1. Management of thyroid nodule

2.  Introduction.  Guidelines recommendation.  Thyroid nodule work up.  Medical therapy in thyroid nodule  Thyroid nodule in children  Thyroid nodule in pregnancy.

3. Introduction  It is a common clinical problem.  Female : 5% & male : 1%.  High-resolution ultrasound (US) can detect thyroid nodules in 19–67%.  Thyroid Carcinoma occurs in 5-15% of any thyroid nodule (1).  Well differentiated thyroid CA represent 90% of all thyroid CA. (1) Hegedus L 2004 Clinical practice. The thyroid nodule. N Engl J Med 351:1764–1771.

4. Thyroid nodule work up  What is the appropriate evaluation of clinically or incidentally discovered thyroid nodule(s)?  What laboratory tests and imaging modalities are indicated?  What is the role of fine-needle aspiration (FNA)?  What is the role of medical therapy of patients with benign thyroid nodules?  How should thyroid nodules in children and pregnant women be managed?

5. Strength of Panelists’ Recommendations  (A) : Strongly recommends. The recommendation is based on good evidence that the service or intervention can improve important health outcomes.  (B) : The recommendation is based on fair evidence that the service or intervention can improve important health outcomes.

6. Strength of Panelists’ Recommendations  (C) : based on expert opinion.  (D) : Recommends against : based on expert opinion.  (E) : Recommends against : based on fair evidence that the service or intervention does not improve important health outcomes or that harms outweigh benefits.  (F) : Strongly recommends against: based on good evidence that the service or intervention does not improve important health outcomes or that harms outweigh benefits

7. Strength of Panelists’ Recommendations  (I) : Recommends neither for nor against: If the evidence is lacking that the service or intervention improves important health outcomes, the evidence is of poor quality, or the evidence is conflicting. As a result, the balance of benefits and harms cannot be determined.

8. Thyroid nodule  Discrete lesion within the thyroid gland that is radiologically distinct from the surrounding thyroid parenchyma.  What is Incidentalomas? Nonpalpable nodules detected on US or other anatomic imaging studies. PET 1-2 % thyroid nodule risk of malignancy is 33%

9. Thyroid nodule work up size as a factor  only nodules >1 cm should be evaluated.  If nodules <1 cm that require evaluation.  Thyroid cancer in one or more first-degree relatives.  History of head and neck irradiation.  Lymphadenopathy on examination or imaging studies.  Suspicious US findings.

10. Thyroid nodule work up  Complete history & physical exam.  Risk factors.  Serum TSH & US thyroid.  Radionuclide Thyroid scan if TSH subnormal.  If TSH high normal : increased risk of malignancy in a thyroid nodule. Boelaert K, Horacek J, Holder RL, Watkinson JC, Sheppard MC, Franklyn JA 2006 Serum thyrotropin concentration as a novel predictor of malignancy in thyroid nodules investigated by fine-needle aspiration. J Clin Endo Metab91:4295–4301.

11. Recommendation  Measure serum TSH. If subnormal, a radionuclide thyroid scan.( A)  US thyroid should be performed in all patients with known or suspected thyroid nodules.(A)

12. Thyroid nodule suspicious US finding  Microcalcifications.  Hypoechoic.  Increased nodular vascularity.  infiltrative margins.  Absence of halo.  taller than wide on transverse view.

13. Recommendation  FNA is the procedure of choice in the evaluation of thyroid nodules. (A)  US guidance FNA:.(B) o > 50% cystic, o Nonpalpable, o Located posteriorly in the thyroid lobe o Initial FNA non diagnostic

14. Thyroid nodule work up Hx, P/E, TSH Low TSH 123I or 99Tc Scan Hyper functioning Evaluate and Rx for Hyperthyroidism High Normal TSH Thyroid US Non functioning Nodule Do FNA No nodule Elevated TSH Normal TSH Evaluate and Rx for Hypothyroidism FNA not Indicated

15. Thyroid FNA be Benign Follow up Indeterminate Follicular Neoplasm Hurthle cell neoplasm Consider 123I Scan if TSH Low Normal Suspicious or malignant PTC Pre op US Surgery Non diagnostic Repeat US guided FNA Non diagnostic Close follow up ( US /6 month) or surgery

16. Thyroid FNAC benign pathology  Follow up with serial US ( 6-18 months): (B) Volume by 50 %. FNA Dimensions of two nodule by 20% with minimal increase of 2mm in solid nodules.

17. Medical therapy benign thyroid nodule  Thyroid hormone in doses that suppress the serumTSH to subnormal levels may result : Nodule size. Prevent the appearance of new nodules in regions of the world with borderline low iodine intake.

18. Thyroid nodule in children  7/1000 per year  Malignant nodule 15-20%.  The diagnostic and therapeutic approach to one or more thyroid nodules in a child should be the same as it would be in an adult (clinical evaluation, serum TSH, US, FNA).( A)

19. Thyroid nodule in pregnancy  Nodules discovered in pregnant women are more likely to be malignant than those found in nonpregnant women.  Euthyroid  Hypothyroid FNA should be performed in pregnancy.  Hyperthyroid Radionuclide scan after pregnancy & cessation of lactation.

20. Malignant thyroid nodule in pregnancy PTC early in pregnancy US monitoring Grow substantially Surgery 2 nd trimester Stable in size Surgery after delivery

21. Malignant thyroid nodule in pregnancy  If suspicious for PTC : LT4 to keep TSH 0.1–1mU/L