This document provides an overview of evaluating thyroid nodules. It defines a thyroid nodule and discusses prevalence. The importance of evaluating nodules is to exclude thyroid cancer. Evaluation involves patient history, physical exam, ultrasound of the nodule, and fine needle aspiration biopsy if indicated. Nodule characteristics on ultrasound and biopsy results are discussed. Management depends on biopsy results and may include surgery, radiation, or medication. Post-operative care involves risk stratification and monitoring for recurrence.

1. EVALUATION OF
A THYROID
NODULE
VIJAY SHEWALE
KIMS , TRIVANDRUM
14TH AUG 2013

2. INTRODUCTION
• DEFINITION- A discrete lesion within the
thyroid gland that is palpably and/or
radiologically distinct from surrounding
thyroid parenchyma.

3. INTRODUCTION
• PREVALENCE- Epidemiological studies have
shown that prevalence of palpable thyroid
nodule is 5% in women and 1% in men. This
prevalence increases upto 19 – 67 % if
detected by ultrasound.
• Nodular goitre prevalence increases by age

5. INTRODUCTION
• The importance of thyroid nodule rests with
the need to exclude thyroid malignancy which
occurs in 5 – 15 %

6. HOW WAS THE NODULE FOUND
• Palpation with a physical exam
• Incidental finding on diagnostic work up
• Self detection
• Surveillance
• Work up for symptoms of hyper or
hypothyroidism

7. CLINICAL EVALUATION

8. HISTORY
• Age , sex
• Swelling in front or side of a neck
• h/o pain
• Sudden increase in size
• Pressure symptoms such as hoarseness of
voice , dyspnoea , dysphagia (rarely)

9. HISTORY
• h/o hyperthyroid – loss of weight in spite of
good appetite, intolerance to heat, excessive
sweating
CNS symptoms like- irritability , insomnia,
tremor of hands, muscle weakness
EYE symptoms such as staring look, difficulty
in closing eye, double vision
CNS and EYE symptoms are s/o primary

10. HISTORY
CVS symptoms like palpitations , chest pain ,
dyspnoea on exertion are s/o secondary
hyperthyroid
• h/o hypothyroid- increase in weight in spite of
poor appetite, facial puffiness, loss of hair,
lethargy, poor memory, constipation,
oligomenorrhoea

11. HISTORY
PAST HISTORY
• h/o neck irradiation ,
• h/o thyroid disease in family

12. EXAMINATION
General examination-
Signs of hyperthyroid- tachycardia, tremor, moist
skin, eye signs like exophthalmos look, Von
Graefe’s sign, lid retraction, joffroy’s
sign,stellwag’s sign, moebius sign

13. EXAMINATION
Local examination-
• Movement of swelling with deglutition
• Size , consistency of nodule
• Tracheal deviation, retrosternal extension
• Cervical lymphadenopathy

14. WORK UP

15. THE AMERICAN THYROID
ASSOCIATION (ATA) GUIDELINES FOR
THYROID NODULE
2009 , REVISED IN 2013

17. SERUM TSH
• Low TSH may be associated with functioning
nodule, very unlikely to be malignant
• TSH has trophic effect on thyroid cancer
growth mediated by TSH receptors on tumor
cells
• TSH suppression is an independent predictor
for relapse free survival in differentiated
thyroid cancer

19. ULTRASOUND SCAN
Can answer following questions
• Solid/cystic
• size
• Additional nodule
• Benign or malignant feature

20. ULTRASOUND SCAN
BENIGN
• Iso / hyper echoic
• Coarse calcifications
• Thin, well defined halo
• Regular margins
• Hypovascular
• No lymph nodes
MALIGNANT
• Hypo echoic
• Micro calcifications
• Thick or absent halo
• Irregular margins
• Hypervascular
• Lymphadenopathy
• Taller than wide lesion

21. HYPOECHOIC

22. HYPERVASCULARITY

23. CALCIFICATIONS, POORLY DEFINED, IRREGULAR MARGINS

24. SOLID

25. Is size predictor of malignancy
• Non palpable nodules have the same risk of
malignancy as palpable nodules with the same
size
• Generally, only nodules >1 cm should be
evaluated, since they have a greater potential to
be clinically significant cancers.
• Nodules <1 cm that require evaluation because of
suspicious US findings, associated
lymphadenopathy, a history of head and neck
irradiation, or a history of thyroid cancer in one
or more first-degree relatives.

26. • Nodules <1 cm lack these warning signs yet
eventually cause morbidity and mortality.
These are rare and, given unfavourable
cost/benefit considerations, attempts to
diagnose and treat all small thyroid cancers in
an effort to prevent these rare outcomes
would likely cause more harm than good.

27. FNAC
• Only gold standard test for proof of
malignancy without surgical pathology
• 23 – 25 gauze no needle is used

28. INDICATIONS FOR US GUIDED FNAC
• Non palpable or difficult to palpate nodule
• Previous non diagnostic cytology
• Nodules with previous benign cytology which
has grown in size

29. FNAC RESULTS
• Nondiagnostic (thy 1)
• Benign(thy2)
• Suspicious for a Follicular Neoplasm/Follicular
Neoplasm(thy3)
• Suspicious for Malignancy(thy4)
• Malignant(thy5)

30. BENIGN
• Scanty normal follicular
cells together with
colloid

31. PAPILLARY
• Nuclear grroving
• Papillary projections
• Orphan annie eye nuclei

32. FOLLICULAR
• Increased cellularity
with a follicular pattern

33. HURTHLE CELL
• Variant of follicular neoplasm
• Oxyphill ( askanazy ) cells predominate

34. MEDULLARY
• Amyloid stroma

35. NON DIAGNOSTIC CYTOLOGY
• In persistent non diagnostic cytology risk of
malignancy is less than 5%
• Surgery should be considered if nodule is solid

36. BENIGN CYTOLOGY
• TSH suppressive dose of thyroxine is not
recommended
• Repeat us guided evaluation after 6 months
• If size same or decrease, continue to follow up
for longer intervals
• If increasing us guided cytology
• Surgery is recommended in recurrent cystic
nodule with benign cytology

37. FOLLICULAR NEOPLASM
• I 123 thyroid scan should be considered if serum
TSH is in low normal level
• Surgery should be consider if no concurrent
hyperfunctioning nodule is present
• Total thyroidectomy if
nodule > 4 cm in size
bilobar nodular disease
h/o radiation exposure or family h/o thyroid
malignancy

38. FOLLICULAR NEOPLASM
• Use of molecular markers such as BRAF,
RET/PTC, Ras, PAX8/PPARy or GALECTIN3 may
be consider

39. PAPILLARY
• Total thyroidectomy unless if nodule is less
than 1 cm and unifocal
• Modified radical neck dissection only if
enlarged lymph nodes are present

40. MEDULLARY
• Total thyroidectomy
• Central compartment lymph node dissection
is recommended
• Modified radical neck dissection only if
enlarged lymph nodes are present

41. ANAPLASTIC
• Total thyroidectomy
• Prognosis is poor

42. LYMPHOMA
• Chemotherapy
• Surgery indicated if pressure symptoms are
present

44. THYROID SCAN
• Only in hyperthyroid
• In hot nodule, surgery is recommended after
preparation
• In cold nodule ,10 % possibility of malignancy.
FNAC is advised, manage accordingly

45. POST OPERATIVE MANAGEMENT
• In DTC , patient are categorized in high or low
risk for recurrence
• AMES (lahey clinic)- age , metastasis,
extension , size
• AGES (mayo clinic 1987)- age , grade,
extension, size
• MACIS (mayo clinic 1993)- metastasis, age ,
completeness of resection , invasion, size

46. POST OPERATIVE MANAGEMENT
• GAMES (MSKCC)- grade , age , metastasis,
extension, size
• TNM
FOR DTC
Age < 45
Stage 1 – any T, any N, M0
Stage2 - any T ,any N , M1

47. POST OPERATIVE MANAGEMENT
Age > 45 in DTC and medullary
Stage 1 – T1 N0 M0
Stage 2- T2 N0 M0
Stage 3- T 3 N0 M0 or T 1-3 N1 M0
Stage 4A- T4a
Stage 4 B – T4b
Stage 4 C – M1

48. POST OPERATIVE MANAGEMENT
• ANAPLASTIC
Stage 4 A- T 4a
Stage 4B- T4b
Stage 4C- T 4c

49. POST OPERATIVE MANAGEMNT
• In differentiated thyroid carcinoma - Iodine
131 ablation to remove any residual thyroid
tissue and malignant cells, to allow follow up
with serum thyroglobulin
• Radioiodine scan, serum thyroglobulin,
ultrasound scan , to monitor the patients for
recurrence

50. POST OPERATIVE MANAGEMENT
• In medullary ca- radiotherapy recommended if
lymph nodes are positive for metastasis
• Tyrosine kinase inhibitors, VEGF receptor
inhibitors are under trial now
• Follow up with serum calcitonin , and CEA

51. THANK YOU