THYROID
NODULES
LISA A. CICO, MSN, NP
UPSTATE MEDICAL UNIVERSITY
BREAST & ENDOCRINE SURGERY
COORDINATOR THYROID CANCER PROGRAM
SURGICAL COORDINATOR BREAST CANCER
PROGRAM
 Comprehensive review of current
OBJECTIVES
Describe tools /
diagnostic testing for
assessment of the
patient with a thyroid
nodule(s)
*Utilize national
guidelines developed
for patients with
thyroid nodules
*Describe some of the
common symptoms of
patients with thyroid
nodules
diagnostic tools and imaging to
assess thyroid nodules
 Review American Thyroid
Association, & National
Comprehensive Cancer Network
Guidelines for patients who
develop thyroid nodules
 Review common symptoms of
patients with thyroid nodule
 Obtaining appropriate
OBJECTIVES
Identify which patients
can safely be followed by
PCP
*Describe
imaging/diagnostic
modalities for following
the patient with thyroid
nodules
*Identify those patients
requiring referral to
specialty
*Identify which specialty
to make an appropriate
referral based on
diagnostic, objective and
symptomatic findings





imaging/diagnostic testing, and
frequency
Overview of ultrasonographic
thyroid terminology
Overview of Betheseda thyroid
nodule pathology terminology
Obtaining appropriate personal and
family history
Identify what patients require
referral and to endocrine or surgery?
Briefly discuss appropriate follow up
for the patient with thyroid cancer
Definition of Thyroid Nodule
 “A discrete lesion within the thyroid gland that is
palpably and/or ultrasonographically distinct from
surrounding thyroid parenchyma”
*ATA Management Guidelines for Patients with Thyroid Nodules and Differentiated
Thyroid Cancer (2006 & 2009 Task Force)
Prevalence


Rallison et al. JAMA 1975
Hogan et al. J Surg Res 2009
60
50
40
Palpation
Autopsy
Ultrasound
30
20
10
0
10
20
30
40
50
60
70
“How was this nodule found?”
 Palpation with a physical exam
 Incidental finding on diagnostic work up
 Self detection
 Surveillance
 Work up for symptoms of hyper/hypothyroidism
 How was found  is it clinically relevant?
Physical Examination of Thyroid Gland
 Visual inspection
 Palpation of thyroid, neck nodes, and supraclavicular
nodes
 Fixed, mobile, soft, tender?
 Reflexes  why?
 HR, BP, weight
Symptoms
 Usually NONE!!
 Occasionally painful, quick onset (cyst)
 Difficulty swallowing
 Hoarseness OR change in voice
 Shortness of breath (or difficulty swallowing) usually
while supine OR hands raised over head
(Pemberton’s Sign)
 Choking sensation
  hyper/hypo thyroid
Symptoms?
Nodules
Hyper/Hypo thyroid
 Difficulty swallowing
 Hyper-functioning
nodule
 Globus sensation
 Hashimoto’s
 Choking sensation
Pertinent History & PE in Evaluation of TNs
History
Physical Findings
 Head & neck
 Rapid growth




irradiation
Whole body irradiation
Nuclear fallout
Family history of
thyroid malignancy
Heredity
 Hoarseness
 Cervical /supraclavicular
lymphadenopathy
 Fixation of nodule or
gland
 > 4 cm
 Solitary
Differential Diagnosis
 Multinodular Goiter
 Hashimoto’s Thyroiditis
 Cancer
 Lymphoma
 Solitary Thyroid Nodule
 Substernal Goiter
Family History
of
Hereditary Diseases
COWDEN’S SYNDROME
FAMILIAL POLYPOSIS
CARNEY COMPLEX
MEN 2
WERNER SYNDROME
THYROID MALIGNANCY
Substernal Goiters
 Short neck
 Stocky build
 Usually incidental finding by CXR or CT
 Many times treated unsuccessfully for asthma
Ultrasound: The Gold Standard
Anyone found to have,
OR is suspected of having a
nodule  evaluate by
ultrasound!!

Pure cystic (relatively rare)

Spongiform appearance in >50% of
nodule volume (aggregration of
multiple microcystic components)

Multiple (?)
BENIGN
CHARACTERISTICS
BENIGN
Septated cyst
BENIGN
Cyst
BENIGN
US (a, transverse; b, longitudinal) scans in 51-year-old woman show 2.4-cm welldefined mixed-echoic hypoechoic nodule (arrows) in right lobe of thyroid gland. Initial
cytologic result was adenomatous hyperplasia, confirmed after 11 months at repeat
aspiration

High-risk history: History of thyroid cancer in one or
more first degree relatives; history of external beam
radiation as a child; exposure to ionizing radiation in
childhood or adolescence; prior hemithyroidectomy with
discovery of thyroid cancer, 18FDG avidity on PET
scanning; MEN2/FMTC-associated RET protooncogene
mutation, calcitonin >100 pg/mL. MEN, multiple
endocrine neoplasia; FMTC, familial medullary thyroid
cancer.

Suspicious features: microcalcifications; hypoechoic;
increased nodular vascularity; infiltrative margins; taller
than wide on transverse view.

FNA cytology may be obtained from the abnormal lymph
node in lieu of the thyroid nodule.

Sonographic monitoring without biopsy may be an
acceptable alternative
ULTRASOUND
CHARACTERISTIC
CONSIDERATIONS
 Hypo-echogenicity compared to
SUSPICIOUS
CHARACTERISTICS








normal thyroid parenchyma
Increased intra-nodular vascularity
Irregular infiltrative margins
Presence of micro-calcifications
Absent halo
Shape taller than width in transverse
dimension
Nodules > 4 cm
Solitary
Difficulty swallowing
ATA Guidelines 2009
Suspicious
Hypoechoic
Suspicious
Increased vascularity
SUSPICIOUS
Increased vascularity
SUSPICIOUS
Calcifications
Poorly defined, irregular margins
SUSPICIOUS
Solid
Multiple Thyroid Nodules
 FNA  what nodule??
 > 1 cm
 Suspicious features
 Dominant / largest one
FNA of Palpable Nodule
Palpation?
Ultrasound?
 What nodule(s) do you
 What nodule(s) do you
FNA?
FNA?
TN with suppressed TSH
 UPTAKE SCAN to assess autonomous nodule
 Compare to U/S  what is the correlation with
Uptake 
 FNA  consider in non - functioning or
isofunctioning with suspicious features
FNA
 Only GOLD standard for proof of malignancy
without surgical pathology
FNA
False Negative
False Positive
 false-negative rate of
 ??
up to 5% with FNA
which may be even
higher with nodules >4
cm
Is Size a Predictor of Malignancy?
< 1 cm
> 1 cm
 NO
 NO
ATA Guidelines 2009
FNA Results
 Nondiagnostic
 Benign
 Atypia of Undetermined Significance (AUS)
 Suspicious for a Follicular Neoplasm/Follicular
Neoplasm
 Suspicious for Malignancy
 Malignant
Bethesda System for Reporting Thyroid Cytopathology
Diagnostic Category
Risk of Malignancy
(%)
Nondiagnostic or
Unsatisfactory
Usual management
Repeat FNA with
ultrasound guidance
Benign
0-3
Clinical Follow up with
ultrasound 6 months
Atypia of Undetermined
significance or Follicular
lesion of Undetermined
significance
5-15
Repeat FNA 3 months; if
same, then lobectomy
Follicular Neoplasm or
suspicious for Follicular
neoplasm
15-30
Surgical Lobectomy
Suspicious for
Malignancy
60-75
Near total thyroidectomy
or surgical lobectomy
Malignant
97-99
Near total thyroidectomy
 TSH
Lab Work
TSH
Free T4
 Free T4
 TPO in suspected thyroiditis
T4
T3
Free T3
 TG  tumor marker in PTC, FTC,
HTC
TPO
Thyroglobulin (TG)
Calcitonin
 Calcitonin  suspected MTC or in
follow up of MTC
Thyroid nodule
FNA
Benign
Exam/Sonogram
6-18 months
No Change
Repeat in 3-5 yrs
20% increase in
diameter in > 2
dimensions
(>2mm) or
volume
increase > 50%
Re-aspirate
Thyroid Nodule
TABLE 3. SONOGRAPHIC AND CLINICAL FEATURES OF THYROID NODULES AND RECOMMENDATIONS FOR FNA
Nodule sonographic or clinical features
Recommended nodule threshold size for FNA
High-risk historya
Nodule WITH suspicious sonographic featuresb
>5mm
Recommendation A
Nodule WITHOUT suspicious sonographic featuresb
>5mm
Recommendation I
Abnormal cervical lymph nodes
Allc
Recommendation A
Microcalcifications present in nodule
≥1cm
Recommendation B
AND hypoechoic
>1cm
Recommendation B
AND iso- or hyperechoic
≥1–1.5 cm
Recommendation C
WITH any suspicious ultrasound featuresb
≥1.5–2.0 cm
Recommendation B
WITHOUT suspicious ultrasound features
≥2.0 cm
Recommendation C
Spongiform nodule
≥2.0 cmd
Recommendation C
Purely cystic nodule
FNA not indicatede
Recommendation E
Solid nodule
Mixed cystic–solid nodule
RAI Uptake Scan
 ONLY IN HYPERTHYROID
 Cold Nodule - 10% incidence of being CA
Thyroid Cancers
 From 2005 to 2009, incidence rates increased by
5.6% per year in men and 7.0% per year in women,
making thyroid cancer the fastest increasing cancer
in both men and women
 Most common endocrine cancer
Projected Cases of Thyroid Cancer
 60, 220 new cases are estimated for 2013

45, 310 female

14, 910 male
 1,850 deaths projected for 2013

1,040 female

810 male

Death rate 0.5 per 100,000 in both male and females
AGE & INCIDENCE
AMCERICAN CANCER SOCIETY / NCCN/ SEER
 Diagnosed at a younger age then most adult cancers
 Median age at diagnosis was 50 years from 2005-2009
 2 out of 3 cases are < 55 years old
 Thyroid cancer in the pediatric population
 Pediatric Incidence 2.0 per 1 million in children <15 yrs and
17.6 per 1 million in children 15-19 yrs
 2% occur in children and teens
 Surgery
TREATMENT
FOR
 Radioactive Iodine Ablation
THYROID
CANCER
 Levothyroxine
 Monitor with WBS / ultrasound
CHILDREN
&
PREGNANT WOMEN
WHEN DO YOU OPERATE???
Complications of Thyroid Surgery
 Recurrent laryngeal nerve injury
 Hypo parathyroidism
 Bleeding
 Infection
COMPLICATIONS OF
SURGERY
Parathyroid glands
COMPLICATIONS OF
THYROID SURGERY
OR case
Surgery and TC
Low MORTALITY
Should be LOW
MORBIDITY too!!

Thyroid cancers  LOW Mortality!!
 Rod Stewart, Julie Andrews, Joe Piscopo

IF surgery is required, always refer to
someone who does at least > 50 / year
Always exceptions to the rules :
 Roger Ebert, Supreme Court Justice
Reinquist

NO drains!!

NO RR tracks!!

Dermabond is ulgy on the neck, and often
opens a bit…

Summary
Refer to Endocrin0logy or
Surgery
Can safely follow with
ultrasound
 Children
 Nodule < 1 cm
 Pregant women
 Stable nodules with no change
 Nodules > 1 cm with suspicious
Repeat in 6 months x 2, then
annually
features
 Compressive symptoms
 HT with globus symptoms
 ULTRASOUND!! Even if
already had CT, carotid
doppler, etc
 Monitor TFTs with U/S
Endocrine OR Surgery?
ENDOCRINE
 Suspected/known
abnormal TFTs with
TNs
 Pregnant
 If FNA needed
 Children
SURGERY
 If suspect surgery is
indictated
Thank You
QUESTIONS?