EVALUATION OF A THYROID NODULE

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

7. CLINICAL EVALUATION

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

34. MEDULLARY
• Amyloid stroma

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