Dimyati Achmad
Introduction
Diagnostic Procedure
The Management
Introduction
Is a discrete lesion within the thyroid gland that is palpably
and/or ultrasonographically distinct from the surrounding
thyroid parenchyma.
Thyroid incidentalomas
Non palpable nodules are easily seen on ultrasound or
other anatomic imaging studies.
Palpable solitary nodules of the thyroid gland :
USA UK
WOMEN 6.4 % 1.5 %
MEN 5.3 % 0.8 %
• Nodules must approach 1 cm in diameter to be recognized on
palpation.
• + 50 % of 60 years old persons have thyroid nodules.
Castro MR. 2005; ATA 2006 ; Wartofsky L. 2008
Generally, only nodules larger than 1 cm should be
evaluated, because they have the potential to be
clinically significant cancers.
MALIGNANT THYROID
BENIGN THYROID LESIONS
NEOPLASMS
Colloid nodule
Thyroiditis Papillary carcinoma
Thyroid cyst Follicular carcinoma
Hemiabenetic thyroid Medullary thyroid carcinoma
Follicular adenoma Anaplastic carcinoma
Teratoma Metastatic carcinoma
Lipoma Sarcoma
C-cell adenoma Lymphoma
George L. A. 1997; Wartofsky L. 2008
1. PTC 80 – 85%
2. FTC 10 – 15%
3. ATC/MTC 3 – 5%
Malignant
85 – 95 %
Benign
BENIGN ( 85 – 95% )
MALIGNANT ( 5 – 15 % )
The Management ? Controversial
Diagnostic Procedure
• Clinical Examination
• Serum Thyrotropin (TSH) level
• Thyroid Neck Sonography (US)
• Fine Needle Aspiration Cytology (FAC)
Thyroid Nodule
Clinical Exam
No Suspicious
Suspicion for Malignancy
Suspicious for malignancy :
• Gender : Male , Age : < 20 years or > 60 years
• Prior head and neck irradiation during childhood
• Family history of thyroid carcinoma
• Rapid growth, hoarness
• Hard and irregular consistency
• Fixation of the nodule to extrathyroidal tissues
• Ipsilateral cervical lymhadenopathy
Serum TSH Level
Measurement of serum TSH is indicated to
rule out the presence of underlying thyroid
disorders ( hypo or hyperthyroidism )
• Low
• Normal/High
Measurement of serum Thyroglobulin (Tg) has no role
in the diagnostic evaluation of thyroid nodules
Thyroid Nodule
No Suspicious
Clinical Exam
Suspicion for Malignancy
Serum TSH
Level
Low Normal/High
Radionucleid Thyroid Neck
Thyroid Scan Sonography
Suspicious for Malignancy
• Solid Hypoechogenicity nodule
• Microcalcification
• Absence of peripheral Halo
• Irregular borders
• Taller than wide shape
Sonographic Pattern Estimated Risk of Malignancy
High Suspicion > 70 – 90 %
Intermediate Suspicion 10 – 20 %
Low Suspicion 5 – 10 %
Very Low Suspicion <3%
Benign <1%
Wartofsky L. 2008
• Computed tomography ( CT )
• Magnetic resonance imaging ( MRI )
• Positron emission tomography ( PET )
are not indicated as routine procedure may be required in
selected patients with clinical evidence of local extension
or of distant metastases
Thyroid
Sonography
High Intermediate Low Very Low Benign
Suspicion Suspicion Suspicion Suspicion
Fine Needle Aspiration Cytology
Thyroid Sonography FAC
• High/Intermediate Suspicion Pattern Size of Nodule > 1 cm
• Low Suspicion Pattern > 1,5 cm
• Very Low Suspicion Pattern > 2 cm
Thyroid
Sonography
High Intermediate Low Very Low Benign
Suspicion Suspicion Suspicion Suspicion
FAC : FAC : FAC :
> 1 cm > 1,5 cm > 2cm
The results of FAC exam ( The Bethesda System)
• Non Diagnostic or Unsatisfactory
• Benign
• Atypia of undetermined significance or follicular lesion of
undeterminated significance ( AUS / FLUS )
• Follicular neoplasm or suspicious for a follicular neoplasm
( FN/FSN )
• Suspicious for malignancy
• Malignancy
The Management
FAC
Non Benign AUS / FN/FSN Suspicion Malignancy
Diagnostic FLUS
Repeat TSH Lobectomy Lobectomy or
FNA Suppression Block Paraffin Total
or Completion Thyroidectomy
Thyroidectomy Thyroidectomy
Thyroid Nodule
• Clinical Examination : No Suspicion
• Thyroid Sonography : Benign
• FAC : No FAC
• Size / Unilateral : 1,5 cm
TSH Suppression : Levothyroxin
6 Months ( USG )
Response TSH Supp.
No Response Lobectomy
Thyroid Nodule
• Clinical Examination : No Suspicion
• Thyroid Sonography : Benign
• FNA : No FNA
• Size / Unilateral : 2 cm
No TSH Suppression
Lobectomy
Thyroid Nodule
• Clinical Examination : No Suspicion
• Thyroid Sonography : Benign
• FNA : No FNA
• Size / Unilateral : 8 cm
No TSH Suppression
Isthmolobectomy
Thyroid Nodule
• Clinical Examination : Suspicious for
Malignancy
• Thyroid Sonography : Intermediate Suspicion
Pattern
• FNA : AUS / FLUS
• Size / Unilateral : 5 cm
Lobectomy / Isthmolobectomy Block Paraffin
Positive Malignant : Completion Thyroidectomy
Thyroid Nodule
• Clinical Examination : Suspicious for
Malignancy
• Thyroid Sonography : Intermediate Suspicion
Pattern
• FNA : FN/FSN
• Size / Unilateral : 6 cm
Lobectomy / Isthmolobectomy Block Paraffin
Positive Malignant : Completion Thyroidectomy
Thyroid Nodule
• Clinical Exam. : Suspicious for malignancy
• Thyroid Sonography : High Suspicion Pattern
• FNA : Suspicious for
malignancy
• Size / Unilateral : 5 cm
Lobectomy / Isthmolobectomy Block Paraffin
Malignant : Completion Thyroidectomy
Thyroid Nodule
• Clinical Examination : Suspicious for
Malignancy
• Thyroid Sonography : High Suspicion Pattern
• FAC : Malignant
• Size / Unilateral : 2 cm
ATA
Guidelines
Thyroid
2015
PERSONALIZED TREATMENT
LOBECTOMY
Thyroid Nodule
• Clinical Examination : Suspicious for
Malignancy
• Thyroid Sonography : High Suspicion Pattern
• FAC : Malignant
• Size / Unilateral : 5 cm
ATA
Guidelines
Thyroid
2015
TRADITIONAL PARADIGM
PERSONALIZED TREATMENT
TOTAL THYROIDECTOMY
Neck sonography features of Lymph nodes, predictive of malignant
involvement
Sign Reported Sensitiviy % Reported Specificity %
MIcrocalcification 5 – 69 93 - 100
Cystic aspect 10 - 34 91 - 100
Peripheral Vascularity 40 - 86 57 - 93
Hyperechogenicity 30 – 87 43 - 95
Round Shape 37 70
Haugen ,BR (ATA) 2015
• Clinical Examination : Suspicious for
Malignancy
• Thyroid Sonography : High Suspicion
Pattern
• Neck Sonography : Cystic Aspect and
Peripheral
Vascularity
• FAC Thyroid : Malignant
• Size/ Unilateral : 5 cm
• Lymph Nodes : Level III, 2 and 4 cm
Thyroid : Total Thyroidectomy
Lymph Nodes : Open Biopsy
( Frozen Section )
Positive Malignancy
Right RND
• Lobectomy / Isthmolobectomy
No Levothyroxin Subtitution
Thyroid Neck Sonography ( every years )
Thyroglobulin / Anti Thyroglobulin Antibody Level
• Total Thyroidectomy
Thyroid Remnant Ablation
Thyroglobulin / Anti Thyroglobulin Antibody Level
TSH Suppression / Levothyroxin Substitution
Thyroid Neck Sonography ( every years )
Whole Body Scanning ( 18 Mo. )
FDG - PET Scan.
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