Evaluation of Thyroid Nodules

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  • In most centers, the routine initial diagnostic evaluation of a solitary thyroid nodule no longer includes imaging studies.
    In the past, radionuclide scanning was an important imaging study performed routinely in the initial assessment of a thyroid nodule.
  • however, 5-8% of warm or cold nodules are malignant.
  • Figure 2. Scintigram of a Solitary Functioning Nodule in the Right Thyroid Lobe. Scintigraphy that was performed with the use of technetium-99m-labeled pertechnetate shows suppression of extranodular uptake in thyroid tissue. From:   Hegedus: N Engl J Med, Volume 351(17).October 21, 2004.1764-1771
  • Superimposition of abnormal nodular tissue and normally functional thyroid tissue can give impression of normally functioning tissue
    It is estimated that only half of malignant thyroid nodules present as cold defects
  • Figure 1. Sonogram of the neck in the transverse plane showing a normal right thyroid lobe and isthmus. L=small thyroid lobe in a patient who is taking suppressive amounts of L-thyroxine, I=isthmus, T=tracheal ring ( dense white arc is calcification, distal to it is artefact), C=carotid artery ( note the enhanced echoes deep to the fluid-filled blood vessel), J=jugular vein, S=Sternocleidomastoid muscle, m=strap muscle.
  • Figure 2. Sonogram of the left lobe of the thyroid gland in the transverse plane showing a rounded lobe of a goiter. L=enlarged lobe, I= widened isthmus, T=trachea, C=carotid artery ( note the enhanced echoes deep to the fluid-filled blood vessel), J=jugular vein, S=Sternocleidomastoid muscle, m=strap muscles, E=esophagus.
  • Usullally less than one cm. estimates up to 6 % of populatulation. Increase with age. One study said as many as 50% of women over 50 have them. Manage as a palpable nodule. If greater than 1.5 cm, do fnab. If less or benign, followup in 6 months.
    Figure 6. Sonograms of the right thyroid lobe in the longitudinal plane showing a 2.7 x 3.2 mm hypoechoic nodule that is delineated in the lower panel by the xx and ++ symbols. Note the linear hypoechoic structure below that (arrow). In the upper panel the bright structure is a Doppler signal and indicates a blood vessel below the nodule. The nodule is not vascular.
  • Unsatisfactory – 50% will be diagnostic on reaspiration.
  • Figure 9. Sonogram from an ultrasound guided fine needle aspiration biopsy showing a hypoechoic small nodule. The bright spot (above the arrows) is the tip of the needle within the nodule at the instant of aspiration. N=nodule.
  • Follicular
    Lymphocytes – hashimoto’s
    Colloid
    Subacute (granulomatous) thyroiditis – multinucleate giant cell.
  • Thick branching papillary tissue fragment with fibrovascular core in FNA
    Psammoma bodies
    Azurophilic granules containing calcitonin
    4. pleomorphic nuclei and prominent nucleoli. Anaplastic
  • Evaluation of Thyroid Nodules

    1. 1. Evaluation of ThyroidEvaluation of Thyroid NodulesNodules Eric OliverEric Oliver August 30, 2007August 30, 2007
    2. 2. ObjectivesObjectives  Discuss Common Causes of Thyroid NodulesDiscuss Common Causes of Thyroid Nodules  Highlight Application of Imaging Studies inHighlight Application of Imaging Studies in Evaluation of the Thyroid NoduleEvaluation of the Thyroid Nodule
    3. 3. The Thyroid NoduleThe Thyroid Nodule  It is estimated that the prevalence of thyroidIt is estimated that the prevalence of thyroid nodules in the general population is 4 - 7%.nodules in the general population is 4 - 7%.  Benign adenomas or cysts account forBenign adenomas or cysts account for approximately 90% of detected thyroid nodules.approximately 90% of detected thyroid nodules.  In the U.S., ~10,000 to 17,000 new cases ofIn the U.S., ~10,000 to 17,000 new cases of primary thyroid cancer are diagnosed each year.primary thyroid cancer are diagnosed each year.  1,000 - 2,000 people die each year from primary1,000 - 2,000 people die each year from primary thyroid carcinomas.thyroid carcinomas.
    4. 4. Causes of Thyroid NodularityCauses of Thyroid Nodularity  BenignBenign  Follicular AdenomasFollicular Adenomas  Multinodular goiter (colloid adenoma)Multinodular goiter (colloid adenoma)  Hashimoto’s thyroiditisHashimoto’s thyroiditis  Cysts (colloid, simple, hemorrhagic)Cysts (colloid, simple, hemorrhagic)
    5. 5. Causes of Thyroid NodularityCauses of Thyroid Nodularity  MalignantMalignant  Papillary CarcinomaPapillary Carcinoma  Follicular CarcinomaFollicular Carcinoma  Medullary CarcinomaMedullary Carcinoma  Anaplastic and poorly differentiated carcinomaAnaplastic and poorly differentiated carcinoma  Primary lymphoma of the thyroidPrimary lymphoma of the thyroid  Metastatic carcinoma (especially breast and renal cellMetastatic carcinoma (especially breast and renal cell carcinoma)carcinoma)
    6. 6. Low SuspicionLow Suspicion  Family history of autoimmune disease (eg,Family history of autoimmune disease (eg, Hashimoto’s thyroiditis)Hashimoto’s thyroiditis)  Family history of benign thyroid nodule orFamily history of benign thyroid nodule or goitergoiter  Presence of thyroid hormonal dysfunctionPresence of thyroid hormonal dysfunction  Pain or tenderness associated with nodulePain or tenderness associated with nodule  Soft, smooth, and mobile noduleSoft, smooth, and mobile nodule
    7. 7. Hegedus: N Engl J Med, Volume 351(17).October 21, 2004.1764-1771Hegedus: N Engl J Med, Volume 351(17).October 21, 2004.1764-1771
    8. 8. Case 1Case 1 A 16 year old female is seen because of a 6 monthA 16 year old female is seen because of a 6 month history of fatigue, nervousness, tremor, heathistory of fatigue, nervousness, tremor, heat intolerance, polyphagia and weight loss. Her scholasticintolerance, polyphagia and weight loss. Her scholastic work has declined in quality. Recently she noticed somework has declined in quality. Recently she noticed some enlargement of her neck and prominence of her eyes.enlargement of her neck and prominence of her eyes. Physical examination reveals: B.P. 130/60 mm Hg.,Physical examination reveals: B.P. 130/60 mm Hg., pulse 96/minute, smooth warm skin, eyelid retraction,pulse 96/minute, smooth warm skin, eyelid retraction, symmetric thyroid enlargement, fine hand tremor andsymmetric thyroid enlargement, fine hand tremor and mild muscle weakness. Her TSH is low.mild muscle weakness. Her TSH is low.
    9. 9. Low TSHLow TSH  Suspect independently functioning thyroidSuspect independently functioning thyroid  ~10 percent of patients with a solitary nodule~10 percent of patients with a solitary nodule have a suppressed level of serum thyrotropinhave a suppressed level of serum thyrotropin  Next Step: ScintographyNext Step: Scintography
    10. 10. Radionuclide ScanningRadionuclide Scanning  Used to identify whether a nodule is functioning.Used to identify whether a nodule is functioning.  Functioning nodules are nearly always benignFunctioning nodules are nearly always benign  Approximately 90 percent of nodules areApproximately 90 percent of nodules are nonfunctioningnonfunctioning  5 percent of nonfunctioning nodules are malignant5 percent of nonfunctioning nodules are malignant  Thus, in the patient with a suppressed level of serumThus, in the patient with a suppressed level of serum thyrotropin, radionuclide confirmation of a functioningthyrotropin, radionuclide confirmation of a functioning nodule may obviate the need for biopsy.nodule may obviate the need for biopsy.
    11. 11. ScintigraphyScintigraphy  Usually either Technetium or RadioiodineUsually either Technetium or Radioiodine  Normal follicular cells will trap both but onlyNormal follicular cells will trap both but only radioiodine is added to tyrosine and stored inradioiodine is added to tyrosine and stored in the colloid spacethe colloid space  Both benign and almost all malignant neoplasticBoth benign and almost all malignant neoplastic tissue concentrate both radioisotopes less thantissue concentrate both radioisotopes less than normal thyroid tissuenormal thyroid tissue  5-8% of warm or cold nodules are malignant5-8% of warm or cold nodules are malignant
    12. 12. Cold NodulesCold Nodules  ThyroiditisThyroiditis  FibrosisFibrosis  CystCyst  Non-functioning AdenomaNon-functioning Adenoma  Multinodular GoiterMultinodular Goiter  MalignancyMalignancy
    13. 13. ScintigraphyScintigraphy
    14. 14. Hot NodulesHot Nodules  Functioning AdenomaFunctioning Adenoma  ThyroiditisThyroiditis  Multinodular goiterMultinodular goiter
    15. 15. ScintigraphyScintigraphy
    16. 16. Limitations of ScintigraphyLimitations of Scintigraphy  Two dimensional scanning techniqueTwo dimensional scanning technique  Inability to measure the size of a noduleInability to measure the size of a nodule accuratelyaccurately  Missed malignant thyroid nodulesMissed malignant thyroid nodules
    17. 17. Case 2Case 2 TR is a 40 year old female who presents for herTR is a 40 year old female who presents for her annual physical. On exam, you palpate a 1.5x 2annual physical. On exam, you palpate a 1.5x 2 cm nodule in the right lobe of her thyroidcm nodule in the right lobe of her thyroid gland. The nodule is non-tender and mobile.gland. The nodule is non-tender and mobile. Both her TSH and free T4 are normal.Both her TSH and free T4 are normal. What test would you order next?What test would you order next?
    18. 18. UltrasonographyUltrasonography  Facilitate fine needle aspiration biopsy of a noduleFacilitate fine needle aspiration biopsy of a nodule  Assess the comparative size of nodules, lymph nodes,Assess the comparative size of nodules, lymph nodes, or goiters in patients who are under observation oror goiters in patients who are under observation or therapytherapy  Evaluate for recurrence of a thyroid mass after surgeryEvaluate for recurrence of a thyroid mass after surgery
    19. 19. Normal Right Thyroid LobeNormal Right Thyroid Lobe
    20. 20. GoiterGoiter
    21. 21. IncidentalomasIncidentalomas
    22. 22. Fine-Needle Aspiration BiopsyFine-Needle Aspiration Biopsy  Most important step in the diagnostic evaluation of thyroidMost important step in the diagnostic evaluation of thyroid nodules, exception would include hyperthyroidism wherenodules, exception would include hyperthyroidism where scintigraphy should be performed first or highly suspiciousscintigraphy should be performed first or highly suspicious exams warranting immediate surgery.exams warranting immediate surgery.  Mean sensitivity higher than 80% and specificity higher thanMean sensitivity higher than 80% and specificity higher than 90%.90%.  Can categorize tissue into the following diagnostic categories:Can categorize tissue into the following diagnostic categories: malignant, benign, thyroiditis, follicular neoplasm, suspicious, ormalignant, benign, thyroiditis, follicular neoplasm, suspicious, or nondiagnosticnondiagnostic  Cost Effective – some studies estimate that it reduces cost by 25Cost Effective – some studies estimate that it reduces cost by 25 % and reduce the need for diagnostic thyroidectomy by 20-50%.% and reduce the need for diagnostic thyroidectomy by 20-50%.
    23. 23. FNAB LimitationsFNAB Limitations  Hypocellular aspirates may be observed in cysticHypocellular aspirates may be observed in cystic nodules, or they may be related to biopsy technique.nodules, or they may be related to biopsy technique.  The absence of malignant cells in an acellular orThe absence of malignant cells in an acellular or hypocellular specimen does not exclude malignancy.hypocellular specimen does not exclude malignancy.  Inability to reliably distinguish a benign follicularInability to reliably distinguish a benign follicular neoplasm from a malignant neoplasm.neoplasm from a malignant neoplasm.  Aspirates may be required from multiple sites of theAspirates may be required from multiple sites of the nodule to improve sampling.nodule to improve sampling.
    24. 24. FNABFNAB
    25. 25. Ultrasound Guided FNABUltrasound Guided FNAB
    26. 26. FNABFNAB
    27. 27. FNABFNAB
    28. 28. Case 3Case 3  F.H. is a 66 year old man who complains of a “aF.H. is a 66 year old man who complains of a “a bump in his throat.” He states that he has alsobump in his throat.” He states that he has also developed some discomfort while eating moredeveloped some discomfort while eating more recently. PMH is significant for childhood neckrecently. PMH is significant for childhood neck irradiation. There is no palpable mass on examirradiation. There is no palpable mass on exam and oropharynx is clear.and oropharynx is clear.
    29. 29. Algorithm for theAlgorithm for the Cost-EffectiveCost-Effective Evaluation andEvaluation and Treatment of aTreatment of a ClinicallyClinically Detectable SolitaryDetectable Solitary Thyroid NoduleThyroid Nodule Hegedus: N Engl J Med,Hegedus: N Engl J Med, Volume 351(17).Volume 351(17). October 21, 2004.October 21, 2004. 1764-17711764-1771
    30. 30. Take Home PointsTake Home Points  Hyperfunctioning nodules (Low TSH, HighHyperfunctioning nodules (Low TSH, High T3/T4) are almost always benign and biopsy isT3/T4) are almost always benign and biopsy is generally not recommended. Scintigraphy maygenerally not recommended. Scintigraphy may aid in evaluation and treatment.aid in evaluation and treatment.  Consider FNAB for patients with normal andConsider FNAB for patients with normal and hypofunctioning nodules.hypofunctioning nodules.  Patients in which there is a high suspicion canPatients in which there is a high suspicion can immediately be referred to ENT for surgery.immediately be referred to ENT for surgery.
    31. 31. ReferencesReferences  http://www.thyroidmanager.org/FunctionTests/ultra-frame.htmhttp://www.thyroidmanager.org/FunctionTests/ultra-frame.htm  Ford. Evaluation of Thyroid Nodules. http://ctm.stanford.edu/06-07/ThyroidFord. Evaluation of Thyroid Nodules. http://ctm.stanford.edu/06-07/Thyroid %20Nodule_Ford_6_18_07.pdf%20Nodule_Ford_6_18_07.pdf  Hegedus: N Engl J Med, Volume 351(17).October 21, 2004.1764-1771Hegedus: N Engl J Med, Volume 351(17).October 21, 2004.1764-1771  Miller. Management of Thyroid Nodules. Radiology Rounds. MGH DepartmentMiller. Management of Thyroid Nodules. Radiology Rounds. MGH Department of Radiology. 2005.of Radiology. 2005. http://www.massgeneralimaging.org/newsletter/march_2005http://www.massgeneralimaging.org/newsletter/march_2005  Nguyen GK. Fine-needle aspiration of the thyroid: an overview. CytoJournalNguyen GK. Fine-needle aspiration of the thyroid: an overview. CytoJournal 2005,2005, 2:2:1212 http://bmc.ub.uni-potsdam.de/1742-6413-2-12/http://bmc.ub.uni-potsdam.de/1742-6413-2-12/  Ross. Evaluation of the Thyroid Nodule. J Nucl Med 1991; 32:2181-2192.Ross. Evaluation of the Thyroid Nodule. J Nucl Med 1991; 32:2181-2192.  Society of Nuclear Medicine Procedure Guideline for Thyroid Scintigraphy. 1999.Society of Nuclear Medicine Procedure Guideline for Thyroid Scintigraphy. 1999. http://interactive.snm.org/docs/pg_ch05_0403.pdfhttp://interactive.snm.org/docs/pg_ch05_0403.pdf

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