Solitary thyroid nodule

By: Yehia Matter EL-ashcker

any thyroid disese may present itself as STN:

1.Clinically apparent solitary nodule on top of MNG2.Simple nodule eg colloid nodule3. Autonomous toxic nodule4. Focal thyroiditis( Hashimoto_De Quervain_Riedel)5.Cyst eg haemorrghic6.adenomas eg follicular7.carcinoma (papillary-follicular-anaplastic-lymphoma)

Clinical picture:• symptom:

1.Neck swelling2. Painful swelling: in case of *hae *thyroiditis *malignancy3. Toxic manifestation :in toxic nodules4.Criteria of malignany:in malignant nodules

• signs:1. Usually in lower pole.

2. Firm ,hard or cystic. 3.moves up and down with deglutition

investigation:

1.Thyroid scan.2.US.3. Thyroid function test.4.Biopsy:FNAC-true cut needle- excision.

treatment schemea.Multiple :subtotal thyroiddectomyb.Solitary :*cystic ->Aspiration :simple cyst " no further ttt" ->suspicious of malignancy if : Haemorrhagic aspirate Incomplete disapperance "i.e residual mass" +ve cytological exam Rapidly reaccumulating: Managed according to type and operability  

*Solid: I123 scana.Warm nodules   : hemi-thyroidectomy & biopsyb.Hot nodules :toxic nodules : before 45 =hemi-thyroidectomy & after 45 =1st therapyc.Cold nodules : biopsy  : benign = hemi-thyroidectomy &  malignant = according to type an operability

1.clinically apparent solitary nodule on top of MNG:Clinically: STNUS: MNGpathology :NE :STN MP : dormant nodule (fibrous tissue capsule with necrotic tissue, area of Haemorrhage & destroyed thyroid follicles) complications & ttt :as MNG

2-colloid nodule • female 20-30 years complaining of STN• MP: fibrous tissue with capsule surrounding inactive thyroid

follicles filled with colloid • ttt: with compression manifestations, retrosternal extension,

bad cosmosis -> hemithyroidectomy

3- thyroid cyst• NE :STN with +ve pajet test• MP : Fibrous tissue capsule containing serous fluid, colloid

material or blood• US :cyst• ttt: Aspiration up to 3 times if simple cyst• suspicious of malignancy (Haemorrhagic aspirate, residual

tissue mass, rapidly reaccumulating, +ve cytology) -> hemithyroidectomy or total thyroidectomy according to pathology

4-autonomous toxic nodule "ATN" • Etiology: autonomous activity of solitary nodule "with no thyroid Ab.) • pathology :• NE : STN + toxic manifestations • ME : over activity nodule surrounded by suppressed thyroid tissue • this over active nodule consists of autonomously active thyroid follicles

surrounded by fibrous tissue • Investigation :increase in T3,T4 & decrease in TSH,• U. S :Solitary solid nodule• thyroid scan -> hot nodule• ttt : <45yrs - >hemi-thyroidectomy, >45yrs - >radioactive I131

5.Thyroiditis A- autoimmune (Hashimoto) thyroiditis :• 30 - 50 yrs, may give a family history of thyroiditis • NE :STN +/- Pain & tenderness , rubbery or firm in consistency. Initially - > toxic

manifestations, later on - > manifestations if hypothyroidism • MP : infiltration of the thyroid gland in the affected area by lymphocytes & plasma cells. • Complications : Hypothyroidism , Malignant change (malignant lymphoma) - > 70 fold

increase in the risk O (papillary carcinoma) • Investigation :• Thytoid function tests : initial hyperthyroidism then hypothyroidism ( increas in TSH &

decrease in T3 & T4)• Thyroid Antibodies : anti microsomal Ab. , anti thyroglobulin Ab. • Thyroid biopsy • TTT : hemi-thyroidectomy with retrosternal extension, compression manifestations or

suspicious of malignancy

B-subacute thyroiditis (Granulomatous - de Quervain's thyroiditis) :• Female 30-40 years, history of URTI 2 weeks ago, followed by neck

pain & toxic manifestations • NE:tender STN• MP : degeneration of thyroid follicles that become surrounded by

giant cs forming granuloma• Investigation : increase in Esr, T3,T4 & decrease in TSH, radio

active iodine uptake• TTT: the disease is self-limited so ttt is primarily symptomatic

(Prednisolone & NSAID)

C- Riedel's thyroiditis ( fibrosing or woody) :• Female with history of collagen disease complaining STN - >

hard, fixed with compression manifestations • MP :replacement of thyroid tissue by fibrous tissue, which

also invades the adjacent tissue • Investigation : tissue biopsy, normal thyroid functions,

thyroid scan - > normal uptake but not appear on the scan • TTT : with sever compression manifestations - > isthmectomy

to decompress the trachea

6- follicular adenoma• NE :Solitary thyroid nodule which is firm & well encapsulated • ME :several histological variants (embryonal, fetal, follicular

& microfollicular) • C/P: STN ( may be functioning) • Investigations : tisse biopsy - >no anglo capsular invasion • Thyroid scan - > warm nodules (if functioning) • TTT :hemi-thyroidectomy

7-Malignant STN• usually - > papillary, follicular or medullary thyroid carcinoma • Rarely - > lymphoma or anaplaatic carcinoma A -Papillary thyroid carcinoma • 15-40yrs complaining of STN with malignant criteria :• Rapidly growing & associated with dysphagia & hoarseness of voice• Hard, >1cm, fixed to the skin or sternomastoid wit enlarged Cx. LNs & +ve berr's

sign• MP : papillary projections formed of C. T core covered by a malignant cuboidal

epithelium with a characteristic pale empty nuclei - > orphan Annie nuclei + nuclear drooves & pseudo-inclusion + psammoma bodies.

• Investigations :increasw in S.thyroglobulin thyroid scan - > cold nodule, neck U/S, CT&MRI, indirect larygoscope & FNAC + metastatic work up

B. follicular carcinoma

• female 40-60yrs complaining of STN with malignant criteria

• MP : thyroid follicles with variable degree of differentiation (solid sheets of malignant cells may be present).

• angiocapsular invasion is a characteristic feature & according to its degree, follicular carcinoma may be :

• non-invasive : if angiocapsular invasion is minimal

• invasive :if angio capsular is moderate or marked

• spread mainly by blood, differentiated tumour & may be functioning

• investigations :

• increase in S.thyroglobulin , Thyroid scan - >cold nodule , Neck U/S, CT&MRI

• Indirect larygoscope & trucut or open surgical biopsy + metastatic work up•  

ttt of differentiated thyroid carcinoma (papillary & follicular) • 1- total (in high risk group) or near total thyroidectomy (in low risk group) to

avoid injury of parathyroids & RLN at least on one side• 2- Lymphadectomy : for involved Cx. LNs -> cherry picking or modified 🍒

block dissection "spare sternomastoid, accessory nerve & Internal jugular vein"

• 3-thyroid tissue suppression :post operative thyroxin in a full suppressive dose (making TSH < 1 micro micro /L) as tge tumour is TSH dependant

• 4-radiactive iodin scanning and ablation : post operative whole body scan using radioactive I131 to detect metastasis (done after stoppage of T4 for 6 weeks in order to permit a high stimulating level of TSH on the metastasis) - > if metastasis is found - >theraputic dosses of radio active iodine (I131)

c. Medullary thyroid carcinoma • ♀ 40-60yrs complaining of STN with malignant criteria • MP : aheets of malignant cs " spindlr shaped or polygonal)

separated by collagen & amyloid (amyloid is a diagnostic finding) • +ve immunohistocemistry for calcitonin • metastasize early - > 50% of patients have neck LNs at time of

diagnosis • , functioning tumour - >secretes calcitonin, CEA, PGs& serotonin &

doses not taje up radioactive I

TTT : • 1-ttt pheochromocytoma 1st if present • 2- MTC is ttt by :• Total thyroidectomy • lymphadenectomy ( routine central neck clearance + ipsilateral

modified radical block dissection if tumor > 1.5 cm) • adjuvent radio & chemotherapy • 3- prophylactic total thyroidectomy for family member proved to

have RET gene mutation

Thank you