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ADENOMA OF THYROID GLAND
By Ashik Kareem
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thyroid
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ANATOMY
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STATISTICS OF THYROID CANCER
National Cancer Registry Program (NCRP) by Indian Council of Medical Research.
Data of >3,00,000 patients from 1984 – 1993
Among MALES 1 per 1,00,000 FEMALES 1.8 per 1,00,000
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HISTORY Symptoms The most common presentation of a
thyroid nodule, benign or malignant, is a painless mass in the region of the thyroid gland.
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HISTORY (CONTINUED...) Risk factors Thyroid exposure to irradiation
low or high dose external irradiation (40-50 Gy [4000-5000 rad])
especially in childhood for: large thymus, acne, enlarged tonsils, cervical adenitis,
sinusitis, and malignancies Schneider and co-workers (1986) studied, with long term
F/U, 3000 patients who underwent childhood irradiation.1145 had thyroid nodules318/1145 had thyroid cancer (mostly papillary)
Age and SexBenign nodules occur most frequently in women 20-40 yearsMen have a higher risk of a nodule being malignant
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HISTORY (CONTINUED…)
Family HistoryHistory of family member with thyroid
carcinomaHistory of family member with other endocrine
abnormalities (parathyroid, adrenals)History of familial polyposis (Gardner’s
syndrome)
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EVALUATION OF THE THYROID NODULE(PHYSICAL EXAM)
Examination of the thyroid nodule: consistency - hard vs. soft size - < 4.0 cm Multinodular vs. solitary nodule Mobility with swallowing Mobility with respect to surrounding tissues Well circumscribed vs. ill defined borders
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PHYSICAL EXAM (CONTINUED…)
Examine for ectopic thyroid tissue Indirect or fiberoptic laryngoscopy
vocal cord mobility evaluate airway preoperative documentation of any unrelated
abnormalities Systematic palpation of the neck
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EVALUATION OF THE THYROID NODULE(BLOOD TESTS)
Thyroid function tests thyroxine (T4) triiodothyronin (T3) thyroid stimulating hormone (TSH)
Serum Calcium Thyroglobulin (TG) Calcitonin
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EVALUATION OF THE THYROID NODULE(RADIOIMAGING)
Radioimaging usually not used in initial work-up of a thyroid nodule
Chest radiograph Computed tomography Magnetic resonance imaging
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EVALUATION OF THE THYROID NODULE(ULTRASONOGRAPHY) Advantages Most sensitive procedure or identifying
lesions in the thyroid (2-3mm) 90% accuracy in categorizing nodules
as solid, cystic, or mixed (Rojeski, 1985) Best method of determining the
volume of a nodule (Rojeski, 1985) Can detect the presence of lymph
node enlargement and calcifications Noninvasive and inexpensive
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ULTRASONOGRAPHY (CONTINUED…) When to use Ultrasonography: Long term follow-up for the following:
to evaluate the involution of a multinodular gland or a solitary benign nodule under suppression therapy
monitor for reaccumulation of a benign cystic lesion follow thyroid nodules enlargement during pregnancy
Evaluation of a thyroid nodule: help localize a lesion and direct a needle biopsy when a
nodule is difficult to palpate or is deep-seated Determine if a benign lesion is solid or cystic
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ULTRASONOGRAPHY (CONTINUED…)
Disadvantages Unable to reliably diagnose true cystic lesions Cannot accurately distinguish benign from malignant
nodules
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EVALUATION OF THE THYROID NODULE(RADIOISOTOPE SCANNING)
Prior to FNA, was the initial diagnostic procedure of choice
Performed with: technetium 99m pertechnetate or radioactive iodine
Technetium 99m pertechnetate cost-effective readily available short half-life trapped but not organified by the thyroid - cannot determine
functionality of a nodule
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RADIOISOTOPE SCANNING (CONTINUED…)
Radioactive iodine radioactive iodine (I-131, I-125, I-
123) is trapped and organified can determine functionality of a
thyroid nodule
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RADIOISOTOPE SCANNING (CONTINUED...)
LimitationsNot as sensitive or specific as fine needle aspiration
in distinguishing benign from malignant nodule90%-95% of thyroid nodules are hypofunctioning, with
10%-20% being malignant (Geopfert, 1994, Sessions, 1993)Campbell and Pillsbury (1989) performed a meta-
analysis of 10 studies correlating the results of radionuclide scans in patients with solitary thyroid nodules with the pathology reports following surgery and found: 17% of cold nodules, 13% of warm or cool nodules, and 4%
of hot nodules to be malignant
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RADIOISOTOPE SCANNING (CONTINUED…)
Specific uses of thyroid scanning: Preoperative evaluation
When patients have benign (by FNA), solid (by U/S) lesions
When patients have nonoxyphilic follicular neoplasms
Postoperative evaluationimmediately postop for localization of residual
cancer or thyroid tissuefollow-up for tumor recurrence or metastasis
(Geopfert, 1994)
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EVALUATION OF THE THYROID NODULE(FINE-NEEDLE ASPIRATION)
Currently considered to be the best first-line diagnostic procedure in the evaluation of the thyroid nodule:
Advantages: Safe Cost-effective Minimally invasive Leads to better selection of patients for surgery than any
other test (Rojeski, 1985)
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FINE-NEEDLE ASPIRATION (CONTINUED…)
FNA halved the number of patients requiring thyroidectomy (Mazzaferri, 1993)
FNA has double the yield of cancer in those who do undergo thyroidectomy (Mazzaferri, 1993)
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FINE-NEEDLE ASPIRATION (CONTINUED…)
Pathologic results are categorized as: positive, negative, or Indeterminate
Limitations skill of the aspirator
Sampling error in lesions <1cm, >4cm, multinodular lesions, and hemorrhagic lesions
Error can be diminished using ultrasound guidance expertise of the cytologist difficulty in distinguishing some benign cellular adenomas
from their malignant counterparts (follicular and Hurthle cell) False negative results = 1%-6% False positive results = 3%-6%
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Thyroid Neoplasm
Benign Malignant
Secondary
Primary
• All ADENOMA are invariably follicular
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Benign ThyroidNeoplasm
Benign Thyroid
Neoplasm
• COLLOID Most commonest type of benign thyroid neoplasm Do not have the potential for micro invasion
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May grow large. More than one may be present. Initially very small - undetectable without any imaging technique Distinguished by the presence of apparently gelatinous mass of colloid Fibrous capsule is absent
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• FETAL They may also called as microfollicular (due to the potential for microinvasion)
They have small, closely packed follicles
The follicles are lined by epithelium
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• EMBRYONAL
Also known as ATYPICAL adenoma
These adenomas also have the potential for microinvasion
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• Hurthle Cell
They are also called as OXYPHILL or ONCOCYTIC type of adenoma.
They also have the potential for microinvasion
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CLINICAL PRESENTATION As a clinically silent tumor, in case of “cold” or“warm” adenoma.
As a functional tumor, producing excessive thyroid hormones (‘hot’ adenoma).Hyperthyroidism may also be present in this condition and referred to as a ‘toxic thyroid adenoma’
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TREATMENT OPTIONS
Clinical follow up with REGULAR MONITORING. - watching for changes in nodule size and symptoms - repeat ultrasonography or needle aspiration biposy if the nodule grows
Surgical management ‘THYROIDECTOMY’
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THANK YOU...
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