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Solitary nodule of thyroid

Solitary nodule of thyroid. Prof.P.Ragumani.MS. MMC & RG GGH.Ch.3. A discrete swelling in an otherwise impalpable gland is termed isolated or solitary .

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Solitary nodule of thyroid

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  1. Solitary nodule of thyroid Prof.P.Ragumani.MS. MMC & RG GGH.Ch.3

  2. A discrete swelling in an otherwise impalpable gland is termed isolated or solitary. • Dominant swelling in a gland is clinical evidence of generalised abnormality in the form of a palpable contralateral lobe or generalised mild nodularity. • About 70% of discrete thyroid swellings are clinically isolated and about 30% are dominant

  3. Some 15% of isolated swellings prove to be malignant, and an additional 30–40% are follicular adenomas. The remainder are non neoplastic, largely consisting of areas of colloid degeneration, thyroiditis or cysts Solitary palpable nodules are about four times more prevalent in women than in men

  4. The prevalence of thyroid nodules detected on palpation(broken line) or by ultrasonography or post-mortem examination(solid line)

  5. The risk of malignancy in thyroid swellings (‘rule of12’). The risk of cancer in a thyroid swelling can be expressed as a factorof 12. The risk is greater in isolated vs. dominant swellings, solid vs.cystic swellings and men vs. women.

  6. Presenting complaints Swelling in front of neck Dysphagia Dyspnoea Hoarseness of voice Hypothyroid/ hyperthyroid features

  7. SYMPATHETIC TRUNK – Horner’s syndrome Enophthalmos Miosis Anhydrosis Ptosis • Palpate for thrill BERRY’S SIGN – malignant thyroid engulfs the carotid sheath completely hence pulsation not felt.

  8. PALPATION OF CERVICAL NODES.

  9. most solitary thyroid nodules are benign and can be classified as • Adenomas • Colloid nodules, • Congenital abnormalities, • Cysts • Infectious nodules • lymphocytic or granulomatous nodules • hyperplasia

  10. FOLLICULAR ADENOMA • Solitary • well-defined, intact capsule

  11. Follicular adenoma of the thyroid. A solitary, well-circumscribed nodule is seen

  12. Microscopically • arranged in uniform follicles that contain colloid . • The neoplastic cells are uniform, with well-defined cell borders. • Occasionally, the neoplastic cells acquire brightly eosinophilic granular cytoplasm (oxyphil or Hürthle cell change)

  13. even benign follicular adenomas on occasion exhibit focal nuclear pleomorphism atypia prominent nucleoli (endocrine atypia) Papillary change is not a typical feature of adenomas and, if present, should raise the suspicion of an encapsulated papillary carcinoma

  14. follicular adenoma. Well-differentiated follicles resemble normal thyroid parenchyma

  15. Follicular carcinoma of the thyroid. A few of the glandular lumens contain recognizable colloid.

  16. The hallmark of all follicular adenomas is the presence of an intact well-formed capsule encircling the tumor. • Careful evaluation of the integrity of the capsule is therefore critical in the distinction of follicular adenomas from follicular carcinomas, which demonstrate capsular and/or vascular invasion .

  17. Lab investigations • THYROID PROFILE serum TSH – 0.5 – 5micro units/ml TOTAL T4 - 50- 150nanomol/lit TOTAL T3 - 1.5- 3.5nanomol/lit Free T4 - 12-28picomol/lit Free T3 - 3-9picomol/lit Thyroglobulin - <1-35microgram/lit • SERUM CALCIUM 8-10nmol/l

  18. Thyroid imaging AP CXR with large retrosternal goitre X ray chest and neck • retrosternal thyroid extension • thyroid calcification • bony or mediastinal LN • lung metastases • Tracheal deviation and compression

  19. ultrasound • Non invasive and no radiation exposure • Information about size,shape,extend and multicentricity of gland • Distinguishing from solid from cystic ones • To asses cervical lymphadenopathy • To guide FNAC

  20. ultrasound Large left lobe with solid and Cystic components Dominant solid nodule in right lobe

  21. 47-year-old woman with thyroid nodule. Transverse ultrasound image of thyroid shows 7-mm well-defined, longer than wide (anteroposterior diameter, 7 mm; transverse diameter, 4 mm) isoechoic nodule (arrow). Fine-needle aspiration biopsy of the nodule was confirmed papillary carcinoma with extrathyroidal invasion.

  22. Haemorrhagic thyroid cyst

  23. papillary thyroid carcinoma with BRAFV600E mutation. On transverse sonogram, 1.2-cm irregular-shaped, markedly hypoechoic nodule (arrows) with peripheral calcification is noted in isthmic portion of thyroid gland. Sonography diagnosed nodule as malignancy. Sonography-guided fine needle aspiration and total thyroidectomy confirmed papillary thyroid carcinoma with extracapsular invasion.

  24. CYTOLOGY

  25. Parameters for cytologic assessment of solitary nodules (1) cellularity, (2) colloid content, (3) acinar formation, (4) papillary formation, (5) intranuclear cytoplasmic inclusions, (6) nuclear grooves, (7) marginal vacuoles, (8) Hürthle cells, (9) presence of various inflammatory cells, (10) cellular atypia.

  26. FNAC • Investigation of choice for discrete thyroid swelling • Excellent patient compliance • Simple and quick to perform • Safe, efficacious and cost effective • Provides pre op diagnosis and therefore planning

  27. FNAC TECHNIQUE 23 guage needle Multiple passes Ideally from periphery of lesion Reaspirate after fluid drawn Immediately smeared and fixed Papanicolaou stain common

  28. FNACRESULTS • Thy1 non diagnostic • Thy2 non-neoplastic • Thy3 follicular • Thy4 suspicious of malignancy • Thy5 malignant

  29. Thy2 aspiration cytology. Non-neoplastic appearances with scanty normal follicular cells together with colloid Thy3 aspiration cytology. Follicular neoplasm showing increased cellularity with a follicular pattern.

  30. Thy5 aspiration cytology. Papillary carcinoma withtypical cellular variability and nuclear inclusions.

  31. FNAC of papilary carcinoma of thyroid showing intracytoplasmic inclusions( orphan annie eyes and psomama bodies)

  32. FNACLIMITATIONS Hypocellular aspirates may be observed in cystic nodules, or they may be related to biopsy technique. The absence of malignant cells in an acellular or hypocellular specimen does not exclude malignancy. Inability to reliably distinguish a benign follicular neoplasm from a malignant neoplasm. Aspirates may be required from multiple sites of the nodule to improve sampling.

  33. FNNAC Fine needle non aspiration cytology or cytopuncture or fine needle capillary sampling Principle of capillary suction of fluid in to a thin channel 23 guage needle is used Used in cytological assesment of thyroid, breast and lymph nodes

  34. ADVANTAGES Easy to perform Amount of cellular yield was found to be better Cellular degeneration is lesser Smears with better maintenance of architexture Yield diagnostically superior specimen.

  35. FNNAC smear of follicular neoplasm showing hypercellularity, less trauma and better retained architecture in comparison to FNAC smear

  36. FNNAC smear of colloid goitre showing less blood in the background in comparison to FNAC smear

  37. RADIONUCLIDE IMAGING • For the assesment of thyroid function • Demonstrates the function of thyroid nodule in comparision to the surrounding structures hot- excess uptake(5%) warm-normal uptake cold- no uptake(20%) • imaging done with gamma camera

  38. Radioactive iodine scan of the thyroid, with the arrow showing an area of decreased uptake, a cold nodule.

  39. Hot nodule showing increased activity than the surrounding

  40. Warm nodule normal uptake

  41. Radioisotopes • Tc99m • I 131 • I 123 • I 125 • Thallium 201 • Gallium 67 Iodine is trapped and organified Tecnitium trapped but not organified

  42. Tc99m Most commonly used radionuclide(99-mass number; m-metastable) Administered IV Pure gamma ray emitter Short half life Images can be obtained quickly Administered as pertechnate(Tco4).

  43. I 123 Shorter half life (12-13 hrs) Obtain quicker image Low dose radiation Good choice for lingual thyroids and subternal goitre

  44. I 131 Longer duration (8 days) Emits beta rays Used for thyroid carcinoma screening modality of choice for the evaluation of distant metastasis.

  45. THALLIUM 201 • Expensive, role poorly defined • Can detect (but not treat) mets. • Not trapped or organified- mechanism unclear • Advantages not necessary to be off thyroid replacement patients with large body iodine pool or hypofunctioning thyroid

  46. OTHER IMAGING AGENTS • Tc-99m sestamibi • Tc-99m pentavalent DMSA • Radioiodinated MIBG developed for medullary (APUD derivative) Radiolabelled monoclonal antibodies

  47. CT For detecting regional &distant metasasis from thyroid cancer to detect retrosternal involvement

  48. MRI diagnosis of cervical LN metastasis

  49. Fused computerised tomography and positron emission tomography scans showing a left-sided thyroid neoplasm FDG PET To screen for metastasis in thyroid cancer

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