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Kakatiya Medical College, Warangal
Road Map to Benign Thyroid Disorders
DR RAMESH KOORAPATI MS
Dept of General Surgery
Evaluation of Thyroid Disorders
Clinical assessment Investigations
Clinical assessment Physiological v/s Pathological Anatomical - Unilateral v/s Bilateral Pathology – Benign v/s Malignant Functional status General condition of the patient
DIFFERENTIAL DIAGNOSIS
UNILATERAL
SOLITARY THYROID NODULE
DIFFERENTIAL DIAGNOSIS
BILATERAL
SYMMETRICAL * PHYSIOLOGICAL * FUNCTIONAL
ASYMMETRICAL* MNG* DOMINANT NODULE* CARCINOMA THYROID* THYROIDITIS
AETIOLOGICAL CLASSIFICATION OF THYROID SWELLINGS
SIMPLE GOITRE DIFFUSE HYPERPLASTIC PHYSIOLOGOCAL PUBERTAL PREGNANCY MULTI NODULAR GOITRE
TOXIC DIFFUSE GRAVE’ DISEASE MULTINODULAR TOXIC ADENOMA
NEOPLASTIC BENIGN MALIGNANT
INFLAMMATORY AUTOIMMUNE GRANULOMATUS FIBROSING INFECTIVE OTHERS
INVESTIGATIONSESSENTIAL
THYROID FUNCTION TESTS-----T3 T4 TSH
THYROID USG PATHOLOGICAL------- FNAC,BIOPSY
SPECIAL INVESTIGATIONS
THYROID SCINTIGRAPHY CORE BIOPSY CT / MRI NECK SPECIAL X-RAYS TUMOR MARKERS THYROID ANTIBODIES PET SCAN TRH SUPPRESION TESTS
FNAC
INITIAL INVESTIGATION OF CHOICE
STN / MNG / SUSPECIOUS NODULES
REPLACED ONTABLE FROZEN SECTION STUDIES
LIMITATIONS OF FNAC CAN NOT DIFFERENTIATE FOLLICULAR ADENOMA
v/s
CARCINOMA
FALSE NEGATIVE RATES 6 % -10 %
BLIND ---- SAMPLING ERRORS
ISOTOPE SCANNING
TOXIC NODULE
MULTI NODULAR GOITRE WITH TOXIC SYMPTOMS
FOLLOWUP OF CARCINOMA THYROID
BENIGN THYROID DISORDERS -
CLINICAL PRESENTATIONS
SOLITARY OR DOMINANT NODULE
DIFFUSE OR MULTINODULAR GOITRE
FUNCTIONAL DISORDERS
SOLITARY NODULE THYROID
DEFINITION:-
DISCREAT SWELLING IN AN OTHERWISE IMPALPABLE GLAND
NORMAL ULTRASOUND BENIGN NODULE ON US
Solitary / Dominant Nodule (Non – toxic)
SOLITARY THYROID NODULE v/s DOMINANT NODULE
THYROID – FNA BIOPSY:
Class I (10%)
Class II (60 – 75%)
Class III (20%)
Class IV (5%)
Class V (5 – 15%)
NON – DIAGNOSTIC
NODULES
BENIGN NODULES
FOLLICULAR LESIONS
SUSPICIOUS NODULES
MALIGNANT NODULES
Road Map to Benign Thyroid Disorders
Normal Gland
Solitary / Dominant Nodule (Non – toxic)
Road Map to Benign Thyroid Disorders
False Negatives with FNAC
Solitary / Dominant Nodule (Non – toxic)
Road Map to Benign Thyroid Disorders
False Negatives with FNAC
Solitary / Dominant Nodule (Non – toxic)
NON - DIAGNOSTIC NODULES (Class I)
Due to:
• Cystic Nodules
• Benign / Malignant sclerotic lesions
• Thick / Calcified capsule
• Abscesses / Necrotic lesions
• Hypervascular lesions
• Sampling Error / Faulty Technique
Road Map to Benign Thyroid DisordersSolitary / Dominant Nodule (Non – toxic)
Reaspiration using US guidance
Malignancy = 2 – 12%
Treatment options:
Pure Colloid, completely
cystic on US
Complex lesions Solid lesions
Clinical and US follow up Surgery Surgery
Road Map to Benign Thyroid Disorders
Thyroid Cyst
Solitary / Dominant Nodule (Non – toxic)
BENIGN NODULES (Class II)
Road Map to Benign Thyroid Disorders
Isoechoic homogeneous subcapsular nodule (arrows)
with regular margin
Solitary / Dominant Nodule (Non – toxic)
BENIGN THYROID NODULE
Treatment Options:
• Clinical Follow up
• Levothyroxine Suppressive Therapy
• Surgery
Road Map to Benign Thyroid DisordersSolitary / Dominant Nodule (Non – toxic)
LEVOTHYROXINE Routinely NOT recommended
May be Considered MUST be Avoided
• Young Patients from
Endemic areas with small
nodules
• Non – autonomous
Nodules
• Large Nodules
• Long Standing
• Low Normal TSH
• Post Menopausal
• Men > 60yrs
• Osteoporosis
• Cardiovascular Disease
Road Map to Benign Thyroid DisordersSolitary / Dominant Nodule (Non – toxic)
SURGERY INDICATIONS
• Compressive Symptoms
• Cosmetic Reasons
• Patients anxious (psychological)
Road Map to Benign Thyroid DisordersSolitary / Dominant Nodule (Non – toxic)
FNAB cannot differentiate benign from malignant
Repeated FNAB – NOT Recommended
Core Needle Biopsy – NOT Recommended
20 % are Malignant
Surgical Excision (Lobectomy + Isthmectomy OR
Total Thyroidectomy)
FOLLICULAR LESIONS (Class III)
Road Map to Benign Thyroid DisordersSolitary / Dominant Nodule (Non – toxic)
Road Map to Benign Thyroid Disorders
FOLLICULAR ADENOMANodule shows micro follicles, is sharply circumscribed by a
capsule, and there is no invasion of the capsule or blood vessels
FOLLICULAR CARCINOMAwith Vascular invasion
Solitary / Dominant Nodule (Non – toxic)
Includes:
• Cytological features suggesting malignancy but do
not fulfill the criteria for a definite diagnosis
• Insufficient cellularity but with cellular features
strongly suggesting malignancy
60% are Malignant
Surgery + Intraoperative Frozen Section
SUSPICIOUS NODULES (Class IV)
Road Map to Benign Thyroid DisordersSolitary / Dominant Nodule (Non – toxic)
MANAGEMENT OF SOLITARY THYROID NODULE
THANK YOU…
