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 or clinical features Recommended nodule threshold size for FNA

High-risk historya

Nodule WITH suspicious sonographic featuresb >5mm Recommendation A

Nodule WITHOUT suspicious sonographic featuresb >5mm Recommendation I

Abnormal cervical lymph nodes Allc Recommendation A

Microcalcifications present in nodule ≥1cm Recommendation B

Solid nodule

AND hypoechoic >1cm Recommendation B

AND iso- or hyperechoic ≥1–1.5 cm Recommendation C

Mixed cystic–solid nodule

WITH any suspicious ultrasound featuresb ≥1.5–2.0 cm Recommendation B

WITHOUT suspicious ultrasound features ≥2.0 cm  Recommendation C

Spongiform nodule ≥2.0 cmd Recommendation C

Purely cystic nodule FNA not indicatede Recommendation E

TABLE 3. SONOGRAPHIC AND CLINICAL FEATURES OF THYROID NODULES AND RECOMMENDATIONS FOR FNA

RAI Uptake Scan

  ONLY IN HYPERTHYROID

  Cold Nodule - 10% incidence of being CA

 From 2005 to 2009, incidence rates increased by 5.6% per year in men and 7.0% per year in women, making thyroid cancer the fastest increasing cancer in both men and women

 Most common endocrine cancer

Thyroid Cancers

Projected Cases of Thyroid Cancer

 60, 220 new cases are estimated for 2013   45, 310 female   14, 910 male

  1,850 deaths projected for 2013   1,040 female   810 male   Death rate 0.5 per 100,000 in both male and females

AGE & INCIDENCE AMCERICAN CANCER SOCIETY / NCCN/ SEER

  Diagnosed at a younger age then most adult cancers   Median age at diagnosis was 50 years from 2005-2009   2 out of 3 cases are < 55 years old

  Thyroid cancer in the pediatric population   Pediatric Incidence 2.0 per 1 million in children <15 yrs and

17.6 per 1 million in children 15-19 yrs   2% occur in children and teens

TREATMENT FOR

THYROID

CANCER

  Surgery

  Radioactive Iodine Ablation

  Levothyroxine

  Monitor with WBS / ultrasound

CHILDREN &

PREGNANT WOMEN

W H E N D O Y O U O P E R A T E ? ? ?

Complications of Thyroid Surgery

  Recurrent laryngeal nerve injury

  Hypo parathyroidism

  Bleeding

  Infection

Parathyroid glands

COMPLICATIONS OF SURGERY

OR case

COMPLICATIONS OF THYROID SURGERY

Surgery and TC

Low MORTALITY

  Thyroid cancers LOW Mortality!! Rod Stewart, Julie Andrews, Joe Piscopo

  Always exceptions to the rules : Roger Ebert, Supreme Court Justice

Reinquist

Should be LOW MORBIDITY too!!

  IF surgery is required, always refer to someone who does at least > 50 / year

  NO drains!!

  NO RR tracks!!

  Dermabond is ulgy on the neck, and often opens a bit…

Summary

Refer to Endocrin0logy or Surgery

  Children   Pregant women   Nodules > 1 cm with suspicious

features   Compressive symptoms   HT with globus symptoms

  ULTRASOUND!! Even if already had CT, carotid doppler, etc

Can safely follow with ultrasound

  Nodule < 1 cm   Stable nodules with no change Repeat in 6 months x 2, then

annually

  Monitor TFTs with U/S

ENDOCRINE SURGERY

 Suspected/known abnormal TFTs with TNs

 Pregnant

 If FNA needed

 Children

 If suspect surgery is indictated

Endocrine OR Surgery?

Q U E S T I O N S ?

Thank You