solitary thyroid nodule

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  • solitary thyroid nodule

    1. 1. TOPIC DISCUSSION Solitary Thyroid Nodule CHALINEE WAJANANAWAT
    2. 2. Objective 1. ทราบถึงหลักการในการซักประวัติและตรวจร่างกายผู้ป่วยที่มี Solitary thyroid nodule ได้อย่างถูกต้อง 2. สามารถวินิจฉัยและวินิจฉัยแยกโรคผู้ป่วยที่มี Solitary thyroid nodule ได้ 3. สามารถเลือกส่ง Further Investigation ได้อย่างเหมาะสม ในผู้ป่วยที่มี Solitary thyroid nodule 4. สามารถวางแผนการรักษาเบื้องต้นในผู้ป่วยที่มี Solitary thyroid nodule ได้อย่างเหมาะสม
    3. 3. CASE PROFILE Identification data : ผู้ป่วยหญิงไทยคู่ อายุ 52 ปี ภูมิลำเนา อ . เมือง จ . ลำปาง อาชีพ ทำนา Source of information : จากการซักประวัติผู้ป่วย และข้อมูลทางการแพทย์ Reliability : น่าเชื่อถือมาก
    4. 5. CHIEF COMPLAINT มีก้อนที่คอโตมา 2 ปีก่อนมาโรงพยาบาล
    5. 6. NECK MASS……….. IS THAT THYROID GLAND??
    6. 8. Evaluation of thyroid Disease ?…… <ul><li>History ( family history, history of goiter, local symptoms, </li></ul><ul><li> symptoms of hyper/ hypothyroidism) </li></ul><ul><li>Physical examination (general, thyroid gland) </li></ul><ul><li>Laboratory tests </li></ul>
    7. 9. <ul><li>Duration </li></ul><ul><li>Progression </li></ul><ul><li>Local symptoms : pain, difficulty in swallowing or breathing, </li></ul><ul><ul><ul><ul><ul><li>hoarseness </li></ul></ul></ul></ul></ul><ul><li>Living in endemic goiter area </li></ul><ul><li>Family history of goiter, hyperthyroidism, CA thyroid </li></ul>
    8. 10. PRESENT ILLNESS 2 ปีก่อนมารพ . ผู้ป่วยคลำได้ก้อนที่บริเวณลำคอด้านซ้าย ขนาดเท่าหัวแม่มือ ไม่มีอาการหิวบ่อย ใจสั่น กินจุ ท้องเสีย หงุดหงิด ไม่มีไข้ ไม่มีอาการคลื่นไส้อาเจียน ผู้ป่วยรู้สึกว่าก้อนค่อยๆ โตขึ้นทีละน้อย ไม่มีการเจ็บที่ก้อน ไม่มีเสียงแหบ ไม่ได้ไปพบแพทย์ 2 เดือนก่อนมารพ . สังเกตว่าก้อนโตขึ้นอย่างรวดเร็วจนขนาด เท่าไข่ไก่ ไม่มีน้ำหนักลด ไม่มีอาการผิดปกติอื่นร่วม มีเพื่อนบ้าน เป็นมะเร็งต่อมไทรอยด์ จึงมาพบแพทย์
    9. 11. PAST HISTORY : มีประวัติเป็นโรคความดันโลหิตสูง ไม่ได้ทานยาใดๆ : ปฎิเสธการมีโรคประจำตัวอื่นๆ เช่น เบาหวาน : ปฏิเสธการได้รับอุบัติเหตุ : ปฏิเสธประวัติการแพ้ยา อาหาร หรือสารเคมี
    10. 12. FAMILY HISTORY : มารดาเป็นโรคมะเร็งมดลูก ผ่าตัดแล้ว ปัจจุบันเสียชีวิต : ปฏิเสธโรคถ่ายทอดทางพันธุกรรมอื่นๆ : ปฏิเสธบุคคลอื่นในครอบครัวมีอาการเหมือนผู้ป่วย
    11. 13. PHYSICAL EXAMINATION <ul><li>V / S : T 36 °c PR 80 / min </li></ul><ul><li>RR 16 / min BP 110/60 mmHg BMI 22 (W=50/H=160) </li></ul><ul><li>GA : A middle - aged woman c normal conciousness , </li></ul><ul><li>no pallor, no jx, no cyanosis, no puffy face </li></ul><ul><li>Skin : No moist skin, no onycholysis, normal hair distribution </li></ul><ul><li>Eye : No staring eyes, no lid lag, lid retraction </li></ul><ul><li>Lung : Normal breath sound, no adventitious sound </li></ul><ul><li>Heart : Regular, no murmur, symmetrical pulse </li></ul>
    12. 14. PHYSICAL EXAMINATION <ul><li>GI :Soft, no mass, no distension, no tenderness, </li></ul><ul><li> Active BS, Liver & Spleen can not palpable </li></ul><ul><li>GU : CVA –ve, kidney can not palpable </li></ul><ul><li>Extremities : No edema , no deformity, no tremor </li></ul><ul><li> no clubbing of fingers </li></ul><ul><li>Lymph node : can not palpable </li></ul><ul><li>CNS : WNL, DTR reflex 2+ </li></ul>
    13. 15. PHYSICAL EXAMINATION…THYROID GLAND
    14. 19. PHYSICAL EXAMINATION NECK : Mass at left neck anterior to sternocleidomastoid muscle Size 4x5 cm. , irregular shape firm cosistency, rough surface ill-defind border, Not tender move on swallowing, no bruit
    15. 21. <ul><li>Thyroid nodule of left lobe with clinical euthyriod </li></ul>PROBLEM LIST
    16. 22. Am Fam Physician 2003;67:559-66 DIFFERNTIAL DIAGNOSIS
    17. 23. <ul><li>Lymphadenopathy </li></ul><ul><li>Evidence of local invasion </li></ul><ul><li> -Vocal cord paralysis </li></ul><ul><li>-Dysphagia </li></ul><ul><li>Firm, fixed nodules </li></ul><ul><li>Family history of MEN II </li></ul><ul><li>Radiation exposure </li></ul><ul><li>Male </li></ul><ul><li>Older age </li></ul><ul><li>Younger age </li></ul><ul><li>Rapid increase in size </li></ul><ul><li>Previous thyroid cancer </li></ul>MAJOR RISK FACTOR….
    18. 24. Diagnostic tests <ul><li>Ultrasound </li></ul><ul><li>Radionuclide scintigraphy </li></ul><ul><li>Radiography </li></ul><ul><li>CT and MRI </li></ul><ul><li>FNA </li></ul><ul><li>Thyroid function test </li></ul>
    19. 25. <ul><li>Can identify presence of nodules. </li></ul><ul><li>May be able to characterize follicular vs. solid. </li></ul><ul><li>Evaluated thyroid gland </li></ul><ul><li>Aid in biopsy. </li></ul><ul><li>Not able to rule our malignant nodule </li></ul>Thyroid ULTRASOUND……
    20. 26. Thyroid Scans <ul><li>Purpose </li></ul><ul><ul><li>Determine function of the gland and/or a nodule </li></ul></ul><ul><ul><li>within the gland </li></ul></ul><ul><li>Hot nodules - usually independently functioning nodules </li></ul><ul><ul><ul><ul><ul><li>Rarely, rarely malignant </li></ul></ul></ul></ul></ul><ul><li>Cold nodules - either adenoma or maligancy </li></ul><ul><ul><ul><ul><ul><li>15% chance of malignancy in adults. </li></ul></ul></ul></ul></ul>
    21. 27. Nuclear Medicine Thyroid Scans Cold Nodule The majority of all nodules Most benign Some malignant Hot Nodule <5% of all nodules Rarely malignant
    22. 28. <ul><li>Radiography : </li></ul><ul><ul><li>flecks of calcification </li></ul></ul><ul><ul><li>Psammoma bodies- Papillary CA </li></ul></ul><ul><li>CT and MRI : </li></ul><ul><ul><li>Irregular margin </li></ul></ul><ul><li>FNA : </li></ul><ul><li>Thyroid function test : </li></ul><ul><li>Serum calcitonin : </li></ul>OTHER….
    23. 29. <ul><li>Thyroid nodule of left lobe with clinical euthyriod </li></ul>PROBLEM LIST
    24. 30. PLAN FOR MANAGEMENT……..
    25. 31. ข้อสอบศรว . ปี 2551/1 A 62 year-old woman with cief complaint of neck mass. Physical exam reveals a thyroid nodule, 2*2*2 cm. clinically Euthyroid. what is appropriate investigation? 1. T3,TSH 2. Thyroid scan 3. FNA 4. Thyroid uptake of I-131 5. Ultrasound
    26. 32. Modified from: Castro, MR, Gharib, H. Endocr Pract 2003; 9:128. Approach Solitary Thyroid nodule..
    27. 33. Fine needle aspiration(FNA)
    28. 34. FNA…….. <ul><li>Best tool for determining pathology other than surgical excision. </li></ul><ul><li>Can be as high as 80 % sensitive and 95% specific. </li></ul><ul><li>Operator dependent in obtaining adequate amount of tissue. </li></ul><ul><ul><li>25 gauge needle is optimal. </li></ul></ul><ul><li>Should not be relied on if negative in patient with previous </li></ul><ul><li>neck irradiation. </li></ul>
    29. 41. Fine Needle Aspiration Benign (70-80%) Follicular Neoplasia (5-8%) Suspicious (5-8%) Malignant (3-5%) Inadequate (10-20%)
    30. 42. Modified from: Castro, MR, Gharib, H. Endocr Pract 2003; 9:128. Approach Solitary Thyroid nodule..
    31. 43. PLAN FOR MANAGEMENT…….. -FNA Follicular neoplasm ,Suspected for CA thyroid
    32. 44. Thyroid Malignancies-Follicular <ul><li>Well-differentiated thyroid carcinoma </li></ul><ul><li>20 % of malignancies </li></ul><ul><li>Distinguished from normal follicular adenomas </li></ul><ul><li>by invasion of capsule or blood vessels. </li></ul><ul><li>Ioidine deficiency related. </li></ul><ul><li>Male : female = 3 : 1 </li></ul><ul><li>Hematogenous spreading </li></ul><ul><li>More distance metastasis </li></ul>
    33. 45. <ul><li>Capsular invasion must be present </li></ul><ul><li>FNA inadequate for diagnosis </li></ul>Thyroid Malignancies-Follicular
    34. 46. <ul><li>Clinical manifestations </li></ul><ul><li>85 % solitary thyroid mass or rapid developrment </li></ul><ul><li>of single firm nodule in old goiter </li></ul><ul><li>Pain or local invasion in late staged </li></ul><ul><li>2-9% : LN metastasis </li></ul><ul><li>19 % : pathology LN metastasis </li></ul><ul><li>10-72% : Distant metastasis to bone or lung </li></ul><ul><li>in first visit </li></ul>
    35. 47. PLAN FOR MANAGEMENT…….. -Investigation? -patient education -Definite treatment
    36. 48. Chest X-ray
    37. 49. Chest X-ray
    38. 50. <ul><li>-Multiple soft tissue nodule of varying size in both lower lung </li></ul><ul><li>-Heart is normal </li></ul><ul><li>-both costophrenic angles are sharp </li></ul><ul><li>-bony thorax is intact </li></ul><ul><li>Impression multiple soft tissue nodule metastasis? </li></ul>
    39. 51. Thyroid Mets <ul><li>Breast </li></ul><ul><li>Lung </li></ul><ul><li>Renal </li></ul><ul><li>GI </li></ul><ul><li>Melanoma </li></ul>
    40. 52. <ul><li>Management </li></ul><ul><li>Total thyroidectomy or near total thyroidectomy </li></ul><ul><li>Exogenous thyroid hormone supplement </li></ul><ul><li>Postop whole body RAI scan </li></ul><ul><li>Postop I131 ablation </li></ul>Thyroid Malignancies-Follicular: Treatment
    41. 53. <ul><li>EORTC , 1979 </li></ul><ul><li>Age , Cell type, Distant metastasis, Sex, T-category, Differentiation. </li></ul><ul><li>Mayo clinic , 1987 (AGES) </li></ul><ul><li>Age, Tumor grade, Tumor extension, Tumor size. </li></ul><ul><li>Lahey clinic, 1988 (AMES) </li></ul><ul><li>Age, Distant metastasis, Tumor extension, Tumor size. </li></ul>Thyroid Malignancies-Follicular: Prognosis
    42. 54. -TSH -TG <ul><li>-TSH </li></ul><ul><li>-TG </li></ul><ul><li>Whole body </li></ul><ul><li>-CXR </li></ul><ul><li>TSH </li></ul><ul><li>TG </li></ul><ul><li>TSH </li></ul><ul><li>TG </li></ul><ul><li>TSH </li></ul><ul><li>TG </li></ul>6mo -1 st yr หยุดยา 1mo 3 mo 4 th year Non-stop 5 th yr 6 th ….. FOLLOW UP
    43. 55. Fine Needle Aspiration Benign (70-80%) Follicular Neoplasia (5-8%) Suspicious (5-8%) Malignant (3-5%) Inadequate (10-20%)
    44. 56. Follicular adenoma <ul><li>Most common benign tumor of thyroid </li></ul><ul><li>Pathology shows an encapsulated mass consisting of numerous small follicles </li></ul><ul><li>May be functional (toxic adenoma) or non-functional </li></ul><ul><li>Treatment : </li></ul><ul><ul><ul><li>Thyroid lobectomy with Isthmectomy </li></ul></ul></ul><ul><ul><ul><li>( Thyroid suppression ) </li></ul></ul></ul>
    45. 57. Follicular adenoma
    46. 58. Thyroid Cancer <ul><li>Uncommon cancer in Thailand </li></ul><ul><li>Most common endocrine gland malignancy </li></ul><ul><li>1.8-3.5 per100,000 population </li></ul><ul><li>Female : Male ratio = 3 : 1 </li></ul><ul><li>More common in Southern Region </li></ul>1.9 3.5 1.9 1.8
    47. 59. <ul><li>Uncommon cancer in Thailand </li></ul><ul><li>Most common endocrine gland malignancy </li></ul><ul><li>1.8-3.5 per100,000 population </li></ul><ul><li>Female : Male ratio = 3 : 1 </li></ul><ul><li>More common in Southern Region </li></ul>1.9 1.8 Thyroid Cancer
    48. 60. 1.9 3.5 1.9 1.8 Thyroid Cancer
    49. 61. <ul><li>Slow growing tumor </li></ul><ul><li>Lymphatic invasion and capsular invasion </li></ul><ul><li>Lymphatic spreading </li></ul><ul><li>Best prognosis (95% 10 yr survival) </li></ul>Thyroid Malignancies- Papillary <ul><li>Most common </li></ul><ul><li>Well-differentiated thyroid carcinoma </li></ul><ul><li>30% have node metastasis </li></ul><ul><li>at diagnosis </li></ul><ul><li>Radiation related </li></ul><ul><li>TSH related </li></ul><ul><li>male : female = 3-4 : 1 </li></ul>
    50. 62. Thyroid Malignancies- Papillary
    51. 63. Treatment Depend on size <1 cm – Lobectomy & isthmectomy >1 cm – Total thyroidectomy with/with out neck dissection Thyroid Malignancies- Papillary
    52. 64. Neck metastasis <ul><li>Central neck dissection </li></ul><ul><ul><li>Lymph node ใน paratracheal , pretracheal , tracheoesophageal, </li></ul></ul><ul><ul><li>cricothyroid , top superior mediastinal groups , </li></ul></ul><ul><ul><li>internal jugular chain ทั้ง 2 ข้าง ส่ง frozen section </li></ul></ul><ul><ul><li>ถ้า positive ทำ modified or funtional neck dissection โดย </li></ul></ul><ul><ul><li>preserve internal jugular vein , sternocleidomastoid muscle , </li></ul></ul><ul><ul><li>spinal accessory ไว้ </li></ul></ul>
    53. 65. <ul><li>ถ้ามี superior mediastinal lymph node metastasis </li></ul><ul><li>ควรทำ superior mediastinal lymph node dissection </li></ul><ul><li>จนถึง arch of aorta โดย approach วิธีใดวิธีหนึ่ง ดังนี้ </li></ul><ul><ul><li> -Suprasternal approach </li></ul></ul><ul><ul><li> -Resection of the medial one third of the clavicle </li></ul></ul><ul><ul><li> -Resection of the manubrium </li></ul></ul><ul><ul><li> -Median sternotomy </li></ul></ul>
    54. 66. Prognosis <ul><li>Papillary carcinoma มี 10 year-survival rate 84% </li></ul><ul><li>Follicular carcinoma มี 10 year-survival rate 76% </li></ul><ul><ul><li>-42% ใน widely invasive carcinoma </li></ul></ul><ul><ul><li>-86% ใน minimally invasive carcinoma </li></ul></ul>
    55. 67. Hurthle cell neoplasm <ul><li>variant of follicular neoplasma </li></ul><ul><li>3% of thyroid cancer </li></ul><ul><li>Usually do not uptake I-131 (only 10%) </li></ul><ul><li>Usually multifocal and bilateral </li></ul><ul><li>FNAC diagnosis hurthle cell neoplasm (20% carcinoma) </li></ul><ul><li>higher mortality rate than follicular carcinoma </li></ul>
    56. 68. Medullary carcinoma - C-cell orgin (parafollicular cell) - calcitonin production - 5% thyroid malignancy - female : male = 1.5:1 - age 50 years - associate with MEN - Cervical and mediastinal node metastases
    57. 69. Management Total thyroidectomy With/without node dissection Radioactive Iodine ablasion Monitor by serum calcitonin
    58. 70. Anaplastic Thyroid carcinoma <ul><li>Undifferentiate thyroid carcinoma </li></ul><ul><li>Poorest prognosis (50% < 6M) </li></ul><ul><li>More common in old age </li></ul><ul><li>Painful, hard neck mass, and symptoms of extension </li></ul><ul><li>Lymphatic and hematogenous spreading </li></ul><ul><li>Highly aggressive with local extension at time of diagnosis . </li></ul><ul><li>Airway obstruction , SVC syndrome </li></ul><ul><li>LN metastasis : 50% , lung metastasis </li></ul>
    59. 71. TREATMENT <ul><li>Early case (1%) </li></ul><ul><li>-No extracapsular extension </li></ul><ul><li>-Total thyroidectomy </li></ul><ul><li>-Modified neck dissection </li></ul><ul><li>-External radiation </li></ul><ul><li>Late case (99%) </li></ul><ul><li>Total thyroidectomy with Modified neck dissection : </li></ul><ul><li> 5 year-survival rate < 7% (75% ตายใน 1 ปี ) </li></ul><ul><li>Unresectable tumor : tracheostomy + external radiation </li></ul><ul><li>+ chemotherapy </li></ul>
    60. 73. MERRY X’ MAS & THANK YOU

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