Download - Thyroid mass
Thyroid mass Presented by
Dr- Hayam M. AL-moutary
Case
• A 42-year-old woman presents with a palpable mass on the left lobe of thyroid gland
• How to deal with these case?
• She has no neck pain and no symptoms of thyroid dysfunction.
• The patient has no family history of thyroid disease and no history of external irradiation.
• physical examination reveals a solitary, mobile thyroid nodule, 2 cm by 3 cm, without lymphadenopathy
• Which investigations should be performed?
• Assuming that the nodule is benign ,which, if any, treatment should be recommended?
Content
Anatomy& physiology of thyroid glandType of thyroid massApproach patient with thyroid noduleType of thyroid malignancyIodine deficiency disorder (IDD)Management
Thyroid Anatomy• a butterfly-shaped
endocrine gland, located on the anterior (front) side of the neck
• Composed of right & left lob connecting by isthmus
• supplied with arterial blood from the superior thyroid artery and the inferior thyroid artery
Thyroid physiology
Thyroid mass
cancerNodule goiter
Epidemiology • In the United States, 4 to 7 percent of the adult
population have a palpable thyroid nodule.• Nodules are more common in women and increase in
frequency with age and with decreasing iodine intake.• The prevalence is much greater with the inclusion of
nodules that are detected by ultrasonography or at autopsy.
• Malignant nodule corresponds to approximately 2 to 4 per 100,000 people per year, constituting only 1 percent of all cancers and 0.5 percent of all cancer deaths.
Causes of thyroid nodules
• Benign• Multi noduler goiter• Hashimotos thyrioditis• Simple or hemorrhagic cysts• Follicular adenomas• Sub acute thyrioditis
AACE/AME Guidelines 2010
Causes of thyroid nodules
• Malignant• Papillary carcinoma• Follicular carcinoma• Hurthie cell carainoma• Medullary carcinoma• Anaplastic carcinoma• Primary thyroid lymphoma• Metastatic malignant lesion
AACE/AME Guidelines 2010
History
o Ageo Family history of thyroid disease or cancero Previous head or neck irradiationo Rate of growth of the neck masso Dysphonia, dysphagia, or dyspnea
AACE/AME Guidelines 2010
History
o Symptoms of hyperthyroidism orhypothyroidismo Use of iodine-containing drugs or supplements Most nodules are asymptomatic, and absence
of symptoms does not rule out malignancy
Physical Examination
• A careful physical examination of the thyroid gland and cervical lymph nodes
o Location, consistency, and size of the nodule(s)o Neck tenderness or paino Cervical adenopathy The risk of cancer is similar in patients with asolitary nodule or with MNG (Grade B )
AACE/AME Guidelines 2010
Factors suggesting increased risk of malignant potential (grade C):
• History of head and neck irradiation• Family history of MTC or MEN2• Age <20 or >70 years• Male sex• Growing nodule• Firm or hard consistency• Cervical adenopathy• Fixed nodule• Persistent hoarseness, dysphonia, dysphagia, or dyspnea
AACE/AME Guidelines 2010
Laboratory Evaluation
• TSH Assay• Serum Free Thyroxine and Free
Triiodothyronine• Calcitonin Assay
Laboratory Evaluation• Serum TSH should be tested (grade B)• If TSH level is low (<0.5 μIU/mL), measure free
T4 and T3; if TSH level is high (>5.0 μIU/mL), measure free T4 and TPOAb (grade C)
• Serum calcitonin should be measured if FNA or family history suggests MTC (grade B)
AACE/AME Guidelines 2010
UltrasoundIndication of thyroid ultrasound(grade C)1. Palpable thyroid nodule2. History of neck irradiation3. Family history of thyroid carcinoma orMEN24. Patient with unexplained cervical
lymphadenopathy5. Not indicated as screening exam
AACE/AME Guidelines 2010
Fine-Needle Aspiration Biopsy
•Thyroid FNA biopsy has been established as reliable and safe and has become an integral part of thyroid nodule evaluation
•Clinical management of thyroid nodules should be guided by the results of ultrasonographic evaluation and FNA biopsy
Sensitivity 83 % Specificity 92 %
Result of FNASuspicious or indeterminate
Inadequate Malignant or positive
Benign or negative
•cytologic results that suggest a malignant lesion but do not completely fulfill the criteria for a definitive diagnosis
•smears with few or no follicular cells
•primary (thyroid) or •secondary(metastatic) cancers
•colloid nodule•Hashimoto’s thyroiditis
•cyst,•thyroiditis
Thyroid Scintigraphy
•Perform thyroid scintigraphy for a thyroid nodule or MNG if theTSH level is below the lower limit of the
normal range (grade B) In iodine-deficient areas (grade C)
AACE/AME Guidelines 2010
Thyroid Scintigraphy
On the basis of the pattern of radionuclide uptake, nodules may be classified as Hyper functioning (“hot”) Hypo functioning(“cold”)
Thyroid Scintigraphy
Hot nodules almost never represent clinically significant malignant lesions, whereas cold nodules have a reported malignant risk of about 5% to 15%.
Hot & cold nodule
Thyroid nodule
History& physical examination
TSHLow TSH
High or normal
scintigraphy
coldhot
Perform FNAbenign
U/S guided FNA
Benign-veMalignant +ve
Suspicious Inadequate
Repeat FNA Surgery Surgery Observe and repeat FNAC
1 yearOr
levothroxin
Disadvantage Advantage Treatment type
Hospitalization, high cost, vocal cord paralysis ,hypothyroidism
Relief symptom & nodule surgery
Reduce bone density, arrthmia No need hospitalization , low cost, prevent new
nodule to growth
Levothroxin
Use contrceptive , hypothyridism Risk of thryioditis
No need for hospitalizationLow cost, decrease nodule
40% in 1 year
Ridioidoin
Pain full , vocal cord paralysis, No need for hospitalizationLow cost, decrease nodule
45% in 6 month
Ethinol injection
Laser therapy
Thyroid Malignancies- Papillary
• Most common• 30% have node metastasis at diagnosis• Radiation related• Histologically, psammoma bodies
distinguish from benign adenoma.
Thyroid Malignancies-Follicular
• 20 % of malignancies• Distinguished from normal follicular
adenomas by invasion of capsule or blood vessels.
• May be difficult to determine on FNA
Thyroid Malignancies- Medullary
• 5-10% of cases• arise from the C cells which produce calcitonin• diagnosis based on elevated thyrocalcitonin
levels and thyroid nodule (cold)
Thyroid Malignancies- Anaplastic
• < 10%• Highly aggressive with local extension at time
of diagnosis.• No suitable therapy• Prognosis < 1 yr from diagnosis
Iodine Deficiency• Iodine is a chemical element. It is found in
trace amounts in the human body, in which its only known function is in the synthesis of thyroid hormones
• Severe iodine deficiency results in impaired thyroid hormone synthesis and/or thyroid enlargement (goiter).
• More common in female
iodine deficiency disorders (IDDs), include
endemic goiter, hypothyroidism, cretinism, decreased fertility rate, increased infant mortality, mental retardation.
pathophysiology
• Normal dietary iodine intake is 100-150 mcg/d.
Clinically • HistoryGoiter - Patients with IDD most commonly
present with goiterHypothyroidism - Individuals with severe
iodine deficiency may also have hypothyroidism and may complain of fatigue, weight gain, cold intolerance, dry skin, constipation, or depression
• Cretinism . Cretinism can be divided into neurologic and myxedematous subtypes. Both conditions can be prevented by adequate maternal and childhood iodine intake. – Neurologic cretinism is thought to be caused by severe IDD
with hypothyroidism in the mother during pregnancy and is characterized by mental retardation, abnormal gait, but not by goiter or hypothyroidism in the child.
– Myxedematous cretinism is considered a result of iodine deficiency and hypothyroidism in the fetus during late pregnancy or in the neonatal period, resulting in mental retardation, short stature, goiter, and hypothyroidism
Physical
The first sign of iodine deficiency is diffuse thyroid enlargement, which becomes multinodular over time.
In patients with hypothyroidism due to severe iodine deficiency, one might see signs such as dry skin, periorbital edema, and delayed relaxation phase of the deep tendon reflexes.
Laboratory Studies
• The kidneys excrete approximately 90% of ingested iodine
• median 24-hour urine iodine collection• random urine iodine-to-creatinine ratio 50-100 mcg of iodine per liter mild iodine deficiency 20-49 mcg of iodine per liter moderate deficiency less than 20 mcg of iodine per liter severe deficiency
Other Tests T4 T3
TSH
normal or decrease
normal or slightly elevated
normal to increased
euthyroidism and iodine deficiency
decreased decreased increased hypothyroidism
Treatment
• non-pharmacologicalDiet The WHO recommendations for iodine intake
are 150 mcg/d for adults and adolescents200 mcg/d for pregnant or lactating women,
• PharmacologicalPotassium iodide (Lugol solution, SSKI, Pima)Levothyroxine (Synthroid, Levothroid, Levoxyl)12.5-50 mcg/d PO and increase by 25-50 mcg/d
PO q2-4wk, not to exceed 100-200 mcg/d PO• Surgery
Summary
• Most nodules are asymptomatic, and absence of symptoms does not rule out malignancy
• The initial evaluation should include measurement of the serum thyrotropin level and a fine-needle aspiration, preferably guided by ultrasonography
• IDD are common in our region can be preventable by take recommended dose of iodine from natural source
Reference
e medicineAACE/AME Guidelines 2010Swansons family medicine review 6th edition