Approach to the Thyroid Nodule

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Approach to the Thyroid Nodule

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The Goiters Thyroid gland enlargement

• Nodular Goiter
• gt Solitary nodule
• Cold or Hot (Toxic adenoma)
• Solid or Cystic (simple, complex)
• Painful or not
• Firm or soft
• Fixed or not
• gt Multinodular goiter
• Non toxic
• Toxic (autonomous function)
• Retrosternal goiter

• Diffuse Goiter
• Endemic
• Sporadic
• Enzymatic defect (congenital)
• Drug induced (e.g. lithium)
• Others
• Graves disease
• Hashimotos
• Subacute thyroiditis

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A 52 y.o. female was found to have an enlarged
thyroid on routine physical examination
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Our patient was found to have a thyroid nodule
A discrete lesion within the thyroid gland that
is palpably and/or ultrasonographically distinct
from the surrounding thyroid parenchyma
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Butwhat is really a thyroid nodule ?

• Benign nodules (colloid, adenomatous hyperplasia)
• Cystic lesions (colloid, thyroglossal duct cyst)
• Adenomas (Follicular, Hurthle cell)
• Thyroid cancer (Medullary or non-medullary)
• Lymphoma of thyroid
• Others

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About thyroid nodules

• The prevalence of palpable thyroid nodules in
  iodine sufficient areas is 5 in women and 1 in
  males
• The prevalence of thyroid nodules in random
  ultrasound is 19-67 (higher in female and
  elderly)
• Thyroid cancer may occur in 5-10 of thyroid
  nodules
• The etiology is poorly understood and depends on
  type of nodule (RET mutation in thyroid cancer,
  activating mutation of TSH receptor in toxic
  adenoma etc). There may be a familial
  predisposition.

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Clinical Presentation

• A palpable lesion found by self- or medical
  examination
• A non-palpable nodule found on imaging for
  unrelated reasons, mostly hypothyroidism and
  bolus (incidentaloma)
• Work-up for hyperthyroidism
• An acute painful nodule (hemorrhagic cyst)

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Thyroid Imaging
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Neck Ultrasound
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Neck CT
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Our patient has a solitary nodule and asks you
about its significance

• Mass effect ?
• Thyroid function ?
• Benign or malignant lesion ?

Non-palpable nodules have same risk of malignancy
as palpable nodules
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Mass effect
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Clinical consequences of mass effect

• Cosmetics
• Psychological distress
• Dysphagia (Barium swallow)
• Tracheal compression (Flow loops)
• Pumberton sign
• Hoarseness

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Dysphagia
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Tracheal compression
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Our patient has a single nodule 2.5 cm diameter
with no mass effect. Whats next ?
Algorithm for work-up of thyroid nodules
Apply to all palpable nodules and those
non-palpable larger than 1 cm
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Nodule Palpable/Nonpalpable
US TSH

Hypo/Normal Hyper
Scan
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Functional Imaging (Technetium Thyroid
Scintigraphy)
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Hot nodule Cold nodule
Cold nodule
Toxic adenoma
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Nodule Palpable/Nonpalpable
US TSH

Hypo/Normal Hyper
Scan
Hot
Treat or follow
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Treatment of Toxic Adenoma

• When to treat ?
• Subclinical hyperthyroidism
• Overt hyperthyroidism
• How to treat ?
• Antithyroid drugs
• Radioactive iodine
• Surgery

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Nodule Palpable/Nonpalpable
US TSH

Hypo/Normal Hyper
Scan
FNA
Cold Hot
Treat or follow
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Fine Needle Aspiration
Pitfalls of FNA No Quick Diff Not enough
follicular cells Non palpable nodule False
negatives
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Nodule Palpable/Nonpalpable
US
TSH
Hypo/Normal Hyper
Scan
FNA
Cold Hot
Treat or follow
Benign Indeterminate Malignant
Follow Repeat
Operate
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Thyroid cytology
Benign cytology large amount of colloid with
few typical
follicular cells

• Indeterminate cytology
• Few colloid and large amount of follicular cells
• Large, medium and microfollicular patterns
• Solid patterns

• Malignant cytology
• Intranuclear inclusions, grooves, psamoma, etc
• High cellular density
• Papillary patterns
• Capsular invasion

Follicular and Hurthel adenomas are diagnosed
only upon pathology (capsular and/or vascular
invasion)
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Normal Thyroid Colloid nodule
Papillary Thyroid Cancer
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Risk factors for thyroid cancer
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Treating Thyroid Nodules

• Surgery malignancy, hyperthyroidism, mass
  effect, cosmetic/psychological
• Radioactive iodine hyperthyroidism, mass effect
• Percutaneous ethanol
• Antithyroid drugs
• Thyroxine suppression therapy
• Follow up

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Thyroxine suppressive therapy
Wemeau JL et al. J Clin Endocrinol Metab
874928- 34, 2002
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Our patient has a benign FNA report. Whats the
need for follow-up and how ?

• False negative FNA in up to 5
  
  
  
  (less when US guidance)
• Changes in functionality
• Size changes with mass effect

• Follow-up for functional changes
• Clinical features
• Serial TSH measurements
• Follow-up for anatomic changes
• by palpation
• by US very operator-dependent
• by CT

Consider TSH suppression trial Repeat FNA
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