Management

of Thyroid Nodule

AgusYuwono
Endocrinology and Metabolic
Division
 Introduction
Thyroid nodule is the mostly endocrinal
neoplasma

Clinical awareness involving :

 How to exclude malignancy of the thyroid
 Size and pressure symptom of the thyroid
nodule
 Others : cosmetic and anxieaty about the nodule
Introduction…

In United States 4-7% of adult population have

a palpable thyroid

Only 1 of 20 clinically identified nodule is

malignant

The most common diagnosis of tyroid nodule

are :
- Colloid nodule,cysts, and thyroiditis 80 %
- Benign follicular neoplasma 10-15 %
- Thyroid carcinoma 5 %
Introduction…

• The management of solitary thyroid nodule

remains controversial

• The most important thing was to exclude

malignancy of thyroid nodule
 Diagnostic
• The history and physical examination
remains the start of point to diagnose
thyroid nodul
Clinical finding with high suspicion of
malignancy :

- family history of medullary thyroid Ca

- rapid tumor growth
- very firm or hard nodule
- fixation of the nodule to adjacent
structures
- paralyse of vocal cord
- regional lymhadenopathy
• Clinical finding with moderate suspicion of
malignancy:

- age of either < 20 years or > 70 year

- male sex
- history of head and neck irradiation
- a nodule > 4 cm in diameter or partially cystic
- symptoms of compression:
dysphagia,dysphonia, hoarseness, dyspnea
and cough
 Laboratory examination
• Biochemical test routinely needed is
measurement of thyrotropin level

• If the level of thyrotropin is subnormal :

F T4 and F T3 shoud be measured to
determine the presence and degree of
hyperthyroidism
Lab exam…

10 % patients with solitary nodule

supressed level of serum thyrotropin
suggest a benign hyperfunctioning
nodule

If serum thyrotropin is elevated

anti thyroperoxidase shoud be done to
confirm hashimoto’s thyroiditis
 Imaging
The common imaging examination
performed :
- Radionuclide scanning
- Ultrasonography
- Other methode : CT and MRI
 Radionuclide scanning
- Radionuclide scanning performed to
determine whether a nodule is
functioning
- A scan with Iodium-131 or Technetium-
99
- This methode can determine hot nodule
and warm nodule (hiperfunctionig) and
cold nodule (non functioning)
 Ultrasonography

- can detect nonpalpable thyroid accurately

- estimate the size and volume of nodule

- differentiate symple cyst, mixed cystic and solid

nodule

- provides guidance for FNAB as well as therapeutic

procedure

- monitoring effects of treatment

 Fine Needle Aspiration Biobsy
(FNAB)

• FNAB relatively not expensive, easy to

learn, and complication are rare
• The technique can determine the histology
of thyroid tissue
• Can reduce thyroidectomy approximately
50 %
 Treatment of thyroid nodule
The main therapeutic options are ;
1. Surgery
2. Hormon suppresion therapy (levothyroxine)
3. Radioiodine
4. Percutaneus Ethanol Injection
5. US – guided Interstitial Laser photocoagulation
6. Observation
 Surgery

The main indications of surgery are :

- Clinical and cytologic feature suggestive of
cancer
- Growth of the nodule
- Reccurence of cystic nodule after aspiration
- Neck discomfort
- Cosmetic concern
- Patient’s anxiety about the nodule
Surgery…
The choice of surgery are :

Hemithyroidectomy and istmectomy :

One thyroid lobe enlarged

Subtotal thyroidectomy bilateral :

Nontoxic multinodular goiter

Thoracototomy:
Isolated intratracheal (rare)
Surgery…
Complications of surgery were :
- hypothyroidism
- reccurence of the nodule
- bleeding
- postoperative tracheal obstruction
- hypoparathyroidism
- recurrent laryngeal nerve injury
 Hormon supression therapy
(Levothyroxine)
• Thyroxine is the most widely used for benign
solitary nodule

• Thyroxine suppress the secretion of thyrotropin

• The growth of normal thyroid nodule depend on

thyrotropin, therefore supression of thyrotropin
secretion will result in decrease in nodule size
 Hormon …

The main indications are :

- benign solitary nodule thyroid non toxic
- multinodular goiter non toxic

Tretment with levothroxine at a dose sufficient to

keep serum thyrotropin a level < 0,3 mU/lt

Suggested to prevent growth of a benign nodule

Hormon …
• This therapy for the long time
• Should be monitor of serum thyrotropin level
• If thyrotropin suppressed < 0,1 mU/lt
- increase risk of atrial fibrilation
- abnormality of cardiac
- reduced bone density
• Regrowth of nodule occurs after cessation of
therapy
 Radioiodine
The main indications :
• functioning nodule with or without biochemical
hyperthyroid

Contraindications :
• Pregnancy
• Breast feeding women

After Single dose I 131 of 100 Gy

• Normalized serum thyrotropin
• Normalized thyroid radionuclide scanning
• Thyroid volume reduced an average 40 %
Radioiodine…

The main side effect :

• hypothyroidism approximately 10 %
• It has been used 5 year after treatment
• Frequency of the risk increases over
time
• The risk greater in patients with thyroid
peroxidase antibodies and with iodine
uptake in extranodular thyroid tissue
Radioiodine…
• Thyroid function shoud be checked
regularly during first year and yearly to
detect hypothyroidism

• Biopsy should be done if nodul growth

after iodine therapy
 Percutaneus Ethanol Injection
(PEI)
The main indications are :
- Benign functioning and non
functioning solid thyroid nodule
- Prevent the recurrence of the cysts
- Alternative to radioiodine or surgery
especially for patients with small
nodule
Percutaneus …
The mechanism is coagulative necrosis
and small vessel thrombosis

Multiple injections usually

- causing mild to moderate pain
- transient paralyse of recurrent
laryngeal nerve
 US-guided Interstitial Laser
Photocoagulation (ILP)

• With low power of laser energy

• Thermal energy cause necrosis of nodule
without tissue damage around the nodule
• Almost no side effect of thyroid function
 Observation
• Benign thyroid nodule be followed with US
every 6-18 month after initial FNAB
• Easily palpable nodule do not require US
monitoring
• If nodule size is stable interval monitoring
maybe longer
• If there is evidence for growth by palpation
or US repeat FNAB preferably with US
Conclusion and Recomendation

• For the patient who presents with a

nodule, the main concern is to exclude the
possibility of thyroid cancer

• Initial evaluation should be include

measurement of serum thyrotropin level
and FNAB preverable guided by
ultrasonography
Conclusion …

• If the thyrotropin level is suppressed,

radionuclide scanning should be
performed

• If the patient has a family history of

medullary thyroid or multiple endocrin
neoplasia - MEN type 2 serum calcitonin
level should checked
Conclusion...

• If the case of functioning benign nodule,

Radioiodine is the choice of therapy

• For the non functioning cystic nodules, the

choice of therapy are aspiration and ethanol
injection therapy

• Patient with benign cytology should be follow

yearly with palpation and measurement of serum
thyrotropin level
Conclusions…

• If there is evidence of growth of benign

nodule, it should be repeated
ultrasonography and FNAB
 Summary
• Thyroid nodule is the mostly endocrinal
neoplasia

• The clinical awareness was how to exclude

malignancy of thyroid nodule.

• The initial evaluation of the thyroid nodule

involve the history and physical examination,
laboratory investigation, imaging of the thyroid
and Fine needle aspiration biopsy (FNAB).
• Patient with suspicion for cancer, should
be offered surgery regardless of the results
of fine-needle aspiration

• If the thryrotropin suppressed, radionuclide

scanning should be performed
• For the functioning benign nodule
radioiodine is the choice of therapy

• For the non functioning cystic nodule,

aspiration and ethanol injection may be
considered

• If the nodules are solid ethanol injection or

laser therapy may be considered
Solitary thyroid nodule :

Benign thyroid nodule consist

- thyroid adenoma
- cysts
- infections nodule (thyroiditis)
- hyperplasia

Malignant nodule thyroid (thyroid carcinoma) :

- well differentiated carcinoma (papillare and
follicular)
- poorly differentiated carcinoma (medullar and
anaplastic)
Multinodular Goiter:

- mostly benign nodule

- because of iodium deficiency
- separated into toxic and non toxic nodule