Solitary thyroid nodule ppt by dr koorapati ramesh

Kakatiya Medical College, Warangal

Road Map to Benign Thyroid Disorders

DR RAMESH KOORAPATI MS

Dept of General Surgery

Evaluation of Thyroid Disorders

Clinical assessment Investigations

Clinical assessment Physiological v/s Pathological Anatomical - Unilateral v/s Bilateral Pathology – Benign v/s Malignant Functional status General condition of the patient

DIFFERENTIAL DIAGNOSIS

UNILATERAL

SOLITARY THYROID NODULE

DIFFERENTIAL DIAGNOSIS

BILATERAL

SYMMETRICAL * PHYSIOLOGICAL * FUNCTIONAL

ASYMMETRICAL* MNG* DOMINANT NODULE* CARCINOMA THYROID* THYROIDITIS

AETIOLOGICAL CLASSIFICATION OF THYROID SWELLINGS

SIMPLE GOITRE DIFFUSE HYPERPLASTIC PHYSIOLOGOCAL PUBERTAL PREGNANCY MULTI NODULAR GOITRE

TOXIC DIFFUSE GRAVE’ DISEASE MULTINODULAR TOXIC ADENOMA

NEOPLASTIC BENIGN MALIGNANT

INFLAMMATORY AUTOIMMUNE GRANULOMATUS FIBROSING INFECTIVE OTHERS

INVESTIGATIONSESSENTIAL

THYROID FUNCTION TESTS-----T3 T4 TSH

THYROID USG PATHOLOGICAL------- FNAC,BIOPSY

SPECIAL INVESTIGATIONS

THYROID SCINTIGRAPHY CORE BIOPSY CT / MRI NECK SPECIAL X-RAYS TUMOR MARKERS THYROID ANTIBODIES PET SCAN TRH SUPPRESION TESTS

FNAC

INITIAL INVESTIGATION OF CHOICE

STN / MNG / SUSPECIOUS NODULES

REPLACED ONTABLE FROZEN SECTION STUDIES

LIMITATIONS OF FNAC CAN NOT DIFFERENTIATE FOLLICULAR ADENOMA

v/s

CARCINOMA

FALSE NEGATIVE RATES 6 % -10 %

BLIND ---- SAMPLING ERRORS

ISOTOPE SCANNING

TOXIC NODULE

MULTI NODULAR GOITRE WITH TOXIC SYMPTOMS

FOLLOWUP OF CARCINOMA THYROID

BENIGN THYROID DISORDERS -

CLINICAL PRESENTATIONS

SOLITARY OR DOMINANT NODULE

DIFFUSE OR MULTINODULAR GOITRE

FUNCTIONAL DISORDERS

SOLITARY NODULE THYROID

DEFINITION:-

DISCREAT SWELLING IN AN OTHERWISE IMPALPABLE GLAND

NORMAL ULTRASOUND BENIGN NODULE ON US

Solitary / Dominant Nodule (Non – toxic)

SOLITARY THYROID NODULE v/s DOMINANT NODULE

THYROID – FNA BIOPSY:

Class I (10%)

Class II (60 – 75%)

Class III (20%)

Class IV (5%)

Class V (5 – 15%)

NON – DIAGNOSTIC

NODULES

BENIGN NODULES

FOLLICULAR LESIONS

SUSPICIOUS NODULES

MALIGNANT NODULES

Road Map to Benign Thyroid Disorders

Normal Gland

Solitary / Dominant Nodule (Non – toxic)

Road Map to Benign Thyroid Disorders

False Negatives with FNAC

Solitary / Dominant Nodule (Non – toxic)

Road Map to Benign Thyroid Disorders

False Negatives with FNAC

Solitary / Dominant Nodule (Non – toxic)

NON - DIAGNOSTIC NODULES (Class I)

Due to:

• Cystic Nodules

• Benign / Malignant sclerotic lesions

• Thick / Calcified capsule

• Abscesses / Necrotic lesions

• Hypervascular lesions

• Sampling Error / Faulty Technique

Road Map to Benign Thyroid DisordersSolitary / Dominant Nodule (Non – toxic)

Reaspiration using US guidance

Malignancy = 2 – 12%

Treatment options:

Pure Colloid, completely

cystic on US

Complex lesions Solid lesions

Clinical and US follow up Surgery Surgery

Road Map to Benign Thyroid Disorders

Thyroid Cyst

Solitary / Dominant Nodule (Non – toxic)

BENIGN NODULES (Class II)

Road Map to Benign Thyroid Disorders

Isoechoic homogeneous subcapsular nodule (arrows)

with regular margin

Solitary / Dominant Nodule (Non – toxic)

BENIGN THYROID NODULE

Treatment Options:

• Clinical Follow up

• Levothyroxine Suppressive Therapy

• Surgery

Road Map to Benign Thyroid DisordersSolitary / Dominant Nodule (Non – toxic)

LEVOTHYROXINE Routinely NOT recommended

May be Considered MUST be Avoided

• Young Patients from

Endemic areas with small

nodules

• Non – autonomous

Nodules

• Large Nodules

• Long Standing

• Low Normal TSH

• Post Menopausal

• Men > 60yrs

• Osteoporosis

• Cardiovascular Disease

Road Map to Benign Thyroid DisordersSolitary / Dominant Nodule (Non – toxic)

SURGERY INDICATIONS

• Compressive Symptoms

• Cosmetic Reasons

• Patients anxious (psychological)

Road Map to Benign Thyroid DisordersSolitary / Dominant Nodule (Non – toxic)

FNAB cannot differentiate benign from malignant

Repeated FNAB – NOT Recommended

Core Needle Biopsy – NOT Recommended

20 % are Malignant

Surgical Excision (Lobectomy + Isthmectomy OR

Total Thyroidectomy)

FOLLICULAR LESIONS (Class III)

Road Map to Benign Thyroid DisordersSolitary / Dominant Nodule (Non – toxic)

Road Map to Benign Thyroid Disorders

FOLLICULAR ADENOMANodule shows micro follicles, is sharply circumscribed by a

capsule, and there is no invasion of the capsule or blood vessels

FOLLICULAR CARCINOMAwith Vascular invasion

Solitary / Dominant Nodule (Non – toxic)

Includes:

• Cytological features suggesting malignancy but do

not fulfill the criteria for a definite diagnosis

• Insufficient cellularity but with cellular features

strongly suggesting malignancy

60% are Malignant

Surgery + Intraoperative Frozen Section

SUSPICIOUS NODULES (Class IV)

Road Map to Benign Thyroid DisordersSolitary / Dominant Nodule (Non – toxic)

MANAGEMENT OF SOLITARY THYROID NODULE

THANK YOU…