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In the Name of God. Thyroid Nodules. Nodular thyroid disease is a common problem Five percent are likely to be malignant Assessment for malignant potential is important. Prevalence and Incidence of Thyroid Nodules and Cancer. Prevalence Nodule % Clinical 4-7 Radiological 40

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thyroid nodules
Thyroid Nodules
  • Nodular thyroid disease is a common problem
  • Five percent are likely to be malignant
  • Assessment for malignant potential is important
prevalence and incidence of thyroid nodules and cancer
Prevalence and Incidence of Thyroid Nodules and Cancer
  • Prevalence
    • Nodule %
      • Clinical 4-7
      • Radiological 40
      • Autopsy 50
    • Carcinoma
      • Autopsy 5.7
      • Gharib H. Current evaluation of thyroid nodules. Trends Endocrinol Metab. 1994;5:365-369.
thyroid nodular disease
Thyroid Nodular Disease
  • Thyroid gland nodules are common in the general population
  • Palpable nodules occur in approximately 5% of the US population, mainly in women
  • Most thyroid nodules are benign
    • Less than 5% are malignant
    • Only 8% to 10% of patients with thyroid nodules have thyroid cancer
multinodular goiter mng
Multinodular Goiter (MNG)
  • MNG is an enlarged thyroid gland containing multiple nodules
    • The thyroid gland becomes more nodular with increasing age
    • In MNG, nodules typically vary in size
    • Most MNGs are asymptomatic
  • MNG may be toxic or nontoxic
    • Toxic MNG occurs when multiple sites of autonomous nodule hyperfunction develop, resulting in thyrotoxicosis
    • Toxic MNG is more common in the elderly
prevalence and incidence of thyroid nodules and cancer1
Prevalence and Incidence of Thyroid Nodules and Cancer
  • Incidence %
    • Nodule 0.1
    • Carcinoma 0.004
nodular thyroid disease
Nodular Thyroid Disease
  • The annual incidence of thyroid nodules is approximately 0.1%
  • The annual incidence of thyroid carcinoma is 0.004%
  • Thus, 1 in 20 nodules (5%) is likely to be malignant
thyroid lesions that may present as a nodule
Thyroid Lesions That May Present As a Nodule
  • Adenoma
  • Carcinoma
  • Acute hemorrhage into thyroid
  • Multinodular goiter
  • Thyroiditis
thyroid lesions that may present as a nodule1
Thyroid Lesions That May Present As a Nodule
  • Effect of prior operation or 131-I therapy
  • Thyroid hemi agenesis
  • Cyst
  • Metastasis
nonthyroidal lesions that may present as a nodule
Nonthyroidal Lesions That May Present As a Nodule
  • Parathyroid adenoma or cyst
  • Thyroglossal cyst
  • Cystic hygroma
slide13

Thyroid CancerStatistics

  • Incidence rose 3.8% per year, faster than any other malignancy between 1992-2001
  • 8th most common cancer in women
  • Annual incidence 25,000; deaths 1,500
  • Prevalence 300,000

CP1216465-4

slide14

Thyroid cancer types

Follicular cell origin

C cell origin

MTC

PTC

FTC

HCC

ATC

Sporadic

Familial

FMTC

MEN2A

MEN2B

CP1216465-5

slide15

Medullary

4%

Hurthle

1%

Anaplastic

1%

Follicular

9%

Papillary

85%

Thyroid CancerRelative Frequency

*National Cancer Database: SEER Registry

CP1216465-6

thyroid cancer incidence and mortality

Incidence: Males

Incidence: Females

Death: Females

Death: Males

Thyroid CancerIncidence and Mortality

Rates/100,000

Age at diagnosis (yr)

CP1216465-7

slide17

Size

  • Type
  • Invasion
  • RAI uptake
  • Metastasis
  • Dx delay
  • Tx
  • RAI Rx
  • Follow-up
  • Age
  • Sex
  • RöRx

Patient

Tumor

Rx

Outcome

CP1216465-8

slide18

Invasive

Microcarcinoma

PTC

CP1216465-9

pathological classification of thyroid neoplasms
Pathological Classification of Thyroid Neoplasms
  • Benign
  • Adenoma
    • Follicular
      • A. Colloid variant
      • B. Embryonal
      • C. Fetal
      • D. Hurthle cell variant
  • Teratoma
pathological classification of thyroid carcinoma
Pathological Classification of Thyroid Carcinoma
  • Papillary adenocarcinoma
    • Pure papillary
    • Mixed papillary and follicular
    • Micro carcinoma
    • Diffuse sclerosing
pathological classification of thyroid carcinoma1
Pathological Classification of Thyroid Carcinoma
  • Follicular carcinoma
    • Pure follicular
    • Clear cell carcinoma
    • Hurthle cell carcinoma
pathological classification of thyroid neoplasms1
Pathological Classification of Thyroid Neoplasms
  • Medullary carcinoma
  • Other malignant tumors
    • Lymphoma
    • Metastatic tumor
    • Epidermoid carcinoma
thyroid nodule history taking
Thyroid NoduleHistory Taking
  • Past history of radiation, surgery?
  • Family history of goiter, MEA, or medullary cancer
  • Symptoms of hyper- or hypothyroidism?
  • Cardiac symptoms?
  • Degree of patient’s concern?
factors which increase the possibility that a nodule is malignant
Factors Which Increase the Possibility That a Nodule Is Malignant
  • Recent onset and growth
  • Compression
  • Young age, male sex
  • Familial incidence
  • Radiation exposure
slide26

Neural crest

Thyroid

C cells

Autonomic ganglia GI tract

MTC Origin

Adrenal

medulla

CP1216465-45

mtc unique features
Produces calcitonin

Does not concentrate 131I

LN metastasis occur early

Patients with macrometastasis have poor prognosis

Surgery is the only effective Tx

MTCUnique Features

CP1216465-46

slide28

MEN 2B

3%

FMTC

12%

MEN 2A

10%

Sporadic

75%

MTCSubtypes

CP1216465-47

slide29

Face

Eyelids

Lips

Clinical Features and MEN-2B

  • Marfanoid features
  • Ganglioneuroma

CP1216465-50

multiple endocrine neoplasia men
Multiple Endocrine Neoplasia (MEN)
  • Multiple clinical presentations
  • Multiple family members affected
  • Multiple endocrine glands involved
  • Multicentric lesions within a gland
  • Multiple pathologic processes (hyperplasia, adenoma, carcinoma)
  • Hereditary disorder

CP1216465-51

slide31

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

RET Characteristics

Extracellular

MEN2A FMTC MEN2B

532 : duplication de nucléotides

Cadherin-like domain

Cys 609

Cys 611

Cys 618

Cys 620

Cys 634

Cys 609

Cys 611

Cys 618

Cys 620

Cys 634

Cysteine-rich region

Transmembrane domain

Glu 768

790

791

Tyrosine kinase domain

Val 804

883

Met 918

Ser 891

Intracellular

RET protein

RET exons

Clin Endocrinol 61:299, 2004

CP1216465-52

thyroid nodule examination
Thyroid NoduleExamination
  • Thyrotoxic, euthyroid, hypo?
  • Single nodule or multinodular?
  • Hard, fixed node?
  • Voice, stridor, dysphagia?
factors which increase the possibility that a nodule is malignant1
Factors Which Increase the Possibility That a Nodule Is Malignant.
  • Hard consistency
  • Fixation
  • Enlarged lymph nodes
  • Vocal cord paralysis
diagnosis of thyroid nodules
Diagnosis of Thyroid Nodules
  • Imaging studies
  • Morphologic studies
  • Laboratory studies
thyroid scan
Thyroid Scan
  • Most functioning nodules are benign, and this is the most useful finding.
  • Most cancers are “cold”, but so are most benign nodules.
thyroid incidentalomas
Thyroid Incidentalomas
  • High-resolution ultrasonography has made it possible to detect many non-palpable nodules, or “incidentalomas” in the thyroid.
thyroid ultrasound findings in favor of malignant nodules
Thyroid Ultrasound Findings in Favor of Malignant Nodules
  • Hypoechoic lesions
  • Irregular margins
  • Presence of microcalcifications
  • Absence of halo
  • Internal or central blood flow
thyroid ultrasound findings in favor of malignant nodules low suspicion
Thyroid Ultrasound Findings in Favor of Malignant Nodules: Low Suspicion
  • Echo-free cyctic lesion
  • Homogeneously hyperechoic lesion
slide45

Benign nodule

PTC

Benign node

PTC node

CP1216465-35

cytopathologic diagnostic categories for thyroid fine needle aspiration fna specimens
Cytopathologic Diagnostic Categories for Thyroid Fine-needle Aspiration (FNA) Specimens
  • Diagnostic (satisfactory)
    • Benign (negative)
    • Suspicious (indeterminate)
    • Malignant (positive)
  • Nondiagnostic (unsatisfactory)
cytopathologic diagnostic categories for thyroid fna benign
Cytopathologic Diagnostic Categories for Thyroid FNA- Benign
  • Benign thyroid nodule
  • Hashimoto’s thyroiditis
  • Subacute thyroiditis
  • Cyst
cytopathologic diagnostic categories for thyroid fna suspicious
Cytopathologic Diagnostic Categories for Thyroid FNA- Suspicious
  • Follicular neoplasm
  • Hurthle cell neoplasm
  • Other findings suggestive nut not diagnostic of a malignant lesion
cytopathologic diagnostic categories for thyroid fna malignant
Cytopathologic Diagnostic Categories for Thyroid FNA- Malignant
  • Papillary carcinoma
  • Medullary carcinoma
  • Anaplastic carcinoma
  • Metastatic carcinoma
  • Lymphoma
cytopathologic diagnostic categories for thyroid fna nondiagnostic
Cytopathologic Diagnostic Categories for Thyroid FNA- Nondiagnostic
  • Technical considerations such as excessive air- drying or insufficient specimens can result in a nondiagnostic interpretation.
comparison between the results of the current and previous study of thyroid nodules
Comparison Between the Results of the Current and Previous Studyof Thyroid Nodules

Patients

current previous

558 patients 765 patients 1991-1999 1979-1989

  • Nodular goiter 59.5%82%
  • Carcinoma 30.5% 10.2%
  • Adenoma 7.7% 6.5%
  • Thyroiditis 2.3% 1%
  • Miscellaneous

558

30.5%

10.2%

0.5%

-

thyroid nodule case 2
A 41-year-old woman is referred for evaluation of a thyroid nodule. The patient’s history dates back 5 years, when a thyroid nodule was discovered in the left side of her thyroid.

Routine thyroid function tests were normal. A thyroid ultrasound revealed the nodule to be 2.6 cm and solid. A fine needle aspiration biopsy was “indeterminate”.

Thyroid NoduleCase 2
thyroid nodule case 2 continued
She was placed on L-thyroxine suppressive therapy, but she was not consistent in taking her medications.The physician attempted a repeat FNA 2 weeks ago.

The results of this biopsy were “ follicular neoplasm.” The physician advised surgery, but the patient has insisted upon a second opinion.

Thyroid NoduleCase 2 (Continued)
thyroid nodule case 2 continued1
On examination, the patient is well developed, well nourished, having a BP of 130/70 and a PR of 88 beats per minute. The thyroid reveals a 2.5-cm smooth lesion in the left lobe of the

that moves easily with swallowing. The patient’s skin is warm and dry. There is no tremor nor other peripheral signs of hypothyroidism or hyperthyroidism.

Thyroid NoduleCase 2 (Continued)
thyroid nodule case 2 ouestions
Thyroid NoduleCase 2 (Ouestions)
  • 1- what is her diagnosis?
  • 2- what would be your next diagnostic step?
  • 3- based on the results of these studies, would you do additional thyroid tests?
  • 4- what is the natural history of this disorder?
goiters thyroid condition
Goiters Thyroid Condition
  • Nontoxic diffuse and nodular goiter
  • Diffuse toxic goiter
  • Thyroiditis
  • Benign neoplasms
  • Thyroid cancer
disorders of the thyroid gland
Disorders of the Thyroid Gland
  • Nontoxic diffuse and nodular goiter
  • Hypothyroidism
  • Thyrotoxicosis
  • Thyroiditis
  • Benign neoplasms
  • Thyroid cancer
types of thyroiditis
Types of Thyroiditis
  • Hashimoto’s
  • Postpartum
  • Silent or painless
  • Subacute
  • Suppurative
  • Reidel’s
thyroid disease with immunologic aspects
Thyroid Disease With Immunologic Aspects
  • Autoimmune thyrotoxicosis (Graves’ disease)
  • Autoimmune thyroiditis
    • Hashimoto’s thyroiditis
    • Lymphocytic thyroiditis of childhood and adolescence
    • Postpartum thyroiditis
    • Atrophic thyroiditis
    • Some cases of silent thyroiditis
various clinical presentations of thyroiditis syndromes
Various Clinical Presentations of Thyroiditis Syndromes
  • Goiter
  • Hypothyroidism
  • Thyrotoxicosis
  • Pain in the neck
  • Thyroid nodule
  • Suppuration of the thyroid
phases of subacute thyroiditis
Phases of Subacute Thyroiditis
  • Premorbid
  • Thyrotoxic: thyroid pain, fever
    • Decreased radioactive iodine uptake, increased ESR
    • Increased serum T4, decreased TSH
slide70

RAIU

TSH

ESR=100

phases of subacute thyroiditis1
Phases of Subacute Thyroiditis
  • Hypothyroid
  • Post-morbid: normalization of radioactive iodine uptake, ESR, serum T4, and TSH
treatment of subacute thyroiditis
Treatment of Subacute Thyroiditis
  • Symptomatic: NSAIDS or a glucocorticoid
  • Beta-blockers indicated if there are signs of thyrotoxicosis
  • Levothyroxine may be given during hypothyroid phase
characteristics of hashimoto s thyroiditis
Characteristics of Hashimoto’s Thyroiditis
  • Thyroid gland moderately enlarged, firm, bosselated
  • Circulating antithyroid autoantibodies
  • Positive perchlorate discharge test
  • Increased serum TSH
  • More common in iodine sufficient areas
slide77

The specimen in Panel A shows typical changes of Hashimoto’s thyroiditis, including lymphoid follicles with germinal centers (G), small lymphocytes and plasma cells (P), thyroid follicles with Hürthle-cell metaplasia

(H), and minimal colloid material (C).

goiter and subclinical hypothyroidism in a postpartum woman
A 27 year old woman is found to have a small diffuse goiter 4 months after delivery of an infant. She is tired, but otherwise well, and PE reveals only diffuse goiter.

Her serum T4 is 6.1 mcg/dl, T3RU 26%, and TSH 28.2 mU/L.

Goiter and Subclinical Hypothyroidism in a Postpartum Woman
goiter and subclinical hypothyroidism in a postpartum woman1
Goiter and Subclinical Hypothyroidism in a Postpartum Woman
  • What should be done for this patient?
  • Would you do anything different if she was nursing her infant, or if she had had palpitations, tremor, increased perspiration and irritability for several weeks about one month earlier?
silent thyroiditis
Silent Thyroiditis
  • Clinical course similar to subacute thyroiditis
  • There is little or no thyroid tenderness
  • A brief phase of thyrotoxicosis followed by hypothyroidism and then resolution
silent thyroiditis1
Silent Thyroiditis
  • A proportion pf patients develop permanent hypothyroidism
  • RAIU suppressed, normal ESR, presence of anti-TPO antibodies
postpartum thyroiditis
Postpartum Thyroiditis
  • May present as hypothyroidism or thyrotoxicosis
  • Evolves into euthyroidism in most cases
  • Usually painless
  • Most patients have positive antithyroglobulin or antimicrosomal antibodies
slide87

The specimen in Panel B, obtained from a patient with painless postpartum thyroiditis, shows normal follicles with minimal Hürthle-cell metaplasia (H) and dense lymphocytic infiltration

(WG) without germinal centers.

riedel s thyroiditis
Riedel’s Thyroiditis
  • Rare disorder usually affecting middle-aged women
  • Likely autoimmune etiology
  • Fibrous tissue replaces thyroid gland
  • Patients present with a rapidly enlarging hard neck mass