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Evaluation of Thyroid Nodules
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Evaluation of Thyroid Nodules

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    Evaluation of Thyroid Nodules Evaluation of Thyroid Nodules Presentation Transcript

    • Evaluation of Thyroid Nodules Michael L. Tuggy, MD Swedish Family Medicine, Seattle, WA
    • Case 1
      • 42 y.o. male with no active medical problems. During your routine physical, note a thyroid nodule. Told by ENT last year not to worry about it.
      • PE: 1 x 2cm R lower pole nodule.
      • What information do you want from the patient?
    • Age as a Risk Factor
      • Age
        • young patients (<20 years of age)
        • thyroid nodules are much more likely to be malignant (40-50%).
        • elderly (>60 years of age) -higher risk, especially of more aggressive thyroid tumors.
    • Gender and Thyroid Nodules
      • Gender
        • male -higher risk if nodule present
        • females
          • have many more nodules
          • less likely to be malignant.
          • still have majority of thyroid cancers
    • Other major risks
      • Radiation to head and neck.
        • 40% risk of thyroid cancer usually 25 years later.
        • Exposed populations- Polynesian studies
      • Family History of MEN II, Gardner’s Syndrome, Cowden’s disease.
    • Historical Red Flags
      • Recent growth
      • Soft tissue swelling
      • Vocal changes
      • Dysphagia
      • Signs of thyroid dysfunction
    • Case 2
      • 26 y.o. Eritrean female with a 2-3 year history of goiter. No symptoms but noted enlargement on right for 1 year.
      • P.E.: 3x4 cm Right sided thyroid mass, firm, adherent to soft tissue.
      • What physical findings are worrisome?
      • How can you best clarify the nature of the nodule?
    • Thyroid Exam
    • Physical Exam of the Thyroid
      • Use both hands simultaneously to evaluate for symmetry
      • Patient upright - screening exam
      • Patient supine with neck in extension- detailed exam. Swallowing assists in elevating gland.
      • Evaluation of other neck structures.
      • Voice changes (recurrent laryngeal nerve).
    •  
    • Thyroid Scans
      • Purpose
        • Determine function of the gland and/or a nodule within the gland
      • Hot nodules - usually independently functioning nodules
        • Rarely, rarely malignant
      • Cold nodules - either adenoma or maligancy
        • 15% chance of malignancy in adults.
    • Thyroid Ultrasound
      • Can identify presence of nodules.
      • May be able to characterize follicular vs. solid.
      • Not able to rule our malignant nodule
      • Aid in biopsy.
      Thyroid
    • Case 3
      • 30 y.o. WF with enlarging cold benign thyroid adenoma (diagnosis from previous FNA biopsy).
      • PE: 4 x 5 cm mass on Right
      • What do you do now?
    • Fine-Needle Aspiration
      • Best tool for determining pathology other than surgical excision.
      • Can be as high as 80 % sensitive and 95% specific.
      • Operator dependent in obtaining adequate amount of tissue. 25 gauge needle is optimal.
      • Should not be relied on if negative in patient with previous neck irradiation.
        • Multifocal tumors common.
    • Interpreting the Biopsy Report
      • What you get:
        • benign
        • indeterminate
        • suspicious
        • inadequate specimen
      • What it means:
        • benign - 90-95% likelihood it is benign
        • indeterminate- who knows?
        • suspicious- it’s malignant.
        • inadequate specimen - do it again (and again)
    • Thyroid Malignancies- Papillary
      • Most common
      • 30% have node metastasis at diagnosis
      • Radiation related
      • Histologically, psammoma bodies distinguish from benign adenoma.
    • Thyroid Malignancies-Follicular
      • 20 % of malignancies
      • Distinguished from normal follicular adenomas by invasion of capsule or blood vessels.
      • May be difficult to determine on FNA
    • Thyroid Malignancies- Medullary
      • 5-10% of cases
      • arise from the C cells which produce calcitonin
      • diagnosis based on elevated thyrocalcitonin levels and thyroid nodule (cold)
    • Thyroid Malignancies- Anaplastic
      • < 10%
      • Highly aggressive with local extension at time of diagnosis.
      • No suitable therapy
      • Prognosis < 1 yr from diagnosis
    • Treatment
      • For all malignancies, excision of the the lobe (or if post-radiation the entire gland).
      • XRT- very specific and well tolerated- I 131 therapy.
      • Anaplastic tumors - palliative radiation and XRT.
    • What about those benign nodules?
      • No specific treatment is needed.
      • Thyroid suppression may shrink size of adenomas
      • Not proven to be effective or necessary
      • May hide malignancies - ? Periodic biopsies or scans.
    • Case 4 - This weeks puzzler!
      • 40 y.o. WF s/p I 131 ablation for Grave’s Dz. 6 years ago.
      • Persistant R thyroid nodule 2 x 1.5 cm in size.
      • What is the likely diagnosis?
    • Outcomes
      • Case 1. - Papillary cancer - 3 (+) nodes
        • no metastasis at 1 year.
      • Case 2. - Follicular cancer - 5 (+) nodes
        • no metastasis at 1.5 years
      • Case 3. - Large adenoma with incidental 1 cm papillary carcinoma superior to nodule.
        • No recurrence at 5 years.
      • Case 4. - Non-functional adenoma
    • Modified from: Castro, MR, Gharib, H. Endocr Pract 2003; 9:128.
    • Summary: Solitary Nodule Evaluation
      • TSH – if low – scan – if hot nodule, then observe.
      • Normal TSH - Do I scan first or FNA first?-
        • high risk - scan and FNA
          • Is the nodule cold or hot?
          • Cold - FNA biopsy
        • low risk - FNA
          • if indeterminate- scan and re-FNA or excisional biopsy.
      • Anti-perioxidase Antibody – helpful if low- TSH to diagnose thyroiditis.
    •  
    • Never assume a solitary thyroid nodule is benign. Prove it.