Sipos 1 Update on Thyroid Nodules New Imaging Techniques Jennifer A. Sipos, MD Associate Professor Division of Endocrinology The Ohio State University Prevalence of Endocrine Disorders in U.S. Adults Endocrine Condition Prevalence Metabolic syndrome 35-40% Obesity 25-50% Diabetes 5-25% Hyperlipidemia 15-20% Osteoporosis 7% Thyroid nodules 30-70% Golden SH., et al. J Clin Endo Metab 2009; 94:1853-78 Mazzaferri M. New England Journal Medicine 1993; 328:553-558 Guth S., et al. Eur J Clin Invest 2009; 39:699-706
16
Embed
Prevalence of Endocrine Disorders in U.S. Adults01) Update on Thyroid...Prevalence of Endocrine Disorders in U.S. Adults Endocrine Condition Prevalence Metabolic syndrome 35-40% Obesity
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Sipos 1
Update on Thyroid NodulesNew Imaging Techniques
Jennifer A. Sipos, MDAssociate Professor
Division of EndocrinologyThe Ohio State University
Prevalence of Endocrine Disorders in U.S. Adults
Endocrine Condition Prevalence
Metabolic syndrome 35-40%
Obesity 25-50%
Diabetes 5-25%
Hyperlipidemia 15-20%
Osteoporosis 7%
Thyroid nodules 30-70%
Golden SH., et al. J Clin Endo Metab 2009; 94:1853-78Mazzaferri M. New England Journal Medicine 1993; 328:553-558Guth S., et al. Eur J Clin Invest 2009; 39:699-706
Sipos 2
Benign Malignant
Causes of thyroid nodules
g
Multinodular goiter (colloid adenoma)
Hashimoto’s (chronic lymphocytic) thyroiditis
CystColloidSimpleHemorrhagic
F lli l d
Papillary carcinoma
Follicular carcinoma
Medullary carcinoma
Anaplastic carcinoma
Primary thyroid lymphoma
Metastatic carcinoma Follicular adenomas
Hurthle cell adenomas
breastmelanomarenal cell
Epidemiology – thyroid nodules
Autopsy/
Palpation
Autopsy/ Ultrasound
Mazzaferri 1993 NEJM 328:553-9
Sipos 3
How good are we at finding nodules?Ultrasound vs. Palpation
es fo
und
by U
S
50%
Brander 1992 J Clin Ultrasound 20: 37-42
# N
odul
e
94%
Nodule size by US
Palpable Thyroid Nodules
Sipos 4
Nonpalpable Thyroid Nodules
Not all that is palpable is a nodule…..
Sipos 5
American Thyroid Association Management Guidelines
Thyroid sonography should be performed in all patients with known or suspected thyroid nodules
Recommendation rating: A
Cooper, et al Thyroid 2009
Concerning Clinical Features
High clinical suspicion
• Rapid tumor growthRapid tumor growth• Very firm nodule (rock hard)• Fixation to adjacent structures• Vocal cord paresis• Enlarged regional lymph nodes• Family history of PTC or MEN 2• Distant metastases
Positive Predictive Value (PPV) – good (70-75%)
Negative Predictive Value (NPV) – unacceptable (85%)
•History of radiation exposure to the head/neck
Hamming JF., et al. Arch Int Med 1990; 150:1088Rago T., et al. Clin Endo 2007; 66:13
Diagnostic yield of sequential aspirations in 120 patients with multiple nodules and cancer
FNA performed on Number of nodules >1cm
2 (n = 73) 3 (n = 27) ≥ 4 (n = 20)
Largest nodule 86.3 51.8 55
Largest 2 nodules 100 81.5 85
Largest 3 nodules 100 95
Largest 4 nodules 100
FNA of only the largest nodule in a patient with 2 nodules would have missed 13.7% of cancers. In patients with 3 nodules, 48.2% of cancers would have been missed by performing an FNA on the largest nodule only.
Frates et al 2006 JCEM 91: 3411-17
Epidemiology of Thyroid Cancer
Aschebrook-Kilfoy 2013 Cancer Epidemiol Biomark Prev 22: 1252-9
Sipos 14
Changing mode of diagnosis in PTMC
• FNA for thyroid nodules has more than doubled from 2006-2011
• Thyroid FNA grew as a percentage of all FNA f 49% t 65%from 49% to 65% Sosa et al 2013 Surgery epub
Hay et al 2008 Surgery 144: 980-7
Papillary microcarcinomaLikelihood of disease progression with observation
Multivariate analysis: Age <40y RR 4 348 (2 293 8 196) Age <40y RR 4.348 (2.293-8.196)
p<0.0001 T≥9mm RR 4.717 (1.961-11.364)
p=0.0005
Ito et al 2013 Thyroid epub
Sipos 15
Natural history—benign nodules
Of 268 benign nodules studied 89% had grown (more than 15%) at five years
Average increase in volume was 69%
Of 74 nodules re-biopsied, only one revealed malignancy
Solid nodules grew more than cystic
Alexander 2003 Ann Internal Med 138: 315-8
Follow up
Repeat U/S 6-18 months after FNA
Repeat FNA if >50% change in volume or 20% change in nodule diameter in at least twochange in nodule diameter in at least two dimensions with minimum increase of at least 2mm
Interval for the next follow-up may be every 3-5 years
Cooper et al 2009 Thyroid 19
Sipos 16
Indications for surgery
Malignant, suspicious, or indeterminate cytologycytology