Thyroid Nodules: What to do next?

Transcription

1 Thyroid Nodules: What to do next? Ally P. H. Prebtani Professor of Medicine Internal Medicine, Endocrinology & Metabolism McMaster University Canada

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3 Learning Objectives Epidemiology Clinical Risk factors Role of U/S Role of FNA Management Follow up

4 Cases 1. 24yo woman 3cm left sided thyroid nodule. Solid. No Comp Sx. No FH or XRT. TSH n yo man 1cm complex thyroid nodule. No FH/XRT. TSH yo woman 3cm cystic nodule. No Comp Sx. No FH/XRT. TSH n.

5 Epidemiology Up to 50% on ultrasound Many incidentalomas What to do?? 5% clinically palpable U/S too Sensitive? Thyroid Incidentaloma Carotid duplex, etc. Particularly for nodules that are < 1 cm Posterior in the gland

6 Etiology

7 Why good standardized reports useful? Optimize patient care Appropriate use of: f/u U/S FNABx Determine post-test probability of benign vs malignant lesions Cost effectiveness Research implications Standardize care

8 What is the evidence? ATA 2016 guidelines Endocrine Society Radiology guidelines Don t want to over-investigate or underinvestigate

9 What to Endocrinologists want to know? Taller than wider Echoicity Intranodal vascular flow Microcalcifications Heterogeneity Margins/Halo Solid vs cystic vs mixed Size But this is NOT the only thing we look at Comparison with prior imaging and any changes Lymph node reporting also

10 Based on that We have clinical information to decide on risk of malignancy and can decide if: FNAB Clinical surveillance U/S surveillance Surgical referral Do nothing

11 Frustrating Reports Multinodular goitre (MNG) with no dominant nodules 1.4cm thyroid nodule in left lobe 1.9cm nodule, suggest FNAB

12 Rads & Endo Great relationship Let us work together to improve patient care and choose wisely our testing How Endos can help: Make others aware/educate that most nodules are benign Choose wise use of U/S Put more history on our reqs and prior U/S and FNA results Selective request of FNA for nodule(s)

13 Clinical Risk Factors Thyroid Cancer N Engl J Med 351;17 October 21, 2004

14 History General Country of origin Symptoms of thyroid dysfunction Orbitopathy Neck or Nodule Growth Pain Compressive symptoms Dysphagia, dysphonia, dyspnea XRT Autoimmune diseases Pheo, Hyperparathyroidism FH cancer/thyroid goitre/dysfunction

15 Thyroid Gland Exam Size Shape & Symmetry Consistency Mobility Nodularity Tenderness Lymph nodes Use Water/Something to Drink Pemberton s sign

16 Is it always that obvious?

17 Investigations TSH Thyroid Ultrasound Fine Needle Aspiration Biopsy FNAB Thyroid Scan

18 Thyroid U/S Benign Characteristics Regular border Halo (sonolucent rim) Hyperechoic Egg shell calcification N/A Malignant Characteristics Irregular border No Halo Hypoechoic (more vascular) Microcalcification (Psammoma Bodies) Intranodular vascular spots (color doppler)

19 U/S, Risk CA, FNA Guidance Haugen et al. THYROID Volume 26, Number 1, 2016

20 Who Needs FNA? Thyroid Nodule Management, Executive Summary, Endocr Pract. 2016;22(No. 5)

21 Fine Needle Aspiration (FNA) 22-25G Needle, 10cc syringe Done in Office No local Safe 3-5 passes SN 95-99% False Negative rate 1-5% SP > 95%

22 FNAB

23 FNA Results 1. Nondiagnostic: repeat FNA via U/S 15-20% 2. Benign: macrofollicular or "colloid" adenomas, chronic autoimmune (Hashimoto's) thyroiditis 60% 3. Suspicious/Indeterminant/AUS: microfollicular or cellular adenomas (follicular neoplasm/lesions) 15% 4. Malignant 5%

24 Burman K et al. NEJM 373;24

25 Thyroid Scan Technetium-99m Pertechnetate 5-10 mci IV Scan 20 minutes later I uci po, scan 4-6h later ($$$) Indications Low TSH? Hot nodule? If Follicular lesion/neoplasm? Functioning adenoma

26 Thyroid Scan Thyroid nodule: risk of malignancy 6.5% only 5-10% of nodules Cold nodule 16-20% malignant Warm Nodule (indeterminant) 5% malignant Hot Nodule Tc-99m < 5% malignant I 123 < 1% malignant

27 Management N Engl J Med 351;17 October 21, 2004

28 Summary of Approach Haugen et al. THYROID Volume 26, Number 1, 2016

29 Bottom Line Common Most benign Assess Risk Factors/Neck Exam TSH FNAB Surgery vs Clinical/Ultrasonographic f/u

30 Question # 1 Which nodules should not get a FNABx? 1. Solid > 3cm hypoechoic 2. Purely cystic 3. Complex 2.5cm with Hx of XRT and growth 4. Spongiform 5. 2 & 4

31 Question # 2 What is the next best test once a thyroid nodule is discovered? 1. Surgical referral 2. FNABx 3. Thyroid scan 4. TSH

32 Cases 1. 24yo woman 3cm left sided thyroid nodule. Solid. No Comp Sx. No FH or XRT. TSH n yo man 1cm complex thyroid nodule. No FH/XRT. TSH yo woman 3cm cystic nodule. No Comp Sx. No FH/XRT. TSH n.