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Evaluation of Thyroid Nodules Michael L. Tuggy, MD Swedish Family Medicine, Seattle, WA

Evaluation of Thyroid Nodules

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Page 1: Evaluation of Thyroid Nodules

Evaluation of Thyroid Nodules

Michael L. Tuggy, MD

Swedish Family Medicine, Seattle, WA

Page 2: Evaluation of Thyroid Nodules

Case 1

• 42 y.o. male with no active medical problems. During your routine physical, note a thyroid nodule. Told by ENT last year not to worry about it.

• PE: 1 x 2cm R lower pole nodule.

What information do you want from the patient?

Page 3: Evaluation of Thyroid Nodules

Age as a Risk Factor

• Age – young patients (<20 years of age)– thyroid nodules are much more likely to be

malignant (40-50%).– elderly (>60 years of age) -higher risk,

especially of more aggressive thyroid tumors.

Page 4: Evaluation of Thyroid Nodules

Gender and Thyroid Nodules

• Gender – male -higher risk if nodule present– females

• have many more nodules• less likely to be malignant.• still have majority of thyroid cancers

Page 5: Evaluation of Thyroid Nodules

Other major risks

• Radiation to head and neck. – 40% risk of thyroid cancer usually 25 years

later.– Exposed populations- Polynesian studies

• Family History of MEN II, Gardner’s Syndrome, Cowden’s disease.

Page 6: Evaluation of Thyroid Nodules

Historical Red Flags

• Recent growth

• Soft tissue swelling

• Vocal changes

• Dysphagia

• Signs of thyroid dysfunction

Page 7: Evaluation of Thyroid Nodules

Case 2• 26 y.o. Eritrean female with a 2-3 year

history of goiter. No symptoms but noted enlargement on right for 1 year.

• P.E.: 3x4 cm Right sided thyroid mass, firm, adherent to soft tissue.

What physical findings are worrisome?

How can you best clarify the nature of the nodule?

Page 8: Evaluation of Thyroid Nodules

Thyroid Exam

Page 9: Evaluation of Thyroid Nodules

Physical Exam of the Thyroid

• Use both hands simultaneously to evaluate for symmetry

• Patient upright - screening exam

• Patient supine with neck in extension- detailed exam. Swallowing assists in elevating gland.

• Evaluation of other neck structures.

• Voice changes (recurrent laryngeal nerve).

Page 10: Evaluation of Thyroid Nodules
Page 11: Evaluation of Thyroid Nodules

Thyroid Scans

• Purpose – Determine function of the gland and/or a

nodule within the gland

• Hot nodules - usually independently functioning nodules – Rarely, rarely malignant

• Cold nodules - either adenoma or maligancy– 15% chance of malignancy in adults.

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Thyroid Ultrasound

• Can identify presence of nodules.

• May be able to characterize follicular vs. solid.

• Not able to rule our malignant nodule

• Aid in biopsy.

Thyroid

Page 13: Evaluation of Thyroid Nodules

Case 3

• 30 y.o. WF with enlarging cold benign thyroid adenoma (diagnosis from previous FNA biopsy).

• PE: 4 x 5 cm mass on Right

What do you do now?

Page 14: Evaluation of Thyroid Nodules

Fine-Needle Aspiration• Best tool for determining pathology other

than surgical excision.

• Can be as high as 80 % sensitive and 95% specific.

• Operator dependent in obtaining adequate amount of tissue. 25 gauge needle is optimal.

• Should not be relied on if negative in patient with previous neck irradiation.– Multifocal tumors common.

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Interpreting the Biopsy Report• What you get:

– benign– indeterminate– suspicious– inadequate specimen

• What it means:– benign - 90-95% likelihood it is benign– indeterminate- who knows?– suspicious- it’s malignant.– inadequate specimen - do it again (and again)

Page 16: Evaluation of Thyroid Nodules

Thyroid Malignancies- Papillary• Most common

• 30% have node metastasis at diagnosis

• Radiation related

• Histologically, psammoma bodies distinguish from benign adenoma.

Page 17: Evaluation of Thyroid Nodules

Thyroid Malignancies-Follicular

• 20 % of malignancies

• Distinguished from normal follicular adenomas by invasion of capsule or blood vessels.

• May be difficult to determine on FNA

Page 18: Evaluation of Thyroid Nodules

Thyroid Malignancies- Medullary

• 5-10% of cases

• arise from the C cells which produce calcitonin

• diagnosis based on elevated thyrocalcitonin levels and thyroid nodule (cold)

Page 19: Evaluation of Thyroid Nodules

Thyroid Malignancies- Anaplastic

• < 10%

• Highly aggressive with local extension at time of diagnosis.

• No suitable therapy

• Prognosis < 1 yr from diagnosis

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Treatment

• For all malignancies, excision of the the lobe (or if post-radiation the entire gland).

• XRT- very specific and well tolerated- I131 therapy.

• Anaplastic tumors - palliative radiation and XRT.

Page 21: Evaluation of Thyroid Nodules

What about those benign nodules?

• No specific treatment is needed.

• Thyroid suppression may shrink size of adenomas

• Not proven to be effective or necessary

• May hide malignancies - ? Periodic biopsies or scans.

Page 22: Evaluation of Thyroid Nodules

Case 4 - This weeks puzzler!

• 40 y.o. WF s/p I131 ablation for Grave’s Dz. 6 years ago.

• Persistant R thyroid nodule 2 x 1.5 cm in size.

What is the likely diagnosis?

Page 23: Evaluation of Thyroid Nodules

Outcomes• Case 1. - Papillary cancer - 3 (+) nodes

– no metastasis at 1 year.

• Case 2. - Follicular cancer - 5 (+) nodes– no metastasis at 1.5 years

• Case 3. - Large adenoma with incidental 1 cm papillary carcinoma superior to nodule.– No recurrence at 5 years.

• Case 4. - Non-functional adenoma

Page 24: Evaluation of Thyroid Nodules

Modified from: Castro, MR, Gharib, H. Endocr Pract 2003; 9:128.

Page 25: Evaluation of Thyroid Nodules

Summary:Solitary Nodule Evaluation

• TSH – if low – scan – if hot nodule, then observe.• Normal TSH - Do I scan first or FNA first?-

– high risk - scan and FNA • Is the nodule cold or hot?• Cold - FNA biopsy

– low risk - FNA• if indeterminate- scan and re-FNA or

excisional biopsy.• Anti-perioxidase Antibody – helpful if low- TSH to

diagnose thyroiditis.

Page 26: Evaluation of Thyroid Nodules
Page 27: Evaluation of Thyroid Nodules

Never assume a solitary thyroid nodule is benign. Prove it.