Thyroid Nodules Management

Thyroid Nodules ManagementSupervisor DR. Mohand Al.Sherfy

Students
Fatima Latif Hamad
Nour Al.Huda Jaleel
Rose Razag

Embryology

• The thyroid gland arise as a diverticulum originating in the foramen caecum which lie at the midline at the junction of ant.2/3 and post.1/3 of the tongue).then descend through thyroglossal duct.
• Failure to descend of the thyroid lead to;
• ectopic thyroid ,
• Lingual thyroid ;
• thyroglossal cyst which may cause fistula.
• Retrosternium goiter if descend too far.
• Pyramidal lobe

Surgical anatomy

• Normal wt of thyroid gland is 20 -25 gm, functional unite is lobule which contain 20 -40 follicles ,
• .blood supply from sup and inf thyroid arteries..branches from ??
• Venouse return ;
• Internal jugular vein
• Brachiocephalic vein


Incidance: 3-4% of adult pop.
Female:male 4:1
Importance of distinction bet. Solitary &dominant nodule
Riskof malig. 5%

Dif dx of thyroid nodule

Dominant nodule of MNG
Adenoma
Cyst
Ca
Localised form of thyroiditis
colloid nodule

Features of hx &exam indicate high risk of ca.

Extreme of age chance of malig. 50%
Rapid growth & local invasion
Hx of radiation
Family hx of med. ,pap. Ca. Or gardener synd.ie fam. Poliposes
On exam.firm ,fixed nod. To adjacent str. Vocal cord paralysis , LN enalrgment


What single test best predict the need for surgical intervention

FNA
70% BENIGN
15% SUSP.
5% MLIG.
FNA can dx
Colloid G.,Hash. Thyroiditis,pap ca.,med, ca. ,lyphoma, anaplastic ca.
Accuracy rate more than 95%

What is the problem of FNA

to avoid mis dx of ca. By FNA surgery should be adviced in ;

1- all proven malignant nod.

2-all cytologica dx of folicular neoplasm
3-all atypical cellular pattern
4-cyst recur after aspiration
5- on clinical ground susp. Of malignancy even if cytology is benign

Lab. investigation

TSH
TG
Serum calcitonin
Thyroid autoAB


Benefit of U.S
Categorize nod as cystic , solid or mixed
Measure the size
Detemine the presenceof other nodule
To detect LN
Follow up of pt. Managed conservatively to detect increase of volume of susp. Nod.

What other test may be useful in evaluation of thyroid nodule

Thyroid scan
Either iodine131 or Tc99
Tc 99 isotop of choice
Avilable
Unexpensive
Low radiation risk
Problem
No tissue dx, cannot dif. Bet. Benign & malig.
Cold 80% benign ,some worm nod 5%malig

D.Dx of cold nodule

Cyst
,adenoma
,colloid nod
,thyroiditis
,ca


Indications of isotop scan in STN
REC. Nod. After previous thyroid surgery
Retrosternal goitre
Pt. With bulky short neck with susp. Of goitre in whom no thyroid enlargement is palp.

Indication of surgery in pt with STN

Proven or suspected malig.
Pressure sympt.
Hyperfunctioning nod.
Cosmesis
Anxious pt
Pt wish

What is minimal extent of throidectomy for STN

Is thier any role for non surgical therapy

If FNA benign & no obst. Symp.

Follow up every 6 month complete cervical exam & repeat FNA if no susp. Of malig. Then pt should be seen every year

Indication of surgery in a cyst

Rec . Cyst
Malig. Cytology
Bloody aspirate
Residual lump
Larg cyst >4 cm


Type of surgery
• 1-total thyroidectomy with thyroxin replacement long life
• 2- near total thyroidectomy -- total lobectomy + subtotal lobectomy + isthmstectomy
• 2-subtotal thyroidectomy 8 mg from each lobe
• 3- lobectomy lobectomy + isthmstectomy

THANK YOU