PRACTICE GUIDELINES: Thyroid Nodules and Cancer 2017 ESEO Alexandria

Transcription

1 PRACTICE GUIDELINES: Thyroid Nodules and Cancer 2017 ESEO Alexandria James V. Hennessey MD Associate Professor of Medicine Harvard Medical School

2 Case 1 28 year old woman sees OB for routine visit ROS: Negative except for occasional dysphonia PE: BP 122/78, HR 72 BPM, 5 5, 120 lbs. Thyroid Exam: 2.5 cm smooth nodule left Moves easily with swallowing 1 cm left SCM lymph node palpable

3 Questions to be answered: How frequently are thyroid nodules and thyroid cancer encountered?

4 8X 5X CT MRI Scanners first introduced (35) Morris LGT et al Thyroid 23(7):

5 THYROID NODULES PREVALENCE: 30-50% Risk of nodule (U/S or Autopsy) 4-8% risk palpable nodule THYROID CANCER 64,300 cases in U.S (Estimate) 0.005% of U.S. population < 5% fatal (1980 deaths in 2016 estimated) Cancer Facts and Figures 2016 American Cancer Society

6 Risk of malignancy per nodule High Risk malignancy / nodule Kwong N et al JCEM 100:

7 DIAGNOSIS: Hx favors benign diagnosis? FHx Hashimoto s Probably NOT FHx of MNG Probably NOT FHx Benign nodule Probably NOT helpful Sx of Hyperthyroidism

8 Adjusted Odds Ratio TSH & Risk of Malignancy * 11.8 *=P< < 0.4 mu/l * >5.5 * TSH Boelaert et al JCEM 91(110:

9 Percent TSH and Malignancy Risk 843 Surgical patients with pre-op TSH * * * P < Malignancy 0 TSH < > 5.0 Haymart MR et al JCEM 93:809-14

10 Mean TSH TSH and Malignancy Risk 843 Surgical patients with pre-op TSH * * p=0.002 Stage I/II Stage III/IV Haymart MR et al JCEM 93: TSH

11 Solitary vs. MNG Photos courtesy of Marla Barkoff M.D.

12 Thyroid Cancer Risk: Multinodular (MNG) versus Single Nodule (SN) Goiter Squares/horizontal lines: Odds ratio/95%ci; diamonds: pooled odds ratio Brito JP et al. Thyroid Apr;23(4):449-55

13 Summary of High Risk History 1. Family Hx Thyroid Cancer 1 relative 2. Hx XRT/Ionizing Irradiation as child (Adolescent) 3. Surgical Dx Thyroid Cancer in contralateral lobe FDG-PET positive nodule 5. MEN2/FMTC RET proto-oncogene positive 6. Calcitonin > 100 pg/ml 7. MEN 2 (MCT, Hyperpara., Pheochromocytoma 8. Familial Medullary Thyroid Cancer Haugen BR et al Thyroid 26(1):1-133

14 Case 2 63 year old woman seen in the ER for dizziness. PE: Stable VS, Thyroid nl, Heart RRR Labs: Routine chemistry nl, TSH 2.3 IU/L Carotid Ultrasound: No vascular lesion Three cm hypoechoic nodules left thyroid lobe Ultrasonographic features described Doppler flow study performed

15 Incidentaloma Facts Frequency: 19-67% in prospective studies Thyroid Cancer found in 4% of FNAs the # of nodule FNAs will Cancer rates Incidental thyroid cancer characteristics: Capsule invasion 20% or Extra thyroidal 17-21% Positive cervical lymph nodes 12-25% Tumor multifocality 32-39% Distant metastases % Thyroid cancer specific mortality 1% Mazzaferri, E JAMA 295:

16 Ultrasound Pattern = Risk High Suspicion = 70-90% Cancer Risk Hypoechoic, microcalcs, irregular border Hypoechoic, microlobulated margin Hypoechoic, irreg margin, Taller than wide Hypoechoic, irreg margin, X-thyroid Extension Irregular margins, suspicious Lymph nodes Haugen BR et al Thyroid 26(1):1-133

17 High Suspicion Images

18 Ultrasound Pattern = Risk High Suspicion = 70-90% Cancer Risk Hypoechoic, microcalcs, irregular border Hypoechoic, microlobulated margin Hypoechoic, irreg margin, Taller than wide Hypoechoic, irreg margin, X-thyroid Extension Irregular margins, suspicious Lymph nodes Intermediate suspicion = 10-20% Risk Hypoechoic with regular margins Haugen BR et al Thyroid 26(1):1-133

19 Intermediate Suspicion

20 Ultrasound Pattern = Risk Low Suspicion = 5-10% Risk of cancer Hyperechoic, solid, regular margins Isoechoic, solid, regular margins Partially Cystic, eccentric solid area Haugen BR et al Thyroid 26(1):1-133

21 Low Suspicion

22 Ultrasound Pattern = Risk Low Suspicion = 5-10% Risk of cancer Hyperechoic, solid, regular margins Isoechoic, solid, regular margins Partially Cystic, eccentric solid area Very Low suspicion = <3% Risk of cancer Spongiform, partially cystic no suspicions features Haugen BR et al Thyroid 26(1):1-133

23 Very Low Suspicion

24 Ultrasound Pattern = Risk Low Suspicion = 5-10% Risk of cancer Hyperechoic, solid, regular margins Isoechoic, solid, regular margins Partially Cystic, eccentric solid area Very Low suspicion = <3% Risk of cancer Spongiform, partially cystic no suspicions features Benign Purely cystic Haugen BR et al Thyroid 26(1):1-133

25 Benign

26 Fine Needle Aspiration FNA is the procedure of choice in Rec. 7 the evaluation of thyroid nodules when clinically indicated. Strong Recommendation, High-quality evidence Haugen BR et al Thyroid 26(1):1-133

27 Who to Biopsy? R8 Sonographic Risk Pattern Estimated Malignancy Risk Consider Biopsy Strength of Recommenda tion Quality of Evidence High Suspicion >70-90% > 1 cm Strong Moderate Intermediate Suspicion 10-20% > 1 cm Strong Low Low Suspicion 5-10% > 1.5 cm Weak Low Very Low suspicion < 3% > 2 cm Weak Moderate Benign < 1% No Strong Low FNA NOT recommended for nodules not meeting above criteria, including ALL nodules < 1cm Strong Moderate Haugen BR et al Thyroid 26(1):1-133

28 Indeterminate FNA Malignancy Prediction with Bethesda System Category Risk of Malig What next? Non-Dx 1-4+% Re-do (U/S) Benign 0-3% Clinical F/U Atypical 5-15% Re-do (U/S) Foll Neoplas % Lobectomy Suspicious 60-75% Total Tx Malignant 97-99% Total Tx Ali SZ & Cibas E 2009 The Bethesda system for Reporting Thyroid Cytopathology. New York: Springer

29 Indeterminate: What Next? Mutation Panel BRAF, RET, RAS, RET/PTC, PAX8/PPARγ, etc. Modest Positive Predictive value (50-60%) Higher Negative Predictive value (85-90+%) Gene Expression Classifier: id benign nodules High Negative predictive value (94-95%) mirna +/- Mutation panel in FNA or circulation Modest Positive Predictive value (50-60%) Higher Negative Predictive value (85-90+%)

30 FNA Disposition Inadequate Malignant Indeterminate Benign Repeat FNA US guidance Surgery Repeat FNA Cytogenetics? Inadequate Mutation Mut. Neg. B9 Close F/U Surgery? Surgery T-Tx? Surgery Hemi or Follow

31 Thanks for Your Attention