5. Thyroid nodule
• Common problem (women 4 times more
common )
• Majority benign
• 5% malignant
• 10% malignant in solitary thyroid nodule
6. Thyroid nodule- Tripple assessment
1. History and physical examination
2. Imaging ( Ultrasound neck ± CT scan, CXR)
3. Biopsy (Fine needle aspiration, Core biopsy,
Hemithyroidectomy)
Additional investigations:
1. Thyroid function test
2. Laryngoscopy – indirect to assess vocal cord
(recurrent laryngeal nerve involvement)
7. Factors suggesting a malignant diagnosis
•Age younger than 15 years or older than 45 years
•Male sex
•Associated symptoms of dysphagia or dysphonia
•Family history of thyroid carcinoma
•History of neck irradiation
•Prior history of thyroid carcinoma
•Firm, hard or immobile nodule
•Presence of cervical lymphadenopathy
9. Ultrasound neck
• Assess the thyroid nodule and cervical lymph
nodes
• Operator dependent
• To determine whether the thyroid nodule has
features of malignancy
• More sensitive to assess the cervical
lymphadenapathy
• Assist in thyroid or lymph node biopsy
21. Spongiform nodules
• aggregation of multiple
microcystic components
in more than 50% of the
volume of the nodule
• •“honeycomb of internal
cystic spaces”
• •Less than 1% risk of
malignancy
24. Fine needle aspiration cytology
•Indications:
- All palpable solitary thyroid nodule
- Dominant nodule of MNG
- Impalpable suspicious nodule more than
1 cm
- Huge goitre suspecting cancer
25. FNAC report
1. Carcinoma (papillary, medullary, poorly diff or
anaplastic) or suspicious for malignancy
2. Follicular or Hurthle cell neoplasm
3. Thyroid Lymphoma
4. Benign (nodular goitre, colloid goitre,
hyperplastic nodule, hashimoto thyroiditis)
5. Insufficient biopsy
28. Impalpable small benign thyroid nodules
• Surveillance should include repeat ultrasound
after 6-12 months, if stable for 1-2 years then
subsequent ultrasound can be considered at 3-
5 year intervals.
• NCCN Guidelines Version 2.2012
29. Papillary thyroid carcinoma
• 80% of thyroid malignancies
• Micropapillary carcinoma ( tumour <1cm)
needs hemithyroidectomy
• If tumour > 1 cm , needs completion
thyroidectomy
• Total thyroidectomy with or without modified
radical neck dissection
30. Follicular thyroid neoplasm
• Follicular thyroid ca accounts for 10% of thyroid
malignancies
• Hemithyroidectomy for solitary thyroid
carcinoma, no need completion if tumour less
than 1 cm
• Spread via blood vessels to lung, bone, brain
and liver
31. Hurtle cell neoplasm
• Hurtle cell ca is a variant of follicular thyroid ca
• Hemithyroidectomy for solitary thyroid nodule
• Completion thyroidectomy for tumour more
than 1cm
32. Post surgical therapy for differentiated
thyroid carcinoma
• TSH suppressive therapy
• Radioiodine Ablation therapy
33. TSH suppressive therapy
•High risk patient:
- < 0.1 mU/L
•Low risk patient:
- 0.1- 0.5 mU/L
Patient who remain disease free for several years:
maintain TSH within normal range
34. Radioactive Iodine Ablation therapy
• For differentiated thyroid carcinoma
• Tumour size more than 1 cm
• Gross residual disease
• Distant metastatic disease
• Patient without gross residual disease who are
at higher risk for recurrence ( high risk
histology, vascular invasion, cervical nodal
metastasis)
35. Radioactive Iodine Ablation therapy
•Done in Radionuclear department in Hosp Kuala
Lumpur , National Cancer Institute in Putrajaya and Hosp
Likas
•Preparation for RAI:
-withold thyroxine for 1 month (so that TSH > 30)
- Thyrogen (component to make T4; 2 doses; cost 2k)
- no seafood for two weeks
- No iodine contrast for 2 week
37. Postop radioiodine may be used to:
• Ablate the thyroid remnant, which will help in
surveillance for recurrence disease using serum
thyroglobulin or whole body scan
• Eliminate suspected micrometastases
• Eliminate know persistent disease
38. Radioactive Iodine Ablation therapy
• Ablation dose 80-150mci
• Keep in isolation ward for 5 days
• WBS (whole body scan) post therapy to detect
any functioning thyroid tissue in thyroid bed ,
cervical region or else where.
• Serum Thyroglobulin and serum TSH
measurement
41. Follow up for Differentiated thyroid cancer
• History and neck examination
• Check the thyroid function test, make sure TSH
well suppressed
• Check serum thyroglobulin + antithyroglobulin
antibodies (prevent false negative)
42. Medullary thyroid carcinoma
•Preop workup:
- Basal calcitonin level
- CEA
- Se calcium
- Pheochromocytoma screening
- neck ultrasound
- CT neck thorax if calcitonin >400pg/ml
43. Medullary thyroid carcinoma
•Total thyroidectomy ± central neck dissection
•Total thyroidectomy and Modified radical neck
dissection
•Post op:
- Thyroxine to normalize TSH
- External beam radiotherapy for gross
incomplete resection
