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approach to thyroid nodule
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APPROACH APPROACH TO TO
THYROID NODULETHYROID NODULE
Dr. (Maj. Gen.) K J ShettyDr. (Maj. Gen.) K J ShettyConsultant EndocrinologistConsultant Endocrinologist
MD, FRCP (Edin.), FICPMD, FRCP (Edin.), FICP
INTRODUCTIONINTRODUCTION
Thyroid Nodule:Thyroid Nodule: – Common Outpatient Clinical ProblemCommon Outpatient Clinical Problem
4 to 8% OF ADULTS4 to 8% OF ADULTS13 to 67% ON USG EXAM13 to 67% ON USG EXAM(Female : Male – 8:1)(Female : Male – 8:1)
– Importance: Concern of CarcinomaImportance: Concern of Carcinoma5% Malignant5% MalignantRelative Common-ness and possibility of complete cure if Relative Common-ness and possibility of complete cure if detected earlydetected early
– Solution:Solution: Evolve a safe, expedient, reliable and cost Evolve a safe, expedient, reliable and cost effective management strategyeffective management strategy
PRESENT SCENARIOPRESENT SCENARIO
Widely Divergent ApproachWidely Divergent Approach– Primary Consultant : GP, Internist, Surgeon, Primary Consultant : GP, Internist, Surgeon,
ENT Specialist, Surgical OncologistENT Specialist, Surgical Oncologist– Bias of the consultant - reluctance to follow guidelinesBias of the consultant - reluctance to follow guidelines– Inadequate use/ Improper prioritization of Inadequate use/ Improper prioritization of
investigative toolsinvestigative tools– Insufficient knowledge of pathophysiology Insufficient knowledge of pathophysiology
natural history of thyroid nodulenatural history of thyroid nodule
indications, merits, and shortcomings of various investigative indications, merits, and shortcomings of various investigative toolstools
Approach to Thyroid NoduleApproach to Thyroid NoduleSteps:Steps:
EvaluationEvaluation – MorphologyMorphology– FunctionalFunctional– ImmunologicalImmunological– CytologicalCytological– HistopathologicalHistopathological
Tools AvailableTools Available– Clinical History & ExaminationClinical History & Examination– Biochemical / Immunological TestsBiochemical / Immunological Tests– Imaging – USG/SCANImaging – USG/SCAN– Aspiration CytologyAspiration Cytology
Thyroid NoduleThyroid NoduleSteps in Evaluation:Steps in Evaluation: – Clinical ExaminationClinical Examination– Biochemical ExaminationBiochemical Examination– Ultrasound EvaluationUltrasound Evaluation– CytologyCytology
Clinical EvaluationClinical Evaluation
AsymptomaticAsymptomaticSymptomaticSymptomaticHyper/ Hypo-thyroidismHyper/ Hypo-thyroidismMechanical Mechanical
DyspnoeaDyspnoeaDysphagiaDysphagiaHoarsenessHoarsenessPainPainRapid Increase In SizeRapid Increase In SizeCosmeticCosmeticPast History (Previous Surgery, Irradiation)Past History (Previous Surgery, Irradiation)Family HistoryFamily History
CLINICAL EVALUATION (cont’d)CLINICAL EVALUATION (cont’d) GeneralGeneral– Sex: M > FSex: M > F– Age: < 20 ; > 60 YrsAge: < 20 ; > 60 Yrs
SystemicSystemic : EUTHYROID/ HYPO/ HYPER : EUTHYROID/ HYPO/ HYPER
NeckNeck : NODULE: SOLITARY / MULTINODULAR : NODULE: SOLITARY / MULTINODULAR– Size/ Intra-thoracic/ ExtensionSize/ Intra-thoracic/ Extension– Consistency: Firm/Hard/CysticConsistency: Firm/Hard/Cystic– Mobile/FixedMobile/Fixed– TendernessTenderness
Lymph nodesLymph nodes : Number and level : Number and level
CLINICAL POINTERS TO MALIGNANCYCLINICAL POINTERS TO MALIGNANCY
Main PointersMain Pointers– Recent Rapid Increase In SizeRecent Rapid Increase In Size– Development of Hoarseness of voiceDevelopment of Hoarseness of voice– Positive Family HistoryPositive Family History– Age & SexAge & Sex– Past History of Neck IrradiationPast History of Neck Irradiation– Hard Fixed NoduleHard Fixed Nodule– Regional lymph nodesRegional lymph nodes
Misconcepts of MalignancyMisconcepts of Malignancy– Size: Smaller Ones – NO RISKSize: Smaller Ones – NO RISK– Multi-Nodular – NO RISKMulti-Nodular – NO RISK– Pain – HIGH RISKPain – HIGH RISK
Biochemical Evaluation Biochemical Evaluation – Lab EvaluationLab Evaluation – First Step: Assess Functional Status – First Step: Assess Functional Status by TFTby TFT– TSH AssayTSH Assay: Most Useful : Most Useful – T3/T4T3/T4: Not Necessary if TSH is normal: Not Necessary if TSH is normal– TSH:TSH:
Absent/ Low - Toxic Nodule : T3/ T4 IndicatedAbsent/ Low - Toxic Nodule : T3/ T4 IndicatedElevated - Hypothyroid : T4 indicatedElevated - Hypothyroid : T4 indicated
– FT3/FT4FT3/FT4: Preferred to TT3/ TT4: Preferred to TT3/ TT4– Thyroid AntibodiesThyroid Antibodies
Thyroid Peroxidase (TPO)Thyroid Peroxidase (TPO)ANTI-THYROGLOBULIN Ab (TgAb) ANTI-THYROGLOBULIN Ab (TgAb) TSH ReceptorTSH ReceptorAntibodies (TSIAb) Graves (Not Routinely Available)Antibodies (TSIAb) Graves (Not Routinely Available)
(Hashimotos and Graves)(Hashimotos and Graves)
Ultrasonography (USG)Ultrasonography (USG)
**High Resolution USG: Exceptional ClarityHigh Resolution USG: Exceptional Clarity*Nodules < 1.5 cm*Nodules < 1.5 cm*Metastatic Nodules In Neck (Clinically not palpable)*Metastatic Nodules In Neck (Clinically not palpable)
• Assists in Localising Nodules for FNAC Assists in Localising Nodules for FNAC • Inexpensive, non invasive, readily availableInexpensive, non invasive, readily available• USG to Endocrinologist USG to Endocrinologist Stethoscope to CardiologistStethoscope to Cardiologist• LimitationLimitation: Little help in differentiating benign : Little help in differentiating benign from cancerfrom cancer
No Single Characteristic: Predictive for malignancyNo Single Characteristic: Predictive for malignancyDenote Higher Risk in combination of some:Denote Higher Risk in combination of some:CompositionComposition Incidence percentage Incidence percentage– SolidSolid 27%27%– Mixed (complex)Mixed (complex) 7% 7%– Pure cysticPure cystic > 4 cm: 6% > 4 cm: 6% < 4 cm: Negligible < 4 cm: Negligible
CalcificationCalcification– Microcalcification : x 3 higher risk without calcificationMicrocalcification : x 3 higher risk without calcification– 95% specificity95% specificity
- Coarse Calcification x 2 Risk- Coarse Calcification x 2 RiskCervical Lymph Nodes : Highly Suggestive of PTC Cervical Lymph Nodes : Highly Suggestive of PTC
Fine Needle Aspiration Cytology (FNAC) / Fine Needle Aspiration Cytology (FNAC) /
Biopsy (FNAB)Biopsy (FNAB) Crucial Step in evaluationCrucial Step in evaluationSimple, safe, accurate and cost effective Simple, safe, accurate and cost effective Assess Reliability Guidelines (Mayo Clinic)Assess Reliability Guidelines (Mayo Clinic)– Experienced, Preferably dedicated cyto-pathologistExperienced, Preferably dedicated cyto-pathologist– Multiple Sites of Aspiration (2-4)Multiple Sites of Aspiration (2-4)– A Low False Negative RateA Low False Negative Rate
Literature 1 – 11 %Literature 1 – 11 %Acceptable < 5%Acceptable < 5%Diagnostic Sample : 2 Slides - > 6 Groups EachDiagnostic Sample : 2 Slides - > 6 Groups Each
> 10 Follicular Cells In each > 10 Follicular Cells In each groupgroup
Benign………………………. 70%Benign………………………. 70%Indeterminate………………..10%Indeterminate………………..10%Malignant…………………… 5%Malignant…………………… 5%Non Diagnostic………………15%Non Diagnostic………………15%
Benign: Colloid NodulesBenign: Colloid Nodules– 70% Simple Cysts70% Simple Cysts– AutoImmune/ Lymphocytic ThyroiditisAutoImmune/ Lymphocytic Thyroiditis
Malignant:Malignant: – Papillary (Commonest) 83%Papillary (Commonest) 83%– Follicular : 11%Follicular : 11%– Medullary (MTC) 5%Medullary (MTC) 5%– Anaplastic Anaplastic 1% 1%
Indeterminate Category: (10%)Indeterminate Category: (10%)
2 GROUPS:2 GROUPS:– Suspicious for malignancy: definitive evidence Suspicious for malignancy: definitive evidence
for malignancy not evidentfor malignancy not evident– Follicular neoplasm: not possible to Follicular neoplasm: not possible to
differentiate from adenoma and carcinoma differentiate from adenoma and carcinoma (capsular/ lymphovascular invasion)(capsular/ lymphovascular invasion)
Both sub-groups qualify for surgeryBoth sub-groups qualify for surgery
Non-Diagnostic (20%)Non-Diagnostic (20%)
Solid LesionSolid Lesion - Insufficient No. of follicular Cells- Insufficient No. of follicular Cells
- Re-Aspiration Indicated after 4 - Re-Aspiration Indicated after 4 weeksweeks
– diagnostic aspirate in 50%diagnostic aspirate in 50%
– if non diagnostic : surgeryif non diagnostic : surgery
Cystic LesionCystic Lesion - Aspirate Unsatisfactory- Aspirate Unsatisfactory
- Solid Component- Biopsy Mandatory- Solid Component- Biopsy Mandatory
- If not feasible - Surgery- If not feasible - Surgery
THYROID SCINTIGRAPHYTHYROID SCINTIGRAPHY
Using Radioactive Iodine (IUsing Radioactive Iodine (I131131) / Technitium (99 mTc)) / Technitium (99 mTc)Depending on uptake classified as:Depending on uptake classified as:– HOTHOT: 5% Toxic Nodule : < 5% Malignant: 5% Toxic Nodule : < 5% Malignant– COLDCOLD: 80 – 85% : 10 – 15% Malignant: 80 – 85% : 10 – 15% Malignant– WARMWARM 10-15% : 9% Malignant 10-15% : 9% Malignant– Expensive/ Availability Only In Special CentresExpensive/ Availability Only In Special Centres– Overlap: Small Nodules MaskedOverlap: Small Nodules Masked
Use Limited ToUse Limited To : :– Indeterminate (Suspicious/Follicular) on FNACIndeterminate (Suspicious/Follicular) on FNAC– Follow Up of “hot” noduleFollow Up of “hot” nodule– Diagnosis of ectopic goitre / Substernal ExtensionDiagnosis of ectopic goitre / Substernal Extension
NORMAL Tc99m THYROID UPTAKENORMAL Tc99m THYROID UPTAKE
HOT NODULEHOT NODULE
COLD NODULECOLD NODULE
MULTI-NODULAR GOITREMULTI-NODULAR GOITRE
MANAGEMENTMANAGEMENT
Based on Combination of Input From:Based on Combination of Input From:– HistoryHistory– Clinical ExaminationClinical Examination– Ultrasound EvaluationUltrasound Evaluation– CytologyCytology
( Benign Nodules, Malignant Nodules, Indeterminate, Nondiagnostic)( Benign Nodules, Malignant Nodules, Indeterminate, Nondiagnostic)
Therapeutic Options:Therapeutic Options:1.1. Follow-Up With Periodic Clinical and lab inputFollow-Up With Periodic Clinical and lab input2.2. SurgerySurgery3.3. RadiotherapyRadiotherapy4.4. Medical therapyMedical therapy
MANAGEMENT (contd….)MANAGEMENT (contd….)
BENIGN NODULES (70%):BENIGN NODULES (70%):– Euthyroid: No Pressure symptoms Yearly Follow upEuthyroid: No Pressure symptoms Yearly Follow up
Cosmetically Acceptable Clinical/Biochem./ USGCosmetically Acceptable Clinical/Biochem./ USG
> 20% > 20% ↑ - Repeat FNAC↑ - Repeat FNAC– Role of Suppressive Rx with T4 – Not ProvenRole of Suppressive Rx with T4 – Not Proven– Beware of subclinical HyperthyroidismBeware of subclinical Hyperthyroidism– Euthyroid: Pressure + Cosmetic Problem – Limited SurgeryEuthyroid: Pressure + Cosmetic Problem – Limited Surgery– Toxic Nodule: Medical (CMZ/PTU Toxic Nodule: Medical (CMZ/PTU ++ Propranolol) Propranolol)
I I 131131 / Surgery / Surgery
MANAGEMENT (cont…)MANAGEMENT (cont…)
Malignant Nodules: 5%Malignant Nodules: 5%
PTCPTC : Total Thyroidectomy with Ipsilateral Central : Total Thyroidectomy with Ipsilateral Central Compartment Lymph Node ClearanceCompartment Lymph Node Clearance
FTCFTC: Non/Min. Invasive – Lobectomy: Non/Min. Invasive – Lobectomy Invasive: Complete Thyroidectomy (Total)Invasive: Complete Thyroidectomy (Total)
Follow Up for BothFollow Up for Both : I : I131131 ablation after 6/52 ablation after 6/52 High Dose Thyroxine High Dose Thyroxine
TSH Suppression (<0.1mu/L)TSH Suppression (<0.1mu/L)MTCMTC: Total Thyroidectomy with complete LN Clearance: Total Thyroidectomy with complete LN ClearanceANAPLASTICANAPLASTIC : Aggressive tumour- TLC/Decompression : Aggressive tumour- TLC/Decompression
MANAGEMENT (cont…)MANAGEMENT (cont…) INDETERMINATE (10%)INDETERMINATE (10%)
FOLLICULAR NEOPLASM / SUSPICIOUS FOR MALIGNANCY
SURGERY WITH INTRAOPERATIVE FROZEN SECTION
TOTAL THYROIDECTOMY
+
LYMPH NODE CLEARANCE
MANAGEMENT (cont…)MANAGEMENT (cont…)
NON DIAGNOSTIC : 20%NON DIAGNOSTIC : 20%
CYSTS : > 4 cm– REPEATED FNAC – NONDIAGNOSTIC/ SURGERY
NODULE – – SURGERY – EXCISIONAL BIOPSY
APPROACH TO THYROID NODULE – AN ALGORITHMAPPROACH TO THYROID NODULE – AN ALGORITHM
USG
CLINICAL EVALUATION+
TFT + IMMUNOLOGY
SOLID COMPLEX CYSTS WITH SOILD COMPUND
PURE CYSTS
FNAC
< 4cm > 4 cm
FOLLOW UP SURGERY
PATIENT WITH THYROID NODULE
EUTHYROID HYPERTHYROID HYPOTHYROID
ANTITHYROID DRUGS/
I 131 ABLATION / SURGERY
T4 REPALCEMENT
FNAC OF NODULE
CYTOLOGY REPORT
BENIGN (70%) MALIGNANT (5%) INDETERMINATE (10%) NON DIAGNOSTIC (15%)
PRESSURE SYMPTOMS/ COSMETIC PROBLEMS – NIL YEARLY FOLLOWUP
SCINTIGRAPHY
(I131/ 99 mTc)Rpt FNAC WITH USG
Rpt FNAC
SUSPICIOUS
WARM COLD DIAGNOSTIC
SURGERY
FOLLOWUP
> 20% INCREASE
SUPPRESSION WITH T4 – 6– 12 MONTHS NON-
DIAGNOSTIC
ALGORITHM (CONTD….)
CONCLUSIONCONCLUSION
Thyroid Nodule- A common ProblemThyroid Nodule- A common Problem
Evaluation: Evaluation: – Arbitrary, Inconsistent, DivergentArbitrary, Inconsistent, Divergent– Based on Personal PreferenceBased on Personal Preference
Long-term experience & advances in Long-term experience & advances in diagnostic aids: diagnostic aids: – Fresh Guidelines laying down systematic Fresh Guidelines laying down systematic
step-wise approachstep-wise approach– Misconcepts correctedMisconcepts corrected
THANK YOUTHANK YOU