We apply the guidelines from ATA, ETA, NCCN, AME and AACE on thyroid nodules and thyroid cancer on a cased based discussion

1. Thyroid Nodules & Cancer
Jeremy F. Robles, MD, FPCP, FPSEM
Lucy E. Mamba, MD, FPCP, FPSEM

2. Thyroid Nodules &
Cancer
• Diagnostic approach to thyroid Nodules
• Fine needle aspiration Biopsy / UTZ guided
• Medical & Surgical management of nodules
• Post-Surgery Radio-iodine therapy
• Staging & Follow-up of Thyroid Cancer

3. Thyroid Nodules &
Cancer
• 2009 - American Thyroid Association (ATA)
• 2010 - Combined Guidelines
American Association of Clinical Endocrinology (AACE)
Asociazione Medici Endocrinologi (AME)
European Thyroid Association (ETA)
• 2013 - National Comprehensive Cancer Network (NCCN)

4. 30/F consulted for throat discomfort
noted 3 months prior

5. Thyroid Nodules & Cancer
ATA / AACE / AME / ETA
•History of irradiation
•Familial thyroid cancer
Pertinent •Rapid growth & hoarseness
History •Age <14 yo and >70 yo
•Male sex
•Persistent dysphagia or dyspnea
•Vocal cord paralysis
Pertinent •Lateral cervical neck lymphadenopathy
Physical •Fixation of the nodules to surrounding tissues
Examination •Location, consistency, size of nodule(s)
•Neck tenderness or pain

6. Thyroid Nodules & Cancer
What laboratory test or imaging will you order for
patients with thyroid nodule(s)?
a.) TSH & Thyroid Ultrasound
b.) Paired FT4 & TSH only
c.) Ct-scan of the neck
d.) Thyroid Sestamibi scan

7. Thyroid Nodules & Cancer
ATA AACE, AME, ETA NCCN
(2009) (2010) (2013)
Thyroid
Stimulating Yes (A) Yes (A) Yes
Hormone (TSH)
Free Thyroxine
Yes (B)
(FT4)
Thyroid
ULTRASOUND Thyroid (A) Thyroid (B)
& Neck

8. Diagnostic Approach to Thyroid Nodules
ATA 2009 Work-up of Thyroid Nodule Detected by Palpation or Imaging
Low TSH History, PE, TSH Normal / High TSH
Thyroid Scan Non Functioning Diagnostic UTZ
Hyperfunctioning
No Nodule
Nodule on UTZ
do FNAB
Evaluate &
Treat for Elevated Normal
Hyperthyroidism TSH TSH
Evaluate & FNA not
treat for needed
Hypothyroidism

9. Diagnostic Approach to Thyroid Nodules
AACE / AME / ETA
History & PE 2010
Thyroid UTZ with focus on
TSH & FT4, calcitonin ?
stratification for malignancy
Low TSH or MNG in
Nodule diameter Nodule diameter Normal TSH
iodine deficient region
<1 cm without >1 cm or <1 cm with
suspicious Hx or suspicious Hx or
suspicious UTZ suspicious UTZ
Suspicious for malignancy Normofunctioning
findings findings
by clinical or UTZ criteria or cold on thyroid scan
Follow-up No Yes
FNAB
Benign
Follicular lesion suspicious,
Surgery
Positive for Malignant cells

10. Diagnostic Approach to Thyroid Nodules
TSH + UTZ
(central & lateral neck)
Thyroid Scan
FNAB
NCCN
2013

11. Thyroid Nodules & Cancer
What laboratory test or imaging will you order for
patients with thyroid nodule(s)?
a.) TSH & Thyroid Ultrasound
b.) Paired FT4 & TSH only
c.) Ct-scan of the neck
d.) Thyroid Sestamibi scan

12. Thyroid Nodules & Cancer
Only thyroid nodules > 1 cm should be biopsied.
a.) True
b.) False

13. Sonographic Features of Interest
ATA (2009) NCCN (2013)
NODULE WITH SUSPICIOUS
SONOGRAPHIC FEATURES > 0.5 cm >/= 1 cm
NODULE WITHOUT SUSPICIOUS
SONOGRAPHIC FEATURES > 0.5 cm > 1.5 cm
SUSPICIOUS CERVICAL LYMPH NODES FNA Node &
ALL Thyroid Nodules
COMPLEX WITH SUSPICIOUS
SONOGRAPHIC FEATURES >/= 1.5 - 2 cm
COMPLEX WITHOUT SUSPICIOUS
UTZ FEATURES >/= 2 cm
SPONGIFORM NODULE
>/= 2 cm
PURELY CYSTIC NODULE FNAB NOT INDICATED
SUSPICIOUS SONOGRAPHIC FEATURES
Hypoechoic, Microcalcifications, Increased central vascularity,
Infiltrative margins, Taller than wide in transverse plane

14. Thyroid Nodules & Cancer
Only thyroid nodules > 1 cm should be biopsied.
a.) True
b.) False

15. Thyroid Nodules &
Cancer
• Diagnostic approach to thyroid Nodules
• Fine needle aspiration Biopsy / UTZ guided
• Medical & Surgical management of nodules
• Post-Surgery Radio-iodine therapy
• Staging & Follow-up of Thyroid Cancer

16. 30/F consulted for throat discomfort
noted 3 months prior
Ultrasound of the thyroid showed a
2.5 cm solid nodule on the
inferior lobe
TSH & FT4 are normal

17. Diagnosis: Nodular Non-toxic Goiter
Clinically & Biochemically Euthyroid

18. Thyroid Nodules & Cancer
- Nodules > 1 cm ( solid & hypoechoic )
- Any size on UTZ with extracapsular growth or cervical LN
metastasis
Indications for - Any size with history of neck irradiation; PTC, MTC or
FNAB MEN2 in 1st degree relatives; previous thyroid surgery for
cancer, increased calcitonin
- <1 cm with UTZ finding associated with malignancy
- hot nodules should be excluded from FNAB
- Do not biopsy hot areas on radioisotope scan
Multinodular
glands - If with cervical lymphadenopathy, biopsy both suspicious
nodule and LN
Complex - Sample solid component via UTZ guided biopsy
(solid-cystic) - Submit FNAB specimen and fluid for cytologic examination
AACE/ AME/ETA

19. Ultrasound Guided Biopsy
• Nodules < 1 cm if clinical information or
ultrasound findings are suspicious
• Nonpalpable nodules
• Predominantly cystic
• Located posteriorly in the thyroid lobe
• Repeat FNAB for nodule with initial non-
diagnostic cytology result
ATA / AACE /AME / ETA

20. Cytopathologic Diagnosis:
Suspicious for
Papillary Thyroid Carcinoma

21. Bethesda Classification of Thyroid Cytology
SUGGESTED ALTERNATE % RISK OF
CATEGORY CATEGORY MALIGNANCY
Benign <1
Atypia of Indeterminate Follicular lesions,
R/O neoplasm, atypical
undetermined Follicular Lesion, Cellular 5 - 10
significance Follicular Lesion
Neoplasm Suspicious for Neoplasm 20 - 30
Suspicious for
- 50 - 75
Malignancy
Malignant - 100
Non-Diagnostic Unsatisfactory -
2009

22. cytologic adequacy = presence of at leastsix
FNAB follicular cell groups, each containing
10–15 cells derived from at least
(ATA 2009) two aspirates of a nodule

23. Thyroid Nodules &
Cancer
• Diagnostic approach to thyroid Nodules
• Fine needle aspiration Biopsy / UTZ guided
• Medical & Surgical management of nodules
• Post-Surgery Radio-iodine therapy
• Staging & Follow-up of Thyroid Cancer

24. Thyroid Nodules & Cancer
What thyroid surgery should the patient undergo?
( Suspicious Papillary Thyroid Cancer)
a.) Lobectomy with isthmusectomy
b.) Near total thyroidectomy
c.) Total thyroidectomy
d.) Discuss with the surgeon

25. Thyroid Surgery
(Definitions)
• Total Thyroidectomy
• Removal of all grossly visible thyroid tissue
• Near Total Thyroidectomy
• Removal of all grossly visible thyroid tissue, leaving
only a small amount [<1g] of tissue adjacent to the
recurrent laryngeal nerve near the ligament of
Berry
• Subtotal Thyroidectomy
• leaving >1 g of tissue with the posterior capsule on
the uninvolved side
ATA 2009

26. Thyroid Nodules & Cancer
What thyroid surgery should this patient undergo?
( Suspicious Papillary Thyroid Cancer)
a.) Lobectomy with isthmusectomy
b.) Near total thyroidectomy
c.) Total thyroidectomy
d.) Discuss with the surgeon

27. Surgical Management for
Differentiated Thyroid Cancer
• Remove the Primary tumor
• Minimize treatment related morbidity
• Accurate staging of the disease
• Facilitate post-operative post-radioiodine
treatment, where appropriate
• Long term surveillance for disease recurrence
• Minimize risk of recurrence & metastatic
spread
ATA 2009

28. Thyroid Nodules & Cancer
What will you do if the thyroid biopsy turned out to
be Benign?
a.) Lobectomy with isthmusectomy
b.) Levothyroxine suppression
c.) Ultrasound Guided Percutaneous Ethanol
injection (PEI)
d.) Monitor the patient within 6-18 months

29. Benign Nodules
• Clinical, thyroid UTZ & TSH in 6 - 18 month
• Repeat FNAB with UTZ guidance if clinically
or with UTZ suspected features
• Repeat UTZ in cases of > 50% increase in
volume
• Consider repeat UTZ guided FNAB in
6 - 18 months even with benign initial
cytologic results
AACE/ AME/ETA

30. Thyroid Nodules & Cancer
What will you do if the thyroid biopsy turned out to
be Benign?
a.) Lobectomy with isthmusectomy
b.) Levothyroxine suppression
c.) Ultrasound Guided Percutaneous Ethanol
injection (PEI)
d.) Monitor the patient within 6-18 months

31. Levothyroxine suppression
• LT4 suppression therapy of benign thyroid
nodules in iodine sufficient populations is
not recommended.
• LT4 therapy or iodine supplementation may
be considered in young patients who live in
iodine deficient geographic areas and have
small thyroid nodules & in those who have
nodular goiters and no evidence of
functional autonomy
ATA/AACE/ AME/ETA

32. LT4 Suppression
• Avoid LT4 in patients with
• osteoporosis, CVD, systemic illness
• large thyroid nodules
• long standing goiter
• low-normal TSH levels
• postmenopausal women
• age older than 60 yo (men) AACE / AME / ETA

33. Ultrasound Guided
Percutaneous Ethanol Injection
• Effective in Benign thyroid cyst and complex
nodules with a large fluid component
• This should not be performed in solitary
solid nodules or multinodular goiter
AACE / AME / ETA

34. Surgery for Benign lesions
• Indications:
• Presence of local pressure symptoms
clearly associated with the nodule
• Previous external irradiation
• Progressive nodule growth
• Suspicious UTZ features
• Cosmetic issues
AACE / AME / ETA

35. NCCN 2013

36. Surgery for Papillary Thyroid Cancer
c For microcarcinoma (< 1cm), a total thyroidectomy may not be
needed. Age is an approximation and not an absolute determination.
NCCN 2013
dTall cell variant, columnar cell, or poorly differentiated features.

37. NCCN 2013

38. Surgery for Follicular Thyroid Cancer
NCCN 2013

39. Surgical Histopathologic Diagnosis:
Papillary Thyroid Carcinoma

40. Thyroid Nodules &
Cancer
• Diagnostic approach to thyroid Nodules
• Fine needle aspiration Biopsy / UTZ guided
• Medical & Surgical management of nodules
• Post-Surgery Radio-iodine therapy
• Staging & Follow-up of Thyroid Cancer

41. Post-operative Radioiodine
Remnant Ablation
• For patients with known distant metastases,
gross extrathyroidal extension of the tumor
regardless of tumor size, or primary tumor
size >4 cm even in the absence of other
higher risk features
• For selected patients with 1– 4cm thyroid
cancers confined to the thyroid
* LT4 withdrawal 2-3 weeks or LT3 treeatment for 2-4 weeks
and LT3 withdrawal for 2 weeks with TSH > 30 mU/L. Resume ATA 2009
LT4 therapy on 2nd - 3rd day post RAI therapy.

42. Post-operative Radioiodine
Remnant Ablation
• RAI ablation is not recommended for
patients with unifocal cancer <1 cm without
other higher risk features
• RAI ablation is not recommended for
patients with multifocal cancer when all foci
are <1 cm in the absence other higher risk
features
ATA 2009

43. Thyroid Nodules &
Cancer
• Diagnostic approach to thyroid Nodules
• Fine needle aspiration Biopsy / UTZ guided
• Medical & Surgical management of nodules
• Post-Surgery Radio-iodine therapy
• Staging & Follow-up of Thyroid Cancer

44. Postoperative (AJCC/UICC) staging
• Permit prognostication for an individual patient
• Tailor postoperative adjunctive therapy RAI
therapy / TSH suppression risk for disease
recurrence and mortality
• To make decisions regarding the frequency and
intensity of follow-up
• Accurate communication regarding a patient
among health care professionals
ATA 2009

45. ATA 2009

46. Surgical Histopathologic Diagnosis:
Papillary Thyroid Carcinoma (Stage 1),
S/P Total Thyroidectomy,
S/P Radioiodine Therapy (100 mci)

47. Differentiated Thyroid Cancer
(Long Term Management)
• Check for persistent tumor within 1st year
of treatment by
• Clinical evidence of tumor
• Imaging evidence of tumor
• Undetectable serum Tg levels during
TSH suppression and stimulation in the
absence of interfering antibodies
• --measured /monitored every 6-12 months
ATA 2009

49. TSH suppression therapy
• High-risk
• macroscopic tumor invasion,
• incomplete tumor resection
• distant metastases
• thyroglobulinemia out of proportion to
what is seen on the posttreatment scan
ATA 2009

50. TSH suppression therapy
• Intermediate-risk
• microscopic invasion of tumor into the
perithyroidal soft tissues at initial
surgery
• cervical lymph node metastases or 131I
uptake outside the thyroid bed on the
RxWBS done after thyroid remnant
ablation
• tumor with aggressive histology or
vascular invasion ATA 2009

51. TSH suppression therapy
• Low-risk
• macroscopic tumor invasion,
• incomplete tumor resection,
• distant metastases
• thyroglobulinemia out of proportion to
what is seen on the posttreatment scan
ATA 2009

52. TSH suppression therapy
• High-risk and intermediate-risk:
• TSH suppression to <0.1mU/L
• Low-risk : maintenance of the TSH = or
slightly below the lower limit of normal
(0.1–0.5mU/L)
ATA 2009

53. Thyroid Nodules & Cancer
Jeremy F. Robles, MD, FPCP, FPSEM
Lucy E. Mamba, MD, FPCP, FPSEM