Thyroid Nodules - JOzao

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    The Work-up of a Thyroid Nodule:

    A Case Presentation and DiscussionJunko Ozao

    PGY-3

    Mount Sinai General Surgery

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    CC: thyroid nodule on PET scan

    HPI: A.P. is a 52 y.o. F s/p sigmoid resection for a4.9 cm mod-differentiated adenoca c 2/14lymph nodes positive on 5/6/2005 (T3bN1Mx).In preparation for surgery, the pt underwent a

    PET scan, where an increased uptake in herthyroid was noted. Pt denies pain, troublebreathing, hoarseness or dysphagia. No hx ofradiation exposure.

    Med and Surg Hx: hysterectomy 2000 for fibroids.

    Meds: none All: none

    Fam Hx: mother with hypothyroidism

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    P.E.- 2cm firm nodule in right mid-pole of

    thyroid, no LAD Labs: TSH: 2.24 (0.35-5.5) PTH 42(10-65)

    Ultrasound:2.4x1.6x1.3cm nodule on R lobe

    with calcifications seen, smaller 0.5x0.3x0.5cmnodule in R superior pole; left lobeunremarkable

    Thyroid scan: non-diagnostic FNA: papillary thyroid cancer

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    Uncomplicated total thyroidectomy was

    performed on 6/5/2005 Pathology-1.7cm papillary thyroid carcinoma,

    uninvolved tissue Hashimotos thyroiditis, 2

    lymph nodes negative for tumor Currently undergoing chemo for sigmoid ca

    Possibility and timing of iodine ablation being

    discussed with oncology

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    Work-up of a Thyroid Nodule

    Prevalence and risk factors

    H&P

    Labs Imaging Modalities

    Biopsy

    Management Controversial topics

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    Prevalence Large population studies-Framingham study showed

    clinically significant nodules in 6.4% women and 1.5%men ages 30-59 (total 4.2%) but thought to besignificantly understated

    Ultrasounds- 20% to 76% of females had at least onethyroid nodule on ultrasound

    Autopsy surveys show 37 to 57% of patients withthyroid nodules

    Vander JB, et al. The significance of nontoxic thyroid nodules. Final report of a 15 year study of theincidence of thyroid malignancy. Ann Intern Med 1968;69:537.Belfiore et al. High frequency of cancer in cold thyroid nodules occuring at a young age. Acta Endocrinol1989;121:197

    Rice CO et al. Incidence of nodules in the thyroid. Arch Surg 1932;24:505. Mortensen JD, Woolner LB,Bennett, WA. Gross and microscopic findings in clinically normal thyroid glands. J Clin Endocrinol Metab1955; 15:1220

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    Risk Factors of nodules and of

    carcinoma

    Increased risk of nodules with age Increased risk of carcinoma in adults over 60

    and under 30

    Solitary palpable nodules are about 4x moreprevalent in women than in men However, among pts with nodules- rate of

    carcinoma 2x as high in men as in women (8%

    vs. 4%)

    Wong CKM, et al. Thyroid nodules: Rational management. World J Surg 2000;24:934-941

    Mazzaferri EL. Management of a solitary thyroid nodule. NEJM 1993;328:553-559

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    Nodules are very commonestimates of 9million adults in the US have a thyroid nodule

    New nodules appear at a rate of 0.8%/yrThyroid cancer is rare 4/100,000 per year-12,000

    new cases/yr in US

    1% of all malignancies

    0.5% of all cancer deaths-1,000/yr

    Up to 35% of thyroids at autopsy containclinically silent carcinoma Wong CKM, et al. Thyroid nodules: Rational management. World J Surg 2000;24:934-941

    Mazzaferri EL. Management of a solitary thyroid nodule. NEJM 1993;328:553-559

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    Exposure to radiation, especially in childhood isassociated with increased prevalence of thyroid

    nodules and malignancy-2%/yr increased riskwith peak incidence 15-20 years Presence of a nodule in a child is 2x as likely to be

    carcinoma

    Two large series 20-27% of patients with priorradiation exposure had thyroid nodularity and 30 to33% of the nodules were carcinomas

    Prior family history of thyroid cancer

    Schneider AB et al. Radiation-induced tumors of the head and neck following childhood

    irradiation.J Clin Endocrinol Metab. 1985;61(3):547-50.Favus MJ et al. Thyroid cancer occurring as a late consequence of head and neck irradiation.Evaluation of 1056 patients. N Engl J of Med 1976;294:1019; Cerletty JM et al. Radiation-related thyroid carcinoma. Arch Surg 1978;113:1072.

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    Rate of Carcinoma in Thyroid Nodules

    Significant selection bias in surgical series

    North Carolina study in a community hospital pts withnodules were referred to surgery without biopsy and

    6.5% of excised nodules were carcinomas Catania, Italy 2327 pts with nodules were evaled by

    FNA and of those 391 were selected for surgery.Carcinomas were found in 28 which was 5% of total

    Werk EE, Vernon BM, Gonzalez, JJ. Cancer in thyroid nodules. A community hospital survey. Arch InternMed 1984; 144:474.Belfiore et al. High frequency of cancer in cold thyroid nodules occuring at a young age. Acta

    Endocrinol 1989;121:197

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    Causes of Thyroid Nodules

    Benign- >90% Multinodular goiter (colloid

    adenoma) Hashimotos (chronic

    lymphocytic) thyroiditis Cysts: colloid, simple, or

    hemorrhagic-7-14% can bemalignant- most commonlypapillary ca with a cysticcomponent with most increasedsize 2-4cm

    Follicular Adenoma Macrofollicular adenoma

    Microfollicular or cellular Hurthle-cell (oxyphil cell)

    adenomas- macro ormicrofollicular

    Malignant -about 6%

    Papillary

    Follicular

    Minimally or widely invasive

    Oxyphilic type

    Medullary

    Anaplastic

    Primary thyroid lymphoma

    Metastatic carcinoma

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    Toxic Multinodular Goiter

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    Papillary Carcinoma

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    Work-up of a Thyroid Nodule

    Prevalence and risk factors

    H&P

    Labs Imaging Modalities

    Biopsy

    Management Controversial topics

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    H&P

    Age and gender Recent history of hoarseness, dysphagia or

    dyspnea

    Sxs of hypothyroidism or hyperthyroidism Family h/o thyroid or endocrine disease

    h/o prior radiation exposure, especially early in

    life

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    Thorough history of other endocrine disorders-MEN type IIand other malignant syndromes ---familial adenomatous polyposis, Gardnerssyndrome

    Palpate thyroiddetermine size and consistencyof thyroid nodule(s), shape, location andmobility

    Examine for cervical LAD Hard, fixed, irregular-shaped nodules and LAD

    are suggestive of malignancy

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    Work-up of a Thyroid Nodule

    Prevalence and risk factors

    H&P

    Labs Imaging Modalities

    Biopsy

    Management Controversial topics

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    Laboratory

    Thyroid function tests- should be assessed

    Calcitonin if suspect medullary thyroid disease

    Most thyroid nodules are euthyroid

    However, if TSH is low, the possibility of a hot noduleis increased- may want to consider thyroid scintigraphy

    TSH is high suggestive of Hashimotos thyroiditis- maywant to ultrasound to see if nodularity is lymphocytic

    infiltrate vs. TSH induced hyperplasia vs. thyroid tumor Still should fully evaluate a nodule- may have co-existence of

    malignancy and thyroiditis

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    Work-up of a Thyroid Nodule

    Prevalence and risk factors

    H&P

    Labs Imaging Modalities

    Biopsy

    Management Controversial topics

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    Imaging- Thyroid Scintigraphy

    Utilizes iodine or technetium-99m pertechnate- more is taken upand organified by functional tissue

    Non-functioning thyroid nodule is cold and mandates furtherwork-up by FNA

    The scan is often used in working up nodules in patients withhigh TSH levels but has many problems Nelson et al. showed that only slightly more than one-half of

    their excised malignant thyroid nodules appeared cold becausethe scan is 2-D there is apposition of normal thyroid tissue nextto abnormal tissue

    Nelson RL et al. Rectilinear thyroid scanning as a predictor of malignancy. Ann of Intern Med 1978;88:41.

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    Also although 80% of nodules greater than 2cm appear cold-smaller nodules can be indeterminate

    Malignancy has been shown to occur 15-20% of cold nodulesand, additionally, in 5-9% of nodules with uptake that is warmor hot

    This is not very sensitive or specific for malignancythus, warmor hot nodules still mandate a continued aggressive approach to

    work-up- may not really change management Traditionally hot nodules rxed in past with radioactive iodine or

    taken to surgery Thyroid scintigraphy has fallen out of favor- definitely questions

    about how cost-effective it is for routine evaluation for patientswith nodules

    Nelson RL et al. Rectilinear thyroid scanning as a predictor of malignancy. Ann of Intern Med 1978;88:41.Price DC et al. Radioisotopic evaluatio