INCIDENTAL THYROID NODULES INCIDENTAL THYROID NODULES AND PROMINENT LYMPH NODES AND PROMINENT LYMPH NODES ON CHEST CT ON CHEST CT Richard M. Gore, MD North Shore University Health System University of Chicago Evanston, IL SCBT/MR 2010 March 7, 2010 15:50-16:10
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•• Jornal Brasileiro de PneumologiaJornal Brasileiro de Pneumologia•• J bras pneumolJ bras pneumol 33:13333:133--140,140, 20072007•••• Mediastinal lymph node distribution, size and number: Mediastinal lymph node distribution, size and number:
definitions based on an anatomical studydefinitions based on an anatomical study**•••••• Aurelino Fernandes Schmidt JAurelino Fernandes Schmidt JúúniorI; Olavo Ribeiro niorI; Olavo Ribeiro
•• 42% of patients with left heart failure 42% of patients with left heart failure showed LAD. 62% showed regression with showed LAD. 62% showed regression with treatmenttreatment
•• LAD group showed lower EF (34% vs LAD group showed lower EF (34% vs 43%), larger R superior pul vein, more 43%), larger R superior pul vein, more peribronchovascular thickeningperibronchovascular thickening
THE THYROID NODULE THE THYROID NODULE PANDEMICPANDEMIC
•• 44--8% adults by palpation8% adults by palpation•• 41% adults by ultrasound41% adults by ultrasound•• 50% adults at autopsy50% adults at autopsy•• 25,690 new cases annually25,690 new cases annually•• 1,460 annual mortality1,460 annual mortality
INCIDENTAL THYROID LESIONS SEEN INCIDENTAL THYROID LESIONS SEEN ON NECK CT AND MRION NECK CT AND MRI
EPIDEMIC OF NODULAR EPIDEMIC OF NODULAR THYROID DISEASETHYROID DISEASE
•• Assume a cost of Assume a cost of $1,500 for US$1,500 for US--guided FNA and guided FNA and cytologic analysiscytologic analysis
•• Thyroid operations Thyroid operations cost $20,000 eachcost $20,000 each
THE STAGERING POTENTIALTHE STAGERING POTENTIALCOST OF THYROID NODULESCOST OF THYROID NODULES
•• 35,000,000 neck and chest CT 35,000,000 neck and chest CT performed annuallyperformed annually
•• 10% have thyroid nodules10% have thyroid nodules•• 3.5 million patients with nodules 3.5 million patients with nodules •• $1,500 X 3.5 million= $5,250,000,000$1,500 X 3.5 million= $5,250,000,000•• $5,250,000,000/ 1,500= $3,500,000$5,250,000,000/ 1,500= $3,500,000
INCIDENTAL THYROIDINCIDENTAL THYROIDNODULES ON NECK CTNODULES ON NECK CT
•• 3.9% prevalence of malignant nodules3.9% prevalence of malignant nodules•• 7.4% prevalence of potentially malignant 7.4% prevalence of potentially malignant
lesionslesions•• Patients Patients ≤≤ 35 y.o. have a significantly 35 y.o. have a significantly
greater rate of malignancygreater rate of malignancy•• CT underestimates the number of nodules CT underestimates the number of nodules
INCIDENTAL THYROIDINCIDENTAL THYROIDNODULES ON NECK CTNODULES ON NECK CT
•• No distinguishing features on CT could No distinguishing features on CT could confidently identify a lesion as malignantconfidently identify a lesion as malignant
•• Features that warrant suspicion: punctate Features that warrant suspicion: punctate calcifications, larger size, younger patientcalcifications, larger size, younger patient
PATIENT LIFE EXPECTANCYPATIENT LIFE EXPECTANCYAND COMORBIDITIESAND COMORBIDITIES
•• Defer evaluation unless patient Defer evaluation unless patient symptomatic or hyperthyroidsymptomatic or hyperthyroid
•• For you who are about to die, we For you who are about to die, we salute yousalute you
Patient < 50 years oldPatient < 50 years old
ULTRASOUND EXAMULTRASOUND EXAM
•• Document the number and size of nodulesDocument the number and size of nodules•• Marked hypoechogenicityMarked hypoechogenicity•• Intranodular vascularityIntranodular vascularity•• Incomplete peripheral haloIncomplete peripheral halo•• Irregular marginIrregular margin•• Central microcalcificationCentral microcalcification
WHAT ABOUT THE 75 MILLION OTHERS OF WHAT ABOUT THE 75 MILLION OTHERS OF US OLDER THAN 50 YEARS AND THE US OLDER THAN 50 YEARS AND THE
12,000 BOOMERS REACHING 50 EACH DAY12,000 BOOMERS REACHING 50 EACH DAY
•• No one ever got sued for recommending a No one ever got sued for recommending a thyroid ultrasound for an incidental thyroid thyroid ultrasound for an incidental thyroid nodule found on MDCTnodule found on MDCT
THYROID CANCER RISK THYROID CANCER RISK EVALUATIONEVALUATION
•• History of radiationHistory of radiation•• Personal or FH of endocrine neoplasmsPersonal or FH of endocrine neoplasms•• Male genderMale gender•• Hoarseness or dysphagiaHoarseness or dysphagia•• AdenopathyAdenopathy•• Thyroid function testsThyroid function tests
NODULES < 8mm or 8NODULES < 8mm or 8--15 mm 15 mm without worrisome featureswithout worrisome features
•• Risk factorsRisk factors•• AgeAge•• Life expectancy and Life expectancy and
comorbiditiescomorbidities•• Patient counseling to Patient counseling to
report any changereport any change•• Reevaluation with Reevaluation with
ultrasound in 6 ultrasound in 6 monthsmonths
Wording of reportWording of report
•• In an asymptomatic patient with normal In an asymptomatic patient with normal thyroid function, no history of radiation or thyroid function, no history of radiation or other thyroid cancer risk factors, this lesion other thyroid cancer risk factors, this lesion is statistically most likely benign.is statistically most likely benign.
NODULES 8NODULES 8--15 mm WITH 15 mm WITH ≥≥ 1 WORRISOME FEATURE1 WORRISOME FEATURE
•• Mural thickeningMural thickening•• Mural nodularityMural nodularity•• CalcificationCalcification•• FNA with FNA with
ultrasound ultrasound guidanceguidance
NODULES > 15 mmNODULES > 15 mm
•• FNA with FNA with ultrasound ultrasound guidanceguidance