Thyroid Nodules2

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Thyroid Nodules2

  1. 1. Thyroid Nodules March 19, 2003
  2. 2. Objectives ? Identify patients at risk for thyroid cancer ? Understand general approach toward laboratory and radiologic evaluation of solitary thyroid nodules ? Familiarity with treatment modalities to facilitate appropriate follow up and referral
  3. 3. Case presentations: JM 26 y/o Latino male patient c/o increased unilateral neck swelling for approximately one year. He thinks it may have been present since he was a teenager. Per his chart he was referred to ENT about 1 year ago, in which they note a right neck swelling and recommend f/u in 3mo if persistence or enlargement. Currently the mass is firm, fixed and about 1.5cm over the right lateral neck. There are no remaining masses over his neck, but the in the right lobe of his thyroid you note a similar 1cm firm, nontender nodule.
  4. 4. Case presentations MK 53 y/o Ukrainian male presenting with 6 month history of unilateral nontender neck swelling. Notes at onset rapid growth, now stable. Denies other neck swellings. On exam, 3cm rubbery,slightly mobile, nontender nodule on left lateral lobe of thyroid
  5. 5. History Medical history: - personal history of thyroid disease - signs or symptoms of hyper/hypo thyroidism - symptoms of local invasion: hoarseness, dysphagia, neck pain - history of onset and rate of growth of nodule - history of radiation to head or neck
  6. 6. History Family history: - family history of thyroid ca or polyposis (Gardner’s syndrome) or autoimmune thyroiditis (Hashimoto’s)
  7. 7. History of Radiation Exposure Greatest risk of thyroid ca: exposure in childhood ? Hodgkins lymphoma – with radiation treatment ? US born- 1940’s/50’s frequent use of radiation to treat nonmalignant conditions (ie: chronic cystic acne) - often medical records unavailable - ask if mother had to leave room during tx, contradictory hx is memory of purple light (UV tx) - low risk if radiation tipped rods placed through nose to post. pharynx to shrink tonsils/adenoids of children
  8. 8. History of Radiation Exposure ? Foreign born- -1986 Chernobyl, atomic bombing in Nagasaki/Hiroshima, Marshall Islanders exposed to nuclear testing -map of Chernobyl: www.greenfield.fortunecity.com/flytrap/250/31.jpg
  9. 9. Physical Exam Inspection Palpation: thyroid- note if nodules are: solid or cystic , smooth or nodular diffuse or localized soft or hard mobile or fixed painful or nontender note size and location if nodule is less than 1 cm often difficult to palpate on exam
  10. 10. Physical Exam cont. Palpation- Lymph nodes- crucial to check for lymphadenopathy Physical exam for any signs of hyper or hypothyroid disease, such as exothalpmos, reflex abnormalities, myxedema
  11. 11. “Red Flags” for thyroid cancer ? Male gender ? Extremes in Age (<20 y/o or >65 y/o) ? Rapid growth of nodule ? Symptoms of local invasion (dysphagia, hoarseness, neck pain) ? History of radiation to head or neck ? Family hx of thyroid cancer or polyposis (Gardner’s)
  12. 12. Back to the patients… JM: 26 y/o male Medical hx: no symptoms of thyroid dysfxn no personal hx of thyroid disease no known exposure to radiation no symptoms of local invasion Family hx: none PE: Firm fixed nodule with LAD nl reflexes, no signs of thyroid disease
  13. 13. Back to the patients… MK: 53 y/o male Medical hx: no symptoms of thyroid dysfxn no personal hx of thyroid disease + known exposure to Chernobyl at age 36 no symptoms of local invasion Family hx: none PE: Cystic soft mass, no LAD nl reflexes, no signs of thyroid disease
  14. 14. Epidemiology of Thyroid Nodules: Palpable nodules- 4-7% of population - one study with 30% incidental nodule on US - 23% of solitary nodules are dominant in multinodular goiter - women 4x> men, more often in areas of iodine deficiency - thyroid ca in 5-10% of palpable nodules
  15. 15. Types of thyroid nodules Adenoma: Carcinoma: Macrofollicular adenoma (colloid) Papillary (75%) Microfollicular adenoma (fetal) Follicular (10%) Medullary (5-10%) Embyronal adenoma (trabecular) Anaplastic (5%) Hurthle cell adenoma (oxyphilic, oncocytic) Other: thyroid lymphoma (5%) Atypical adenoma Adenoma with papillae Colloid Nodule Signet-ring adenoma Dominant nodule in multinodule goiter Cyst: Other: Simple cyst Inflammatory disorders (subacute or Cystic/solid tumors (hemorrhagic, necrotic) chronic lymphocytic thyroiditis, granulomatous disease) Developmental- dermoid, unilateral lobe agenesis
  16. 16. Diagnosis Laboratory Evaluation Fine Needle Aspiration Radiology Ultrasound Nuclear Imaging
  17. 17. Laboratory Evaluation Sensitive TSH – all patients to differentiate hypo vs hyperthyroid - important in determining next step of workup - not useful in determining malignant from benign nodule Serum calcitonin – measure in patients with family hx of medullary thyroid ca Antithyroid peroxidase antibodies and thyroglobulin - not to differentiate malignant from benign. helpful in diagnosing Grave’s or Hasimoto’s
  18. 18. Fine-Needle Aspiration ? Euthyroid patient – first step ? Most cost effective in determining malignant vs. benign ? Most accurate (~95% depending on biopsy skill and cytopathologist skill) ? Sensitivity 68-98%, specificity 72-100%, false (– ) 0-5% ? Sampling error in large (>4cm) and small (<1cm) nodules ? Results improved with US guided FNA, not routinely used due to costs
  19. 19. Fine Needle Aspiration ? Results: benign- macrofollicular or “colloid” adenomas, Hashimoto’s – 74% suspicious or indeterminant/inadequate – microfollicular or cellular adenoma (follicular neoplasm) 22% malignant - 4%
  20. 20. Thyroid Scintigraphy ? Cannot reliably distinguish malignant vs. benign ? Measures the amount of iodine trapped within a nodule ? Nodule classified as : cold- decreased uptake warm- uptake similar to surrounding tissue hot- increased uptake (10%)
  21. 21. Thyroid Scintigraphy ? Use with 1. suppressed TSH 2. indeterminate cytology ? Cold and warm- malignant 5-8% ? Hot nodule- almost always nonmalignant ? Indeterminate scan-perform suppression scan-if autonomous continue to uptake iodine
  22. 22. Ultrasound ? Exquisitely sensitive in ascertaining the size and number of nodules ? Anatomic information vs. functional information ? Cannot differentiate malignant vs. benign ? Often as extension of PE resulting in “incidentalomas” ? Uses: follow-up FNA guidance- indeterminant lesions decreases from 15% to 4% when used multinodular goiter
  23. 23. Treatment ? surgery- main indications: malignant or indeterminate cytology on FNA suspicious history/PE if presurgical dx of malignancy- total or partial thyroidectomy (controversial) ? postoperative radioactive iodine: for high-risk (metastatic, nodal disease, gross residual disease) Target TSH is 0.5 microunits per mL or greater suppresion for high-risk
  24. 24. Treatment Benign nodule- repeat biopsy (6-24mo) - repeat biopsy if nodule enlarges/changes - follow with clinical exams indefinitely Hot nodule (autonomous)- with thyrotoxicosis- radioactive iodine (I131)
  25. 25. Patient Cases… JM- ? TSH 3.22 FT4 1.28 ? FNA- “cyst fluid with hemosiderin laden macrophages and epithelium favored is a brachial cleft cyst; however the presence of a rare intranuclear inclusion and mild atypia necessitates further evaluation” ? Surgical biopsy- “lymph node with metatstatic papillary thyroid cancer”
  26. 26. Patient Cases… JM – Total thyroidectomy, thymectomy Post operative I131 ablation 1 year post operative- NM I123 scan negative TSH suppression with levothyroxine
  27. 27. Patient Cases… MK- ? FNA- “scant colloid, macrophages and proteinaceous fluid, most c/w thyroid cyst. No thyroid epithelium identified” ? US- “large complex cystic mass within the left thyroid lobe” ? FNA- “benign thyroid nodule with cystic features- hemosiderin laden macrophages, colloid and mixed follicular epithelium” ? TSH 0.21 FT4 1.67 ? Thyroid Scintigraphy- “warm nodule corresponding with palpable nodule, no evidence of suppression of lobes of thyroid”
  28. 28. References 1. Welker M, Orlov D, Thyroid Nodules, American Family Physician 2003; 6:559-566 2. Mazzafarri EL. Management of Solitary Thyroid Nodule. N Engl J Med 1993;328:553-9. 3. Feld S, AACE clinical practice guidelines for the diagnosis and management of thyroid nodules. Thyroid Task Force. Endocr Pract 1996;2:78-84 4. Singer P, Treatment Guidelines for Patients With Thyroid Nodules and Well-Differentiated Thyroid Cancer. Arch of Internal Med. 1996;156:2165-2172. 5. Herring A. Assessment of Nondiagnostic Ultrasound Guided FNA of Thyroid Nodules. J of Clin Endocr and Metabolism 2002;87-11.

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