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

Jeremy F. Robles, MD, FPCP, FPSEMLucy E. Mamba, MD, FPCP, FPSEM

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


• 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)

30/F consulted for throat discomfort noted 3 months prior


ATA / AACE / AME / ETA

Pertinent History

•History of irradiation•Familial thyroid cancer•Rapid growth & hoarseness•Age <14 yo and >70 yo•Male sex•Persistent dysphagia or dyspnea

Pertinent Physical

Examination

•Vocal cord paralysis•Lateral cervical neck lymphadenopathy•Fixation of the nodules to surrounding tissues•Location, consistency, size of nodule(s)•Neck tenderness or pain


What laboratory test or imaging will you order for patients with thyroid nodule(s)?

a.) TSH & Thyroid Ultrasound

b.) Paired FT4 & TSH only

c.) Ct-scan of the neck

d.) Thyroid Sestamibi scan


ATA(2009)

AACE, AME, ETA(2010)

NCCN(2013)

Thyroid Stimulating

Hormone (TSH)Yes (A) Yes (A) Yes

Free Thyroxine (FT4)

Yes (B)

ULTRASOUND Thyroid (A) Thyroid (B)Thyroid & Neck

Diagnostic Approach to Thyroid Nodules

Low TSHLow TSH History, PE, TSHHistory, PE, TSH Normal / High TSHNormal / High TSH

Thyroid ScanThyroid Scan Non Non FunctioningFunctioning Diagnostic UTZDiagnostic UTZ

HyperfunctioningHyperfunctioning

Evaluate & Evaluate & Treat for Treat for

HyperthyroidisHyperthyroidismm

Nodule on UTZNodule on UTZdo FNABdo FNAB

No NoduleNo Nodule

ElevatedElevatedTSHTSH

NormalNormalTSHTSH

Evaluate & Evaluate & treat for treat for

HypothyroidisHypothyroidismm

FNA not FNA not neededneeded

ATA 2009 Work-up of Thyroid Nodule Detected by Palpation or ATA 2009 Work-up of Thyroid Nodule Detected by Palpation or ImagingImaging


History & PEHistory & PE

Thyroid UTZ with focus on Thyroid UTZ with focus on stratification for malignancystratification for malignancy TSH & FT4, calcitonin ?TSH & FT4, calcitonin ?

Nodule diameter Nodule diameter <1 cm without <1 cm without

suspicious Hx or suspicious Hx or suspicious UTZ suspicious UTZ

findingsfindings

Nodule diameter Nodule diameter >1 cm or <1 cm >1 cm or <1 cm with suspicious with suspicious Hx or suspicious Hx or suspicious

UTZ findingsUTZ findings

Normal TSH Normal TSH

Suspicious for Suspicious for malignancy by clinical malignancy by clinical

or UTZ criteriaor UTZ criteria

Normofunctioning Normofunctioning or cold on thyroid or cold on thyroid

scanscan

Low TSH or MNG in Low TSH or MNG in iodine deficient iodine deficient

regionregion

NoNo YesYesFollow-upFollow-up

FNABFNAB

BenignBenignFollicular lesion Follicular lesion

suspicious,suspicious,Positive for Malignant Positive for Malignant

cellscells

SurgerySurgery

AACE / AME / ETAAACE / AME / ETA20102010


NCCNNCCN20132013

Thyroid ScanThyroid Scan

TSH + UTZTSH + UTZ(central & lateral neck)(central & lateral neck)

FNABFNAB


What laboratory test or imaging will you order for patients with thyroid nodule(s)?

a.) TSH & Thyroid Ultrasound

b.) Paired FT4 & TSH only

c.) Ct-scan of the neck

d.) Thyroid Sestamibi scan


Only thyroid nodules > 1 cm should be biopsied.

a.) True

b.) False

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 ALL FNA Node & 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 FEATURESSUSPICIOUS SONOGRAPHIC FEATURESHypoechoic, Microcalcifications, Increased central Hypoechoic, Microcalcifications, Increased central vascularity, vascularity, Infiltrative margins, Taller than wide in Infiltrative margins, Taller than wide in transverse planetransverse plane


Only thyroid nodules > 1 cm should be biopsied.

a.) True

b.) False







30/F consulted for throat discomfort noted 3 months prior

Ultrasound of the thyroid showed a 2.5 cm solid nodule on the

inferior lobeTSH & FT4 are normal

Diagnosis: Nodular Non-toxic GoiterClinically & Biochemically Euthyroid


Indications for FNAB

- Nodules > 1 cm ( solid & hypoechoic )- Any size on UTZ with extracapsular growth or cervical LN metastasis- Any size with history of neck irradiation; PTC, MTC or MEN2 in 1st degree relatives; previous thyroid surgery for cancer, increased calcitonin - <1 cm with UTZ finding associated with malignancy- hot nodules should be excluded from FNAB

Multinodular glands

- Do not biopsy hot areas on radioisotope scan- If with cervical lymphadenopathy, biopsy both suspicious nodule and LN

Complex (solid-cystic)

- Sample solid component via UTZ guided biopsy- Submit FNAB specimen and fluid for cytologic examination AACE/ AME/ETAAACE/ AME/ETA

Ultrasound Guided Biopsy

•Nodules < 1 cm if clinical information or ultrasound findings are suspicious

•Nonpalpable nodules

•Predominantly cystic

•Located posteriorly in the thyroid lobe

•Repeat FNAB for nodule with initial non-diagnostic cytology result

ATA / AACE /AME / ATA / AACE /AME / ETAETA

Cytopathologic Diagnosis: Suspicious for

Papillary Thyroid Carcinoma

SUGGESTEDCATEGORY

ALTERNATE CATEGORY

% RISK OF MALIGNANCY

Benign < 1

Atypia of undetermined significance

Indeterminate Follicular lesions, R/O neoplasm,

atypical Follicular Lesion, Cellular Follicular Lesion

5 - 10

NeoplasmSuspicious for

Neoplasm20 - 30

Suspicious for Malignancy

- 50 - 75

Malignant - 100

Non-Diagnostic Unsatisfactory -

Bethesda Classification of Thyroid Cytology

20092009

FNABFNAB(ATA (ATA 2009)2009)

cytologic adequacy = presence of at cytologic adequacy = presence of at leastsix follicular cell groups, each leastsix follicular cell groups, each

containing containing 10–15 cells derived from at least 10–15 cells derived from at least

two aspirates of a noduletwo aspirates of a nodule








What thyroid surgery should the patient undergo?( Suspicious Papillary Thyroid Cancer)

a.) Lobectomy with isthmusectomy

b.) Near total thyroidectomy

c.) Total thyroidectomy

d.) Discuss with the surgeon

Thyroid Surgery(Definitions)

• Total Thyroidectomy

• Removal of all grossly visible thyroid tissue

• Near Total Thyroidectomy

• Removal of all grossly visible thyroid tissue, leaving only a small amount [<1g] of tissue adjacent to the recurrent laryngeal nerve near the ligament of Berry

• Subtotal Thyroidectomy

• leaving >1 g of tissue with the posterior capsule on the uninvolved side

ATA 2009ATA 2009


What thyroid surgery should this patient undergo?

( Suspicious Papillary Thyroid Cancer)


b.) Near total thyroidectomy

c.) Total thyroidectomy

d.) Discuss with the surgeon

Surgical Management for Differentiated Thyroid

Cancer•Remove the Primary tumor

•Minimize treatment related morbidity

•Accurate staging of the disease

•Facilitate post-operative post-radioiodine treatment, where appropriate

•Long term surveillance for disease recurrence

•Minimize risk of recurrence & metastatic spread

ATA 2009ATA 2009


What will you do if the thyroid biopsy turned out to be Benign?


b.) Levothyroxine suppression

c.) Ultrasound Guided Percutaneous Ethanol injection (PEI)

d.) Monitor the patient within 6-18 months

Benign Nodules •Clinical, thyroid UTZ & TSH in 6 - 18

month

•Repeat FNAB with UTZ guidance if clinically or with UTZ suspected features

•Repeat UTZ in cases of > 50% increase in volume

•Consider repeat UTZ guided FNAB in 6 - 18 months even with benign initial cytologic results

AACE/ AME/ETAAACE/ AME/ETA


What will you do if the thyroid biopsy turned out to be Benign?


b.) Levothyroxine suppression

c.) Ultrasound Guided Percutaneous Ethanol injection (PEI)

d.) Monitor the patient within 6-18 months

Levothyroxine suppression •LT4 suppression therapy of benign

thyroid nodules in iodine sufficient populations is not recommended.

•LT4 therapy or iodine supplementation may be considered in young patients who live in iodine deficient geographic areas and have small thyroid nodules & in those who have nodular goiters and no evidence of functional autonomy

ATA/AACE/ ATA/AACE/ AME/ETAAME/ETA

LT4 Suppression •Avoid LT4 in patients with

•osteoporosis, CVD, systemic illness

•large thyroid nodules

•long standing goiter

•low-normal TSH levels

•postmenopausal women

•age older than 60 yo (men) AACE / AME / ETAAACE / AME / ETA

Ultrasound GuidedPercutaneous Ethanol

Injection•Effective in Benign thyroid cyst and

complex nodules with a large fluid component

•This should not be performed in solitary solid nodules or multinodular goiter

AACE / AME / ETAAACE / AME / ETA

Surgery for Benign lesions•Indications:

•Presence of local pressure symptoms clearly associated with the nodule

•Previous external irradiation

•Progressive nodule growth

•Suspicious UTZ features

•Cosmetic issuesAACE / AME / ETAAACE / AME / ETA

NCCN 2013NCCN 2013

c For microcarcinoma (< 1cm), a total thyroidectomy may not be needed. Age is an approximation and not an absolute determination.

dTall cell variant, columnar cell, or poorly differentiated features.NCCN 2013NCCN 2013

Surgery for Papillary Thyroid Cancer

NCCN 2013NCCN 2013

NCCN 2013NCCN 2013

Surgery for Follicular Thyroid Cancer

Surgical Histopathologic Diagnosis: Papillary Thyroid Carcinoma







Post-operative Radioiodine Remnant

Ablation•For patients with known distant

metastases, gross extrathyroidal extension of the tumor regardless of tumor size, or primary tumor size >4 cm even in the absence of other higher risk features

•For selected patients with 1– 4cm thyroid cancers confined to the thyroid

ATA 2009ATA 2009

* LT4 withdrawal 2-3 weeks or LT3 treeatment for 2-4 weeks and LT3 withdrawal for 2 weeks with TSH > 30 mU/L. Resume LT4 therapy on 2nd - 3rd day post RAI therapy.

Post-operative Radioiodine Remnant

Ablation•RAI ablation is not recommended

for patients with unifocal cancer <1 cm without other higher risk features

•RAI ablation is not recommended for patients with multifocal cancer when all foci are <1 cm in the absence other higher risk features

ATA 2009ATA 2009







Postoperative (AJCC/UICC) stagingPostoperative (AJCC/UICC) staging

•Permit prognostication for an individual patient

•Tailor postoperative adjunctive therapy RAI therapy / TSH suppression risk for disease recurrence and mortality

• To make decisions regarding the frequency and intensity of follow-up

•Accurate communication regarding a patient among health care professionals

ATA 2009ATA 2009

ATA 2009ATA 2009

Surgical Histopathologic Diagnosis: Papillary Thyroid Carcinoma (Stage

1), S/P Total Thyroidectomy,S/P Radioiodine Therapy (100 mci)

Differentiated Thyroid Cancer Differentiated Thyroid Cancer (Long Term Management) (Long Term Management)

•Check for persistent tumor within 1st year of treatment by

•Clinical evidence of tumor

•Imaging evidence of tumor

•Undetectable serum Tg levels during TSH suppression and stimulation in the absence of interfering antibodies

•--measured /monitored every 6-12 months ATA 2009ATA 2009

TSH suppression therapyTSH suppression therapy

•High-risk

•macroscopic tumor invasion,

•incomplete tumor resection

•distant metastases

•thyroglobulinemia out of proportion to what is seen on the posttreatment scan

ATA 2009ATA 2009


•Intermediate-risk

•microscopic invasion of tumor into the perithyroidal soft tissues at initial surgery

•cervical lymph node metastases or 131I uptake outside the thyroid bed on the RxWBS done after thyroid remnant ablation

•tumor with aggressive histology or vascular invasion

ATA 2009ATA 2009


•Low-risk

•macroscopic tumor invasion,

•incomplete tumor resection,

•distant metastases

•thyroglobulinemia out of proportion to what is seen on the posttreatment scan

ATA 2009ATA 2009


•High-risk and intermediate-risk:

•TSH suppression to <0.1mU/L

•Low-risk : maintenance of the TSH = or slightly below the lower limit of normal (0.1–0.5mU/L)

ATA 2009ATA 2009

Jeremy F. Robles, MD, FPCP, FPSEMLucy E. Mamba, MD, FPCP, FPSEM


Health & Medicine

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