Thyroid nodule History History Physical examination Physical examination –Euthyroid –Hypothyroid –Hyperthyroid Labs Labs –TSH –(antibodies)

Thyroid nodule Imaging Imaging –US –Scan if TSH is low

Toxic adenoma

Thyroid nodule Imaging Imaging –US –Scan if TSH is low –CT usually precedes referral FNA FNA –US-guided

Thyroid nodule There are 3 ways to diagnose a thyroid nodule: There are 3 ways to diagnose a thyroid nodule: ultrasound guided FNA ultrasound guided FNA

Thyroid nodule FNA result FNA result –Papillary carcinoma –Follicular LESION Carcinoma Carcinoma Adenoma Adenoma Adenomatous colloid nodule Adenomatous colloid nodule –Insufficient for diagnosis

Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer (Cooper, THYROID 2006;16: (

Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer (Cooper, THYROID 2006;16: ) FNA Results

Thyroid nodule FNA result FNA result –Papillary carcinoma –Follicular LESION Carcinoma Carcinoma Adenoma Adenoma Adenomatous colloid nodule Adenomatous colloid nodule –Insufficient for diagnosis

Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer (Cooper, THYROID 2006;16: ) FNA Results

Thyroid nodule conservative approach for most patients with thyroid nodules that are cytologically indeterminate on fine-needle aspiration and benign according to gene- expression classifier results. conservative approach for most patients with thyroid nodules that are cytologically indeterminate on fine-needle aspiration and benign according to gene- expression classifier results. (Alexander, N Engl J Med. 2012;367:705-15)

Non-mailgnant indications for thyroidectomy Goiter Goiter

Non-mailgnant indications for thyroidectomy Goiter Goiter –Symptomatic

Non-mailgnant indications for thyroidectomy Goiter Goiter –Symptomatic –Esthetic

Non-mailgnant indications for thyroidectomy Goiter Goiter –Symptomatic –Esthetic Hyperthyroidism Hyperthyroidism

Before and after total thyroidectomy

THYROID CANCERS CALSSIFICATION: CALSSIFICATION:

THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS

THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS OTHER THYROID CANCERS

THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS Papillary Papillary

THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS Papillary Papillary Follicular Follicular

THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS Papillary Papillary Follicular Follicular OTHER THYROID CANCERS

THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS Papillary Papillary Follicular Follicular OTHER THYROID CANCERS Medullary Medullary

THYROID CANCERS CALSSIFICATION: CALSSIFICATION: DIFFERENTIATED THYROID CANCERS Papillary Papillary Follicular Follicular OTHER THYROID CANCERS Medullary Medullary Anaplastic (?poorly differentiated papillary carcinoma) Anaplastic (?poorly differentiated papillary carcinoma)

Differentiated thyroid cancer FollicularPapillary Age Gender (Sex) Mode of Spread Multifocality Prognosis after surgery (20-y survival)

Differentiated thyroid cancer FollicularPapillary Age Gender (Sex) Mode of Spread Multifocality Prognosis after surgery (20-y survival)

Differentiated thyroid cancer FollicularPapillary Age FF Gender (Sex) Mode of Spread Multifocality Prognosis after surgery (20-y survival)

Differentiated thyroid cancer FollicularPapillary Age FF Gender (Sex) Blood borne Lymphatic Mode of Spread Multifocality Prognosis after surgery (20-y survival)

Differentiated thyroid cancer FollicularPapillary Age FF Gender (Sex) Blood borne Lymphatic Mode of Spread NoYesMultifocality Prognosis after surgery (20-y survival)

Differentiated thyroid cancer FollicularPapillary Age FF Gender (Sex) Blood borne Lymphatic Mode of Spread NoYesMultifocality ExcellentExcellenter Prognosis after surgery (20-y survival)

Differentiated thyroid cancer Staging Staging –T1 - Tumor 2 cm or less in greatest dimension limited to the thyroid. –T2 - Tumor more than 2 cm, but not more than 4 cm, in greatest dimension limited to the thyroid. –T3 - Tumor more than 4 cm in greatest dimension limited to the thyroid. –T4a - Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve. –T4b - Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.

Differentiated thyroid cancer Staging Staging –N1a - Metastasis to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes). –N1b - Metastasis to unilateral, bilateral, or contralateral cervical or superior mediastinal lymph nodes.

Prognostic factors A G E S Age Age Sex (Gender) Sex (Gender) Extension Extension Size Size

Prognosis (Lahey Clinic) Age Age Metastasis Metastasis Extension Extension Size Size

Prognosis (Lahey Clinic) Age Age Metastasis (NOT lymph node) Metastasis (NOT lymph node) Extension Extension Size Size

Prognosis (Lahey Clinic) Age Age Metastasis (NOT lymph node) Metastasis (NOT lymph node) Extension (to neighboring structures) Extension (to neighboring structures) Size Size

Prognosis (Mayo Clinic) MACIS Prognostic score MACIS Prognostic score Metastasis, Age, Completeness of resection, vascular Invasion, Size. Metastasis, Age, Completeness of resection, vascular Invasion, Size. M + 3 if Metastasis is found M + 3 if Metastasis is found A = Age (y) x 0.08 A = Age (y) x 0.08 C + 1 if resection is inComplete C + 1 if resection is inComplete I + 1 if vascular invasion (pathologists report) I + 1 if vascular invasion (pathologists report) S0.3 x largest diameter in centimeters (Size) S0.3 x largest diameter in centimeters (Size)

Prognosis (MSKCC) Even more complicated scoring Even more complicated scoring Includes Includes –Tumor grade –Lymph node involvement –multifocality

Complications of thyroid surgery

Thyroid operations Lobectomy ± isthmus Lobectomy ± isthmus Near total thyroidectomy Near total thyroidectomy Total thyroidectomy Total thyroidectomy –± modified neck dissection for known involved lymph nodes

Operations for papillary carcinoma Lobectomy (low risk) Lobectomy (low risk) –Difficult to justify radical surgery for such a good prognosis cancer Total/near total thyroidectomy (high risk) Total/near total thyroidectomy (high risk) –Treatment with radioactive iodine-131 –Detection of distant metastases Total thyroidectomy + modified neck dissection (known lymph node metastasis) Total thyroidectomy + modified neck dissection (known lymph node metastasis)

Extensive spread of papillary carcinoma

Operations for follicular carcinoma Total thyroidectomy Total thyroidectomy Near total thyroidectomy Near total thyroidectomy –Treatment with radioactive iodine-131 –Detection of distant metastases

Adjuvant treatment Scan for residual glandular tissue Scan for residual glandular tissue –I 131 full body scan –Maximal TSH stimulation Destruction of thyroid remnant Destruction of thyroid remnant –High dose I 131 (Maximal TSH stimulation) Treatment Treatment –High dose I 131 (Maximal TSH stimulation) Suppressive T4 for life Suppressive T4 for life Follow up Follow up –Thyroglobulin (Tg) with maximal TSH stimulation –I 131 full body scan as indicated by Tg