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Approach to the Thyroid Nodule

- בסט' בן קרלוס דראנדוקריני מכון

, בלינסון רבין רפאי מרכז

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The Goiters Thyroid gland enlargement

Nodular Goiter

> Solitary noduleCold or Hot (Toxic adenoma)Solid or Cystic (simple, complex)Painful or notFirm or softFixed or not

> Multinodular goiterNon toxicToxic (autonomous function)Retrosternal goiter

Diffuse Goiter

• Endemic

• Sporadic Enzymatic defect (congenital)

Drug induced (e.g. lithium)

• Others

Graves disease

Hashimotos

Subacute thyroiditis

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A 52 y.o. female was found to have an enlarged thyroid on routine physical examination

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A discrete lesion within the thyroid gland that is palpably and/or ultrasonographically distinct from the

surrounding thyroid parenchyma

Our patient was found to have a thyroid nodule

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• Benign nodules (colloid, adenomatous hyperplasia)

• Cystic lesions (colloid, thyroglossal duct cyst)

• Adenomas (Follicular, Hurthle cell)

• Thyroid cancer (Medullary or non-medullary)

• Lymphoma of thyroid

• Others

But…what is really a thyroid nodule ?

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About thyroid nodules

• The prevalence of palpable thyroid nodules in iodine sufficient areas is 5% in women and 1% in males

• The prevalence of thyroid nodules in random ultrasound is 19-67 % (higher in female and elderly)

• Thyroid cancer may occur in 5-10% of thyroid nodules

• The etiology is poorly understood and depends on type of nodule (RET mutation in thyroid cancer, activating mutation of TSH receptor in toxic adenoma etc). There may be a familial predisposition.

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• A palpable lesion found by self- or medical examination

• A non-palpable nodule found on imaging for unrelated reasons, mostly hypothyroidism and bolus (incidentaloma)

• Work-up for hyperthyroidism

• An acute painful nodule (hemorrhagic cyst)

Clinical Presentation

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Thyroid ImagingThyroid Imaging

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Neck Ultrasound

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Neck CT

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Our patient has a solitary nodule and asks you about its significance

• Mass effect ?

• Thyroid function ?

• Benign or malignant lesion ?

Non-palpable nodules have same risk of malignancy as palpable nodules

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Mass effect

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Clinical consequences of mass effect

• Cosmetics

• Psychological distress• Dysphagia (Barium swallow)

• Tracheal compression (Flow loops)

• Pumberton sign

• Hoarseness

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Dysphagia

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Tracheal compression

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Our patient has a single nodule 2.5 cm diameter with no mass effect. What’s next ?

Algorithm for work-up of thyroid nodules

Apply to all palpable nodules and those non-palpable larger than 1

cm

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NodulePalpable/Nonpalpable

US TSH

Hypo/Normal Hyper

Scan

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Functional Imaging(Technetium Thyroid Scintigraphy)

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Hot nodule Cold nodule

Toxic adenoma Cold nodule

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NodulePalpable/Nonpalpable

US TSH

Hypo/Normal Hyper

Scan

Hot

Treat or follow

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Treatment of Toxic Adenoma

• When to treat ?– Subclinical hyperthyroidism– Overt hyperthyroidism

• How to treat ?– Antithyroid drugs– Radioactive iodine– Surgery

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NodulePalpable/Nonpalpable

US TSH

Hypo/Normal Hyper

Scan

Cold Hot

FNA

Treat or follow

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Fine Needle Aspiration

Pitfalls of FNA

No Quick Diff

Not enough follicular cells

Non palpable nodule

False negatives

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NodulePalpable/Nonpalpable

US TSH

Hypo/Normal Hyper

Scan

Cold Hot

Benign Indeterminate Malignant

Follow Repeat Operate

FNA

Treat or follow

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Thyroid cytology

Indeterminate cytology

• Few colloid and large amount of follicular cells

• Large, medium and microfollicular patterns

• Solid patterns

Malignant cytology

• Intranuclear inclusions, grooves, psamoma, etc

• High cellular density

• Papillary patterns

• Capsular invasion

Benign cytology: large amount of colloid with few

typical follicular cells

Follicular and Hurthel adenomas are diagnosed only upon pathology (capsular

and/or vascular invasion)

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Normal Thyroid Colloid nodule

Papillary Thyroid Cancer

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Risk factors for thyroid cancer

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Treating Thyroid Nodules

• Surgery: malignancy, hyperthyroidism, mass effect, cosmetic/psychological

• Radioactive iodine: hyperthyroidism, mass effect

• Percutaneous ethanol

• Antithyroid drugs

• Thyroxine suppression therapy

• Follow up

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Thyroxine suppressive therapy

Wemeau JL et al. J Clin Endocrinol Metab 87:4928- 34, 2002

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Our patient has a benign FNA report. What’s the need for follow-up and how ?

• False negative FNA in up to 5% (less when US guidance)

• Changes in functionality

• Size changes with mass effect

• Follow-up for functional changes

– Clinical features

– Serial TSH measurements

• Follow-up for anatomic changes

– by palpation

– by US very operator-dependent – by CT Consider

TSH suppression trial

Repeat FNA

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