APPROACH TO THYROID NODULE

Dr. (Maj. Gen.) K J Shetty
Consultant Endocrinologist
MD, FRCP (Edin.), FICP

INTRODUCTION
Thyroid Nodule:
– Common Outpatient Clinical Problem
4 to 8% OF ADULTS 13 to 67% ON USG EXAM (Female : Male – 8:1)

– Importance: Concern of Carcinoma
5% Malignant Relative Common-ness and possibility of complete cure if detected early

– Solution: Evolve a safe, expedient, reliable and cost effective management strategy

PRESENT SCENARIO
Widely Divergent Approach
– Primary Consultant : GP, Internist, Surgeon, ENT Specialist, Surgical Oncologist – Bias of the consultant - reluctance to follow guidelines – Inadequate use/ Improper prioritization of investigative tools – Insufficient knowledge of pathophysiology
natural history of thyroid nodule indications, merits, and shortcomings of various investigative tools

Approach to Thyroid Nodule Steps:
Evaluation
– – – – – – – – – Morphology Functional Immunological Cytological Histopathological Clinical History & Examination Biochemical / Immunological Tests Imaging – USG/SCAN Aspiration Cytology

Tools Available

Thyroid Nodule Steps in Evaluation:
– Clinical Examination – Biochemical Examination – Ultrasound Evaluation – Cytology

Clinical Evaluation
Asymptomatic Symptomatic Hyper/ Hypo-thyroidism Mechanical
Dyspnoea Dysphagia Hoarseness Pain Rapid Increase In Size Cosmetic Past History (Previous Surgery, Irradiation) Family History

CLINICAL EVALUATION (cont’d)
General
– Sex: M > F – Age: < 20 ; > 60 Yrs

Systemic : EUTHYROID/ HYPO/ HYPER Neck : NODULE: SOLITARY / MULTINODULAR
– – – – Size/ Intra-thoracic/ Extension Consistency: Firm/Hard/Cystic Mobile/Fixed Tenderness

Lymph nodes : Number and level

CLINICAL POINTERS TO MALIGNANCY
Main Pointers
– – – – – – – – – – Recent Rapid Increase In Size Development of Hoarseness of voice Positive Family History Age & Sex Past History of Neck Irradiation Hard Fixed Nodule Regional lymph nodes Size: Smaller Ones – NO RISK Multi-Nodular – NO RISK Pain – HIGH RISK

Misconcepts of Malignancy

Biochemical Evaluation
– Lab Evaluation – First Step: Assess Functional Status by TFT – TSH Assay: Most Useful – T3/T4: Not Necessary if TSH is normal – TSH:
Absent/ Low - Toxic Nodule : T3/ T4 Indicated Elevated - Hypothyroid : T4 indicated

– FT3/FT4: Preferred to TT3/ TT4 – Thyroid Antibodies
Thyroid Peroxidase (TPO) ANTI-THYROGLOBULIN Ab (TgAb) TSH Receptor Antibodies (TSIAb) Graves (Not Routinely Available)

(Hashimotos and Graves)

Ultrasonography (USG)
*High Resolution USG: Exceptional Clarity
*Nodules < 1.5 cm *Metastatic Nodules In Neck (Clinically not palpable)

• • •

Assists in Localising Nodules for FNAC Inexpensive, non invasive, readily available USG to Endocrinologist Stethoscope to Cardiologist • Limitation: Little help in differentiating benign from cancer

No Single Characteristic: Predictive for malignancy Denote Higher Risk in combination of some: Composition Incidence percentage
– – – Solid Mixed (complex) Pure cystic 27% 7% > 4 cm: 6% < 4 cm: Negligible

Calcification
– Microcalcification : x 3 higher risk without calcification – 95% specificity

- Coarse Calcification x 2 Risk Cervical Lymph Nodes : Highly Suggestive of PTC

Fine Needle Aspiration Cytology (FNAC) / Biopsy (FNAB)
Crucial Step in evaluation Simple, safe, accurate and cost effective Assess Reliability Guidelines (Mayo Clinic)
– – – Experienced, Preferably dedicated cyto-pathologist Multiple Sites of Aspiration (2-4) A Low False Negative Rate Literature 1 – 11 % Acceptable < 5% Diagnostic Sample : 2 Slides - > 6 Groups Each > 10 Follicular Cells In each group

Benign………………………. 70% Indeterminate………………..10% Malignant…………………… 5% Non Diagnostic………………15%

Benign: Colloid Nodules
– 70% Simple Cysts – AutoImmune/ Lymphocytic Thyroiditis

Malignant:
– Papillary (Commonest) 83% – Follicular : 11% – Medullary (MTC) 5% – Anaplastic 1%

Indeterminate Category: (10%)
2 GROUPS:
– Suspicious for malignancy: definitive evidence for malignancy not evident – Follicular neoplasm: not possible to differentiate from adenoma and carcinoma (capsular/ lymphovascular invasion)

Both sub-groups qualify for surgery

Non-Diagnostic (20%)
Solid Lesion - Insufficient No. of follicular Cells
- Re-Aspiration Indicated after 4 weeks
– diagnostic aspirate in 50% – if non diagnostic : surgery

Cystic Lesion - Aspirate Unsatisfactory
- Solid Component- Biopsy Mandatory

- If not feasible - Surgery

THYROID SCINTIGRAPHY
Using Radioactive Iodine (I131) / Technitium (99 mTc) Depending on uptake classified as:
– – – – – HOT: 5% Toxic Nodule : < 5% Malignant COLD: 80 – 85% : 10 – 15% Malignant WARM 10-15% : 9% Malignant Expensive/ Availability Only In Special Centres Overlap: Small Nodules Masked

Use Limited To :
– Indeterminate (Suspicious/Follicular) on FNAC – Follow Up of “hot” nodule – Diagnosis of ectopic goitre / Substernal Extension

NORMAL Tc99m THYROID UPTAKE

HOT NODULE

COLD NODULE

MULTI-NODULAR GOITRE

MANAGEMENT
– – – –

Based on Combination of Input From:
History Clinical Examination Ultrasound Evaluation Cytology

( Benign Nodules, Malignant Nodules, Indeterminate, Nondiagnostic)

Therapeutic Options:
1. 2. 3. 4. Follow-Up With Periodic Clinical and lab input Surgery Radiotherapy Medical therapy

MANAGEMENT (contd….) BENIGN NODULES (70%):
– Euthyroid: No Pressure symptoms Cosmetically Acceptable – – – – Yearly Follow up Clinical/Biochem./ USG > 20% ↑ - Repeat FNAC Role of Suppressive Rx with T4 – Not Proven Beware of subclinical Hyperthyroidism Euthyroid: Pressure + Cosmetic Problem – Limited Surgery Toxic Nodule: Medical (CMZ/PTU + Propranolol) I 131 / Surgery

MANAGEMENT (cont…)

Malignant Nodules: 5%
PTC : Total Thyroidectomy with Ipsilateral Central Compartment Lymph Node Clearance FTC: Non/Min. Invasive – Lobectomy Invasive: Complete Thyroidectomy (Total) Follow Up for Both : I131 ablation after 6/52 High Dose Thyroxine TSH Suppression (<0.1mu/L) MTC: Total Thyroidectomy with complete LN Clearance ANAPLASTIC : Aggressive tumour- TLC/Decompression

MANAGEMENT (cont…)

INDETERMINATE (10%)
FOLLICULAR NEOPLASM / SUSPICIOUS FOR MALIGNANCY

SURGERY WITH INTRAOPERATIVE FROZEN SECTION

TOTAL THYROIDECTOMY + LYMPH NODE CLEARANCE

MANAGEMENT (cont…)

NON DIAGNOSTIC : 20%
CYSTS : > 4 cm
– REPEATED FNAC – NONDIAGNOSTIC/ SURGERY

NODULE –
– SURGERY – EXCISIONAL BIOPSY

APPROACH TO THYROID NODULE – AN ALGORITHM
PATIENT WITH THYROID NODULE CLINICAL EVALUATION + TFT + IMMUNOLOGY

EUTHYROID USG

HYPERTHYROID ANTITHYROID DRUGS/ I 131 ABLATION / SURGERY

HYPOTHYROID T4 REPALCEMENT

SOLID

COMPLEX CYSTS WITH SOILD COMPUND < 4cm FNAC FOLLOW UP

PURE CYSTS

> 4 cm SURGERY

ALGORITHM (CONTD….)
FNAC OF NODULE
CYTOLOGY REPORT

BENIGN (70%)

MALIGNANT (5%)

INDETERMINATE (10%)
SCINTIGRAPHY (I131/ 99 mTc)

NON DIAGNOSTIC (15%)

PRESSURE SYMPTOMS/ COSMETIC PROBLEMS – NIL YEARLY FOLLOWUP
SUPPRESSION WITH T4 – 6– 12 MONTHS

Rpt FNAC WITH USG

WARM

COLD

DIAGNOSTIC

NONDIAGNOSTIC

> 20% INCREASE Rpt FNAC FOLLOWUP

SUSPICIOUS

SURGERY

CONCLUSION
Thyroid Nodule- A common Problem Evaluation:
– Arbitrary, Inconsistent, Divergent – Based on Personal Preference

Long-term experience & advances in diagnostic aids:
– Fresh Guidelines laying down systematic step-wise approach – Misconcepts corrected

THANK YOU

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