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THYROID NODULE in detail with diagnosis and management
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- 2. WHAT ARE THYROIDNODULES? - Abnormal growth within the thyroid gland - Clinical Manifestation of underlying thyroid disease
- 3. EPIDEMIOLOGY More common infemales than in males 4:1 ratio ncidence increases with age Most common in areas where iodine is deficient or iodine is low in water and food content, or no iodine fortification programs seen in inland areas and some 3rd world countries 50% of the population has nodules but only 5%- 10% are palpable
- 4. ETIOLOGY BENIGN -: ThyroidAdenoma and Thyroid Cysts THYROID ADENOMA - 5 main types - Follicular Adenoma, Hurtle Cell Adenoma, Toxic Adenoma, Papillary Adenoma THYROID CYST - 2 Main Types - Dominant Nodules of Multinodular Goiter and Hashimoto Thyroiditis
- 5. ETIOLOGY MALIGNANT - Thyroid Carcinoma -Thyroid Lymphoma - Metastatic Cancer from breast or renal carcinoma are rare
- 6. RED FLAGS •Thyroid nodulesin male patients have a higher risk for malignancy. However, thyroid nodules are much more common in women which is why their absolute risk of a cancerous nodule is higher. •Males less than 14 yo or greater than 70yo •History of head or neck radiation •Family History of MEN2 syndrome, Differentiated Thyroid cancer (papillary, follicular or medullary thyroid cancer), Gardner Syndrome (Thyroid nodules in male patients have a higher risk for malignancy. However, thyroid nodules are much more common in women which is why their absolute risk of a cancerous nodule is higher.)
- 7. SIGNS AND SYMPTOMS •Rapidgrowth of thyroid nodule •Recent onset of persistent hoarseness, dysphagia or dyspnea •Palpatory Findings • Firm or hard nodule • Fixed nodule • Cervical Lymphadenopathy • A solid nodule on thyroid ultrasound or a cold nodule on thyroid scintigraphy should raise suspicion for thyroid cancer.
- 8. DIAGNOSIS •ALL thyroid nodulesshould be evaluated for malignancy including thyroid incidentalomas •Perform Ultrasound and check TSH levels —> normal, elevated or low •Patients with low TSH perform thyroid scintigraphy •Patients with elevated TSH are associated with higher risk of malignancy in thyroid nodules •Ultrasound is indicated for patients with palpable nodules or clinical suspicion of malignancy, each nodule should be assessed individually •FNAC if ultrasound indicates need (Solid, hypoechoic nodules with irregular margins, microcalcifications, taller-than-wide shape, extrathyroidal growth, and/or cervical lymphadenopathy should raise suspicion for malignancy and require further evaluation with FNAC.) •Perform additional tests for hyper/hypothyroidism; lab work up for thyroid cancer markers in serum (e.g. calcitonin for medullary carcinoma.
- 9. TOXIC ADENOMA EPIDEMIOLOGY 3rd mostcommon cause of hyperthyroidism; more common in females than males; seen in ages 30 - 50 years old PATHOPHYSIOLOGY Gain of function mutation in TSH receptor gene found in thyroid follicle cells, adipose cells and orbital fibroblast —> autonomous functioning of thyroid follicular cells found in a single nodule —> focal hyperplasia within the gland —> overproduction of thyroid hormone —> decrease secretion of TSH from pituitary gland (negative feedback) —> hormone suppression in the rest of the thyroid gland
- 10. CLINICAL PRESENTATION Typically painlessbut palpable nodule in a normal gland. Patient presents with palpitations, weightless, heat intolerance, anxiety, menstrual irregularities, muscle weakness —> SYMPTOMS OF THYROTOXICOSIS. Tachycardia, tremor, lid lag —> SIGNS OF THYROTOXICOSIS
- 11. DIAGNOSTIC 1.TFT - ThyroidFunction Test —> Increased T3 and Decreased TSH 2.Ultra Sound - Sonographic signs of benign nodule, instances of increased perfusion 3.Thyroid Scintigraphy 4.FNAC
- 12. TREATMENT Initial Beta blockers tocontrol symptoms Antithyroid drugs to achieve normal thyroid function or hormone levels (euthyroidism) Definitive Hemithyroidectomy - removal of thyroid lobe and base Isthmusectomy - used for solitary toxic adenoma Radioactive Iodine Ablation Less Invasive For patients not candidate for surgery or Radioactive Iodine Ablation Ethanol Ablation Radiofrequency Ablation Laser Ablation
- 13. FOLLICULAR ADENOMA EPIDEMIOLOGY Most commoncause of thyroid adenoma; 10% - 15% become malignant * Hurtle Cell Adenoma is a sub-type of Follicular Adenoma arising from glandular epithelial cells PATHOPHYSIOLOGY A benign encapsulated tumor of the thyroid gland that is surrounded by a thin fibrous capsule.
- 14. CLINICAL PRESENTATION Slow growingsolitary nodule, Patients typically present with normal thyroid function or hormone levels (euthyroidism). In rare cases patients present with symptoms of hyperthyroidism Approximately 1% can develop into toxic adenomas
- 15. DIAGNOSTIC 1.TFT - ThyroidFunction Test —> Normal TSH 2.Ultra Sound - Sonographic signs of malignancy or sign of benign appearance 3.FNAC - Unable to distinguish between follicular adenoma or carcinoma Confirmatory Test •Surgical excision with histological analysis •Findings: normal follicular structure with no tumor invasion into the surrounding tissues (e.g., capsule, blood vessels) •Invasion into the surrounding tissues is the characteristic sign of follicular carcinoma, which is also why it is technically impossible to differentiate between adenoma and carcinoma without surgical resection and inspection of the whole nodule.
- 16. TREATMENT Definitive and Treatment- Thyroid surgery - No further treatment is required if. Initial excision indicates no evidence of cancer •If histopathology identifies follicular cancer a complete thyroidectomy and adjuvant treatment of thyroid cancer is needed
- 17. TOXIC MULTINODULAR GOITER EPIDEMIOLOGY 2ndmost common cause of hyperthyroidism; more common in females than males; seen in ages greater than 60 years old, common in iodine deficient regions, develops in 10% of patients with long standing/chronic nodular goiter PATHOPHYSIOLOGY 1.Chronic Iodine deficiency or thyroid dysfunction —> decreased hormone production —> increased TRH secretion by hypothalamus —> persistent TSH stimulation of the thyroid gland — > hyperplasia of thyroid nodules —> increased T3 and T4 non-toxic multi nodular goiter 2.Multiple somatic mutation of the TSH receptor in 60% patients with long standing goiter —> autonomous functioning of some nodules —> increased T3 and T4 toxic multi nodular goiter/plummer disease
- 18. CLINICAL PRESENTATION Painless goiterwith multiple palpable nodules - Patient presents with palpitations/tachycardia, weightloss, arrhythmia, hyperreflexia, anxiety, irritability, heat intolerance, anxiety, muscle weakness —> SYMPTOMS OF THYROTOXICOSIS.
- 19. DIAGNOSTIC 1.TFT - ThyroidFunction Test —> Increased T3 and Decreased TSH 2.Ultra Sound - Multiple nodule within parenchyma of thyroid gland; increased perfusion 3.Thyroid Scintigraphy 1. Increased radioactive uptake by multiple hot (hyper functioning) nodules 2. Suppression of rest of the gland and intervening parenchyma noted by decreased uptake 3. Cold (hypo functioning) nodules may be present 4.FNAC - not routinely required only in instances of suspicion of malignancy 5.Histopathology of Resected Tissue - distended patches of enlarged follicular cells with colloid and with flattened epithelium
- 20. THYROID CYST ETIOLOGY -consists of 2 types: Simple cyst - fluid filled and benign Complex cyst - partly solid with 5-10% risk of becoming malignant Caused by the (1) cystic degeneration of thyroid tissue, (2) involution of follicular adenoma and (3) thyroid cancer CLINICAL PRESENTATION •Palpable thyroid nodule •Hemorrhage into cyst —> pain, rapid enlargement of the nodule(s) —> hoarseness/dysphonia, dysphagia, due to compression of the superior and recurrent laryngeal nerve
- 21. DIAGNOSTIC 1.TFT - TypicallyNormal 2.Ultrasound - Cystic components appear dark (anechoic) or may be mixed with solid components showing decreased brightness on ultrasonography (hypoechoic) 3.FNAC •Not recommended for purely cystic nodules •Partly cystic nodules - Partly cystic thyroid nodules are associated with a low malignant potential, observation is recommended for nodules < 1.5 cm in size. - Very low risk pattern: Consider FNAC if size is 2 cm ≥
- 22. TREATMENT •Benign Cysts • Asymptomaticcysts - Observation • Large/Symptomatic Cysts - Aspiration with/without Ethanol Ablation (Ethanol Ablation Can be curative in some cases. However, cysts recur in up to 90% of patients after aspiration) • Consider Surgery if aspiration is ineffective •Malignant Cysts • Treat like Thyroid cancer —> Surgery —> Total Thyroidectomy, Hemithyroidectomy, Radioactive Iodine Ablation, TSH Suppression Therapy, • Active Surveillance - Multimorbid patient with high surgical risk or short life expectancy • Palliative therapy: Palliative radiation therapy and/or chemotherapy may be considered for advanced malignancy
- 23. TREATMENT FOLLOW UP •Physical Exam •BiochemicalTests •Ultrasound of Neck •If relapse is suspected perform further imaging is required PROGNOSIS 5 year survival rate
- 24. HASHIMOTO THYROIDITIS The mostcommon type of autoimmune thyroiditis (benign cyst) and the leading cause of hypothyroidism in iodine-sufficient areas. Associated with HLA-DR3 (varies by ethnicity) Caused by autoantibody-mediated destruction of thyroid tissue, which usually leads to hypothyroidism. Diagnosis is confirmed by positive thyroid antibodies antithyroid peroxidase and antithyroglobulin antibodies Presentation Moderately enlarged , non-tender thyroid (may be preceded by hyperthyroid state Histology Hurthle cells, lymphoid aggregates with germinal centers
- 25. PREGNANT PATIENTS DIAGNOSTIC - lowTSH - defer thyroid scintigraphy until after delivery and cessation of breastfeeding •Growing nodules or newly symptomatic patients should undergo thyroid ultra sound •FNAC can be performed if indicated TREATMENT •Radioactive Iodine Ablation is contraindicated during pregnancy and breastfeeding •If malignancy is diagnosed or suspected during pregnancy • Postpone surgery until after delivery • Surgery during 2nd semester is safe in patients with Aggressive cancer or advanced growth • Administer levothyroxine if surgery is deferred —> maintain TSH at normal to low levels
- 26. CHILDREN Thyroid nodules arefrequently malignant Surgical excision should be considered for cold nodules as well as hot nodules. - Same management as seen in Thyroid nodules in adults
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