THYROID NODULES - Amazon Web Servicesenp-network.s3. thyroid nodules *Identify those patients requiring

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  • L I S A A . C I C O , M S N , N P U P S T A T E M E D I C A L U N I V E R S I T Y B R E A S T & E N D O C R I N E S U R G E R Y

    C O O R D I N A T O R T H Y R O I D C A N C E R P R O G R A M S U R G I C A L C O O R D I N A T O R B R E A S T C A N C E R

    P R O G R A M

    THYROID NODULES

  • 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 nodules

      Comprehensive review of current diagnostic tools and imaging to assess thyroid nodules

      Review American Thyroid Association, & National Comprehensive Cancer Network Guidelines for patients who develop thyroid nodules

      Review common symptoms of patients with thyroid nodule

  • OBJECTIVES 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 frequency

      Overview of ultrasonographic thyroid terminology

      Overview of Betheseda thyroid nodule pathology terminology

      Obtaining appropriate personal and family history

      Identify what patients require referral and to endocrine or surgery?

      Briefly discuss appropriate follow up for the patient with thyroid cancer

  • Definition of Thyroid Nodule

      “A 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)

  • Prevalence

      Rallison et al. JAMA 1975   Hogan et al. J Surg Res 2009

  • “How was this nodule found?”

      Palpation with a physical exam   Incidental finding on diagnostic work up   Self detection   Surveillance   Work up for symptoms of hyper/hypothyroidism

      How was found  is it clinically relevant?

  • Physical Examination of Thyroid Gland

      Visual inspection   Palpation of thyroid, neck nodes, and supraclavicular

    nodes   Fixed, mobile, soft, tender?   Reflexes  why?   HR, BP, weight

  • Symptoms

      Usually NONE!!   Occasionally painful, quick onset (cyst)   Difficulty swallowing   Hoarseness OR change in voice   Shortness of breath (or difficulty swallowing) usually

    while supine OR hands raised over head (Pemberton’s Sign)

      Choking sensation   hyper/hypo thyroid

  • Nodules Hyper/Hypo thyroid

      Difficulty swallowing

      Globus sensation

      Choking sensation

      Hyper-functioning nodule

      Hashimoto’s

    Symptoms?

  • History Physical Findings

      Head & neck irradiation

      Whole body irradiation   Nuclear fallout   Family history of

    thyroid malignancy   Heredity

      Rapid growth   Hoarseness   Cervical /supraclavicular

    lymphadenopathy   Fixation of nodule or

    gland   > 4 cm   Solitary

    Pertinent History & PE in Evaluation of TNs

  • Differential Diagnosis

      Multinodular Goiter   Hashimoto’s Thyroiditis   Cancer   Lymphoma

      Solitary Thyroid Nodule   Substernal Goiter

  • C O W D E N ’ S S Y N D R O M E F A M I L I A L P O L Y P O S I S

    C A R N E Y C O M P L E X M E N 2

    W E R N E R S Y N D R O M E T H Y R O I D M A L I G N A N C Y

    Family History of

    Hereditary Diseases

  • Substernal Goiters

      Short neck   Stocky build

      Usually incidental finding by CXR or CT   Many times treated unsuccessfully for asthma

  • Ultrasound: The Gold Standard

    Anyone found to have, OR is suspected of having a nodule  evaluate by ultrasound!!

  • BENIGN CHARACTERISTICS

      Pure cystic (relatively rare)

      Spongiform appearance in >50% of nodule volume (aggregration of multiple microcystic components)

      Multiple (?)

  • Septated cyst

    BENIGN

  • Cyst

    BENIGN

  • US (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

  • ULTRASOUND CHARACTERISTIC

    CONSIDERATIONS

      High-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

  • SUSPICIOUS CHARACTERISTICS

      Hypo-echogenicity compared to normal thyroid parenchyma

      Increased intra-nodular vascularity   Irregular infiltrative margins   Presence of micro-calcifications   Absent halo   Shape taller than width in transverse

    dimension   Nodules > 4 cm   Solitary   Difficulty swallowing

    ATA Guidelines 2009

  • Hypoechoic

    Suspicious

  • Increased vascularity

    Suspicious

  • Increased vascularity

    SUSPICIOUS

  • Calcifications Poorly defined, irregular margins

    SUSPICIOUS

  • Solid

    SUSPICIOUS

  • Multiple Thyroid Nodules

      FNA  what nodule??  > 1 cm  Suspicious features  Dominant / largest one

  • Palpation? Ultrasound?

      What nodule(s) do you FNA?

      What nodule(s) do you FNA?

    FNA of Palpable Nodule

  • TN with suppressed TSH

      UPTAKE SCAN to assess autonomous nodule

      Compare to U/S  what is the correlation with Uptake 

      FNA  consider in non - functioning or isofunctioning with suspicious features

  • FNA

      Only GOLD standard for proof of malignancy without surgical pathology

  • False Negative False Positive

      false-negative rate of up to 5% with FNA which may be even higher with nodules >4 cm

      ??

    FNA

  • < 1 cm > 1 cm

      NO

    ATA Guidelines 2009

      NO

    Is Size a Predictor of Malignancy?

  • FNA Results

      Nondiagnostic   Benign   Atypia of Undetermined Significance (AUS)   Suspicious for a Follicular Neoplasm/Follicular

    Neoplasm   Suspicious for Malignancy   Malignant

    Bethesda System for Reporting Thyroid Cytopathology

  • Diagnostic Category Risk of Malignancy (%)

    Usual management

    Nondiagnostic or Unsatisfactory

    Repeat FNA with ultrasound guidance

    Benign 0-3 Clinical Follow up with ultrasound 6 months

    Atypia of Undetermined significance or Follicular lesion of Undetermined significance

    5-15 Repeat FNA 3 months; if same, then lobectomy

    Follicular Neoplasm or suspicious for Follicular neoplasm

    15-30 Surgical Lobectomy

    Suspicious for Malignancy

    60-75 Near total thyroidectomy or surgical lobectomy

    Malignant 97-99 Near total thyroidectomy

  • Lab Work

      TSH   Free T4

      TPO in suspected thyroiditis

      TG  tumor marker in PTC, FTC, HTC

      Calcitonin  suspected MTC or in follow up of MTC

    TSH

    Free T4

    T4

    T3

    Free T3

    TPO

    Thyroglobulin (TG)

    Calcitonin

  • Thyroid nodule

    FNA

    Benign

    Exam/Sonogram 6-18 months

    No Change

    Repeat in 3-5 yrs

    20% increase in diameter in > 2

    dimensions (>2mm) or

    volume increase > 50%

    Re-aspirate Thyroid Nodule

  • Nodule sonographic