Presenter: Sana Ghaznavi• Speakers Bureau/Honoraria: N/A
• Consulting Fees: Consultant - Eisai
• Grants/Research Support: N/A
• Patents: N/A• Other: N/A
• The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.
Objectives
• Algorithm for evaluation of thyroid nodules• When (and when not) to order neck US
• DDx thyroid mass• Work up and risk stratification of thyroid nodules
• Ultrasound• Cytology• Molecular testing
• When to refer to Endocrinology• Discussion/Questions
Suspicion of a thyroid nodule
Neck ultrasound
TSH
TSH normal or elevated
Nodule risk stratification
TSH suppressed (HYPERthyroidism)
Thyroid scan
Is there a nodule in the thyroid? Is the nodule suspicious for cancer?
Algorithm for Evaluation of a Thyroid Nodule
How are thyroid nodules discovered? • Patient palpation• Clinician palpation• Incidental imaging finding
• Carotid US• CT head or chest• PET scan
• Thyroid imaging for non-specific complaints• Fatigue, sore neck• Abnormal thyroid function tests
When you suspect a thyroid nodule1. Is there really a mass present? • Soft tissue (e.g. skin folds)• Normal neck anatomy
• Tracheal rings, thyroid cartilage, hyoid bone
2. Is the mass inside the thyroid or outside the thyroid? • Extrinsic lesions
• Thyroglossal duct cyst• Lymph nodes• Parathyroid gland
When you suspect a thyroid nodule3. Is the thyroid mass focal or diffuse? • Diffuse enlargement
• Hyperplasia (e.g. goitre from iodine deficiency)• Inflammation (Hashimoto’s thyroiditis)• Other pathology: lymphoma• Large nodule occupying the entire thyroid lobe
• Focal lesion• A thyroid nodule!• Extremely common finding on ultrasound (up to 50% of
patients)
DDx: Benign Thyroid Nodules
• Benign (adenomatous) nodule • Autonomous nodule (aka ”hot nodule” or “toxic adenoma”)• Cyst
DDx: Malignant Thyroid Nodules
• Primary thyroid cancer• Papillary (85%)• Follicular (5-10%)• Anaplastic (< 1%)• Medullary (3-5%)
• Other• Metastatic from another site (uncommon; primary is usually known) • Lymphoma (rare)
Top reasons NOT to order an Neck US
• Abnormal thyroid function tests (high or low TSH) • Positive Anti-TPO antibodies• Symptoms of hypothyroidism (e.g. fatigue, weight gain, cold
intolerance)
In the ABSENCE of a palpable abnormality in the thyroid
The Rising Incidence of Thyroid Cancer
Davies L and Welch H.G. Increasing Incidence of Thyroid Cancer in the United States, 1973-2002. JAMA. 2006; 295(18): 2164-67.
The Rising Incidence of Thyroid Cancer
Davies L and Welch H.G. Increasing Incidence of Thyroid Cancer in the United States, 1973-2002. JAMA. 2006; 295(18): 2164-67.
The Rising Incidence of Thyroid Cancer in Canada
4
23
Topstad & Dickinson, CMAJ 2017. “Thyroid cancer incidence in Canada: a national cancer register analysis”.
The Rising Incidence of Thyroid Cancer
• Large reservoir of asymptomatic “disease” in the Canadian and worldwide population
• Majority of the increase in incidence is accounted for by discovery of papillary microcarcinomas
• Incidence rising, mortality largely stable• The process of finding microcarcinomas begins with the detection of
thyroid nodules
Components of a High Quality Neck US Report
• Size of lobes• Nodule characterization
• Size• Composition (solid vs. cystic)• Shape (taller than wide)• Margins (smooth vs. irregular, extrathyroidal extension)• Echogenicity (hypoechoic ie. dark, vs. iso- or hyperechoic)• Microcalcification (subjective! Not always an easy call)
• +/- doppler (blood flow)• Use of ATA or ACR-TIRADS risk stratification system• Management recommendations
• Clinical context is key
Suspicion of a thyroid nodule
Neck ultrasound
TSH
TSH normal or elevated
Nodule risk stratification
TSH suppressed (HYPERthyroidism)
Thyroid scan
Is there a nodule in the thyroid? Is the nodule suspicious for cancer?
Is the nodule functioning (making thyroid hormone)?
Algorithm for Evaluation of a Thyroid Nodule
TSH Suppressed + Thyroid Nodule Present• Is the nodule making excess thyroid hormone?
• Thyroid scan: • Order through private radiology or nuclear medicine dept (order simultaneous TFT)
Cold nodule“photopenic”area
Hot noduleRest of the gland is suppressed
LOW malignancy rate
Variable malignancy ratebased on US appearance
Choosing Wisely: A Brief Interlude Into Thyroid Labs for Workup of a Thyroid Nodule
• Screen with TSH only (no free T4 or free T3 needed)• No role for TPO Antibodies (Hashimoto’s thyroiditis)• No role for TSH receptor antibodies [TRAB] (Graves disease)
Suspicion of a thyroid nodule
Neck ultrasound
TSH
TSH normal or elevated
Nodule risk stratification
TSH suppressed (HYPERthyroidism)
Thyroid scan
Is there a nodule in the thyroid? Is the nodule suspicious for cancer?
Is the nodule functioning (making thyroid hormone)?
Is this a hot nodule?
To biopsy or not to biopsy?
Algorithm for Evaluation of a Thyroid Nodule
Surgery vs. Surveillance
Molecular
FNAC
Ultrasound
Risk Stratification of Thyroid Nodules
TIRADS or ATA risk
MONITOR nodules < 1 cm
ATA nodule riskstratificationsystem
TIRADS nodule riskstratificationsystem
Surgery vs. Surveillance
Molecular
FNAC
Ultrasound
Risk Stratification of Thyroid Nodules
TIRADS or ATA risk
TBSRTC
INDETERMINATE
Surgery vs. Surveillance
Molecular
FNAC
Ultrasound
Risk Stratification of Thyroid Nodules
TIRADS or ATA risk
TBSRTC
AFIRMA GECThyroSeqThyroSPEC (Local)
ThyroSPEC• ~20% of thyroid biopsies in Alberta will come back “indeterminate”
(not outright malignant or benign)• One way we manage these is molecular testing• Starting in April 2020 we will have reflex testing of all indeterminate
thyroid nodules biopsied in Calgary• Patient does not pay• Interpretation of results/clinical management may need Endo referral• [email protected]
When to refer your patient with a thyroid nodule?
• Long term monitoring of thyroid nodules/goitre• Prior benign biopsy, growth or change of the nodule• Indeterminate biopsy +/- molecular testing interpretation• High suspicion nodule < 1 cm• Suspicious nodule or malignant cytology and
• Comorbid patient• Pregnant patient
For cases being referred to Calgary• If you get a malignant biopsy refer directly to
• Endocrine surgeon• H+N thyroid surgeon
• Our surgeons will refer to Endocrinology Central Access & Triage for post-operative management
• A team of 6 thyroid cancer specialists in Calgary triage every new case and patients are assigned an Endocrinologist based on their prognostic group
References• Haugen BR, Alexander EK, Bible KC et al. 2015 American Thyroid Association
Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26(1):1-113.
• Davies L and Welch H.G. Increasing Incidence of Thyroid Cancer in the United States, 1973-2002. JAMA. 2006; 295(18): 2164-67.
• Topstad D and Dickinson J.A. Thyroid cancer incidence in Canada: a national cancer registry analysis. CMAJ. 2017; 5(3):E612-16.
• Choosing Wisely Canada “Endocrinology & Metabolism: 5 things physicians and patients should question”. https://choosingwiselycanada.org/endocrinology-and-metabolism/ accessed on March 5, 2020.
Questions?
Sana Ghaznavi, MD, FRCPCClinical Assistant Professor
Endocrinology & MetabolismUniversity of Calgary
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