THYROIDNODULES LISA A. CICO, MSN, NP UPSTATE MEDICAL UNIVERSITY BREAST & ENDOCRINE SURGERY COORDINATOR THYROID CANCER PROGRAM SURGICAL COORDINATOR BREAST CANCER PROGRAM
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
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
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)
Prevalence Rallison et al. JAMA 1975 Hogan et al. J Surg Res 2009
“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?
Physical Examination of Thyroid Gland Visual inspection Palpation of thyroid, neck nodes, and supraclavicular nodes Fixed, mobile, soft, tender? Reflexes why? HR, BP, weight
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
Symptoms? Nodules Hyper/Hypo thyroid Difficulty swallowing Globus sensation Choking sensation Hyper-functioning nodule Hashimoto’s
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
Differential Diagnosis Multinodular Goiter Hashimoto’s Thyroiditis Cancer Lymphoma Solitary Thyroid Nodule Substernal Goiter
Family HistoryofHereditary Diseases Cowden’s SyndromeFamilial PolyposisCarney ComplexMEN 2Werner Syndrome Thyroid malignancy
Substernal Goiters Short neck Stocky build Usually incidental finding by CXR or CT Many times treated unsuccessfully for asthma
Ultrasound: The Gold Standard Anyone found to have, OR is suspected of having a nodule evaluate by ultrasound!!
Pure cystic (relatively rare) • Spongiform appearance in >50% of nodule volume (aggregration of multiple microcystic components) • Multiple (?) BENIGN CHARACTERISTICS
BENIGN Septated cyst
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
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
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
Suspicious Increased vascularity
SUSPICIOUS Increased vascularity
SUSPICIOUS CalcificationsPoorly defined, irregular margins
Multiple Thyroid Nodules • FNA what nodule?? • > 1 cm • Suspicious features • Dominant / largest one
FNA of Palpable Nodule Palpation? Ultrasound? What nodule(s) do you FNA? What nodule(s) do you FNA?
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
FNA Only GOLD standard for proof of malignancy without surgical pathology
FNA False Negative False Positive false-negative rate of up to 5% with FNA which may be even higher with nodules >4 cm ??
Is Size a Predictor of Malignancy? < 1 cm > 1 cm NO ATA Guidelines 2009 NO
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
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
TABLE 3. SONOGRAPHIC AND CLINICAL FEATURES OF THYROID NODULES AND RECOMMENDATIONS FOR FNA
RAI Uptake Scan ONLY IN HYPERTHYROID Cold Nodule - 10% incidence of being CA
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
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
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
Surgery • Radioactive Iodine Ablation • Levothyroxine • Monitor with WBS / ultrasound TREATMENT FOR THYROID CANCER
CHILDREN& PREGNANT WOMEN When do you operate???
Complications of Thyroid Surgery Recurrent laryngeal nerve injury Hypo parathyroidism Bleeding Infection