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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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