Thyroid nodule

History Physical examination

– Euthyroid– Hypothyroid– Hyperthyroid

Labs– TSH– (antibodies)

Thyroid nodule

Imaging– US– Scan if TSH is low

Toxic adenoma

Thyroid nodule

Imaging– US– Scan if TSH is low– CT usually precedes referral

FNA– US-guided

Thyroid nodule

There are 3 ways to diagnose a thyroid nodule:

ultrasound guided FNAultrasound guided FNAultrasound guided FNA

Thyroid nodule

FNA result– Papillary carcinoma– Follicular LESION

Carcinoma Adenoma Adenomatous colloid nodule

– Insufficient for diagnosis

Management Guidelines for Patients withThyroid Nodules and Differentiated Thyroid Cancer

(Cooper, THYROID 2006;16:109-141(

Management Guidelines for Patients withThyroid Nodules and Differentiated Thyroid Cancer

(Cooper, THYROID 2006;16:109-141) FNA Results

Thyroid nodule

FNA result– Papillary carcinoma

–Follicular LESIONCarcinomaAdenomaAdenomatous colloid nodule

– Insufficient for diagnosis

Management Guidelines for Patients withThyroid Nodules and Differentiated Thyroid Cancer

(Cooper, THYROID 2006;16:109-141) FNA Results

Thyroid nodule

conservative approach for most patients with thyroid nodules that are

cytologically indeterminate on fine-needle aspiration and benign according to

gene-expression classifier results.

(Alexander, N Engl J Med. 2012;367:705-15)

Non-mailgnant indications for thyroidectomy

Goiter

Non-mailgnant indications for thyroidectomy

Goiter– Symptomatic

Non-mailgnant indications for thyroidectomy

Goiter– Symptomatic– Esthetic

Non-mailgnant indications for thyroidectomy

Goiter– Symptomatic– Esthetic

Hyperthyroidism

Before and after total thyroidectomy

THYROID CANCERS

CALSSIFICATION:

THYROID CANCERS

CALSSIFICATION:

DIFFERENTIATED THYROID CANCERS

THYROID CANCERS

CALSSIFICATION:

DIFFERENTIATED THYROID CANCERS

OTHER THYROID CANCERS

THYROID CANCERS

CALSSIFICATION:

DIFFERENTIATED THYROID CANCERS

Papillary

THYROID CANCERS

CALSSIFICATION:

DIFFERENTIATED THYROID CANCERS

Papillary Follicular

THYROID CANCERS

CALSSIFICATION:

DIFFERENTIATED THYROID CANCERS

Papillary Follicular

OTHER THYROID CANCERS

THYROID CANCERS

CALSSIFICATION:

DIFFERENTIATED THYROID CANCERS

Papillary Follicular

OTHER THYROID CANCERS Medullary

THYROID CANCERS

CALSSIFICATION:

DIFFERENTIATED THYROID CANCERS Papillary Follicular

OTHER THYROID CANCERS Medullary Anaplastic (?poorly differentiated

papillary carcinoma)

Differentiated thyroid cancer

Follicular Papillary

Age

Gender (Sex)Mode of SpreadMultifocality

Prognosis after surgery(20-y survival)

Differentiated thyroid cancer

Follicular Papillary

35-55 25-45 Age

Gender (Sex)Mode of SpreadMultifocality

Prognosis after surgery(20-y survival)

Differentiated thyroid cancer

Follicular Papillary

35-55 25-45 Age

F F Gender (Sex)Mode of SpreadMultifocality

Prognosis after surgery(20-y survival)

Differentiated thyroid cancer

Follicular Papillary

35-55 25-45 Age

F F Gender (Sex)

Blood borne Lymphatic Mode of SpreadMultifocality

Prognosis after surgery(20-y survival)

Differentiated thyroid cancer

Follicular Papillary

35-55 25-45 Age

F F Gender (Sex)

Blood borne Lymphatic Mode of Spread

No Yes Multifocality

Prognosis after surgery(20-y survival)

Differentiated thyroid cancer

Follicular Papillary

35-55 25-45 Age

F F Gender (Sex)

Blood borne Lymphatic Mode of Spread

No Yes Multifocality

Excellent Excellenter Prognosis after surgery(20-y survival)

Differentiated thyroid cancer

Staging – T1 - Tumor 2 cm or less in greatest dimension

limited to the thyroid.– T2 - Tumor more than 2 cm, but not more than 4

cm, in greatest dimension limited to the thyroid.– T3 - Tumor more than 4 cm in greatest dimension

limited to the thyroid.– T4a - Tumor of any size extending beyond the

thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve.

– T4b - Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.

Differentiated thyroid cancer

Staging– N1a - Metastasis to Level VI (pretracheal,

paratracheal, and prelaryngeal/Delphian lymph nodes).

– N1b - Metastasis to unilateral, bilateral, or contralateral cervical or superior mediastinal lymph nodes.

Prognostic factors

A G E S

Age Sex (Gender) Extension Size

Prognosis (Lahey Clinic)

Age Metastasis Extension Size

Prognosis (Lahey Clinic)

Age Metastasis (NOT lymph node) Extension Size

Prognosis (Lahey Clinic)

Age Metastasis (NOT lymph node) Extension (to neighboring

structures) Size

Prognosis (Mayo Clinic)

MACIS Prognostic score Metastasis, Age, Completeness of resection,

vascular Invasion, Size.

M + 3 if Metastasis is found A = Age (y) x 0.08 C + 1 if resection is inComplete I + 1 if vascular invasion (pathologists

report) S 0.3 x largest diameter in centimeters

(Size)

Prognosis (MSKCC)

Even more complicated scoring Includes

– Tumor grade– Lymph node involvement– multifocality

Complications of thyroid surgery

Thyroid operations

Lobectomy ± isthmus Near total thyroidectomy Total thyroidectomy

– ± modified neck dissection for known involved lymph nodes

Operations for papillary carcinoma

Lobectomy (low risk)– Difficult to justify radical surgery for such a

good prognosis cancer

Total/near total thyroidectomy (high risk) – Treatment with radioactive iodine-131– Detection of distant metastases

Total thyroidectomy + modified neck dissection (known lymph node metastasis)

Extensive spread of papillary carcinoma

Operations for follicular carcinoma

Total thyroidectomy Near total thyroidectomy

– Treatment with radioactive iodine-131

– Detection of distant metastases

Adjuvant treatment

Scan for residual glandular tissue– I131 full body scan– Maximal TSH stimulation

Destruction of thyroid remnant– High dose I131 (Maximal TSH stimulation)

Treatment – High dose I131 (Maximal TSH stimulation)

Suppressive T4 for life

Follow up– Thyroglobulin (Tg) with maximal TSH stimulation– I131 full body scan as indicated by Tg