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Management of Thyroid Nodules

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Management of Thyroid Nodules B-ENT, 2007, 3, Suppl. 6, 93-102 Management of thyroid nodules J. P. Monnoye*, M. Hamoir**, C. de Burbure***, G. Chantrain****, P. Gasmanne*****, P. Levie*, R. Loncke******, O. Desgain*, V. Monnoye* and Ch. Malherbe******* *Department of Otolaryngology, Cliniques Ste Anne-St Remi, Brussels; **Department of Otolaryngology, Head and Neck Surgery, St Luc University Hospital, Catholic University of Louvain, Brussels; ***Pathology, St-Luc University Hospital, Catholic University of Louvain, Brussels; ****Department of Otolaryngology, University Hospital St-Pierre, ULB, Brussels; *****Department of Otolaryngology, CHU Charleroi, Charleroi; ******Department of Otolaryngology, H. Hartziekenhuis, Roeselare; *******Internal Medicine Department, Endocrine-Metabolic Unit, Brussels Key-words. Guidelines; thyroid nodules; review; management Abstract. Management of thyroid nodules. These Belgian guidelines for ENT surgeons about thyroid nodules were elaborated in the light of personal practical experience and the recent advances in diagnosis and management described in the literature. Thyroid nodules are a common finding, particularly in women and in areas of iodine depletion. The prevalence in the general population averages 3 to 7% on palpation and almost 50% on ultrasound. The major difficulty facing the clinician is how best to assess and manage these thyroid nodules. The authors have attempted to simplify the assessment of thyroid nodules, to classify them, and to present the most common current therapeutic management options. 1. Introduction in men and the prevalence 2. Benign nodules increases in areas with iodine The following guidelines are deficiency and ionizing radiation 2.1. Adenomas based on recent peer-reviewed exposure.10 2.1.1. Follicular adenoma is a articles evaluated by the authors to On ultrasonography the preva- common thyroid tumour, with a rate between Ia and III according lence ranges from 19% to 46% in greater incidence in women than to Belgian evidence levels the general population, may be in men. (BEL).1-9 even higher at autopsy, and may reach 49.5% in clinically healthy Around 90% of solitary thyroid 1.1. Definition people.11 nodules are adenomas, which may undergo haemorrhagic transforma- A thyroid nodule is a tumefaction tion, cystic or necrotic degenera- of a part of the thyroid gland. 1.3. Classification of thyroid tion. Malignant transformation is Its prevalence and incidence nodules rare. Most patients are euthyroid can vary greatly according to Thyroid nodules are either benign and consult for a painless tume- the investigations carried out, the or malignant and are further faction but rapid growth due to population studied, gender, age as subdivided following on histo- haemorrhage may cause neck pain. well as the patients’ past medical pathology. Benign nodules are At histopathology, a follicular history. classified into adenomas, cysts adenoma is an encapsulated and other benign lesions.12 tumour that consists of cells repro- 1.2. Epidemiological overview Malignant tumours are predomi- ducing the thyroid architecture. The finding of thyroid nodules by nantly epithelial in nature, and are It is either round or oval and simple palpation increases by either classified into differentiated surrounded by a fibrous capsule. 0.1% every year of life of the types which can be papillary, It is 4-5 times more frequent patient with a prevalence averaging follicular or medullary carcino- than cancer. Several types exist, 3 to 7% in the general population. mas or into undifferentiated namely: macrofollicular (colloid), Thyroid nodules are four times tumours such as insular and microfollicular (fetal), trabecular more common in women than anaplastic carcinomas. (embryonic) and normofollicular. 94 J. P. Monnoye et al. 2.1.2. Variants: 30 and 40 years of age, is two to tion, which makes it difficult to three times more frequent in distinguish from a follicular ade- – A toxic adenoma is a benign women, and has a good prognosis. noma: differential diagnosis is thyroid tumour that has It presents as a firm, mostly non- based on signs of capsular and escaped pituitary control. It encapsulated mass. vascular invasion, a high mitotic corresponds to a solitary nodule At histopathology, there are index and the presence of metas- with autonomous function. some purely papillary carcinomas, tases. – Hürthle cell adenoma is a some with a follicular predomi- There are particular types of totally encapsulated tumour nance, a diffuse sclerosing variant, follicular carcinomas, such as composed mainly of oncocytic tall and columnar cell variants, Hürthle cell carcinomas, or fol- cells (75%), and is synony- and they may also present as licular carcinomas with oxyphilic mous with oxyphilic or microcarcinomas. The histologi- cells. They are in fact uncommon Askenazy’s adenoma. cal criteria of a papillary carcino- aggressive variants of follicular ma are the presence of papillae carcinomas and account for 3-6% 2.2. Cysts formed by cells bordering a of thyroid tumours.14,15 They Cystic nodules account for 15 fibrovascular axis, the presence of generally present as a hot solitary to 25% of thyroid nodules, laminated calcified nodules nodule at scintigraphy and are are benign and are the result of (psammoma bodies, found in 50% more frequent in women in their degenerative changes either within of the cases), and voluminous pale fifties. Malignancy indicators are the normal thyroid parenchyma or nuclei with early lymphatic inva- clear vascular and capsular inva- a nodular goitre. Malignant change sion. sion. can occur in 20% of nodules larger Papillary carcinoma has the 3.1.3. Medullary carcinoma than 4 cm. Cystic nodules can best prognosis among the various appear rapidly as a mass that is types of thyroid cancers with the Medullary carcinomas originate often very sensitive. risk of recurrence increasing after from the C cells of the thyroid the age of 40. Microcarcinomas gland and represent 5-10% of thy- 2.3. Other benign nodules (smaller than 1 cm) have an excel- roid carcinomas. Parafollicular C lent prognosis. Patients with cells do not capture iodine and are Other benign nodules can be seen extension outside the thyroid and not regulated by TSH. A genetic in Hashimoto’s thyroiditis, de distant and lymphatic metastases enquiry has to be pursued in every Quervain’s thyroiditis and rarely at diagnosis have a less favourable case as there is a familial form in cases of infection. prognosis.13 transmitted in an autosomal domi- nant mode and in which both thy- 3. Malignant nodules 3.1.2. Follicular carcinoma roid lobes can be affected from the Follicular carcinoma constitutes start. The existence of specific 3.1. Well differentiated carcino- 10-20% of thyroid cancers. It is tumour markers facilitates diagno- mas typically a solitary, encapsulated sis. Well differentiated carcinomas of nodule with a greyish-white Medullary carcinomas have a the thyroid represent 80-85% of macroscopic appearance, and firm consistency at histopatholo- thyroid cancers. They are divided metastasizes by vascular invasion gy, their colour varies from according to their histopathology to the lung and bone. Follicular brown-yellow to pale pink and into papillary, follicular and less carcinoma with minimal invasion they have regular nuclei and abun- commonly, medullary carcino- has an excellent prognosis, while dant granular cytoplasm. The mas. the invasive form less so. It occurs diagnosis is confirmed by at a later age than papillary carci- immunohistochemistry with anti- 3.1.1. Papillary carcinoma noma (50-60 years of age) and its calcitonin antibodies and carcino- Papillary carcinoma is the com- prevalence increases by a factor of embryonic antigen. monest thyroid cancer with 2 in areas that are iodine deficient. Medullary carcinoma tends to 12,000 new cases per year in the At histopathology, this malig- metastasize to the cervical and United States. It is often multifo- nant epithelial tumour of the thy- mediastinal lymph nodes and less cal, has a peak incidence between roid has a follicular differentia- frequently to the lung, liver and Management of thyroid nodules 95 bone. In suspected familial cases types and accounts for less than carcinoma, and a medullary of medullary carcinoma, the close 5% of thyroid cancers. It usually carcinoma or an intrathyroid relatives should have calcitonin occurs in patients above the age of metastasis. levels measured as well as a pen- 50 with a goitre or a thyroid Survival is not modified by tagastrin test from the age of 5. nodule and has a peak incidence surgery, radiotherapy or chemo- The prognosis varies according to around 70 years of age. The therapy, averages 2-6 months and the age at first treatment and the tumour is rapidly invasive and rarely beyond 12 months. 10-year survival rate is around metastasizes readily to the lung, 85% in patients under the age of bone, brain and liver. 3.3. Other malignant tumours 30 who have no metastases or The tumour is composed of These consist mainly of sarcomas, lymphadenopathy and a tumour giant fusiform or polygonal cells lymphomas, histiocytosis, ter- diameter less than 4 cm. For the at histopathology. There is often a atomas and metastases from the other patients, the 10-year survival mixture of several cell types, breast, kidney, lung, colon or a rate drops to 10%. The sporadic along with keratinised, osteoblas- melanoma (see Table 1). forms have a worse prognosis than tic or sarcomatous cells. Epithelial the familial forms. structures are often present. Immunohistochemical studies 4. Management of a thyroid 3.2. Poorly differentiated carci- have to be performed systemati- nodule3,6,8,9,15,16 nomas cally. Keratin is the most useful epithelial marker and is present in – Anamnesis is essential, taking 3.2.1. Insular carcinoma 40-100% of the cases. Other anti- into account family history, The insular thyroid carcinoma bodies will enable discrimination gender, age (under 20, above usually presents as a nodule with between lymphoma or more rarely 60 years of age), any past or without an associated goitre. a poorly differentiated follicular medical history of irradiation to At histopathological examina- tion, insular carcinomas have a leveled architecture filled with Table 1 cavities.
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