evaluation of a thyroid nodule by vijay

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EVALUATION OF A THYROID NODULE VIJAY SHEWALE KIMS , TRIVANDRUM 14 TH AUG 2013

INTRODUCTION:

INTRODUCTION DEFINITION- A discrete lesion within the thyroid gland that is palpably and/or radiologically distinct from surrounding thyroid parenchyma.

INTRODUCTION:

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

INTRODUCTION:

INTRODUCTION The importance of thyroid nodule rests with the need to exclude thyroid malignancy which occurs in 5 – 15 %

HOW WAS THE NODULE FOUND:

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

CLINICAL EVALUATION:

CLINICAL EVALUATION

HISTORY:

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)

HISTORY:

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

HISTORY:

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

HISTORY:

HISTORY PAST HISTORY h/o neck irradiation , h/o thyroid disease in family

EXAMINATION:

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

EXAMINATION:

EXAMINATION Local examination- Movement of swelling with deglutition Size , consistency of nodule Tracheal deviation, retrosternal extension Cervical lymphadenopathy

WORK UP:

WORK UP

THE AMERICAN THYROID ASSOCIATION (ATA) GUIDELINES FOR THYROID NODULE 2009 , REVISED IN 2013:

THE AMERICAN THYROID ASSOCIATION (ATA) GUIDELINES FOR THYROID NODULE 2009 , REVISED IN 2013

SERUM TSH:

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

ULTRASOUND SCAN:

ULTRASOUND SCAN Can answer following questions Solid/cystic size Additional nodule Benign or malignant feature

ULTRASOUND SCAN:

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

PowerPoint Presentation:

HYPOECHOIC

PowerPoint Presentation:

HYPERVASCULARITY

PowerPoint Presentation:

CALCIFICATIONS, POORLY DEFINED, IRREGULAR MARGINS

PowerPoint Presentation:

SOLID

Is size predictor of malignancy:

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.

PowerPoint Presentation:

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.

FNAC:

FNAC Only gold standard test for proof of malignancy without surgical pathology 23 – 25 gauze no needle is used

INDICATIONS FOR US GUIDED FNAC:

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

FNAC RESULTS:

FNAC RESULTS Nondiagnostic (thy 1) Benign(thy2) Suspicious for a Follicular Neoplasm/Follicular Neoplasm(thy3) Suspicious for Malignancy(thy4) Malignant(thy5)

BENIGN:

BENIGN Scanty normal follicular cells together with colloid

PAPILLARY:

PAPILLARY Nuclear grroving Papillary projections Orphan annie eye nuclei

FOLLICULAR:

FOLLICULAR Increased cellularity with a follicular pattern

HURTHLE CELL:

HURTHLE CELL Variant of follicular neoplasm Oxyphill ( askanazy ) cells predominate

MEDULLARY:

MEDULLARY Amyloid stroma

NON DIAGNOSTIC CYTOLOGY:

NON DIAGNOSTIC CYTOLOGY In persistent non diagnostic cytology risk of malignancy is less than 5% Surgery should be considered if nodule is solid

BENIGN CYTOLOGY:

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

FOLLICULAR NEOPLASM:

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

FOLLICULAR NEOPLASM:

FOLLICULAR NEOPLASM Use of molecular markers such as BRAF, RET/PTC, Ras , PAX8/ PPARy or GALECTIN3 may be consider

PAPILLARY:

PAPILLARY Total thyroidectomy unless if nodule is less than 1 cm and unifocal Modified radical neck dissection only if enlarged lymph nodes are present

MEDULLARY:

MEDULLARY Total thyroidectomy Central compartment lymph node dissection is recommended Modified radical neck dissection only if enlarged lymph nodes are present

ANAPLASTIC:

ANAPLASTIC Total thyroidectomy Prognosis is poor

LYMPHOMA:

LYMPHOMA Chemotherapy Surgery indicated if pressure symptoms are present

THYROID SCAN:

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

POST OPERATIVE MANAGEMENT:

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

POST OPERATIVE MANAGEMENT:

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

POST OPERATIVE MANAGEMENT:

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

POST OPERATIVE MANAGEMENT:

POST OPERATIVE MANAGEMENT ANAPLASTIC Stage 4 A- T 4a Stage 4B- T4b Stage 4C- T 4c

POST OPERATIVE MANAGEMNT:

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

POST OPERATIVE MANAGEMENT:

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

THANK YOU:

THANK YOU

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