Prevalence of Endocrine Disorders in U.S. Adults01) Update on Thyroid...Prevalence of Endocrine...
Transcript of Prevalence of Endocrine Disorders in U.S. Adults01) Update on Thyroid...Prevalence of Endocrine...
Sipos 1
Update on Thyroid NodulesNew Imaging Techniques
Jennifer A. Sipos, MDAssociate Professor
Division of EndocrinologyThe Ohio State University
Prevalence of Endocrine Disorders in U.S. Adults
Endocrine Condition Prevalence
Metabolic syndrome 35-40%
Obesity 25-50%
Diabetes 5-25%
Hyperlipidemia 15-20%
Osteoporosis 7%
Thyroid nodules 30-70%
Golden SH., et al. J Clin Endo Metab 2009; 94:1853-78Mazzaferri M. New England Journal Medicine 1993; 328:553-558Guth S., et al. Eur J Clin Invest 2009; 39:699-706
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Benign Malignant
Causes of thyroid nodules
g
Multinodular goiter (colloid adenoma)
Hashimoto’s (chronic lymphocytic) thyroiditis
CystColloidSimpleHemorrhagic
F lli l d
Papillary carcinoma
Follicular carcinoma
Medullary carcinoma
Anaplastic carcinoma
Primary thyroid lymphoma
Metastatic carcinoma Follicular adenomas
Hurthle cell adenomas
breastmelanomarenal cell
Epidemiology – thyroid nodules
Autopsy/
Palpation
Autopsy/ Ultrasound
Mazzaferri 1993 NEJM 328:553-9
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How good are we at finding nodules?Ultrasound vs. Palpation
es fo
und
by U
S
50%
Brander 1992 J Clin Ultrasound 20: 37-42
# N
odul
e
94%
Nodule size by US
Palpable Thyroid Nodules
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Nonpalpable Thyroid Nodules
Not all that is palpable is a nodule…..
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American Thyroid Association Management Guidelines
Thyroid sonography should be performed in all patients with known or suspected thyroid nodules
Recommendation rating: A
Cooper, et al Thyroid 2009
Concerning Clinical Features
High clinical suspicion
• Rapid tumor growthRapid tumor growth• Very firm nodule (rock hard)• Fixation to adjacent structures• Vocal cord paresis• Enlarged regional lymph nodes• Family history of PTC or MEN 2• Distant metastases
Positive Predictive Value (PPV) – good (70-75%)
Negative Predictive Value (NPV) – unacceptable (85%)
•History of radiation exposure to the head/neck
Hamming JF., et al. Arch Int Med 1990; 150:1088Rago T., et al. Clin Endo 2007; 66:13
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History, physical
TSH
High, normal TSH Low TSH
Ultrasound
>1cm<1cm
Thyroid scan
FT4, TT3
Functioning Nonfunctioning>1cm
U/S guided FNARepeat U/S
in 6-24 mo
Functioning
“Hot”
No FNA
Rx hyperthyroidism
Nonfunctioning
“Cold/warm”
Ultrasound-guided
FNA
Imaging
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Size and composition as predictors of malignancy
Characteristic No. benign
No.malignant
% Malignant
pValue
Size (mm) 0.48
11 14 9 135 15 1011-14.9 135 15 10
15-19.9 167 16 8.7
20-24.9 149 19 11.3
25-29.9 112 11 8.9
>30 208 33 13.7
Composition <0.01
Completely solid 330 55 14 3
Frates et al 2006 JCEM 91: 3411-17
Completely solid 330 55 14.3
Predominantly solid 209 24 10.3
Mixed solid and cystic 129 8 5.8
Predominantly cystic 85 2 2.3
Completely cystic 7 0 0
US Predictors of Malignancy for Thyroid Nodules
US feature Mean sensitivity
(range)
Mean specificity
(range)
Increased flow 77 (57-92) 79 (35-97)
Irregular borders 58 (48-78) 85 (74-95)
Taller than wide 58 (33-84) 81 (60-92)
Hypoechogenicity 53 (26 87) 73 (43 94)Hypoechogenicity 53 (26-87) 73 (43-94)
Microcalcifications 42 (29-59) 91 (86-95)
*Review of 15 large studies
Sipos JA, Thyroid 2009;19:1363-1372
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Thyroid Imaging Reporting and Data System(TIRADS)
Horvath, et al. 2009 JCEM 90:1748-51
Park et al 2009 Thyroid 19: 1257-64
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Park et al 2009 Thyroid 19: 1257-64
ElastographyMeasure of tissue stiffness by application of an external force
Elastic=Benign Firm=Malignant
Meta-analysis of 8 studies (mostly European and Asian)
Lippolis PV et al. 2011 JCEM 96(11): E1826-30Bojunga et al 2010 Thyroid 20(10): 1145-50
y ( y p )
n=639 nodules
Sensitivity 92% (88-96%) Specificity 90% (85-95)
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Thyroid Imaging Reporting and Data SystemTIRADS
Russ et al 2013 Eur J Endocrinol 168: 649-55
Thyroid imaging reporting and data systemTI-RADS
Russ et al 2013 Eur J Endocrinol 168: 649-55
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TI-RADS and elastography for predicting benignity
Russ et al 2013 Eur J Endocrinol epub
PET and Thyroid Nodules
18 studies – 55,160 patients
571 (1%) with unexpected focal
Systematic Review
uptake in thyroid
322 underwent “diagnostic confirmation”
33% malignant; 4.7% “indeterminate”
Shie P 2009 Nuc Med Commun 30(9): 742-8
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Fine Needle Aspiration
Indications for FNANodule features Threshold
size for FNARecommendation
rating
HIGH RISK HISTORY
Suspicious US features
>5mm A
No suspicious US features >5mm I
Abnormal LNs All A
Microcalcifications ≥1cm B
NOT HIGH RISK-SOLID NODULE
Hypoechoic
>1cm B
Iso- or hyperechoic ≥1-1.5cm C
MIXED CYSTIC-SOLID NODULE ≥1.5-2cm BMIXED CYSTIC SOLID NODULE
Suspicious US features
1.5 2cm B
No suspicious US features ≥2cm C
Spongiform nodule ≥2cm C
Purely cystic nodule No FNA E
Cooper et al 2009 Thyroid 12:1-48
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Diagnostic yield of sequential aspirations in 120 patients with multiple nodules and cancer
FNA performed on Number of nodules >1cm
2 (n = 73) 3 (n = 27) ≥ 4 (n = 20)
Largest nodule 86.3 51.8 55
Largest 2 nodules 100 81.5 85
Largest 3 nodules 100 95
Largest 4 nodules 100
FNA of only the largest nodule in a patient with 2 nodules would have missed 13.7% of cancers. In patients with 3 nodules, 48.2% of cancers would have been missed by performing an FNA on the largest nodule only.
Frates et al 2006 JCEM 91: 3411-17
Epidemiology of Thyroid Cancer
Aschebrook-Kilfoy 2013 Cancer Epidemiol Biomark Prev 22: 1252-9
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Changing mode of diagnosis in PTMC
• FNA for thyroid nodules has more than doubled from 2006-2011
• Thyroid FNA grew as a percentage of all FNA f 49% t 65%from 49% to 65% Sosa et al 2013 Surgery epub
Hay et al 2008 Surgery 144: 980-7
Papillary microcarcinomaLikelihood of disease progression with observation
Multivariate analysis: Age <40y RR 4 348 (2 293 8 196) Age <40y RR 4.348 (2.293-8.196)
p<0.0001 T≥9mm RR 4.717 (1.961-11.364)
p=0.0005
Ito et al 2013 Thyroid epub
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Natural history—benign nodules
Of 268 benign nodules studied 89% had grown (more than 15%) at five years
Average increase in volume was 69%
Of 74 nodules re-biopsied, only one revealed malignancy
Solid nodules grew more than cystic
Alexander 2003 Ann Internal Med 138: 315-8
Follow up
Repeat U/S 6-18 months after FNA
Repeat FNA if >50% change in volume or 20% change in nodule diameter in at least twochange in nodule diameter in at least two dimensions with minimum increase of at least 2mm
Interval for the next follow-up may be every 3-5 years
Cooper et al 2009 Thyroid 19
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Indications for surgery
Malignant, suspicious, or indeterminate cytologycytology
Compressive symptoms
≥2 “insufficient” FNAs
Cosmetic
Large toxic gnodule/goiter
Graves disease
Enlarging benign nodule
From Lange Endocrinology 7th ed.