9. thyroid nodule.ppt [read-only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfincidence occur...

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Thyroid Nodules ENDOCRINOLOGY DIVISION ENDOCRINOLOGY DIVISION Dr. HAKIMI, SpAK Dr. MELDA DELIANA, SpAK Dr. SISKA MAYASARI LUBIS, SpA

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Page 1: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Thyroid Nodules

ENDOCRINOLOGY DIVISION ENDOCRINOLOGY DIVISION

Dr. HAKIMI, SpAK

Dr. MELDA DELIANA, SpAK

Dr. SISKA MAYASARI LUBIS, SpA

Page 2: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Anatomical Considerations

Page 3: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

The Thyroid Nodule

Congenital anomalies

� Thyroglossal duct cyst

Inflammatory lesions

� Inflammatory foci� Inflammatory foci

� Compensatory regenerative nodules (TSH,TGI)

Hyperplasia

Neoplasia

� Benign

� Malignant

Page 4: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Follicular epithelial neoplasms

� Follicular adenoma

� Differentiated: Papillary, Follicular Poorly Differentiated (Insular) Anaplastic

Parafollicular epithelial neoplasms

� Medullary carcinoma

� Mixed/composite carcinoma

Other primary epithelial neoplasms

Primary non-epithelial neoplasms

Secondary tumors

Page 5: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Incidence

� Occur in only 0,05-1,8% of children

� The most common form of cancer is papilary thyroid carcinoma

� Folicular adenomas & colloid cysts is majority of � Folicular adenomas & colloid cysts is majority of benign tyhroid nodules

Page 6: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

The Approach to Investigationof the Thyroid Nodule

� Clinical examination

� Thyroid function tests

� Ultrasound

� Cytology of fine needle aspirate (FNAB)

Thyroid scan� Thyroid scan

� MRI

Page 7: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Clinical examination

� Painless nodules

� Firm or hard consistency

� Fixed to surrounding tissue

� Rapid growth

Cervical adenopathy, hoarseness, dysphagia� Cervical adenopathy, hoarseness, dysphagia

� Exposed to irradiation

� Family history of thyroid cancer or pheochromocytoma

� Other syndromes associated with nodular thyroid disease

Page 8: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Thyroid function tests� Anti TPO & anti Tg Abs

Abs (+) � underlying CLT, doesn’t exclude

thyroid cancer

� TSH, T4, T3� TSH, T4, T3

elevation T4 or/and T3 � functioning nodules

� Serum calcitonin

for familial case of thyroid cancer

� Genetic screening for mutation of RET proto-oncogen � suspected multiple endocrine

neoplasia type 2

Page 9: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Methods of Ret/PTC Analysis

DNA

� PCR analysis of ret/PTC gene rearrangements has been difficult due to variable break-point sites leading to heterogeneous tumor profiles

RNA

� RT-PCR for ret/PTC mRNA is the “gold standard”

� Variability of expression; not “all or none”

Protein

� Immunohistochemistry

Page 10: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Ret/PTC Gene Rearrangements

Page 11: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Ultrasonography

� Non invasive method

� Confirm & evaluate the morphological characteristic of thyroid nodules

� Cystic or homogeneously hyperechoic � lower

risk of malignancy

� Solid hypoechoic, calcifications, irreguler shape & absence of a halo � malignant nodules

Page 12: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

The limitation :

� No reliably predict of malignancy

� Depend on individual experiences

Page 13: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Ultrasonography

YROIDYROID

ASS

Page 14: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Cytology of fine needle aspirate & biopsy (FNA)

� 20% of FNAB are insufficient or non diagnostic �

Repeat aspiration is ussually successful

� Identifiable on cytology by the presence of characteristic cell abnormalitiescharacteristic cell abnormalities

� In very young children, open excisional biopsy is suitable alternative

Page 15: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Fine Needle Aspiration Biopsy

Page 16: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Computed Tomography

� Distinguish cystic from solid

� Extent of lesion

� Vascularity (with contrast)

� Detection of unknown primary (metastatic)� Detection of unknown primary (metastatic)

� Pathologic node (lucent, >1.5cm, loss of shape)

� Avoid contrast in thyroid lesions

Page 17: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Computed Tomography

Page 18: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Magnetic Resonance Imaging

� Similar information as CT

� Better for upper neck and skull base

� Vascular delineation with infusion

Page 19: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Magnetic Resonance Imaging

Page 20: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Differential Diagnosis

Page 21: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Therapy

Excision for benign tumors & cysts

Malignant thyroid tumors �

� Total or near total thyroidectomy

Radioiodine ablation� Radioiodine ablation

� Monitoring for recurrence & disease progression

� Thyroid nodules < 1 cm or with benign cytology �

follow by serial ultrasound every 6-12 months

� Significant interval growth � repeated FNAB

Page 22: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Treatment of Thyroid Cancer � Papillary and follicular thyroid cancer

� Generally excellent prognosis

� Risk for recurrence for as long as 30 years

� Initial management

� Surgery and radioactive iodine� Surgery and radioactive iodine

� LT4 suppressive therapy

� Follow-up

� Physical examination

� Radioactive iodine scans

� Serum Tg

� TSH and T4

Page 23: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Standard Treatment of Thyroid Cancer

Total

Thyroidectomy

RAI

Whole Body Scan

Tg Assay

Suppression

Therapy1 Year

Ablation

Cohen EG, et al. Otolaryngol Clin North Am. 2003;36:129-157.

Mazzaferri EL, et al. J Clin Endocrinol Metab. 2003;88:1433-1441.

Sherman SI. Lancet. 2003;361:501-511.

Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463.

Mazzaferri EL, et al. Endocr Relat Cancer. 2002;9(4):227-247.

Page 24: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Thyroid Cancer Initial Treatment Strategy

Surgery Intermediate

and High RiskLow Risk

Diagnosis of Thyroid Cancer

RAI AblationPhysical Exam

Ultrasound

Total

Thyroidectomy

Lobectomy

Isthmusectomy

and High RiskLow Risk

Kinder BK. Curr Opin Oncol. 2003;15):71-77.

Sherman SI. Lancet. 2003;361:501-511.

Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463.

Page 25: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Radioactive Iodine

� Destroys remnants of normal thyroid tissue

� Destroys thyroid cancer cells

� Identifies distant metastases

� Maximizes sensitivity and specificity of serum thyroglobulin

Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463.

Cohen EG, et al. Otolaryngol Clin North Am. 2003;36:129-157.

Page 26: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

TSH Suppression

Pituitary

TSH -

Pituitary

TSH -

Normal Thyroid Cancer Patients

Thyroid

T4

+Thyroid

T4

+

Minimum LT4 to

suppress TSH

without thyrotoxicosisBraverman LE, Utiger RD, eds. Werner & Ingbar’s The Thyroid: A Fundamental and

Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000.

Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463.

Sherman SI. Lancet. 2003;361:501-511.

Page 27: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid

Target TSH Suppression

<0.1 0.1 to 0.4 0.5 to 1

Low to

Undetectable

Suppressed but

Detectable Low Normal

TSH,

Optimal TSH

<0.1 0.1 to 0.4 0.5 to 1

• Most patients with

no evidence of

disease

• Persistent or recurrent

disease

• High-risk patients

• Very low-risk

patients

• Long-term

survivors

TSH,

mIU/L

Patients

Mazzaferri EL, et al. J Clin Endocrinol Metab. 2001;86:1447-1463.

Sherman SI. Lancet. 2003;361:501-511.

Braverman LE, Utiger RD, eds. Werner & Ingbar’s The Thyroid: A Fundamental and Clinical Text.

8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000.

Page 28: 9. THYROID NODULE.ppt [Read-Only]ocw.usu.ac.id/.../mk_end_slide_thyroid_nodules.pdfIncidence Occur in only 0,05-1,8% of children The most common form of cancer is papilary thyroid