Post on 05-Aug-2020
transcript
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Thyroid Disease
James Bonucchi, DO, ECNU, FACE
CoxHealth
Disclosures
Sanofi‐Aventis speaker’s bureau.
Astra‐Zenica speaker’s bureau
BI‐Lilly speaker’s bureau.
Objectives
Thyroid nodule work up
What scans and when
Management of thyroid nodules
Thyroid cancer treatment.
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Case Presentation
54 year old female
Previous hypothyroidism
Hypertension/Hyperlipidemia
Presents to PCP with weeks of neck pain
Peri‐menopausal symptoms
With addition of BP med feeling some fatigue
Denies dysphagia or palpitations
MRI
MRI Report
C‐spine without problems
1.1 cm lesion of the right lobe of the thyroid gland is nonspecific in appearance and could represent a cyst although a solid lesion is not excluded.
Would recommend further evaluation with ultrasound or nuclear medicine thyroid scan if clinically indicated.
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What was my next next step?
Thyroid nodule work up
TSH measurement:
High or normal TSH, thyroid US next step
TSH low, radionuclide thyroid scan next step
Haugen et al, Thyroid 2016 ATA guidelines
Further Case Information
No family history of thyroid cancer
No history of radiation exposure
Clinically euthyroid
On exam, thyroid nodule not palpable but R thyroid more full than L
TSH was 2.99
Questions about the history, or other questions about the patient?
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Thyroid US
Thyroid US
US Report
The right lobe measures 3.8 x 1.3 x 1.2 cm.
0.7 x 0.6 x 0.5 cm hypoechoic nodule with calcifications. No evidence of increased color‐flow present.
The left lobe measures 2.4 x 0.9 x 0.8 cm.
Uniform echogenicity and color‐flow.
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What to do now?
Observation
Small size (5 mm)
No family history of thyroid cancer
No history of radiation exposure
TSH not elevated
BUT
Calcified
TSH upper range of normal
Solitary nodule
Further work up
Iodine scan?
Biopsy?
Repeat US?
Thyroid Nodule Patterns
Haugen et al, Thyroid 2016 ATA guidelines
Thyroid nodule work up
Haugen et al, Thyroid 2016 ATA guidelines
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When to Biopsy?
Haugen et al, Thyroid 2016 ATA guidelines
Case
7 mm nodule, solid hypoechoic with microcalcifications. Nodule is taller than wide.
‐elected to follow due to less than 1 cm in size.
6 month US
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6 month US
Right thyroid nodule, enlarged to 0.8 x 0.7 x 0.8 cm from 0.7 x 0.6 x 0.5 cm in 6 months.
Hypoechoic, taller than wide. Solid. With microcalcifations. Ill‐defined margins.
Next Step?
Iodine scan?
Biopsy?
Repeat US
Thyroid nodule FNA
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FNA results
Haugen et al, Thyroid 2016 ATA guidelines
FNA results
‐ Non diagnostic: Repeat FNA vs. surgery
‐ Benign: Observation, risk of malignancy 0‐3%.
Follow with serial US
‐ Suspicious for malignancy: 60‐75% risk (At Cox, over 90% risk) hemithyroidectomy vs. total thyroidectomy
‐Malignant: 97‐99% (at Cox 99% risk) total thyroidectomy.
FNA results
Atypia of Undetermined Significance (AUS) and Follicular Lesion of Undetermined Significance FLUS: 5‐15% risk of malignancy
Follicular neoplasm: 15‐30% risk of malignancy
Surgery, Follow‐up Imaging, Molecular testing
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Molecular testing
Papillary thyroid cancer: BRAF, RET/PTC, RAS mutations
Follicular carcinoma: RAS, PAX8, PPAR‐gamma mutations
Molecular testing
Thyroseq v3: Mutational analysis 112 genes tested: NPV: 97‐98% PPV: 64‐68%
Afirma: mRNA genomic sequencing 167 genes
NPV 96%, PPV: 47%,
ThyraMIR/ThyGenX: miRNA genes and mutational analysis. NPV 91‐97%, PPV: 68‐82%
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At Cox
Currently use Afirma for most cases
Thyroseq FDA approved for under 18.
Thyroid nodules
TSH suppression with levothyroxine not recommended.
Growing nodules >4cm on repeat FNA benign, consider surgery.
Follow most benign nodules with periodic US.
‐expect modest growth, need not repeat FNA.
Symptomatic cysts that recur after drainage, consider surgery.
Haugen et al, Thyroid 2016 ATA guidelines
Back to the case
Concerning appearing nodule, enlarging, FNA performed
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Final Path
Thyroid, right, fine needle aspiration:
Satisfactory for evaluation.
Malignant
Papillary thyroid carcinoma.
What is the next step?
Pre‐op neck US
Haugen et al, Thyroid 2016 ATA guidelines
Imaging
Consideration for CT scan with contrast should be made
risk of iodine suppression
PET scan pre‐op generally not recommended
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Thyroid surgery
With malignant FNA
After neck US, next step is thyroid surgery
‐hemithyroidecomy
‐total thyroidectomy
+/‐ central and/or lateral neck dissection
Extent of surgery
• Thyroid cancer < 1 cm in size without extra‐thyroidal extension on imaging or lymphadenopathy on imaging: Thyroid lobectomy.
• Thyroid cancer 1‐4 cm without extra‐thyroidal extension without lymphadenopathy total thyroidectomy vs hemi‐thyroidectomy for low risk tumors.
Extent of surgery
• Thyroid cancer >4 cm: total thyroidectomy
• Thyroid cancer with positive or suspect lymph nodes on imaging, total thyroidectomy with compartment neck dissection.
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Extent of surgery
• Central neck dissection recommended for disease T3, T4 or extra‐thyroidal extension
• Not recommended for most T1,T2 disease
Lateral neck
If pre‐op imaging shows concerning lymph nodes:
US guided FNA with Thyroglobulin washout. (>1 ng/ml)
Positive: lateral neck dissection recommended levels 2‐4 or involved compartment.
Back to the case
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Total Thyroidectomy
Thyroid, total thyroidectomy:Papillary carcinoma 7 mm maximal diameter.No extension beyond inked margins.
Thyroid, isthmus:Papillary thyroid carcinoma, approximately 2 mm in diameter.Margins negative.
Thyroid, left lobe:Interfollicular lymphoid aggregates, NO tumor elements identified.
Perithyroidal lymph nodes, two:No atypical features present.
Summary to this point
Incidental thyroid nodule on MRI
First US 5 mm
Repeat 6 months later 7 mm
FNA shows papillary thyroid cancer
Final path shows multifocal thyroid cancer, less than 1 cm.
How do we proceed now?
Thyroid cancer classificationAge is now 55
Haugen et al, Thyroid 2016 ATA guidelines
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Thyroid cancer risk
Haugen et al, Thyroid 2016 ATA guidelines
Thyroid cancer treatment after surgery
Radioactive iodine
TSH suppression with thyroid hormone replacement
On going surveillance
Radio‐active Iodine?
Pros vs. Cons
Ease of follow up
Secondary malignancy risk
Change in life expectancy
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ATA low risk
Radioactive iodine generally not recommended in ATA low risk patients
TSH Goal: 0.5‐2 If unstimulated Tg <0.2
0.1‐0.5 if unstimulated Tg >0.2
Haugen et al, Thyroid 2016 ATA guidelines
ATA intermediate risk
Consider remnant ablation lower dose 30 mCipreferred
TSH goal 0.1‐0.5
Haugen et al, Thyroid 2016 ATA guidelines
ATA high risk
Adjuvant ablation consider 100‐200 mCi
TSH goal <0.1
Haugen et al, Thyroid 2016 ATA guidelines
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Remnant ablation
Thyroid cancer surveillance
Unstimulated Thyroglobulin panel levels
Periodic neck ultrasounds
rTSH stimulated Thyroglobulin panel and/or whole body scan
Follow with endocrinologist for 20 years or more
Patient Update
Levothyroxine 150 mcg/d replacement therapy
Post therapy: Tg <0.2, TSH 0.28 (0.3‐5)
US no evidence of recurrence 5 years out.
Has a few benign appearing lymph nodes.
Tg remains undetectable 10 years later
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Summary
Thyroid incidentalomas are a common problem
US is the most sensitive test for thyroid nodules
Operator dependent
Thyroid scan if TSH low
Appropriate treatment of hyperthyroidism
Indications for FNA of thyroid nodules
Appropriate treatment for thyroid cancer with help of
neighborhood thyroid cancer endocrinologist.
Questions?
Thank You