Evaluation of Thyroid Nodules Michael L. Tuggy, MD Swedish Family Medicine, Seattle, WA.
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Transcript of Evaluation of Thyroid Nodules Michael L. Tuggy, MD Swedish Family Medicine, Seattle, WA.
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Evaluation of Thyroid Nodules
Michael L. Tuggy, MD
Swedish Family Medicine, Seattle, WA
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Case 1
• 42 y.o. male with no active medical problems. During your routine physical, note a thyroid nodule. Told by ENT last year not to worry about it.
• PE: 1 x 2cm R lower pole nodule.
What information do you want from the patient?
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Age as a Risk Factor
• Age – young patients (<20 years of age)– thyroid nodules are much more likely to be
malignant (40-50%).– elderly (>60 years of age) -higher risk,
especially of more aggressive thyroid tumors.
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Gender and Thyroid Nodules
• Gender – male -higher risk if nodule present– females
• have many more nodules
• less likely to be malignant.
• still have majority of thyroid cancers
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Other major risks
• Radiation to head and neck. – 40% risk of thyroid cancer usually 25 years
later.– Exposed populations- Polynesian studies
• Family History of MEN II, Gardner’s Syndrome, Cowden’s disease.
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Historical Red Flags
• Recent growth
• Soft tissue swelling
• Vocal changes
• Dysphagia
• Signs of thyroid dysfunction
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Case 2• 26 y.o. Eritrean female with a 2-3 year history
of goiter. No symptoms but noted enlargement on right for 1 year.
• P.E.: 3x4 cm Right sided thyroid mass, firm, adherent to soft tissue.
What physical findings are worrisome?
How can you best clarify the nature of the nodule?
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Thyroid Exam
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Physical Exam of the Thyroid
• Use both hands simultaneously to evaluate for symmetry
• Patient upright - screening exam• Patient supine with neck in extension-
detailed exam. Swallowing assists in elevating gland.
• Evaluation of other neck structures.• Voice changes (recurrent laryngeal nerve).
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Thyroid Scans
• Purpose – Determine function of the gland and/or a nodule
within the gland
• Hot nodules - usually independently functioning nodules – Rarely, rarely malignant
• Cold nodules - either adenoma or maligancy– 15% chance of malignancy in adults.
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Thyroid Ultrasound
• Can identify presence of nodules.
• May be able to characterize follicular vs. solid.
• Not able to rule our malignant nodule
• Aid in biopsy.
Thyroid
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Case 3
• 30 y.o. WF with enlarging cold benign thyroid adenoma (diagnosis from previous FNA biopsy).
• PE: 4 x 5 cm mass on Right
What do you do now?
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Fine-Needle Aspiration• Best tool for determining pathology other than
surgical excision.
• Can be as high as 80 % sensitive and 95% specific.
• Operator dependent in obtaining adequate amount of tissue. 25 gauge needle is optimal.
• Should not be relied on if negative in patient with previous neck irradiation.– Multifocal tumors common.
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Interpreting the Biopsy Report• What you get:
– benign– indeterminate– suspicious– inadequate specimen
• What it means:– benign - 90-95% likelihood it is benign– indeterminate- who knows?– suspicious- it’s malignant.– inadequate specimen - do it again (and again)
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Thyroid Malignancies- Papillary• Most common
• 30% have node metastasis at diagnosis
• Radiation related
• Histologically, psammoma bodies distinguish from benign adenoma.
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Thyroid Malignancies-Follicular
• 20 % of malignancies
• Distinguished from normal follicular adenomas by invasion of capsule or blood vessels.
• May be difficult to determine on FNA
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Thyroid Malignancies- Medullary
• 5-10% of cases
• arise from the C cells which produce calcitonin
• diagnosis based on elevated thyrocalcitonin levels and thyroid nodule (cold)
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Thyroid Malignancies- Anaplastic
• < 10%
• Highly aggressive with local extension at time of diagnosis.
• No suitable therapy
• Prognosis < 1 yr from diagnosis
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Treatment
• For all malignancies, excision of the the lobe (or if post-radiation the entire gland).
• XRT- very specific and well tolerated- I131 therapy.
• Anaplastic tumors - palliative radiation and XRT.
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What about those benign nodules?
• No specific treatment is needed.
• Thyroid suppression may shrink size of adenomas
• Not proven to be effective or necessary
• May hide malignancies - ? Periodic biopsies or scans.
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Case 4 - This weeks puzzler!
• 40 y.o. WF s/p I131 ablation for Grave’s Dz. 6 years ago.
• Persistant R thyroid nodule 2 x 1.5 cm in size.
What is the likely diagnosis?
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Outcomes• Case 1. - Papillary cancer - 3 (+) nodes
– no metastasis at 1 year.
• Case 2. - Follicular cancer - 5 (+) nodes– no metastasis at 1.5 years
• Case 3. - Large adenoma with incidental 1 cm papillary carcinoma superior to nodule.– No recurrence at 5 years.
• Case 4. - Non-functional adenoma
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Modified from: Castro, MR, Gharib, H. Endocr Pract 2003; 9:128.
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Summary:Solitary Nodule Evaluation
• TSH – if low – scan – if hot nodule, then observe.• Normal TSH - Do I scan first or FNA first?-
– high risk - scan and FNA • Is the nodule cold or hot?• Cold - FNA biopsy
– low risk - FNA• if indeterminate- scan and re-FNA or excisional
biopsy.• Anti-perioxidase Antibody – helpful if low- TSH to diagnose
thyroiditis.
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Never assume a solitary thyroid nodule is benign. Prove it.