ 2 cm Mixed solid-cystic

N/HIGH TSH

Thyroid Ultrasound



Fine needle aspiration biopsy if:

• ≥ 1 cm Solid

• ≥ 2 cm Mixed solid-cystic

N/HIGH TSH

Thyroid Ultrasound


Ultrasound in 6-18 months after initial FNA

If stable Next follow up 3-5 years


Biopsy: – Malignant

– Suspicious (indeterminate) for neoplasm

– Follicular lesion

Follow-up US shows significant growth

Indications for surgery: – Family/personal history of familial thyroid cancer (MEN2,

FMTC)

– Recurrent cystic nodule with benign FNA (cosmetic concerns)

– Compressive symptoms

– > 4 cm

Refer to endocrine or ENT


Thyroid nodules



Outline


Subclinical

Hypothyroidism


TSH

log/linear inverse relationship

between serum TSH and FT4

Presented by: Ontario’s Geriatric Steering Committee 29 Surks M I , Hollowell J G JCEM 2007;92:4575-4582

TSH distribution by age groups


% TSH >4.5 mIU/L



prevalence 4 to 15% – USA NHANES III 4.3 %

– Europe • 4.2 % iodine-deficient areas

• 23.9 % abundant iodine intake

↑ with age

females > males whites > blacks

75% have TSH <10

Endocrine Reviews 29: 76–131, 2008


Causes of SHypo

Inadequate replacement therapy for overt hypothyroidism – inadequate dosage

– non-adherence

– drug interactions • iron, calcium carbonate, cholestyramine, dietary soy, fiber,

etc.

– increased T4 clearance • phenytoin, carbamazepine, phenobarbital, etc.

– malabsorption

CMAJ 2012;184:205


Causes of SHypo

Chronic autoimmune thyroiditis

Recovery from thyroiditis

Central hypothyroidism

TSH receptor gene mutations

CMAJ 2012;184:205


Causes of SHypo

Drugs impairing thyroid function: – iodine and iodine-containing medications

• amiodarone, radiographic contrast agents

– lithium carbonate

– cytokines (especially interferon α)

– aminoglutetimide

– ethionamide

– sulfonamides

– sulfonylureas

CMAJ 2012;184:205


Progression to overt hypothyroidism

% /year TSH

↑ N

TPO + 4.3% 2.0%

- 2.6% 0.5%


Vascular effects of SHypo

↑ systemic vascular resistance

↑ arterial stiffness

Altered endothelial function

↑ atherosclerosis

Altered coagulability

Rodondi N. et al. JAMA. 2010;304(12):1365-1374

Presented by: Ontario’s Geriatric Steering Committee Biondi B , Cooper D S Endocrine Reviews 2008;29:76-131


Increased CHD events and mortality

Rodondi N. et al. JAMA. 2010;304(12):1365-1374


Lipid effects of hypothyroidism

Pearce E N JCEM 2012;97:326-333


Effect of LT4 on dyslipidemia

Biondi B , Cooper D S Endocrine Reviews 2008;29:76-131 Cochrane Database Syst Rev 2007 Jul 18;(3):CD003419

Overall - no effect on cholesterol levels, HDL-C, LDL-C, triglycerides, ApoA, ApoB, or Lp(a)


Hypothyroid symptoms score

Cochrane Database Syst Rev 2007 Jul 18;(3):CD003419


Emotional Function tests

Jul 18;(3):CD003419


Health Related Quality of Life Cochrane Database Syst Rev 2007 Jul 18;(3):CD003419


Cognitive function

Cochrane Database Syst Rev 2007 Jul 18;(3):CD003419


Consider LT4 treatment

High background CV risk

– Diastolic dysfunction

– Diastolic hypertension

– Atherosclerotic risk factors

– Dyslipidemia

– Diabetes


Consider LT4 treatment


Ongoing trials of SHypo in the elderly

IEMO 80-plus Thyroid Trial Collaboration

– www.iemo.nl

Thyroid Hormone Replacement for

Subclinical Hypo-Thyroidism Trial (TRUST)

– www.trustthyroidtrial.com


Subclinical

Hypothyroidism Take home message


Repeat TSH, FT4, Thyroid antibodies in 3-6

months

No evidence of benefit for Rx with LT4

Consider treatment if:

– TSH > 10 mU/L

– Cardiac disease

– Symptoms



Thyroid nodules



Outline


Subclinical

Hyperthyroidism



Prevalence (NHANES III)

– TSH < 0.4 mU/L: 2%

– TSH < 0.1 mU/L: 0.7%

Latrogenic

– 14 - 21% of those on LT4 therapy

Most patients are asymptomatic

– Elderly can present with hypothyroid symptoms

Biondi B , Cooper D S Endocrine Reviews 2008;29:76-131


Causes of SHyper

Endogenous causes

– Graves’ disease

– Autonomously functioning thyroid adenoma

– Multinodular goiter

Exogenous causes

– Excessive thyroid hormone replacement

– Intentional thyroid hormone suppression



Non-thyroid causes of SHyper

1st trimester pregnancy

Non-thyroidal illness

Psychiatric illness

Administration of drugs – dopamine, glucocorticoids

Pituitary or hypothalamic insufficiency

Decreased age-related thyroid hormone clearance or pituitary set point



SHyper Mood and cognition

Conflicting data – reduced feeling of well-being

– feelings of fear, anxiety, hostility

– inability to concentrate

– ↑ risk of dementia and Alzheimer’s Disease

Confounding factors – autoimmunity

– depression itself

Screening bias



SHyper Cardiovascular effects

Impaired quality of life

– increased heart rate

– reduced exercise capacity

Atrial fibrillation - elderly

↑ Left ventricular mass

– negative prognostic cardiovascular factor in the

general population



SHyper Skeletal effects

Accelerated bone turnover

– In postmenopausal patients

Increased fracture risk

– TSH ≤ 0.1 mU/L vs. N TSH

– 3-fold increased risk of hip fracture

– 4-fold increased risk of vertebral fracture



Fracture risk and LT4 dose

BMJ 2011;342:d2238


SHyper management algorithm

Physical exam

↓TSH and N FT4 + N FT3



Large goitre

Surgical intervention

if significant airway

compression

Physical exam




Physical exam


Large goitre

Surgical intervention

if significant airway

compression

No goitre

Depends on

degree of TSH

suppression



Repeat TSH FT4 FT3 in 3-6 months

TSH 0.1 - 0.4 mU/L



Age >65 years

Post-menopausal women

Cardiac risk factors

Cardiac disease

Osteoporosis

Repeat TSH FT4 FT3 in 3-6 months

TSH 0.1 - 0.4 mU/L



Repeat TSH FT4 FT3 in 6 weeks

(sooner if CVS problems)

TSH < 0.1 mU/L





TSH < 0.1 mU/L

Work-up for overt

hyperthyroidism





TSH < 0.1 mU/L

Work-up for overt

hyperthyroidism

Referral to endocrinology


Low TSH + high FT4

Increased uptake:

Graves disease

Toxic nodule

Toxic multi-nodular goitre

Thyroid gland stimulation by HCG

Decreased uptake: Thyroiditis

Extra-thyroidal sources Exogenous

Endogenous

Thyroid scan

Thyroid uptake


Increased uptake:

Graves disease

Toxic nodule


Thyroid gland stimulation

by HCG

Low TSH + high FT4

Thyroid uptake

Presented by: Ontario’s Geriatric Steering Committee Thyroid scan

Increased uptake:

Graves disease

Toxic nodule



by HCG

Low TSH + high FT4

Thyroid uptake


Decreased uptake:

Thyroiditis

Extra-thyroidal sources Exogenous

Endogenous

Thyroid scan

Increased uptake:

Graves disease

Toxic nodule



by HCG

Low TSH + high FT4

Thyroid uptake



LOW TSH


Thyroid scan – toxic nodule(s)

Normal scan Abnormal scan

uptake on R side with

suppression on L side


Toxic nodule

Management

– Radioactive I131

– Surgery

– Consider pre-treatment with anti-thyroid drugs

if symptomatic or poor surgical candidate



Thyroid scan – Grave’s disease

Normal uptake (<15%) Increased uptake in Graves disease (30-50%)

http://www.shen-nong.com/image/eng/shen-nong/health/hyperthyroidism/western/img_07.jpg


Thyroid Receptor Ab - TRAb (Thyroid Stimulating

Immunoglobulin - TSI) in 85-

90% of Grave’s disease


Thyroid Receptor Ab -

TRAb (Thyroid

Stimulating

Immunoglobulin - TSI) in

85-90% of Grave’s

disease

NB TRAb (TSI)

NOT covered

by MOH labs


Graves’ disease

Management

– Consider beta-blocker

– Anti-thyroid drugs

• Propylthiouracil (ODB coverage)

• Methimazole

– Consider bone health



Subclinical

Hyperthyroidism Take home message


SHyper

Clinical effects in the elderly

– Mood and cognition

– Atrial fibrillation

– Increased fracture risk


Take home message - SHyper

Repeat TSH FT4 FT3

in 3-6 months

TSH 0.1 - 0.4 mU/L



TSH < 0.1 mU/L


Take home message - SHyper

Thyroid uptake and scan


Repeat TSH FT4 FT3

in 3-6 months

TSH 0.1 - 0.4 mU/L



TSH < 0.1 mU/L


Thyroid nodules



Outline


Thank you!

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Thyroid disease - geriatrics.otn.cageriatrics.otn.ca/pluginfile.php/91/mod_resource/content/0/Thyroid... · 4 Presented by: Ontario’s Geriatric Steering Committee Thyroid nodule