solitary thyroid nodule

TOPIC DISCUSSIONTOPIC DISCUSSIONSolitary Solitary Thyroid NoduleThyroid Nodule

CHALINEE WAJANANAWATCHALINEE WAJANANAWAT

ObjectiveObjective

1.ทราบถึ�งหลักการในการซักประวัติ�แลัะติรวัจร�างกายผู้��ป�วัยท��มี� Solitary thyroid nodule ได้�อย�างถึ�กติ�อง2.สามีารถึวั�น�จฉัยแลัะวั�น�จฉัยแยกโรคผู้��ป�วัยท��มี� Solitary thyroid nodule ได้�3.สามีารถึเลั(อกส�ง Further Investigation ได้�อย�างเหมีาะสมี ในผู้��ป�วัยท��มี� Solitary thyroid nodule 4.สามีารถึวัางแผู้นการรกษาเบ(*องติ�นในผู้��ป�วัยท��มี� Solitary thyroid nodule ได้�อย�างเหมีาะสมี

CASE PROFILECASE PROFILE

Identification data :ผู้��ป�วัยหญิ�งไทยค�� อาย, 52 ป- ภู�มี�ลั/าเนา อ.เมี(อง จ.ลั/าปาง

อาชี�พ ท/านาSource of information :จากการซักประวัติ�ผู้��ป�วัย แลัะข้�อมี�ลัทางการแพทย3Reliability :น�าเชี(�อถึ(อมีาก

CHIEF COMPLAINTCHIEF COMPLAINT

มี�ก�อนท��คอโติมีา2ป-ก�อนมีาโรงพยาบาลั

NECK MASS………..NECK MASS………..

IS THAT THYROID GLAND??IS THAT THYROID GLAND??

Evaluation of thyroid Disease ?……Evaluation of thyroid Disease ?……

•History ( family history, history of goiter, local symptoms, symptoms of hyper/ hypothyroidism)

•Physical examination (general, thyroid gland)•Laboratory tests

•Duration•Progression•Local symptoms : pain, difficulty in swallowing or breathing,

hoarseness•Living in endemic goiter area•Family history of goiter, hyperthyroidism, CA thyroid

PRESENT ILLNESSPRESENT ILLNESS

2ป-ก�อนมีารพ.ผู้��ป�วัยคลั/าได้�ก�อนท��บร�เวัณลั/าคอด้�านซั�ายข้นาด้เท�าหวัแมี�มี(อ ไมี�มี�อาการห�วับ�อย ใจส�น ก�นจ, ท�องเส�ย หง,ด้หง�ด้ ไมี�มี�ไข้� ไมี�มี�อาการคลั(�นไส�อาเจ�ยน ผู้��ป�วัยร��ส�กวั�าก�อนค�อยๆโติข้�*นท�ลัะน�อย ไมี�มี�การเจ6บท��ก�อน ไมี�มี�เส�ยงแหบ ไมี�ได้�ไปพบแพทย3

2เด้(อนก�อนมีารพ . สงเกติวั�าก�อนโติข้�*นอย�างรวัด้เร6วัจนข้นาด้เท�าไข้�ไก� ไมี�มี�น/*าหนกลัด้ ไมี�มี�อาการผู้�ด้ปกติ�อ(�นร�วัมี มี�เพ(�อนบ�านเป7นมีะเร6งติ�อมีไทรอยด้3 จ�งมีาพบแพทย3

PAST HISTORYPAST HISTORY

::มี�ประวัติ�เป7นโรคควัามีด้นโลัห�ติส�ง ไมี�ได้�ทานยาใด้ๆ :ปฎิ�เสธการมี�โรคประจ/าติวัอ(�นๆ เชี�น เบาหวัาน :ปฏิ�เสธการได้�รบอ,บติ�เหติ, :ปฏิ�เสธประวัติ�การแพ�ยา อาหาร หร(อสารเคมี�

FAMILY HISTORYFAMILY HISTORY

:มีารด้าเป7นโรคมีะเร6งมีด้ลั�ก ผู้�าติด้แลั�วั ป;จจ,บนเส�ยชี�วั�ติ :ปฏิ�เสธโรคถึ�ายทอด้ทางพนธ,กรรมีอ(�นๆ :ปฏิ�เสธบ,คคลัอ(�นในครอบครวัมี�อาการเหมี(อนผู้��ป�วัย

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

•V/S :T 36 °c PR 80 /min RR 16/min BP 110/60 mmHg BMI 22 (W=50/H=160) •GA :A middle-aged woman c normal conciousness , no pallor, no jx, no cyanosis, no puffy face•Skin: No moist skin, no onycholysis, normal hair distribution •Eye: No staring eyes, no lid lag, lid retraction•Lung :Normal breath sound, no adventitious sound•Heart :Regular, no murmur, symmetrical pulse

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

•GI :Soft, no mass, no distension, no tenderness, Active BS, Liver & Spleen can not palpable

•GU : CVA –ve, kidney can not palpable•Extremities : No edema, no deformity, no tremor

no clubbing of fingers•Lymph node : can not palpable•CNS : WNL, DTR reflex 2+

PHYSICAL EXAMINATION…THYROID GLANDPHYSICAL EXAMINATION…THYROID GLAND

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

NECK :

Mass at left neck anterior to sternocleidomastoid muscleSize 4x5 cm. , irregular shapefirm cosistency, rough surface ill-defind border, Not tender move on swallowing, no bruit

•Thyroid nodule of left lobe with clinical euthyriod

PROBLEM LISTPROBLEM LIST

2Am Fam Physician 2Am Fam Physician0 0 3 ;6 7 :5 5 90 0 3 ;6 7 :5 5 9-66-66

DIFFERNTIAL DIAGNOSISDIFFERNTIAL DIAGNOSIS

MAJOR RISK FACTOR….MAJOR RISK FACTOR….

• Lymphadenopathy• Evidence of local

invasion -Vocal cord paralysis

-Dysphagia• Firm, fixed nodules• Family history of

MEN II

• Radiation exposure

• Male• Older age• Younger age• Rapid increase in

size• Previous thyroid

cancer

Diagnostic testsDiagnostic tests

•Ultrasound•Radionuclide scintigraphy•Radiography•CT and MRI•FNA•Thyroid function test

Thyroid

ULTRASOUND……ULTRASOUND……

• Can identify presence of nodules.

• May be able to characterize follicular vs. solid.

• Evaluated thyroid gland

• Aid in biopsy.• Not able to rule our

malignant nodule

Thyroid ScansThyroid Scans

• Purpose – Determine function of the gland and/or

a nodule within the gland

• Hot nodules - usually independently functioning nodules

» Rarely, rarely malignant

• Cold nodules - either adenoma or maligancy

» 15% chance of malignancy in adults.

Nuclear Medicine Thyroid ScansNuclear Medicine Thyroid Scans

Cold NoduleThe majority of all nodules

Most benignSome malignant

Hot Nodule<5% of all nodulesRarely malignant

OTHER….OTHER….

• Radiography : – flecks of calcification – Psammoma bodies- Papillary CA

• CT and MRI :– Irregular margin

• FNA : • Thyroid function test :• Serum calcitonin :

•Thyroid nodule of left lobe with clinical euthyriod

PROBLEM LISTPROBLEM LIST

PLAN FOR MANAGEMENT……..PLAN FOR MANAGEMENT……..

ข้�อสอบศรวัข้�อสอบศรวั..

ป-2551/1 A 62 year-old woman with cief complaint of neck mass. Physical exam reveals a thyroid nodule, 2*2*2 cm. clinically Euthyroid. what is appropriate investigation?1. T3,TSH2. Thyroid scan3. FNA4. Thyroid uptake of I-1315. Ultrasound

Modified from: Castro, MR, Gharib, H. Endocr Pract 2003; 9:128.

ApproachApproach Solitary Thyroid nodule.. Solitary Thyroid nodule..

Fine needle aspiration(FNA)Fine needle aspiration(FNA)

FNA……..FNA……..

•Best tool for determining pathology other than surgical excision.•Can be as high as 80 % sensitive and 95% specific.•Operator dependent in obtaining adequate amount of tissue.

25 gauge needle is optimal.•Should not be relied on if negative in patient with previous neck irradiation.

Benign(70-80%)

FollicularNeoplasia

(5-8%)

Suspicious(5-8%)

Malignant(3-5%)

Inadequate(10-20%)

Fine Needle AspirationFine Needle Aspiration

Modified from: Castro, MR, Gharib, H. Endocr Pract 2003; 9:128.

ApproachApproach Solitary Thyroid nodule.. Solitary Thyroid nodule..

PLAN FOR MANAGEMENT……..PLAN FOR MANAGEMENT……..

-FNAFollicular neoplasm ,Suspected for CA thyroid

Thyroid Malignancies-Follicular

•Well-differentiated thyroid carcinoma•20 % of malignancies•Distinguished from normal follicular adenomas by invasion of capsule or blood vessels.•Ioidine deficiency related.•Male : female = 3 : 1•Hematogenous spreading •More distance metastasis

• Capsular invasion must be present• FNA inadequate for diagnosis

Thyroid Malignancies-Follicular

Clinical manifestations•85 % solitary thyroid mass or rapid developrment of single firm nodule in old goiter•Pain or local invasion in late staged•2-9% : LN metastasis•19 % : pathology LN metastasis•10-72% : Distant metastasis to bone or lung in first visit

PLAN FOR MANAGEMENT……..PLAN FOR MANAGEMENT……..

-Investigation?-patient education-Definite treatment

Chest X-ray

Chest X-ray

-Multiple soft tissue nodule of varying size in both lower lung

-Heart is normal-both costophrenic angles are sharp-bony thorax is intact

Impression multiple soft tissue nodule metastasis?

Thyroid Thyroid MetsMets

•Breast•Lung•Renal•GI•Melanoma

Management•Total thyroidectomy or near total thyroidectomy•Exogenous thyroid hormone supplement •Postop whole body RAI scan•Postop I131 ablation

Thyroid Malignancies-Follicular: Treatment

•EORTC , 1979 Age , Cell type, Distant metastasis, Sex, T-category, Differentiation.•Mayo clinic , 1987 (AGES) Age, Tumor grade, Tumor extension, Tumor size.•Lahey clinic, 1988 (AMES) Age, Distant metastasis, Tumor extension, Tumor size.

Thyroid Malignancies-Follicular: Prognosis

-TSH-TG

• -TSH• -TG• Whole body• -CXR

• TSH• TG

• TSH• TG

• TSH• TG

6mo -1st yrหย,ด้ยา 1mo

3 mo 4th yearNon-stop

5th yr 6th …..

FOLLOW UPFOLLOW UP

Benign(70-80%)

FollicularNeoplasia

(5-8%)

Suspicious(5-8%)

Malignant(3-5%)

Inadequate(10-20%)

Fine Needle AspirationFine Needle Aspiration

Follicular adenomaFollicular adenoma

• Most common benign tumor of thyroid• Pathology shows an encapsulated mass

consisting of numerous small follicles• May be functional (toxic adenoma) or

non-functional

• Treatment : •Thyroid lobectomy with Isthmectomy

•( Thyroid suppression )

Follicular adenomaFollicular adenoma

Thyroid CancerThyroid Cancer

• Uncommon cancer Uncommon cancer in Thailandin Thailand

• Most common Most common endocrine gland endocrine gland malignancymalignancy

• 1.8-3.5 per100,000 1.8-3.5 per100,000 populationpopulation

• Female : Male ratio Female : Male ratio = 3 : 1= 3 : 1

• More common in More common in Southern RegionSouthern Region

1.9

3.5

1.9

1.8

• Uncommon cancer Uncommon cancer in Thailandin Thailand

• Most common Most common endocrine gland endocrine gland malignancymalignancy

• 1.8-3.5 per100,000 1.8-3.5 per100,000 populationpopulation

• Female : Male ratio Female : Male ratio = 3 : 1= 3 : 1

• More common in More common in Southern RegionSouthern Region

1.9

1.8

0% 20% 40% 60% 80% 100%

ChiangMai

KhonKaen

Bangkok

Songkhla

Thailand

Male

Female

Thyroid CancerThyroid Cancer

1.9

3.5

1.9

1.8

0% 20% 40% 60% 80% 100%

ChiangMai

KhonKaen

Bangkok

Songkhla

Female Papillary

Female Follicular

Female Others

Thyroid CancerThyroid Cancer

Thyroid Malignancies- PapillaryThyroid Malignancies- Papillary

•Most common•Well-differentiated thyroid carcinoma •30% have node metastasis at diagnosis•Radiation related•TSH related•male : female = 3-4 : 1

• Slow growing tumor• Lymphatic invasion

and capsular invasion

• Lymphatic spreading

• Best prognosis (95% 10 yr survival)

Thyroid Malignancies- PapillaryThyroid Malignancies- Papillary

TreatmentDepend on size <1 cm – Lobectomy & isthmectomy >1 cm – Total thyroidectomy with/with out neck dissection

Thyroid Malignancies- PapillaryThyroid Malignancies- Papillary

Neck metastasisNeck metastasis

Central neck dissectionLymph node ใน paratracheal , pretracheal , tracheoesophageal, cricothyroid , top superior mediastinal groups , internal jugular chain ท*ง 2 ข้�าง ส�ง frozen sectionถึ�า positive ท/า modified or funtional neck dissection โด้ย preserve internal jugular vein , sternocleidomastoid muscle , spinal accessory ไวั�

ถึ�ามี� superior mediastinal lymph node metastasis ควัรท/า superior mediastinal lymph node dissection

จนถึ�ง arch of aorta โด้ย approach วั�ธ�ใด้วั�ธ�หน��ง ด้งน�* -Suprasternal approach -Resection of the medial one third of the clavicle -Resection of the manubrium -Median sternotomy

PrognosisPrognosis

Papillary carcinoma มี� 10 year-survival rate 84%Follicular carcinoma มี� 10 year-survival rate 76%

-42% ใน widely invasive carcinoma-86% ใน minimally invasive carcinoma

Hurthle cell neoplasm

•variant of follicular neoplasma• 3% of thyroid cancer•Usually do not uptake I-131 (only 10%)• Usually multifocal and bilateral •FNAC diagnosis hurthle cell neoplasm (20% carcinoma)•higher mortality rate than follicular carcinoma

Medullary carcinoma

- C-cell orgin (parafollicular cell) - calcitonin production - 5% thyroid malignancy - female : male = 1.5:1 - age 50 years - associate with MEN - Cervical and mediastinal node metastases

ManagementTotal thyroidectomyWith/without node dissectionRadioactive Iodine ablasionMonitor by serum calcitonin

Anaplastic Thyroid carcinomaAnaplastic Thyroid carcinoma

•Undifferentiate thyroid carcinoma•Poorest prognosis (50% < 6M)•More common in old age•Painful, hard neck mass, and symptoms of extension•Lymphatic and hematogenous spreading•Highly aggressive with local extension at time of diagnosis.•Airway obstruction , SVC syndrome•LN metastasis : 50% , lung metastasis

TREATMENTTREATMENT

•Early case (1%) -No extracapsular extension -Total thyroidectomy -Modified neck dissection -External radiation•Late case (99%) Total thyroidectomy with Modified neck dissection :

5 year-survival rate < 7% (75% ติายใน 1 ป-) Unresectable tumor : tracheostomy + external radiation

+ chemotherapy

MERRY X’ MAS

& THANK YOU