Dubai Thyroid Clinic

Dubai Thyroid Clinic

Definition:

A discrete swelling in an otherwise impalpable gland is termed solitary thyroid nodule

  • Prevalence: 3-5 % of adult population.
  • Female:Male – 4:1
  • Importance of STN lies in the risk of malignancy compared with other thyroid swellings.
  • 10 –15% of STN are malignant.

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Types  of Solitary Thyroid Nodule (STN): 

  • Dominant nodule of a multinodular goitre
  • Thyroid adenoma
  • Thyroid cyst
  • Thyroid carcinoma
  • Localised form of thyroiditis, colloid goiter

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Work up of a STN-History:
  • Age and gender 
    • Children: Child with a thyroid nodule – 50% chance of it being malignant
    • Men > 50yrs
  • Exposure to radiation for Hodgkin’s/ Ca Breast
    • 35 yrs after exposure
    • 7-10% of exposed  patients
    • 100   Rads - Thyroid nodules/ Thyroid carcinoma
    • >2000 Rads - Prevent thyroid neoplasm/ Thyroid gland destroyed
  • Rapid nodule growth
  • Pain, Hoarseness, Compressive symptoms
  • History for specific endocrine disorders-medullary carcinoma, MEN type2
  • Family h/o thyroid carcinoma

Evaluation of STN: 

  • Lab Evaluation:
    • Thyroid function test (T3, T4, TSH) - To identify patients with unsuspected hyperthyroid states and dictate appropriate workup.
    • Serum calcitonin level-Medullary carcinoma is strongly suspected.
    • Detection of thyroid autoantibodies in patients with toxic features (anti microsomal and anti thyroglobulin antibodies).
  • Ultrasound:
    • Nature of the swelling (Solid or cystic) – cystic lesions are usually but not always benign.
    • To detect nodules of a MNG which are not clinically palpable.
    • To detect lymph nodes.
    • Follow up of patients who are managed conservatively to detect increased volume of a suspicious lesion.

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  • Thyroid scan:
    • Using Iodine131 or Technetium-pertechnetate 99m.
    • On scanning swellings are categorised as hot (overactive), warm (active) or cold (underactive)
    • Not useful in distinguishing benign and malignant lesions since majority of cold nodules are benign (80%) and some warm nodules are malignant (5%)
    • Only indication is in patients with toxic features to differentiate Toxic adenoma (rest of the gland is suppressed) from toxic MNG.

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  • FNAC:
    • Single most useful investigation which can detect most of the conditions.
    • A specimen is considered adequate if at least six properly prepared smears contain 15-20 groups of well preserved clumps of follicular epithelium.
    • Can diagnose colloid nodules, thyroiditis, papillary carcinoma, medullary carcinoma, anaplastic carcinoma and lymphoma.
    • Cannot distinguish between a follicular adenoma and carcinoma.
    • Follicular cells in FNAC, 6-20% chance of malignancy.
    • Sensitivity – 89%
    • Specificity - 91%
    • False negative rate, 1- 6%. Hence benign nodules diagnosed by FNAC should be followed sequentially with ultrasound to make sure the characteristics do not change.
    • FNAC results – benign, suspicious or malignant.
    • Suspicious lesions increased incidence of malignancy.
  • MRI, CT (Rarely indicated)
    • Only to evaluate retro-sternal extension
  • PET scan using FDGF18 (fluorodeoxyglucose F18)
    • It can differentiate benign from malignant but highly expensive and can not replace biopsy

Treatment options:

  • Levothyroxine: (in benign nodule ) to keep TSH below 1 mU/L. It has many side effects, so not recommended.
  • Surgery: indicated in
    • FNAC positive or clinically suspicious (eldery, male, hard texture, fixed, recurrent laryngeal nerve palsy, lymphadenopathy, recurrent cyst)
    • Cosmosis, Toxic nodule, Pressure symptoms
    • Methods - Lobectomy + isthemusectomy: In pt with low risk factors & Benign
    • Total thyroidectomy: In pt with high risk factors, Benign nodules & Malignant nodules
  • Radioiodine: indicated in functioning nodule, contraindicated in pregnancy, lacatation, children. S/E: hypothyroidism, carcinogenic, fetal anomalies in pregnant women.
  • Percutaneous ethanol injection, and laser photocoagulation. 

Guidelines:

According to American Thyroid Association  & American Association of Clinical Endocrinology:

  • Radionuclide scan is only indicated in:
    • suppressed TSH
    • if FNAC → follicular neoplasia
  • FNAC should be guided by U/S especially if the nodule is partially cystic.
  • Benign nodule → Life long Follow-up every year (TSH, neck palpation, FNAC), if functioning : Iodine -131 is TTT of choice, and Surgery is indicated in:
    • very large nodule, Partially cystic, young patient, pregnant
  • malignant nodule → surgry
  • Autoimmune thyroidits → cortison + L-thyroxin
  • Infections → control 

 

Dubai Thyroid Clinic - DRHC provides treatment for hypothyroidism, hyperthyroidism, thyroid cancer, thyroid disease, thyroidectomy and thyroid surgery .

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