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Approach to the Lumpy Thyroid Katherine A. Kovacs, MD MSc FRCPC

Approach to the Lumpy Thyroid Katherine A. Kovacs, MD MSc FRCPC. Setting of Thyroid Nodule Discovery. Routine neck palpation by physician Self-examination by patient Incidental finding during radiological procedure. Clinical Relevance of Nodule Discovery. Potential malignancy

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Approach to the Lumpy Thyroid Katherine A. Kovacs, MD MSc FRCPC

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  1. Approach to the Lumpy ThyroidKatherine A. Kovacs, MD MSc FRCPC

  2. Setting of Thyroid Nodule Discovery • Routine neck palpation by physician • Self-examination by patient • Incidental finding during radiological procedure

  3. Clinical Relevance of Nodule Discovery • Potential malignancy • Clue to underlying thyroid pathology (i.e., Hashimoto’s thyroiditis) • Potential for thyroid dysfunction • Potential for compressive symptoms

  4. BENIGN: Colloid nodule Hashimoto thyroiditis Simple or hemorrhagic cyst Follicular adenoma Subacute thyroiditis MALIGNANT: Follicular cell-derived carcinoma Papillary Follicular Anaplastic C-cell-derived carcinoma Medullary Thyroid lymphoma Metastatic carcinoma Etiology of Thyroid Nodules

  5. EVALUATIONHistory • Thyroid function status • Associated pain • Compressive symptoms/Cosmetic • Establish risk factors for malignant disease • age < 30 or > 60; male sex • exposure to ionizing radiation • family history • rapid growth

  6. EVALUATIONPhysical Examination • Number, size & consistency of lumps • Mobility • Tenderness • Presence of lymphadenopathy • Compressive signs

  7. EVALUATIONTSH • Low-normal or suppressed TSH (< 0.5) • autonomous nodule(s) • overt hyperthyroidism indication for radioisotope scan (hot nodule, especially by I123, almost always benign) • High-normal or elevated TSH • Hashimoto’s thyroiditis • Overt hypothyroidism higher risk of malignancy

  8. EVALUATIONUltrasound • Most sensitive test to detect thyroid nodules and recommended for all patients identified to have one or more thyroid nodules • Assess size & number of nodules • Assess for sonographic characteristics that are higher risk for malignancy • Select nodule(s) for biopsy • Accuracy dependent on expertise

  9. MNG vs Solitary Nodule • Risk of cancer is the same in MNGs vs glands with solitary nodule • Selection for FNA should be based on U/S features rather than on size or clinically “dominant” nodules

  10. U/S Features Indicating Higher Risk of Malignancy

  11. EVALUATIONConsider Other Radiology • Technetium or I123 scan • most nodules are cold; AVOID as a routine • useful when suspecting hot nodule (low TSH) • CT thyroid/chest • useful in assessing retrosternal goitre

  12. EVALUATIONFNA

  13. EVALUATIONWhen to Perform FNA

  14. Indications for U/S-guided FNA • Palpation-guided FNA non-diagnostic • Complex (solid/cystic) nodule • Palpable small nodule (< 1.5 cm) • Impalpable incidentaloma • Abnormal cervical nodes • Nodule with suspicious U/S features

  15. EVALUATIONFNA Categories

  16. MANAGEMENTTreatment/Surveillance • Toxic Adenoma/MNG • surgery, high-dose RI or alcohol/laser ablation • Follicular Neoplasm • surgery for definitive diagnosis or close F/U • Carcinoma • surgery, RI PRN, & T4 suppress to TSH < 0.1 • Others • palpation, TSH, ?ultrasound, rebiopsy PRN • controversial: T4 suppression to TSH 0.1-0.4

  17. Unanswered Questions • Sufficient length of time to follow a nodule and maximum growth allowed to conclude that it is benign

  18. Case 1: Toxic Adenoma • 32-yr-old female manager of music store • c/o 2-3 yrs panic attacks, palpitations; 1 yr goitre, irregular menses, insomnia; 6-8 mo fatigue, muscle weakness; few weeks hand tremor, weight gain • medications: none • no FH thyroid cancer

  19. Case 1 (cont’d) • O/E: • normal weight, BP 138/70, HR 110 (regular) • easily visible goitre with ovoid mass in L lobe (4x normal size lobe); R lobe slightly palpable with tiny nodule • hands warm and sweaty • proximal muscle weakness

  20. Case 1 (cont’d) • Investigations: • TSH < 0.05, FT4 46 (Jan. 19) • Nuclear thyroid scan: 4.3 x 3 cm ovoid mass in L lobe with markedly increased uptake; mostly absent uptake in R lobe; 24 hr thyroid uptake 36 % (Feb. 2) • TSH 0.03, FT4 53.3, HCG < 0.5 (when I saw Mar. 19)

  21. Normal Thyroid Scan

  22. Thyroid scan in Toxic Adenoma

  23. Case 1 (cont’d) • Treatment: • high-dose radioiodine • Response: • marked shrinkage • induction of biochemical hypothyroidism

  24. Case 2: Multinodular Goitre • 34-yr-old taxi driver • large goitre x 9 years, gradual enlargement • pressure sensation when supine, nocturnal dry cough, frequent choking • mild fatigue, tendency to heat intolerance, gaining weight • medications: none • no FH thyroid disease

  25. Case 2 (cont’d) • O/E: • moderately overweight, BP 148/92, HR 90 (regular) • easily visible irregular goitre, roughly 8x normal size • hands very warm

  26. Case 2 (cont’d) • Investigations: • TSH 0.2, FT4 15.8 • U/S: diffusely enlarged heterogeneous thyroid

  27. Ultrasound MNG

  28. Thyroid Scan in MNG

  29. Case 2 (cont’d) • Treatment: • high-dose radioiodine 29 mC on 3 occasions • Response: • modest shrinkage • induction of biochemical hypothyroidism

  30. Case 3: Colloid Nodule • 54-yr-old male chief of security • lump in thyroid detected at routine physical • no compressive symptoms • no symptoms of thyroid dysfunction • no hx significant radiation exposure • no FH thyroid cancer; mom - goitre

  31. Case 3 (cont’d) • O/E: • mildly overweight, BP 160/92, HR 75 (regular) • easily visible, mobile L thyroid mass • no lymphadenopathy • clinically euthyroid

  32. Case 3 (cont’d) • Investigations: • TSH 1.27 • U/S: solitary 3.4 cm inferior L thyroid nodule • Nuclear thyroid scan: solitary cold nodule • FNA x 3: unsatisfactory (cyst contents, inflammatory cells, few epithelial cells) • shrunk after procedure • U/S-guided FNA: cyst contents, fragment of thyroid tissue with normal-looking follicles • repeated after nodule grew - colloid nodule

  33. Ultrasound Thyroid Nodule

  34. Fine Needle Aspiration

  35. Thyroid Scan in Cold Nodule

  36. Case 4: Follicular Neoplasm • 46-yr-old woman on disability • incidental thyroid nodule detected during CT pulm/angio for pulmonary emboli • dysphagia to liquids & solids • irritability, weight gain, fatigue, constipation • no history of significant radiation exposure • no FH thyroid cancer

  37. Case 4 (cont’d) • O/E: • moderately overweight, BP 120/68, HR 60 (regular) • easily visible, mobile R thyroid mass • no lymphadenopathy • clinically euthyroid

  38. Case 4 (cont’d) • Investigations: • TSH 1.11 • U/S: solitary 3.8 cm R complex thyroid nodule • FNA: few groups of follicular epithelial cells favouring neoplasm or colloid nodule • Pathology on resection: follicular adenoma

  39. Conclusions

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