LISA A. CICO, MSN, NP UPSTATE MEDICAL UNIVERSITY BREAST & ENDOCRINE SURGERY COORDINATOR THYROID CANCER PROGRAM SURGICAL COORDINATOR BREAST CANCER PROGRAM THYROID NODULES

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 Comprehensive review of current 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

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 Obtaining appropriate 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

“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

Nodules Hyper/Hypo thyroid Difficulty swallowing Globus sensation Choking sensation Hyper-functioning nodule Hashimoto’s Symptoms?

History Physical Findings Head & neck irradiation Whole body irradiation Nuclear fallout Family history of thyroid malignancy Heredity Rapid growth Hoarseness Cervical /supraclavicular lymphadenopathy Fixation of nodule or gland > 4 cm Solitary Pertinent History & PE in Evaluation of TNs

Differential Diagnosis Multinodular Goiter Hashimoto’s Thyroiditis Cancer Lymphoma Solitary Thyroid Nodule Substernal Goiter

COWDEN’S SYNDROME FAMILIAL POLYPOSIS CARNEY COMPLEX MEN 2 WERNER SYNDROME THYROID MALIGNANCY Family History of Hereditary Diseases

Substernal Goiters Short neck Stocky build Usually incidental finding by CXR or CT Many times treated unsuccessfully for asthma

AT A Gui deli nes 200 9

Ultrasound: The Gold Standard Anyone found to have, OR is suspected of having a nodule  evaluate by ultrasound!!

BENIGN CHARACTERISTICS  Pure cystic (relatively rare)  Spongiform appearance in >50% of nodule volume (aggregration of multiple microcystic components)  Multiple (?)

Septated cyst BENIGN

Cyst BENIGN

US (a, transverse; b, longitudinal) scans in 51-year-old woman show 2.4-cm well- defined mixed-echoic hypoechoic nodule (arrows) in right lobe of thyroid gland. Initial cytologic result was adenomatous hyperplasia, confirmed after 11 months at repeat aspiration BENIGN

ULTRASOUND CHARACTERISTIC CONSIDERATIONS 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, 18 FDG 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

SUSPICIOUS CHARACTERISTICS Hypo-echogenicity compared to 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

Hypoechoic Suspicious

Increased vascularity Suspicious

Increased vascularity SUSPICIOUS

Calcifications Poorly defined, irregular margins SUSPICIOUS

Solid SUSPICIOUS

Multiple Thyroid Nodules FNA  what nodule??  > 1 cm  Suspicious features  Dominant / largest one

Palpation? Ultrasound? What nodule(s) do you FNA? FNA of Palpable Nodule

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

False Negative False Positive false-negative rate of up to 5% with FNA which may be even higher with nodules >4 cm ?? FNA

< 1 cm > 1 cm NO ATA Guidelines 2009 NO Is Size a Predictor of Malignancy?

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 CategoryRisk of Malignancy (%) Usual management Nondiagnostic or Unsatisfactory Repeat FNA with ultrasound guidance Benign0-3Clinical Follow up with ultrasound 6 months Atypia of Undetermined significance or Follicular lesion of Undetermined significance 5-15Repeat FNA 3 months; if same, then lobectomy Follicular Neoplasm or suspicious for Follicular neoplasm 15-30Surgical Lobectomy Suspicious for Malignancy 60-75Near total thyroidectomy or surgical lobectomy Malignant97-99Near total thyroidectomy

Lab Work TSH Free T4 TPO in suspected thyroiditis TG  tumor marker in PTC, FTC, HTC Calcitonin  suspected MTC or in follow up of MTC TSH Free T4 T4 T3 Free T3 TPO Thyroglobulin (TG) Calcitonin

Thyroid noduleFNABenign Exam/Sonogram 6-18 months No ChangeRepeat in 3-5 yrs 20% increase in diameter in > 2 dimensions (>2mm) or volume increase > 50% Re-aspirate Thyroid Nodule

Nodule sonographic or clinical featuresRecommended nodule threshold size for FNA High-risk history a a Nodule WITH suspicious sonographic features b b >5mmRecommendation A Nodule WITHOUT suspicious sonographic features b b >5mmRecommendation I Abnormal cervical lymph nodesAll c c Recommendation A Microcalcifications present in nodule≥1cmRecommendation B Solid nodule AND hypoechoic>1cmRecommendation B AND iso- or hyperechoic≥1–1.5 cmRecommendation C Mixed cystic–solid nodule WITH any suspicious ultrasound features b b ≥1.5–2.0 cmRecommendation B WITHOUT suspicious ultrasound features≥2.0 cm Recommendation C Spongiform nodule≥2.0 cm d d Recommendation C Purely cystic noduleFNA not indicated e e Recommendation E TABLE 3. SONOGRAPHIC AND CLINICAL FEATURES OF THYROID NODULES AND RECOMMENDATIONS FOR FNA

RAI Uptake Scan ONLY IN HYPERTHYROID Cold Nodule - 10% incidence of being CA

 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 Thyroid Cancers

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  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 yrs  2% occur in children and teens

TREATMENT FOR THYROID CANCER Surgery Radioactive Iodine Ablation Levothyroxine Monitor with WBS / ultrasound

CHILDREN & PREGNANT WOMEN WHEN DO YOU OPERATE???

Complications of Thyroid Surgery Recurrent laryngeal nerve injury Hypo parathyroidism Bleeding Infection

Parathyroid glands COMPLICATIONS OF SURGERY

OR case COMPLICATIONS OF THYROID SURGERY

Surgery and TC Low MORTALITY Thyroid cancers  LOW Mortality!!  Rod Stewart, Julie Andrews, Joe Piscopo Always exceptions to the rules :  Roger Ebert, Supreme Court Justice Reinquist Should be LOW MORBIDITY too!! IF surgery is required, always refer to someone who does at least > 50 / year NO drains!! NO RR tracks!! Dermabond is ulgy on the neck, and often opens a bit…

Summary Refer to Endocrin0logy or Surgery  Children  Pregant women  Nodules > 1 cm with suspicious features  Compressive symptoms  HT with globus symptoms  ULTRASOUND!! Even if already had CT, carotid doppler, etc Can safely follow with ultrasound  Nodule < 1 cm  Stable nodules with no change Repeat in 6 months x 2, then annually  Monitor TFTs with U/S

ENDOCRINE SURGERY  Suspected/known abnormal TFTs with TNs  Pregnant  If FNA needed  Children  If suspect surgery is indictated Endocrine OR Surgery?

QUESTIONS? Thank You