Thyroid Nodules ENDOCRINOLOGY DIVISION ENDOCRINOLOGY DIVISION Dr. HAKIMI, SpAK Dr. MELDA DELIANA, SpAK Dr. SISKA MAYASARI LUBIS, SpA
Anatomical Considerations
The Thyroid Nodule Congenital anomalies Thyroglossal duct cyst Inflammatory lesions Inflammatory foci Compensatory regenerative nodules (TSH,TGI) Hyperplasia Neoplasia Benign Malignant
Follicular epithelial neoplasms Follicular adenoma Differentiated: Papillary, Follicular Poorly Differentiated (Insular) Anaplastic Parafollicular epithelial neoplasms Medullary carcinoma Mixed/composite carcinoma Other primary epithelial neoplasms Primary non-epithelial neoplasms Secondary tumors
Incidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid carcinoma Folicular adenomas & colloid cysts is majority of Folicular adenomas & colloid cysts is majority of benign tyhroid nodules
The Approach to Investigation of the Thyroid Nodule Clinical examination Thyroid function tests Ultrasound Cytology of fine needle aspirate (FNAB) Thyroid scan MRI
Clinical examination Painless nodules Firm or hard consistency Fixed to surrounding tissue Rapid growth Cervical adenopathy, hoarseness, dysphagia Exposed to irradiation Family history of thyroid cancer or pheochromocytoma Other syndromes associated with nodular thyroid disease
Thyroid function tests Anti TPO & anti Tg Abs Abs (+) underlying CLT, doesn t exclude thyroid cancer TSH, T4, T3 elevation T4 or/and T3 functioning nodules Serum calcitonin for familial case of thyroid cancer Genetic screening for mutation of RET protooncogen suspected multiple endocrine neoplasia type 2
Methods of Ret/PTC Analysis DNA PCR analysis of ret/ptc gene rearrangements has been difficult due to variable break-point sites leading to heterogeneous tumor profiles RNA RT-PCR for ret/ptc mrna is the gold standard Variability of expression; not all or none Protein Immunohistochemistry
Ret/PTC Gene Rearrangements
Ultrasonography Non invasive method Confirm & evaluate the morphological characteristic of thyroid nodules Cystic or homogeneously hyperechoic lower risk of malignancy Solid hypoechoic, calcifications, irreguler shape & absence of a halo malignant nodules
The limitation : No reliably predict of malignancy Depend on individual experiences
Ultrasonography YROID ASS
Cytology of fine needle aspirate & biopsy (FNA) 20% of FNAB are insufficient or non diagnostic Repeat aspiration is ussually successful Identifiable on cytology by the presence of characteristic cell abnormalities In very young children, open excisional biopsy is suitable alternative
Fine Needle Aspiration Biopsy
Computed Tomography Distinguish cystic from solid Extent of lesion Vascularity (with contrast) Detection of unknown primary (metastatic) Pathologic node (lucent, >1.5cm, loss of shape) Avoid contrast in thyroid lesions
Computed Tomography
Magnetic Resonance Imaging Similar information as CT Better for upper neck and skull base Vascular delineation with infusion
Magnetic Resonance Imaging
Differential Diagnosis
Therapy Excision for benign tumors & cysts Malignant thyroid tumors Total or near total thyroidectomy Radioiodine ablation Monitoring for recurrence & disease progression Thyroid nodules < 1 cm or with benign cytology follow by serial ultrasound every 6-12 months Significant interval growth repeated FNAB
Treatment of Thyroid Cancer Papillary and follicular thyroid cancer Generally excellent prognosis Risk for recurrence for as long as 30 years Initial management Surgery and radioactive iodine LT 4 suppressive therapy Follow-up Physical examination Radioactive iodine scans Serum Tg TSH and T 4
Standard Treatment of Thyroid Cancer Total Thyroidectomy RAI Ablation Cohen EG, et al. Otolaryngol Clin North Am. 2003;36:129-157. Mazzaferri EL, et al. J Clin Endocrinol Metab. 2003;88:1433-1441. Sherman SI. Lancet. 2003;361:501-511. Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463. Mazzaferri EL, et al. Endocr Relat Cancer. 2002;9(4):227-247. Suppression Therapy 1 Year Whole Body Scan Tg Assay
Thyroid Cancer Initial Treatment Strategy Diagnosis of Thyroid Cancer Low Risk Surgery Intermediate and High Risk Lobectomy Isthmusectomy Total Thyroidectomy Physical Exam Ultrasound RAI Ablation Kinder BK. Curr Opin Oncol. 2003;15):71-77. Sherman SI. Lancet. 2003;361:501-511. Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463.
Radioactive Iodine Destroys remnants of normal thyroid tissue Destroys thyroid cancer cells Identifies distant metastases Maximizes sensitivity and specificity of serum thyroglobulin Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463. Cohen EG, et al. Otolaryngol Clin North Am. 2003;36:129-157.
TSH Suppression Normal Pituitary TSH - Thyroid Cancer Patients Pituitary TSH - + Thyroid T 4 + Minimum LT 4 to suppress TSH without thyrotoxicosis Thyroid T 4 Braverman LE, Utiger RD, eds. Werner & Ingbar s The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000. Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463. Sherman SI. Lancet. 2003;361:501-511.
Target TSH Suppression Optimal TSH Low to Undetectable Suppressed but Detectable Low Normal TSH, miu/l <0.1 0.1 to 0.4 0.5 to 1 Patients Persistent or recurrent disease High-risk patients Most patients with no evidence of disease Very low-risk patients Long-term survivors Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463. Sherman SI. Lancet. 2003;361:501-511. Braverman LE, Utiger RD, eds. Werner & Ingbar s The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000.