Presentation for thyroid nodule management

1. Management of
Thyroid Nodules
Presented by:
Dr. Hend Abdallah Elsheimy
MD Internal Medicine

2. Introduction
• A discrete lesion that is palpably and/or
ultrasonographically distinct from surrounding
thyroid parenchyma
• More frequent in women and elderly.
• In iodine-sufficient areas palpable thyroid
nodules is ≈ 5% in women & 1% in men.
• High-resolution US detected nodules in 19%-
68% (Incidentaloma)

3. Introduction
• 7% to 10% of clinically relevant nodules are
likely malignant
• Focal 18FDG-PET uptake in a sonographically
confirmed nodule increases malignancy risk to
35%

4. Clinical Presentation
• Symptoms, family history of thyroid disorders or
thyroid cancer, and history of head and neck
radiation.
• Most thyroid nodules are nonfunctional,
autonomously functioning nodules cause clinical
hyperthyroidism.
• Thyroid nodules typically present as a painless
lump.

5. Clinical Findings Associated With
Malignant Thyroid Nodules

6. Laboratory Investigation
• TSH should be measured in all patients. Suppressed
TSH suggests a toxic nodule which is confirmed with
scintigraphy.
• The routine measurement of serum thyroglobulin
is not recommended.
• Serum calcitonin is not routinely measured but may
be considered in certain cases.
• Calcium and PTH when a nodular lesion is suggestive
of parathyroid adenoma

7. Imaging
Thyroid ultrasonography (US)
❑The sonographic features classify the risk of
malignancy to help direct decision making for FNA
from thyroid nodules or cervical lymph nodes.
❑Always perform US evaluation of incidentalomas
detected by CT or MRI prior to FNA
❑Ultrasound elastography (USE): for measurement of
tissue stiffness. The stiffer the nodule, the higher the
risk of cancer. Used as a complimentary tool.

9. IMAGING
❑Thyroid scintigraphy (radionuclide scan) IN
nodules associated with low TSH, hot nodules
have a lower risk of malignancy.
❑CT , MRI & PET/CT are not routinely used

10. FNA cytology
❑FNA with cytologic evaluation is the
procedure of choice for patients requiring
biopsy.
❑FNA cytology is reported using the Bethesda
System for Reporting Thyroid Cytopathology.
❑Consider core needle biopsy in solid lesions
with persistent unsatisfactory results.

12. TREATMENT
• Surgical treatment:
❑Thyroid nodules are surgically resected if indicated
based upon cytology results.
❑ Consider Lobectomy for benign very large nodule
large (>4 cm) or causing compressive symptoms.
❑Surgical removal or percutaneous ethanol injection
(PEI) can be considered for recurrent cystic nodules
with benign cytology.

13. TREATMENT
❑For autonomously functioning thyroid nodules
(AFTNs), radioactive iodine or surgery is preferred.

14. 2020 ETA Clinical Practice Guideline for the Use of
Image-Guided Ablation in Benign Thyroid Nodules
❑US-guided thermal ablation (TA) may be
considered for selected cases as alternative
options to the well established treatments.
❑Risk of malignancy should be reliably ruled out
and the advantages and disadvantages of TA
discussed with the patient.
❑Ethanol Ablation is preferred for cystic (or
predominantly cystic) symptomatic nodules.

15. 2020 ETA Clinical Practice Guideline for the Use of
Image-Guided Ablation in Benign Thyroid Nodules
❑TA may be considered for cystic lesions that
relapse after EA or for those with a residual
solid nodule following EA.
❑Spongiform and complex nodules are better
candidates for TA than solid compact nodules.
❑TA is considered in young patients with small
AFTN and incomplete suppression of
perinodular thyroid tissue.

16. 2020 ETA Clinical Practice Guideline for the Use of
Image-Guided Ablation in Benign Thyroid Nodules
❑Laser and radiofrequency ablation are the
most thoroughly assessed techniques, with
similar satisfactory clinical results.
❑Microwaves and high-intensity focused
ultrasound therapy options remain to be fully
evaluated.

17. Thyroid Nodule During Pregnancy
❑ Generally managed as nonpregnant subjects. FNA is
recommended for suspicious nodules.
❑ In subnormal TSH levels during the second half of
pregnancy, postpone radionuclide thyroid scan until after
delivery and cessation of breastfeeding.
❑ If FNA shows indeterminate cytology, US monitoring and
postponing surgery until after delivery is recommended.
❑ When thyroid malignancy is diagnosed during the first or
second trimester, thyroidectomy should be performed during
the second trimester.

18. Thyroid Nodule During Pregnancy
❑When thyroid malignancy is diagnosed during
the third trimester, in absence of aggressive
findings, surgical treatment can be deferred until
the immediate postpartum period.
❑ For patients with suspicious or malignant
thyroid nodules in whom surgery is postponed
until after delivery, maintain TSH at low-normal
levels (e.g., 0.5-1.0 mIU/L)

20. References
• 2015 American Thyroid Association Management Guidelines for Adult Patients
with Thyroid Nodules and Differentiated Thyroid Cancer; 2016. THYROID, Volume
26, Number 1.
• 2020 European Thyroid Association Clinical Practice Guideline for the Use of
Image-Guided Ablation in Benign Thyroid Nodules; 2020. Eur Thyroid J;9:172–185,
• ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the
ACR TI-RADS Committee; 2017. J Am Coll Radiol ;14:587-595.
• Thyroid cytology reporting by the Bethesda System: A two-year
experience at an academic institute; 2017. Indian Journal of Pathology
and Oncology, January-March, 2018;5(1):35-41
• American Association Of Clinical Endocrinologists, American College Of
Endocrinology, And Associazione Medici Endocrinologi Medical guidelines
for
clinical practice for the diagnosis and management of thyroid nodules –
2016 update; 2016. Endocrine practice vol 22 (suppl 1).
• Williams text book of endocrinology 14th Edition; 2020.