1. THYROID TREATMENT AND VITAMIN D UPDATE A CPMC Regional CME Event - An Integrated Approach Saturday October 27, 2012

2. MANAGEMENT OF THYROID NODULES: REVIEW OF ATA GUIDELINES Gerald Kangelaris, MD San Francisco Otolaryngology

3. No Financial Disclosures

4. INTRODUCTION 50 F presenting for HME - No significant complaints Hyper- or hypo-thyroid symptoms Voice or swallowing changes - Physical examination ~1-2cm rounded nodule in thyroid bed that elevates with swallowing - How to manage this nodule and counsel patient? http://blogs.ktk985.com/2010/05/

5. INTRODUCTION Questions - Do I have cancer? - Is thyroid cancer bad? - How do we work this up? - Do I need a biopsy?

6. INTRODUCTION Thyroid Nodules are prevalent - Palpable: 5% in women, 1% in men - Ultrasound: Up to 67% of individuals Tan GH, Gharib H. Thyroid incidentalomas: management approaches to nonpalpable nodules discovered incidentally on thyroid imaging. Ann Intern Med 1997;126:226-231. Mortensen JD, Woolner LB, Bennett WA. Gross and microscopic findings in clinically normal thyroid glands. J Clin Endocrinol Metab 1955;15:1270-80. http://library.med.utah.edu/WebPath/jpeg4/ENDO021.jpg - Autopsy: 50% one thyroid nodule 36% nodules greater than 2cm in size

7. INTRODUCTION Thyroid carcinoma occurs in 5-15% of nodules History can increase risk, but not specific - Older age - Male sex - History of radiation exposure - Family history

8. OUTLINE OF DISCUSSION Overview of Thyroid Cancer Evaluation of Newly Discovered Thyroid Nodules - Laboratory - Radiographic - FNA - Ultrasound characteristics - Management & follow-up of benign nodules

9. THYROID CANCER Thyroid Follicular Epithelial Cell Derived - Papillary carcinoma - Follicular carcinoma - Anaplastic carcinoma Parafollicular C-Cell Derived - Medullary carcinoma Miscellaneous - Lymphoma - Metastases

10. THYROID CANCER Incidence 48,000 new cases in US 75% female, 25% male Most rapidly increasing incidence of all malignancies 5 th most common cancer in women Prevalence - 460,000 cases 360,000 women, 100,000 men Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov). SEER Stat Database: Incidence - SEER 9 Regs Public-Use, Nov 2005 Sub (1973-2003), National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch, released April 2006.

11. THYROID CANCER Papillary Thyroid Cancer - 85% of all differentiated thyroid cancers - F:M ratio 2.5:1 - Peak incidence 4 th & 5 th decade - Risk factors Radiation exposure Family history Majority arise spontaneously

12. THYROID CANCER Papillary Thyroid Cancer - Biology Lymphotropic  Intrathyroidal lymphatics  Regional cervical lymphatics Slow growth Benign course  10 year survival >90% Can be progressive  Disease recurrence >15% Stack BC et al. American Thyroid Association Consensus Review and Statement Regarding the Anatomy, Terminology, and Rationale for Lateral Neck Dissection in Differentiated Thyroid Cancer. Thyroid 2012;22(5):501-9.

13. THYROID CANCER Papillary Thyroid Cancer - Prognostic Features Age: Older is worse Tumor size Soft tissue invasion Distant metastases Certain histologic subtypes  Insular  Tall cell  Diffuse sclerosing

14. THYROID CANCER Follicular Thyroid Carcinoma - 10% of differentiated thyroid carcinomas - Peak incidence 5 th to 6 th decade - F:M ratio 3:1 - Biologic behavior Direct extension & hematogenously Slow growth, benign course  5 year survival rates ~90%

15. THYROID CANCER Follicular Thyroid Carcinoma - Role of FNA Cannot distinguish between follicular adenoma or carcinoma Carcinoma defined by capsular or vascular invasion - Continuum Minimally invasive FTC http://jcp.bmj.com/content/56/6/401.full

16. THYROID CANCER Follicular Thyroid Carcinoma - Prognostic features Age Widely invasive nature (capsular, vascular) Tumor size Histopathologic subtype  Hürthle cell  Insular

17. THYROID CANCER AJCC Staging - T Stage T1: <2cm T2: 2-4cm T3: >4cm but limited to thyroid parenchyma T4: Extends beyond thyroid parenchyma - N Stage N0: No regional nodal metastases N1a: Level VI nodal metastases N1b: Cervical or mediastinal nodal metastases AJCC Cancer Staging Manual, Seventh Edition (2010).

18. THYROID CANCER AJCC Staging - Under 45 years - Over 45 years AJCC Cancer Staging Manual, Seventh Edition (2010). Stage IAny TAny NM0 Stage IIAny TAny NM1 Stage IT1N0M0 Stage IIT2N0M0 Stage IIIT3N0M0 T1-3N1aM0 Stage IVT1-3N1bM0 T4Any NM0 Any TAny NM1

19. ATA GUIDELINES Evaluation of Clinically or Incidentally Discovered Thyroid Nodule

20. ATA GUIDELINES What nodule deserve evaluation? - Generally nodules >1cm or focal update on FDG-PET - History and Exam History of irradiation FHx of thyroid carcinoma Thyroid cancer syndrome Rapid growth Hoarseness Swallowing difficulties Cervical adenopathy

21. ATA GUIDELINES Laboratory workup - TSH If subnormal, perform radionuclide thyroid scan Recommendation: A - Tg not necessary Insensitive and nonspecific test for thyroid cancer Recommendation: F - Calcitonin No recommendation for or against Recommendation: I

22. ATA GUIDELINES Radiographic workup - Ultrasound Performed on all patients with known or suspected thyroid nodule Recommendation: A - Avoid iodinated contrasted CT

23. ATA GUIDELINES FNA biopsy - Most accurate and cost-effective method - Recommendation: A Ultrasound guided FNA - Higher likelihood nondiagnostic cytology >25-50% cystic Difficult to palpate or posterior - Recommendation: B

24. ATA GUIDELINES FNA biopsy Cooper DS et al. Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 2009;19(11):1167-1214.

25. ATA GUIDELINES Ultrasound: High risk - Hypoechoic Kangelaris GT, et al. Role of Ultrasound in Thyroid Disorders. Otolaryngologic Clinics of N America 2010:43(6):1209-27.

26. ATA GUIDELINES Ultrasound: High risk - Microcalcifications Kangelaris GT, et al. Role of Ultrasound in Thyroid Disorders. Otolaryngologic Clinics of N America 2010:43(6):1209-27.

27. ATA GUIDELINES Ultrasound: High risk - Increased vascularity Kangelaris GT, et al. Role of Ultrasound in Thyroid Disorders. Otolaryngologic Clinics of N America 2010:43(6):1209-27.

28. ATA GUIDELINES Ultrasound: High risk - Irregular infiltrative margins - Absent halo - Shape taller than width

29. ATA GUIDELINES Ultrasound: Low risk - Purely cystic Kangelaris GT, et al. Role of Ultrasound in Thyroid Disorders. Otolaryngologic Clinics of N America 2010:43(6):1209-27.

30. ATA GUIDELINES Ultrasound: Low risk - Spongiform Kangelaris GT, et al. Role of Ultrasound in Thyroid Disorders. Otolaryngologic Clinics of N America 2010:43(6):1209-27.

31. ATA GUIDELINES FNA categories - Malignant Risk of malignancy >95% - Suspicious for Malignancy Risk of malignancy 50-75% - Indeterminate or Suspicious for Neoplasm Change to: Neoplasm, Either Follicular or Hürthle Cell Neoplasm Risk of malignancy 15-25% - Follicular Lesion of Undetermined Significance Risk of malignancy 5-10% - Benign - Nondiagnostic

32. ATA GUIDELINES Nondiagnostic cytopathology - Repeat with ultrasound guidance Diagnostic in 75% solid nodules, 50% cystic nodules Recommendation: A - Repeatedly nondiagnostic Close observation or surgical excision Excision more strongly considered with solid nodules Recommendation: B

33. ATA GUIDELINES Multinodular thyroid - Patient have same risk of malignancy - If multiple nodules ≥1 cm, FNA those with suspicious US appearance Recommendation: B - If none has suspicious US features, aspirate the largest and follow the remaining with serial US Recommendation: C - Consider radionuclide scan if TSH is low Recommendation: B

34. ATA GUIDELINES Benign nodules - Follow-up repeat US 6-18 months FNA has 5% false(-) - If nodule size stable, expand US interval 3-5 years Recommendation: C - If nodular growth, repeat FNA with US guidance Recommendation: B

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