2013 4-14 CDO TEPI - thyroid nodules and cancer (Case Based Approach)

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We apply the guidelines from ATA, ETA, NCCN, AME and AACE on thyroid nodules and thyroid cancer on a cased based discussion

Text of 2013 4-14 CDO TEPI - thyroid nodules and cancer (Case Based Approach)

  • 1. Thyroid Nodules & Cancer Jeremy F. Robles, MD, FPCP, FPSEM Lucy E. Mamba, MD, FPCP, FPSEM
  • 2. Thyroid Nodules & Cancer Diagnostic approach to thyroid Nodules Fine needle aspiration Biopsy / UTZ guided Medical & Surgical management of nodules Post-Surgery Radio-iodine therapy Staging & Follow-up of Thyroid Cancer
  • 3. Thyroid Nodules & Cancer 2009 - American Thyroid Association (ATA) 2010 - Combined Guidelines American Association of Clinical Endocrinology (AACE) Asociazione Medici Endocrinologi (AME) European Thyroid Association (ETA) 2013 - National Comprehensive Cancer Network (NCCN)
  • 4. 30/F consulted for throat discomfort noted 3 months prior
  • 5. Thyroid Nodules & Cancer ATA / AACE / AME / ETA History of irradiation Familial thyroid cancer Pertinent Rapid growth & hoarseness History Age 70 yo Male sex Persistent dysphagia or dyspnea Vocal cord paralysis Pertinent Lateral cervical neck lymphadenopathy Physical Fixation of the nodules to surrounding tissuesExamination Location, consistency, size of nodule(s) Neck tenderness or pain
  • 6. Thyroid Nodules & Cancer What laboratory test or imaging will you order for patients with thyroid nodule(s)?a.) TSH & Thyroid Ultrasoundb.) Paired FT4 & TSH onlyc.) Ct-scan of the neckd.) Thyroid Sestamibi scan
  • 7. Thyroid Nodules & Cancer ATA AACE, AME, ETA NCCN (2009) (2010) (2013) Thyroid Stimulating Yes (A) Yes (A) YesHormone (TSH)Free Thyroxine Yes (B) (FT4) ThyroidULTRASOUND Thyroid (A) Thyroid (B) & Neck
  • 8. Diagnostic Approach to Thyroid Nodules ATA 2009 Work-up of Thyroid Nodule Detected by Palpation or Imaging Low TSH History, PE, TSH Normal / High TSH Thyroid Scan Non Functioning Diagnostic UTZ Hyperfunctioning No Nodule Nodule on UTZ do FNAB Evaluate & Treat for Elevated NormalHyperthyroidism TSH TSH Evaluate & FNA not treat for needed Hypothyroidism
  • 9. Diagnostic Approach to Thyroid Nodules AACE / AME / ETA History & PE 2010 Thyroid UTZ with focus on TSH & FT4, calcitonin ? stratification for malignancy Low TSH or MNG inNodule diameter Nodule diameter Normal TSH iodine deficient region 1 cm or 1 cm should be biopsied.a.) Trueb.) False
  • 13. Sonographic Features of Interest ATA (2009) NCCN (2013) NODULE WITH SUSPICIOUS SONOGRAPHIC FEATURES > 0.5 cm >/= 1 cm NODULE WITHOUT SUSPICIOUS SONOGRAPHIC FEATURES > 0.5 cm > 1.5 cm SUSPICIOUS CERVICAL LYMPH NODES FNA Node & ALL Thyroid Nodules COMPLEX WITH SUSPICIOUS SONOGRAPHIC FEATURES >/= 1.5 - 2 cm COMPLEX WITHOUT SUSPICIOUS UTZ FEATURES >/= 2 cm SPONGIFORM NODULE >/= 2 cm PURELY CYSTIC NODULE FNAB NOT INDICATEDSUSPICIOUS SONOGRAPHIC FEATURESHypoechoic, Microcalcifications, Increased central vascularity,Infiltrative margins, Taller than wide in transverse plane
  • 14. Thyroid Nodules & Cancer Only thyroid nodules > 1 cm should be biopsied.a.) Trueb.) False
  • 15. Thyroid Nodules & Cancer Diagnostic approach to thyroid Nodules Fine needle aspiration Biopsy / UTZ guided Medical & Surgical management of nodules Post-Surgery Radio-iodine therapy Staging & Follow-up of Thyroid Cancer
  • 16. 30/F consulted for throat discomfort noted 3 months prior Ultrasound of the thyroid showed a 2.5 cm solid nodule on the inferior lobe TSH & FT4 are normal
  • 17. Diagnosis: Nodular Non-toxic GoiterClinically & Biochemically Euthyroid
  • 18. Thyroid Nodules & Cancer - Nodules > 1 cm ( solid & hypoechoic ) - Any size on UTZ with extracapsular growth or cervical LN metastasisIndications for - Any size with history of neck irradiation; PTC, MTC or FNAB MEN2 in 1st degree relatives; previous thyroid surgery for cancer, increased calcitonin - 4 cm even in the absence of other higher risk features For selected patients with 1 4cm thyroid cancers confined to the thyroid* LT4 withdrawal 2-3 weeks or LT3 treeatment for 2-4 weeksand LT3 withdrawal for 2 weeks with TSH > 30 mU/L. Resume ATA 2009LT4 therapy on 2nd - 3rd day post RAI therapy.
  • 42. Post-operative Radioiodine Remnant Ablation RAI ablation is not recommended for patients with unifocal cancer