Chief’s Morning Report October 4, 2011

HPI: 57 yo female presents to clinic with a h/o DM, HTN for new patient visit. Pt has no complaints.

PMH: DM, HTN PSH: hysterectomy Social: married for 30 years, housewife. No TED. FH: DM, HTN, colon cancer Meds: metformin, glipizide, HCTZ, calcium + vitamin D

Vitals: AF, BP130/75, HR76, RR18, SaO2 98% RA General: Alert, oriented, NAD HEENT: PERRLA, EOMI, firm, mobile, palpable thyroid nodule approximately 1cm CV: regular rhythm, normal rate; no murmurs Pulm: BCTA, no wheezing or crackles Abdomen: soft, NTND, + BS Extremities: no edema, 2+ reflexes, 5/5 strength throughout

On further questioning, pt states that she noticed the nodule 6 months ago and she thinks it has gotten slightly larger since then. She denies palpitations, weight changes, insomnia, fatigue, hair changes.

Clinical Questions 1. What should be the next step in workup of this patient’s thyroid nodule? 2.If this patient asks what her risks of having cancer, what should you tell her?

Thyroid nodules are common, a prevalence of 3%-7%. The prevalence of clinically in apparent thyroid nodules is estimated with US at 20%- 76% in the general population. 20%-48% of patients with one palpable thyroid nodule have additional nodules on US. More common in elderly persons, women, those with iodine deficiency, and those with a history of radiation exposure.

Diagnosis and Management of Thyroid Nodules History (Grade B) Age Family history of thyroid disease or cancer Prior Head/Neck XRT Rate of growth of neck mass Dysphonia, dysphagia or dyspnea Sxs of hyper- or hypothyroidism Use of iodine-containing drugs/supplements

Physical Exam Careful exam of thyroid and cervical lymph nodes (Grade A) Record location, consistency, size of nodules. Record neck tenderness or pain and adenopathy (Grade C).

When should you perform Diagnostic Imaging? High-resolution US is the most sensitive test available to detect thyroid lesions. US evaluation is recommended for (Grade B): Patients at risk for thyroid malignancy Patients with palpable thyroid nodules or MNGs. Patients with lymphadenopathy MRI and CT are not indicated for routine thyroid nodule evaluation (Grade D). Perform scintigraphy for a thyroid nodule or MNG if the TSH level is below the lower limit or if ectopic thyroid tissue or retrosternal goiter is suspected.

Who is at risk?

Laboratory Evaluation TSH (Grade A) If TSH is decreased, measure free thyroxine and total or free triiodothyronine If TSH is increased, measure free thyroxine and TPOAb (Grade B) Testing for antithyroglobulin antibodies should be restricted to patients with US and clinical findings suggestive of chronic lymphocytic thyroiditis when serum levels of TPOAb are normal (Grade C)

Serum thyroglobulin is not recommended in the diagnosis, unless the patient is undergoing surgery for malignancy and then it can be used to detect potential false negative results (Grade C) TRAb should be measured in patients with TSH is below the reference range (Grade D)

Calcitonin Basal serum calcitonin level may be useful (Grade B) Nonstimulated serum calcitonin may be considered before thyroid surgery for nodular goiter (Grade B) Mandatory with a history or suspicion of MTC or MEN 2 (Grade A) If increased, repeat and then check pentagastrin or calcium-stimulation test to increase the accuracy (Grade B)

When should you biopsy? FNA biopsy is recommended (Grade B) for nodules: >1cm that is solid and hypoechoic on US Any size with US findings suggestive of extracapsular growth or metastatic cervical lymph nodes Any size with patient history of neck XRT in childhood or adolescence; PTC, MTC or MEN 2 in first-degree relatives; prior thyroid surgery for cancer; increased calcitonin levels in the absence of interfering factors Diameter <10mm along with US findings associated with malignancy; the coexistence of ≥ 2 suspicious US criteria. Nodules that are hot on scintigraphy should be excluded from FNA.

Thyroid FNA Biopsy Clinical management of thyroid nodules should be guided by the combination of US evaluation and FNA biopsy (Grade A) Cytologic diagnosis is more reliable and the nondiagnostic rate is lower when FNA is performed with US guidance (Grade B)

Most (60-80%) FNA biopsy results are benign % are follicular lesions/neoplasm, % are malignant, % are suspicious, and 10-15% are nondiagnostic. The results help guide you toward medical vs. surgical management.

Management and Therapy Clinical management should be guided by US results and FNA biopsy.

Management and Therapy Nondiagnostic nodules by FNA Benign Nodules by FNA Follicular lesions by FNA Suspicious Nodules by FNA Malignant Nodules by FNA

Management and Therapy Nondiagnostic nodules by FNA Repeat with US guidance (Grade B) Persistently nondiagnostic solid nodules should be surgically excised (Grade C) Core Needle Biopsy may offer additional data

Benign Nodules by FNA Follow-up with clinical, US exams, TSH measurement in 6-18 months (Grade D) Repeat UGFNA where clinical or US features are suspicious and in cases of >50% increase in nodule volume(Grade B) Consider repeat UGFNA in 6-18 months even if benign (Grade D) Routine LT4 not recommended (Grade B) Surgical resection if sxs from mass effect or cosmetic concerns, suspicious US, prior XRT.

Radioiodine therapy for hyperfunctioning and/or symptomatic goiter, prior surgery, or surgical risk (Grade B) –Before treatment, UGFNA biopsy should be done (Grade B) –Avoid iodine before administration of radioiodine, stop antithyroid drugs ≥1 week before treatment –Contraindicated in pregnant or breastfeeding women (Grade A) and perform pregnancy tests –Follow-up thyroid function after therapy (Grade B)

Follicular lesions by FNA Repeat FNA, CNB and molecular and histochemical markers are not recommended. Surgical resection (Grade B) Clinical follow-up in minority of cases with favorable clinical, US, cytologic and immunocytochemical features (Grade D)

Suspicious Nodules by FNA Surgery (Grade B) Intraoperative frozen section is useful (Grade D)

Malignant Nodules by FNA If differentiated carcinoma, surgery (Grade A) If anaplastic carcinoma, metastatic lesions, and lymphoma, further diagnostic workup recommended (Grade B) US and FNA any concomitant suspicious nodules or lymph nodes and vocal cord assessment

Thyroid Nodule during Pregnancy Manage the same as in nonpregnant women (Grade C) Avoid radioactive agents (Grade A) Suppressive LT4 therapy for nodules is not recommended (Grade C) For growing nodule, follow-up with US and FNA (Grade C) If follicular on biopsy, surgery can be deferred until after delivery (Grade C) If malignant, recommendations based on trimester

Back to the patient…

Clinical Questions 1. What should be the next step in workup of this patient’s thyroid nodule? 2.If this patient asks what her risks of having cancer, what should you tell her?

References Gharib, H., Papini, E., Paschke, R., Duick, D., Valcavi, R. (2010). American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules. Endocrine Practice, Volume 16 (Suppl 1), 3-43.

Questions?