Slide 1: DHAHRAN AL JANOUB HOSPITAL CME PROGRAMME Rabe’ Al awal 10th1431 Nodular Thyroid : Nodular Thyroid Management Dr. Sharif Al Khatib Clinical Approach : Clinical Approach Systemic pathology Underlying etiology Local pathology Risk factors Slide 4: Systemic pathology Hyperthyroid Euthyroid Hypothyroid What is the patient’s clinical thyroid function case? Clinical Approach : Clinical Approach Systemic pathology Underlying etiology Local pathology Risk factors Slide 6: Local pathology Pressure on:
Recurrent laryngeal nerve: Hoarseness.
Intra-thoracic and chest outlet structures: venous return compromise, Horner syn. … Clinical Approach : Clinical Approach Systemic pathology Underlying etiology Risk factors Local pathology Slide 8: Risk factors Is the nodule:
Increasing in size ? (25% malignant).
Discrete ? (4.3% malignant).
Larger than 4 cm ?
Fixed to other structures ?
Causing lymphoadenopathy ? Is the cyst:
Relapsed after aspiration ?
Larger than 3 cm ? (all malignant cysts > 3 cm)
Its aspirate is sanguine ? (12% malignant) The patient:
Is male (discrete nodule in females multiplies their thyroid cancer risk 6 times while in males it does 37 times).
Ages <20 or >60 (the risk is doubled).
Has Hx of radiation exposure (33%will develop neoplasm of which 6% are malignant).
Has familial Hx of thyroid cancer (this multiplies the risk in the first degree relatives 5.8 times in males and 4.9 times in females).
Is oophorectomized female (risk increases 6.5 times). Clinical Approach : Clinical Approach Systemic pathology Underlying etiology Risk factors Local pathology Slide 10: Underlying etiology What is the patient iodine intake like?
High (Hashimoto thyroiditis)
Low ( functional mechanism of MTG) Fine Needle Aspiration Biopsy : Fine Needle Aspiration Biopsy It appeared in 1930 and became popular among Scandinavians in 1960s who introduced it universally.
It is safe, easy, cheep, and accurate in approaching thyroid nodules. Technique:
10 ml Syringe with G22 to 25 needle, slides
Multiple entries through the nodule while holding negative pressure.
Release of negative pressure before the needle is out.
Uncapping the syringe, taking 5 ml of air then recapping it.
Spreading sample on slides and leaving it to dry (Romanovsky) or fixing it with alcohol (Papanicolaou). None Aspiration Fine Needle Biopsy US Guided FNA This helped to decrease nondiagnostic samples from 5 – 20% to 2.8%. Sensitivity & Specificity : Sensitivity & Specificity False positive results Hashimoto Thyroiditis is the main reason. False negative results Technical reasons (small or necrotic nodules
Lymphoma might be misdiagnosed as Hashimoto Disease. Sensitivity: 83%
Accuracy: 95% by: 13.8%
by: 22.6% Sequential FNA Thyroid US Scan : Thyroid US Scan Gland and nodules sizes.
Nodules sizes surveillance.
Structure and contents of the nodules.
Nodules counting, it will show new nodules in 20 – 48% of clinically single nodules.
It can show small nodules down to 3 mm even 1 mm when 13 mega Hz probe is used. It not very helpful in spotting malignant nodules definitely but it provides some suggesting sings like:
Heterogeneity, borders irregularity, calcifications, marginal sonolucent echo (halo sign) , extrathyroid extension. Doppler Ultrasonography Thyroid Scan : Doppler Ultrasonography Thyroid Scan An IV ultrasonic contrast Medium (Levovist®) is injected while thyroid doppler scan is on. The period from injection until the medium starts to appear and the period until it peaks are measured in addition to images of the nodules.
Carcinomas, adenomas and hyperplastic nodules shows different types of vascularity, start and peak periods but these differences were not reliable statistically keeping this investigation of little importance.
However, the introduction of new technologies like High Resolution Pulsed and Power Doppler Ultrasonography improved sensitivity and specificity in follicular neoplasms to 87.5 and 92% respectively.
They also enabled to perform give subjective velocimetric parameters like peak systolic velocity (V max), end-diastolic velocity (V min), pulsatility index (PI) and resistance index (RI) which improved accuracy remarkably Thyroid Isotope Scan : Thyroid Isotope Scan Indications are controversial but can be simplified like:
Nodularity with Toxicity. Interpretation of isotope scan depends on its radioactive material (Tc99 and I123 ):
I123 Inters follicular cells to form hormones, so I123 scan hot nodule if functionally hot and verse-versa.
Unlikely, Tc99 hot nodules are not always functionally hot, and if they are not they are called Discordant Nodules which were thought to hold significantly higher malignancy risk. Slide 16: NODULAR GOITRE TOXIC MULTI DISCRETE FNA Slide 18: DISCRETE FNA Diagnostic Non-Diagnostic
REPEAT Suspicious (10%) Malignant (4%) Benign (69%) Slide 20: Papilary Ca. Medulary Ca. Slide 21: Papilary Ca. Medulary Ca. Depending mainly on size and other prognostic scores, there is a wide range of procedures, generally, better prognostic score pt has less radical thyroid procedure.
AGES: Age, Gender, Extent, Size.
AMES: Age, Metastases, Extent, Size.
However 4 targets shoud be achieved as much as possible:
Eradication of the primary tumour.
Helping adjuvant therapies
Prevention of local an general recurrence.
Minimizing complications Slide 22: Papilary Ca. Medulary Ca. Its multicentricity multifocality and its high propensity to lymphatic metastsis makes total thyroidectomy and modified neck LND of the affected side the most common approach Slide 23: Surveillance:
It is the default treatment.
A clinical examination and US scan are performed at 6 – 12 months intervals.
If FNA is benign thyroid malignancy risk is 0.9%. However, more accuracy by repeating FNA Thyroxin:
Works on decreasing TSH.
It might be used to decrease nodule sizes but this is on the expense of very low TSH and remarkable side effects. However, small nodules (<3cm) response better.
Has no effect regarding recurrence prevention according to Hedguis study.
Side effects are cardiac, skeletal, and turning autonomous nodule into toxic one. Slide 24: More aggressive approach: LOBECTOMY and proper histopathology examination to exclude malignancy and to determine further management.
Less aggressive approach depend on other malignancy predictive factors like:
Immunologic staining for Na \I Symporter and oncogens presentations either in the FNA or the peripheral blood.
Imaging studies like:
PET which seems most predictive.
Duplex study of the nodule with Levovest.
High Resolution Pulsed and Power Doppler Ultrasonography.
US scan Follicular ca. (14%).
Hurthle cell ca (15%).
Lymphoma. Slide 25: Exception:
All nodules > 3 cm should undergo lobectomy even with benign or suspicious FNA Slide 28: OBSERVE
US Scan Slide 29: Medical treatment (antithyoid and β blocker)
avoidance of surgery
Long period (6-8 m).
High recurrence rate.
Hypothyroism. Surgical treatment:
Quick normalization of thyroid function.
Less recurrence (4 – 10%).
Less hypothyroidism risk (20 – 40%).
Local and general surgical complications which have higher risk here. Radioiodine:
Avoidance of surgery
Slow response 8 -12 wks.
Hypothyroidism 80 – 90%
Contraindicated in pregnancy and lactation. Treatment according to specific cases. : Treatment according to specific cases. Toxic nodule:
First choice: surgical removal (Lobectomy / nodulectomy)
Alternatively: radioiodine particularly in age > 45. Toxic Multinodular Goitre:
First (even the only) choice: Surgical removal.
If the nodules are responsible for hyperthyroidism so operation should address them by complete removal which lets the other suppressed tissue to come back to normal activity.
Similarly, if hyperthyroidism is due to the over-functioning internodular tissue the later should be removed with 1 -2 g left. Cysts : Cysts Aspirate
Repeat US DISAPPEARS RESIDUAL
AS A NODULE US MONITORING
TO 3 TIMES It is NOT a FNA if you send the aspirate to cytology Surgical complications. : Surgical complications. We must weight any benefits of any surgery with these complications:
Respiratory tract obstruction in large goitres.
Thyroid storm (rare)
Hypothyroidism within 2 – 5 yrs
Hypoparathyroidism in < 0.5%. Appears after 2 -3 days and even after 2 – 3 weeks.
Recurrent nerve damage. Slide 33: Percutaneous Ethanol Injection Ethanol 95 or 99% is injected through FNA needle guided by US. The amount is 0.5 – 1.5 ml per ml of the nodule volume or 1/3 of the cyst aspirated fluid volume.
This is done in 1-2 sessions weekly.
Indications are mainly toxic nodules and Plummer disease. However it is less effective in cold and cystic nodules.
Malignancy should be excluded by 2 FNABs at 6 months interval. Nodules in Hashimoto thyroiditis. : Nodules in Hashimoto thyroiditis. Operative treatment is restricted in relief of pressure symptoms.
Prednizolone sometimes. Procedure of choice: bilat. Subtotal thyroidectomy Slide 35: THANK YOU Ready for not too much questions !!!