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

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