Successfully reported this slideshow.

2013 4-14 CDO TEPI - thyroid nodules and cancer (Case Based Approach)

5,839 views

Published on

We apply the guidelines from ATA, ETA, NCCN, AME and AACE on thyroid nodules and thyroid cancer on a cased based discussion

Published in: Health & Medicine
  • Be the first to comment

2013 4-14 CDO TEPI - thyroid nodules and cancer (Case Based Approach)

  1. 1. Thyroid Nodules & Cancer Jeremy F. Robles, MD, FPCP, FPSEM Lucy E. Mamba, MD, FPCP, FPSEM
  2. 2. Thyroid Nodules & Cancer• Diagnostic approach to thyroid Nodules• Fine needle aspiration Biopsy / UTZ guided• Medical & Surgical management of nodules• Post-Surgery Radio-iodine therapy• Staging & Follow-up of Thyroid Cancer
  3. 3. Thyroid Nodules & Cancer• 2009 - American Thyroid Association (ATA)• 2010 - Combined Guidelines American Association of Clinical Endocrinology (AACE) Asociazione Medici Endocrinologi (AME) European Thyroid Association (ETA)• 2013 - National Comprehensive Cancer Network (NCCN)
  4. 4. 30/F consulted for throat discomfort noted 3 months prior
  5. 5. Thyroid Nodules & Cancer ATA / AACE / AME / ETA •History of irradiation •Familial thyroid cancer Pertinent •Rapid growth & hoarseness History •Age <14 yo and >70 yo •Male sex •Persistent dysphagia or dyspnea •Vocal cord paralysis Pertinent •Lateral cervical neck lymphadenopathy Physical •Fixation of the nodules to surrounding tissuesExamination •Location, consistency, size of nodule(s) •Neck tenderness or pain
  6. 6. Thyroid Nodules & Cancer What laboratory test or imaging will you order for patients with thyroid nodule(s)?a.) TSH & Thyroid Ultrasoundb.) Paired FT4 & TSH onlyc.) Ct-scan of the neckd.) Thyroid Sestamibi scan
  7. 7. Thyroid Nodules & Cancer ATA AACE, AME, ETA NCCN (2009) (2010) (2013) Thyroid Stimulating Yes (A) Yes (A) YesHormone (TSH)Free Thyroxine Yes (B) (FT4) ThyroidULTRASOUND Thyroid (A) Thyroid (B) & Neck
  8. 8. Diagnostic Approach to Thyroid Nodules ATA 2009 Work-up of Thyroid Nodule Detected by Palpation or Imaging Low TSH History, PE, TSH Normal / High TSH Thyroid Scan Non Functioning Diagnostic UTZ Hyperfunctioning No Nodule Nodule on UTZ do FNAB Evaluate & Treat for Elevated NormalHyperthyroidism TSH TSH Evaluate & FNA not treat for needed Hypothyroidism
  9. 9. Diagnostic Approach to Thyroid Nodules AACE / AME / ETA History & PE 2010 Thyroid UTZ with focus on TSH & FT4, calcitonin ? stratification for malignancy Low TSH or MNG inNodule diameter Nodule diameter Normal TSH iodine deficient region <1 cm without >1 cm or <1 cm withsuspicious Hx or suspicious Hx or suspicious UTZ suspicious UTZ Suspicious for malignancy Normofunctioning findings findings by clinical or UTZ criteria or cold on thyroid scan Follow-up No Yes FNAB Benign Follicular lesion suspicious, Surgery Positive for Malignant cells
  10. 10. Diagnostic Approach to Thyroid Nodules TSH + UTZ(central & lateral neck) Thyroid Scan FNAB NCCN 2013
  11. 11. Thyroid Nodules & Cancer What laboratory test or imaging will you order for patients with thyroid nodule(s)?a.) TSH & Thyroid Ultrasoundb.) Paired FT4 & TSH onlyc.) Ct-scan of the neckd.) Thyroid Sestamibi scan
  12. 12. Thyroid Nodules & Cancer Only thyroid nodules > 1 cm should be biopsied.a.) Trueb.) False
  13. 13. Sonographic Features of Interest ATA (2009) NCCN (2013) NODULE WITH SUSPICIOUS SONOGRAPHIC FEATURES > 0.5 cm >/= 1 cm NODULE WITHOUT SUSPICIOUS SONOGRAPHIC FEATURES > 0.5 cm > 1.5 cm SUSPICIOUS CERVICAL LYMPH NODES FNA Node & ALL Thyroid Nodules COMPLEX WITH SUSPICIOUS SONOGRAPHIC FEATURES >/= 1.5 - 2 cm COMPLEX WITHOUT SUSPICIOUS UTZ FEATURES >/= 2 cm SPONGIFORM NODULE >/= 2 cm PURELY CYSTIC NODULE FNAB NOT INDICATEDSUSPICIOUS SONOGRAPHIC FEATURESHypoechoic, Microcalcifications, Increased central vascularity,Infiltrative margins, Taller than wide in transverse plane
  14. 14. Thyroid Nodules & Cancer Only thyroid nodules > 1 cm should be biopsied.a.) Trueb.) False
  15. 15. Thyroid Nodules & Cancer• Diagnostic approach to thyroid Nodules• Fine needle aspiration Biopsy / UTZ guided• Medical & Surgical management of nodules• Post-Surgery Radio-iodine therapy• Staging & Follow-up of Thyroid Cancer
  16. 16. 30/F consulted for throat discomfort noted 3 months prior Ultrasound of the thyroid showed a 2.5 cm solid nodule on the inferior lobe TSH & FT4 are normal
  17. 17. Diagnosis: Nodular Non-toxic GoiterClinically & Biochemically Euthyroid
  18. 18. Thyroid Nodules & Cancer - Nodules > 1 cm ( solid & hypoechoic ) - Any size on UTZ with extracapsular growth or cervical LN metastasisIndications for - Any size with history of neck irradiation; PTC, MTC or FNAB MEN2 in 1st degree relatives; previous thyroid surgery for cancer, increased calcitonin - <1 cm with UTZ finding associated with malignancy - hot nodules should be excluded from FNAB - Do not biopsy hot areas on radioisotope scanMultinodular glands - If with cervical lymphadenopathy, biopsy both suspicious nodule and LN Complex - Sample solid component via UTZ guided biopsy(solid-cystic) - Submit FNAB specimen and fluid for cytologic examination AACE/ AME/ETA
  19. 19. Ultrasound Guided Biopsy• Nodules < 1 cm if clinical information or ultrasound findings are suspicious• Nonpalpable nodules• Predominantly cystic• Located posteriorly in the thyroid lobe• Repeat FNAB for nodule with initial non- diagnostic cytology result ATA / AACE /AME / ETA
  20. 20. Cytopathologic Diagnosis: Suspicious forPapillary Thyroid Carcinoma
  21. 21. Bethesda Classification of Thyroid Cytology SUGGESTED ALTERNATE % RISK OF CATEGORY CATEGORY MALIGNANCY Benign <1 Atypia of Indeterminate Follicular lesions, R/O neoplasm, atypicalundetermined Follicular Lesion, Cellular 5 - 10 significance Follicular Lesion Neoplasm Suspicious for Neoplasm 20 - 30Suspicious for - 50 - 75 Malignancy Malignant - 100Non-Diagnostic Unsatisfactory - 2009
  22. 22. cytologic adequacy = presence of at leastsix FNAB follicular cell groups, each containing 10–15 cells derived from at least(ATA 2009) two aspirates of a nodule
  23. 23. Thyroid Nodules & Cancer• Diagnostic approach to thyroid Nodules• Fine needle aspiration Biopsy / UTZ guided• Medical & Surgical management of nodules• Post-Surgery Radio-iodine therapy• Staging & Follow-up of Thyroid Cancer
  24. 24. Thyroid Nodules & Cancer What thyroid surgery should the patient undergo?( Suspicious Papillary Thyroid Cancer)a.) Lobectomy with isthmusectomyb.) Near total thyroidectomyc.) Total thyroidectomyd.) Discuss with the surgeon
  25. 25. Thyroid Surgery (Definitions)• Total Thyroidectomy • Removal of all grossly visible thyroid tissue• Near Total Thyroidectomy • Removal of all grossly visible thyroid tissue, leaving only a small amount [<1g] of tissue adjacent to the recurrent laryngeal nerve near the ligament of Berry• Subtotal Thyroidectomy • leaving >1 g of tissue with the posterior capsule on the uninvolved side ATA 2009
  26. 26. Thyroid Nodules & Cancer What thyroid surgery should this patient undergo?( Suspicious Papillary Thyroid Cancer)a.) Lobectomy with isthmusectomyb.) Near total thyroidectomyc.) Total thyroidectomyd.) Discuss with the surgeon
  27. 27. Surgical Management forDifferentiated Thyroid Cancer• Remove the Primary tumor• Minimize treatment related morbidity• Accurate staging of the disease• Facilitate post-operative post-radioiodine treatment, where appropriate• Long term surveillance for disease recurrence• Minimize risk of recurrence & metastatic spread ATA 2009
  28. 28. Thyroid Nodules & CancerWhat will you do if the thyroid biopsy turned out tobe Benign?a.) Lobectomy with isthmusectomyb.) Levothyroxine suppressionc.) Ultrasound Guided Percutaneous Ethanolinjection (PEI)d.) Monitor the patient within 6-18 months
  29. 29. Benign Nodules• Clinical, thyroid UTZ & TSH in 6 - 18 month• Repeat FNAB with UTZ guidance if clinically or with UTZ suspected features• Repeat UTZ in cases of > 50% increase in volume• Consider repeat UTZ guided FNAB in 6 - 18 months even with benign initial cytologic results AACE/ AME/ETA
  30. 30. Thyroid Nodules & CancerWhat will you do if the thyroid biopsy turned out tobe Benign?a.) Lobectomy with isthmusectomyb.) Levothyroxine suppressionc.) Ultrasound Guided Percutaneous Ethanolinjection (PEI)d.) Monitor the patient within 6-18 months
  31. 31. Levothyroxine suppression • LT4 suppression therapy of benign thyroid nodules in iodine sufficient populations is not recommended. • LT4 therapy or iodine supplementation may be considered in young patients who live in iodine deficient geographic areas and have small thyroid nodules & in those who have nodular goiters and no evidence of functional autonomy ATA/AACE/ AME/ETA
  32. 32. LT4 Suppression• Avoid LT4 in patients with • osteoporosis, CVD, systemic illness • large thyroid nodules • long standing goiter • low-normal TSH levels • postmenopausal women • age older than 60 yo (men) AACE / AME / ETA
  33. 33. Ultrasound GuidedPercutaneous Ethanol Injection• Effective in Benign thyroid cyst and complex nodules with a large fluid component• This should not be performed in solitary solid nodules or multinodular goiter AACE / AME / ETA
  34. 34. Surgery for Benign lesions• Indications: • Presence of local pressure symptoms clearly associated with the nodule • Previous external irradiation • Progressive nodule growth • Suspicious UTZ features • Cosmetic issues AACE / AME / ETA
  35. 35. NCCN 2013
  36. 36. Surgery for Papillary Thyroid Cancerc For microcarcinoma (< 1cm), a total thyroidectomy may not beneeded. Age is an approximation and not an absolute determination. NCCN 2013dTall cell variant, columnar cell, or poorly differentiated features.
  37. 37. NCCN 2013
  38. 38. Surgery for Follicular Thyroid Cancer NCCN 2013
  39. 39. Surgical Histopathologic Diagnosis: Papillary Thyroid Carcinoma
  40. 40. Thyroid Nodules & Cancer• Diagnostic approach to thyroid Nodules• Fine needle aspiration Biopsy / UTZ guided• Medical & Surgical management of nodules• Post-Surgery Radio-iodine therapy• Staging & Follow-up of Thyroid Cancer
  41. 41. Post-operative Radioiodine Remnant Ablation • For patients with known distant metastases, gross extrathyroidal extension of the tumor regardless of tumor size, or primary tumor size >4 cm even in the absence of other higher risk features • For selected patients with 1– 4cm thyroid cancers confined to the thyroid* LT4 withdrawal 2-3 weeks or LT3 treeatment for 2-4 weeksand LT3 withdrawal for 2 weeks with TSH > 30 mU/L. Resume ATA 2009LT4 therapy on 2nd - 3rd day post RAI therapy.
  42. 42. Post-operative Radioiodine Remnant Ablation• RAI ablation is not recommended for patients with unifocal cancer <1 cm without other higher risk features• RAI ablation is not recommended for patients with multifocal cancer when all foci are <1 cm in the absence other higher risk features ATA 2009
  43. 43. Thyroid Nodules & Cancer• Diagnostic approach to thyroid Nodules• Fine needle aspiration Biopsy / UTZ guided• Medical & Surgical management of nodules• Post-Surgery Radio-iodine therapy• Staging & Follow-up of Thyroid Cancer
  44. 44. Postoperative (AJCC/UICC) staging• Permit prognostication for an individual patient• Tailor postoperative adjunctive therapy RAI therapy / TSH suppression risk for disease recurrence and mortality• To make decisions regarding the frequency and intensity of follow-up• Accurate communication regarding a patient among health care professionals ATA 2009
  45. 45. ATA 2009
  46. 46. Surgical Histopathologic Diagnosis:Papillary Thyroid Carcinoma (Stage 1), S/P Total Thyroidectomy, S/P Radioiodine Therapy (100 mci)
  47. 47. Differentiated Thyroid Cancer (Long Term Management)• Check for persistent tumor within 1st year of treatment by • Clinical evidence of tumor • Imaging evidence of tumor • Undetectable serum Tg levels during TSH suppression and stimulation in the absence of interfering antibodies• --measured /monitored every 6-12 months ATA 2009
  48. 48. TSH suppression therapy• High-risk • macroscopic tumor invasion, • incomplete tumor resection • distant metastases • thyroglobulinemia out of proportion to what is seen on the posttreatment scan ATA 2009
  49. 49. TSH suppression therapy• Intermediate-risk • microscopic invasion of tumor into the perithyroidal soft tissues at initial surgery • cervical lymph node metastases or 131I uptake outside the thyroid bed on the RxWBS done after thyroid remnant ablation • tumor with aggressive histology or vascular invasion ATA 2009
  50. 50. TSH suppression therapy• Low-risk • macroscopic tumor invasion, • incomplete tumor resection, • distant metastases • thyroglobulinemia out of proportion to what is seen on the posttreatment scan ATA 2009
  51. 51. TSH suppression therapy• High-risk and intermediate-risk: • TSH suppression to <0.1mU/L• Low-risk : maintenance of the TSH = or slightly below the lower limit of normal (0.1–0.5mU/L) ATA 2009
  52. 52. Thyroid Nodules & Cancer Jeremy F. Robles, MD, FPCP, FPSEM Lucy E. Mamba, MD, FPCP, FPSEM

×