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Thyroid Nodules. Hollis Moye Ray, MD SEAHEC Internal Medicine June 3, 2011. Thyroid Nodules. Palpable: 4 – 7% Detected on ultrasound: 20 – 65% More common: aging, women Cancer risk: 5 – 10%. Benign Causes. Multinodular (sporadic) goiter ("colloid adenoma")

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thyroid nodules

Thyroid Nodules

Hollis Moye Ray, MD

SEAHEC Internal Medicine

June 3, 2011

thyroid nodules1
Thyroid Nodules
  • Palpable: 4 – 7%
  • Detected on ultrasound: 20 – 65%
  • More common: aging, women
  • Cancer risk: 5 – 10%
benign causes
Benign Causes
  • Multinodular (sporadic) goiter ("colloid adenoma")
  • Hashimoto's (chronic lymphocytic) thyroiditis
  • Cysts: colloid, simple, or hemorrhagic
  • Follicular adenomas
    • Macrofollicular adenomas
    • Microfollicular or cellular adenomas
  • Hurthle-cell (oxyphil-cell) adenomas
    • Macro- or microfollicular patterns
malignant causes
Malignant Causes
  • Papillary carcinoma
  • Follicular carcinoma
    • Minimally or widely invasive
    • Oxyphilic (Hurthle-cell) type
  • Medullary carcinoma
  • Anaplastic carcinoma
  • Primary thyroid lymphoma
  • Metastatic carcinoma (Breast, renal cell, others)
thyroid cancer
Thyroid Cancer
  • Lower prevalence in
    • “Hot nodules”
    • Multinodular goiters
  • Higher prevalence in
    • Male
    • Children
    • Adults < 20 or > 60 years old
    • History of head/neck irradiation
    • Family history of thyroid cancer
    • Rapid growth
    • Hoarseness
evaluation
Evaluation
  • History
    • Rapid growth?
    • Family history?
    • Irradiation?
    • Cancer syndromes?
  • Physical Examination
    • Fixed, hard mass
    • Vocal cord paralysis
    • Cervical lymphadenopathy
    • Obstructive symptoms
evaluation1
Evaluation
  • TSH
    • Low  Thyroid scintigraphy
    • Not low  US to select for FNA biopsy; evaluate for hypothyroidism
  • Ultrasound
    • High risk of cancer: hypoechoic, microcalcifications, increased central vascularity, irregular margins, taller than wide, documented enlargement, size >3cm
    • Low risk of cancer: hyperechoic, peripheral vascularity, pure cyst, comet-tail shadowing
evaluation2
Evaluation
  • Thyroid Scintigraphy
    • Select nodules for FNA
    • Uses radioisotope to detect “hot” and “cold”
      • Most benign and virtually all malignant thyroid nodules are “cold” (take up less/no isotope)
      • Helps to guide FNA biopsy
evaluation3
Evaluation
  • FNA biopsy
    • Procedure of choice
    • Safe and simple
    • 90 – 95% of sensitive
    • False negative rate only 1 – 11%
    • What to biopsy? Basically all >1cm EXCEPT
      • Spongiform nodules < 2cm
      • Purely cystic nodules
other lab tests
Other Lab Tests
  • Calcitonin
    • Controversial – consider if hypercalcemic, family history, or MEN type 2s
  • Anti-TPO Antibodies
    • Only recommended if suspicious for autoimmune disease (i.e. Hashimoto’s)
  • Thyroglobulin
    • Does not discriminate benign from malignant
    • Can be useful s/p thyroidectomy or ablation
diagnostic categories
Diagnostic Categories
  • Benign —macrofollicular or adenomatoid/hyperplastic nodules, colloid adenomas, nodular goiter, and Hashimoto's thyroiditis.
  • Follicular lesion of undetermined significance — lesions with atypical cells, or mixed macro- and microfollicular nodules.
  • Follicular neoplasm —microfollicular nodules (i.e. Hurthle cell lesions)
  • Suspicious for malignancy
  • Malignant
  • Nondiagnostic
benign nodules
Benign Nodules
  • Macrofollicular or adenomatoid/hyperplastic nodules, colloid adenomas, nodular goiter, and Hashimoto's thyroiditis
  • Followed without surgery
  • T4 therapy (?) – MAY decrease size, prevent further growth
  • Periodic ultrasound monitoring
  • Repeat aspiration if change in size, texture, or new symptoms
follicular lesion of undetermined significance
Follicular lesion of undetermined significance
  • Nodules with atypical cells, nodules w/ both macro and microfollicular features
  • Risk of malignancy: 5-10%
  • Excision: no definite consensus
    • ? Follow with aspiration - if atypical cells found, then excise
follicular neoplasm microfollicular
Follicular neoplasm (microfollicular)
  • If TSH normal – typically surgery
  • If TSH low - perform thyroid scintigraphy
    • If hyperthyroid – radioiodine tx or surgery
    • Hyperfunctioning (autonomous) – followed
    • Non-autonomous – surgery w/path eval for vascular or capsular invasion
      • 15 – 25% cancerous
malignancy surgery
Malignancy = Surgery*
  • Papillary and Follicular - well-differentiated and good prognosis if in early stage
  • Medullary
  • Anaplastic – poorly differentiated and aggressive
  • Metastatic
  • Suspicious for malignancy – surgery
    • 50 – 75% malignant
  • *Thyroid lymphoma – the exception
    • Radiation, not surgery!
management of other path findings
Management of other path findings
  • Nondiagnostic FNA – repeat under US
  • Cystic thyroid nodules – followed or excised for therapeutic reasons if recurrent
  • Ablation – benign, autonomous, or cystic
    • Inject ethanol or other sclerosing agent
    • Controversial (complications, prolonged pain)
references
References
  • MKSAP 15: Endocrinology and Metabolism
  • Harrison’s Internal Medicine
  • UpToDate: Thyroid Nodules