THYROID NODULES. LISA A. CICO, MSN, NP UPSTATE MEDICAL UNIVERSITY BREAST & ENDOCRINE SURGERY COORDINATOR THYROID CANCER PROGRAM SURGICAL COORDINATOR BREAST CANCER PROGRAM. Comprehensive review of current diagnostic tools and imaging to assess thyroid nodules - PowerPoint PPT Presentation
LISA A. CICO, MSN, NPUPSTATE MEDICAL UNIVERSITYBREAST & ENDOCRINE SURGERYCOORDINATOR THYROID CANCER PROGRAMSURGICAL COORDINATOR BREAST CANCER PROGRAMTHYROIDNODULES
OBJECTIVES Describe tools / diagnostic testing for assessment of the patient with a thyroid nodule(s)*Utilize national guidelines developed for patients with thyroid nodules*Describe some of the common symptoms of patients with thyroid nodulesComprehensive review of current diagnostic tools and imaging to assess thyroid nodulesReview American Thyroid Association, & National Comprehensive Cancer Network Guidelines for patients who develop thyroid nodulesReview common symptoms of patients with thyroid noduleOBJECTIVES Identify which patients can safely be followed by PCP *Describe imaging/diagnostic modalities for following the patient with thyroid nodules*Identify those patients requiring referral to specialty *Identify which specialty to make an appropriate referral based on diagnostic, objective and symptomatic findings
Obtaining appropriate imaging/diagnostic testing, and frequencyOverview of ultrasonographic thyroid terminologyOverview of Betheseda thyroid nodule pathology terminologyObtaining appropriate personal and family historyIdentify what patients require referral and to endocrine or surgery?Briefly discuss appropriate follow up for the patient with thyroid cancerDefinition of Thyroid NoduleA discrete lesion within the thyroid gland that is palpably and/or ultrasonographically distinct from surrounding thyroid parenchyma
*ATA Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer (2006 & 2009 Task Force)-what is palpable does NOT always correspond to ultrasound findings
-ultrasound inexpensive, non invasive, dimensions of gland, nodules
Prevalence Rallison et al. JAMA 1975Hogan et al. J Surg Res 2009
Not everyone will have an obvious goiter or thyroid nodule7How was this nodule found?Palpation with a physical examIncidental finding on diagnostic work upSelf detectionSurveillance Work up for symptoms of hyper/hypothyroidism
How was found is it clinically relevant?
-PCP, GYN most common-PET, CT, Carotid ultrasounds-looking at picture or checking in mirror-patients who are being seen for work up hyper/hypo thyroid-surveillance for high risk exposure to radiation, acne treatments, nuclear fallout-chernobyl widespread exposure to fallout**clinically relevant if exposed to radiation, +PET, etc.8Physical Examination of Thyroid GlandVisual inspectionPalpation of thyroid, neck nodes, and supraclavicular nodesFixed, mobile, soft, tender?Reflexes why?HR, BP, weight
Hyper/hypo reflex; would want to do TSHFree t4TPO is suspect hypo HT9
?due to thyroid nodules??10SymptomsUsually NONE!!Occasionally painful, quick onset (cyst)Difficulty swallowing Hoarseness OR change in voiceShortness of breath (or difficulty swallowing) usually while supine OR hands raised over head (Pembertons Sign)Choking sensation hyper/hypo thyroid
Hoarseness DD: Reflux, cancer, polyps
Hyper r/o hyperfx nodule11NodulesHyper/Hypo thyroidDifficulty swallowing
Choking sensationHyper-functioning nodule
HashimotosSymptoms?TFTs nodules and function are two separate issues usually hyperfunctioning nodule?, Hashimotos?
swallowing how big are the nodules? How many?
Associated with Thyromegaly?
substernal goiters 12HistoryPhysical FindingsHead & neck irradiationWhole body irradiationNuclear falloutFamily history of thyroid malignancyHeredity
Rapid growthHoarsenessCervical /supraclavicular lymphadenopathyFixation of nodule or gland> 4 cmSolitary
Pertinent History & PE in Evaluation of TNsCHERNOBYL: exposure under age 14**but not always the rule**
Heredity:Cowdens SyndromeFamilial PolyposisCarney ComplexMEN 2Werner Syndrome
13Differential DiagnosisMultinodular GoiterHashimotos ThyroiditisCancerLymphoma
Solitary Thyroid NoduleSubsternal Goiter
Lymphoma no operation, tx with radiation and chemo but found on surgical path
Difference betw surgical and cytopath???14Cowdens SyndromeFamilial PolyposisCarney ComplexMEN 2Werner SyndromeThyroid malignancy
Family HistoryofHereditary Diseases
Substernal GoitersShort neckStocky build
Usually incidental finding by CXR or CTMany times treated unsuccessfully for asthma
CT to assess tracheal narrowing &/or deviationPFTs may reveal obstructive diseaseCXR reveals thyroid mass
ATA Guidelines 2009ATA Guidelines 2009, revised 2013
THE DAVINICI CODE!!!!17Ultrasound: The Gold StandardAnyone found to have,OR is suspected of having a nodule evaluate by ultrasound!!Not invasive inexpensive Dimension of gland and nodulesIs used to monitor size and growthHelps determine IF a biopsy is necessaryUnique characteristics of nodules18BENIGNCHARACTERISTICSPure cystic (relatively rare)
Spongiform appearance in >50% of nodule volume (aggregration of multiple microcystic components)
Thyroid nodule22US (a, transverse; b, longitudinal) scans in 51-year-old woman show 2.4-cm well-defined mixed-echoic hypoechoic nodule (arrows) in right lobe of thyroid gland. Initial cytologic result was adenomatous hyperplasia, confirmed after 11 months at repeat aspiration BENIGN
23ULTRASOUND CHARACTERISTICCONSIDERATIONSHigh-risk history: History of thyroid cancer in one or more first degree relatives; history of external beam radiation as a child; exposure to ionizing radiation in childhood or adolescence; prior hemithyroidectomy with discovery of thyroid cancer, 18FDG avidity on PET scanning; MEN2/FMTC-associated RET protooncogene mutation, calcitonin >100 pg/mL. MEN, multiple endocrine neoplasia; FMTC, familial medullary thyroid cancer.
Suspicious features: microcalcifications; hypoechoic; increased nodular vascularity; infiltrative margins; taller than wide on transverse view. FNA cytology may be obtained from the abnormal lymph node in lieu of the thyroid nodule.
Sonographic monitoring without biopsy may be an acceptable alternative
SUSPICIOUSCHARACTERISTICSHypo-echogenicity compared to normal thyroid parenchymaIncreased intra-nodular vascularityIrregular infiltrative marginsPresence of micro-calcificationsAbsent haloShape taller than width in transverse dimensionNodules > 4 cmSolitaryDifficulty swallowing
ATA Guidelines 2009
**With the exception of suspicious cervical lymphadenopathy, which is a specific but insensitive finding no single sonographic feature or combinations of features is adequately sensitive or specific to identify all malignant nodules. However, certain features and combination of features have high predictive value for malignancy. Furthermore, the most common sonographic appearances of papillary and follicular thyroid cancer differ. A PTC is generally solid or predominantly solid and hypoechoic, often with infiltrative irregular margins and increased nodular vascularity. Micro-calcifications, if present, are highly specific for PTC, but may be difficult to distinguish from colloid. Conversely, follicular cancer is more often iso- to hyperechoic and has a thick and irregular halo, but does not have microcalcifications (49). Follicular cancers that are 1 cmSuspicious featuresDominant / largest one
In the presence of two or more thyroid nodules >1 cm, those with a suspicious sonographic appearance (see text and Table 3) should be aspirated preferentially.
(b) If none of the nodules has a suspicious sonographic appearance and multiple sonographically similar coalescent nodules with no intervening normal parenchyma are present, the likelihood of malignancy is low and it is reasonable to aspirate the largest nodules only and observe the others with serial US examinations.
**FNA by palpation OR ultrasound???
31Palpation?Ultrasound?What nodule(s) do you FNA?
What nodule(s) do you FNA?FNA of Palpable NoduleCan you feel calcifications? Can you feel any of the worrisome features of nodules? NO32TN with suppressed TSHUPTAKE SCAN to assess autonomous nodule
Compare to U/S what is the correlation with Uptake
FNA consider in non - functioning or isofunctioning with suspicious featuresA low or low-normal serum TSH concentration may suggest the presence of autonomous nodule(s).
A technetium 99 mTc pertechnetate or 123I scan should be performed and directly compared to the US images to determine functionality of each nodule >11.5 cm.
FNA should then be considered only for those isofunctioning or nonfunctioning nodules, among which those with suspicious sonographic features should be aspirated preferentially.
FNAOnly GOLD standard for proof of malignancy without surgical pathology
SURGICAL V. CYTOPATH??35False NegativeFalse Positivefalse-negative rate of up to 5% with FNA which may be even higher with nodules >4 cm ??FNAfalse-negative rate of up to 5% with FNA (41,80), which may be even higher with nodules >4 cm benign nodules may decrease in size, they often increase in size, albeit slowly (82). One study of cytologically benign thyroid nodules 1 cm NO
ATA Guidelines 2009NO
Is Size a Predictor of Malignancy?Nonpalpable nodules have the same risk of malignancy as palpable nodules with the same sizeGenerally, only nodules >1 cm should be evaluated, since they have a greater potential to be clinically significant cancers. Nodules 5mmRecommendation IAbnormal cervical lymph nodesAllc Recommendation AMicrocalcifications present in nodule1cmRecommendation BSolid noduleAND hypoechoic>1cmRecommend