Solitary thyroid nodule by / Dr.hossam mohammed mahmoud supervised By/ Dr .nasser Zaghloul faculty of medicine Minia university

1. Prepared by : Hossam Mohammed Mahmoud
Supervised by : Dr . Naser Zaghloul

2. SOLITARY NODULE THYROID
DEFINITION:-
DISCREAT SWELLING IN AN OTHERWISE IMPALPABLE GLAND

3.  IntroductIon
* In the general population, thyroid nodules are
discovered by palpation in 3% to 7%, and by US
in 20% to 76% .
* palpable thyroid nodule is 5% in women and
1% in men .
* 5- 15 % of them are malignant .
* Prevalence increases directly with age,
exposure to ionizing radiation, and iodine
deficiency

4. * 4-7 % of adults have palpable
thyroid nodule
* 1 of 20 is malignant .
* 50 % of 60 years old persons
have thyriod nodules .
In uSA :

5. rISk fActorS of mAlIgnAncy
History Physical examination
Age <20 or >70 years larger than 3 cm
Male sex Rapid tumor growth
History of childhood
head/neck irradiation
Very firm nodule, irregular
surface
Family history of PTC,
MTC, or MEN2
Fixation to adjacent
structure
Cervical lymphadenopathy
Cold nodule on thyroid
scan
Solid or complex cyst on
US

6. fActorS SuggeStIng benIgn
thyroId nodule
F.Hx of autoimmune disease (Hashimoto’s
thyroiditis)
F.Hx of benign thyroid nodule or goiter
Presense of thyroid hormone dysfunction,
hypothyroid or hyperthyroid
Pain or tenderness associated with nodule
Soft, smooth, mobile
MNG without a predominant nodule
Warm nodule on thyroid scan
Simple cyst on US

7. Etiology
Benign Malignant
Dominant nodule of a
multinodular goitre.
Primary:
Follicular cell-derived
carcinoma:
PTC,
FTC,
anaplastic thyroid carcinoma
C-cell–derived carcinoma:
MTC
Thyroid lymphoma
Colloid nodule Secondaries:
Metastatic carcinomaHashimoto’s thyroiditis
Simple or hemorrhagic cyst
Follicular adenoma
Subacute thyroiditis
Autonomous toxic nodule
Plummer’s Disease

8. ManagEMEnt
 (1) History
 (2) Examinations .
 (3) Investigations
 (4) Treatment .
* Personal
* Present
* past
* Family
* Laboratory
* Radiological
* Biopsy

9. (1) History :
Personal Present Past Family
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
* 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 .
h/o neck
irradiation
h/o thyroid disease
in family
Ex:
-autoimmune
disease
- carcinoma

10. (2) ExaMinations :
 Factors suggesting malignancy :
* larger than 3 cm * hard with irregular surface
* Fixed * Cervical lymphadenopathy
 Factors suggesting benign nodule :
* Pain or tenderness associated with nodule
* Soft, smooth, mobile

11. (3) invEstigations :
 Laboratory :
⃝ 1 - Thyroid functions test :
TSH level ( N : 0.5-6 uU/ml )
Hyperthyroid ( ↓ TSH )
( hyper-functioning)
radionuclide imaging
(scan)
Euthyroid (Normal
TSH )
Hypothyrioid ( ↑ TSH )
You must ask for :
⃝ 2 – Serum Antibodies :
Anti-thyroglobulin , anti-peroxidase
To exclude Hashimoto’s
+
FNABC ( 5 % turn to lymphomas )
N.B : scan is only indicated in :
1-is suppressed TSH
2-if FNAC→follicular neoplasia

12.  ⃝ 3 – If there is family history of Medullary
carcinoma OR MEN-II ( not routinely done )
ask for :
1- serum calcitonin
2- serum Calcium
3- urinary catecholamines
N.B : screening in familial type is by calcitonin
level , If High we do total thyroidectomy even
normal thyroid function .

13.  Imaging :
⃝ 1 – Ultrasound :
* Can answer following questions
* Solid/cystic
* Size of the nodule and size of gland .
* Additional nodules
* malignant feature
* Can guide in: FNACB , cyst aspiration,
ethanol injection , and laser therapy .
Hypo echoic , Micro-calcifications , Irregular
margins , Hypervascular (by doppler ) ,
Lymphadenopathy

14. Hypo-echoic Hyper-vascular
-CALCIFICATIONS,
- POORLY DEFINED
- IRREGULAR MARGINS

15.  Imaging :
⃝ 2 – Radionuclide scan :
Using Iodine131 OR Technetium-pertechnetate
99m.
* cold nodule ( non-functioning ) (90%) : cancer risk 5- 10 %
* hot nodule (functioning ) (10 %) : cancer risk 1%
Only in hyperthyroid ( suppressed TSH )
* Not useful in distinguishing benign and malignant lesions since
majority of cold nodules are benign (80%) and some warm
nodules are malignant (5%)
* It can reveal retrosternal extension .
Cold nodule Hot nodule

16. Other imaging methods
 MRI , CT Rarely indicated.
Only to evaluate retro-sternal extension .
 PET scan using FDGf18 (fluorodeoxyglucose F18 )
It can differentiate
benign from malignant
But
Highly expensive and can
not replace biopsy

17. (3) FNACB the most direct and most specific
 Sensitivity: 70-90% ( after 2-4 passes of needle ) , specificity :70-
90%
 False negative result: 1-6 %
 Reliability depend on: Operator , Cytopathologist
 can not differentiate between follicular adenoma and carcinoma
 should guided with sonar .
 Findings :
+ve ( malignant ) - ve ( benign )
- Commonest is PTC
- MTC
-anaplastic carcinoma
- metastatic cancers
- Colloid nodule
-Macrofollicular adenoma
-Lymphocystic thyroiditis
-Granulomatus thyroiditis
-Benign cyst
Suspicious
-Follicular neoplasms
-Hürthle cell neoplasms
-Atypical PTC
- Lymphoma

18. ImmuNohIstoChemICAl mArkers
 HBME-1 (Hector Battifora mesothelial cell -1 )
monoclonal antibody
stains papillary cancer positively but
does not stain benign follicular tumors
 Galectin-3
acts as a cell-death suppressor
distinguish benign from malignant
thyroid follicular tumors

19. TreaTmenT opTions :
 1- Levothyroxine : ( in benign nodule ) to keep TSH below
0.1 mU/L
Have many Side effects , so not recommended
 2- surgery : indicated in :
- FNAC positive or clinically suspicious : ( eldery ,male , hard texture
, fixed , recurrent laryngeal nerve palsy , lymphadenopathy ,
recurrent cyst
- Cosmosis - Toxic nodule - Pressure symptoms
**methods
* Lobectomy + isthemusectomy: In pt with
low risk factors & Benign
* Total thyroidectomy: In pt with high risk factors
Benign nodules & Malignant nodules

20.  3- Radioiodine : indicated in functioning
nodule, contraindicated in pregnancy , lacatation ,
children . S/E : hypothyroidism , carcinogenic , fetal
anomalies in pregnant women .
 4- Percutaneous ethanol injection , and
laser photocoagulation .

21. * Guidelines : according to American Thyroid Association 1996
& American Association of Clinical Endocrinology
 Radionuclide scan is only indicated in :
1 - suppressed TSH
2 - if FNAC → follicular neoplasia
 FNAC should be guided by U/S especially if the nodule is
partially cystic .
 benign nodule → Life long Follow-up every year by
( TSH , neck palpation , FNAC ) , if functioning : Iodine -131 is
TTT of choice , and Surgery is indicated in :
 - very large nodule , OR - partially cystic , - young
patient , pregnant
 malignant nodule → surgry
 Autoimmune thyroidits → cortison + L-thyroxin
 Infections → control .

22. Revised
American Thyroid
Association
Guidelines
2009