SOLITARY THYROID NODULE
Done by Dr. Dana Al-Zarraq
Supervised y Dr. Saleh Hammad
Solitary Thyroid nodules
• MC solitary thyroid nodule is benign colloid nodule, it accounts for
60% cases of solitary thyroid nodule.
• 2nd MC cause of solitary thyroid nodule is follicular adenoma (30%).
History and physical examination
History :
• Details regarding the nodule, such as time of onset, change in size, and associated
symptoms such as pain, dysphagia, dyspnea, or choking, should be elicited.
• Risk factors for malignancy, such as exposure to ionizing radiation and family history
of thyroid and other malignancies associated with thyroid cancer.
• History of exposure to low-dose ionizing radiation to the thyroid gland places the
patient at increased risk for developing papillary thyroid cancer.
• Risk is maximum 20 to 30 years after exposure.
Physical Examination
• Thyroid gland is best palpated from behind the patient and with the
neck in mild extension.
• Nodules that are hard, gritty, or fixed to surrounding structures such
as the trachea or strap muscles are more likely to be malignant .
Diagnostic Investigations
Laboratory Studies
• Most patients with thyroid nodules are euthyroid. Determining the blood TSH level is
helpful.
Tg levels :
• Thyroglubulin is only made by the thyroid gland .
• Extremely elevated in metastatic disease.
• Its level increase with destructive process of thyroid or over active states.
• It is used for monitoring patients with differentiated thyriod cancer for recurrence
especially after thyroidectomy and RAI ablation .
• Serum calcitonin in patients with MTC or a family history of MTC or
MEN2.
• All patients with MTC should have :
• Testing for RET oncogen mutation
• 24 hour collection for VMA ,metanephrin and catecholamines to rule
out pheochromocytoma .
• 10% of the pt with familial MTC and MEN2 have de novo RET oncogen
mutation, and their children are at risk of thyroid cancer.
Imaging
• Ultrasound is helpful for detecting nonpalpable thyroid nodules,
differentiating solid from cystic nodules, and identifying adjacent
lymphadenopathy.
• Ultrasound evaluation can identify features of a nodule that increase
the risk of malignancy, such as fine stippled calcification and enlarged
regional nodes.
• Ct scan is used for local invasion and retrosternal extension thet may
alter patients staging and surgical appraoch .
Scanning the thyroid with 123I or 99mTc is rarely necessary, and
thyroid scanning currently is recommended in :
• the assessment of thyroid nodules only in patients who have follicular
thyroid nodules on FNAC .
• And a suppressed TSH.
FNA
• Single most important test in the evaluation of thyroid masses.
• Ultrasound guidance is recommended for nodules that are difficult to palpate
and for cystic or solid-cyst icnodules that recur after the initial aspiration.
• If a FNAC is reported as nondiagnostic, it generally should be repeated.
• When FNAC is used in complex nodules, the solid portion should be sampled.
• The risk of malignancy in the setting of a suspicious cytology is about 20%.
• It is less reliable in history of head and neck radiation or positive family history
thyroid cancer (multifocal and occult).
Thyroid Cyst
• Simple thyroid cysts resolve with aspiration in about 75% of cases
• Hemithyroidectomy:−
• If the cyst persists after three attempts at aspiration
• Cysts >4 cm in diameter
• Complex cysts with solid and cystic components (higher incidence of
malignancy, 15%).
Colloid Nodule
• Observation with serial ultrasound and Tg measurements.
• Hemithyroidectomy: If a nodule enlarges on TSH suppression, causes
compressive symptoms, or for cosmetic reasons.
• Total thyroidectomy:
• Patient who has had previous irradiation of the thyroid gland or
• has a family history of thyroid cancer, because of the high incidence
of thyroid cancer and decreased reliability of FNAC in this setting.
Papillary Carcinoma of Thyroid
• Accounts for 80% of all thyroid malignancies in iodine-sufficient areas.
• MC thyroid cancer in children & individuals exposed to external radiation.
• More often in women, 30–40 years.
• Grossly: Hard & whitish remain flat on sectioning with a blade with
macroscopic calcification, necrosis, or cystic changes.
• Multifocality is common (up to 85% of cases) on microscopic examination.
• Multifocality is associated with an increased risk of cervical nodal metastases,
rarely invade adjacent structures such as the trachea, esophagus & RLNs.
• Rarely encapsulated.
• Other variants: Tall cell, insular, columnar, diffuse sclerosing, clear cell,
trabecular, and poorly differentiated types; account for about1%;
associated with a worse prognosis .
• Histological Characteristics of Papillary Carcinoma Thyroid :
• Papillary projections.
• Orphan Annie eye nuclei.
• Psammoma bodies.
Clinical Features:
• Most patients are euthyroid & present with a slow-growing painless mass
in the neck.
• Dysphagia, dyspnea dysphonia are associated with locally advanced
invasive disease.
• Lymph node metastases are common, especially in children young adults,
and may be the presenting complaint.
• Distant metastases are uncommon at initial presentation, but may
ultimately develop in up to 20% of patients.
• MC sites of metastasis: Lungs>bone >liver >brain.
Treatment:
• Total or near-total thyroidectomy :
• If high risk tumors or bilateral tumor .
• Low risk tumors may be treated with total/near total or hemithyroidectomy if :
• Less than 1 cm .
• Unifocal.
• No hx of head and neck radiation .
• Intrathyroid tumor .
• During thyroidectomy, enlarged central neck nodes should be
removed.
• Biopsy-proven lymph node metastases detected clinically or by
imaging in the lateral neck in patients with papillary carcinoma are
managed with modified radical neck dissection.
Prognosis:
• PTC have an excellent prognosis with a >95% 10-year survival rate.
• Prognostic scoring systems ; AGES,MACIS,TNM.
follicular Carcinoma of Thyroid
• FTC account for 10% of thyroid cancers.
• Occurs more commonly in iodine-deficient areas.
• More common in women with mean age of 50 years.
• Genes implicated in FCT: p53, PTEN, Ras, PAX8/PPAR1.
Pathology:
• Usually solitary lesion surrounded by capsule.
• Histologically, follicles are present, but the lumen may be devoid of
colloid.
• Malignancy is defined by the presence of capsular and vascular
invasion,
• Tumor infiltration and invasion, as well as tumor thrombus within the
middle thyroid or jugular veins, may be apparent at operation.
Clinical Features:
• Usually present as solitary thyroid nodules, occasionally with a history of
rapid size increase, and long-standing goiter.
• Pain is uncommon, unless hemorrhage into the nodule has occurred.
• Cervical lymphadenopathy is uncommon at initial presentation (about
5%).
• Preoperative clinical diagnosis of cancer is difficult unless distant
metastases are present.
• Large follicular tumors (>4 cm) in older men are more likely to be
malignant.
• MC site of metastasis is bone (Osteolytic metastasis)
• MC site of metastasis: VertebraQ>Ribs >Pelvis Bones >Skull.
Diagnosis:
• FNAC is unable to distinguish benign follicular lesions from follicular
carcinomas,
• Intraoperative frozen-section examination usually is not helpful, but
should be performed when there is evidence of capsular or
vascularinvasion, or when adjacent lymphadenopathy is present.
Treatment:
• Follicular lesion: Hemithyroidectomy (80% of these patients will have
benign adenomas).
• Thyroid cancer: Total thyroidectomy.
• Total thyroidectomy in older patients with follicular lesions >4 cm
because of the higher risk of cancer in this setting (50%).
• Prophylactic nodal dissection is unwarranted because nodal
involvement is infrequent .
Prognosis:
• Cumulative mortality: 15% at 10 years and 30% at 20 years.
• Most important prognostic factor: Age and distant metastasis .
Hürthle Cell Carcinoma
• Account for 3% of all thyroid malignancies.
• Considered to be a subtype of follicular thyroid cancer.
Pathology:
• Characterized by vascular or capsular invasion and can’t be diagnosed by
FNAC.
Treatment:
• Unilateral Hürthle cell adenomas: Hemithyroidectomy.
• Invasive Hürthle cell neoplasms: Total thyroidectomy + Routine central neck
node removalQ (MRND when lateral neck nodes are palpable).
• Thyroglobulin isn’t effective in monitoring .
Post operative management of differentiated
cancers
Radioactive iodine I131 :
• Treats >70% of lung micromets.
• Protocole :
• 6 week prescan stop T4, start T3 , then T3 should be stopped 2 weeks
before scan.
• TSH >30 is optimal .
• External beam radiotherapy and chemotherapy
• Used for unreseced or recurrent disease , and for the bone pain from
bone mets .
Thyroid hormone replacement:
• Two functions :
• Replacement therapy post total or near total thyroidectomy .
• Or TSH suppression.
Follow up or papillary and follicular Ca
1) Thyroglobulin level ( stimulated more sensitive then unstimulated)
2) Imaging ; neck us at 6-12 months , then annually for 3 to 5 years .
Ps. If US and RAI scan are normal and Tg is high do PET scan.
Medullary Carcinoma Thyroid
• Neuroendocrine carcinoma arising from parafollicular ‘C’ cells of
thyroid• Parafollicular ‘C’ cells secrete calcitonin
• ‘C’ Cells are concentrated superolaterally in thyroid lobes, from where
MTC usually develops.
• Most MTCs (75–80%) arise sporadically.
• Spread is both lymphatic & hematogenous.
• MC site of metastasis: Liver
Diagnosis:
• Diagnosed by FNAC.
• I131 scan is of no use as MTC is TSH independent.
• Tumor marker: Calcitonin is raised in almost all cases of MTC.
• Calcitonin excess in MTC is not associated with hypocalcemia.
Treatment:
• Total thyroidectomy + Central LN dissection ± Ipsilateral MRND if
tumor >1 cm.
• If nodes are positive on ipsilateral side: Bilateral MRND.
MTCFollow-up:
• Level of Calcitonin falls after resection and is raises again in cases of
recurrence, used for follow up.
• Prognosis:
• MTC is associated with poor prognosis.
Anaplastic Carcinoma
• Accounts for 1% of all thyroid malignancies.
• Mainly affect women in 7th and 8th decade.
• The typical patient has a long-standing neck mass, which rapidly
enlarges and may be painful.
• Most aggressive form of thyroid cancer.
Pathology:
• Grossly: Firm & whitish in appearance.
• Microscopically, sheets of cells with marked heterogeneity &
characteristic giant & multinucleated cells.
Clinical Features:
• Typical manifestation: An older patient with dysphagia, cervical
tenderness & a painful, rapidly enlarging neck mass.
• Superior vena cava syndrome can also be part of the findings.
• The clinical situation deteriorates rapidly into tracheal obstruction &
rapid local invasion of surrounding structures.
• Associated symptoms: Dysphonia, dysphagia & dyspnea.
• Lymph nodes usually are palpable at presentation.
• Evidence of metastatic spread also may be present.
• MC site of metastasis: Lungs.
Diagnosis:
• Confirmed by FNAC revealing characteristic giant & multinucleated
cells.
• Incisional biopsy occasionally is needed to confirm the diagnosis.
Treatment:
• Thyroidectomy for resectable mass (may lead to a small improvement in
survival, especially in younger individuals).
• Combined radiation & chemotherapy in an adjuvant setting in patients
with resectable disease has been associated with prolonged survival.
• Tracheostomy to alleviate airway obstruction.
Prognosis:
• Most aggressive thyroid malignancies, with <6 months survival.
Metastatic Tumors of Thyroid
• Rare, most cases are found in autopsy.
• MC site of primary: CA BreastQ > CA Lung.
• If thyroid metastases is detected pre-mortem, MC site of primary: RCC
> CA Breast > CA Lung.
Thyroid lymphoma
• MC type is NHL B cellQ type, of intermediate grade.
• Majority of patients have thyroid disease plus cervical or mediastinal
lymph nodes.
• More common in females.
• Most thyroid lymphomas develop in patients with Chronic
Lymphocytic Thyroiditis.
Clinical Features:
• Lymphomas are rapidly growing tumours, present with rapidly
enlarging neck mass which is often painless.
• Patients may present with acute respiratory distress & dysphagia.
• About 10–30% present with symptoms relating to local invasion,
including hoarseness, dyspnoea with stridor, or dysphagia.
Diagnosis:
• Diagnosis is confirmed by core-needle biopsy.
• Treatment: External Beam Radiotherapy + Chemotherapy.
• THANK YOU
