Evaluation of a thyroid nodule by vijay
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This document provides an overview of evaluating thyroid nodules. It defines a thyroid nodule and discusses prevalence. The importance of evaluating nodules is to exclude thyroid cancer. Evaluation involves patient history, physical exam, ultrasound of the nodule, and fine needle aspiration biopsy if indicated. Nodule characteristics on ultrasound and biopsy results are discussed. Management depends on biopsy results and may include surgery, radiation, or medication. Post-operative care involves risk stratification and monitoring for recurrence.
Evaluation of a thyroid nodule by vijay
- 1. EVALUATION OF A THYROID NODULE VIJAY SHEWALE KIMS , TRIVANDRUM 14TH AUG 2013
- 2. INTRODUCTION • DEFINITION- A discrete lesion within the thyroid gland that is palpably and/or radiologically distinct from surrounding thyroid parenchyma.
- 3. INTRODUCTION • PREVALENCE- Epidemiological studies have shown that prevalence of palpable thyroid nodule is 5% in women and 1% in men. This prevalence increases upto 19 – 67 % if detected by ultrasound. • Nodular goitre prevalence increases by age
- 5. INTRODUCTION • The importance of thyroid nodule rests with the need to exclude thyroid malignancy which occurs in 5 – 15 %
- 6. HOW WAS THE NODULE FOUND • Palpation with a physical exam • Incidental finding on diagnostic work up • Self detection • Surveillance • Work up for symptoms of hyper or hypothyroidism
- 8. HISTORY • Age , sex • Swelling in front or side of a neck • h/o pain • Sudden increase in size • Pressure symptoms such as hoarseness of voice , dyspnoea , dysphagia (rarely)
- 9. HISTORY • h/o hyperthyroid – loss of weight in spite of good appetite, intolerance to heat, excessive sweating CNS symptoms like- irritability , insomnia, tremor of hands, muscle weakness EYE symptoms such as staring look, difficulty in closing eye, double vision CNS and EYE symptoms are s/o primary
- 10. HISTORY CVS symptoms like palpitations , chest pain , dyspnoea on exertion are s/o secondary hyperthyroid • h/o hypothyroid- increase in weight in spite of poor appetite, facial puffiness, loss of hair, lethargy, poor memory, constipation, oligomenorrhoea
- 11. HISTORY PAST HISTORY • h/o neck irradiation , • h/o thyroid disease in family
- 12. EXAMINATION General examination- Signs of hyperthyroid- tachycardia, tremor, moist skin, eye signs like exophthalmos look, Von Graefe’s sign, lid retraction, joffroy’s sign,stellwag’s sign, moebius sign
- 13. EXAMINATION Local examination- • Movement of swelling with deglutition • Size , consistency of nodule • Tracheal deviation, retrosternal extension • Cervical lymphadenopathy
- 14. WORK UP
- 15. THE AMERICAN THYROID ASSOCIATION (ATA) GUIDELINES FOR THYROID NODULE 2009 , REVISED IN 2013
- 17. SERUM TSH • Low TSH may be associated with functioning nodule, very unlikely to be malignant • TSH has trophic effect on thyroid cancer growth mediated by TSH receptors on tumor cells • TSH suppression is an independent predictor for relapse free survival in differentiated thyroid cancer
- 19. ULTRASOUND SCAN Can answer following questions • Solid/cystic • size • Additional nodule • Benign or malignant feature
- 20. ULTRASOUND SCAN BENIGN • Iso / hyper echoic • Coarse calcifications • Thin, well defined halo • Regular margins • Hypovascular • No lymph nodes MALIGNANT • Hypo echoic • Micro calcifications • Thick or absent halo • Irregular margins • Hypervascular • Lymphadenopathy • Taller than wide lesion
- 21. HYPOECHOIC
- 22. HYPERVASCULARITY
- 23. CALCIFICATIONS, POORLY DEFINED, IRREGULAR MARGINS
- 24. SOLID
- 25. Is size predictor of malignancy • Non palpable nodules have the same risk of malignancy as palpable nodules with the same size • Generally, only nodules >1 cm should be evaluated, since they have a greater potential to be clinically significant cancers. • Nodules <1 cm that require evaluation because of suspicious US findings, associated lymphadenopathy, a history of head and neck irradiation, or a history of thyroid cancer in one or more first-degree relatives.
- 26. • Nodules <1 cm lack these warning signs yet eventually cause morbidity and mortality. These are rare and, given unfavourable cost/benefit considerations, attempts to diagnose and treat all small thyroid cancers in an effort to prevent these rare outcomes would likely cause more harm than good.
- 27. FNAC • Only gold standard test for proof of malignancy without surgical pathology • 23 – 25 gauze no needle is used
- 28. INDICATIONS FOR US GUIDED FNAC • Non palpable or difficult to palpate nodule • Previous non diagnostic cytology • Nodules with previous benign cytology which has grown in size
- 29. FNAC RESULTS • Nondiagnostic (thy 1) • Benign(thy2) • Suspicious for a Follicular Neoplasm/Follicular Neoplasm(thy3) • Suspicious for Malignancy(thy4) • Malignant(thy5)
- 30. BENIGN • Scanty normal follicular cells together with colloid
- 31. PAPILLARY • Nuclear grroving • Papillary projections • Orphan annie eye nuclei
- 32. FOLLICULAR • Increased cellularity with a follicular pattern
- 33. HURTHLE CELL • Variant of follicular neoplasm • Oxyphill ( askanazy ) cells predominate
- 35. NON DIAGNOSTIC CYTOLOGY • In persistent non diagnostic cytology risk of malignancy is less than 5% • Surgery should be considered if nodule is solid
- 36. BENIGN CYTOLOGY • TSH suppressive dose of thyroxine is not recommended • Repeat us guided evaluation after 6 months • If size same or decrease, continue to follow up for longer intervals • If increasing us guided cytology • Surgery is recommended in recurrent cystic nodule with benign cytology
- 37. FOLLICULAR NEOPLASM • I 123 thyroid scan should be considered if serum TSH is in low normal level • Surgery should be consider if no concurrent hyperfunctioning nodule is present • Total thyroidectomy if nodule > 4 cm in size bilobar nodular disease h/o radiation exposure or family h/o thyroid malignancy
- 38. FOLLICULAR NEOPLASM • Use of molecular markers such as BRAF, RET/PTC, Ras, PAX8/PPARy or GALECTIN3 may be consider
- 39. PAPILLARY • Total thyroidectomy unless if nodule is less than 1 cm and unifocal • Modified radical neck dissection only if enlarged lymph nodes are present
- 40. MEDULLARY • Total thyroidectomy • Central compartment lymph node dissection is recommended • Modified radical neck dissection only if enlarged lymph nodes are present
- 41. ANAPLASTIC • Total thyroidectomy • Prognosis is poor
- 42. LYMPHOMA • Chemotherapy • Surgery indicated if pressure symptoms are present
- 44. THYROID SCAN • Only in hyperthyroid • In hot nodule, surgery is recommended after preparation • In cold nodule ,10 % possibility of malignancy. FNAC is advised, manage accordingly
- 45. POST OPERATIVE MANAGEMENT • In DTC , patient are categorized in high or low risk for recurrence • AMES (lahey clinic)- age , metastasis, extension , size • AGES (mayo clinic 1987)- age , grade, extension, size • MACIS (mayo clinic 1993)- metastasis, age , completeness of resection , invasion, size
- 46. POST OPERATIVE MANAGEMENT • GAMES (MSKCC)- grade , age , metastasis, extension, size • TNM FOR DTC Age < 45 Stage 1 – any T, any N, M0 Stage2 - any T ,any N , M1
- 47. POST OPERATIVE MANAGEMENT Age > 45 in DTC and medullary Stage 1 – T1 N0 M0 Stage 2- T2 N0 M0 Stage 3- T 3 N0 M0 or T 1-3 N1 M0 Stage 4A- T4a Stage 4 B – T4b Stage 4 C – M1
- 48. POST OPERATIVE MANAGEMENT • ANAPLASTIC Stage 4 A- T 4a Stage 4B- T4b Stage 4C- T 4c
- 49. POST OPERATIVE MANAGEMNT • In differentiated thyroid carcinoma - Iodine 131 ablation to remove any residual thyroid tissue and malignant cells, to allow follow up with serum thyroglobulin • Radioiodine scan, serum thyroglobulin, ultrasound scan , to monitor the patients for recurrence
- 50. POST OPERATIVE MANAGEMENT • In medullary ca- radiotherapy recommended if lymph nodes are positive for metastasis • Tyrosine kinase inhibitors, VEGF receptor inhibitors are under trial now • Follow up with serum calcitonin , and CEA
- 51. THANK YOU