Thyroid Noudle

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Thyroid Noudle

  1. 1. Thyroid Nodules
  2. 2. Thyroid Nodules <ul><li>Prevalence and incidence </li></ul><ul><li>Palpable nodules: 4-7 % of the population </li></ul><ul><li>Incidentally on US: almost 50 %, </li></ul><ul><li>75 % multi nodular, 25 % solitary </li></ul><ul><li>Thyroid cancer: 5-10 % of palpable nodules </li></ul><ul><li>The main objective of evaluating thyroid nodules is to </li></ul><ul><li>exclude malignancy </li></ul>
  3. 3. Type of thyroid nodules Cyst : simple cyst, mixed cystic-solid Colloid nudule : dominant nodule in MNG Adenoma : Follicular, Hurthle cell, Atypical Thyroiditis : Hashimoto’s, subacute Infection : Granulomatous disease, Abscess Developmental anomalies : unilateral lobe agenesis, cystic hygroma, Dermoid, Teratoma Carcinoma : papillary ( 75 %), follicular ( 5-10 %), medullary ( 5-10 %) , anaplastic ( 5 %), lymphoma ( 5 %), metastatic
  4. 4. Factors associated with increase risk for malignant thyroid nodule <ul><li>History (moderate increase risk) </li></ul><ul><ul><ul><li>Age < 20 or > 60 years </li></ul></ul></ul><ul><ul><ul><li>Male sex </li></ul></ul></ul><ul><ul><ul><li>Exposure of RT (especially in childhood) </li></ul></ul></ul><ul><ul><ul><li>F.Hx of thyroid cancer or polyposis </li></ul></ul></ul><ul><li>Physical finding (highly increase risk) </li></ul><ul><ul><ul><li>larger than 3 cm </li></ul></ul></ul><ul><ul><ul><li>Rapid tumor growth </li></ul></ul></ul><ul><ul><ul><li>Very firm nodule, irregular surface </li></ul></ul></ul><ul><ul><ul><li>Fixation to adjacent structure </li></ul></ul></ul><ul><ul><ul><li>Symptom of local invasion: dysphagia, hoarseness </li></ul></ul></ul><ul><ul><ul><li>Cervical lymphadenopathy </li></ul></ul></ul><ul><ul><ul><li>Cold nodule on thyroid scan </li></ul></ul></ul><ul><ul><ul><li>Solid or complex cyst on US </li></ul></ul></ul>
  5. 5. Factors suggesting benign thyroid nodule <ul><li>F.Hx of autoimmune disease (Hashimoto’s thyroiditis) </li></ul><ul><li>F.Hx of benign thyroid nodule or goiter </li></ul><ul><li>Presense of thyroid hormone dysfunction, </li></ul><ul><li>hypothyroid or hyperthyroid </li></ul><ul><li>Pain or tenderness associated with nodule </li></ul><ul><li>Soft, smooth, mobile </li></ul><ul><li>MNG without a predominant nodule </li></ul><ul><li>Warm nodule on thyroid scan </li></ul><ul><li>Simple cyst on US </li></ul>
  6. 6. Investigation <ul><li>Laboratory evaluation </li></ul><ul><ul><li>TSH: screening for hyper or hypothyroid </li></ul></ul><ul><ul><li>T 3, T 4 : when TSH are low normal or high normal </li></ul></ul><ul><ul><li>Serum antithyroid peroxidase (anti-TPO), </li></ul></ul><ul><li>antithyroglobulin (anti-Tg) if suspected thyroiditis </li></ul><ul><li>Imaging study </li></ul><ul><ul><li>CT, MRI, PET: not cost-effective in initial evaluation of </li></ul></ul><ul><li>thyroid nodule </li></ul><ul><ul><li>Ultrasound: characters that increase risk for malignant; </li></ul></ul><ul><li>ill defined margin, irregular shape, solid echo, hypoechoic , </li></ul><ul><li>calcification (fine): sensitivity 75 %, specificity 61 % </li></ul><ul><ul><li>Thyroid isotope scanning : 131 I , 123 I , 99 TC </li></ul></ul><ul><ul><ul><ul><ul><li>cold nodule ( 84 %): cancer risk 15 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>warm nodule ( 10.5 %): cancer risk 9 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>hot nodule ( 5.5 %): cancer risk 1 % </li></ul></ul></ul></ul></ul><ul><ul><li>T hyroxine suppression therapy with US follow up </li></ul></ul><ul><li> sensitivity 83 %, specificity 33 % </li></ul>
  7. 7. US: A solitary hypoechoic nodule at Rt. Lobe thyroid Slide 12 Slide 12
  8. 8. Isotope scan : Left: Normal thyroid Right: A cold nodule Lt.lobe thyroid
  9. 9. Diagnostic procedure: <ul><li>Fine needle aspiration cytology (FNA) </li></ul><ul><ul><ul><li>Sensitivity: 70-90 %, specificity 70-90 % </li></ul></ul></ul><ul><ul><ul><li>False negative result: 3-8 % </li></ul></ul></ul><ul><ul><ul><li>Reliability depend on: </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Operator </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cytopathologist </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Type of tumor: follicular neoplasm has </li></ul></ul></ul></ul></ul><ul><li>20-30 % false negative rate </li></ul>
  10. 10. Thyroid Nodule TSH test Euthyroid Thyrotoxic Thyroid scan FNA Cold nodule Hot nodule 131 I or surgery Benign Suspicious Malignant Inadequate Observe or T 4 - Px Surgery Repeat FNA FU 6-12 M Suggested strategy for the management of thyroid nodules
  11. 11. Thyroid incedentalomas <ul><li>Incidence: 30-60 % (Autopsy), 13-50 % (Ultrasound) </li></ul><ul><li>Size: usually < 1.5 cm </li></ul><ul><li>Incidence of cancer: < 5 %, mostly papillary CA </li></ul>Thyroid incedentaloma Hx. H+N RT, F.Hx. CA thyroid Positive Negative US guide FNA US finding Cytology Suspected Benign appearance Malignant or (< 1.5 cm) ( > 1.5 cm ) Observe Malignant Benign Surgery Observe
  12. 12. <ul><li> Frequency Malignant histology </li></ul><ul><li>Benign 60-65 % 3-8 % </li></ul><ul><li>Colloid or nodule goiter </li></ul><ul><li>Thyroiditis </li></ul><ul><li>Suspicious 10-15 % 20-30 % </li></ul><ul><li>Follicular neoplasm </li></ul><ul><li>Hurthle cell lesion </li></ul><ul><li>Cellular smear </li></ul><ul><li>Lymphoma </li></ul><ul><li>Malignant 3-5 % 95 % </li></ul><ul><li>Papillary </li></ul><ul><li>Medullary </li></ul><ul><li>Anaplastic </li></ul><ul><li>Inadequate 15 % 5 % </li></ul><ul><li>Techincal problem </li></ul><ul><li>Degernerative nodule </li></ul><ul><li>Hemorrhagic cyst </li></ul>Result of thyroid FNA interpretation
  13. 13. Colloid nodule : A: FNA B: Histopathology
  14. 14. Hoshimoto’s thyroiditis A: FNA B: Histopathology
  15. 15. Papillary carcinoma : A: FNA B: Histopathology
  16. 16. A: FNA B: Follicular adenoma C: Follicular carcinoma

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