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CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE. Department of Internal Medicine and Gastroenterology University of Bologna L. Bolondi, L. Rasciti. Caso clinico. Donna di 56 anni, sposata con 3 figli, in menopausa da 5 anni.

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department of internal medicine and gastroenterology university of bologna l bolondi l rasciti

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Department of Internal Medicine and GastroenterologyUniversity of BolognaL. Bolondi, L. Rasciti

caso clinico
Caso clinico
  • Donna di 56 anni, sposata con 3 figli, in menopausa da 5 anni.
  • Si accorge, guardandosi allo specchio, di lieve asimmetria della circonferenza del collo (modica tumefazione a sin);
  • Il medico palpa una formazione nodulare, di consistenza parenchimatosa, non dolente, verosimilmente riferibile al lobo tiroideo sin. Non rileva linfoadenopatie.
caso clinico3
Caso clinico
  • Funzione tiroidea (FT3, FT4, TSH) nella norma
  • Autoanticorpi (anti TG, antimicrosomiali) nella norma
  • Emocromocitometrico, GOT, GPT, Azotemia, Glicemia, Protidemia totale ed elettroforesi, VES, Es; urine nella norma
  • Viene inviata per esame ecografico
slide4

NODULO ISOECOGENO CON AREA LIQUIDA INTERNA.

AL DOPPLER SEGNI DI VASCOLARIZZAZIONE PERIFERICA

slide5

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Key concepts

  • Thyroid nodules are the most common endocrine disorder, they can be detected in an otherwise normal gland, especially in iodine-deficient areas. The frequency of thyroid nodules increases throughout life.
  • Single nodules are about four times more common in women thanin men.
slide6

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Key concepts

  • Nodules are 10 times more frequent, in comparison to palpation, when the gland is examined at autopsy, during surgery, orby ultrasonography.

Prevalence of palpable thyroid nodules detected at autopsy or by ultrasonography (solid circle) or by palpation (open square) in subjects without radiation exposure or known thyroid disease.

E. Mazzaferri, NEJM 1993

slide12

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Key concepts

  • Less than 1% of thyroid nodules detected at US prove to be malignant.
  • Less than 5% of solitary nodules detected at US are malignant.
  • A significant number of elderly patients have clinically silent thyroid cancers: up to 35% of thyroid glands at autopsy contain tiny (<1.0 cm), clinically unimportant papillary carcinomas.
  • Among nodules removed surgically, an estimated 42 to 77 % are non-neoplastic colloid nodules, 15 to 40 % are adenomas, and 8 to 17 % are carcinomas.
slide13

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

CLASSIFICATION OF THYROID NODULES

Benign Nodules

  • Hyperplastic (colloid) nodule within goiter
  • Follicular Adenoma
        • Colloid variant
        • Hurthle cell variant
  • Papillary Adenoma (suspect for malignancy)
  • Teratoma
slide14

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

  • Hyperplastic and Colloid (adenomatous) nodules are the dominant type of nodules, and can be single or multiple.
  • Most are hypofunctioning and incompletely encapsulated. Cytologic studies usually reveal abundant colloid and benignfollicular cells, but hemorrhagic nodules or highlycellular aspirates may be difficult to differentiate from follicular cancer.
slide15

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

  • A diagnosis of a follicular or Hürthle cell tumor requires further evaluation and management, since the cytologic features of benign follicular or Hürthle cell tumors and low-grade follicular or Hürthle cell cancer are similar.
  • Benign from malignant nodules can only be distinguished by the presence or absence of capsular or vascular invasion on histologic examination of surgical specimens.
  • Follicular and Hürthle cell tumors have respectively a malignancy rate of 10% to 20%, that cannot generally be assessed adequately at FNAB .
slide16

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Malignant Nodules

  • Papillary Carcinoma (75-85%)
      • Pure papillary
      • Mixed papillary and follicular carcinoma
  • Follicular Carcinoma (20-25%)
      • Malignant adenoma
      • Hurthle cell carcinoma or oxyphil carcinoma
      • Clear-cell carcinoma
  • Medullary Carcinoma (5%)
  • Anaplastic Carcinoma (<5%)
  • Lymphoma
  • Metastatic tumor
slide17

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Nodules with sonographic apparence of cysts

  • Fifteen to 25 percent of all thyroid nodules are cystic.
  • High-resolution ultrasound has shown that most of the nodules initially considered to be cystic are complex lesions (solid-cystic).
  • Up to 15 percent are necrotic papillarycancers, and about 30 percent are hemorrhagic adenomas.
slide20

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Dectection of thyroid nodules

  • By chance during routine physical examination
  • By chance during US of the neck performed for other problem (i.e. carotid arteries, lymphnodes etc.)
  • In symptomatic patiens: local pain tenderness swelling dysphagia dysphonia hoarseness
slide21

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Clinical challenge: to identify which nodules are malignant

  • History and physical examination
  • Laboratory evaluation
  • Radionuclide scanning
  • Ultrasonography
  • FNA biopsy
  • UG-FNA biopsy
clinical elements for differential diagnosis
Benign

Family history of benign thyroid nodule or goiter or autoimmune thyroid disease.

Symptoms of hypothyroidism or hyperthyroidism.

Pain or tenderness associated with the nodule.

These factors do not exclude the presence of thyroid cancer.

Malignant

A family history of medullary or papillarythyroid cancer or of familial polyposis (Gardner\'s syndrome).

Age—the young (<20 years old) and the old (>70 years old) have the highest incidence of thyroid cancer.

Rapid tumorgrowth.

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Clinical elements for differential diagnosis
clinical elements for differential diagnosis23
Benign

Soft, smooth, mobile nodule.

Multinodular goiter without a dominant nodule.

These factors do not exclude the presence of thyroid cancer.

Malignant

Gender—the proportion of nodules that are malignant in males is double that in females.

Nodule plus dysphagia or hoarseness.

Firm, hard, irregular, and fixed nodule.

Presence of cervical lymphadenopathy.

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Clinical elements for differential diagnosis
clinical elements for differential diagnosis24
Malignant

History of external neck irradiation during childhood or adolescence (this factor also increases the incidence of nonmalignant thyroid nodular disease) or exposure to nuclear fallout.

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Clinical elements for differential diagnosis

Benign

slide25
Laboratory evaluation

In patients with a thyroid nodule, a sensitive thyroid stimulating hormone (TSH) assay should be done, at a minimum, to determine the presence of hyperthyroidism or hypothyroidism.

Serumcalcitonin should be measured when medullary thyroid carcinoma or MEN IIis suspected.

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

slide26
Radionuclide scanning

Aim: to identify hyperfunctioning nodules that are almost always benign.

Limits: lack of differentiating criteria for hypofunctioning nodules

Not all patients with thyroid nodules require nuclear imaging.

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

slide27

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Ultrasonography

  • Widespread use of ultrasound for examining any neck pathology has resulted in frequent recognition of thyroid nodules, that are too small to be palpated on clinical examination.
  • Usually, such nodules are < 1cm in largest diameter, they are typically asymptomatic, and are not associated with lymph nodes or other suggestions of malignancy.
  • Often incidentally found, such nodules produce a problem because of the difficulty in achieving a specific diagnosis, which is desired by the patient.
slide28
Ultrasonography

In a recent metanalysis (Ann Intern Med, 126:226-31, 1997.), the risk for malignancy in US incidentalomas ranged betwen 0.45% and 13%.

Large malignant nodules have beenreported to be missed by palpation.The greatest size of malignant non palpable nodules was 2.1 cm.

Theexistence of these nodules, detected by US exploration, suggeststhat a simple follow-up neck palpation, may not be the safest management strategy.

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

slide29
Ultrasonography

Currently no ultrasound criteria can distinguish benign from malignant thyroid nodules. However some features are suggestive for malignancy:

Microcalcification

Irregular or microlobulated margin

Hypoechogenicity

Intranodular blood flow pattern

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

slide30

NODULO ISOECOGENO CON AREA LIQUIDA INTERNA.

AL DOPPLER SEGNI DI VASCOLARIZZAZIONE PERIFERICA

slide36

PAPILLARY CARCINOMA

Intranodular Vascularization

slide40
FNA biopsy

FNAB has become the initial test, after clinical and/or US examination, because it is safe and inexpensive and leadsto a better selection of patients for surgery.

FNAB is now believed to be the most effective method available for distinguishing between benign and malignant thyroid nodules.

In this setting the FNAB sensitivity varies from 68 to 98% (mean, 83%) and specificity varies from 72 to 100% (mean, 92%).

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

slide41
FNA biopsy

Provided that an adequate specimen is obtained, three cytologicresults are possible: benign, malignant, and indeterminate (orsuspicious) findings.

A major problem diminishing the potential benefit of FNAB is the unskilled physician performing the biopsy or the inexperienced cytopathologist interpreting the specimens.

Even in skilled hands, however, approximately 10% of biopsy findings are nondiagnostic.

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

slide42
FNA biopsy

Repeated FNAB may be appropriate under several circumstances as follows: (1) when the lesion continues to enlarge; (2) when new clinical features develop that suggest possible malignancy; (3) when the previous cytologic diagnosis was indeterminate, or (4) when there is insufficient material for cytologic diagnosis.

Routine repetitive FNAB of lesions that were previously shown to be benign is rarely indicated.

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

slide43
UG-FNA biopsy

Ultrasound-guided FNAB (UG-FNAB) has emerged as an alternative to conventional FNAB for the diagnostic evaluation of nonpalpable nodules and for the repeat evaluation of nodules with previous nondiagnostic FNAB.

It is also an excellent method for the evaluation of complex nodules by precisely positioning the needle in the solid portion of these nodules.

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

slide44

FNAB OF SOLID THYROID NODULE

The arrow points to the needle

slide45
UG-FNA biopsy

In the literature, the sensitivity and specificity of UG-FNAB amounted to 79% and 85%, respectively.

UG-FNAB is possible for lesions smaller than 1 cm in size, but considering the probable benign nature of most of such lesions, a common alternative course is "observe" such lesions periodically.

Due to the high prevalence of USthyroid nodules, a systematic UG-FNAB performed on all nonpalpablenodules is not advisable.

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

slide46

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

PALPABLE THYROID NODULE

ULTRASONOGRAPHY

NOT PALPABLE THYROID NODULE

SINGLE NODULE  1 cm

or

DOMINANT NODULE

INCREASED RISK

YES

NO

NO

INCREASED RISK

YES

NO

YES

TSH < 0.03

CYST

YES

NO

NO

US SIGNS

FOR MALIGNANCY

YES

NO

YES

FNAB

UG-FNAB

COLD NODULE

NO

YES

HOT NODULE

NO

DIAGNOSTIC

YES

NO

YES

BENIGN

NO

INCREASED RISK

TREATMENT

SUSPICIOUS

TSH < 0.03

TSH > 4.5

YES

YES

FOLLICULAR LESION

NO

SURGERY

CANCER

FOLLOW UP

US and LAB

slide51

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Nodules with sonographic apparence of cysts

  • Bothbenign and malignant lesions may yield bloody fluid; clear,amber fluid usually indicates a benign lesion.
  • Cystic lesionsoften yield insufficient numbers of cells for diagnosis.
slide58

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

Benign Nodules

  • Hyperplastic nodules (within goitre)
  • Follicular Adenoma
        • Colloid variant
        • Hurthle cell variant
  • Papillary Adenoma (suspect for malignancy)
  • Teratoma
slide59

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

  • Papillary carcinomais usually recognizable in specimensobtained by fine-needle aspiration biopsy. The smears tend tobe cellular, and the cells have large nuclei with a pale ground-glassappearance.
  • Follicular carcinoma isa tumor most reliably identified by invasion of the capsuleor of vessels by malignant cells in surgical specimens (difficult diagnosis at fine-needle aspiration biopsy).
  • Medullary and Anaplastic carcinomasand Lymphomas (a particular risk in patients with Hashimoto\'sdisease) can ordinarily be identified by fine-needle aspirationbiopsy.
slide60

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

  • A diagnosis of a follicular or Hürthle cell tumor requires further evaluation and management, since the cytologic features of benign follicular or Hürthle cell tumors and low-grade follicular or Hürthle cell cancer are similar.
  • Benign from malignant nodules can only be distinguished by the presence or absence of capsular or vascular invasion on histologic examination of surgical specimens.
  • Follicular and Hürthle cell tumors, diagnosed by using FNAB, have respectively a malignancy rate of 10% to 20%, that cannot generally be assesed at FNAB .
slide61

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

  • Macrofollicular adenomas have no malignat potential
  • Although macrofollicular colloid adenomas have no malignantpotential, about 5 percent of microfollicular adenomas, 5 percentof Hurthle-cell adenomas, and 25 percent of embryonal adenomasarefollicular cancers.
slide62

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

  • A diagnosis of a follicular or Hürthle cell tumor requires further evaluation and management, since the cytologic features of benign follicular or Hürthle cell tumors and low-grade follicular or Hürthle cell cancer are similar.
  • Benign from malignant nodules can only be distinguished by the presence or absence of capsular or vascular invasion on histologic examination of surgical specimens.
  • Follicular and Hürthle cell tumors, diagnosed by using FNAB, have respectively a malignancy rate of 10% to 20%, that cannot generally be assesed at FNAB .
slide63

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

  • Colloid (adenomatous) nodules are the dominant type of nodules, and can be single or multiple.
  • Most are hypofunctioning and incompletely encapsulated. Cytologic studies usually reveal abundant colloid and benignfollicular cells, but hemorrhagic nodules or highlycellular aspirates may be difficult to differentiate from follicular cancer.
slide64

CLINICAL AND SONOGRAFIC APPROACH TO THE THYROID NODULE

  • Follicular adenomas, which are thought to be monoclonal tumors, tend to besingle lesions with well-developed fibrous capsules and a uniformhistologic structure distinct from the normal surrounding thyroid.They are classified according to the size or presence of folliclesand the degree of cellularity.
  • Although macrofollicular colloid adenomas have no malignantpotential, about 5 percent of microfollicular adenomas, 5 percentof Hurthle-cell adenomas, and 25 percent of embryonal adenomasarefollicular cancers.
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