APPROACH

TO
THYROID NODULE

Dr. (Maj. Gen.) K J Shetty

Consultant Endocrinologist
MD, FRCP (Edin.), FICP
 INTRODUCTION

Thyroid Nodule:
– Common Outpatient Clinical Problem
4 to 8% OF ADULTS
13 to 67% ON USG EXAM
(Female : Male – 8:1)
– Importance: Concern of Carcinoma
5% Malignant
Relative Common-ness and possibility of complete cure if
detected early
– Solution: Evolve a safe, expedient, reliable and cost
effective management strategy
 PRESENT SCENARIO
Widely Divergent Approach
– Primary Consultant : GP, Internist, Surgeon,
ENT Specialist, Surgical Oncologist
– Bias of the consultant - reluctance to follow guidelines
– Inadequate use/ Improper prioritization of
investigative tools
– Insufficient knowledge of pathophysiology
natural history of thyroid nodule
indications, merits, and shortcomings of various investigative
tools
 Approach to Thyroid Nodule
Steps:
Evaluation
– Morphology
– Functional
– Immunological
– Cytological
– Histopathological
Tools Available
– Clinical History & Examination
– Biochemical / Immunological Tests
– Imaging – USG/SCAN
– Aspiration Cytology
 Thyroid Nodule
Steps in Evaluation:
– Clinical Examination
– Biochemical Examination
– Ultrasound Evaluation
– Cytology
 Clinical Evaluation
Asymptomatic
Symptomatic
Hyper/ Hypo-thyroidism
Mechanical
Dyspnoea
Dysphagia
Hoarseness
Pain
Rapid Increase In Size
Cosmetic
Past History (Previous Surgery, Irradiation)
Family History
CLINICAL EVALUATION (cont’d)
General
– Sex: M > F
– Age: < 20 ; > 60 Yrs
Systemic : EUTHYROID/ HYPO/ HYPER
Neck : NODULE: SOLITARY / MULTINODULAR
– Size/ Intra-thoracic/ Extension
– Consistency: Firm/Hard/Cystic
– Mobile/Fixed
– Tenderness
Lymph nodes : Number and level
CLINICAL POINTERS TO MALIGNANCY

Main Pointers
– Recent Rapid Increase In Size
– Development of Hoarseness of voice
– Positive Family History
– Age & Sex
– Past History of Neck Irradiation
– Hard Fixed Nodule
– Regional lymph nodes
Misconcepts of Malignancy
– Size: Smaller Ones – NO RISK
– Multi-Nodular – NO RISK
– Pain – HIGH RISK
 Biochemical Evaluation
– Lab Evaluation – First Step: Assess Functional Status

by TFT
– TSH Assay: Most Useful
– T3/T4: Not Necessary if TSH is normal
– TSH:
Absent/ Low - Toxic Nodule : T3/ T4 Indicated
Elevated - Hypothyroid : T4 indicated
– FT3/FT4: Preferred to TT3/ TT4
– Thyroid Antibodies
Thyroid Peroxidase (TPO)
ANTI-THYROGLOBULIN Ab (TgAb)
TSH Receptor
Antibodies (TSIAb) Graves (Not Routinely Available)
(Hashimotos and Graves)
 Ultrasonography (USG)
*High Resolution USG: Exceptional Clarity
*Nodules < 1.5 cm
*Metastatic Nodules In Neck (Clinically not palpable)
• Assists in Localising Nodules for FNAC
• Inexpensive, non invasive, readily available
• USG to Endocrinologist
Stethoscope to Cardiologist
• Limitation: Little help in differentiating benign
from cancer
No Single Characteristic: Predictive for malignancy
Denote Higher Risk in combination of some:
Composition Incidence percentage
– Solid 27%
– Mixed (complex) 7%
– Pure cystic > 4 cm: 6%
< 4 cm: Negligible
Calcification
– Microcalcification : x 3 higher risk without calcification
– 95% specificity
- Coarse Calcification x 2 Risk
Cervical Lymph Nodes : Highly Suggestive of PTC
Fine Needle Aspiration Cytology (FNAC) /
Biopsy (FNAB)
Crucial Step in evaluation
Simple, safe, accurate and cost effective
Assess Reliability Guidelines (Mayo Clinic)
– Experienced, Preferably dedicated cyto-pathologist
– Multiple Sites of Aspiration (2-4)
– A Low False Negative Rate
Literature 1 – 11 %
Acceptable < 5%
Diagnostic Sample : 2 Slides - > 6 Groups Each
> 10 Follicular Cells In each
group
Benign………………………. 70%
Indeterminate………………..10%
Malignant…………………… 5%
Non Diagnostic………………15%
Benign: Colloid Nodules
– 70% Simple Cysts
– AutoImmune/ Lymphocytic Thyroiditis

Malignant:
– Papillary (Commonest) 83%
– Follicular : 11%
– Medullary (MTC) 5%
– Anaplastic 1%
Indeterminate Category: (10%)
2 GROUPS:
– Suspicious for malignancy: definitive evidence
for malignancy not evident
– Follicular neoplasm: not possible to
differentiate from adenoma and carcinoma
(capsular/ lymphovascular invasion)
Both sub-groups qualify for surgery
 Non-Diagnostic (20%)

Solid Lesion - Insufficient No. of follicular Cells

- Re-Aspiration Indicated after 4 weeks
– diagnostic aspirate in 50%
– if non diagnostic : surgery

Cystic Lesion - Aspirate Unsatisfactory

- Solid Component- Biopsy Mandatory
- If not feasible - Surgery
 THYROID SCINTIGRAPHY
Using Radioactive Iodine (I131) / Technitium (99 mTc)
Depending on uptake classified as:
– HOT: 5% Toxic Nodule : < 5% Malignant
– COLD: 80 – 85% : 10 – 15% Malignant
– WARM 10-15% : 9% Malignant
– Expensive/ Availability Only In Special Centres
– Overlap: Small Nodules Masked
Use Limited To :
– Indeterminate (Suspicious/Follicular) on FNAC
– Follow Up of “hot” nodule
– Diagnosis of ectopic goitre / Substernal Extension
NORMAL Tc99m THYROID UPTAKE
HOT NODULE
COLD NODULE
MULTI-NODULAR GOITRE
 MANAGEMENT
Based on Combination of Input From:
– History
– Clinical Examination
– Ultrasound Evaluation
– Cytology
( Benign Nodules, Malignant Nodules, Indeterminate, Nondiagnostic)
Therapeutic Options:
1. Follow-Up With Periodic Clinical and lab input
2. Surgery
3. Radiotherapy
4. Medical therapy
 MANAGEMENT (contd….)

BENIGN NODULES (70%):

– Euthyroid: No Pressure symptoms Yearly Follow up
Cosmetically Acceptable Clinical/Biochem./ USG
> 20% ↑ - Repeat FNAC
– Role of Suppressive Rx with T4 – Not Proven
– Beware of subclinical Hyperthyroidism
– Euthyroid: Pressure + Cosmetic Problem – Limited Surgery
– Toxic Nodule: Medical (CMZ/PTU + Propranolol)

I 131 / Surgery
 MANAGEMENT (cont…)
Malignant Nodules: 5%
PTC : Total Thyroidectomy with Ipsilateral Central
Compartment Lymph Node Clearance
FTC: Non/Min. Invasive – Lobectomy
Invasive: Complete Thyroidectomy (Total)
Follow Up for Both : I131 ablation after 6/52

High Dose Thyroxine

TSH Suppression (<0.1mu/L)

MTC: Total Thyroidectomy with complete LN Clearance
ANAPLASTIC : Aggressive tumour- TLC/Decompression
 MANAGEMENT (cont…)
INDETERMINATE (10%)
FOLLICULAR NEOPLASM / SUSPICIOUS FOR MALIGNANCY

SURGERY WITH INTRAOPERATIVE FROZEN SECTION

TOTAL THYROIDECTOMY
+
LYMPH NODE CLEARANCE
 MANAGEMENT (cont…)
NON DIAGNOSTIC : 20%

CYSTS : > 4 cm
– REPEATED FNAC
– NONDIAGNOSTIC/ SURGERY
NODULE –
– SURGERY – EXCISIONAL BIOPSY
APPROACH TO THYROID NODULE – AN ALGORITHM

PATIENT WITH THYROID NODULE

CLINICAL EVALUATION
+
TFT + IMMUNOLOGY

EUTHYROID HYPERTHYROID HYPOTHYROID

ANTITHYROID DRUGS/ T4 REPALCEMENT

USG
I 131 ABLATION / SURGERY

SOLID COMPLEX CYSTS WITH PURE CYSTS

SOILD COMPUND

< 4cm > 4 cm

FNAC FOLLOW UP SURGERY

 ALGORITHM (CONTD….)

FNAC OF NODULE

CYTOLOGY REPORT

BENIGN (70%) MALIGNANT (5%) INDETERMINATE (10%) NON DIAGNOSTIC (15%)

PRESSURE SYMPTOMS/ SCINTIGRAPHY

COSMETIC PROBLEMS – NIL Rpt FNAC WITH USG
(I131/ 99 mTc)
YEARLY
FOLLOWUP
SUPPRESSION WITH
T4 – 6– 12 MONTHS WARM COLD DIAGNOSTIC NON-
DIAGNOSTIC
> 20% INCREASE

FOLLOWUP
Rpt FNAC

SUSPICIOUS

SURGERY
 CONCLUSION
Thyroid Nodule- A common Problem
Evaluation:
– Arbitrary, Inconsistent, Divergent
– Based on Personal Preference
Long-term experience & advances in
diagnostic aids:
– Fresh Guidelines laying down systematic
step-wise approach
– Misconcepts corrected
THANK YOU