LISA A . CICO, MSN, NPUPSTATE MEDICAL UNIVERSITYBREAST & ENDOCRINE SURGERYCOORDINATOR THYROID CANCER
PROGRAMSURGICAL COORDINATOR BREAST
CANCER PROGRAM
THYROIDNODULES
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
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 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
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
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)
0
10
20
30
40
50
60
10 20 30 40 50 60 70
PalpationAutopsyUltrasound
Prevalence
Rallison et al. JAMA 1975
Hogan et al. J Surg Res 2009
“How was this nodule found?”
Palpation with a physical examIncidental finding on diagnostic work upSelf detectionSurveillance Work up for symptoms of
hyper/hypothyroidism
How was found is it clinically relevant?
Physical Examination of Thyroid Gland
Visual inspectionPalpation of thyroid, neck nodes, and
supraclavicular nodesFixed, mobile, soft, tender?Reflexes why?HR, BP, weight
Symptoms
Usually NONE!!Occasionally painful, quick onset (cyst)Difficulty swallowing Hoarseness OR change in voiceShortness of breath (or difficulty swallowing)
usually while supine OR hands raised over head (Pemberton’s Sign)
Choking sensation hyper/hypo thyroid
Nodules Hyper/Hypo thyroid
Difficulty swallowing
Globus sensation
Choking sensation
Hyper-functioning nodule
Hashimoto’s
Symptoms?
History Physical Findings
Head & neck irradiation
Whole body irradiation
Nuclear falloutFamily history of
thyroid malignancyHeredity
Rapid growthHoarsenessCervical
/supraclavicular lymphadenopathy
Fixation of nodule or gland
> 4 cmSolitary
Pertinent History & PE in Evaluation of TNs
Differential Diagnosis
Multinodular GoiterHashimoto’s ThyroiditisCancerLymphoma
Solitary Thyroid NoduleSubsternal Goiter
COWDEN’S SYNDROMEFAMILIAL POLYPOSIS
CARNEY COMPLEXMEN 2
WERNER SYNDROMETHYROID MALIGNANCY
Family Historyof
Hereditary Diseases
Substernal Goiters
Short neckStocky build
Usually incidental finding by CXR or CTMany times treated unsuccessfully for
asthma
Ultrasound: The Gold Standard
Anyone found to have,OR is suspected of having a nodule evaluate by ultrasound!!
BENIGN
CHARACTERISTICS
Pure cystic (relatively rare)
Spongiform appearance in >50% of nodule volume (aggregration of multiple microcystic components)
Multiple (?)
Septated cyst
BENIGN
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
BENIGN
ULTRASOUND CHARACTERISTIC
CONSIDERATIONS
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
SUSPICIOUS
CHARACTERISTICS
Hypo-echogenicity compared to normal thyroid parenchyma
Increased intra-nodular vascularityIrregular infiltrative marginsPresence of micro-calcificationsAbsent haloShape taller than width in
transverse dimensionNodules > 4 cmSolitaryDifficulty swallowing
ATA Guidelines 2009
Hypoechoic
Suspicious
Increased vascularity
Suspicious
Increased vascularity
SUSPICIOUS
CalcificationsPoorly defined, irregular margins
SUSPICIOUS
Solid
SUSPICIOUS
Multiple Thyroid Nodules
FNA what nodule??> 1 cmSuspicious featuresDominant / largest one
Palpation? Ultrasound?
What nodule(s) do you FNA?
What nodule(s) do you FNA?
FNA of Palpable Nodule
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
False Negative False Positive
false-negative rate of up to 5% with FNA which may be even higher with nodules >4 cm
??
FNA
< 1 cm > 1 cm
NO
ATA Guidelines 2009
NO
Is Size a Predictor of Malignancy?
FNA Results
NondiagnosticBenignAtypia of Undetermined Significance (AUS)Suspicious for a Follicular
Neoplasm/Follicular NeoplasmSuspicious for MalignancyMalignant
Bethesda System for Reporting Thyroid Cytopathology
Diagnostic Category Risk of Malignancy (%)
Usual management
Nondiagnostic or Unsatisfactory
Repeat FNA with ultrasound guidance
Benign 0-3 Clinical Follow up with ultrasound 6 months
Atypia of Undetermined significance or Follicular lesion of Undetermined significance
5-15 Repeat FNA 3 months; if same, then lobectomy
Follicular Neoplasm or suspicious for Follicular neoplasm
15-30 Surgical Lobectomy
Suspicious for Malignancy
60-75 Near total thyroidectomy or surgical lobectomy
Malignant 97-99 Near total thyroidectomy
Lab Work
TSHFree T4
TPO in suspected thyroiditis
TG tumor marker in PTC, FTC, HTC
Calcitonin suspected MTC or in follow up of MTC
TSH
Free T4
T4
T3
Free T3
TPO
Thyroglobulin (TG)
Calcitonin
Thyroid nodule
FNA
Benign
Exam/Sonogram 6-18
months
No Change
Repeat in 3-5 yrs
20% increase in diameter in
> 2 dimensions (>2mm) or
volume increase >
50%
Re-aspirate Thyroid Nodule
Nodule sonographic or clinical features Recommended nodule threshold size for FNA
High-risk historya
Nodule WITH suspicious sonographic featuresb >5mm Recommendation A
Nodule WITHOUT suspicious sonographic featuresb >5mm Recommendation I
Abnormal cervical lymph nodes Allc Recommendation A
Microcalcifications present in nodule ≥1cm Recommendation B
Solid nodule
AND hypoechoic >1cm Recommendation B
AND iso- or hyperechoic ≥1–1.5 cm Recommendation C
Mixed cystic–solid nodule
WITH any suspicious ultrasound featuresb ≥1.5–2.0 cm Recommendation B
WITHOUT suspicious ultrasound features ≥2.0 cm Recommendation C
Spongiform nodule ≥2.0 cmd Recommendation C
Purely cystic nodule FNA not indicatede Recommendation E
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
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
Thyroid Cancers
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
TREATMENT
FOR
THYROID
CANCER
Surgery
Radioactive Iodine Ablation
Levothyroxine
Monitor with WBS / ultrasound
CHILDREN&
PREGNANT WOMEN
WHEN DO YOU OPERATE???
Complications of Thyroid Surgery
Recurrent laryngeal nerve injury
Hypo parathyroidism
Bleeding
Infection
Parathyroid glands
COMPLICATIONS OF SURGERY
OR case
COMPLICATIONS OF THYROID SURGERY
Surgery and TC
Low MORTALITY
Thyroid cancers LOW Mortality!! Rod Stewart, Julie Andrews, Joe Piscopo
Always exceptions to the rules : Roger Ebert, Supreme Court Justice
Reinquist
Should be LOW MORBIDITY too!!
IF surgery is required, always refer to someone who does at least > 50 / year
NO drains!!
NO RR tracks!!
Dermabond is ulgy on the neck, and often opens a bit…
Summary
Refer to Endocrin0logy or Surgery
Children Pregant women Nodules > 1 cm with
suspicious features Compressive symptoms HT with globus symptoms
ULTRASOUND!! Even if already had CT, carotid doppler, etc
Can safely follow with ultrasound
Nodule < 1 cm Stable nodules with no
changeRepeat in 6 months x 2, then
annually
Monitor TFTs with U/S
ENDOCRINE SURGERY
Suspected/known abnormal TFTs with TNs
Pregnant
If FNA needed
Children
If suspect surgery is indictated
Endocrine OR Surgery?
QUESTIONS?
Thank You
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