Approach to the Thyroid Nodule

‫‪Approach to the‬‬ ‫‪Thyroid Nodule‬‬ ‫דר' קרלוס בן-בסט‬ ‫מכון אנדוקריני‬ ‫מרכז רפאי רבין, בלינסון‬ ‫1‬ The Goiters Thyroid gland enlargement Diffuse Goiter • Endemic • Sporadic Enzymatic defect (congenital) Drug induced (e.g. lithium) Nodular Goiter > Solitary nodule Cold or Hot (Toxic adenoma) Solid or Cystic (simple, complex) Painful or not Firm or soft Fixed or not • Others Graves disease Hashimotos Subacute thyroiditis > Multinodular goiter Non toxic Toxic (autonomous function) Retrosternal goiter 2 A 52 y.o. female was found to have an enlarged thyroid on routine physical examination 3 Our patient was found to have a thyroid nodule A discrete lesion within the thyroid gland that is palpably and/or ultrasonographically distinct from the surrounding thyroid parenchyma 4 But…what is really a thyroid nodule ? • • • • • • Benign nodules (colloid, adenomatous hyperplasia) Cystic lesions (colloid, thyroglossal duct cyst) Adenomas (Follicular, Hurthle cell) Thyroid cancer (Medullary or non-medullary) Lymphoma of thyroid Others 5 About thyroid nodules • The prevalence of palpable thyroid nodules in iodine sufficient areas is 5% in women and 1% in males • The prevalence of thyroid nodules in random ultrasound is 19-67 % (higher in female and elderly) • Thyroid cancer may occur in 5-10% of thyroid nodules • The etiology is poorly understood and depends on type of nodule (RET mutation in thyroid cancer, activating mutation of TSH receptor in toxic adenoma etc). There may be a familial predisposition. 6 Clinical Presentation • A palpable lesion found by self- or medical examination • A non-palpable nodule found on imaging for unrelated reasons, mostly hypothyroidism and bolus (incidentaloma) • Work-up for hyperthyroidism • An acute painful nodule (hemorrhagic cyst) 7 Thyroid Imaging 8 Neck Ultrasound 9 10 11 12 Neck CT 13 14 15 16 17 Our patient has a solitary nodule and asks you about its significance • Mass effect ? • Thyroid function ? • Benign or malignant lesion ? Non-palpable nodules have same risk of malignancy as palpable nodules 18 Mass effect 19 Clinical consequences of mass effect • • • • • • Cosmetics Psychological distress Dysphagia (Barium swallow) Tracheal compression (Flow loops) Pumberton sign Hoarseness 20 Dysphagia 21 Tracheal compression 22 Our patient has a single nodule 2.5 cm diameter with no mass effect. What’s next ? Algorithm for work-up of thyroid nodules Apply to all palpable nodules and those non-palpable larger than 1 cm 23 Nodule Palpable/Nonpalpable US TSH Hypo/Normal Hyper Scan 24 Functional Imaging (Technetium Thyroid Scintigraphy) 25 Hot nodule Cold nodule Toxic adenoma Cold nodule 26 Nodule Palpable/Nonpalpable US TSH Hypo/Normal Hyper Scan Hot Treat or follow 27 Treatment of Toxic Adenoma • When to treat ? – Subclinical hyperthyroidism – Overt hyperthyroidism • How to treat ? – Antithyroid drugs – Radioactive iodine – Surgery 28 Nodule Palpable/Nonpalpable US TSH Hypo/Normal Hyper FNA Scan Cold Hot Treat or follow 29 Fine Needle Aspiration Pitfalls of FNA No Quick Diff Not enough follicular cells Non palpable nodule False negatives 30 Nodule Palpable/Nonpalpable US Hypo/Normal TSH Hyper FNA Cold Scan Hot Benign Indeterminate Malignant Treat or follow Follow Repeat Operate 31 Thyroid cytology Benign cytology: large amount of colloid with few typical follicular cells Indeterminate cytology Malignant cytology • Few colloid and large • Intranuclear inclusions, amount of follicular cells grooves, psamoma, etc • Large, medium and • High cellular density microfollicular patterns • Papillary patterns • Solid patterns • Capsular invasion Follicular and Hurthel adenomas are diagnosed only upon pathology (capsular and/or vascular invasion) 32 33 Normal Thyroid Colloid nodule Papillary Thyroid Cancer 34 Risk factors for thyroid cancer 35 36 Treating Thyroid Nodules • Surgery: malignancy, hyperthyroidism, mass effect, cosmetic/psychological • Radioactive iodine: hyperthyroidism, mass effect • Percutaneous ethanol • Antithyroid drugs • Thyroxine suppression therapy • Follow up 37 Thyroxine suppressive therapy Wemeau JL et al. J Clin Endocrinol Metab 87:4928- 34, 2002 38 Our patient has a benign FNA report. What’s the need for follow-up and how ? • • • False negative FNA in up to 5% (less when US guidance) Changes in functionality Size changes with mass effect • • Follow-up for functional changes – Clinical features – Serial TSH measurements Follow-up for anatomic changes – by palpation – by US very operator-dependent – by CT Consider TSH suppression trial Repeat FNA 39 40