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THYROID nodules ppt june 2013.pptx
- 1. L I S A A . C I C O , M S N , N P U P S T A T E M E D I C A L U N I V E R S I T Y B R E A S T & E N D O C R I N E S U R G E R Y C O O R D I N A T O R T H Y R O I D C A N C E R P R O G R A M S U R G I C A L C O O R D I N A T O R B R E A S T C A N C E R P R O G R A M THYROID NODULES
- 3. OBJECTIVES Describe tools / diagnostic testing for assessment of the patient with a thyroid nodule(s) *Utilize national guidelines developed for patients with thyroid nodules *Describe some of the common symptoms of patients with thyroid nodules Comprehensive review of current diagnostic tools and imaging to assess thyroid nodules Review American Thyroid Association, & National Comprehensive Cancer Network Guidelines for patients who develop thyroid nodules Review common symptoms of patients with thyroid nodule
- 4. OBJECTIVES Identify which patients can safely be followed by PCP *Describe imaging/diagnostic modalities for following the patient with thyroid nodules *Identify those patients requiring referral to specialty *Identify which specialty to make an appropriate referral based on diagnostic, objective and symptomatic findings Obtaining appropriate imaging/diagnostic testing, and frequency Overview of ultrasonographic thyroid terminology Overview of Betheseda thyroid nodule pathology terminology Obtaining appropriate personal and family history Identify what patients require referral and to endocrine or surgery? Briefly discuss appropriate follow up for the patient with thyroid cancer
- 5. Definition of Thyroid Nodule “A discrete lesion within the thyroid gland that is palpably and/or ultrasonographically distinct from surrounding thyroid parenchyma” *ATA Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer (2006 & 2009 Task Force)
- 6. 0 10 20 30 40 50 60 10 20 30 40 50 60 70 Palpation Autopsy Ultrasound Prevalence Rallison et al. JAMA 1975 Hogan et al. J Surg Res 2009
- 8. “How was this nodule found?” Palpation with a physical exam Incidental finding on diagnostic work up Self detection Surveillance Work up for symptoms of hyper/hypothyroidism How was found is it clinically relevant?
- 9. Physical Examination of Thyroid Gland Visual inspection Palpation of thyroid, neck nodes, and supraclavicular nodes Fixed, mobile, soft, tender? Reflexes why? HR, BP, weight
- 11. Symptoms Usually NONE!! Occasionally painful, quick onset (cyst) Difficulty swallowing Hoarseness OR change in voice Shortness of breath (or difficulty swallowing) usually while supine OR hands raised over head (Pemberton’s Sign) Choking sensation hyper/hypo thyroid
- 12. Nodules Hyper/Hypo thyroid Difficulty swallowing Globus sensation Choking sensation Hyper-functioning nodule Hashimoto’s Symptoms?
- 13. History Physical Findings Head & neck irradiation Whole body irradiation Nuclear fallout Family history of thyroid malignancy Heredity Rapid growth Hoarseness Cervical /supraclavicular lymphadenopathy Fixation of nodule or gland > 4 cm Solitary Pertinent History & PE in Evaluation of TNs
- 14. Differential Diagnosis Multinodular Goiter Hashimoto’s Thyroiditis Cancer Lymphoma Solitary Thyroid Nodule Substernal Goiter
- 15. C O W D E N ’ S S Y N D R O M E F A M I L I A L P O L Y P O S I S C A R N E Y C O M P L E X M E N 2 W E R N E R S Y N D R O M E T H Y R O I D M A L I G N A N C Y Family History of Hereditary Diseases
- 16. Substernal Goiters Short neck Stocky build Usually incidental finding by CXR or CT Many times treated unsuccessfully for asthma
- 18. Ultrasound: The Gold Standard Anyone found to have, OR is suspected of having a nodule evaluate by ultrasound!!
- 19. BENIGN CHARACTERISTICS Pure cystic (relatively rare) Spongiform appearance in >50% of nodule volume (aggregration of multiple microcystic components) Multiple (?)
- 21. Cyst BENIGN
- 23. US (a, transverse; b, longitudinal) scans in 51-year-old woman show 2.4-cm well- defined mixed-echoic hypoechoic nodule (arrows) in right lobe of thyroid gland. Initial cytologic result was adenomatous hyperplasia, confirmed after 11 months at repeat aspiration BENIGN
- 24. ULTRASOUND CHARACTERISTIC CONSIDERATIONS High-risk history: History of thyroid cancer in one or more first degree relatives; history of external beam radiation as a child; exposure to ionizing radiation in childhood or adolescence; prior hemithyroidectomy with discovery of thyroid cancer, 18FDG avidity on PET scanning; MEN2/FMTC-associated RET protooncogene mutation, calcitonin >100 pg/mL. MEN, multiple endocrine neoplasia; FMTC, familial medullary thyroid cancer. Suspicious features: microcalcifications; hypoechoic; increased nodular vascularity; infiltrative margins; taller than wide on transverse view. FNA cytology may be obtained from the abnormal lymph node in lieu of the thyroid nodule. Sonographic monitoring without biopsy may be an acceptable alternative
- 25. SUSPICIOUS CHARACTERISTICS Hypo-echogenicity compared to normal thyroid parenchyma Increased intra-nodular vascularity Irregular infiltrative margins Presence of micro-calcifications Absent halo Shape taller than width in transverse dimension Nodules > 4 cm Solitary Difficulty swallowing ATA Guidelines 2009
- 29. Calcifications Poorly defined, irregular margins SUSPICIOUS
- 30. Solid SUSPICIOUS
- 31. Multiple Thyroid Nodules FNA what nodule?? > 1 cm Suspicious features Dominant / largest one
- 32. Palpation? Ultrasound? What nodule(s) do you FNA? What nodule(s) do you FNA? FNA of Palpable Nodule
- 33. TN with suppressed TSH UPTAKE SCAN to assess autonomous nodule Compare to U/S what is the correlation with Uptake FNA consider in non - functioning or isofunctioning with suspicious features
- 35. FNA Only GOLD standard for proof of malignancy without surgical pathology
- 36. False Negative False Positive false-negative rate of up to 5% with FNA which may be even higher with nodules >4 cm ?? FNA
- 37. < 1 cm > 1 cm NO ATA Guidelines 2009 NO Is Size a Predictor of Malignancy?
- 38. FNA Results Nondiagnostic Benign Atypia of Undetermined Significance (AUS) Suspicious for a Follicular Neoplasm/Follicular Neoplasm Suspicious for Malignancy Malignant Bethesda System for Reporting Thyroid Cytopathology
- 39. Diagnostic Category Risk of Malignancy (%) Usual management Nondiagnostic or Unsatisfactory Repeat FNA with ultrasound guidance Benign 0-3 Clinical Follow up with ultrasound 6 months Atypia of Undetermined significance or Follicular lesion of Undetermined significance 5-15 Repeat FNA 3 months; if same, then lobectomy Follicular Neoplasm or suspicious for Follicular neoplasm 15-30 Surgical Lobectomy Suspicious for Malignancy 60-75 Near total thyroidectomy or surgical lobectomy Malignant 97-99 Near total thyroidectomy
- 40. Lab Work TSH Free T4 TPO in suspected thyroiditis TG tumor marker in PTC, FTC, HTC Calcitonin suspected MTC or in follow up of MTC TSH Free T4 T4 T3 Free T3 TPO Thyroglobulin (TG) Calcitonin
- 41. Thyroid nodule FNA Benign Exam/Sonogram 6-18 months No Change Repeat in 3-5 yrs 20% increase in diameter in > 2 dimensions (>2mm) or volume increase > 50% Re-aspirate Thyroid Nodule
- 42. Nodule sonographic or clinical features Recommended nodule threshold size for FNA High-risk historya Nodule WITH suspicious sonographic featuresb >5mm Recommendation A Nodule WITHOUT suspicious sonographic featuresb >5mm Recommendation I Abnormal cervical lymph nodes Allc Recommendation A Microcalcifications present in nodule ≥1cm Recommendation B Solid nodule AND hypoechoic >1cm Recommendation B AND iso- or hyperechoic ≥1–1.5 cm Recommendation C Mixed cystic–solid nodule WITH any suspicious ultrasound featuresb ≥1.5–2.0 cm Recommendation B WITHOUT suspicious ultrasound features ≥2.0 cm Recommendation C Spongiform nodule ≥2.0 cmd Recommendation C Purely cystic nodule FNA not indicatede Recommendation E TABLE 3. SONOGRAPHIC AND CLINICAL FEATURES OF THYROID NODULES AND RECOMMENDATIONS FOR FNA
- 43. RAI Uptake Scan ONLY IN HYPERTHYROID Cold Nodule - 10% incidence of being CA
- 44. From 2005 to 2009, incidence rates increased by 5.6% per year in men and 7.0% per year in women, making thyroid cancer the fastest increasing cancer in both men and women Most common endocrine cancer Thyroid Cancers
- 45. Projected Cases of Thyroid Cancer 60, 220 new cases are estimated for 2013 45, 310 female 14, 910 male 1,850 deaths projected for 2013 1,040 female 810 male Death rate 0.5 per 100,000 in both male and females
- 46. AGE & INCIDENCE AMCERICAN CANCER SOCIETY / NCCN/ SEER Diagnosed at a younger age then most adult cancers Median age at diagnosis was 50 years from 2005-2009 2 out of 3 cases are < 55 years old Thyroid cancer in the pediatric population Pediatric Incidence 2.0 per 1 million in children <15 yrs and 17.6 per 1 million in children 15-19 yrs 2% occur in children and teens
- 47. TREATMENT FOR THYROID CANCER Surgery Radioactive Iodine Ablation Levothyroxine Monitor with WBS / ultrasound
- 48. CHILDREN & PREGNANT WOMEN W H E N D O Y O U O P E R A T E ? ? ?
- 49. Complications of Thyroid Surgery Recurrent laryngeal nerve injury Hypo parathyroidism Bleeding Infection
- 52. OR case COMPLICATIONS OF THYROID SURGERY
- 53. Surgery and TC Low MORTALITY Thyroid cancers LOW Mortality!! Rod Stewart, Julie Andrews, Joe Piscopo Always exceptions to the rules : Roger Ebert, Supreme Court Justice Reinquist Should be LOW MORBIDITY too!! IF surgery is required, always refer to someone who does at least > 50 / year NO drains!! NO RR tracks!! Dermabond is ulgy on the neck, and often opens a bit…
- 54. Summary Refer to Endocrin0logy or Surgery Children Pregant women Nodules > 1 cm with suspicious features Compressive symptoms HT with globus symptoms ULTRASOUND!! Even if already had CT, carotid doppler, etc Can safely follow with ultrasound Nodule < 1 cm Stable nodules with no change Repeat in 6 months x 2, then annually Monitor TFTs with U/S
- 55. ENDOCRINE SURGERY Suspected/known abnormal TFTs with TNs Pregnant If FNA needed Children If suspect surgery is indictated Endocrine OR Surgery?
- 56. Q U E S T I O N S ? Thank You
Editor's Notes
- -what is palpable does NOT always correspond to ultrasound findings -ultrasound inexpensive, non invasive, dimensions of gland, nodules
- Not everyone will have an obvious goiter or thyroid nodule
- -PCP, GYN most common -PET, CT, Carotid ultrasounds -looking at picture or checking in mirror -patients who are being seen for work up hyper/hypo thyroid -surveillance for high risk exposure to radiation, acne treatments, nuclear fallout -chernobyl widespread exposure to fallout **clinically relevant if exposed to radiation, +PET, etc.
- Hyper/hypo reflex; would want to do TSH Free t4 TPO is suspect hypo HT
- ?due to thyroid nodules??
- Hoarseness DD: Reflux, cancer, polyps Hyper r/o hyperfx nodule
- TFTs nodules and function are two separate issues usually hyperfunctioning nodule?, Hashimoto’s? swallowing how big are the nodules? How many? Associated with Thyromegaly? substernal goiters
- CHERNOBYL: exposure under age 14**but not always the rule** Heredity: Cowden’s Syndrome Familial Polyposis Carney Complex MEN 2 Werner Syndrome
- Lymphoma no operation, tx with radiation and chemo but found on surgical path Difference betw surgical and cytopath???
- CT to assess tracheal narrowing &/or deviation PFTs may reveal obstructive disease CXR reveals thyroid mass
- ATA Guidelines 2009, revised 2013 THE DAVINICI CODE!!!!
- Not invasive inexpensive Dimension of gland and nodules Is used to monitor size and growth Helps determine IF a biopsy is necessary Unique characteristics of nodules
- Thyroid nodule
- **With the exception of suspicious cervical lymphadenopathy, which is a specific but insensitive finding no single sonographic feature or combinations of features is adequately sensitive or specific to identify all malignant nodules. However, certain features and combination of features have high predictive value for malignancy. Furthermore, the most common sonographic appearances of papillary and follicular thyroid cancer differ. A PTC is generally solid or predominantly solid and hypoechoic, often with infiltrative irregular margins and increased nodular vascularity. Micro-calcifications, if present, are highly specific for PTC, but may be difficult to distinguish from colloid. Conversely, follicular cancer is more often iso- to hyperechoic and has a thick and irregular halo, but does not have microcalcifications (49). Follicular cancers that are <2 cm in diameter have not been shown to be associated with metastatic disease (50).
- In the presence of two or more thyroid nodules >1 cm, those with a suspicious sonographic appearance (see text and Table 3) should be aspirated preferentially. (b) If none of the nodules has a suspicious sonographic appearance and multiple sonographically similar coalescent nodules with no intervening normal parenchyma are present, the likelihood of malignancy is low and it is reasonable to aspirate the largest nodules only and observe the others with serial US examinations. **FNA by palpation OR ultrasound???
- Can you feel calcifications? Can you feel any of the worrisome features of nodules? NO
- A low or low-normal serum TSH concentration may suggest the presence of autonomous nodule(s). A technetium 99 mTc pertechnetate or 123I scan should be performed and directly compared to the US images to determine functionality of each nodule >1–1.5 cm. FNA should then be considered only for those isofunctioning or nonfunctioning nodules, among which those with suspicious sonographic features should be aspirated preferentially.
- SURGICAL V. CYTOPATH??
- false-negative rate of up to 5% with FNA (41,80), which may be even higher with nodules >4 cm benign nodules may decrease in size, they often increase in size, albeit slowly (82). One study of cytologically benign thyroid nodules <2 cm followed by ultrasonography for about 38 months found that the rate of thyroid nodule growth did not distinguish between benign and malignant nodules higher false-negative rate with palpation FNA (1–3%) (40,84,85) than with US FNA (0.6%)
- Nonpalpable 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. Nodules <1 cm lack these warning signs yet eventually cause morbidity and mortality. These are rare and, given unfavorable 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. Approximately 1–2% of people undergoing PET will incidental nodules discovered (uptake due to thyroiditis, or thyroid malignancy FNA)
- 6 ways of reporting, used to be 4 AUS re-FNA in 3 months, if same, treat as suspicious
- ATA guidelines
- TSH, Free T4 *not a predictor of malignancy* Hyper UPTAKE SCAN ? HOT nodule Hypo nodule worrisome characteristics of cancer? TPO/TG Suspected Hashimotos will be elevated TG Used as tumor marker in thyroid cancers Calcitonin IF suspicious for MTC or as tumor marker in known MTC
- a High-risk history: History of thyroid cancer in one or more first degree relatives; history of external beam radiation as a child; exposure to ionizing radiation in childhood or adolescence; prior hemithyroidectomy with discovery of thyroid cancer, 18FDG avidity on PET scanning; MEN2/FMTC-associated RET protooncogene mutation, calcitonin >100 pg/mL. MEN, multiple endocrine neoplasia; FMTC, familial medullary thyroid cancer. bSuspicious features: microcalcifications; hypoechoic; increased nodular vascularity; infiltrative margins; taller than wide on transverse view. cFNA cytology may be obtained from the abnormal lymph node in lieu of the thyroid nodule. dSonographic monitoring without biopsy may be an acceptable alternative (see text) (48). eUnless indicated as therapeutic modality (see text).
- Only way to determine malignancy is FNA, bx
- SO, why do we evaluate thyroid nodules in the first place?? On the chance they harbor a cancer
- http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-031941.pdf ACS NCCN ATA
- Ablation / Elation indications have changed Specialties involved: surgery, endo, NO med onc
- The diagnostic and therapeutic approach to one or more thyroid nodules in a child should be the same as it would be in an adult (clinical evaluation, serum TSH, US, FNA). How should thyroid nodules in pregnant women be managed? It is uncertain if thyroid nodules discovered in pregnant women are more likely to be malignant than those found in nonpregnant women (103), since there are **no population-based studies on this question. The evaluation is the same as for a nonpregnant patient, with the exception that a radionuclide scan is contraindicated. In addition, for patients with nodules diagnosed as DTC by FNA during pregnancy, delaying surgery until after delivery does not affect outcome (104).
- Complications of surgery
- Surgery: globus symptoms, FNA needed, Endo: likely not to require surgery, or to evaluate for surgery, HT, hyperthyroid