Evaluation of a thyroid nodule by vijay

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EVALUATION OF A THYROID NODULE

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Evaluation of a thyroid nodule by vijay

  1. 1. EVALUATION OF A THYROID NODULE VIJAY SHEWALE KIMS , TRIVANDRUM 14TH AUG 2013
  2. 2. INTRODUCTION • DEFINITION- A discrete lesion within the thyroid gland that is palpably and/or radiologically distinct from surrounding thyroid parenchyma.
  3. 3. INTRODUCTION • PREVALENCE- Epidemiological studies have shown that prevalence of palpable thyroid nodule is 5% in women and 1% in men. This prevalence increases upto 19 – 67 % if detected by ultrasound. • Nodular goitre prevalence increases by age
  4. 4. INTRODUCTION • The importance of thyroid nodule rests with the need to exclude thyroid malignancy which occurs in 5 – 15 %
  5. 5. HOW WAS THE NODULE FOUND • Palpation with a physical exam • Incidental finding on diagnostic work up • Self detection • Surveillance • Work up for symptoms of hyper or hypothyroidism
  6. 6. CLINICAL EVALUATION
  7. 7. HISTORY • Age , sex • Swelling in front or side of a neck • h/o pain • Sudden increase in size • Pressure symptoms such as hoarseness of voice , dyspnoea , dysphagia (rarely)
  8. 8. HISTORY • h/o hyperthyroid – loss of weight in spite of good appetite, intolerance to heat, excessive sweating CNS symptoms like- irritability , insomnia, tremor of hands, muscle weakness EYE symptoms such as staring look, difficulty in closing eye, double vision CNS and EYE symptoms are s/o primary
  9. 9. HISTORY CVS symptoms like palpitations , chest pain , dyspnoea on exertion are s/o secondary hyperthyroid • h/o hypothyroid- increase in weight in spite of poor appetite, facial puffiness, loss of hair, lethargy, poor memory, constipation, oligomenorrhoea
  10. 10. HISTORY PAST HISTORY • h/o neck irradiation , • h/o thyroid disease in family
  11. 11. EXAMINATION General examination- Signs of hyperthyroid- tachycardia, tremor, moist skin, eye signs like exophthalmos look, Von Graefe’s sign, lid retraction, joffroy’s sign,stellwag’s sign, moebius sign
  12. 12. EXAMINATION Local examination- • Movement of swelling with deglutition • Size , consistency of nodule • Tracheal deviation, retrosternal extension • Cervical lymphadenopathy
  13. 13. WORK UP
  14. 14. THE AMERICAN THYROID ASSOCIATION (ATA) GUIDELINES FOR THYROID NODULE 2009 , REVISED IN 2013
  15. 15. SERUM TSH • Low TSH may be associated with functioning nodule, very unlikely to be malignant • TSH has trophic effect on thyroid cancer growth mediated by TSH receptors on tumor cells • TSH suppression is an independent predictor for relapse free survival in differentiated thyroid cancer
  16. 16. ULTRASOUND SCAN Can answer following questions • Solid/cystic • size • Additional nodule • Benign or malignant feature
  17. 17. ULTRASOUND SCAN BENIGN • Iso / hyper echoic • Coarse calcifications • Thin, well defined halo • Regular margins • Hypovascular • No lymph nodes MALIGNANT • Hypo echoic • Micro calcifications • Thick or absent halo • Irregular margins • Hypervascular • Lymphadenopathy • Taller than wide lesion
  18. 18. HYPOECHOIC
  19. 19. HYPERVASCULARITY
  20. 20. CALCIFICATIONS, POORLY DEFINED, IRREGULAR MARGINS
  21. 21. SOLID
  22. 22. Is size predictor of malignancy • Non palpable nodules have the same risk of malignancy as palpable nodules with the same size • Generally, only nodules >1 cm should be evaluated, since they have a greater potential to be clinically significant cancers. • Nodules <1 cm that require evaluation because of suspicious US findings, associated lymphadenopathy, a history of head and neck irradiation, or a history of thyroid cancer in one or more first-degree relatives.
  23. 23. • Nodules <1 cm lack these warning signs yet eventually cause morbidity and mortality. These are rare and, given unfavourable cost/benefit considerations, attempts to diagnose and treat all small thyroid cancers in an effort to prevent these rare outcomes would likely cause more harm than good.
  24. 24. FNAC • Only gold standard test for proof of malignancy without surgical pathology • 23 – 25 gauze no needle is used
  25. 25. INDICATIONS FOR US GUIDED FNAC • Non palpable or difficult to palpate nodule • Previous non diagnostic cytology • Nodules with previous benign cytology which has grown in size
  26. 26. FNAC RESULTS • Nondiagnostic (thy 1) • Benign(thy2) • Suspicious for a Follicular Neoplasm/Follicular Neoplasm(thy3) • Suspicious for Malignancy(thy4) • Malignant(thy5)
  27. 27. BENIGN • Scanty normal follicular cells together with colloid
  28. 28. PAPILLARY • Nuclear grroving • Papillary projections • Orphan annie eye nuclei
  29. 29. FOLLICULAR • Increased cellularity with a follicular pattern
  30. 30. HURTHLE CELL • Variant of follicular neoplasm • Oxyphill ( askanazy ) cells predominate
  31. 31. MEDULLARY • Amyloid stroma
  32. 32. NON DIAGNOSTIC CYTOLOGY • In persistent non diagnostic cytology risk of malignancy is less than 5% • Surgery should be considered if nodule is solid
  33. 33. BENIGN CYTOLOGY • TSH suppressive dose of thyroxine is not recommended • Repeat us guided evaluation after 6 months • If size same or decrease, continue to follow up for longer intervals • If increasing us guided cytology • Surgery is recommended in recurrent cystic nodule with benign cytology
  34. 34. FOLLICULAR NEOPLASM • I 123 thyroid scan should be considered if serum TSH is in low normal level • Surgery should be consider if no concurrent hyperfunctioning nodule is present • Total thyroidectomy if nodule > 4 cm in size bilobar nodular disease h/o radiation exposure or family h/o thyroid malignancy
  35. 35. FOLLICULAR NEOPLASM • Use of molecular markers such as BRAF, RET/PTC, Ras, PAX8/PPARy or GALECTIN3 may be consider
  36. 36. PAPILLARY • Total thyroidectomy unless if nodule is less than 1 cm and unifocal • Modified radical neck dissection only if enlarged lymph nodes are present
  37. 37. MEDULLARY • Total thyroidectomy • Central compartment lymph node dissection is recommended • Modified radical neck dissection only if enlarged lymph nodes are present
  38. 38. ANAPLASTIC • Total thyroidectomy • Prognosis is poor
  39. 39. LYMPHOMA • Chemotherapy • Surgery indicated if pressure symptoms are present
  40. 40. THYROID SCAN • Only in hyperthyroid • In hot nodule, surgery is recommended after preparation • In cold nodule ,10 % possibility of malignancy. FNAC is advised, manage accordingly
  41. 41. POST OPERATIVE MANAGEMENT • In DTC , patient are categorized in high or low risk for recurrence • AMES (lahey clinic)- age , metastasis, extension , size • AGES (mayo clinic 1987)- age , grade, extension, size • MACIS (mayo clinic 1993)- metastasis, age , completeness of resection , invasion, size
  42. 42. POST OPERATIVE MANAGEMENT • GAMES (MSKCC)- grade , age , metastasis, extension, size • TNM FOR DTC Age < 45 Stage 1 – any T, any N, M0 Stage2 - any T ,any N , M1
  43. 43. POST OPERATIVE MANAGEMENT Age > 45 in DTC and medullary Stage 1 – T1 N0 M0 Stage 2- T2 N0 M0 Stage 3- T 3 N0 M0 or T 1-3 N1 M0 Stage 4A- T4a Stage 4 B – T4b Stage 4 C – M1
  44. 44. POST OPERATIVE MANAGEMENT • ANAPLASTIC Stage 4 A- T 4a Stage 4B- T4b Stage 4C- T 4c
  45. 45. POST OPERATIVE MANAGEMNT • In differentiated thyroid carcinoma - Iodine 131 ablation to remove any residual thyroid tissue and malignant cells, to allow follow up with serum thyroglobulin • Radioiodine scan, serum thyroglobulin, ultrasound scan , to monitor the patients for recurrence
  46. 46. POST OPERATIVE MANAGEMENT • In medullary ca- radiotherapy recommended if lymph nodes are positive for metastasis • Tyrosine kinase inhibitors, VEGF receptor inhibitors are under trial now • Follow up with serum calcitonin , and CEA
  47. 47. THANK YOU

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