management of the thyroid nodule neil s tolley md frcs dlo st mary’s hospital 28 th february 2002

Management of the Thyroid NoduleManagement of the Thyroid Nodule

Neil S Tolley MDNeil S Tolley MD FRCS DLOFRCS DLO

St Mary’s Hospital 28St Mary’s Hospital 28thth February 2002 February 2002

Thyroid NoduleThyroid Nodule

• Malignant Disease – rare, <1% all Malignant Disease – rare, <1% all malignancies. Only 15% mortality.malignancies. Only 15% mortality.

• Benign Disease – Common. 15% Benign Disease – Common. 15% have a goitre. 7% palpable. Over have a goitre. 7% palpable. Over 8000 Thyroidectomies per annum in 8000 Thyroidectomies per annum in the uk.the uk.


• Autopsy - 37% have nodules, 12% solitaryAutopsy - 37% have nodules, 12% solitary

• 5% have a clinically apparent solitary nodule5% have a clinically apparent solitary nodule

• Overall incidence of malignancy is between Overall incidence of malignancy is between 10-30%10-30%

• UK 3,000/annum & 250 deathsUK 3,000/annum & 250 deaths

• Deaths (anaplastic, medullary). Differentiated Deaths (anaplastic, medullary). Differentiated cancer death rate is relatively lowcancer death rate is relatively low


• Clinician has to be surgically selectiveClinician has to be surgically selective

• EpidemiologyEpidemiology

• HistoryHistory

• ExaminationExamination

• InvestigationsInvestigations


• Papillary – 80%, 80% multicentric. Seen in children. Papillary – 80%, 80% multicentric. Seen in children. Nodes (60%), 20% Lung metastases at presentation, Nodes (60%), 20% Lung metastases at presentation, Bone rareBone rare

• Follicular – 15% focal, older age (6Follicular – 15% focal, older age (6 thth decade) Nodes decade) Nodes (10%), Lung & Bone (20-30%)(10%), Lung & Bone (20-30%)

• Medullary – 4%Medullary – 4%• Anaplastic – 2%Anaplastic – 2%• Others – Hurthle, Lymphoma, Sarcoma, SCC,Others – Hurthle, Lymphoma, Sarcoma, SCC,• Secondaries (breast, lung & kidney)Secondaries (breast, lung & kidney)

Thyroid Nodule - EpidemiologyThyroid Nodule - Epidemiology

• Papillary more common with DXT Papillary more common with DXT historyhistory

• Incidence of Thyroid cancer 50% if Incidence of Thyroid cancer 50% if received low dose DXT (800-1000 received low dose DXT (800-1000 rads) T&A’s, Thymus, Skin problemsrads) T&A’s, Thymus, Skin problems

• Belarus/Ukraine increased 12-34 foldBelarus/Ukraine increased 12-34 fold

• Follicular Iodine deficiencyFollicular Iodine deficiency

• Lymphoma Hashimoto’sLymphoma Hashimoto’s

Thyroid Nodule – History/ExaminationThyroid Nodule – History/Examination

• Rapid growth, Fixed, HardRapid growth, Fixed, Hard

• Vocal cord palsyVocal cord palsy

• Recurrent cystic noduleRecurrent cystic nodule

• Age – very young or oldAge – very young or old

• Neck node metastasesNeck node metastases

• Sudden change in size of a thyroid noduleSudden change in size of a thyroid nodule

Thyroid Nodule – investigationsThyroid Nodule – investigations

• Haematological – TFT’s, Autoantibodies, Haematological – TFT’s, Autoantibodies, Calcitonin, RET-proto-oncogeneCalcitonin, RET-proto-oncogene

• Radiology – USS, TC99m or Iodine131Radiology – USS, TC99m or Iodine131

• FNACFNAC

• CT/MRICT/MRI

Thyroid Nodule – USSThyroid Nodule – USS

• 20% Solid, 5% Cystic - Malignant20% Solid, 5% Cystic - Malignant• Papillary – Cloudy/Punctate (Psammoma bodies). Papillary – Cloudy/Punctate (Psammoma bodies).

Areas cystic necrosis common. Nodes may show Areas cystic necrosis common. Nodes may show calcification, can be solid or entirely cystic (chocolate calcification, can be solid or entirely cystic (chocolate cysts)cysts)

• Follicular – Rarely cystic. Amorphous calcificationFollicular – Rarely cystic. Amorphous calcification• Medullary – Coarse or Psammomatous calcification. Medullary – Coarse or Psammomatous calcification.

50% neck or mediastinal involvement. 33% Familial50% neck or mediastinal involvement. 33% Familial• Hashimoto’s – rarely necrosesHashimoto’s – rarely necroses


• Cold Nodules 20% malignant 5% hotCold Nodules 20% malignant 5% hot

• FNAC – incidence of thyroid cancer in FNAC – incidence of thyroid cancer in surgical specimens may reach 29%surgical specimens may reach 29%

• Sensitivity 86%Sensitivity 86%

• Specificity 84%Specificity 84%

• Negative predictive value 97%Negative predictive value 97%


• Risk assessment – patient and tumour factorsRisk assessment – patient and tumour factors

• Low risk – papillary, age < 45yrs, Low risk – papillary, age < 45yrs, tumour < 4cmtumour < 4cm

• High risk – Follicular, age > 45 yrs, tumour > High risk – Follicular, age > 45 yrs, tumour > 4cm4cm

• Mortality 2% low, 45% high 15% intermediateMortality 2% low, 45% high 15% intermediate


• A nodule > 3cm with Follicular cells has a 30% chance of A nodule > 3cm with Follicular cells has a 30% chance of malignancymalignancy

• Nodule 2-3cm observe, repeat USS and FNACNodule 2-3cm observe, repeat USS and FNAC• Is this for the GPSI?Is this for the GPSI?• Education yes – appropriate pre-assessment investigations Education yes – appropriate pre-assessment investigations

can be requested, Bloods, USS & FNAC.can be requested, Bloods, USS & FNAC.• Refer to ENT in the forum of a combined Thyroid clinicRefer to ENT in the forum of a combined Thyroid clinic• The GPSI can be used to promote Thyroid surgery as a The GPSI can be used to promote Thyroid surgery as a

domain for the ENT surgeondomain for the ENT surgeon

management of the thyroid nodule neil s tolley md frcs dlo st mary’s hospital 28 th february 2002

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