Approach to Thyroid nodules
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The document outlines the approach to evaluating thyroid nodules. The initial steps include taking a history, physical exam, measuring serum TSH, and performing an ultrasound. If TSH is low, a radioactive iodine scan is also done. Fine-needle aspiration biopsy is recommended if ultrasound shows characteristics associated with malignancy or if the nodule has grown over time. The evaluation is similar for pregnant patients, though radioactive scans are avoided during pregnancy.
Approach to Thyroid nodules
- 1. Approach to Prepared by: Amro Adawi 6th year medical student
- 2. Approach to Preface Thyroid nodules come to clinical attention when noted by the patient, or as an incidental finding during routine physical examination, or during a radiologic procedure. Thyroid incidentalomas Nonpalpable thyroid nodules that are detected during other imaging procedures. Have approximately the same risk of malignancy as palpable nodules . The prevalence of cancer is high in : Children Adults less than 30 or over 60 years old history of head and neck irradiation Patients with a family history of thyroid cancer
- 3. Approach to How ? History Rapid growth of a neck mass, Childhood head and neck irradiation, Total body irradiation for bone marrow transplantation, Family history of thyroid cancer, or thyroid cancer syndromes (eg, MEN2)
- 4. Approach to How ? Physical examination A fixed hard mass, obstructive symptoms, cervical lymphadenopathy, or vocal cord paralysis all suggest the possibility of cancer.
- 5. Approach to History and physical examination lack the sensitivity and specificity sufficient to diagnose thyroid cancer
- 6. Approach to How ? Now WHAT are the next steps to evaluate a thyroid nodule
- 7. Approach to First step DoSerum TSH Thyroid function should be assessed in all patients with thyroid nodules.
- 8. Approach to First step Low TSH level is a way to screen for hyperfunctioning nodules
- 9. Approach to How ? BUT, 95% of nodules are hypofunctioning (cold)
- 10. Approach to How ? Low TSH may be associated with functioning nodules, very unlikely to be malignant. TSH has a trophic effect on thyroid cancer growth mediated by TSH receptors on tumor cells. Higher TSH is associated with more advanced stage of thyroid cancer.
- 11. Approach to How ? Check TSH Low Normal or high Radioisotope scan + US What to do ?? Hot Cold Observation
- 12. Approach to Why US? Conformation of a sonographically identifiable nodule corresponding to the palpable abnormality. Detection of additional non-palpable nodules for which FNA may be indicated. Identification of the sonographic characteristics of the thyroid nodule.
- 13. Approach to Why US? Characteristics of thyroid nodule on US: 1. Echogenicity (hypo-hyper-iso) 2. Calcifications (micro-dense) 3. Margins (infiltrative-regular well defined) 4. Vascularity (intranodular-peripheral-absent) 5. Shape High risk Hypoechoic ,solid Low risk Spongiform Peripheral vascularity
- 14. Approach to How ? If TSH is normal or high ……. WHAT is the next step ? Do Ultrasound FNA if the criteria was met Monitor if criteria for FNA not met
- 15. Approach to How ? Recommendations to do FNA
- 16. Approach to How ? Palpation VS US-guided FNA If what you feel is what you see on US and it is predominantly solid Go for Palpation FNA
- 17. Approach to How ? US-guided FNA for nodules ATA guidelines 2009 1.Nonpalpable and difficult to palpate nodules 2.Predominantly cystic nodules 3.Nodules with a nondiagnostic cytology from palpation or US FNA -nondiagnostic rate 50% lower than palpation FNA 4.Nodules with a prior benign cytology that have grown -false negative rate lower than palpation FNA
- 18. Approach to How ? Serum thyroglobulin Can be elevated in many thyroid diseases. An elevated level does not help discriminate benign from malignant thyroid nodules. So, we do not measure serum thyroglobulin levels as part of the evaluation of patients with a thyroid nodule.
- 19. Approach to Special Pregnancy Thyroid radionuclide scanning is contraindicated during pregnancy. A pregnant woman found to have a thyroid nodule should be evaluated in the same way as if she were not pregnant. So, fine-needle-aspiration biopsy of the nodule should be done (as it would be for most nonpregnant patients)
- 20. Approach to Summary The initial evaluation in all patients with a thyroid nodule (discovered either by palpation or incidentally noted on a radiologic procedure, includes: a history, physical examination, neck ultrasonography, and measurement of serum thyroid stimulating hormone (TSH). Thyroid scintigraphy should be performed in patients with a low serum TSH concentration. Fine-needle aspiration (FNA) biopsy is the most accurate method for evaluating thyroid nodules and selecting patients for thyroid surgery.
- 21. THANK YOU