Management of Solitary Cold Thyroid Nodule

8/6/2019 Management of Solitary Cold Thyroid Nodule

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Management of SolitaryManagement of SolitaryCold Thyroid NoduleCold Thyroid Nodule

((A RetroA Retro-- & Prospective Study)& Prospective Study)ByBy

Abdullah MohamedAbdullah MohamedEzzatEzzatFakhrFakhrElEl--DinDin

SupervisorsSupervisors

Prof. Dr.Prof. Dr. MohamedMohamed KadryKadry MohamedMohamed KadryKadryProfessor of General SurgeryProfessor of General Surgery

Prof. Dr.Prof. Dr. MagdiMagdi HassanHassan ElEl--ShahawiShahawiProfessor of Surgical OncologyProfessor of Surgical Oncology


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The solitary thyroid nodule isThe solitary thyroid nodule is

defined as a discrete palpabledefined as a discrete palpable

swelling in an otherwise impalpableswelling in an otherwise impalpablegland.gland.

It is a clinical diagnosis. Many ofIt is a clinical diagnosis. Many ofthese cases prove to be multithese cases prove to be multi--

nodular but presenting as a singlenodular but presenting as a single

thyroid nodule.thyroid nodule.


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The incidence of solitary thyroid nodule isThe incidence of solitary thyroid nodule is

about 4%about 4%

Females are more affected than males (4:1)Females are more affected than males (4:1)Commonest in the age group between 21Commonest in the age group between 21--4040

yearsyears

Malignancy is found in about 8Malignancy is found in about 8--10% of these10% of thesenodulesnodules

The chance of malignancy in the solitary coldThe chance of malignancy in the solitary cold

thyroid nodule is 15thyroid nodule is 15--20%20%


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AnatomyAnatomy


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Anatomy ofthe thyroid

gland


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Simple (colloid) noduleSimple (colloid) nodule

Autonomous (toxic) noduleAutonomous (toxic) nodule

Inflammatory nodule:Inflammatory nodule:AcuteAcute thyroiditisthyroiditis

GranulomatousGranulomatous thyroiditisthyroiditis

AutoimmuneAutoimmune thyroiditisthyroiditis

RiedelRiedelss thyroiditisthyroiditis

CystsCysts

Pathology of the Solitary Thyroid Nodule:Pathology of the Solitary Thyroid Nodule:


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NeoplasticNeoplastic nodule:nodule:

Epithelial tumors:Epithelial tumors:Follicular adenomaFollicular adenoma

Papillary carcinomaPapillary carcinoma

Follicular carcinomaFollicular carcinomaHHrthlerthle cell (cell (oncocyticoncocytic) tumors) tumors

Clear cell tumorClear cell tumor

Squamous cell,Squamous cell,

mucinousmucinous

and related tumorsand related tumors

Poorly differentiated carcinomaPoorly differentiated carcinoma

Undifferentiated carcinomaUndifferentiated carcinoma

Medullary carcinomaMedullary carcinoma

Lymphoid tumors and tumor likeLymphoid tumors and tumor likeconditionsconditions

Metastatic tumorsMetastatic tumors


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Clinical examinationClinical examinationLaboratory studiesLaboratory studies

Radiological studies:Radiological studies:

Neck ultrasonographyNeck ultrasonographyIsotope scanning of the thyroidIsotope scanning of the thyroid

CT scanCT scan

Histopathological studies:Histopathological studies:

Fine needle aspiration cytologyFine needle aspiration cytology

Frozen sectionFrozen section

Final histopathological examinationFinal histopathological examination

Diagnostic Tools of Solitary Thyroid NoduleDiagnostic Tools of Solitary Thyroid Nodule


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Benefits:Benefits:

Detection ofDetection of multinodularitymultinodularityDifferentiates texture of the nodule (cysticDifferentiates texture of the nodule (cystic vsvs solid andsolid andhomogenoushomogenous vsvs heterogeneous)heterogeneous)

Detects and follows the size of the noduleDetects and follows the size of the nodule

Detection of thyroid calcificationDetection of thyroid calcification

Exploration of the neck for enlarged lymph nodesExploration of the neck for enlarged lymph nodesGuidance of FNAGuidance of FNA

Color Doppler sonography in malignancy predictionColor Doppler sonography in malignancy prediction

Disadvantages:Disadvantages:Operator dependentOperator dependentDoes not clearly delineate anatomy between thyroidDoes not clearly delineate anatomy between thyroidand adjacent structuresand adjacent structures

Cannot diagnose malignancyCannot diagnose malignancy

Thyroid UltrasonographyThyroid Ultrasonography


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Appearance of thyroid carcinoma onAppearance of thyroid carcinoma onthyroid scan:thyroid scan:

No change.No change.

Enlargement of the lobe without alterationEnlargement of the lobe without alterationin the apparent activity.in the apparent activity.

Encroachment on the edge of the lobeEncroachment on the edge of the lobe

(benign lesion tend to displace rather than(benign lesion tend to displace rather thanencroach on the lobe).encroach on the lobe).

Presents as cold area within the lobe.Presents as cold area within the lobe.

Isotope Scanning of the Thyroid GlandIsotope Scanning of the Thyroid Gland


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Disadvantages:Disadvantages:

Radiation exposureRadiation exposure

Difficult to detect lesions in theDifficult to detect lesions in the

periphery orperiphery or isthumusisthumus

Normal tissue over nonfunctioningNormal tissue over nonfunctioning

nodule may mask findingsnodule may mask findingsCannot diagnose malignancyCannot diagnose malignancy


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Fine Needle Aspiration and CytologyFine Needle Aspiration and Cytology

Benefits:Benefits:

Simple, safe, painless, well toleratedSimple, safe, painless, well tolerated

procedure and can be repeated manyprocedure and can be repeated manytimes when neededtimes when needed

Enables definite diagnosis ofEnables definite diagnosis of

malignancymalignancy

Diagnostic accuracy is more than 90%Diagnostic accuracy is more than 90%


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Limitations:Limitations:

Technical difficulties including samplingTechnical difficulties including samplingerror, inadequate preparation of theerror, inadequate preparation of the

aspirate, and interpretation errorsaspirate, and interpretation errors

False positive resultsFalse positive results

False negative resultsFalse negative results

Less reliable for cystic lesionsLess reliable for cystic lesions

Differentiation between follicular adenomaDifferentiation between follicular adenoma

and well differentiated carcinomaand well differentiated carcinoma


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Cytological InterpretationCytological Interpretation

Positive malignancy: Malignant cells arePositive malignancy: Malignant cells are

presentpresent

Suspicious: In presence of nuclearSuspicious: In presence of nuclear atypiaatypiaandand hypercellularityhypercellularity

Negative: No evidence of malignant cellsNegative: No evidence of malignant cells

Unsatisfactory: Inadequate specimen forUnsatisfactory: Inadequate specimen for

interpretationinterpretation


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Indications of surgical resection ofIndications of surgical resection of

thyroid nodule influenced by FNACthyroid nodule influenced by FNACAll proven malignant nodulesAll proven malignant nodules

AllAll cytologicallycytologically diagnosed folliculardiagnosed follicular

neoplasmsneoplasmsAll lesions exhibiting an atypical but nonAll lesions exhibiting an atypical but non--diagnostic cellular pattern on cytologydiagnostic cellular pattern on cytology

Cystic nodules which recur followingCystic nodules which recur followingaspirationaspiration

When on clinical grounds, suspicion ofWhen on clinical grounds, suspicion of

malignancy is high even if the cytologymalignancy is high even if the cytologyreport suggests benign diseasereport suggests benign disease


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Findings that may increase risk ofFindings that may increase risk of

malignancy in thyroid nodulesmalignancy in thyroid nodules

Solitary cold noduleSolitary cold nodule

Male sex, age >40 yearsMale sex, age >40 years

Rapidly enlargingRapidly enlargingHoarseness orHoarseness or dysphagiadysphagia

History of neck irradiation, family history of thyroidHistory of neck irradiation, family history of thyroidcarcinomacarcinoma

Inherited tumor syndromes e.g. MEN type IIInherited tumor syndromes e.g. MEN type II

Irregular, hard, fixed, ill defined marginsIrregular, hard, fixed, ill defined margins

IpsilateralIpsilateral lymphadenopathy or distant metastaseslymphadenopathy or distant metastases

HypoechoicHypoechoic nodule or cyst >4 cm or complex cystnodule or cyst >4 cm or complex cystMicrocalcificationsMicrocalcifications

Vascular or capsular invasionVascular or capsular invasion


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Treatment of the Solitary ColdTreatment of the Solitary Cold

Thyroid NoduleThyroid NoduleNonNon--Surgical:Surgical:

No treatment, just followNo treatment, just follow--up by FNACup by FNAC

Hormone suppressive therapyHormone suppressive therapyAspiration of a cystAspiration of a cyst

Ethanol injectionEthanol injection

Recently, Laser photocoagulationRecently, Laser photocoagulationSurgical:Surgical:

IsthmoIsthmo--lobectomylobectomy

Near totalNear total thyroidectomythyroidectomyTotalTotal thyroidectomythyroidectomy


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Indications for TotalIndications for Total ThyroidectomyThyroidectomyHighHigh--risk patients with highrisk patients with high--risk tumorrisk tumor

Young patients with bulky nodal disease requiringYoung patients with bulky nodal disease requiringRAI ablationRAI ablation

Patients with:Patients with:

Gross disease in both lobes of the thyroidGross disease in both lobes of the thyroid

GrossGross extrathyroidalextrathyroidal tumor requiring RAI ablationtumor requiring RAI ablation

Preoperative diagnosis of poorly differentiatedPreoperative diagnosis of poorly differentiatedtumortumor

Medullary thyroid carcinomaMedullary thyroid carcinoma

Thyroid cancer with history of radiationThyroid cancer with history of radiation

OperableOperable anaplasticanaplastic thyroid carcinomathyroid carcinoma

Distant metastasis requiring RAI ablationDistant metastasis requiring RAI ablation


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HypoparathyroidismHypoparathyroidism

Recurrent laryngeal nerve injuryRecurrent laryngeal nerve injury

Superior laryngeal nerve injurySuperior laryngeal nerve injury

Air way obstruction:Air way obstruction:

RRecurrent laryngeal nerve injuryecurrent laryngeal nerve injury

CervicalCervical haematomahaematoma

LaryngealLaryngeal oedemaoedema

TracheomalaciaTracheomalacia

Thyroid insufficiencyThyroid insufficiency

StitchStitch granulomagranuloma

Thoracic duct injury andThoracic duct injury and chylouschylous leakageleakage

Scar complicationsScar complications

Infectious complicationInfectious complication

PneumothoraxPneumothorax

Miscellaneous anatomical complicationsMiscellaneous anatomical complications

Complications ofComplications of ThyroidectomyThyroidectomy


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Material and MethodsMaterial and Methods


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Fifty patients presented, to theFifty patients presented, to the

Surgical Oncology Department inSurgical Oncology Department inthe National Cancer Institute, withthe National Cancer Institute, with

clinically palpable single thyroidclinically palpable single thyroidnodule which proved to be cold bynodule which proved to be cold by

thyroidthyroid scintigraphyscintigraphy, will be the, will be thematerial of the present studymaterial of the present study


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All patients were subjected to:All patients were subjected to:

History and clinical examinationHistory and clinical examination

Laboratory investigations including T3, T4,Laboratory investigations including T3, T4,

TSH estimationTSH estimation99m99mTcTc pertechnatatepertechnatate thyroid scanthyroid scan

Neck ultrasonographyNeck ultrasonography

CXR, abdominal ultrasonography forCXR, abdominal ultrasonography formalignant casesmalignant cases

PrePre--operative FNACoperative FNAC

Histopathological examinationHistopathological examination

Sensitivity, Specificity and Accuracy of FNACSensitivity, Specificity and Accuracy of FNAC

were calculated by comparing cytologywere calculated by comparing cytologyresults with histopathological resultsresults with histopathological results


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ResultsResults


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Female82.0%

Male18.0%

Sex Distribution


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Age distributionAge distribution

Item No. %

Age (years)


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Clinical presentation of the solitary thyroid noduleClinical presentation of the solitary thyroid nodule

Item No. %Main symptom:Neck swellingPain

Dysphagia/DyspneaVoice changeToxic manifestation(s)

481

100

96.02.0

2.00.00.0

Signs:Consistency:

FirmHardCystic

3695

72.018.010.0

Movement with deglutation:Movable

Fixed

47

3

94.0

6.0Cervical lymph node enlargement:AbsentPresent

446

88.012.0


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PrePre--operative fine needle aspiration cytology resultsoperative fine needle aspiration cytology results

Item No. %

Benign

MalignantSuspiciousUnsatisfactory

26

13101

52.0

26.020.0

2.0

Total 50 100.0


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Histopathology resultsHistopathology results

Item No. %

Colloid nodule

Adenoma

CystPapillary carcinoma

Follicular carcinoma

Medullary carcinomaAnaplastic carcinoma

Thyroiditis

15

17

37

3

23

0

30.0

34.0

6.014.0

6.0

4.06.0

0.0

Total 50 100.0


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Incidence of malignancy according to histopathology resultsIncidence of malignancy according to histopathology results

Benign nodules70.0%

Malignant nodules30.0%


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Present40.0%

Absent60.0%

Incidence of cervical lymph nodes metastases amongIncidence of cervical lymph nodes metastases among

malignant nodulesmalignant nodules

Present


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Incidence of distant metastases among malignant nodulesIncidence of distant metastases among malignant nodules

Present26.7%

Absent73.3%


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Management of cases with solitary cold thyroid noduleManagement of cases with solitary cold thyroid nodule

Item No. %

Right hemithyroidectomy

Left hemithyroidectomy

Subtotal thyroidectomy

Total thyroidectomyOthers*

15

18

3

104

30.0

36.0

6.0

20.08.0

Adjuvant therapy:

No adjuvant therapy

Radioactive iodine

Radiotherapy

Chemo-irradiation

40

81

1

80.0

16.02.0

2.0

* Others include no treatment, tracheostomy or

pain killers


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One year followOne year follow--up of cases under studyup of cases under study

Free80.0%

Rec.

2.0%

Hypoparath

4.0%

R.L.N injury

6.0%

Mortality

8.0%


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Reliability of FineReliability of Fine--Needle Aspiration and CytologyNeedle Aspiration and Cytology

in the Diagnosis of Solitary Cold Thyroid Nodulesin the Diagnosis of Solitary Cold Thyroid Nodules

HistopathologyPre-operative cytology

Benign MalignantBenign (26) 25 1

Malignant (13) 0 13

Suspicious (10) 9 1Unsatisfactory (1) 1 0

Total 35 15


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Accuracy of FNAC:Accuracy of FNAC:

SensitivitySensitivity = 93.3%= 93.3%

SpecificitySpecificity = 73.5%= 73.5%

AccuracyAccuracy = 79.6%= 79.6%

Positive predictive valuePositive predictive value = 60.9%= 60.9%

Negative predictive valueNegative predictive value = 96.1%= 96.1%False positive fractionFalse positive fraction = 39.1%= 39.1%

False negative fractionFalse negative fraction = 3.8%= 3.8%


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ConclusionConclusion

On the basis of this study we concluded theOn the basis of this study we concluded the


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On the basis of this study, we concluded theOn the basis of this study, we concluded the

followings:followings:

FNAC is a safe, highly sensitive screeningFNAC is a safe, highly sensitive screeningtest for thyroid cancer in patients with solitarytest for thyroid cancer in patients with solitary

cold thyroid nodule and should lead tocold thyroid nodule and should lead torecommendation ofrecommendation of thyroidectomythyroidectomy in thisin thisgroup, however, its specificity is relatively lowgroup, however, its specificity is relatively low

in excluding the question of malignancyin excluding the question of malignancyThe presence of clinically suspicious solitaryThe presence of clinically suspicious solitarythyroid nodule especially if solid bythyroid nodule especially if solid by

ultrasonography, cold byultrasonography, cold by scintigraphyscintigraphy withwithpositive cytology is an indication of surgicalpositive cytology is an indication of surgicalinterventionintervention


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Management of Solitary Cold Thyroid Nodule

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