Thomas H. Brix, MD Ph.d

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Udredning og behandling af knude(er) i thyreoidea

• Thomas H. Brix, MD Ph.d
• Department of Endocrinology and Metabolism, M
• Odense University Hospital
• Odense, Denmark

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Case stories
Jan, er 55 år, ryger 20 cig. Dgl. Henvender sig
med periodevis åndedræts besvær, tør hoste samt
besvær med at synke Obj. Mindre struma, mest
udtalt på vs side. Er der behov for udredning /
behandling? Og hvilken?
Linda, er 21 år. Henvender sig med pludselig
opstået øm hævelse på halsen, kvælningsfornemmelse
, periodevis urolig mindre vægttab Obj. Knude i
vs thyr. lap, øm. Er der behov for udredning /
behandling?, Hvilken?
Jette, er 65 år, ex-ryger. Kommer sjældent i
praksis. Kommer nu til heldbreds tjek. Ingen
organrelaterede klager Obj. Mindre
struma. Problem er der behov for udredning /
behandling? Hvilken?
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The take home message

• Simple nodular goiter (SNG) is very common in
  Denmark
• The etiology of SNG is multifactorial
• The diagnostic evaluation is complex and
  includes
• Clinical examination
• Laboratory investigation
• Some kind of imaging ultrasound and
  scintigraphy
• Fine-needle aspiration
• The cornerstone in the diagnostic evaluation is
  to rule out malignancy and to characterize the
  functional and morphological status of the
  gland/nodule in order to offer the optimal
  treatment
• Most patients need no treatment after malignancy
  is ruled out

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Agenda

1. Introduction
2. Diagnostic algorithm
3. Treatment

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Introduction
Nodular goiters are clinically recognizable
enlargements of the thyroid gland
In the absence of thyroid dysfunction, autoimmune
thyroid disease, thyroiditis, and malignancy this
constitute an entity named simple nodular goiter
Hegedüs et al, 2003 Endocr Rev.
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304 consecutive patients referred due to
suspicion of goitre
No goitre Diffuse goitre Solitary nodule Multi-nodular goitre Thyroid cyst Thyroid cancer
N 35 16 99 138 14 2
Women Men 31 4 16 0 80 19 121 17 13 1 2 0
Age (yr) 46 (20-73) 39 (15-58) 48 (22-85) 56 (17-94) 45 (30-56) 64 (54-74)
Thyroid volume (ml) 12 (6-25) 34 (10-62) 30 (11-134) 50 (7-470) 18 (12-73) 138 (56-220)
Smedegaard et al. (unpublished data)
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Epidemiology of SNG - Denmark

• Tidl. strumaoperation 1,6-2,4
• Synlig struma 2,5-4
• Ved klinisk undersøgelse 10-15
• Ved ultralyd
• forstørret kirtel 15-22
• knude gt 5 mm 30
• knude gt10 mm 17
• kirtler med flere knuder 11
• hvis struma, da knuder hos 67-89

Knudsen et al. 2000
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Introduction clinical picture
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Introduction clinical picture
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Agenda

1. Introduction
2. Diagnostic algorithm
3. Treatment

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Diagnostic algorithm

• Clinical examination
• Laboratory investigation
• Imaging
• Scintigraphy
• Ultrasound
• CT or MR
• PET
• Fine-needle aspiration

The cornerstone in the diagnostic evaluation is
to rule out malignancy and to characterize the
functional and morphological status of the
gland/nodule in order to offer the optimal
treatment if any
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Diagnostic algorithm laboratory investigations
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Diagnostic algorithm, imaging - scintigraphy
Why use scintigraphy in the diagnostic algorithm
of SNG?

• Information of functionality - Hot vs cold
• Detection of ectopic thyroid tissue
• predictive of feasibility of 131I therapy
• Measurement of thyroid iodine uptake
• Monitoring the effect of therapy

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Diagnostic algorithm, imaging - ultrasound
Why use ultrasound in the diagnostic algorithm of
SNG?

• Morphologic information - solid vs cystic nodule
• Estimation of size both glandel and nodule
• Guidance for FNAC
• Monitoring the effect of therapy
• Detection of nonpalpaple nodules

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Diagnostic algorithm - summary
Hegedüs et al, 2003 Endocr rev
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Agenda

1. Introduction
2. Diagnostic algorithm
3. Treatment

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Radiojod, kirurgi eller observation?
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Radiojod

• Toksiske sygdomme (diffus/nodøs)
• Subtoksiske sygdomme (diffus/nodøs)
• Atoksisk struma (lt100 ml)
• Thyreoideacancer (høj dosis)

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Radiojod

• Ulemper
• Langsom indsættende effekt
• Ingen effekt på kolde områder
• Forbigående thyreotoksikose
• Livslang risiko for myksødem
• Isolation til omgivelserne
• Strålebelastning
• Graviditet i 4 mdr.
• Risiko for udvikling af oftalmopati

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Kirurgi

• Stor struma
• Kold knude
• Manglende jodoptagelse i kirtlen
• Svær luftvejspåvirkning
• Svær ophtalmopati ved Graves
• Cancermistanke (afklares ved biopsi)
• Patient-ønske

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The take home message

• Simple nodular goiter is very common in Denmark
• The etiology of SNG is multifactorial
• The diagnostic evaluation is complex and
  includes
• Clinical examination
• Laboratory investigation
• Some kind of imaging ultrasound and
  scintigraphy
• Fine-needle aspiration
• The cornerstone in the diagnostic evaluation is
  to rule out malignancy and to characterize the
  functional and morphological status of the
  gland/nodule in order to offer the optimal
  treatment
• Most patients need no treatment after malignancy
  is ruled out