Management of ThyroidManagement of ThyroidManagement of Thyroid Management of Thyroid Nodules in theNodules in the 2121stst CenturyCenturyNodules in the Nodules in the 2121 CenturyCentury

H h K ddH h K ddHesham KaddourHesham KaddourConsultant ENT/Head& Neck SurgeonConsultant ENT/Head& Neck SurgeonConsultant ENT/Head& Neck SurgeonConsultant ENT/Head& Neck Surgeon

Queen’s University Hospital Queen’s University Hospital –– UKUK

2828thth International Laryngology International Laryngology ConferenceConference

AlexAlexApril April 20102010

The most powerful tool hatThe most powerful tool hatThe most powerful tool hat The most powerful tool hat doctors have….doctors have….

DIAGNOSISDIAGNOSISDIAGNOSISDIAGNOSIS

BMJ BMJ 24 24 Feb. Feb. 20092009, , 338338

Thyroidectomy;Thyroidectomy;HISTORYHISTORY

Bill th fi tBill th fi t•• Billroth first Billroth first thyroidectomy thyroidectomy 18501850

Kocher modernKocher modern•• Kocher modern Kocher modern thyroidectomy thyroidectomy 1872187218721872

•• Nobel Prize Nobel Prize 19121912

• 1883

Kocher’s performs a retrospective review• 5000 career thyroidectomies

• Mortality rates decreased– 40% in 1850 (pre-Kocher & Bilroth)

– 12.6% in 1870’s (Kocher begins practice)12.6% in 1870 s (Kocher begins practice)

– 0.2% in 1898 (end of Kocher’s career)

• Many patients developed cretinism or myxedema

His conclusions ….

Thyroidectomy;Thyroidectomy;HISTORYHISTORY

In presentation to the German Surgical In presentation to the German Surgical p gp gCongress …Congress …

“ …the thyroid gland in“ …the thyroid gland in …the thyroid gland in …the thyroid gland in fact had a function….”fact had a function….”

Theodor Kocher, Theodor Kocher, 18831883

What is goitre?What is goitre?at s go t eat s go t e

Thyroid gland enlargementThyroid gland enlargementThyroid gland enlargementThyroid gland enlargement

Types of goitreTypes of goitreTypes of goitreTypes of goitre

EpidemiologicalEpidemiological•• EndemicEndemic•• SporadicSporadic

MorphologicalMorphological•• MNMNMNMN•• SolitarySolitary

FunctionalFunctionalFunctionalFunctional•• NonNon--toxictoxic

T iT i•• ToxicToxic

Thyroid Nodule; Thyroid Nodule; PathologyPathology

•• Simple cystSimple cyst•• Simple cystSimple cyst•• Complex cystComplex cystp yp y•• Colloid noduleColloid nodule

AdAd•• AdenomaAdenoma•• Hashimoto’s noduleHashimoto’s noduleHashimoto s noduleHashimoto s nodule•• Malignant noduleMalignant nodule

WHOWHOClassificationClassification

•• Grade Grade 00 NonNon--palpablepalpable goitregoitre

Grade IGrade I PalpablePalpable goitregoitre•• Grade IGrade I PalpablePalpable goitregoitre

•• Grade IIGrade II VisibleVisible goitregoitregg

How Common?How Common?How Common?How Common?

•• Palpable Thyroid NodulesPalpable Thyroid Nodules 55%%•• Palpable Thyroid Nodules Palpable Thyroid Nodules 55%%Deandrea et al Endocr.Pract.2002

33 000000 000000•• In UKIn UK 33,,000000,,000000

How Common?How Common?How Common?How Common?

•• HDUS ScanHDUS Scan 5050%%•• HDUS ScanHDUS Scan 5050%%Ezzat et al. Arch Intern Med 1994

3030 000000 000000•• In UKIn UK 3030,,000000,,000000

How Common?How Common?How Common?How Common?•• The annual incidence is The annual incidence is 00..11%%Gharib Thyroid Today 1997Gharib, Thyroid Today 1997

•• U KU K 6060 000000 / year/ yearU KU K 6060,,000 000 / year/ year

The RealityThe RealityThe RealityThe Reality

UKUK 77,,000 000 thyroidectomy/yearthyroidectomy/year

DoH DoH 20042004

The CostThe CostThe CostThe Cost•• ££33,,000000/ procedure / procedure BUPA 2009BUPA 2009

•• The The currentcurrent cost;cost;

UKUK ££2121 000000 000000 / year/ yearUKUK ££2121,,000000,,000000 / year/ year

The CostThe CostThe CostThe Cost

ThTh P t ti lP t ti l C tC t•• The The PotentialPotential CostCost

UKUK ££180180,,000000,,000000 / year/ yearUKUK ££180180,,000000,,000000 / year/ year

Why Bothered?Why Bothered?

Malignant RiskMalignant RiskMalignant RiskMalignant Risk1010 3030%%•• 10 10 –– 3030%%

•• Solitary cold nodulesSolitary cold nodulesyyKountakis et al Ear Nose Throat J 2002

•• 55%%•• Any nodulesAny nodulesMazzaferri EL The New England Journal ofMazzaferri EL The New England Journal of

Medicine 1993

High Risk FactorsHigh Risk Factorsgg

•• Past neck IrradiationPast neck Irradiation

Hi h i t l di tiHi h i t l di ti•• High environmental radiationHigh environmental radiation

•• Family history of Ca thyroidFamily history of Ca thyroid•• Family history of Ca thyroidFamily history of Ca thyroid

•• Males > femalesMales > femalesMales > femalesMales > females

•• Age > Age > 50 50 yearsyearsgg yy

•• Children Children

Head & Neck CarcinomaHead & Neck Carcinoma

• NICE 2004

• IOG

2 weeks referral guidelines2 weeks referral guidelines(NICE 2004)(NICE 2004)

• Hoarseness persisting for more than six weeks.• Ulceration of oral mucosa persisting for more than three

kweeks.• Oral swellings persisting for more than three weeks.• All red or red and white patches of the oral mucosa.All red or red and white patches of the oral mucosa.• Dysphagia persisting for more than three weeks.• Unilateral nasal obstruction, particularly when associated

ith l t di hwith purulent discharge.• Unexplained tooth mobility not associated with periodontal

disease.

• Persistent neck mass > 3 weeks.• Cranial neuropathies.p• Orbital mass.

Neck Lump ClinicNeck Lump ClinicNeck Lump ClinicNeck Lump Clinic

H&NH&N CytologistCytologistH&N H&N SurgeonSurgeon

CytologistCytologist

One Stop ClinicOne Stop Clinic

CNSCNS RadiologistRadiologist

IOGIOG 20042004IOG IOG 20042004

•• MDTMDTC U itC U it•• Cancer UnitCancer Unit

•• Cancer CentreCancer CentreCancer CentreCancer Centre•• Cancer Net WorkCancer Net Work

T mo r Ad isor BoardT mo r Ad isor Board•• Tumour Advisory BoardTumour Advisory Board•• Peers ReviewPeers Review•• Cancer TsarCancer Tsar

MMultiulti DDisciplinaryisciplinary TTeameamMMulti ulti DDisciplinary isciplinary TTeameam

RadiologistRadiologist PathologistPathologist

NuclearNuclear

Thyroid SurgeonThyroid SurgeonEndocrinologistEndocrinologist

NuclearNuclearMedicineMedicinePhysicianPhysician

CNSCNSMDTMDT

CoCo--ordinatorordinator

1414//3131//6262 RulesRules1414//3131//6262 RulesRules

GP ReferralGP Referral Lump ClinicLump ClinicDiagnosisDiagnosis

MDTMDTTreatmentTreatment

00 1414 3131 6262

DAYSDAYS

British Thyroid AssociationBritish Thyroid Association20072007

EEvidencevidence BBasedased MMedicineedicineEEvidence vidence BBased ased MMedicineedicine

II M t l i f RCTM t l i f RCT•• IaIa Meta analysis of RCTsMeta analysis of RCTs•• IbIb RCTRCT

•• IIaIIa Controlled studiesControlled studies•• IIaIIa Controlled studiesControlled studies•• IIbIIb Experimental studiesExperimental studies

•• IIIIII Non experimental studiesNon experimental studiesIIIIII Non experimental studiesNon experimental studies

IVIV E t i iE t i i•• IVIV Expert opinionsExpert opinions

RecommendationsRecommendationsRecommendationsRecommendations•• AA Ia + IbIa + Ib

•• BB IIa + IIb + IIIIIa + IIb + IIIBB IIa IIb IIIIIa IIb III

•• CC IVIV

Management of Thyroid NoduleManagement of Thyroid Nodule

When to refer?When to refer?When to refer?When to refer?

EmergencyEmergency RoutineRoutineUrgent Urgent 2 2 weeksweeksg yg y•Stridor ••AsymptomaticAsymptomatic

••22ndnd opinionopinion••Patient requestPatient request

gg•Change in size•HoarsenessL h d ••Patient requestPatient request•Lymph nodes

BTA 2007

CCombinedombined TThyroidhyroid CCliniclinicCCombined ombined TThyroid hyroid CCliniclinic

RadiologistRadiologist CytologistCytologist

NuclearNuclear

One Stop ClinicOne Stop ClinicEndocrinologistEndocrinologist

NuclearNuclearMedicineMedicinePhysicianPhysician

CNSCNSThyroid Thyroid SurgeonSurgeon

Neck Lump ClinicNeck Lump ClinicNeck Lump ClinicNeck Lump Clinic

H&NH&N CytologistCytologistH&N H&N SurgeonSurgeon

CytologistCytologist

One Stop ClinicOne Stop Clinic

CNSCNS RadiologistRadiologist

Neck Lump Clinicn=60

30

35 Unilateral

Bilateral

Parotid

20

25

Parotid

Thyroid

No Lump

atie

nts

15

20

ber

of P

a

5

10

Num

0Unilateral Bilateral Parotid Thyroid No Lump

Kaddour 2007

Who should performWho should performWho should perform Who should perform thyroidectomy?thyroidectomy?thyroidectomy?thyroidectomy?

•• General SurgeonGeneral Surgeongg

•• Breast SurgeonBreast Surgeon

•• Endocrine SurgeonEndocrine Surgeon

•• Max Fax SurgeonMax Fax Surgeon

ORLORL H & N SurgeonH & N Surgeon•• ORLORL--H & N SurgeonH & N Surgeon

Why ORLWhy ORL H&N Surgeon?H&N Surgeon?Why ORLWhy ORL--H&N Surgeon?H&N Surgeon?

Th h id i i h kTh h id i i h k•• The thyroid is in the neckThe thyroid is in the neck•• Pre / postPre / post--op laryngoscopyop laryngoscopyPre / postPre / post op laryngoscopyop laryngoscopy•• Nerve MonitoringNerve Monitoring•• PhonosurgeryPhonosurgery•• TracheostomyTracheostomy•• TracheostomyTracheostomy•• Endo Orbital DecompressionEndo Orbital Decompression•• Neck DissectionNeck Dissection

L tL t•• LaryngectomyLaryngectomy

Who Does What?Who Does What?100%

80%90%

100%

60%70%80% G S 90

G S 04

40%50%60%

ENT 90

ENT 04

20%30%40%

Max Fax 90

Max Fax 04

0%10%20%

0%

DoH / HES

Who should performWho should performWho should perform Who should perform thyroidectomy?thyroidectomy?thyroidectomy?thyroidectomy?

Th idTh idThyroid Thyroid yySurgeonSurgeonSurgeonSurgeon

SymptomsSymptomsSymptomsSymptoms

•• Asymptomatic Asymptomatic y py pnodulenodule

•• Toxic symptomsToxic symptomsToxic symptomsToxic symptoms•• HypothyroidismHypothyroidism

CC•• Compression Compression symptomssymptoms

•• Metastatic Metastatic symptomssymptomsy py p

Painful ThyroidPainful ThyroidPainful ThyroidPainful Thyroid•• Acute thyroiditisAcute thyroiditis

•• Subacute thyroiditisSubacute thyroiditis

•• Hashimoto’s thyroiditisHashimoto’s thyroiditis

•• Infected thyroInfected thyro--glossal glossal ttcystcyst

•• Acute bleeding into a Acute bleeding into a cyst / nodulecyst / nodulecyst / nodulecyst / nodule

•• Rapidly enlarging Rapidly enlarging thyroid carcinomathyroid carcinomathyroid carcinomathyroid carcinoma

•• Radiation thyroiditisRadiation thyroiditis

HistoryHistoryHistoryHistory•• Detailed historyDetailed history

•• Onset,duration,Onset,duration,

•• SurgerySurgery

•• Family H/oFamily H/oOnset,duration, Onset,duration, coursecourse

A i t dA i t d

Family H/oFamily H/o

•• DrugsDrugs•• Associated Associated

symptomssymptoms•• IrradiationIrradiation

•• SmokingSmoking•• SmokingSmoking

ExaminationExaminationH&N Exam• H&N Exam

• Swelling;Side, Site, Shape, Size, Single, Surface Skin,

• Lymph nodes• Fixation• Trachea C As• Trachea, C As• Retrosternal• 70% Accuracyy

Nodal MetastasesNodal MetastasesNodal MetastasesNodal Metastases

How to examine Neck Nodes?How to examine Neck Nodes?How to examine Neck Nodes?How to examine Neck Nodes?

Video Flexible Rhinolaryngoscopy

TSHTSHTSHTSHLowLowHighHigh

? Hyperthyroidism? Hyperthyroidism? Hypothyroidism? Hypothyroidism ? Hyperthyroidism? Hyperthyroidism

//TT44 TT3 3 / T/ T44

NormalNormal LowLow NormalNormal HighHigh

SubclinicalSubclinicalHypothyroidismHypothyroidism

SubclinicalSubclinicalHyperthyroidismHyperthyroidism

HypothyroidismHypothyroidismHypothyroidismHypothyroidism

HyperthyroidismHyperthyroidismHyperthyroidismHyperthyroidism

FNA CytologyFNA Cytology• The main

investigation• Flow cytometry

for lymphomainvestigation

• Manual X US

for lymphoma

• Cyst aspiration

• Training

C

• Repeat FNA

S C• Cytologist

• Technique

• US Core Biopsy

• Open Biopsy• Technique

• Slides X Liquid

• Open Biopsy

q

FNA CytologyFNA CytologyFNA CytologyFNA Cytology

FNA CytologyFNA Cytology•• SensitivitySensitivity 65 65 –– 9898%% Likelihood that a ptn with

disease has +ve result

•• SpecificitySpecificity 72 72 –– 100100%% Likelihood that a ptn without

disease has -ve result

P P V lP P V l 5050 9696%%•• P P ValueP P Value 50 50 –– 9696%% Fraction of ptns with +ve

result who have disease

F l N tiF l N ti 11 1111%%•• False NegativeFalse Negative 1 1 –– 1111%% FNA –ve; histology +ve

•• FalseFalse PositivePositive 0 0 –– 77%% FNA +ve; histology -ve

Gharib 2003

FNA CytologyFNA CytologyFNA CytologyFNA Cytology•• THYTHY 11 Inadequate / InconclusiveInadequate / InconclusiveTHY THY 11 Inadequate / InconclusiveInadequate / Inconclusive

•• THY THY 22 Benign / CystBenign / Cyst

•• THY THY 33 Follicular lesionFollicular lesion

THYTHY 44•• THY THY 44 SuspiciousSuspicious

•• THY THY 55 MalignantMalignant

US ScanUS ScanUS ScanUS Scan•• NonNon--invasiveinvasive

•• Cost effectiveCost effectiveCost effectiveCost effective

•• Accurate for LNAccurate for LN

•• US/FNACUS/FNAC

•• OperatorOperator•• OperatorOperator

•• AnatomyAnatomy

Suspicious US SignsSuspicious US SignsSuspicious US SignsSuspicious US Signs•• Micro calcificationMicro calcification HighHigh

•• HypoechogenicHypoechogenic ModerateModerateHypoechogenicHypoechogenic ModerateModerate

•• Halo absentHalo absent ModerateModerate

•• IntraIntra--nodular blood flownodular blood flow ModerateModerate

•• Coarse calcificationCoarse calcification Very lowVery low•• Coarse calcificationCoarse calcification Very lowVery low

•• Comet tail signComet tail sign Very lowVery low

US Signs of MalignancyUS Signs of MalignancyUS Signs of MalignancyUS Signs of Malignancy•• Suspicious noduleSuspicious nodule

•• Local tissue Local tissue infiltrationinfiltrationinfiltrationinfiltration

Ab l l hAb l l h•• Abnormal lymph Abnormal lymph nodesnodes

US ClassificationUS ClassificationUS ClassificationUS ClassificationUSUS 00 N b litiN b liti•• US US 00 No abnormalitiesNo abnormalities

•• USUS 11 Cyst / benignCyst / benignUS US 11 Cyst / benignCyst / benign

•• US US 22 Suspicious noduleSuspicious nodule

USUS 33•• US US 33 Malignant noduleMalignant nodule

IncidentalomasIncidentalomasIncidentalomasIncidentalomas•• Asymptomatic nonAsymptomatic non--palpable < palpable < 1010mm mm

nodulesnodules

•• HDUS / CT / MRI imaging HDUS / CT / MRI imaging

E id i hE id i h•• Epidemic phenomenonEpidemic phenomenon

•• MicroMicro--carcinoma; carcinoma; 10 10 –– 3030% at autopsy % at autopsy c oc o ca c o a;ca c o a; 00 3030% at autopsy% at autopsy

•• Significance?Significance?

•• Management?Management?

•• The costThe costThe cost The cost

USFNACUSFNACControversyControversyyy

““Multi nodular goitres have a low Multi nodular goitres have a low ggrisk malignancy and therefore risk malignancy and therefore

do not need FNACdo not need FNAC””do not need FNACdo not need FNAC””

Papillary CaPapillary CaPapillary CaPapillary Ca

n=n=6666

MNG MNG 4848%% Solitary Solitary 5252%%

June et al 2005

Papillary CaPapillary Caap a y Caap a y Can=n=2424

60%

40%

50%

30%

40%

Solitary

MNG

20%3-D Column 3

0%

10%

0%

Kaddour Kaddour 20082008

Risk of MalignancyRisk of MalignancyRisk of MalignancyRisk of Malignancy

8%

9%

6%

7%

8%

4%

5% Solitary

MNG

1%

2%

3%

0%

1%

Papini et al 2002

RecommendationRecommendationRecommendationRecommendation

US MNGUS MNG•• US MNGUS MNG

•• Look for malignant features ofLook for malignant features of•• Look for malignant features of Look for malignant features of the nodulesthe nodules

•• FNA the suspicious noduleFNA the suspicious nodule

•• FNA the largest noduleFNA the largest nodule

USFNACUSFNACControversyControversyyy

““Small nodules (<Small nodules (<11cm) have acm) have aSmall nodules (<Small nodules (<11cm) have a cm) have a low risk malignancy and low risk malignancy and g yg y

therefore do not need FNACtherefore do not need FNAC””

Risk of MalignancyRisk of MalignancyRisk of MalignancyRisk of Malignancy25%

20%

10%

15%Small Nodule

LargeNodule

5%

10%Large Nodule

0%

5%

0%

CT ScanCT ScanCT ScanCT ScanN k & ChN k & Ch•• Neck & ChestNeck & Chest

•• 33D ScanD Scan33D ScanD Scan•• FasterFaster•• CheaperCheaper•• RadiationRadiation•• RadiationRadiation•• Iodine contrast Iodine contrast

mediummedium

CT ScanCT ScanCT ScanCT Scan

MRI ScanMRI Scan•• 3 3 D ScanD Scan

•• Soft tissuesSoft tissuesSoft tissuesSoft tissues

•• No radiationNo radiation

•• False +veFalse +ve

•• SlowerSlower•• SlowerSlower

•• ExpensiveExpensive

•• ClaustrophobicClaustrophobic

MRI / CT ScanMRI / CT ScanMRI / CT ScanMRI / CT Scan•• RetroRetro--sternal sternal

extensionextensionextensionextension

•• Neck nodal Neck nodal metsmets

Local tissueLocal tissue•• Local tissue Local tissue infiltrationinfiltration

•• Pulmonary Pulmonary ttmetsmets

Neck ImagingNeck ImagingSens Spec Accuracy

Exam 74% 81% 77%

CT 84% 83% 83%

MRI 90% 85% 84%

US 76% 100% 90%US 76% 100% 90%

PET CT ScanPET CT ScanF ti lFunctional scanPositron EmissionTomogram PETTomogram PET18FluoroDeoxyGlucose18FDG18FDG

• Recurrence• Residual• Residual• CUP

CXRCXRCC

Barium SwallowBarium SwallowBarium SwallowBarium Swallow

Thyroid Isotopes ScanThyroid Isotopes ScanThyroid Isotopes ScanThyroid Isotopes Scan•• Limited valueLimited value

•• RAIURAIU II123123

•• HyperthyroidismHyperthyroidism

•• Hot noduleHot nodule•• Hot noduleHot nodule

•• Cold noduleCold nodule

•• 2020% sensitivity% sensitivity

•• ExpensiveExpensive

•• RadiationRadiation

Thyroid AntibodiesThyroid AntibodiesThyroid AntibodiesThyroid Antibodies

•• Autoimmune conditionsAutoimmune conditions

•• Limited roleLimited role

•• Grave’s diseaseGrave’s disease

•• Hashimoto’s thyroiditisHashimoto’s thyroiditis

TPO AbTPO Ab•• TPO AbsTPO Abs

•• HR AbsHR Abs•• HR AbsHR Abs

Thyroid NoduleThyroid Nodule

H&N ExamH&N ExamFLXFLX

TFTTFT

HyperHyperHypoHypo NormalNormal ypypHypoHypo NormalNormal

IsotopesIsotopesFNAFNA

++TPOTPO ScanScan++USUS

TPOTPO

FNA CytologyFNA Cytology

DiagnosticDiagnostic 8080 9090%% NonNon--diagnosticdiagnostic 1010 –– 2020%%Diagnostic Diagnostic 80 80 –– 9090%% NonNon diagnostic diagnostic 10 10 2020%%

MalignantMalignant55%%

SuspiciousSuspicious2020%%

BenignBenign7575%%

Cyst: aspirateCyst: aspirate SolidSolid

USFNAUSFNA

SurgerySurgery Follow UpFollow Up

DiagnosticDiagnosticNonNon--diagnosticdiagnostic DiagnosticDiagnostic

FollowFollowSurgerySurgery

FollowFollowalgorithmalgorithm

THYTHY 11 Repeat USFNARepeat USFNATHYTHY 11 pp

FF

THYTHY 22 F/U F/U 33--66//12 12 + USFNA+ USFNA

FFNN THYTHY 33 MDT / LobectomyMDT / LobectomyNNAA

THYTHY 33 MDT / LobectomyMDT / Lobectomy

CC THYTHY 44 MDT / LobectomyMDT / Lobectomy

THYTHY 55 MDT / T t l+ CNDMDT / T t l+ CNDTHYTHY 55 MDT / Total+ CNDMDT / Total+ CND

Thyroidectomy;Thyroidectomy;WHEN?WHEN?

Malignant noduleMalignant nodule•• Malignant noduleMalignant nodule•• Suspicious noduleSuspicious nodule•• Follicular lesionFollicular lesionFollicular lesionFollicular lesion•• Repeat nonRepeat non--diagnostic diagnostic

FNAFNAR t tR t t•• Recurrent cystRecurrent cyst

•• Changing noduleChanging nodule•• Pressure symptomsPressure symptoms•• Pressure symptomsPressure symptoms•• RetrRetr--osternal extensionosternal extension•• CosmeticCosmetic•• Patient’s requestPatient’s request

Cli i l j d tCli i l j d tClinical judgement Clinical judgement over rides clinical over rides clinical

investigationsinvestigations

Thank YouThank YouThank YouThank You

HESham KaddourHESham KaddourHESham KaddourHESham Kaddour

h.kaddour@btinternet.comh.kaddour@btinternet.com