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THYROID NODULES

THYROID NODULES

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THYROID NODULES

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  1. THYROIDNODULES LISA A. CICO, MSN, NP UPSTATE MEDICAL UNIVERSITY BREAST & ENDOCRINE SURGERY COORDINATOR THYROID CANCER PROGRAM SURGICAL COORDINATOR BREAST CANCER PROGRAM

  2. Comprehensive review of current diagnostic tools and imaging to assess thyroid nodules • Review American Thyroid Association, & National Comprehensive Cancer Network Guidelines for patients who develop thyroid nodules • Review common symptoms of patients with thyroid nodule OBJECTIVES Describe tools / diagnostic testing for assessment of the patient with a thyroid nodule(s) *Utilize national guidelines developed for patients with thyroid nodules *Describe some of the common symptoms of patients with thyroid nodules

  3. Obtaining appropriate imaging/diagnostic testing, and frequency • Overview of ultrasonographic thyroid terminology • Overview of Betheseda thyroid nodule pathology terminology • Obtaining appropriate personal and family history • Identify what patients require referral and to endocrine or surgery? • Briefly discuss appropriate follow up for the patient with thyroid cancer OBJECTIVES Identify which patients can safely be followed by PCP *Describe imaging/diagnostic modalities for following the patient with thyroid nodules *Identify those patients requiring referral to specialty *Identify which specialty to make an appropriate referral based on diagnostic, objective and symptomatic findings

  4. Definition of Thyroid Nodule “A discrete lesion within the thyroid gland that is palpably and/or ultrasonographically distinct from surrounding thyroid parenchyma” *ATA Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer (2006 & 2009 Task Force)

  5. Prevalence Rallison et al. JAMA 1975 Hogan et al. J Surg Res 2009

  6. “How was this nodule found?” Palpation with a physical exam Incidental finding on diagnostic work up Self detection Surveillance Work up for symptoms of hyper/hypothyroidism How was found  is it clinically relevant?

  7. Physical Examination of Thyroid Gland Visual inspection Palpation of thyroid, neck nodes, and supraclavicular nodes Fixed, mobile, soft, tender? Reflexes  why? HR, BP, weight

  8. Symptoms Usually NONE!! Occasionally painful, quick onset (cyst) Difficulty swallowing Hoarseness OR change in voice Shortness of breath (or difficulty swallowing) usually while supine OR hands raised over head (Pemberton’s Sign) Choking sensation  hyper/hypo thyroid

  9. Symptoms? Nodules Hyper/Hypo thyroid Difficulty swallowing Globus sensation Choking sensation Hyper-functioning nodule Hashimoto’s

  10. Pertinent History & PE in Evaluation of TNs History Physical Findings Head & neck irradiation Whole body irradiation Nuclear fallout Family history of thyroid malignancy Heredity Rapid growth Hoarseness Cervical /supraclavicular lymphadenopathy Fixation of nodule or gland > 4 cm Solitary

  11. Differential Diagnosis Multinodular Goiter Hashimoto’s Thyroiditis Cancer Lymphoma Solitary Thyroid Nodule Substernal Goiter

  12. Family HistoryofHereditary Diseases Cowden’s SyndromeFamilial PolyposisCarney ComplexMEN 2Werner Syndrome Thyroid malignancy

  13. Substernal Goiters Short neck Stocky build Usually incidental finding by CXR or CT Many times treated unsuccessfully for asthma

  14. ATA Guidelines 2009

  15. Ultrasound: The Gold Standard Anyone found to have, OR is suspected of having a nodule  evaluate by ultrasound!!

  16. Pure cystic (relatively rare) • Spongiform appearance in >50% of nodule volume (aggregration of multiple microcystic components) • Multiple (?) BENIGN CHARACTERISTICS

  17. BENIGN Septated cyst

  18. BENIGN Cyst

  19. BENIGN US (a, transverse; b, longitudinal) scans in 51-year-old woman show 2.4-cm well-defined mixed-echoic hypoechoic nodule (arrows) in right lobe of thyroid gland. Initial cytologic result was adenomatous hyperplasia, confirmed after 11 months at repeat aspiration

  20. High-risk history: History of thyroid cancer in one or more first degree relatives; history of external beam radiation as a child; exposure to ionizing radiation in childhood or adolescence; prior hemithyroidectomy with discovery of thyroid cancer, 18FDG avidity on PET scanning; MEN2/FMTC-associated RET protooncogene mutation, calcitonin >100 pg/mL. MEN, multiple endocrine neoplasia; FMTC, familial medullary thyroid cancer. • Suspicious features: microcalcifications; hypoechoic; increased nodular vascularity; infiltrative margins; taller than wide on transverse view. • FNA cytology may be obtained from the abnormal lymph node in lieu of the thyroid nodule. • Sonographic monitoring without biopsy may be an acceptable alternative ULTRASOUND CHARACTERISTIC CONSIDERATIONS

  21. Hypo-echogenicity compared to normal thyroid parenchyma • Increased intra-nodular vascularity • Irregular infiltrative margins • Presence of micro-calcifications • Absent halo • Shape taller than width in transverse dimension • Nodules > 4 cm • Solitary • Difficulty swallowing ATA Guidelines 2009 SUSPICIOUS CHARACTERISTICS

  22. Suspicious Hypoechoic

  23. Suspicious Increased vascularity

  24. SUSPICIOUS Increased vascularity

  25. SUSPICIOUS CalcificationsPoorly defined, irregular margins

  26. SUSPICIOUS Solid

  27. Multiple Thyroid Nodules • FNA  what nodule?? • > 1 cm • Suspicious features • Dominant / largest one

  28. FNA of Palpable Nodule Palpation? Ultrasound? What nodule(s) do you FNA? What nodule(s) do you FNA?

  29. TN with suppressed TSH UPTAKE SCAN to assess autonomous nodule Compare to U/S  what is the correlation with Uptake  FNA  consider in non - functioning or isofunctioning with suspicious features

  30. FNA Only GOLD standard for proof of malignancy without surgical pathology

  31. FNA False Negative False Positive false-negative rate of up to 5% with FNA which may be even higher with nodules >4 cm ??

  32. Is Size a Predictor of Malignancy? < 1 cm > 1 cm NO ATA Guidelines 2009 NO

  33. FNA Results Nondiagnostic Benign Atypia of Undetermined Significance (AUS) Suspicious for a Follicular Neoplasm/Follicular Neoplasm Suspicious for Malignancy Malignant Bethesda System for Reporting Thyroid Cytopathology

  34. TSH • Free T4 • TPO in suspected thyroiditis • TG  tumor marker in PTC, FTC, HTC • Calcitonin suspected MTC or in follow up of MTC Lab Work TSH Free T4 T4 T3 Free T3 TPO Thyroglobulin (TG) Calcitonin

  35. TABLE 3. SONOGRAPHIC AND CLINICAL FEATURES OF THYROID NODULES AND RECOMMENDATIONS FOR FNA 

  36. RAI Uptake Scan ONLY IN HYPERTHYROID Cold Nodule - 10% incidence of being CA

  37. Thyroid Cancers • From 2005 to 2009, incidence rates increased by 5.6% per year in men and 7.0% per year in women, making thyroid cancer the fastest increasing cancer in both men and women • Most common endocrine cancer

  38. Projected Cases of Thyroid Cancer • 60, 220 new cases are estimated for 2013 • 45, 310 female • 14, 910 male • 1,850 deaths projected for 2013 • 1,040 female • 810 male • Death rate 0.5 per 100,000 in both male and females

  39. AGE & INCIDENCE AMCERICAN CANCER SOCIETY / NCCN/ SEER • Diagnosed at a younger age then most adult cancers • Median age at diagnosis was 50 years from 2005-2009 • 2 out of 3 cases are < 55 years old • Thyroid cancer in the pediatric population • Pediatric Incidence 2.0 per 1 million in children <15 yrs and 17.6 per 1 million in children 15-19 yrs • 2% occur in children and teens

  40. Surgery • Radioactive Iodine Ablation • Levothyroxine • Monitor with WBS / ultrasound TREATMENT FOR THYROID CANCER

  41. CHILDREN& PREGNANT WOMEN When do you operate???

  42. Complications of Thyroid Surgery Recurrent laryngeal nerve injury Hypo parathyroidism Bleeding Infection