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Approach to a thyroid nodule

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Presentation on theme: "Approach to a thyroid nodule"— Presentation transcript:

1 Approach to a thyroid nodule
Andy Sher PGY-2 Family Medicine

2 Case 44 y.o. woman, 2 cm nodule palpable in left lobe of thyroid gland at annual exam – smooth, non-tender. No lymphadenopathy No symptoms of hyper/hypo thyroid. No compressive symptoms Past Med Hx: HTN Meds: HCTZ Fam Hx: no hx of thyroid disease

3 Epidemiology Palpable thyroid nodules – 4-7% of population
Prevalence 19-67% - based on nodules found incidentally on ultrasound 4:1 women:men

4 Epidemiology Geographic areas with iodine deficiency
Thyroid carcinoma in 5-10% of palpable nodules Following ionizing radiation, nodules develop at a rate of 2% annually

5 Presentation Majority are asymptomatic <1% cause hyperthyroidism
Neck pressure or pain if spontaneous hemorrhage

6 History Symptoms of hyper or hypothyroidism
Previous nodules, goiters, family history of autoimmune thyroid disease, thyroid carcinoma, or familial polyposis Hashimoto’s thyroiditis – association with thyroid lymphoma

7 History – Red Flags Male < 20 years, > 65 years
Rapid growth of nodule Symptoms of local invasion (dysphagia, neck pain, hoarseness) Hx of radiation to head or neck Family hx of thyroid CA or polyposis

8 Physical Exam Less than 1 cm usually not palpable
½ of all nodules detected by ultrasonography not detected by physical exam Should also examine for lymphadenopathy

9 Physical Exam Smooth or nodular Diffuse or localized Soft or hard
Mobile or fixed Painful or non-tender

10 Laboratory TSH Serum calcitonin if family hx of medullary thyroid carcinoma Do not use thyroid function tests to differentiate benign from malignant

11 Radiology Ultrasound to document size, location, and character of nodule To determine changes in size of nodules over time or to detect recurrent lesions U/S guided biopsy decreases the incidence of indeterminate specimens

12 Radiology Thyroid scan
Can not reliably distinguish benign from malignant nodules Cold nodules – 5-15% are malignant Hot nodules – almost always benign

13 Fine Needle Aspiration
Should be 1st test in the euthyroid patient Sensitivity 68-98% Specificity % False negative rate 1-11% False positive rate 1-8% Sampling errors in very large and very small nodules – minimized by u/s guided biopsy

14

15 Treatment Surgical treatment indications Malignancy
Indeterminate cytology and suspicious H&P Indeterminate cytology and “cold nodule” Toxic nodules (suppression of TSH, symptoms – a-fib) – can use radioactive iodine or surgery Repeated recurrence of cystic lesions

16 Treatment Benign biopsies – can be followed without surgery and monitored q 6 months by physical exam, u/s Surveillance – change in nodule size and symptoms – repeat FNA if nodule grows.

17 Suppression treatment
Post-operative suppression treatment following resection of cancer TSH should be maintained for target of 0.5 mU per L Greater suppression for high risk patients, metastatic or locally invasive not completely removed

18 Suppression treatment
For benign solitary nodule controversial Follow at 6 month intervals Thyroxine to suppress TSH to 0.1 to 0.5 mU per L for 6-12 months After 12 months, maintain TSH in low normal range

19 Incidental Nodule on U/S
Most are benign and can be monitored without further testing FNA if nodule becomes palpable findings suggestive of malignancy on u/s larger than 1.5 cm Hx of head or neck irradiation Strong family hx of thyroid cancer

20 Case 44 y.o. woman, 2 cm nodule palpable in left lobe of thyroid gland at annual exam – smooth, non-tender. No lymphadenopathy TSH ordered – normal Thyroid u/s – confirms 2 cm nodule, solid FNA - benign

21 Case Repeat U/S at 1 year – nodule now 2.5 cm in size
Repeat FNA – benign Could consider suppression therapy, or continue to follow.


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