approach to a thyroid nodule
DESCRIPTION
Approach to a thyroid nodule. Andy Sher PGY-2 Family Medicine. Case. 44 y.o. woman, 2 cm nodule palpable in left lobe of thyroid gland at annual exam – smooth, non-tender. No lymphadenopathy No symptoms of hyper/hypo thyroid. No compressive symptoms Past Med Hx: HTN Meds: HCTZ - PowerPoint PPT PresentationTRANSCRIPT
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Approach to a thyroid nodule
Andy SherPGY-2 Family Medicine
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Case
44 y.o. woman, 2 cm nodule palpable in left lobe of thyroid gland at annual exam – smooth, non-tender. No lymphadenopathy
No symptoms of hyper/hypo thyroid. No compressive symptoms
Past Med Hx: HTN Meds: HCTZ Fam Hx: no hx of thyroid disease
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Epidemiology
Palpable thyroid nodules – 4-7% of population
Prevalence 19-67% - based on nodules found incidentally on ultrasound
4:1 women:men
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Epidemiology
Geographic areas with iodine deficiency
Thyroid carcinoma in 5-10% of palpable nodules
Following ionizing radiation, nodules develop at a rate of 2% annually
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Presentation
Majority are asymptomatic <1% cause hyperthyroidism Neck pressure or pain if spontaneous
hemorrhage
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History
Symptoms of hyper or hypothyroidism Previous nodules, goiters, family
history of autoimmune thyroid disease, thyroid carcinoma, or familial polyposis
Hashimoto’s thyroiditis – association with thyroid lymphoma
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History – Red Flags
Male < 20 years, > 65 years Rapid growth of nodule Symptoms of local invasion
(dysphagia, neck pain, hoarseness) Hx of radiation to head or neck Family hx of thyroid CA or polyposis
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Physical Exam
Less than 1 cm usually not palpable ½ of all nodules detected by
ultrasonography not detected by physical exam
Should also examine for lymphadenopathy
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Physical Exam
Smooth or nodular Diffuse or localized Soft or hard Mobile or fixed Painful or non-tender
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Laboratory
TSH Serum calcitonin if family hx of
medullary thyroid carcinoma Do not use thyroid function tests to
differentiate benign from malignant
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Radiology
Ultrasound to document size, location, and
character of nodule To determine changes in size of nodules
over time or to detect recurrent lesions U/S guided biopsy decreases the
incidence of indeterminate specimens
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Radiology
Thyroid scan Can not reliably distinguish benign from
malignant nodules Cold nodules – 5-15% are malignant Hot nodules – almost always benign
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Fine Needle Aspiration
Should be 1st test in the euthyroid patient Sensitivity 68-98% Specificity 72-100% False negative rate 1-11% False positive rate 1-8% Sampling errors in very large and very small
nodules – minimized by u/s guided biopsy
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Treatment
Surgical treatment indications Malignancy Indeterminate cytology and suspicious
H&P Indeterminate cytology and “cold nodule” Toxic nodules (suppression of TSH,
symptoms – a-fib) – can use radioactive iodine or surgery
Repeated recurrence of cystic lesions
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Treatment
Benign biopsies – can be followed without surgery and monitored q 6 months by physical exam, u/s
Surveillance – change in nodule size and symptoms – repeat FNA if nodule grows.
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Suppression treatment
Post-operative suppression treatment following resection of cancer
TSH should be maintained for target of 0.5 mU per L
Greater suppression for high risk patients, metastatic or locally invasive not completely removed
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Suppression treatment
For benign solitary nodule controversial
Follow at 6 month intervals Thyroxine to suppress TSH to 0.1 to
0.5 mU per L for 6-12 months After 12 months, maintain TSH in low
normal range
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Incidental Nodule on U/S
Most are benign and can be monitored without further testing
FNA if nodule becomes palpable findings suggestive of malignancy on u/s larger than 1.5 cm Hx of head or neck irradiation Strong family hx of thyroid cancer
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Case
44 y.o. woman, 2 cm nodule palpable in left lobe of thyroid gland at annual exam – smooth, non-tender. No lymphadenopathy
TSH ordered – normal Thyroid u/s – confirms 2 cm nodule,
solid FNA - benign
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Case
Repeat U/S at 1 year – nodule now 2.5 cm in size
Repeat FNA – benign Could consider suppression therapy,
or continue to follow.