Solitary thyroid nodule approach - PowerPoint Presentation

Slide1

Solitary thyroid nodule

approach

History

The most common presentation for a thyroid nodule is?

A swelling noticed by the patient or by family and friends

But if its not apparent how will it present?

Pressure symptoms is 1 way like (dysphagia, dyspnea, stridor, engorged neck veins or even ear pain and change in voice)

Symptoms of hyper or hypothyroidism

(change in weight, heat or cold intolerance, change in bowel habits, sweating,…….so on)

Take history like normal history of onset, change in size, associated symptoms, pain

Our history should focus on

Any family history of thyroid disease

Drug history

And very important to ask about any history of radiation ( keeping in mind risk of papillary carcinoma is highly increased with radiation)

Now we exam our patient

Never forget to make sure is it thyroid? Or a neck swelling?

give the patient a sip of water if it moves upward on swallowing its attached to the thyroid, by?

Pretracheal

fascia

After confirming its of thyroid origin, we do our full exam of a mass first inspect, then palpate (percuss also), then auscultate)

And never miss any extra thyroid signs, neurological exam (reflexes, tremor)

LYMPHNODES!!!

Extrathyroid

?

Graves disease:

Exophthalmos

Lid retraction

Inflamed eyes

Double vision

Pretibial myxedema (non pitting, reddening and thickening of skin)

Lid lag

Hypothyroid:

Puffy face

Myxedema (nonpitting)

Dry skin, coarse hair

Bradycardia

Loss of lateral 1/3 of eyebrow

Hoarseness, slurred speech

Hyperthyroidism: tachycardia, palpitations and might even cause CHF

Before we continue lets take a minute

Goiters can be classified in different ways:

Benign or malignant

Simple or toxic

Diffuse or nodular (multinodular or solitary)

Investigate

Thyroid function tests

Measure free t3, t4, TSH

In thyrotoxicosis? TSH totally suppressed

In hypothyroidism? Elevated

Some things to keep in mind is in pregnancy or estrogen administration increases the level of thyroid hormone (increase thyroid binding globulin) in blood so it makes it harder to diagnose

So we use the T3 radioactive uptake

investigate

TRH and TSH stimulation tests

to determine the site of failure of production of thyroid hormone

Calcitonin levels are of importance too especially in diagnosis of medullary carcinoma

Lets not forget men2 syndrome

Men2A (medullary carcinoma of the thyroid, pheochromocytoma, parathyroid hyperplasia or adenomas)

Men2B (

medullay

carcinoma, pheochromocytoma, and neuromas (mucosal and intestinal)

Back to investigations

Thyroid antibodies

1-anti thyrocyte peroxidase antibody and anti thyroglobulin antibody (

hashimoto

thyroiditis)

2-thyroid stimulating immunoglobulin (graves disease)

And Radioisotope scanning (I123):

To differentiate between hot and cold nodules

If we have a solitary hot nodule it’s a toxic adenoma

If its cold we have multiple options (malignancy, benign, cyst)

ultrasound and FNA

FNA is best for discrete nodules

investigate

And we cant not mention MRI, CT, PET scan

But they aren’t in the routine assessment of a thyroid swelling

Mostly for assessment of a known malignancy, extent of a retrosternal mass, staging, or vascular invasion (MRI)

Now lets put things in a better way (more focused on a solitary nodule)

First keep in mind

Is benign or malignant?

Benign like: cyst, follicular adenoma (either toxic or simple),

thyroditis

Malignant like: medullary, follicular, papillary, anaplastic, maybe lymphoma)

So like we said history

So you’ve asked about everything we already said, family history,

radiation

, symptoms of hyper or hypo thyroid,…

Now u should pay attention to some stuff that might suggest a malignancy

Rapidly progressive

Young less than 15, or old over 65

Pain doesn’t suggest malignancy but if present doesn’t exclude malignancy (medullary cancer can cause dull aching pain)

Hoarseness is worrisome because it indicates malignant involvement of recurrent laryngeal nerve

If patient comes with painful thyroid you suspect subacute thyroiditis, so we ask about?

History of upper respiratory infection (virus) and fever

Pain in thyroid:

Medullary cancer

Bleeding in thyroid

Cyst

Subacute

thyroditis

Physical exam

On inspection or palpation we also have signs the should suggest to us malignancy

Firm

Fixed

Irregular margins

Cervical lymphadenopathy

investigate

Like we said our first investigation Is TFT, and this will direct us to what to do next

If the patient has low TSH it indicates that the nodule is secreting thyroid hormones on its own so we should further investigate by radio isotype:

If we get a hot nodule it’s a toxic adenoma (almost never malignant)

If its cold we should do ultrasound and FNA

On the other hand if we have normal or elevated TSH we don’t do radio isotype we go directly to ultrasound and FNA

Last thing:

ultrasound

Ultrasound often reveals multinodular goiters rather than solitary nodules, so to know the size and number of nodules

To know is it cystic or solid

And make a guess on how malignant is it

It can be used as guidance for FNA for accurate sampling

Might reveal features suggesting malignancy:

Microcalcifications

Irregular margins

Intra nodular vascular spots

Hypo echogenicity within the nodule

Management

Mainly depends on the cytology results from FNA

Malignancy needs surgical intervention depending on type of cancer

Benign lesions might be left alone and monitored if asymptomatic or surgically removed if symptomatic

About 30% of FNA turn out to be cysts and we just drain them, but re accumulation is common

We surgically remove cysts if its growing or painful