Management of the Thyroid Nodule Neil S Tolley MD FRCS DLO St Mary’s Hospital 28 th February 2002

Thyroid Nodule Malignant Disease – rare, <1% all malignancies. Only 15% mortality. Malignant Disease – rare, <1% all malignancies. Only 15% mortality. Benign Disease – Common. 15% have a goitre. 7% palpable. Over 8000 Thyroidectomies per annum in the uk. Benign Disease – Common. 15% have a goitre. 7% palpable. Over 8000 Thyroidectomies per annum in the uk.

Thyroid Nodule Autopsy - 37% have nodules, 12% solitary Autopsy - 37% have nodules, 12% solitary 5% have a clinically apparent solitary nodule 5% have a clinically apparent solitary nodule Overall incidence of malignancy is between 10-30% Overall incidence of malignancy is between 10-30% UK 3,000/annum & 250 deaths UK 3,000/annum & 250 deaths Deaths (anaplastic, medullary). Differentiated cancer death rate is relatively low Deaths (anaplastic, medullary). Differentiated cancer death rate is relatively low

Thyroid Nodule Clinician has to be surgically selective Clinician has to be surgically selective Epidemiology Epidemiology History History Examination Examination Investigations Investigations

Thyroid Nodule Papillary – 80%, 80% multicentric. Seen in children. Nodes (60%), 20% Lung metastases at presentation, Bone rare Papillary – 80%, 80% multicentric. Seen in children. Nodes (60%), 20% Lung metastases at presentation, Bone rare Follicular – 15% focal, older age (6 th decade) Nodes (10%), Lung & Bone (20-30%) Follicular – 15% focal, older age (6 th decade) Nodes (10%), Lung & Bone (20-30%) Medullary – 4% Medullary – 4% Anaplastic – 2% Anaplastic – 2% Others – Hurthle, Lymphoma, Sarcoma, SCC, Others – Hurthle, Lymphoma, Sarcoma, SCC, Secondaries (breast, lung & kidney) Secondaries (breast, lung & kidney)

Thyroid Nodule - Epidemiology Papillary more common with DXT history Papillary more common with DXT history Incidence of Thyroid cancer 50% if received low dose DXT ( rads) T&A’s, Thymus, Skin problems Incidence of Thyroid cancer 50% if received low dose DXT ( rads) T&A’s, Thymus, Skin problems Belarus/Ukraine increased fold Belarus/Ukraine increased fold Follicular Iodine deficiency Follicular Iodine deficiency Lymphoma Hashimoto’s Lymphoma Hashimoto’s

Thyroid Nodule – History/Examination Rapid growth, Fixed, Hard Rapid growth, Fixed, Hard Vocal cord palsy Vocal cord palsy Recurrent cystic nodule Recurrent cystic nodule Age – very young or old Age – very young or old Neck node metastases Neck node metastases Sudden change in size of a thyroid nodule Sudden change in size of a thyroid nodule

Thyroid Nodule – investigations Haematological – TFT’s, Autoantibodies, Calcitonin, RET-proto-oncogene Haematological – TFT’s, Autoantibodies, Calcitonin, RET-proto-oncogene Radiology – USS, TC99m or Iodine131 Radiology – USS, TC99m or Iodine131 FNAC FNAC CT/MRI CT/MRI

Thyroid Nodule – USS 20% Solid, 5% Cystic - Malignant 20% Solid, 5% Cystic - Malignant Papillary – Cloudy/Punctate (Psammoma bodies). Areas cystic necrosis common. Nodes may show calcification, can be solid or entirely cystic (chocolate cysts) Papillary – Cloudy/Punctate (Psammoma bodies). Areas cystic necrosis common. Nodes may show calcification, can be solid or entirely cystic (chocolate cysts) Follicular – Rarely cystic. Amorphous calcification Follicular – Rarely cystic. Amorphous calcification Medullary – Coarse or Psammomatous calcification. 50% neck or mediastinal involvement. 33% Familial Medullary – Coarse or Psammomatous calcification. 50% neck or mediastinal involvement. 33% Familial Hashimoto’s – rarely necroses Hashimoto’s – rarely necroses

Thyroid Nodule Cold Nodules 20% malignant 5% hot Cold Nodules 20% malignant 5% hot FNAC – incidence of thyroid cancer in surgical specimens may reach 29% FNAC – incidence of thyroid cancer in surgical specimens may reach 29% Sensitivity 86% Sensitivity 86% Specificity 84% Specificity 84% Negative predictive value 97% Negative predictive value 97%

Thyroid Nodule Risk assessment – patient and tumour factors Risk assessment – patient and tumour factors Low risk – papillary, age < 45yrs, tumour < 4cm Low risk – papillary, age < 45yrs, tumour < 4cm High risk – Follicular, age > 45 yrs, tumour > 4cm High risk – Follicular, age > 45 yrs, tumour > 4cm Mortality 2% low, 45% high 15% intermediate Mortality 2% low, 45% high 15% intermediate

Thyroid Nodule A nodule > 3cm with Follicular cells has a 30% chance of malignancy A nodule > 3cm with Follicular cells has a 30% chance of malignancy Nodule 2-3cm observe, repeat USS and FNAC Nodule 2-3cm observe, repeat USS and FNAC Is this for the GPSI? Is this for the GPSI? Education yes – appropriate pre-assessment investigations can be requested, Bloods, USS & FNAC. Education yes – appropriate pre-assessment investigations can be requested, Bloods, USS & FNAC. Refer to ENT in the forum of a combined Thyroid clinic Refer to ENT in the forum of a combined Thyroid clinic The GPSI can be used to promote Thyroid surgery as a domain for the ENT surgeon The GPSI can be used to promote Thyroid surgery as a domain for the ENT surgeon