Thyroid Nodules and Cancer: Evaluation and Management Tips

1. SHAHZAD AHMAD M.DF.A.C.E DIPLOMATE AMERICAN BOARD OF INTERNAL MEDICINE DIPLOMATE AMERICAN BOARD OF ENDOCRINOLOGY/DIABETES AND METABOLISM THYROID INSTITUTE OF UTAH

2. Thyroid nodule • discrete lesion in the thyroid gland radiologically distinct from the surrounding Thyroid Nonpalpable nodules are called “incidentilomas”

3. How Common are nodules? • 19-67 % if ultrasound is done

4. How common is Thyroid Cancer • 5-15% depending on risk factors

5. Incidence of thyroid cancer has increased more than threefold. • nearly 50% of the increased incidence is from tumors >2 cm, suggesting that a significant number of patients have clinically important tumors.

6. So you feel a nodule, now what

7. Nonpalpable nodules have the same risk of malignancy as palpable nodules with the same size

8. Who should you send for an ultrasound ? • All patients with a suspected thyroid nodule, nodular goiter, a nodule found incidentally • On (CT) or MRI or on PET scan. Anyone with a first degree relative with thyroid cancer

9. Generally, only nodules >1 cm should be evaluated Any thyroid lesion seen on PET scan should be evaluated by an Endocrinologist

10. appropriate evaluation of clinicallyor incidentally discovered thyroid nodule(s) • Measure TSH • If serum TSH is subnormal, radionuclide thyroid I-123 scan

11. Right Left

12. TOXIC MNG

13. Normal TSH with Irregular gland

14. What will the u/s tell us ?

16. HyperthyroidismDiffuse Goiter,thyroid stimualting immunoglobulin negative

18. Routine FNA is not recommended for subcentimeter nodules unless • Family history of PTC • history of external beam radiation • 18FDGPET–positive thyroid nodules. • Suspicious imaging charecteristics

19. long-termfollow-up of patients with thyroid nodules? • benign nodules require follow-up As there is a 5 % fasle negative rate its actually only 0.6% for u/s guided ! • which may be even higher with • nodules >4 cm

20. reasonable definition of growth is a 20% increase in nodule diameter • serial US examinations 6–18 months after the initial FNA.

21. Cytology interpretation • 6 follicular cell groups ,10-15 cells each • 7% of biopsies can be non diagnostic

22. Follicular neoplam Can be seen in 15-30% of biopsies If the cytology reading reports a follicular neoplasm, a 123I thyroid scan may be considered, if not already done, especially if the serum TSH is in the low-normal range

24. Indeterminate cytology/neoplasm Indeterminate cytology, reported as ‘‘follicular neoplasm’’ or ‘Hurthle cell neoplasm’’ can be found in 15–30% FNA’s carries a 10–30% risk of malignancy

26. If the cytology reading reports a follicular neoplasm, a 123I thyroid scan may be considered

28. The use of molecular markers (e.g., BRAF, RAS,RET=PTC, or galectin-3) may be considered for patients with indeterminate cytology Recommendation rating: C

29. Brief Discussion Of molecular markers • BRAF V-600 E, associated with PTC, predicts aggressive course and lymph node mets • Not associated with Radiation! Enviromental toxins?

31. FOLLICULAR CANCERS • RAS MUTATION seen in approximately 40 percent of follicular cancers • PAX8-PPAR gamma 1, seen in 10 percent of Follicular cancers

32. MOLECULAR ANALYSISOF INDETERMINATE CYTOLOGY • 1056 indeterminate FNA samples • Assessed for- BRAF V600E, RAS,RET/PTC, PAX/PPAR False negative rate at surgery was 5.9% Finding of RAS mutation increased risk of Thyroid cancer to 80% • J Clin Endocrinol Metab 2011;96:3390-7.

33. Cystic nodules Recurrent cystic thyroid nodules with benign cytology should be considered for surgical removal or PEI Recommendation B

35. What is the role of medical therapy for benign thyroid nodules? Old time Endocrinologists are still using Thyroid hormone to “shrink” thyroid nodules

36. 30 YEAR OLD FEMALE WITH MULTI NODULAR GOITER DISCOVERED SEPT 2006 ANTI-TPO 154, ANTI TG AB-368 TSH 7.36 • FNA CONSISTENT WITH WELL DIFFERENTIATED PAPILARY THYROID CANCER ON THE RIGHT • LEFT INDETERMINATE

37. Next step(s) ?

38. Preoperative Ultrasound ? • Preoperative neck ultrasound for cervical lymph nodes is recommended for all patients undergoing thyroidectomy • Use of CT/MRI/PET not recommended by the American Thyroid Association • Cooper ,D.S thyroid 16(2) 109-141 2006

42. Ultrasonographic lymph node "map"

43. WHY TOTAL THYROIDECTOMY? • Multiple Foci of PTC are found in thyroid lobes in up to 80 percent of patients • Upto 40 % can be bilateral The only predictor of contra lateral cancer is multifocality in ipsilateral lobe Katoh R, sasaki , cancer 1992 15;70

44. What does the A.T.A recommend? • NTT for bilateral nodules • NTT if metastatic lymph nodes seen • Age more than 45 • Nodule more than 1 cm

45. Cervical recurrence occurs in up to 25% of patients with papillary thyroid carcinoma (PTC) • The use of total thyroidectomy for most patients with thyroid carcinoma is supported by the following arguments:

46. NODE DISSECTION • should be performed if there is clinical evidence of cervical or mediastinal node metastases due to the increased risk of neck recurrence and mortality Am J Med 1994 Nov;97(5):418-28 MAZAFFERI

47. Extent of surgery improves survival • 50000 patients with NTT, • Survival improved in tumours >1 cm • Patients undergoing lobectomy had a 49% higher mortality rate • 2007 Ann of surgery 246:375-

48. Threshold size for lymph node metastases • 5mm for Pappilary thyroid cancer • 20 mm for Follicular thyroid cancer • Machens et al Cancer 103(11) 2269-2273