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Thyroid Nodules and Cancer

Elizabeth Lamos, MD and Neda Frayha, MD
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Thanks to all the imaging studies we order on our patients, we are finding more and more thyroid nodules - and, as a result, diagnosing more thyroid cancer. In this segment, Elizabeth Lamos discusses the evaluation and management of both incidental thyroid nodules and thyroid cancers for the busy primary care clinician.

Pearls:

  • Thyroid cancers are on the rise in large part because we picking up more of them incidentally on imaging.

  • Ultrasound is your initial test of choice and will help you risk stratify them to determine what should be biopsied and how these nodules should be followed in time.

  • TSH is best and most sensitive thyroid function test. Biotin is a common supplement that interferes with thyroid function testing.

  • Think of thyroid cancers as a primarily surgical issue: find a good one who is experienced in thyroid and lymph node resection.

  • Thyroglobulin hormone and ultrasound are the main mean of monitoring for disease recurrence.

 

  • Thyroid cancers are on the rise in large part because we are picking up smaller nodules incidentally with imaging than we have in the past that end up being biopsied.

    • Some nodules less than 1cm are being picked up that would not have been in the past. There is some debate as to whether or not these are clinically significant.

  • Where to start with thyroid nodules:

    • Ultrasound - size, location, microcalcifications, echogenicity to help you risk stratify the nodule.

      • The American Thyroid Association Guidelines have a table to help risk stratify nodules and gives guidance on what size nodules to biopsy.

      • Haugen BR et. al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016 Jan;26(1):1-133. Doi: 10.1089/thy.2015.0020. PMID: 26462967.

      • For example: a simple cyst is not a recommended biopsy candidate while anything over 2cm or anything under 1cm that is hypoechoic or has microcalcifications or has a rugged border shoulder be biopsied.

      • Pearl: have a good relationship with your ultrasonographer and radiologist because some reports are better than others and you may be misled by a report.

  • Follow-up for benign nodules:

    • The American Thyroid Association is NOT clear on this but generally recommend a repeat ultrasound in 12-24 months depending on risk stratification.

      • Cyst - generally no follow-up needed unless cosmetic changes or you notice it growing.

      • Spongiform - 12-24 months recommended unless moderate or high risk where you’ll want 12 months follow-up.

      • High risk nodule (calcifications, rugged edges, growing) - may need a second negative biopsy in one year

  • Thyroid function testing:

    • TSH is the best and most sensitive test

      • Pearl: Biotin is a common supplement that can interfere with thyroid function tests so hold that before getting those tests.

  • Pathology “gray zone”

    • Atypia (15-25% risk of cancer) and follicular neoplasm (30% risk of cancer) - gray zone where the American Thyroid Association recommends repeating biopsy +/- molecular markers → recommend referral to endocrinology for a discussion of next steps.

    • Suspicious for malignancy (80% risk of cancer) → most are higher risk for surgery.

  • Pathology comes back with cancer:

    • Papillary cancer

      • Vast majority of thyroid cancers

      • Very good prognosis

    • Follicular cancer

      • Trickier prognosis but vast majority do well with a somewhat higher risk of recurrence

    • Medullary cancer

      • Should trigger you to think about genetic syndromes and definitely referral to endocrinologist

      • Also good prognosis

    • Anaplastic cancer

      • Rare but dramatic presentation and poor prognosis

  • If cancer, what’s next?

    • Surgery

      • Referral to surgeon who has expertise in thyroid surgery. In some places this may be ENT or endocrine surgeon.

      • Depending on the type of lesion, some patients may prefer to have the entire thyroid removed as opposed to the just the lobe with the malignant lesion to avoid future surgeries.

      • If central node dissection is necessary, consider this a very technical procedure where having the right surgeon makes a huge difference.

        • Pearl: thyroid cancer is a surgical disease

    • Chemotherapy and radiation

      • Risk-stratified based on the pathology to determine who benefits from radioactive iodine.

      • Some centers will use external beam radiation and immunomodulators in more complicated cases.

  • Overall prognosis? Generally outcomes are good with an excellent surgeon +/- radioactive iodine.

  • What type of monitoring for patients after their surgery?

    • Seen by endocrinologist within one month

    • Thyroglobulin levels are monitored frequently initially and then at least every year, especially before and after radioactive iodine, with the goal of being undetectable.

    • Ultrasound also used to monitor disease at least yearly

    • TSH is also used to monitor but is not straightforward. Depending on their response to therapy, the TSH goals may be different. Work with your endocrinologist to determine what is appropriate for each patient.

Shiv S. -

Any role of Thyroid uptake nuclear scan in assessing thyroid nodules, apart from the us.

Neda F., MD -

Hi Shiv. I asked our expert for this segment, Dr. Lamos, and she wrote the following: "Not really. We no longer use 'cold' nodules to determine whether or not to biopsy." She said that one case in which a nuclear medicine scan could be helpful is in a patient with a low TSH and concern for a toxic nodule. Hope this is helpful!

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The Buzz That Won't Quit Full episode audio for MD edition 193:13 min - 91 MB - M4AHippo PC RAP May 2018 Written Summary 622 KB - PDF

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