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In the Name of God

In the Name of God. Thyroid Nodules. Nodular thyroid disease is a common problem Five percent are likely to be malignant Assessment for malignant potential is important. Prevalence and Incidence of Thyroid Nodules and Cancer. Prevalence Nodule % Clinical 4-7 Radiological 40

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In the Name of God

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  1. In the Name of God

  2. Thyroid Nodules • Nodular thyroid disease is a common problem • Five percent are likely to be malignant • Assessment for malignant potential is important

  3. Prevalence and Incidence of Thyroid Nodules and Cancer • Prevalence • Nodule % • Clinical 4-7 • Radiological 40 • Autopsy 50 • Carcinoma • Autopsy 5.7 • Gharib H. Current evaluation of thyroid nodules. Trends Endocrinol Metab. 1994;5:365-369.

  4. Thyroid Nodular Disease • Thyroid gland nodules are common in the general population • Palpable nodules occur in approximately 5% of the US population, mainly in women • Most thyroid nodules are benign • Less than 5% are malignant • Only 8% to 10% of patients with thyroid nodules have thyroid cancer

  5. Multinodular Goiter (MNG) • MNG is an enlarged thyroid gland containing multiple nodules • The thyroid gland becomes more nodular with increasing age • In MNG, nodules typically vary in size • Most MNGs are asymptomatic • MNG may be toxic or nontoxic • Toxic MNG occurs when multiple sites of autonomous nodule hyperfunction develop, resulting in thyrotoxicosis • Toxic MNG is more common in the elderly

  6. Prevalence and Incidence of Thyroid Nodules and Cancer • Incidence % • Nodule 0.1 • Carcinoma 0.004

  7. Nodular Thyroid Disease • The annual incidence of thyroid nodules is approximately 0.1% • The annual incidence of thyroid carcinoma is 0.004% • Thus, 1 in 20 nodules (5%) is likely to be malignant

  8. Thyroid Lesions That May Present As a Nodule • Adenoma • Carcinoma • Acute hemorrhage into thyroid • Multinodular goiter • Thyroiditis

  9. Thyroid Lesions That May Present As a Nodule • Effect of prior operation or 131-I therapy • Thyroid hemi agenesis • Cyst • Metastasis

  10. Nonthyroidal Lesions That May Present As a Nodule • Parathyroid adenoma or cyst • Thyroglossal cyst • Cystic hygroma

  11. Thyroid CancerStatistics • Incidence rose 3.8% per year, faster than any other malignancy between 1992-2001 • 8th most common cancer in women • Annual incidence 25,000; deaths 1,500 • Prevalence 300,000 CP1216465-4

  12. Thyroid cancer types Follicular cell origin C cell origin MTC PTC FTC HCC ATC Sporadic Familial FMTC MEN2A MEN2B CP1216465-5

  13. Medullary 4% Hurthle 1% Anaplastic 1% Follicular 9% Papillary 85% Thyroid CancerRelative Frequency *National Cancer Database: SEER Registry CP1216465-6

  14. Incidence: Males Incidence: Females Death: Females Death: Males Thyroid CancerIncidence and Mortality Rates/100,000 Age at diagnosis (yr) CP1216465-7

  15. Size • Type • Invasion • RAI uptake • Metastasis • Dx delay • Tx • RAI Rx • Follow-up • Age • Sex • RöRx Patient Tumor Rx Outcome CP1216465-8

  16. Invasive Microcarcinoma PTC CP1216465-9

  17. Pathological Classification of Thyroid Neoplasms • Benign • Adenoma • Follicular • A. Colloid variant • B. Embryonal • C. Fetal • D. Hurthle cell variant • Teratoma

  18. Pathological Classification of Thyroid Carcinoma • Papillary adenocarcinoma • Pure papillary • Mixed papillary and follicular • Micro carcinoma • Diffuse sclerosing

  19. Pathological Classification of Thyroid Carcinoma • Follicular carcinoma • Pure follicular • Clear cell carcinoma • Hurthle cell carcinoma

  20. Pathological Classification of Thyroid Carcinoma • Anaplastic carcinoma

  21. Pathological Classification of Thyroid Neoplasms • Medullary carcinoma • Other malignant tumors • Lymphoma • Metastatic tumor • Epidermoid carcinoma

  22. Thyroid NoduleHistory Taking • Past history of radiation, surgery? • Family history of goiter, MEA, or medullary cancer • Symptoms of hyper- or hypothyroidism? • Cardiac symptoms? • Degree of patient’s concern?

  23. Factors Which Increase the Possibility That a Nodule Is Malignant • Recent onset and growth • Compression • Young age, male sex • Familial incidence • Radiation exposure

  24. Neural crest Thyroid C cells Autonomic ganglia GI tract MTC Origin Adrenal medulla CP1216465-45

  25. Produces calcitonin Does not concentrate 131I LN metastasis occur early Patients with macrometastasis have poor prognosis Surgery is the only effective Tx MTCUnique Features CP1216465-46

  26. MEN 2B 3% FMTC 12% MEN 2A 10% Sporadic 75% MTCSubtypes CP1216465-47

  27. Face Eyelids Lips Clinical Features and MEN-2B • Marfanoid features • Ganglioneuroma CP1216465-50

  28. Multiple Endocrine Neoplasia (MEN) • Multiple clinical presentations • Multiple family members affected • Multiple endocrine glands involved • Multicentric lesions within a gland • Multiple pathologic processes (hyperplasia, adenoma, carcinoma) • Hereditary disorder CP1216465-51

  29. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 RET Characteristics Extracellular MEN2A FMTC MEN2B 532 : duplication de nucléotides Cadherin-like domain Cys 609 Cys 611 Cys 618 Cys 620 Cys 634 Cys 609 Cys 611 Cys 618 Cys 620 Cys 634 Cysteine-rich region Transmembrane domain Glu 768 790 791 Tyrosine kinase domain Val 804 883 Met 918 Ser 891 Intracellular RET protein RET exons Clin Endocrinol 61:299, 2004 CP1216465-52

  30. Thyroid NoduleExamination • Thyrotoxic, euthyroid, hypo? • Single nodule or multinodular? • Hard, fixed node? • Voice, stridor, dysphagia?

  31. Factors Which Increase the Possibility That a Nodule Is Malignant. • Hard consistency • Fixation • Enlarged lymph nodes • Vocal cord paralysis

  32. Diagnosis of Thyroid Nodules • Imaging studies • Morphologic studies • Laboratory studies

  33. Thyroid Scan • Most functioning nodules are benign, and this is the most useful finding. • Most cancers are “cold”, but so are most benign nodules.

  34. Thyroid Incidentalomas • High-resolution ultrasonography has made it possible to detect many non-palpable nodules, or “incidentalomas” in the thyroid.

  35. Thyroid Ultrasound Findings in Favor of Malignant Nodules • Hypoechoic lesions • Irregular margins • Presence of microcalcifications • Absence of halo • Internal or central blood flow

  36. Thyroid Ultrasound Findings in Favor of Malignant Nodules: Low Suspicion • Echo-free cyctic lesion • Homogeneously hyperechoic lesion

  37. Benign nodule PTC Benign node PTC node CP1216465-35

  38. Thyroid CytologyMayo Clinic 1980-1994

  39. Cytopathologic Diagnostic Categories for Thyroid Fine-needle Aspiration (FNA) Specimens • Diagnostic (satisfactory) • Benign (negative) • Suspicious (indeterminate) • Malignant (positive) • Nondiagnostic (unsatisfactory)

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