1 approach to the thyroid nodule דר' קרלוס בן-בסט מכון אנדוקריני...
Post on 27-Dec-2015
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Approach to the Thyroid Nodule
- בסט' בן קרלוס דראנדוקריני מכון
, בלינסון רבין רפאי מרכז
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The Goiters Thyroid gland enlargement
Nodular Goiter
> Solitary noduleCold or Hot (Toxic adenoma)Solid or Cystic (simple, complex)Painful or notFirm or softFixed or not
> Multinodular goiterNon toxicToxic (autonomous function)Retrosternal goiter
Diffuse Goiter
• Endemic
• Sporadic Enzymatic defect (congenital)
Drug induced (e.g. lithium)
• Others
Graves disease
Hashimotos
Subacute thyroiditis
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A 52 y.o. female was found to have an enlarged thyroid on routine physical examination
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A discrete lesion within the thyroid gland that is palpably and/or ultrasonographically distinct from the
surrounding thyroid parenchyma
Our patient was found to have a thyroid nodule
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• Benign nodules (colloid, adenomatous hyperplasia)
• Cystic lesions (colloid, thyroglossal duct cyst)
• Adenomas (Follicular, Hurthle cell)
• Thyroid cancer (Medullary or non-medullary)
• Lymphoma of thyroid
• Others
But…what is really a thyroid nodule ?
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About thyroid nodules
• The prevalence of palpable thyroid nodules in iodine sufficient areas is 5% in women and 1% in males
• The prevalence of thyroid nodules in random ultrasound is 19-67 % (higher in female and elderly)
• Thyroid cancer may occur in 5-10% of thyroid nodules
• The etiology is poorly understood and depends on type of nodule (RET mutation in thyroid cancer, activating mutation of TSH receptor in toxic adenoma etc). There may be a familial predisposition.
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• A palpable lesion found by self- or medical examination
• A non-palpable nodule found on imaging for unrelated reasons, mostly hypothyroidism and bolus (incidentaloma)
• Work-up for hyperthyroidism
• An acute painful nodule (hemorrhagic cyst)
Clinical Presentation
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Thyroid ImagingThyroid Imaging
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Neck Ultrasound
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Neck CT
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Our patient has a solitary nodule and asks you about its significance
• Mass effect ?
• Thyroid function ?
• Benign or malignant lesion ?
Non-palpable nodules have same risk of malignancy as palpable nodules
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Mass effect
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Clinical consequences of mass effect
• Cosmetics
• Psychological distress• Dysphagia (Barium swallow)
• Tracheal compression (Flow loops)
• Pumberton sign
• Hoarseness
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Dysphagia
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Tracheal compression
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Our patient has a single nodule 2.5 cm diameter with no mass effect. What’s next ?
Algorithm for work-up of thyroid nodules
Apply to all palpable nodules and those non-palpable larger than 1
cm
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NodulePalpable/Nonpalpable
US TSH
Hypo/Normal Hyper
Scan
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Functional Imaging(Technetium Thyroid Scintigraphy)
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Hot nodule Cold nodule
Toxic adenoma Cold nodule
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NodulePalpable/Nonpalpable
US TSH
Hypo/Normal Hyper
Scan
Hot
Treat or follow
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Treatment of Toxic Adenoma
• When to treat ?– Subclinical hyperthyroidism– Overt hyperthyroidism
• How to treat ?– Antithyroid drugs– Radioactive iodine– Surgery
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NodulePalpable/Nonpalpable
US TSH
Hypo/Normal Hyper
Scan
Cold Hot
FNA
Treat or follow
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Fine Needle Aspiration
Pitfalls of FNA
No Quick Diff
Not enough follicular cells
Non palpable nodule
False negatives
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NodulePalpable/Nonpalpable
US TSH
Hypo/Normal Hyper
Scan
Cold Hot
Benign Indeterminate Malignant
Follow Repeat Operate
FNA
Treat or follow
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Thyroid cytology
Indeterminate cytology
• Few colloid and large amount of follicular cells
• Large, medium and microfollicular patterns
• Solid patterns
Malignant cytology
• Intranuclear inclusions, grooves, psamoma, etc
• High cellular density
• Papillary patterns
• Capsular invasion
Benign cytology: large amount of colloid with few
typical follicular cells
Follicular and Hurthel adenomas are diagnosed only upon pathology (capsular
and/or vascular invasion)
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Normal Thyroid Colloid nodule
Papillary Thyroid Cancer
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Risk factors for thyroid cancer
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Treating Thyroid Nodules
• Surgery: malignancy, hyperthyroidism, mass effect, cosmetic/psychological
• Radioactive iodine: hyperthyroidism, mass effect
• Percutaneous ethanol
• Antithyroid drugs
• Thyroxine suppression therapy
• Follow up
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Thyroxine suppressive therapy
Wemeau JL et al. J Clin Endocrinol Metab 87:4928- 34, 2002
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Our patient has a benign FNA report. What’s the need for follow-up and how ?
• False negative FNA in up to 5% (less when US guidance)
• Changes in functionality
• Size changes with mass effect
• Follow-up for functional changes
– Clinical features
– Serial TSH measurements
• Follow-up for anatomic changes
– by palpation
– by US very operator-dependent – by CT Consider
TSH suppression trial
Repeat FNA
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