thyroid image screening...ultrasound • asymptomatic patients • recommendation: against...
TRANSCRIPT
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THYROID IMAGE SCREENING
Endocrinologist vs Radiologist
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ACOI 2019 Phoenix
John Sutton, DO, FACOI, FACE, CCD
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NO DISCLOSURES
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USPSTFTHYROID CANCER
SCREENING 2017
• Rising thyroid cancer cases, without associated mortality
• Risk and benefit of screening by physical exam and
ultrasound
• Asymptomatic patients
• Recommendation: Against screening, not likely a benefit
or harm outweigh benefit
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THYROID CANCER
INCIDENCE
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• 1975 = 4.9 cases per 100, 000 people
• 2013 = 15.3 cases per 100,000 people
• Increased 6.7 % per year 1997 to 2009
• Increased 2.1 % per year 2009 to 2013
• Mortality increased only 0.7 people per 100,000/Year
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SYMPTOMATIC PATIENT
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• Hoarseness
• Dysphagia
• Pain
• Lumps
• Neck asymmetry
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ADVERSE HISTORY
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• Radiation history
• Inherited genetic syndrome
• Familial thyroid cancer 1st degree
• Low iodine diet
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INCIDENTAL THYROID
LESIONS RADIOLOGY
• CT & MRI: check for abnormal nodes, include invasion
and size
• 1 to 1.5 cm short axis nodes suspicious
• Thyroid cancer nodes level IV and VI
• Thyroid ultrasound for suspicious thyroid lesions
• Age < 35 yrs eval nodules 1 cm & greater
• Age 35 yrs and older eval nodules 1.5 cm & greater
• Consider limited life expectancy and comorbid conditions
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INCIDENTAL THYROID
LESIONS RADIOLOGY
• CT & MRI: check for abnormal nodes, include invasion
and size
• 1 to 1.5 cm short axis nodes suspicious
• Thyroid cancer nodes level IV and VI
• Thyroid ultrasound for suspicious thyroid lesions
• Age < 35 yrs eval nodules 1 cm & greater
• Age 35 yrs and older eval nodules 1.5 cm & greater
• Consider limited life expectancy and comorbid conditions
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INCIDENTAL THYROID
LESIONS RADIOLOGY
• FDG-PET: Metabolism uptake in lesions of thyroid
suggest malignancy, even if ultrasound not suspicious
• Need thyroid ultrasound and biopsy
• Consider comorbid issues and life expectancy
• Other nuclear med studies may also have thyroid uptake
• MIBI studies should have thyroid ultrasound
• Only 1 in 5 lesions reported in the impression section
undergo additional evaluation but usually lesser age and
size related
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INCIDENTAL THYROID
LESIONS RADIOLOGY
• Ultrasound of non thyroid structures may see
thyroid lesions: Look for microcalcification,
irregular border, hypoechoic, taller than wide
• Adverse ultrasound features obtain thyroid
ultrasound, but consider life expectancy and
comorbid status
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INCIDENTAL THYROID
LESIONS RADIOLOGY
• Nodule size by CT, MRI, PET-CT
underestimate size of lesion not
significant
• Reduces number of thyroid
ultrasounds by 24 %
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AMERICAN THYROID ASSOCIATION
THYROID CANCER SCREENING
• ATA Guidelines indicate no recommendation for
or against screening in relatives of well
differentiated thyroid cancer with no clear
reduction mortality or morbidity
• If nodule identified, check TSH. If TSH is below
normal, obtain nuclear thyroid scan by 123I
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AMERICAN THYROID ASSOCIATION
THYROID CANCER SCREENING
• Thyroglobulin and calcitonin should not be
ordered in these patients by routine
• Focal uptake on FDG-PET should biopsy ≥1cm
nodules associated on ultrasound
• Diffuse uptake in chronic thyroiditis no biopsy
suggested
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AMERICAN THYROID ASSOCIATION
THYROID CANCER GUIDELINES
• Diagnostic ultrasound for known or suspected
thyroid lesions with neck ultrasound for nodes
• FNA suspicious nodules ≥ 1 cm
• FNA unsuspicious nodules ≥ 1.5 cm
• FNA low suspicion nodules ≥ 2 cm
• Purely cystic nodules: No biopsy
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ATA GUIDELINES
THYROID NODULE FEATURES
• Suspicious: Hypoechoic, microcalcifications,
irregular border, taller than wide
• Microcalcification, irregular border and taller
highest specificity for thyroid cancer
• Most benign thyroid nodules are hypoechoic
• Less suspicious: spongiform, hyperechoic,
isoechoic
• Suspicious features primarily associated with
Papillary Thyroid Cancer
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ACR THYROID IMAGING,
REPORTING AND DATA
SYSTEM
(TIRADS)
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ACR TI-RADS
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ACR THYROID IMAGING, REPORTING
AND DATA SYSTEM (TIRADS)
COMPOSITION
• Solid
• Predominately solid
• Predominately cystic
• Cystic
• Spongiform
• Partially cystic nodules low malignancy
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ACR THYROID IMAGING, REPORTING
AND DATA SYSTEM (TIRADS)
ECHOGENICITY
•Hyperechoic
• Isoechoic
•Hypoechoic
•Very Hypoechoic
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ACR THYROID IMAGING, REPORTING
AND DATA SYSTEM (TIRADS)
SHAPE
• Taller than Wide
• Suspicious for malignancy
• In transverse plain, ratio >1 anteroposterior to horizontal
diameter
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ACR THYROID IMAGING, REPORTING
AND DATA SYSTEM (TIRADS)
SIZE
• Maximal longitudinal, anteroposterior and transverse
• Nodule size does not predict malignancy in PTC,
subcentimeter nodules can be malignant
• 2013 study showed nodules 1 to 1.9 cm at 10%
malignancy, increasing to 15 % in 2 cm nodules with larger
nodules more likely to have other than PTC pathology
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ACR THYROID IMAGING, REPORTING
AND DATA SYSTEM (TIRADS)
MARGINS
• Smooth
• Irregular
• Lobulated
• ILL defined
• Halo
• Extrathyroidal extension
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ACR THYROID IMAGING, REPORTING
AND DATA SYSTEM (TIRADS)
ECHOGENIC FOCI
•Punctate
•Macrocalcifications
•Periferal
•Comet-tail
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ACR TI-RADS
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CLINICAL FEATURES IN
THYROID PATIENTS
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THYROID FUNCTION &
MALIGNANCY
• Most patients with thyroid nodule and thyroid cancer are euthyroid
• Low thyroid function more likely malignant
• High thyroid function is less likely malignant
• Nuclear imaging is not routinely necessary in euthyroid or
hypothyroid patients
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NUCLEAR THYROID IMAGING
& THYROID CANCER
• Can be used to determine greater or lesser uptake in
the entire thyroid thyroid or in a nodule
• Thyroid nodules with decreased uptake (cold), more
suggestive of malignancy
• Increased uptake thyroid nodule (hot) less suggestive of
malignancy
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John Sutton, DO, FACOI, FACE, CCD
Past PresidentAmerican College of Osteopathic Internists
Carson City, NV
Thank You