Management Of Solitary Thyroid Nodule


Published on

Published in: Health & Medicine
1 Comment
No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Management Of Solitary Thyroid Nodule

  1. 1. <ul><li>“ MANAGEMENT OF SOLITARY THYROID NODULE ” </li></ul><ul><li>Dr.Anil Haripriya </li></ul><ul><li>Assistant Professor </li></ul><ul><li>Surgery </li></ul><ul><li>NHDC & RI </li></ul>
  2. 2. Introduction <ul><li>Anxiety induced by the fear of malignancy in Solitary Thyroid Nodule (STN) against a background of common benign nodular disease generates the diagnostic dilemma for the clinicians and make its management controversial. </li></ul><ul><li>With the availability of current diagnostic techniques it is now possible to have a selective approach to management of STN by identifying those patients likely to have malignancy and avoiding thyroidectomy in majority of patient with being benign disease. </li></ul>
  3. 3. <ul><li>DEFINITION </li></ul><ul><li>A thyroid nodule is a palpable swelling in a thyroid gland with an otherwise normal appearance. </li></ul><ul><li>Most are benign </li></ul><ul><li>12-28% are malignant STN </li></ul><ul><li>Four times more common in women </li></ul><ul><li>D/D of STN: </li></ul><ul><li>Cyst : </li></ul><ul><li>Thyroid adenoma </li></ul><ul><li>Colloid nodule </li></ul><ul><li>Carcinoma : Papillary (75%) </li></ul><ul><li>Follicular (10%) </li></ul><ul><li>Medullary (5-10%) </li></ul><ul><li>Anaplastic (5%) </li></ul><ul><li>Thyroid lymphoma (5%) </li></ul><ul><li>Others : Inflammatory thyroid disoders </li></ul><ul><li>Chronic lymphocytic thyroiditis </li></ul>
  4. 4. <ul><li>PATIENT PRESENTATION AND DIAGNOSIS : </li></ul><ul><li>- Majority are asymptomatic </li></ul><ul><li>Most are euthyroid, with only </li></ul><ul><li>1% of nodules carry hyperthyroid or thyrotoxicosis. </li></ul><ul><li>SYMPTOMS : </li></ul><ul><li>- Palpable lump </li></ul><ul><li>- Neck pressure (spontaneous haemorrhage into nodule) </li></ul><ul><li>- Symptoms of hypothyroidism </li></ul><ul><li>- Symptoms of hyper thyroidism </li></ul>
  5. 5. OBJECTIVES AND EVALUATION OF THYROID NODULES To exclude malignancy Regarding adequate and ideal treatment of STN METHODS TO ACHIEVE THE OBJECTIVES Clinical evaluation Investigations : FNAC Test of thyroid function Thyroid scintiscan Thyroid USG Fluorescant scanning MRI/CT – very rarely
  6. 6. <ul><li>CLINICAL EVALUATION </li></ul><ul><li>- Multiple nodules and diffuse nodularity => more benign diseases </li></ul><ul><li>- Firm solitary nodule - malignancy </li></ul><ul><li>- About one half of all nodules detected by USG escape detection on clinical examination. </li></ul><ul><li>&quot;RED FLAGS&quot; FOR THYROID CARCINOMA </li></ul><ul><li>Male – gender (16% male, 10% female) </li></ul><ul><li>Extremes in age (< 20 - > 65 yrs) </li></ul><ul><li>Rapid growth of nodule </li></ul><ul><li>Symptoms of local invasion (dysphagia, hoarseness) </li></ul><ul><li>Hard, fixed lesions, nodules > 4 cm </li></ul><ul><li>Cervical lymphadenopathy </li></ul><ul><li>History of radiates to head or neck </li></ul><ul><li>Family history of thyroid carcinoma or polyps </li></ul>
  7. 7. <ul><li>FNAC </li></ul><ul><li>: It is i nvestigation of choice </li></ul><ul><li>Accuracy – 95% </li></ul><ul><li>False negative – 1-11% </li></ul><ul><li>False positive – 1-8% </li></ul><ul><li>Benign Malignant Suspicious Indeterminate </li></ul><ul><li>or inadequate </li></ul><ul><li>70% 5-10% Surgery </li></ul><ul><li>Follow up Surgery Repeat FNAC </li></ul><ul><li>50% 50% </li></ul><ul><li>Monitor Surgery </li></ul><ul><li>Pit fall : Can not differentiate between follicular adeoma and f. carcinoma </li></ul><ul><li>Recently </li></ul><ul><li>Immunocytochemical </li></ul><ul><li>Proton magnetic resonance </li></ul>
  8. 8. <ul><li>TESTS OF THYROID FUNCTION </li></ul><ul><ul><li> TSH with or without low T3 and T4 – suggests nodular form of hashimoto's thyroiditis. </li></ul></ul><ul><ul><li>TSH  with or without elevated T3 and T4 suggests => autonomously hyper functioning nodule </li></ul></ul><ul><ul><li>Serum cacitonin measured => any patient with family history of thyroid carcinoma. </li></ul></ul><ul><li>Can not distinguish whether nodule is benign or malignant. </li></ul>
  9. 9. <ul><li>THYROID SCINTISCAN </li></ul><ul><li>Nuclear imaging cannot reliably distinguish between benign and malignant nodule </li></ul><ul><li>Differentiate STN with multinodular goitre </li></ul><ul><li>Function status of nodule </li></ul><ul><li>Whether metastasis of thyroid carcinoma concentrate iodine and could be immenable to treatment with radioiodine </li></ul><ul><li>Cervical mass containing thyroid tissue </li></ul><ul><li>I123 and Tech99 are commonly used </li></ul><ul><li>I131 used for whole body imaging </li></ul>
  10. 10. 30% 9% 4% 5% Hot 13% 19% 9% 9% Warm 22% 72% 16% 84% Cold Malignant % Malignant % uptake Tc 99 I 123
  11. 11. FNAC is inconclusive and scan shows warm or hot nodules Warm nodules – A trial of TSH suppression using thyroxin may cause regression of nodule Autonomously functioning hot nodule – I131 ablation therapy may serve as a useful alternative to surgery.
  12. 12. <ul><li>ULTRASONOGRAPHY : </li></ul><ul><li>USG cannot distinguish benign from malignant nodules </li></ul><ul><li>change in size of nodules over time, either in follow up of a lesion thought to be benign: </li></ul><ul><li>detecting recurrence in patient with thyroid carcinoma </li></ul><ul><li>incidence of indeterminate specimen from FNA decreases from 15% - < 4% (when FNA used with USG) </li></ul><ul><li>thyroid nodules found incidently during USG of neck for reason not relating to thyroid gland </li></ul><ul><li>monitoring size of nudule during thyroxin suppression therapy </li></ul>
  13. 13. CXR : In presence of obstructive symptoms tracheal deviation or suspected retrosternal extension. Cacification within papillary carcinoma of thyroid as psammona bodies. MRI/CT : STN are being found incidently during MRI/CT for reason not relating to thyroid gland. Fluorescent scanning: Determines intra – thyroid iodine content is an unproven technique for defferentiating bening from malignant thyroid nodule currently remains a research tool.
  14. 15. <ul><li>TREATMENT </li></ul><ul><li>Principles of deciding modalities of treatment : If FNAC – malignant – total thyroidectomy </li></ul><ul><li>If Cyst (benign) - completely aspirated. </li></ul><ul><li>- if recurrences occurs : </li></ul><ul><li> Hemithyroidectomy </li></ul><ul><li>residual nodule is </li></ul><ul><li>palpable after aspiration : </li></ul>
  15. 16. If benign and lesion is solid : thyroid scintiscan Low Risk Warm: TSH suppression trial by thyroixin, if response positive ; continue for 6 months or till nodules disappeared Cold : hemithyroidectomy Hot nodules : I131 ablation or hemithyroidectomy High risk – even if FNAC is negative for malignancy hemithyroidectomy is advocated Hemithyrodectomy is useful if FNAC is inconclusive or reported as follicular neoplasm.
  16. 17. <ul><li>At time of hemithyroidectomy – frozen section should be taken if confirm malignancy – total thyroidectomy </li></ul><ul><li>If inconclusive : Paraffin section should be taken – if positive – completion thyroidectomy </li></ul><ul><li>FOR MALIGNANT NODULE: </li></ul><ul><li>partial / total thyroidectomy - remains controversial and debate continues for type of thyroidectomy </li></ul>
  17. 18. <ul><li>Radioiodine therapy should be used as adjunctive therapy </li></ul><ul><li>Post operative thyroid replacement is a common practice </li></ul><ul><li>Benefits of administration remains controversial specially in low risk patients </li></ul><ul><li>Complication of surgery : </li></ul><ul><li>Recurrent laryngeal nerve damage </li></ul><ul><li>Hypoparathyroidism </li></ul>
  18. 19. CONCLUSION: With the advent of current diagnostic technique and with their appropriate use in diagnosis of STN, it is now possible to have a selective approach to management of STN by identifying the patient likely to have malignancy and avoiding thyroidectomy in majority of patient with benign diseases who can be given conservative medical treatment.
  19. 20. THANK YOU