Solitary thyroid nodule ppt by dr koorapati ramesh

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Solitary thyroid nodule ppt by dr koorapati ramesh

  1. 1. Kakatiya Medical College, Warangal Road Map to Benign Thyroid Disorders
  2. 2. DR RAMESH KOORAPATI MS Dept of General Surgery
  3. 3. Evaluation of Thyroid Disorders <ul><li>Clinical assessment </li></ul><ul><li>Investigations </li></ul>
  4. 4. Clinical assessment <ul><li>Physiological v/s Pathological </li></ul><ul><li>Anatomical - Unilateral v/s Bilateral </li></ul><ul><li>Pathology – Benign v/s Malignant </li></ul><ul><li>Functional status </li></ul><ul><li>General condition of the patient </li></ul>
  5. 5. DIFFERENTIAL DIAGNOSIS UNILATERAL SOLITARY THYROID NODULE
  6. 6. DIFFERENTIAL DIAGNOSIS BILATERAL SYMMETRICAL * PHYSIOLOGICAL * FUNCTIONAL ASYMMETRICAL * MNG * DOMINANT NODULE * CARCINOMA THYROID * THYROIDITIS
  7. 7. AETIOLOGICAL CLASSIFICATION OF THYROID SWELLINGS <ul><li>SIMPLE GOITRE </li></ul><ul><li>DIFFUSE HYPERPLASTIC </li></ul><ul><li>PHYSIOLOGOCAL </li></ul><ul><li>PUBERTAL </li></ul><ul><li>PREGNANCY </li></ul><ul><li>MULTI NODULAR GOITRE </li></ul><ul><li>TOXIC </li></ul><ul><li>DIFFUSE </li></ul><ul><li>GRAVE’ DISEASE </li></ul><ul><li>MULTINODULAR </li></ul><ul><li>TOXIC ADENOMA </li></ul><ul><li>NEOPLASTIC </li></ul><ul><li>BENIGN </li></ul><ul><li>MALIGNANT </li></ul><ul><li>INFLAMMATORY </li></ul><ul><li>AUTOIMMUNE </li></ul><ul><li>GRANULOMATUS </li></ul><ul><li>FIBROSING </li></ul><ul><li>INFECTIVE </li></ul><ul><li>OTHERS </li></ul>
  8. 8. INVESTIGATIONS ESSENTIAL <ul><li>THYROID FUNCTION TESTS-----T3 T4 TSH </li></ul><ul><li>THYROID USG </li></ul><ul><li>PATHOLOGICAL------- FNAC,BIOPSY </li></ul>
  9. 9. SPECIAL INVESTIGATIONS <ul><li>THYROID SCINTIGRAPHY </li></ul><ul><li>CORE BIOPSY </li></ul><ul><li>CT / MRI NECK </li></ul><ul><li>SPECIAL X-RAYS </li></ul><ul><li>TUMOR MARKERS </li></ul><ul><li>THYROID ANTIBODIES </li></ul><ul><li>PET SCAN </li></ul><ul><li>TRH SUPPRESION TESTS </li></ul>
  10. 10. FNAC <ul><li>INITIAL INVESTIGATION OF CHOICE </li></ul><ul><li>STN / MNG / SUSPECIOUS NODULES </li></ul><ul><li>REPLACED ONTABLE FROZEN SECTION STUDIES </li></ul>
  11. 11. LIMITATIONS OF FNAC <ul><li>CAN NOT DIFFERENTIATE FOLLICULAR ADENOMA </li></ul><ul><li>v/s </li></ul><ul><li>CARCINOMA </li></ul><ul><li>FALSE NEGATIVE RATES 6 % -10 % </li></ul><ul><li>BLIND ---- SAMPLING ERRORS </li></ul>
  12. 12. ISOTOPE SCANNING <ul><li>TOXIC NODULE </li></ul><ul><li>MULTI NODULAR GOITRE WITH TOXIC SYMPTOMS </li></ul><ul><li>FOLLOWUP OF CARCINOMA THYROID </li></ul>
  13. 15. BENIGN THYROID DISORDERS - CLINICAL PRESENTATIONS <ul><li>SOLITARY OR DOMINANT NODULE </li></ul><ul><li>DIFFUSE OR MULTINODULAR GOITRE </li></ul><ul><li>FUNCTIONAL DISORDERS </li></ul>
  14. 16. SOLITARY NODULE THYROID DEFINITION:- DISCREAT SWELLING IN AN OTHERWISE IMPALPABLE GLAND
  15. 17. NORMAL ULTRASOUND BENIGN NODULE ON US Solitary / Dominant Nodule (Non – toxic)
  16. 18. SOLITARY THYROID NODULE v/s DOMINANT NODULE
  17. 19. <ul><li>THYROID – FNA BIOPSY: </li></ul>Road Map to Benign Thyroid Disorders Normal Gland Solitary / Dominant Nodule (Non – toxic) Class I (10%) Class II (60 – 75%) Class III (20%) Class IV (5%) Class V (5 – 15%) NON – DIAGNOSTIC NODULES BENIGN NODULES FOLLICULAR LESIONS SUSPICIOUS NODULES MALIGNANT NODULES
  18. 20. Road Map to Benign Thyroid Disorders False Negatives with FNAC Solitary / Dominant Nodule (Non – toxic)
  19. 21. Road Map to Benign Thyroid Disorders False Negatives with FNAC Solitary / Dominant Nodule (Non – toxic)
  20. 22. NON - DIAGNOSTIC NODULES (Class I) <ul><li>Due to: </li></ul><ul><li>Cystic Nodules </li></ul><ul><li>Benign / Malignant sclerotic lesions </li></ul><ul><li>Thick / Calcified capsule </li></ul><ul><li>Abscesses / Necrotic lesions </li></ul><ul><li>Hypervascular lesions </li></ul><ul><li>Sampling Error / Faulty Technique </li></ul>Road Map to Benign Thyroid Disorders Solitary / Dominant Nodule (Non – toxic)
  21. 23. <ul><li>Reaspiration using US guidance </li></ul><ul><li>Malignancy = 2 – 12% </li></ul><ul><li>Treatment options: </li></ul>Road Map to Benign Thyroid Disorders Thyroid Cyst Solitary / Dominant Nodule (Non – toxic) Pure Colloid, completely cystic on US Complex lesions Solid lesions Clinical and US follow up Surgery Surgery
  22. 24. BENIGN NODULES (Class II) Road Map to Benign Thyroid Disorders Isoechoic homogeneous subcapsular nodule (arrows) with regular margin Solitary / Dominant Nodule (Non – toxic)
  23. 25. <ul><li>BENIGN THYROID NODULE </li></ul><ul><li>Treatment Options: </li></ul><ul><li>Clinical Follow up </li></ul><ul><li>Levothyroxine Suppressive Therapy </li></ul><ul><li>Surgery </li></ul>Road Map to Benign Thyroid Disorders Solitary / Dominant Nodule (Non – toxic)
  24. 26. LEVOTHYROXINE <ul><li>Routinely NOT recommended </li></ul>Road Map to Benign Thyroid Disorders Solitary / Dominant Nodule (Non – toxic) May be Considered MUST be Avoided <ul><li>Young Patients from Endemic areas with small nodules </li></ul><ul><li>Non – autonomous Nodules </li></ul><ul><li>Large Nodules </li></ul><ul><li>Long Standing </li></ul><ul><li>Low Normal TSH </li></ul><ul><li>Post Menopausal </li></ul><ul><li>Men > 60yrs </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Cardiovascular Disease </li></ul>
  25. 27. SURGERY INDICATIONS <ul><li>Compressive Symptoms </li></ul><ul><li>Cosmetic Reasons </li></ul><ul><li>Patients anxious (psychological) </li></ul>Road Map to Benign Thyroid Disorders Solitary / Dominant Nodule (Non – toxic)
  26. 28. <ul><li>FNAB cannot differentiate benign from malignant </li></ul><ul><li>Repeated FNAB – NOT Recommended </li></ul><ul><li>Core Needle Biopsy – NOT Recommended </li></ul><ul><li>20 % are Malignant </li></ul><ul><li>Surgical Excision (Lobectomy + Isthmectomy OR Total Thyroidectomy) </li></ul>FOLLICULAR LESIONS (Class III) Road Map to Benign Thyroid Disorders Solitary / Dominant Nodule (Non – toxic)
  27. 29. Road Map to Benign Thyroid Disorders FOLLICULAR ADENOMA Nodule shows micro follicles, is sharply circumscribed by a capsule, and there is no invasion of the capsule or blood vessels FOLLICULAR CARCINOMA with Vascular invasion Solitary / Dominant Nodule (Non – toxic)
  28. 30. <ul><li>Includes: </li></ul><ul><li>Cytological features suggesting malignancy but do not fulfill the criteria for a definite diagnosis </li></ul><ul><li>Insufficient cellularity but with cellular features strongly suggesting malignancy </li></ul><ul><li>60% are Malignant </li></ul><ul><li>Surgery + Intraoperative Frozen Section </li></ul>SUSPICIOUS NODULES (Class IV) Road Map to Benign Thyroid Disorders Solitary / Dominant Nodule (Non – toxic)
  29. 31. MANAGEMENT OF SOLITARY THYROID NODULE
  30. 32. THANK YOU…

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