Solitary thyroid nodule approach

History The most common presentation for a thyroid nodule is? A swelling noticed by the patient or by family and friends But if its not apparent how will it present? Pressure symptoms is 1 way like (dysphagia, dyspnea, stridor, engorged neck veins or even ear pain and change in voice) Symptoms of hyper or hypothyroidism (change in weight, heat or cold intolerance, change in bowel habits, sweating,…….so on) Take history like normal history of onset, change in size, associated symptoms, pain

Our history should focus on Any family history of thyroid disease Drug history And very important to ask about any history of radiation ( keeping in mind risk of papillary carcinoma is highly increased with radiation)

Now we exam our patient Never forget to make sure is it thyroid? Or a neck swelling? give the patient a sip of water if it moves upward on swallowing its attached to the thyroid, by? Pretracheal fascia After confirming its of thyroid origin, we do our full exam of a mass first inspect, then palpate (percuss also), then auscultate) And never miss any extra thyroid signs, neurological exam (reflexes, tremor) LYMPHNODES!!!

Extrathyroid? Graves disease: Exophthalmos Lid retraction Inflamed eyes Double vision Pretibial myxedema (non pitting, reddening and thickening of skin) Lid lag Hypothyroid: Puffy face Myxedema (nonpitting) Dry skin, coarse hair Bradycardia Loss of lateral 1/3 of eyebrow Hoarseness, slurred speech Hyperthyroidism: tachycardia, palpitations and might even cause CHF

Before we continue lets take a minute Goiters can be classified in different ways: Benign or malignant Simple or toxic Diffuse or nodular (multinodular or solitary)

Investigate Thyroid function tests Measure free t3, t4, TSH In thyrotoxicosis? TSH totally suppressed In hypothyroidism? Elevated Some things to keep in mind is in pregnancy or estrogen administration increases the level of thyroid hormone (increase thyroid binding globulin) in blood so it makes it harder to diagnose So we use the T3 radioactive uptake

investigate TRH and TSH stimulation tests to determine the site of failure of production of thyroid hormone Calcitonin levels are of importance too especially in diagnosis of medullary carcinoma Lets not forget men2 syndrome Men2A (medullary carcinoma of the thyroid, pheochromocytoma, parathyroid hyperplasia or adenomas) Men2B (medullay carcinoma, pheochromocytoma, and neuromas (mucosal and intestinal)

Back to investigations Thyroid antibodies 1-anti thyrocyte peroxidase antibody and anti thyroglobulin antibody (hashimoto thyroiditis) 2-thyroid stimulating immunoglobulin (graves disease) And Radioisotope scanning (I123): To differentiate between hot and cold nodules If we have a solitary hot nodule it’s a toxic adenoma If its cold we have multiple options (malignancy, benign, cyst) ultrasound and FNA FNA is best for discrete nodules

investigate And we cant not mention MRI, CT, PET scan But they aren’t in the routine assessment of a thyroid swelling Mostly for assessment of a known malignancy, extent of a retrosternal mass, staging, or vascular invasion (MRI) Now lets put things in a better way (more focused on a solitary nodule)

First keep in mind Is benign or malignant? Benign like: cyst, follicular adenoma (either toxic or simple), thyroditis Malignant like: medullary, follicular, papillary, anaplastic, maybe lymphoma)

So like we said history So you’ve asked about everything we already said, family history, radiation, symptoms of hyper or hypo thyroid,… Now u should pay attention to some stuff that might suggest a malignancy Rapidly progressive Young less than 15, or old over 65 Pain doesn’t suggest malignancy but if present doesn’t exclude malignancy (medullary cancer can cause dull aching pain) Hoarseness is worrisome because it indicates malignant involvement of recurrent laryngeal nerve If patient comes with painful thyroid you suspect subacute thyroiditis, so we ask about? History of upper respiratory infection (virus) and fever Pain in thyroid: Medullary cancer Bleeding in thyroid Cyst Subacute thyroditis

Physical exam On inspection or palpation we also have signs the should suggest to us malignancy Firm Fixed Irregular margins Cervical lymphadenopathy

investigate Like we said our first investigation Is TFT, and this will direct us to what to do next If the patient has low TSH it indicates that the nodule is secreting thyroid hormones on its own so we should further investigate by radio isotype: If we get a hot nodule it’s a toxic adenoma (almost never malignant) If its cold we should do ultrasound and FNA On the other hand if we have normal or elevated TSH we don’t do radio isotype we go directly to ultrasound and FNA

Last thing: ultrasound Ultrasound often reveals multinodular goiters rather than solitary nodules, so to know the size and number of nodules To know is it cystic or solid And make a guess on how malignant is it It can be used as guidance for FNA for accurate sampling Might reveal features suggesting malignancy: Microcalcifications Irregular margins Intra nodular vascular spots Hypo echogenicity within the nodule

Management Mainly depends on the cytology results from FNA Malignancy needs surgical intervention depending on type of cancer Benign lesions might be left alone and monitored if asymptomatic or surgically removed if symptomatic About 30% of FNA turn out to be cysts and we just drain them, but re accumulation is common We surgically remove cysts if its growing or painful