Thyroid nodules - GP North/Sat_Room11_1630... Thyroid Nodules • Common –3-5% palpable –50-70%

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  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Thyroid nodules

    John Chaplin

    www.thyroid.co.nz

    Nick McIvor

    www.neck.co.nz

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Thyroid Nodules

    • Common

    – 3-5% palpable

    – 50-70% ultrasound

    – Increase with age

    – More in women

    – 90-95% benign

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Thyroid Nodule

    • What do you want to know?

    – Is it malignant?

    – Is it toxic?

    – Is it compressive?

    – Cosmetic effect?

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Is it malignant?

    Around 5-10% malignant

    – Decision algorithm for resection based on combination of:

    • Clinical

    – History

    – examination

    • Cytology

    • Bloods

    • Radiology

    – Ultrasound

    – CT/ MRI

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Is it malignant?-History

    • Risk Factors – Family history

    • Papillary – RET-PTC gene mutation

    – x2 first degree relatives

    • Medullary

    – Familial MTC

    – MEN 2a, 2b

    » RET oncogene mutations

    – Radiation exposure

    • Therapeutic

    • Environmental

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Examination

    – Nodule 90%

    – Can be nodule in MNG

    – Nodes 10%

    – Extrathyroid 3-5%

    • Hoarseness

    • Airway

    • Dysphagia

    • Skin

    – Distant 3-5%

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Ultrasound

    • Report says suggestive of PTC – Solid vs cystic

    – Isolated vs multiple

    – Margins -well defined or indistinct

    – Halo - regular or irregular

    – Shape size density

    – Calcification

    • 3 patterns

    – Microcalcification ( highly susp)

    – Eggshell calcification

    – Macrocalcification

    – Blood flow

    • 3 patterns

    – Peripheral

    – Scant internal

    – Prominent internal (Highly susp.)

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Malignant nodule

    • Large >4cm

    • Solitary

    • Taller than wide shape

    • Solid Hypoechoic

    • Absent or irregular halo

    • Infiltrative margin

    • Microcalcification

    • Intranodular blood flow

    • Associated nodes with

    similar features

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Is it malignant ?-FNA

    • Possible results:

    Bethesda category %malig

    I. Non diagnostic 3-8%

    II. Benign 0-3%

    III. Atypical follicular n.sp. 8-15%

    IV. Follicular neoplasm 20-30%

    V. Suspicious for cancer 50-60%

    VI. Carcinoma 97-100%

    FNA is a safe test with negligible risk of seeding

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    FNA results

    Bethesda Plan

    I. Repeat FNA (USG)

    II. Discuss with patient

    III. Repeat FNA or lobectomy

    IV. Diagnostic lobectomy

    V. Lobectomy frozen section

    VI. Total thyroidectomy(+/- nodes)

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Is it toxic/hypothyoid? History/exam

    • Toxic • Heat intolerance • Irritability • Tremor • Exopthalmos • Lid lag • Goitre/ nodule

    • Hypothyroid • Fatigue • Sluggish reflexes • Oedema • Alopecia • Dry skin

    • May be subclinical

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Is it toxic/hypothyroid? Bloods

    • Thyrotoxic

    – TSH= supressed

    – T4, T3= elevated

    – Thyrd Abs +ve in 50%

    Graves

    – Thy Stim Ig =+ve in Graves

    • Hypothyroid

    – TSH= elevated

    – T3,T4= low

    – Thyroid Abs = +ve 90%

    TSH most senstive. ie. can have altered TSH without T3, T4

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    TSH supressed & TSI –ve

    (partic with nodule or goitre) Scintiscan

    • Toxic Goitre

    • Toxic Nodule(s)

    Toxic nodules are almost never malignant

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Thyrotoxicosis surgery vs radio-iodine

    • Surgery – Advantages

    • Single treatment

    • Minimal risk hypothyroidism in ipsilateral nodule

    • Reduced dysthyroid eye disease in Graves

    • Better for toxic goitre

    – Disadvantages • Scar

    • complications

    • RAI – Advantages

    • No surgery

    • May be better in small Graves without eye disease

    – Disadvantages

    • Need repeat doses in large thyroid

    • Risk of hypothyroid in toxic nodule

    • Does not remove antigen

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Is it compressive?

    • Symptoms

    – Pressure

    – Dysphagia

    – Voice

    – Cough

    – Short of breath

    – Exercise intolerance

    – OSA

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Is it compressive?

    • Signs

    – Stridor, wheeze,

    cough, SOB

    – Absent lower border/

    dull to percussion

    thorax

    – Sleep apnoea

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Compressive goitre

    • Investigations

    – Resp function tests

    • Fixed obstruction

    – Laryngeal exam

    • Endoscopy

    • Voice analysis

    – CT

    • Thoracic extension

    • Airway compromise

    • Recurrence

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Thoracic goitre

    • CT

    – Shows thoracic extension

    – Allow planning of access

    – Rare to split sternum but need

    CTSU surgeon

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Cosmesis

    • Trade off:

    – Nodule vs scar

    – Risk op vs no op

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    Thyroid Nodule Summary

    • Essential tests

    – FNA

    • Risk malignancy

    – Ultrasound

    • Risk malignancy

    – TFT

    • Risk toxicity

    • ( or hypothyroidism)

    • Secondary tests

    – Voice analysis

    – CT scan

    – Scintiscan

    – TSIg

    – Thyroid antibodies

    – Resp function tests

  • Auckland

    Head & Neck

    Associates

    Auckland Head and Neck Associates

    www.neck.co.nz

    www.thyroid.co.nz

    http://www.neck.co.nz