Approach to Thyroid Nodules

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1 Approach to Thyroid Nodules Alice Y.Y. Cheng, MD, FRCPC

2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 Outline Thyroid basics Thyroid exam Approach to thyroid nodule Thyroid cancer Epidemiology Treatment

4 Thyroid Follicular cells: Make thyroid hormone (T4, T3) Parafollicular cells Make calcitonin Colloid = protein

5 What can go wrong? Functional Hyper / hypo Primary / Secondary Structural Nodules Both

6 Thyroid Exam

7 Two approaches Anterior Posterior

8 Thyroid exam Inspection anteriorly and laterally Landmark with your fingers Locate the isthmus Do NOT take your fingers off the patient The only things connected to the isthmus are the lobes!

9 Thyroid exam Comment on Size (# times normal) Texture (normal, firm, hard) Symmetry Nodular or smooth Mobility Tenderness

10 Approach to thyroid nodule

11 Haugen BR et al ATA Guidelines. Thyroid 2015;DOI: /thyr

12 Miss. SF 17 year old woman Noted a lump in her neck Corresponds with a thyroid nodule on physical examination

13 Differential diagnosis Benign Colloid Hyperplastic Functional adenoma Cysts Malignant Papillary, follicular, medullary, anaplastic, lymphoma Haugen BR et al ATA Guidelines. Thyroid 2015;DOI: /thyr

14 What are key history features? Onset, rapidity of growth? Obstructive / compressive symptoms? Dyspnea, dysphagia, stridor Voice hoarseness Function? (hyper or hypo) Haugen BR et al ATA Guidelines. Thyroid 2015;DOI: /thyr

15 Risk Factors for malignancy Age (< 20 or >65) Sex (M > F) Radiation history Cancer treatment, BMT Environmental (Chernobyl) Acne, tonsils Family history of thyroid cancer Rapid growth, hoarseness Haugen BR et al ATA Guidelines. Thyroid 2015;DOI: /thyr

16 Risk Factors for malignancy Size (> 4 cm) Fixed Hard Lymphadenopathy Vocal cord paralysis Haugen BR et al ATA Guidelines. Thyroid 2015;DOI: /thyr

17 Investigations TSH (functional?) Functional nodules are BENIGN

18 Question A thyroid scan should be part of the routine work up of thyroid nodules to differentiate between benign or malignant. TRUE FALSE

19 Nuclear Medicine tests NOT necessary in most cases! Uptake: Test of FUNCTION and not structure Useful if HYPERTHYROID Scan: Test of STRUCTURE and not function Useful if HYPERTHYROID and NODULE Only useful finding = hot

20 Ultrasound Investigations True nodule? Cyst? Size? Composition, echogenicity Margins Calcifications (type) Shape Vascularity Haugen BR et al ATA Guidelines. Thyroid 2015;DOI: /thyr

21 Ultrasound predictors of cancer Sensitivity (%) Specificity (%) Microcalcifications Hypoechoic Solid Absence of halo Intranodular vascularity Poorly defined margins Tall>Wide Haugen BR et al ATA Guidelines. Thyroid 2015;DOI: /thyr

22 Risk stratification by U/S HIGH MEDIUM LOW VERY LOW BENIGN Hypoechoic with irregular margins Microcalcifications Taller > wide Interrupted rim calcification Suspicious lymph node Hypoechoic solid nodule with regular margins Hyperechoic or isoechoic solid nodule with regular margins Partly cystic with eccentric solid component Spongiform Cystic with benign-looking solid component Simple cyst Haugen BR et al ATA Guidelines. Thyroid 2015;DOI: /thyr

23 Fine needle aspiration biopsy FNA is the procedure of choice in the evaluation of thyroid nodules (Recommendation A) Ultrasound guided or palpation Haugen BR et al ATA Guidelines. Thyroid 2015;DOI: /thyr

24 U/S Patterns and FNA Suggestions U/S Patterncancer risk Est cancer risk Threshold for FNA Strength High 70-90% 1 cm Strong Intermediate 10-20% 1 cm Strong Low 5-10% 1.5 cm Weak Very Low <3% 2 cm Weak Benign <1% No FNA Strong Do NOT biopsy any nodule < 1 cm Strong Modify cutoffs based on risk factors, suspicious lymph nodes Haugen BR et al ATA Guidelines. Thyroid 2015;DOI: /thyr

25 Multiple nodules and FNA When multiple nodules > 1 cm are present, FNA based on US pattern If multiple similar low or very low risk nodules are present, it is reasonable to FNA the largest ( over 2 cm) and observe the others Haugen BR et al ATA Guidelines. Thyroid 2015;DOI: /thyr

26 FNAB results 1. Malignant = surgery 2. Benign = follow 3. Indeterminate = surgery 4. Inadequate = repeat FNAB

Non-diagnostic cytology Repeat US guided FNAB Repeatedly non-diagnostic cytology WITHOUT suspicious U/S pattern OBSERVE closely or excised

27 Non-diagnostic cytology Repeat US guided FNAB Repeatedly non-diagnostic cytology WITHOUT suspicious U/S pattern OBSERVE closely or excised WITH suspicious U/S pattern, growth, or clinical risk factors SURGERY Haugen BR et al ATA Guidelines. Thyroid 2015;DOI: /thyr

28 F/U of benign cytology US- guided FNA has a very low false negative rate US pattern High suspicion Repeat US and FNA in 12 mo Medium/low suspicion Very low suspicion Repeat US mo, if growth* repeat FNA or observe Utility unknown- if repeated, wait >24 mo If a second FNA is benign, US surveillance is NOT indicated Strength Strong Weak None Strong * Growth defined as 50% increase in volume, or 20% increase in dimensions

29 F/U if NOT initially biopsied US pattern Strength High suspicion Repeat US in 6-12 mo Weak Medium/low suspicion Very low suspicion Repeat US mo Utility unknown- if repeated, wait >24 mo Nodules < 5 mm do not require routine US followup Weak No rec Week

30 Miss. SF 17 year old woman Noted a lump in her neck Corresponds with a thyroid nodule on physical examination WHAT WOULD YOU DO?

31 Take home points Risk factors for malignancy radiation, family history, age, sex, Phillipino Size (>4cm), obstruction/compression Ultrasound features U/S, TSH, FNAB for almost all Uptake & scan ONLY if hyperthyroid Only investigate > 1-2 cm based on risk

32 Thyroid Cancer

33 Cancer Care Ontario: Cancer in Young Adults in Canada, May 2006

34 Thyroid Cancer Differentiated (90%) Papillary Follicular Medullary Anaplastic Lymphoma

37 Usual Treatment Total thyroidectomy vs lobectomy Radioiodine remnant ablation in some I131 inpatient or outpatient Low iodine diet 2 weeks prior Must have TSH > 35 Withdrawal or Thyrogen Whole body scan 1 week later Allows for surveillance with thyroglobulin

38 Treatment Suppressive thyroid replacement TSH < 0.1 in high risk cases TSH other cases

39 Thyroglobulin Surveillance Check at 6-12 months after ablation Stimulated Tg is the best test Withdrawal or Thyrogen Must have NEGATIVE antibody levels I131 whole body scan (not always) Other imaging (U/S, CT, PET)

40 Surveillance Surveillance must be life long! Monitor Clinical exam Ultrasounds Thyroglobulin on suppression Periodic stimulated thyroglobulins

41 Take home points Thyroid cancer is common and growing Prognosis excellent but recurrence rate is high lifelong surveillance Thyroidectomy, suppression, remnant ablation, surveillance with Tg

Thyroid Nodules: What to do next?

Thyroid Nodules: What to do next? Ally P. H. Prebtani Professor of Medicine Internal Medicine, Endocrinology & Metabolism McMaster University Canada Copyright 2017 by Sea Courses Inc. All rights reserved.