Management of the Thyroid Nodule

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Management of the Thyroid Nodule

• Neil S Tolley MD FRCS DLO
• St Marys Hospital 28th February 2002

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Thyroid Nodule

• Malignant Disease rare, lt1 all malignancies.
  Only 15 mortality.
• Benign Disease Common. 15 have a goitre. 7
  palpable. Over 8000 Thyroidectomies per annum in
  the uk.

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Thyroid Nodule

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

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Thyroid Nodule

• Clinician has to be surgically selective
• Epidemiology
• History
• Examination
• Investigations

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Thyroid Nodule

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

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Thyroid Nodule - Epidemiology

• Papillary more common with DXT history
• Incidence of Thyroid cancer 50 if received low
  dose DXT (800-1000 rads) TAs, Thymus, Skin
  problems
• Belarus/Ukraine increased 12-34 fold
• Follicular Iodine deficiency
• Lymphoma Hashimotos

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Thyroid Nodule History/Examination

• Rapid growth, Fixed, Hard
• Vocal cord palsy
• Recurrent cystic nodule
• Age very young or old
• Neck node metastases
• Sudden change in size of a thyroid nodule

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Thyroid Nodule investigations

• Haematological TFTs, Autoantibodies,
  Calcitonin, RET-proto-oncogene
• Radiology USS, TC99m or Iodine131
• FNAC
• CT/MRI

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Thyroid Nodule USS

• 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)
• Follicular Rarely cystic. Amorphous
  calcification
• Medullary Coarse or Psammomatous calcification.
  50 neck or mediastinal involvement. 33
  Familial
• Hashimotos rarely necroses

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Thyroid Nodule

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

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Thyroid Nodule

• Risk assessment patient and tumour factors
• Low risk papillary, age lt 45yrs,
  tumour lt 4cm
• High risk Follicular, age gt 45 yrs, tumour gt
  4cm
• Mortality 2 low, 45 high 15 intermediate

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Thyroid Nodule

• A nodule gt 3cm with Follicular cells has a 30
  chance of malignancy
• Nodule 2-3cm observe, repeat USS and FNAC
• Is this for the GPSI?
• Education yes appropriate pre-assessment
  investigations can be requested, Bloods, USS
  FNAC.
• 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