1) The patient presented with a large multinodular goiter and initial FNAC suggested benign nodular colloid goiter. 2) He later underwent subtotal thyroidectomy and the biopsy revealed papillary carcinoma. 3) This case demonstrates that FNAC can sometimes miss malignancy, so biopsy remains the gold standard

1. Grand round
Dr. Beka Aberra [IM- R2]
Dr. Astarkew Alene [IM – R1]
Dr. Bethelhem Berhanu [R – R2]
Dr. Zinabu A. [SR – R4]

2. Outline
1. Identification
2. History
3. Progress of the patient
4. Case Discussion
5. Multi Disciplinary Approach to Thyroid Nodule
6. Inter Departmental Discussion
7. Take home message
8. References

3. Identification
 MRN - 494576
 NAME – E.Y.
 AGE - 57
 SEX - MALE
 ADDRESS – GULELE, ADDIS ABABA
 MARTIAL STATUS - MARRIED
 DOR - 27/03/2008 E.C
 PHONE NO.- +251-913247089

4. HISTORY [06/12/2008]
 A 57 yrs old male, known asthmatic patient >20yrs on Intermittent Salbutamol puffs
Presented with Anterolateral neck swelling >10 Yrs, not increasing in size
 Has bilateral leg swelling, burning sensation around umbilicus and extremities.
 No Shortness of breath
 No Hyper/Hypo thyroid symptoms identified at the time.
 No Other compressive symptoms identified
 No Weight loss/Loss of appetite.
 No History of smoking or alcohol intake.
 No History of DM,HTN.
 No Family history of similar illness.

5. Physical Exam
 General Appearance : Well Looking
 Vital Sign: BP: 160/100 PR:84 RR: 18 T:36.70c SpO2: 97%,on atmospheric air
 HEENT: Pink conjunctivae, Non-icteric sclera
 LGS: 7*6 cm Anterolateral Neck Swelling, more on the right side, multinodular
soft-firm consistency, non tender, which moves with deglutination.
 CHEST: Clear and Resonant
 CVS: Flat JVP; Heart sounds (S1/S2) are well heard, no murmur or gallop.
 Abdomen: NAD
 MSS: Bilateral Pitting edema
 CNS: NAD

6. HISTORY [06/12/2008]
Assessment: CHF 20 to ? HHD+ Renal simple cyst
Plan;- Lasix 20mg po /day, Nifedipine 20 mg po bid,
Enalapril 5mg/day, Omeprazole 20mg po bid
CBC/UA/RFT/LFT/FBS/LIPID PANEL
CXR/Abdominal U/s/ ECG/ECHO
Neck U/s and FNAC

7. Investigations [09/12/2008]
CBC
WBC 9,600
Neut. 67.5 %
Lymph. 25.1 %
Hemoglobin 17.9 gm/dl
Hematocrit 50.3 %
MCV 98.6
MCH 35.1
Platelet 178,000
RFT
Cr 0.84 mg/dl
BUN 19 mg/dl
LFT
ALP 47 IU/L
GPT 55 IU/L
GOT 45 IU/L
LIPID PANEL
CHOL 160
TG 153
HDL 29
LDL 142ESR 9 mm/hr
FBS 108 mg/dl
Urinalysis
PH 5
Sp Gravity 1.03
Albumin Neg.
Blood Neg.
Leucocytes Neg.
Nitrite Neg.

8.  CXR: There is a Soft tissue mass around right neck area with compression
on trachea. Normal Pulmonary parenchyma and Cardiac size.
 Abdominal U/s: Single Lower pole echo lucent lesion 3.66 cm * 2.94 cm, no
free fluid or lymphadenopathy seen; Renal Simple Cyst.
 ECG: Left Axis deviation
 ECHO: Normal
Investigations [09/12/2008]

9. progress [12/12/2008]
 NECK U/S: The Normal Thyroid Parenchyma is replaced by multiple
well defined heterogeneously hyperechoic masses.There is a left lobe
3*2 cm relatively hypoechoic nodule with micro calcification.
CONCLUSION: Multinodular Goiter 2o to ? Thyroid Adenoma to r/o
Papillary Thyroid Cancer; Please do U/s Guided FNAC.
* Come and discuss for U/s Guided Biopsy.
 FNAC: Aspiration 3*3, hemorrhagic and fluid; Benign Nodular Goiter
with Cystic degenerative changes.
 ASST: Multi Nodular Colloid Goiter with cystic degeneration
+ Dyslipidemia + HTN
 Plan: TFT; Started on Atorvastatin 40mg.

10. progress [26/12/2008]
 Started on Thyroxine 50 µmg Po/Day; Linked to Surgical OPD
TFT Range
fT3 3.65 3.1 - 6.8 pmol/l
fT4 0.92 12 – 22 pmol/l
TSH 0.345 0.28 - 4.3 µlUml
RFT
Cr 0.98 mg/dl
BUN 16.3 mg/dl
LFT
ALP 55 IU/L
GPT 39.7 IU/L
GOT 33.8 IU/L
LIPID PANEL
CHOL 167.8
TG 180.4
HDL 26.4
LDL 113.1
Direct BL 0.185
Total BL 0.564
FBS 89 mg/dl

11. Regular SOPD [26/12/2008]
 P: MNG r/o Papillary Cancer + HTN+ Asthmatic
 Hx: No hypo/hyper thyrodism sx, no cough ,SOB, no weigth loss
 O: G/A:Well Looking; BP: 130/70 PR: 84(Full) T: ATT
Spo2: 93% with atmospheric air.
 LGS: Right Anterolateral neck swelling,multinodular ,non tender, no bruit, no LAP
detected.
 Chest: Audible Wheezes over chest
 Plan :Continue Antihypertensive/ Asthma Meds and link to SRC.

12. SRC Progress [03/01/2009]
 ASS: Euthyroid nodular goiter + Asthma+ HTN
 Subjectively ;no new complaint
 Bp= 110/70 , PR=88
 LGS: there is about 8*6cm anterior neck mass which moves with swallowing more on
the right side.
 Plan;
- Add Beclomethasone 200 µmg Po BID
- Admit to ward for Elective Surgery

13. Surgical Ward Admission Note
[01/05/2009]
P: MNG+ Hypertensive + Asthmatic
Hx: No hot and cold intolerance, hoarseness of voice, cough, shortness of breath ,
No history of radiation
O: G/A: Stable ; BP: 130/80 PR: 84 (Full) RR: 18 T: ATT Spo2: 93% with Atm air
LGS: Same as before
Chest: Clear and resonant
Investigations: Updated CBC with BG; Spirometry/CXR/TFT’s planned
Plan: Prepare for Elective Surgery on [05/05/2009]

14. Progress [01/05/2009]
CBC
WBC 11,300
Neut. 72.1 %
Lymph. 18 %
Hemoglobin 17.6 gm/dl
Hematocrit 52 %
MCV 96.5
MCH 32.7
Platelet 175,000
BG & RH A -
Stool Exam
Few RBC/Pus Cells
Trophozoites of G. Lamblia
seen
 Treated with Tindazole
2 gm po Stat

15. Progress [05/05/2009]
 P: Euthyroid Nodular Goiter + Hypertensive + Asthmatic
 Procedure Note: Subtotal Thyroidectomy done [Bilateral STT + Isthmusectomy + Pyramidal Lobe
removed]
 Plan: Thyroidectomy sample sent for Biopsy.
– Immediate Post Op Evaluation
 O: G/A: Stable and Conscious ; BP: 130/80 PR: 82 (Full) RR: 18 T: ATT Spo2: 93% with Atm air
 LGS: Surgical Dressing over neck
 Chest: Clear and resonant
 Asst; Smooth Post op and Discharged on 08/05/2009 and appointed to come with
biopsy result.

16. Smooth Post STT; To come to SRC with Biopsy result; 2 weeks sick leave given.
[24/05/2009] Biopsy Result
Sections from Solid area showed branching papillae with fibro vascular core and
follicles lined by cells with ovoid enlarged nuclei, nuclear overlapping ,grooves
and clearing
Sections from Colloid area showed macrofollicular growth pattern distended
with colloid; Consistent with nodular colloid goiter.
Diagnosis:Thyroid (Thyroidectomy)_ Papillary Carcinoma
Progress [16/05/2009]

17. SRC Progress [20/07/2009]
TFT Range
T3 0.914 0.8 – 2.0 ng/ml
T4 4.14 5.1 – 14.1ug/dl
TSH 1.49 0.28 - 4.3uIU/ml
Asst: Post Thyroidectomy hypothyroidism
Plan: Thyroxine 100 µg po/day
[29/09/09]
P: Same
Subjectively ;headache
V/S BP 150/100 mmhg
Asst: Post Thyroidectomy hypothyroidism +
Stage 2 HTN
On Thyroxine 100 µg po/day
Continued with Nifedipine 20 mg po bid, Life style
modification

18.  P: Post Thyroidectomy [Bx Papillary Cancer] + Hypertensive + Asthmatic
 TFT;FT3=3.77(2.02-4.43pg/ml),FT4 =2.15(0.93-1.71 ng/dl),
TSH= 0.309
 Plan: Continue Thyroxine 100 µg po/day;TO keep TSH < 0.01
 Appointment after 03 months with TFT
[26/03/2010] Plan: Continue Thyroxine 100 µg po/day; Nifedipine 20 mg po bid
SRC Progress [30/12/2009]
TFT Range
T3 2.1 0.8 – 2.0
T4 7.54 5.1 – 14.1
TSH 2.53 0.28 - 4.3

19. ERC Progress (15/06/2010)
 P-HTN+ hypothyroidism (post thyroidectomy)
-on Nifedipine 20 mg po bid, levothyroxine 50mcg po/d
Subjectively: no compliant
Objectively: BP 140/80
TFT- not done
Asst : fairly controlled HTN+ same
PLAN: refill and see him after 1 month with TFT

20. ERC Progress [1/13/10]
 P-Iatrogenic hypothyroidism +HTN+ asthma
-on nifedipine 20 mg po bid, levothyroxine 50mcg po /d.
 -Subjectively: dyspepsia, no other complaint
 Objectively‘; BP 140/90,PR=72,To=35
TFT: FT3=3.88(2.02-4.43pg/ml),
FT4 =0.924(0.93-1.71 ng/dl)
 Asst : fairly controlled HTN+ same
 Plan: refill and see him after 3 month with TFT

21.  P- Post subtotal thyroidectomy +biopsy proven papillary carcinoma +bronchial asthma
-on nifedipine 20 mg po bid, levothroxine 50mcg po /d, almitamine PRN
 Subjectively: dyspepsia,no other complaint
 Objectively‘; BP 140/90
-TSH= 4.77(0.15-5)
 Plan; -target TSH <0.25
- levothyroxine 75mcg/d
-repeat U/S and see after 01 week
12/6/11- U/S ;bilateral thyroid lobes have normal flow with normal echogenicity and small size,
no mass seen,no cervical LADP
ERC Progress [7/6/2011] endocrinologist
evaluation

22.  P- post subtotal thyroidectomy + biopsy proven papillary CA+ bronchial
asthma+ HTN
-On Nifedipine 20 mg po bid, levothyroxine 75 mcg po /d, almitamine PRN
 Subjectively: no other complaint
 Objectively: BP 130/90
TSH =2.75 (0.15-5),FT4=10.34(9-20),FT3=4.46 (4-8.3)
 Plan:- levothyroxine 100 mcg/d
 Appointed 06 wks. with TSH.
ERC Progress [19/7/2011] endocrinologist
evaluation

23. Thyroid panel summary
Dat
e
26/12/ 08
20/7
/09
30/121/09
20/3
/10
13/7
/10
14/10/10 1/1310
25/
5/1
1
20/6/ 11 19/7/ 11 Range
fT3 3.65pmol/l 3.77pg/ml 4.8pg/ml
3.88pg/
ml
4.3pg/m
l
4.46
pmol/l
3.1 - 6.8 pmol/l
2.02-4.43pg/ml
fT4 0.92pmol/l 2.15ng/dl 0.88 ng/dl
0.924ng
/dl
1.39ng/d
l
10.34
pmol/l
12 – 22 pmol/l
0.93-1.171ng/dl
T3
0.94
1
2.1 2.02 0.8 – 2.0 ng/ml
T4 4.39 7.54
13.5
6
5.1 – 14.1 ug/dl
TSH 0.345 1.46 0.309 2.53 2.53 4.47 2.44 2.78
0.28 - 4.3
uIU/ml

24. Case discussion

25. THE PATIENT CASE
 A 57 yrs old male, Presented with Anterolateral neck
swelling >10Yrs, not increasing in size.
 LGS: 7*6 cm Anterolateral Neck Swelling, more on
the right side, Multinodular Soft-firm consistency,
Non tender, which moves with deglutination.
 NECK U/S [12/12/2008]
The Normal Thyroid Parenchyma is replaced by
multiple well defined heterogeneously hyperechoic
masses.There is a left lobe 3*2 cm relatively
hypoechoic nodule with micro calcification.
CONCLUSION: Multinodular Goiter 2o to ? Thyroid
Adenoma to r/o Papillary Thyroid Cancer; Please do
U/s Guided FNAC.
• FNAC [12/12/2008]
Aspiration 3*3, hemorrhagic and fluid;
Benign Nodular Colloid Goiter with Cystic
degenerative changes.
• Biopsy Result [24/05/2009]
Sections from Solid area showed
branching papillae with fibro vascular
core and follicles lined by cells with ovoid
enlarged nuclei, nuclear overlapping…
Sections from Colloid area showed
macrofollicular growth pattern distended
with colloid; Consistent with nodular
colloid goiter.
Conclusion: Papillary Carcinoma

26. Benign Neoplasms
 These lesions are common (5–10% adults), particularly when assessed by sensitive
techniques such as ultrasound.
 The risk of malignancy is very low for macrofollicular adenomas and
normofollicular adenomas.
 Microfollicular, trabecular, and Hurthle cell variants raise greater concern, and the
histology is more difficult to interpret.

27. Thyroid Cancer
 Thyroid carcinoma is the most common malignancy of the endocrine system.
 Malignant tumors derived from the follicular epithelium are classified according to
histologic features.
 Differentiated tumors, such as papillary thyroid cancer (PTC) or follicular
thyroid cancer (FTC), are often curable, and the prognosis is good for patients
identified with early-stage disease.
 In contrast, anaplastic thyroid cancer (ATC) is aggressive, responds poorly to
treatment, and is associated with a bleak prognosis.

28. Thyroid Cancer
 The incidence of thyroid cancer is ~12/100,000 per year in the United States
and increases with age.
 Prognosis is worse in older persons (>65 years).
 Thyroid cancer is twice as common in women as men, but male gender
is associated with a worse prognosis.
 Additional important risk factors include…

30. Thyroid Cancer
Pathogenesis And Genetic Basis
 Radiation
 TSH and Growth Factors: Many differentiated thyroid cancers
express TSH receptors and, therefore, remain responsive to TSH.
 Higher serum TSH levels, even within normal range, are associated with
increased thyroid cancer risk in patients with thyroid nodules.
 These observations provide the rationale for T4 suppression of TSH in
patients with thyroid cancer.
 Residual expression of TSH receptors also allows treatment with TSH-stimulated
uptake of 131I therapy.
 Oncogenes and Tumor-Suppressor Genes
 RET, BRAF; RAS mutations rarely occur in the same tumor, suggesting that
activation of the MAPK cascade is critical for tumor development.

31. Treatment of Well differentiated Thyroid Ca
 Surgery
 Neartotal thyroidectomy is preferable in almost all patients; complication rates are
acceptably low if the surgeon is highly experienced in the procedure.
 TSH Suppression Therapy
 Because most tumors are still TSH-responsive, levothyroxine[T4] suppression of
TSH is a mainstay of thyroid cancer treatment.
 No prospective studies define the optimal TSH suppression level.The degree
of TSH suppression must be individualized based on risk of recurrence.
 Radioiodine Treatment I131
 After near-total thyroidectomy, substantial thyroid tissue often remains;
Postsurgical radioablation of the remnant thyroid eliminates residual normal
thyroid, facilitating the use of Tg determinations and radioiodine scanning
for long-term follow-up.

32. Treatment of Well differentiated Thyroid
Cancer
New Potential Therapies
 Kinase inhibitors are being explored as a means to target
pathways known to be active in thyroid cancer, including the RAS,
BRAF, EGFR,VEGFR, and angiogenesis pathways.
 A multicenter randomized controlled trial of the multikinase inhibitor
sorafenib in 417 patients with progressive metastatic thyroid cancer reported a
doubling of progression-free survival to 10.8 months in the treatment group
compared with the placebo group.

33. Multi Disciplinary Approach to Thyroid
Nodule & Thyroid Neoplasms

35. Results: The revised guidelines for the management of thyroid
nodules include
 Recommendations regarding initial evaluation,
 Clinical and Ultrasound criteria for Fine-needle aspiration biopsy,
 Interpretation of fine-needle aspiration biopsy results,
 Use of molecular markers, and
 Management of benign thyroid nodules.
 Recommendations regarding the initial management of thyroid
cancer.
 Recommendations related to long-term management of
differentiated thyroid cancer.
Approach To The Patient with
Thyroid Nodules/Neoplasms

36. Approach To The Patient with
Thyroid Nodules/neoplasms
(A) Serum thyrotropin (TSH) should be measured during the initial evaluation of a
patient with a thyroid nodule. (Strong recommendation, Moderate-Q Evidence)
(B) If the Serum TSH is subnormal, a radionuclide (preferably 123I) thyroid scan
should be performed. (Strong recommendation, Moderate-Q evidence)
 If the nodule is hyperfunctioning (‘‘hot,’’ i.e., tracer uptake >> surrounding normal thyroid),
isofunctioning (‘‘warm,’’ i.e., tracer uptake = surrounding thyroid), or nonfunctioning (‘‘cold,’’
i.e., has uptake << surrounding thyroid tissue). Since hyperfunctioning nodules rarely harbor
malignancy,
(C) If the Serum TSH is normal or elevated, a radionuclide scan should not be
performed as the initial imaging evaluation. (Strong recommendation, Moderate-Q
evidence)

37. Approach To The Patient with
Thyroid Nodules

38. Approach To The Patient with
Thyroid Nodules
 The next step in evaluation is Thyroid ultrasound for three reasons:
1. Ultrasound will confirm if the palpable nodule is indeed a nodule.
About 15% of “palpable” nodules are not confirmed on imaging,
and therefore, no further evaluation is required.
2. Ultrasound will assess if there are additional nonpalpable nodules
for which FNA may be recommended based on imaging features and
size.
3. Ultrasound will characterize the imaging features of the nodule,
which, combined with the nodule’s size, facilitate decision making
about FNA.

39. Approach To The Patient with
Thyroid Nodules/neoplasms
Thyroid sonography with survey of the cervical lymph nodes
should be performed in all patients with known or suspected thyroid
nodules. (Strong recommendation, High-Q evidence)
Ultrasound should evaluate the following:
 Thyroid parenchyma (homogeneous or heterogeneous) and gland
size; location, and sonographic characteristics of any nodule(s);
 The presence or absence of any suspicious cervical lymph nodes
in the central or lateral compartments.

40. Approach To The Patient with
Thyroid Nodules/neoplasms

41. Approach To The Patient with
Thyroid Nodules/neoplasms

42. TI-RAD scoring

43. Thyroid Imaging Reporting And Data System
(TI-RADS):intro
 Thyroid nodules - common and overwhelmingly benign
 50% of the general population, palpable – 3-7%.
 Malignancy – 5-7%
 US can avoid unnecessary and costly interventions such as FNAC
and Biopsy.
 2015 – ATA developed the pattern based classification – 5 groups
 Pattern may not fit and may lead to subjectivity, vs point based
TIRAD
 2017 – ACR-TIRADS – Thyroid Imaging Reporting and Data System
 5 ultrasound features -------> 5 TR scores.

44. TIRAD Composition
Echogenecity
Shape
Margin
Echogenic foci
Single score
from mutually
exclusive
choices
More than one
feature in a
score

45. TIRAD Composition
Echogenecity
Shape
Margin
Echogenic foci
Spongiform(0)Cystic (0)
Mixed solid and
cystic(1)
Solid/Predominantly
solid (2)

46. TIRAD Composition
Echogenicity
Shape
Margin
Echogenic foci
Anechoic (0)
Hypoechoic (2)
Hyper/Iso-echoic(1)
Markedly Hypoechoic(3)

47. TIRAD Composition
Echogenecity
Shape
Margin
Echogenic foci
Wider than tall
Taller than wide

48. TIRAD Composition
Echogenecity
Shape
Margin
Echogenic foci
Smooth (0) Ill defined (0)
Extra thyroid ext. (3)Lobulated/irregular (2)

49. TIRAD Composition
Echogenicity
Shape
Margin
Echogenic foci
Comet tail (0)
Punctate/Micro cal. (3)
Macro calcification (1)
Rim/egg shell cal. (2)

50. TIRAD Composition
Echogenecity
Shape
Margin
Echogenic foci
+ nodule
size

51. Risk of malignancy
 TR1 – benign – 0.3%
 TR2 – not suspicious – 1.5%
 TR3 - mildly suspicious – 4.8%
 TR4 - moderately suspicious - 9.1%
 TR5 - highly suspicious – 35%

52. Lymph nodes
Lateral neck dissections for sonographically detected
LN mets will improve patient long term survival and
decrease tumor recurrence rates.
Clinically occult LN mets will be detected.
LN mets in the presence of a very
small nodule – decreases our
threshold to do FNAC

53. Our patient…..First ultrasound – 2016 (before TI-RAD)
Available info –
Echogenecity – hypoechoic - 2
Ecogenic foci – microcalcifications - 3
??Dimension – not clear.
TI-RAD score – atleast 5–
 Size – 3cm
TR4 – Moderately suspicious
Recc – U/S guided FNAC

54. Approach To The Patient with
Thyroid Nodules
 FNA biopsy, ideally performed with ultrasound guidance, has good
sensitivity and specificity when performed by physicians familiar
with the procedure and when the results are interpreted by
experienced cytopathologists.
 The technique is particularly useful for detecting PTC.
However, the distinction between benign and malignant
follicular lesions is often not possible using cytology alone.

55. Approach To The Patient with
Thyroid Nodules
 In several large studies, FNA biopsies yielded the following findings:
 65% Benign,
 5% Malignant or suspicious for malignancy,
 10% Nondiagnostic or yielding insufficient material for diagnosis,
 20% Indeterminate.
 The Bethesda System is now widely used to provide more uniform terminology
for reporting thyroid nodule FNA cytology results.
 Specifically, the Bethesda System subcategorized cytology specimens previously
labeled as Indeterminate into three categories:
• Atypia or Follicular Lesion of Undetermined Significance (AUS/ FLUS),
• Follicular neoplasm, and
• Suspicious for malignancy.

56. Approach To The Patient with
Thyroid Nodules/neoplasms
 Thyroid nodule FNA cytology should be reported using diagnostic groups outlined in the
Bethesda System for Reporting Thyroid Cytopathology. (Strong recommendation,
Moderate-Q evidence)

57. Approach To The Patient with
Thyroid Nodules/neoplasms

58. Thyroid Cytopathology
• The Bethesda System 2017, An Overview
• Best Practice
• Challenges in the Local Context
• Best Practice in the Local Context?

62. Thyroid Cytopathology
 The provisional goal of limiting AUS/FLUS interpretations to 7%
of all thyroid FNA interpretations is increased to 10%.
 The AUS/FLUS to malignant ratio may be a useful laboratory
quality measure that should not exceed 3.0.
 Narrative comments are strongly recommended to further
describe the findings, especially if it would potentially
influence management.
 The possibility of a compromised sample with artifactual
changes should be acknowledged in the report.

63. FNAC of Thyroid: Some Observations
 Practice started in the 1980s
 The incidence of malignant thyroid nodules in patients with one or more
nodules ranges from 6% to 13%
 Provides diagnostic information in 85% of patients with accuracy > 95%
 Most common thyroid lesion is the benign colloid nodule, followed by
nodular goiter, hyperplastic nodules, plain cysts, subacute thyroiditis
and lymphocytic thyroiditis.
 Number of punctures required for the diagnosis of thyroid nodules is not
well established in the literature.
 Recommendation: 2 to 3 punctures on different areas nodule

64. Non Diagnostic Specimens/Error Rate:
Are related to:
Failure in puncture technique (operator error)
Very small nodules
Mixed lesions (cystic/solid contents)
Fibrotic nodules or I
Insufficient number of cells in the specimen
Recommendation: US-Guided FNAC for TBS I &
Suspicious lesions

65. The Local Context & Challenges
Prevalence of thyroid enlargement?
4% to 7% of general population
Use of US: increase to 30% to 50%
Patient load?
Rejection criteria ?
Radiology department?
Lack of uniformity & standard

66. Best Practice, Local Context:
 Priority: Standardized reporting format (adapted to local
context)
 Four categories: Non diagnostic; Benign; Malignant, &
Suspicious for malignancy or Undetermined (follicular
neoplasia or Hurthle cell neoplasm)
 US-Guided FNAC ? For TBS 1 & suspicious lesions
 Rejection criteria?
 Instituting Quality Metrics in Cytopathology demands strong
inter-departmental collaboration

67. OUR CASE
 57/M with Anterior neck swelling of 10years
 P/E 7*6 cm Anterolateral Neck Swelling, more on the right side,
Multinodular Soft-firm consistency, Non tender, which moves with
deglutination.
 NECK U/S: The Normal Thyroid Parenchyma is replaced by multiple
well defined heterogeneously hyperechoic masses.There is a left lobe
3*2 cm relatively hypoechoic nodule with micro calcification.
 FNAC: Aspiration 3*3, hemorrhagic and fluid; Benign Nodular Goiter
with Cystic degenerative changes.
 FT4= 0.92 FT3= 3.65 TSH= 0.345
 P: Euthyroid Nodular Goiter + Hypertensive + Asthmatic
 Procedure Note: Subtotal Thyroidectomy done [Bilateral STT +
Isthmusectomy + Pyramidal Lobe removed]
 Points that speak for malignancy
age, male, size
? Hypothyroidism
 Most importantly U/S finding
 Sonographic suspicious features
(hypoechoic, micro calcification,
increased central vascularity, infiltrative
margin or taller than wide in transverse
plan)
?? U/S guided FNAC
Surgery?? At least left total

68. Post op
Biopsy =Papillary
Carcinoma
fT4 = 0.914 TSH= 1.49,
2.53, 4.77
??Post Thyroidectomy
hypothyroidism
Plan: Thyroxine 100 µg
po/day
Follow up
Adjuvant treatment
TSH suppression
RIA ablation
TSH/ Thyroglobulin
Low risk TSH= 0.1- 0.5
High risk= < 0.1

69. Is he candidate for completion?
When complete total thyroidectomy after lobectomy:
Aggressive variant
Macroscopic multifocal disease
Positive isthmus margins
Cervical lymph node metastases
Extra thyroidal extension
Aggressive=Tall cell, columnar cell, insular, oxyphilic, or poorly differentiated features
 Sections from Solid area showed branching papillae with fibro vascular core and follicles lined by cells with ovoid
enlarged nuclei, nuclear overlapping…
 Sections from Colloid area showed macrofollicular growth pattern distended with colloid; Consistent with nodular
colloid goiter.

70. Management principles
Surgery
Radioactive iodine
Hormonal therapy
EBRT

71. SURGERY
Mainstay of therapy
Extent of thyroidectomy
Lobectomy v Near total /Total thyroidectomy
Low risk vs high risk

72. Low risk ….2015 ATA guidelines…
LOBECTOMY
Papillary tumor size less than 1 cm
Unifocal
No cervical lymph nodes
No extra thyroidal extension
No hx of neck radiation
No family hx
Low stage

73. High risk …. 2015 ATA GUIDLINE
Recommendation…NTT/TT
 Size >1cm
 Multifocal
 Cervical lymph nodes
 Extra thyroidal extension
 No hx of neck radiation
 Family hx
 Male
 Female >50
 Bilateral diseases

74. Follow up
 P/E every 3-6 month for 2 yr ,then annually if disease free
 Serum thyroglobulin level at 6 and 12 month ,then annually if
disease free
 RAIA
 THYROXINE for TSH suppression
 Periodic NECK U/S and CXR
 TSH
 CT /MRI

75. Surgical Summary
Lobectomy is optimal treatment for low risk groups.
Near total or total thyroidectomy should be standard of
care for the high risk groups.
Lymph node dissection should be therapeutic.
Post op follow up should be to the standard.

76. Inter-departmental
Discussion

77. Take Home Message
 The evaluation of a thyroid nodule is stressful for most patients.They
are concerned about the possibility of thyroid cancer, whether verbalized
or not.
 When a suspicious lesion or thyroid cancer is identified earlier, the
generally favorable prognosis and available treatment options
can be reassuring.

78. Take Home Message
 The Surgeon should have a clear plan before surgery based on TIRAD Scores/
The Bethesda System report and subsequent Post Surgical follow-up through
“MDT” groups.
 The main goal of this presentation is to identify, in a “cost-effective manner”, the
small subgroup of individuals with malignant lesions at an earlier stage; by
having a Multidisciplinary Diagnostic Approach to Thyroid nodule involving
the Surgeon; the Radiologist; the Pathologist and the Internist.

79. Reference
Harrison’s Principles of Internal medicine 20th ed.
2015 American Thyroid Association Management: Guidelines for Adult Patients with Thyroid Nodules and
Differentiated Thyroid Cancer.
2017 American College of Radiology
RSNA Articles
Schwartz 11th ed.
Clarks Endocrine Surgery 3rd ed.
Up-to-date 21.6
Patient’s Chart

80. Thank You!