approach to the lumpy thyroid katherine a kovacs md msc frcpc
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Approach to the Lumpy Thyroid Katherine A. Kovacs, MD MSc FRCPC. Setting of Thyroid Nodule Discovery. Routine neck palpation by physician Self-examination by patient Incidental finding during radiological procedure. Clinical Relevance of Nodule Discovery. Potential malignancy

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setting of thyroid nodule discovery
Setting of Thyroid Nodule Discovery
  • Routine neck palpation by physician
  • Self-examination by patient
  • Incidental finding during radiological procedure
clinical relevance of nodule discovery
Clinical Relevance of Nodule Discovery
  • Potential malignancy
  • Clue to underlying thyroid pathology (i.e., Hashimoto’s thyroiditis)
  • Potential for thyroid dysfunction
  • Potential for compressive symptoms
etiology of thyroid nodules
BENIGN:

Colloid nodule

Hashimoto thyroiditis

Simple or hemorrhagic cyst

Follicular adenoma

Subacute thyroiditis

MALIGNANT:

Follicular cell-derived carcinoma

Papillary

Follicular

Anaplastic

C-cell-derived carcinoma

Medullary

Thyroid lymphoma

Metastatic carcinoma

Etiology of Thyroid Nodules
evaluation history
EVALUATIONHistory
  • Thyroid function status
  • Associated pain
  • Compressive symptoms/Cosmetic
  • Establish risk factors for malignant disease
    • age < 30 or > 60; male sex
    • exposure to ionizing radiation
    • family history
    • rapid growth
evaluation physical examination
EVALUATIONPhysical Examination
  • Number, size & consistency of lumps
  • Mobility
  • Tenderness
  • Presence of lymphadenopathy
  • Compressive signs
evaluation tsh
EVALUATIONTSH
  • Low-normal or suppressed TSH (< 0.5)
    • autonomous nodule(s)
    • overt hyperthyroidism

indication for radioisotope scan (hot nodule, especially by I123, almost always benign)

  • High-normal or elevated TSH
    • Hashimoto’s thyroiditis
    • Overt hypothyroidism

higher risk of malignancy

evaluation ultrasound
EVALUATIONUltrasound
  • Most sensitive test to detect thyroid nodules and recommended for all patients identified to have one or more thyroid nodules
  • Assess size & number of nodules
  • Assess for sonographic characteristics that are higher risk for malignancy
  • Select nodule(s) for biopsy
  • Accuracy dependent on expertise
mng vs solitary nodule
MNG vs Solitary Nodule
  • Risk of cancer is the same in MNGs vs glands with solitary nodule
  • Selection for FNA should be based on U/S features rather than on size or clinically “dominant” nodules
evaluation consider other radiology
EVALUATIONConsider Other Radiology
  • Technetium or I123 scan
    • most nodules are cold; AVOID as a routine
    • useful when suspecting hot nodule (low TSH)
  • CT thyroid/chest
    • useful in assessing retrosternal goitre
indications for u s guided fna
Indications for U/S-guided FNA
  • Palpation-guided FNA non-diagnostic
  • Complex (solid/cystic) nodule
  • Palpable small nodule (< 1.5 cm)
  • Impalpable incidentaloma
  • Abnormal cervical nodes
  • Nodule with suspicious U/S features
management treatment surveillance
MANAGEMENTTreatment/Surveillance
  • Toxic Adenoma/MNG
    • surgery, high-dose RI or alcohol/laser ablation
  • Follicular Neoplasm
    • surgery for definitive diagnosis or close F/U
  • Carcinoma
    • surgery, RI PRN, & T4 suppress to TSH < 0.1
  • Others
    • palpation, TSH, ?ultrasound, rebiopsy PRN
    • controversial: T4 suppression to TSH 0.1-0.4
unanswered questions
Unanswered Questions
  • Sufficient length of time to follow a nodule and maximum growth allowed to conclude that it is benign
case 1 toxic adenoma
Case 1: Toxic Adenoma
  • 32-yr-old female manager of music store
  • c/o 2-3 yrs panic attacks, palpitations; 1 yr goitre, irregular menses, insomnia; 6-8 mo fatigue, muscle weakness; few weeks hand tremor, weight gain
  • medications: none
  • no FH thyroid cancer
case 1 cont d
Case 1 (cont’d)
  • O/E:
    • normal weight, BP 138/70, HR 110 (regular)
    • easily visible goitre with ovoid mass in L lobe (4x normal size lobe); R lobe slightly palpable with tiny nodule
    • hands warm and sweaty
    • proximal muscle weakness
case 1 cont d1
Case 1 (cont’d)
  • Investigations:
    • TSH < 0.05, FT4 46 (Jan. 19)
    • Nuclear thyroid scan: 4.3 x 3 cm ovoid mass in L lobe with markedly increased uptake; mostly absent uptake in R lobe; 24 hr thyroid uptake 36 % (Feb. 2)
    • TSH 0.03, FT4 53.3, HCG < 0.5 (when I saw Mar. 19)
case 1 cont d2
Case 1 (cont’d)
  • Treatment:
    • high-dose radioiodine
  • Response:
    • marked shrinkage
    • induction of biochemical hypothyroidism
case 2 multinodular goitre
Case 2: Multinodular Goitre
  • 34-yr-old taxi driver
  • large goitre x 9 years, gradual enlargement
  • pressure sensation when supine, nocturnal dry cough, frequent choking
  • mild fatigue, tendency to heat intolerance, gaining weight
  • medications: none
  • no FH thyroid disease
case 2 cont d
Case 2 (cont’d)
  • O/E:
    • moderately overweight, BP 148/92, HR 90 (regular)
    • easily visible irregular goitre, roughly 8x normal size
    • hands very warm
case 2 cont d1
Case 2 (cont’d)
  • Investigations:
    • TSH 0.2, FT4 15.8
    • U/S: diffusely enlarged heterogeneous thyroid
case 2 cont d2
Case 2 (cont’d)
  • Treatment:
    • high-dose radioiodine 29 mC on 3 occasions
  • Response:
    • modest shrinkage
    • induction of biochemical hypothyroidism
case 3 colloid nodule
Case 3: Colloid Nodule
  • 54-yr-old male chief of security
  • lump in thyroid detected at routine physical
  • no compressive symptoms
  • no symptoms of thyroid dysfunction
  • no hx significant radiation exposure
  • no FH thyroid cancer; mom - goitre
case 3 cont d
Case 3 (cont’d)
  • O/E:
    • mildly overweight, BP 160/92, HR 75 (regular)
    • easily visible, mobile L thyroid mass
    • no lymphadenopathy
    • clinically euthyroid
case 3 cont d1
Case 3 (cont’d)
  • Investigations:
    • TSH 1.27
    • U/S: solitary 3.4 cm inferior L thyroid nodule
    • Nuclear thyroid scan: solitary cold nodule
    • FNA x 3: unsatisfactory (cyst contents, inflammatory cells, few epithelial cells)
        • shrunk after procedure
    • U/S-guided FNA: cyst contents, fragment of thyroid tissue with normal-looking follicles
    • repeated after nodule grew - colloid nodule
case 4 follicular neoplasm
Case 4: Follicular Neoplasm
  • 46-yr-old woman on disability
  • incidental thyroid nodule detected during CT pulm/angio for pulmonary emboli
  • dysphagia to liquids & solids
  • irritability, weight gain, fatigue, constipation
  • no history of significant radiation exposure
  • no FH thyroid cancer
case 4 cont d
Case 4 (cont’d)
  • O/E:
    • moderately overweight, BP 120/68, HR 60 (regular)
    • easily visible, mobile R thyroid mass
    • no lymphadenopathy
    • clinically euthyroid
case 4 cont d1
Case 4 (cont’d)
  • Investigations:
    • TSH 1.11
    • U/S: solitary 3.8 cm R complex thyroid nodule
    • FNA: few groups of follicular epithelial cells favouring neoplasm or colloid nodule
    • Pathology on resection: follicular adenoma
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