THYROID

NODULES

LISA A. CICO, MSN, NP

UPSTATE MEDICAL UNIVERSITY
BREAST & ENDOCRINE SURGERY
COORDINATOR THYROID CANCER PROGRAM
SURGICAL COORDINATOR BREAST CANCER
PROGRAM
 Comprehensive review of current
diagnostic tools and imaging to
OBJECTIVES assess thyroid nodules
Describe tools / Review American Thyroid
diagnostic testing for
assessment of the
patient with a thyroid
Association, & National
nodule(s) Comprehensive Cancer Network
*Utilize national Guidelines for patients who
guidelines developed for
patients with thyroid develop thyroid nodules
nodules
Review common symptoms of
*Describe some of the
common symptoms of patients with thyroid nodule
patients with thyroid
nodules
 Obtaining appropriate
imaging/diagnostic testing, and
OBJECTIVES frequency
Identify which patients can Overview of ultrasonographic
safely be followed by PCP
*Describe
thyroid terminology
imaging/diagnostic Overview of Betheseda thyroid
modalities for following
the patient with thyroid nodule pathology terminology
nodules
*Identify those patients
Obtaining appropriate personal and
requiring referral to
specialty
family history
*Identify which specialty Identify what patients require
to make an appropriate
referral based on referral and to endocrine or surgery?
diagnostic, objective and
symptomatic findings
Briefly discuss appropriate follow up
for the patient with thyroid cancer
Definition of Thyroid Nodule

A discrete lesion within the thyroid gland that is

palpably and/or ultrasonographically distinct from
surrounding thyroid parenchyma

*ATA Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid
Cancer (2006 & 2009 Task Force)
Prevalence

Rallison et al. JAMA 1975

Hogan et al. J Surg Res 2009
How was this nodule found?

Palpation with a physical exam

Incidental finding on diagnostic work up
Self detection
Surveillance
Work up for symptoms of hyper/hypothyroidism

How was found is it clinically relevant?

Physical Examination of Thyroid Gland

Visual inspection
Palpation of thyroid, neck nodes, and supraclavicular
nodes
Fixed, mobile, soft, tender?
Reflexes why?
HR, BP, weight
Symptoms

Usually NONE!!
Occasionally painful, quick onset (cyst)
Difficulty swallowing
Hoarseness OR change in voice
Shortness of breath (or difficulty swallowing) usually
while supine OR hands raised over head
(Pembertons Sign)
Choking sensation
hyper/hypo thyroid
 Symptoms?

Nodules Hyper/Hypo thyroid

Difficulty swallowing

Globus sensation

Choking sensation

Hyper-functioning nodule

Hashimotos
Pertinent History & PE in Evaluation of TNs

History Physical Findings

Head & neck irradiation

Whole body irradiation
Nuclear fallout
Rapid growth
Family history of thyroid malignancy
Hoarseness
Heredity
Cervical /supraclavicular
lymphadenopathy
Fixation of nodule or gland
> 4 cm
Solitary
Differential Diagnosis

Multinodular Goiter
Hashimotos Thyroiditis
Cancer
Lymphoma

Solitary Thyroid Nodule

Substernal Goiter
Family History
of
Hereditary Diseases

COWDENS SYNDROME
FAMILIAL POLYPOSIS
CARNEY COMPLEX
MEN 2
WERNER SYNDROME
THYROID MALIGNANCY
Substernal Goiters

Short neck
Stocky build

Usually incidental finding by CXR or CT

Many times treated unsuccessfully for asthma
Ultrasound: The Gold Standard

Anyone found to have,

OR is suspected of having a
nodule evaluate by
ultrasound!!
 Pure cystic (relatively rare)

BENIGN
CHARACTERISTICS

Spongiform appearance in >50% of

nodule volume (aggregration of
multiple microcystic components)

Multiple (?)
BENIGN

Septated cyst
BENIGN

Cyst
BENIGN

US (a, transverse; b, longitudinal) scans in 51-year-old woman show 2.4-cm well-

defined mixed-echoic hypoechoic nodule (arrows) in right lobe of thyroid gland. Initial
cytologic result was adenomatous hyperplasia, confirmed after 11 months at repeat
aspiration
 High-risk history: History of thyroid cancer in one or more
first degree relatives; history of external beam radiation as
a child; exposure to ionizing radiation in childhood or
ULTRASOUND adolescence; prior hemithyroidectomy with discovery of
CHARACTERISTIC thyroid cancer, 18FDG avidity on PET scanning;
MEN2/FMTC-associated RET protooncogene mutation,
CONSIDERATIONS calcitonin >100 pg/mL. MEN, multiple endocrine
neoplasia; FMTC, familial medullary thyroid cancer.

Suspicious features: microcalcifications; hypoechoic;

increased nodular vascularity; infiltrative margins; taller
than wide on transverse view.

FNA cytology may be obtained from the abnormal lymph

node in lieu of the thyroid nodule.

Sonographic monitoring without biopsy may be an

acceptable alternative
 Hypo-echogenicity compared to normal
thyroid parenchyma
Increased intra-nodular vascularity
SUSPICIOUS
Irregular infiltrative margins
CHARACTERISTICS
Presence of micro-calcifications
Absent halo
Shape taller than width in transverse
dimension
Nodules > 4 cm
Solitary
Difficulty swallowing

ATA Guidelines 2009

Suspicious

Hypoechoic
Suspicious

Increased vascularity
SUSPICIOUS

Increased vascularity
SUSPICIOUS

Calcifications
Poorly defined, irregular margins
SUSPICIOUS

Solid
Multiple Thyroid Nodules

FNA what nodule??

> 1 cm
Suspicious features
Dominant / largest one
 FNA of Palpable Nodule

Palpation? Ultrasound?

What nodule(s) do you FNA?

What nodule(s) do you FNA?

TN with suppressed TSH

UPTAKE SCAN to assess autonomous nodule

Compare to U/S what is the correlation with

Uptake

FNA consider in non - functioning or

isofunctioning with suspicious features
FNA

Only GOLD standard for proof of malignancy

without surgical pathology
 FNA

False Negative False Positive

false-negative rate of up to 5% with FNA

which may be even higher with nodules >4
cm

??
 Is Size a Predictor of Malignancy?

< 1 cm > 1 cm

NO

NO

ATA Guidelines 2009

FNA Results

Nondiagnostic
Benign
Atypia of Undetermined Significance (AUS)
Suspicious for a Follicular Neoplasm/Follicular
Neoplasm
Suspicious for Malignancy
Malignant

Bethesda System for Reporting Thyroid Cytopathology

Diagnostic Category Risk of Malignancy Usual management
(%)

Nondiagnostic or Repeat FNA with

Unsatisfactory ultrasound guidance

Benign 0-3 Clinical Follow up with

ultrasound 6 months
Atypia of Undetermined 5-15 Repeat FNA 3 months; if
significance or Follicular same, then lobectomy
lesion of Undetermined
significance

Follicular Neoplasm or 15-30 Surgical Lobectomy

suspicious for Follicular
neoplasm

Suspicious for 60-75 Near total thyroidectomy

Malignancy or surgical lobectomy

Malignant 97-99 Near total thyroidectomy

 TSH
Free T4
Lab Work
TSH
Free T4
TPO in suspected thyroiditis
T4
T3 TG tumor marker in PTC, FTC,
Free T3
HTC
TPO
Thyroglobulin (TG)
Calcitonin Calcitonin suspected MTC or
in follow up of MTC
20% increase in
diameter in > 2
dimensions Re-aspirate
(>2mm) or Thyroid Nodule
volume
increase > 50%
 TABLE 3. SONOGRAPHIC AND CLINICAL FEATURES OF THYROID NODULES AND RECOMMENDATIONS FOR FNA

Nodule sonographic or clinical features Recommended nodule threshold size for FNA

High-risk history a

Nodule WITH suspicious sonographic featuresb >5mm Recommendation A

Nodule WITHOUT suspicious sonographic featuresb >5mm Recommendation I

Abnormal cervical lymph nodes Allc Recommendation A

Microcalcifications present in nodule 1cm Recommendation B

Solid nodule

AND hypoechoic >1cm Recommendation B

AND iso- or hyperechoic 11.5 cm Recommendation C

Mixed cysticsolid nodule

WITH any suspicious ultrasound featuresb 1.52.0 cm Recommendation B

WITHOUT suspicious ultrasound features 2.0 cm Recommendation C

Spongiform nodule 2.0 cmd Recommendation C

Purely cystic nodule FNA not indicatede Recommendation E

RAI Uptake Scan

ONLY IN HYPERTHYROID

Cold Nodule - 10% incidence of being CA

Thyroid Cancers

From 2005 to 2009, incidence rates increased by

5.6% per year in men and 7.0% per year in women,
making thyroid cancer the fastest increasing cancer
in both men and women

Most common endocrine cancer

Projected Cases of Thyroid Cancer

60, 220 new cases are estimated for 2013

45, 310 female
14, 910 male
1,850 deaths projected for 2013
1,040 female
810 male
Death rate 0.5 per 100,000 in both male and females
AGE & INCIDENCE
AMCERICAN CANCER SOCIETY / NCCN/ SEER

Diagnosed at a younger age then most adult cancers

Median age at diagnosis was 50 years from 2005-2009

2 out of 3 cases are < 55 years old

Thyroid cancer in the pediatric population

Pediatric Incidence 2.0 per 1 million in children <15 yrs and
17.6 per 1 million in children 15-19 yrs
2% occur in children and teens
 Surgery

TREATMENT
Radioactive Iodine Ablation
FOR
THYROID
CANCER Levothyroxine

Monitor with WBS / ultrasound

 CHILDREN
&
PREGNANT WOMEN

WHEN DO YOU OPERATE???

Complications of Thyroid Surgery

Recurrent laryngeal nerve injury

Hypo parathyroidism

Bleeding

Infection
COMPLICATIONS OF
SURGERY

Parathyroid glands
COMPLICATIONS OF
THYROID SURGERY

OR case
 Surgery and TC

Should be LOW
Low MORTALITY
MORBIDITY too!!
Thyroid cancers LOW Mortality!!
Rod Stewart, Julie Andrews, Joe Piscopo

Always exceptions to the rules : IF surgery is required, always refer to

Roger Ebert, Supreme Court Justice someone who does at least > 50 / year
Reinquist
NO drains!!

NO RR tracks!!

Dermabond is ulgy on the neck, and often

opens a bit
 Summary

Refer to Endocrin0logy or Can safely follow with

Surgery ultrasound

Children
Pregant women
Nodules > 1 cm with suspicious
Nodule < 1 cm
features
Stable nodules with no change
Compressive symptoms
Repeat in 6 months x 2, then
HT with globus symptoms
annually

ULTRASOUND!! Even if
Monitor TFTs with U/S
already had CT, carotid
doppler, etc
 Endocrine OR Surgery?

ENDOCRINE SURGERY

Suspected/known abnormal TFTs with TNs

Pregnant

If FNA needed

Children
If suspect surgery is indictated
Thank You

QUESTIONS?