Solitary Thyroid nodules

Question 1

What are they?

Answer 1

great question need to figure that out

they are very common - 5% of women have one 
95% will be benign 
- cyst 
- colloid nodule 
- benign follicular adenoma 
- hyperplastic nodule 
need to work out if malignant

Question 2

how do you know if the lump in the neck is the thyroid?

Answer 2

invested in pre-tracheal fascia

pain an uncommon feature - usually caused by an intra-thyroidal bleed into a cyst

Question 3

what are the important history/exam findings?

Answer 3

Family history of thyroid cancer
Neck irradiation previously 
Neck nodes 
Hoarseness 
TSH measure 
USS-FNA (fine needle aspiration)

Question 4

FNA and USS grading

Answer 4

• Thy1 – inadequate
• Thy2 – Benign		U2
• Thy 3 (a/f) – Atypical	U3
lobectomy	
• Thy4 – Prob malignant 	U4
thyroidectomy
• Thy 5 – malignant		U5
Thyroidectomy

Question 5

TMN grading

Answer 5

• T1 - Tumour size ≤ 2 cm
• T2 - Tumour size > 2 cm but ≤ 4 cm, limited to the thyroid.
• T3 - Tumour size >4 cm, limited to the thyroid or any tumour with minimal extrathyroidal extension (eg, extension to sternothyroid muscle or perithyroid soft tissues)
• T4a - Moderately advanced disease; tumour of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, oesophagus, or recurrent laryngeal nerve
• T4b - Very advanced disease; tumour invades prevertebral fascia or encases carotid artery or mediastinal vessels
• N0 - No regional lymph node metastasis
• N1 - Regional lymph node metastasis:
• N1a - Metastases to level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes)
• N1b - Metastases to unilateral, bilateral, or contralateral cervical (levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (level VII)
• M0 No distant metastasis is found
• M1 Distant metastasis is present

Question 6

how is it managed?

Answer 6

low risk group 
- thyroid lobectomy 
high risk group (T3 or greater) 
- total thyroidectomy 
- consider radio-active iodine

Question 7

follow up if follicular or papillary

Answer 7

TSH lower level of normal (0.4-4 mU/l)
Thyroglobulin – protein precursor of T4/T3; made by thyroid follicular epithelial cell
Use Tg as a tumour cell marker for follow up of patient
Get TSH/Tg measured every 6 months for first 5 years then annually for next 5 years
Consider discharge at 5 years if low risk