Approach to the Thyroid Nodule by sammyc2007

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									‫‪Approach to the‬‬
‫‪Thyroid Nodule‬‬
      ‫דר' קרלוס בן-בסט‬
        ‫מכון אנדוקריני‬
   ‫מרכז רפאי רבין, בלינסון‬




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                      The Goiters
              Thyroid gland enlargement

 Diffuse Goiter                     Nodular Goiter
• Endemic                         > Solitary nodule
                                   Cold or Hot (Toxic adenoma)
• Sporadic
                                   Solid or Cystic (simple, complex)
  Enzymatic defect (congenital)
                                   Painful or not
  Drug induced (e.g. lithium)
                                   Firm or soft
• Others                           Fixed or not
   Graves disease                 > Multinodular goiter
    Hashimotos                     Non toxic
    Subacute thyroiditis           Toxic (autonomous function)
                                   Retrosternal goiter

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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)


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Thyroid Imaging




                  8
Neck Ultrasound




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Neck CT




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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




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Tracheal compression




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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




                 Cold nodule   26
Toxic adenoma
        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


                                    Scan
     FNA



                             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                                  TSH

                          Hypo/Normal                 Hyper


                                                      Scan
            FNA
                                               Cold            Hot


                                                             Treat or
Benign    Indeterminate        Malignant                      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             32

                       invasion)
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            Normal Thyroid
            Colloid nodule




Papillary
Thyroid
Cancer

                             34
Risk factors for thyroid cancer




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       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%   •   Follow-up for functional changes
    (less when US guidance)               – Clinical features
•   Changes in functionality              – Serial TSH measurements
•   Size changes with mass effect    •   Follow-up for anatomic changes
                                          – by palpation
                                          – by US very operator-dependent
               Consider                   – by CT
          TSH suppression trial
             Repeat FNA



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