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Ian Hammond

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Most likely diagnosis? a)Graves disease b)Hashimotos disease c)Multifocal papillary cancer d)Anaplastic thyroid cancer

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Most likely diagnosis? [ 4 mos. s/p thyroidectomy for CA] a)Residual thyroid tissue b) Gelfoam in surgical bed c)Recurrent cancer d)Lymphadenopathy

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Anatomy

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Normal Thyroid Gland: Transverse

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Trachea Strap Muscles Rt IJV Rt CCA Sternomastoid

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Normal Thyroid Gland: Sagittal CranialCaudal

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Volume Thyroid Gland LengthWidthThickness Volume ellipsoid = L x W x T / 0.5 Normal Adult Range (Rt + Lt lobes) = 8 15 ml Correlation with height, surface area

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Indications for Thyroid U/S Evaluation /detection of nodules YES Guidance for FNA YES Thyroid dysfunction LIMITED Weight loss, dysphagia, fatigue, neck pain WEAK AACE, ATA, ACP

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I. DIAGNOSIS

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Thyroid Nodules Palpation 4-8 % adult population U/S 50-65% CT scan, PET-CT, or .. metastasis

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Incidence of malignancy in a nodule 5-15% Whether palpable or not Whether single or multiple

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Thyroid Cancer Papillary 80% Follicular 15% (Hurthle cell) Medullary : 3% familial, MEN Anaplastic: 2% highly aggressive Differentiated cancer

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Large reservoir of clinically occult thyroid cancer in general population 1947 NEJM : VanderLaan - occult PCT common autopsy finding in persons with no history of thyroid disease 1985 Cancer 1985: HR Harach et al (Finland)- thyroid cut in 1 mm. blocks, occult cancer in 35%. If cut thinly enough, would find PTC in almost every Finish thyroid gland

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A Dilemma (National Cancer Institute data) 240% increase Stable Increased incidence mainly due to 1-2 cm papillary cancers

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Method of Detection Palpation (4%) Ultrasound (50-67%)

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Conclusion increasing incidence reflects increased detection of subclinical disease, not an increase in the true occurrence of thyroid cancer Davies L, Welch HG. JAMA 2006; 295:2164-2167.

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Real Increase in Incidence? the incidence rate of differentiated thyroid cancers of all sizes increased across all tumour sizes between 1998 and 2005 in both men and women this suggest that increased diagnostic scrutiny is not the sole explanation Chen AY. Cancer 2009; 115: 3801-3807.

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Basis for management of thyroid nodules Ultrasonography (US), Thyrotropin (TSH) assay, Fine-needle aspiration (FNA) biopsy Thyroid scintigraphy is not necessary for diagnosis in most cases AACE Guidelines

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When to Perform Thyroid Scintigraphy Thyroid nodule (or MNG) if the TSH level is supressed Hot nodule: benign ; no need for FNA AACE Guidelines

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FNA

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Pattern Recognition

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FNA recommendations AACE 2010ATA 2009SRU 2005 High Riskall5 mmn/a Abnormal nodesall Microcalcification< 10 mm10 mm Solid hypoechoic10 mm10 -15 mm15 mm Mixed cystic/solid10 mm15 -20 mm20 mm Spongiformn/a20 mmn/a Purely cysticno Risk Malignancy

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Biopsy / Mortality per 100,000 Hammond I, Schweitzer ME. A Resource Allocation Metric for Thyroid Biopsies. J Am Coll Radiol 2011;8:49-52

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5 Benign leave-alone patterns Colloid cyst Spongiform nodule Cyst with colloid clot Giraffe pattern White knight Bonavita et al. AJR 2009; 193: 207213

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(1)Colloid Cyst: Comet Tail

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(2,3) Benign Colloid Nodule Spongiform Cyst with Colloid Clot * * can mimic cystic changes in cancer

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(4,5)Hashimotos disease Giraffe Pattern White Knight

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Pseudonodule : right lower pole

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Pseudonodule: glandular inhomogeneity

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Pattern % TOH Virmani V, Hammond I. AJR 2011; 196:891895 Benign

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Strongest predictors of malignancy (3485 nodules) Solid Hypoechoic Calcification Frates et al. J Clin Endocrinol Metab 2006; 91: 3411-3417.

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Psammoma bodies Increased expression of osteopontin, a bone matrix protein, in papillary thyroid cancer

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Non-Shadowing Echogenic Foci

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100% BenignMost likely benign Potentially malignant Potentially malignant

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Colloid Crystals

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Bilateral Papillary Carcinoma

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Papillary cancer

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Papillary cancer cystic Cyst with Colloid Clot Papillary Cancer

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Female 56 nodule rt; prior renal CA Path = metastatic renal cell, small focus papillary cell

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Anaplastic Cancer

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Cervical Nodes III: middle jugular IV: low jugular VI : thyroid bed VII: paratracheal

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Lymph Nodes Normal = oval, fatty hilum Central vascularization

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Cervical nodes Microcalcification * Cystic necrosis *

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II. TREATMENT

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General principles of treatment: Remove 1 tumor disease extended beyond the thyroid capsule involved cervical lymph nodes Radioactive Iodine AbIation, where appropriate.

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III. Surveillance

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Surveillance Neck U/S Serum thyroglobulin (Tg) Whole body iodine scan (WBS) PET / CT Low Risk

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Serum Thyroglobulin (Tg) Prohormone of T4 and T3 After total thyroidectomy and radioiodine ablation Tg should be undetectable in case of complete remission

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Cervical Nodes III: middle jugular IV: low jugular VI : thyroid bed VII: paratracheal

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Recurrence thyroid bed: thyroidectomy 8 yrs ago rising Tg CCA Tr

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Pitfall gelfoam in surgical bed Tublin ME et al. J Ultrasound Med 2010; 29: 117-120.

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Gelfoam: Thyroidectomy May 2009 July 2009 Dec 2009

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Lymph Node recurrence: thyroidectomy with RAI - rising Tg

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Teaching Points 1 Papillary cancer = most common Nodule w/u: TSH, U/S If TSH suppressed -> nuclear scan Pattern Recognition: colloid cyst, spongiform nodule giraffe pattern (white knight) = BENIGN Cyst with colloid clot can mimic cystic cancer 85% nodules non-specific morphology

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Teaching Points 2 Microcalcification = strongest predictor of malignancy FNA criteria: 3 societal guidelines Nodes -> infra-hyoid nodes (beware cystic changes, microcacification) Surveillance : U/S, thyroglobulin (Pitfall Gelfoam)