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6/30/2017
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Evaluation and Management of Thyroid Nodules in Primary Care
Chris Sadler, MA, PA-C, CDE, DFAAPAMedical Science Outcomes Liaison – Intarcia Diabetes and Endocrine AssociatesLa Jolla, CAPast President - ASEPA
Disclosures�Employee of Intarcia Therapeutics Inc, I am speaking on my
own behalf and do not represent Intarcia on this subject matter.
�PA Sadler does not intend to discuss the use of any off-label use/unapproved drugs or devices
Objectives
Participants in this session will learn:
1)To recall thyroid nodule ultrasound characteristics
that increase the risk of malignancy
2)To identify when to order an FNA of a thyroid nodule
according to current guidelines
3)To interpret a thyroid US report and know when to
ask for more information
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A 35 yo asymptomatic female is found to have a solitary
2.0 cm which was found to be benign on FNA x2. It has
not grown on yearly US exams x 2 yrs. You recommend:
Pre Test Question 1
Correct answer is…1
1. Reassure, repeat US in 2-3 yrs
2. Repeat FNA just to be sure
3. Continue yearly US exams for life
4. This nodule no longer needs follow-up
A 35 yo asymptomatic female is found to have a solitary 2.0
cm solid, markedly hypoechoic nodule with
microcalcifications on thyroid ultrasound. The TSH is normal.
The most appropriate next step would be to:
Pre Test Question 2
Correct answer is…2
1. Reassure, repeat US 6-12 months
2. Order an FNA
3. Refer for surgery
4. Order thyroid uptake and scan
Thyroid cancer diagnosis rates have increased dramatically
over the last decade along with thyroid cancer mortality rates
Pre Test Question 3
Correct answer is…2
1. True
2. False
3. I don’t know, ask me another question
4. I’ll answer after the lecture
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Thyroid Nodules
Principles of Anatomy and Physiology,, Seventh Edition, 1993, Biological Sciences Textbooks, Inc.
Thyroid Nodule/CA Overview� Using US 19 – 68% of randomly selected adults have thyroid nodules1
� More common in women and elderly1
� 2009 - 37,200 cases of thyroid cancer diagnosed2
� 2014 - 63,000 cases of thyroid cancer diagnosed2
� Mortality rates unchanged despite the increase in thyroid cancer incidence2
1) Guth, S, et al. Very high prevalence of thyroid nodules detected by high frequency
ultrasound examination. Eur J Clin Invest 2009;39:699-706.2) Siegel, R et al. Cancer Statistics, 2014 Cancer J Clin 2014;64:9-29.
Causes of Thyroid Nodules
Benign nodular goiter
Chronic lymphocytic thyroiditis (Hashimoto’s)Simple or hemorrhagic cysts
Toxic autonomous noduleFollicular neoplasm
Subacute thyroiditisPapillary carcinomaFollicular carcinoma
Medullary carcinomaAnaplastic carcinoma
Primary thyroid lymphomaMetastatic tumors
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Laboratory Testing – TSH/Other� A low TSH = low risk for malignancy (indicates need for
thyroid scan) Also check FT4
� An elevated or ULN TSH = increased risk for malignancy in nodular thyroid disease. Check FT4 and TPO antibodies
� A single, non-stimulated serum calcitonin measurement if medullary thyroid carcinoma is suspected due to FNA results or history.
AACE Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules –2016 Update
Thyroid Nodule Work-up
Evaluation: Do you need a
I123 scan?
• If TSH is low – Yes
• If TSH normal or high - No
• Cold nodule = non-functioning (no iodine uptake)
• Most cancers are cold nodules
• most nodules are cold and most are not cancers
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Low TSH: ? Toxic “Hot” Nodule or
Toxic MNG
Hyper-functioning nodules almost never cancer
CLINICAL FACTORS SUGGESTING INCREASED
RISK OF MALIGNANT POTENTIAL
� Hx of head and neck irradiation (<25 yrs ago)
� Family Hx of MTC, MEN 2, PTC, Familial Polyposis coli, Cowden dz, Gardner syndrome
� Age <14, >70
� Male sex
� Firm or hard consistency
� Fixed nodule
� Palpable cervical adenopathy
� Persistent dysphonia, dysphagia, or dyspnea
History & Exam: Nodular Thyroid
• How long has it been there? Is it changing? Any
symptoms (pressure, voice, etc.).
• Lymphadenopathy present or absent
• Fingers assess size poorly; ultrasound required
• Assess for mobility and consistency (fixed and
firm/hard on palpation more suspicious)
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ULTRASOUND FACTORS
SUGGESTING MALIGNANCY� THESE ARE ADDITIVE
� Microcalcifications
� Irregular margins
� Solid – marked hypoechogenicity
� Suspicious cervical lymphadenopathy
� Taller than wide in transverse view
� Extra-capsular extension
� Interrupted rim calcification
QUALITY of the Ultrasound� Experience varies widely: What to look for?
� Documented details of nodule characteristics� Size, location, solid, cystic, mixed
� Hypo/iso/hyperechoic
� Margins, calcifications, vascularity
� Taller than wide, extra-thyroidal extension
� Mention of presence or absence of adenopathy
� Clear report with guidance regarding next steps
� Follow-up – a rapidly growing or changing nodule is more suspicious (change in US characteristics is more prognostic than change in size)
Fine Needle Aspiration
•Best means of evaluating a thyroid nodule.
•For solitary nodule the diagnostic procedure of choice
• If multiple nodules, choose high risk nodules for sampling based on suspicious characteristics, not size
•Dependent on an experienced cytopathologist
(Ultrasound guided FNA is standard of care)
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Fine Needle Aspiration(Ultrasound guided FNA is standard of care)
Who needs an FNA?� Depends on the risk category based on suspicious US characteristics.
Single Feature Approach
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Pattern Approach
ACR - TIRADS
NODULE CHARACTERISTICS
• Normal
• Transverse
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NODULE CHARACTERISTICS
• Normal
• Long axis
Superior Inferior
NODULE CHARACTERISTICS
• Pure CysticBenign, < 1 % Risk
No FNA (but may
aspirate fluid if
symptomatic)
NODULE
CHARACTERISTICS• Spongiform
Very Low
Suspicion
< 3% Risk
Consider FNA
If > 2.0 cm
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NODULE
CHARACTERISTICS
• Partially CysticVery low
Suspicion
< 3 % Risk
Consider FNA
If > 2.0 cm
NODULE
CHARACTERISTICS• Solid hypoechoic, regular margins
• Intermediate suspicion
• 10-20%
• FNA > 1 cm
NODULE
CHARACTERISTICS• Lumpy Bumpy Thyroid
• No need for FNA
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Nodule Characteristics• Solid hypoechoic w/Microcalcifications
High suspicion
> 70-90%
FNA if > 1 cm
(punctate echogenic
Foci)
NODULE
CHARACTERISTICS• Solid iso/hyperechoic
• Regular Margins –
• Low suspicion
• 5-10%
• FNA if > 1.5 cm
NODULE
CHARACTERISTICS• Solid Hypoechoic
• Irregular Margins
• Calcifications
• High suspicion
• 70-90% Risk
• FNA if > 1 cm
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NODULE
CHARACTERISTICS
• Solid Hypoechoic-Taller than Wide (transverse view)
• High suspicion
• > 70-90% Risk
• FNA > 1 cm
LYMPH NODE
CHARACTERISTICS
• Normal Abnormal
• Transverse view
• A/T ratio > 2 A/T ratio < 2
A/T ratio = 1.1
Nodule Characteristics• Extra-capsular invasion
• High suspicion
• > 70-90% Risk
• FNA > 1 cm
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The Onion
Case: Joe A.
• 36 yo male with incidental finding of a 6 mm solid
thyroid mass on MRI during w/u for cervical disc dz.,
no family history or risk factors for thyroid cancer.
• What test do you order?
• TSH
• Ultrasound
Case: Joe A.
• TSH is normal
• Ultrasound Results: 5.6x4x5.5 mm (L x AP x W)
solid hypoechoic nodule in the right lower pole, no
microcalcifications, irregular borders or abnormal
lymph nodes
• What next?
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The most appropriate next step would be to:
Audience Response
Correct answer is…1
1. Reassure, repeat US 12 months
2. Order an FNA
3. Refer for surgery
4. Order thyroid uptake and scan
FNA for Low Risk Patients w/o Abnormal
LNs� Solid Hypoechoic nodule = intermediate risk 10-20%
� But given < 1 cm can reassure and repeat US in 12 months, if > 1 cm and/or more importantly, develops new suspicious features –> FNA.
� If repeat US are stable for several years, then may no longer need to follow this nodule
Case: Keri M.
• 22 yo female presents with left sided nodule on routine exam
•Ultrasound order by PCP: 1.8 cm solid hypoechoic nodule in the left lower pole with irreg. margins
•On exam, the left sided nodule is firm, non-tender
•TSH and TPO antibodies are normal
•Here in my office with very anxious mother
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How would you proceed?
Audience Response
• 1) refer immediately to surgeon
• 2) US guided FNA of left thyroid nodule
• 3) Observe and repeat US in 6 months
• 4) Give thyroid hormone to suppress the nodule and repeat US in 6 months
Correct answer: 2
FNA for Low Risk Patients w/o Abnormal
LNs� Hypoechoic solid > 1.0 cm + irreg. margins
� High suspicion pattern (70-90% risk)
� Iso or Hyperechoic and solid > 1.5 cm
� Complex, non-calcified > 1.5-2.0 cm
� Spongiform nodules > 2.0-2.5 cm
� Multiple nodules
� Prioritize based on above criteria
� If multiple similar appearing, coalescent nodules, FNA the largest
ACR - TIRADS
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Case: Keri M.
JV
CATR
Case: Keri M.
TRCA
JV
Case: Keri M.
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Case: Keri M.
Case: Keri M.
Case: Keri M.
• FNA: Suspicious for Papillary Thyroid Carcinoma
• Suspected metastatic lymph nodes throughout left neck
•Plan: Total Thyroidectomy with radical left neck dissection, postoperative RAI and total body scan
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Thyroid Cancer
• Rare ~ 5-10% of all palpable thyroid nodules
• Female/male ratio = 4:1
Thyroid Cancer�Five types
�Papillary: 60-80% of all cases; slow growing
�Follicular: 15-30%. More aggressive than papillary
�Medullary: 2-10%. Familial, associated with MEN II
�Anaplastic: (rare) Most aggressive of all; 20% five year survival. Differentiates into small and giant cell. Death within 6 months if giant cell
�Thyroid Lymphoma: 4-10% usually women over 50 with Hashimoto’s thyroiditis. Rapid growing neck mass
Thyroid Cancer
• Generally found as a thyroid nodule
• Diagnosis is histological
• Treatment
•Surgical excision
•RAI ablation (none for low risk, lower
doses)
•Radiotherapy?
•Chemotherapy?
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Thyroid Cancer
•Prognosis depends on:
•Type
•Patient’s age at diagnosis
•Extrathyrodal extension or distant
metastases
•In patient with metastatic disease, the
right initial surgery improves prognosis
Case: Rick •42 yo male 2.5 cm nodule in left thyroid lobe
•Solid hyperechoic, well defined borders, no other suspicious features
•Visible, firm, moves well
•FNA 4 years ago = benign cytology
•Yearly US exams stable
•Pt. with young children, continues to worry
•Last US one year ago - no change
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ACR - TIRADS
Case: Rick
�TSH: 1.110 (0.35 - 4.00) , Free
T4: 1.25 (0.89 - 1.80) , TPO
antibodies: negative
What would you do next?
Question 3
1. Repeat US
2. Repeat US guided FNA
3. Refer for surgery
4. Reassure – repeat US in one year
Correct answer: 2
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Benign cytology has low risk for malignancy
Follow-up of cytologically benign nodules
Growth = > 50% increase in volume or > 20% increase in 2 of 3
dimensions (min 2 mm) However growth not related to malignancy
Case: Rick
• Repeat US guided FNA reveals cytology c/w papillary thyroid carcinoma
• Referred for surgical removal
• If 2 US guided FNA’s are benign the risk of malignancy is virtually zero.
• Always listen to the patient
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Follow-up of benign nodules
• Prospective, multicenter, observational study of 992 patients with 1,567 asymptomatic thyroid nodules
•The majority of nodules benign at 5 yrs
•Cancer in only 0.3% of nodules in 5 years
• Of the 5 cancers only 2 had grown, the others had
changes in US characteristics
• Repeat US in 6-18 months in sonographically and
cytologically benign nodules and then ever 3-5 yrs as
long as no significant growth
JAMA 2015;313:926-35
Future for Indolent “Cancers”
�“Encapsulated follicular variant of papillary thyroid carcinoma”
�proposed name change to:
�“Noninvasive follicular thyroid neoplasm with papillary-like nuclear features” (NIFTP)
(This diagnosis only made after surgery but has implications for treatment and follow-up)
Summary
•Thyroid nodules are common and most are
benign
•TSH to determine if scan necessary
•US to identify suspicious nodules based on
single characteristics or patterns
•USG-FNA should be performed on suspicious
nodules
•Follow-up determined by risk category of
nodule
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A 55 yo asymptomatic female is found to have a solitary
2.0 cm solid hypoechoic nodule which was found to be
benign on FNA x2. It has not grown on yearly US exams
x 2 yrs. You recommend:
Post Test Question 1
Correct answer is…1
1. Reassure, repeat US in 2-3 yrs
2. Repeat FNA just to be sure
3. Continue yearly US exams for life
4. This nodule no longer needs follow-up
A 35 yo asymptomatic female is found to have a solitary 2.0
cm solid, markedly hypoechoic nodule with
microcalcifications on thyroid ultrasound. The TSH is normal.
The most appropriate next step would be to:
Post Test Question 2
Correct answer is…2
1. Reassure, repeat US 6-12 months
2. Order an FNA
3. Refer for surgery
4. Order thyroid uptake and scan
Thyroid cancer diagnosis rates have increased dramatically
over the last decade along with thyroid cancer mortality rates
Post Test Question 3
Correct answer is…2
1. True
2. False
3. I still don’t know, quit pestering me
4. Ask me again tomorrow
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Resources•www.thyroid.org - American Thyroid Association
•2015 American Thyroid Association Management
Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer
•www.aace.com – American Association of Clinical
Endocrinologists
•Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules –
2016 Update
•www.endo-society.org - The Endocrine Society
