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Thyroid nodule

Thyroid nodule. History Physical examination Euthyroid Hypothyroid Hyperthyroid Labs TSH (antibodies). Thyroid nodule. Imaging US Scan if TSH is low. Toxic adenoma. Thyroid nodule. Imaging US Scan if TSH is low CT usually precedes referral FNA US-guided. Thyroid nodule.

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Thyroid nodule

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  1. Thyroid nodule • History • Physical examination • Euthyroid • Hypothyroid • Hyperthyroid • Labs • TSH • (antibodies)

  2. Thyroid nodule • Imaging • US • Scan if TSH is low

  3. Toxic adenoma

  4. Thyroid nodule • Imaging • US • Scan if TSH is low • CT usually precedes referral • FNA • US-guided

  5. Thyroid nodule • There are 3 ways to diagnose a thyroid nodule: • ultrasound guided FNA • ultrasound guided FNA • ultrasound guided FNA

  6. Thyroid nodule • FNA result • Papillary carcinoma • Follicular LESION • Carcinoma • Adenoma • Adenomatous colloid nodule • Insufficient for diagnosis

  7. Management Guidelines for Patients withThyroid Nodules and Differentiated Thyroid Cancer(Cooper, THYROID 2006;16:109-141(

  8. Management Guidelines for Patients withThyroid Nodules and Differentiated Thyroid Cancer (Cooper, THYROID 2006;16:109-141)FNA Results

  9. Thyroid nodule • FNA result • Papillary carcinoma • Follicular LESION • Carcinoma • Adenoma • Adenomatous colloid nodule • Insufficient for diagnosis

  10. Management Guidelines for Patients withThyroid Nodules and Differentiated Thyroid Cancer (Cooper, THYROID 2006;16:109-141)FNA Results

  11. Thyroid nodule • conservative approach for most patients with thyroid nodules that are cytologically indeterminate on fine-needle aspiration and benign according to gene-expression classifier results. (Alexander, N Engl J Med. 2012;367:705-15)

  12. Non-mailgnant indications for thyroidectomy • Goiter

  13. Non-mailgnant indications for thyroidectomy • Goiter • Symptomatic

  14. Non-mailgnant indications for thyroidectomy • Goiter • Symptomatic • Esthetic

  15. Non-mailgnant indications for thyroidectomy • Goiter • Symptomatic • Esthetic • Hyperthyroidism

  16. Before and after total thyroidectomy

  17. THYROID CANCERS • CALSSIFICATION:

  18. THYROID CANCERS • CALSSIFICATION: DIFFERENTIATED THYROID CANCERS

  19. THYROID CANCERS • CALSSIFICATION: DIFFERENTIATED THYROID CANCERS OTHER THYROID CANCERS

  20. THYROID CANCERS • CALSSIFICATION: DIFFERENTIATED THYROID CANCERS • Papillary

  21. THYROID CANCERS • CALSSIFICATION: DIFFERENTIATED THYROID CANCERS • Papillary • Follicular

  22. THYROID CANCERS • CALSSIFICATION: DIFFERENTIATED THYROID CANCERS • Papillary • Follicular OTHER THYROID CANCERS

  23. THYROID CANCERS • CALSSIFICATION: DIFFERENTIATED THYROID CANCERS • Papillary • Follicular OTHER THYROID CANCERS • Medullary

  24. THYROID CANCERS • CALSSIFICATION: DIFFERENTIATED THYROID CANCERS • Papillary • Follicular OTHER THYROID CANCERS • Medullary • Anaplastic (?poorly differentiated papillary carcinoma)

  25. Differentiated thyroid cancer

  26. Differentiated thyroid cancer

  27. Differentiated thyroid cancer

  28. Differentiated thyroid cancer

  29. Differentiated thyroid cancer

  30. Differentiated thyroid cancer

  31. Differentiated thyroid cancer • Staging • T1 - Tumor 2 cm or less in greatest dimension limited to the thyroid. • T2 - Tumor more than 2 cm, but not more than 4 cm, in greatest dimension limited to the thyroid. • T3 - Tumor more than 4 cm in greatest dimension limited to the thyroid. • T4a - Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve. • T4b - Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.

  32. Differentiated thyroid cancer • Staging • N1a - Metastasis to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes). • N1b - Metastasis to unilateral, bilateral, or contralateral cervical or superior mediastinal lymph nodes.

  33. A G E S Age Sex (Gender) Extension Size Prognostic factors

  34. Prognosis (Lahey Clinic) • Age • Metastasis • Extension • Size

  35. Prognosis (Lahey Clinic) Age Metastasis (NOT lymph node) Extension Size

  36. Prognosis (Lahey Clinic) Age Metastasis (NOT lymph node) Extension (to neighboring structures) Size

  37. Prognosis (Mayo Clinic) • MACIS Prognostic score • Metastasis, Age, Completeness of resection, vascular Invasion, Size. • M + 3 if Metastasis is found • A = Age (y) x 0.08 • C + 1 if resection is inComplete • I + 1 if vascular invasion (pathologists report) • S 0.3 x largest diameter in centimeters (Size)

  38. Prognosis (MSKCC) • Even more complicated scoring • Includes • Tumor grade • Lymph node involvement • multifocality

  39. Complications of thyroid surgery

  40. Thyroid operations • Lobectomy ± isthmus • Near total thyroidectomy • Total thyroidectomy • ± modified neck dissection for known involved lymph nodes

  41. Operations for papillary carcinoma • Lobectomy (low risk) • Difficult to justify radical surgery for such a good prognosis cancer • Total/near total thyroidectomy (high risk) • Treatment with radioactive iodine-131 • Detection of distant metastases • Total thyroidectomy + modified neck dissection (known lymph node metastasis)

  42. Extensive spread of papillary carcinoma

  43. Operations for follicular carcinoma • Total thyroidectomy • Near total thyroidectomy • Treatment with radioactive iodine-131 • Detection of distant metastases

  44. Adjuvant treatment • Scan for residual glandular tissue • I131 full body scan • Maximal TSH stimulation • Destruction of thyroid remnant • High dose I131 (Maximal TSH stimulation) • Treatment • High dose I131 (Maximal TSH stimulation) • Suppressive T4 for life • Follow up • Thyroglobulin (Tg) with maximal TSH stimulation • I131 full body scan as indicated by Tg

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