Nodul Tiroid

Dr. Menik Herdwiyanti SpPD

Topik

Definisi dan etiologi

Faktor risiko nodul tiroid
Patofisiologi nodul tiroid
Diagnosis
tatalaksana
 Definisi dan etiologi

 neoplasia endokrin yang paling sering ditemukan di klinik.

 Lokasi kelenjar tiroid yang unik, yaitu berada di superfisial  mudah
dapat dideteksi baik
 pemeriksaan fisik , moda diagnostik seperti ultrasonografi, sidik tiroid
(sintigrafi), atau CT scan.
 Adenoma yaitu suatu pertumbuhan jinak jaringan baru dari struktur
kelenjar sedangkan istilah nodul tidak spesifik karena dapat
berupa kista, karsinoma, lobul dari jaringan normal, atau lesi fokal
lain yang berbeda dari jaringan normal.
 2015 American Thyroid Association Management Guidelines for Adult
Patients with Thyroid Nodules and Differentiated Thyroid Cancer
The American Thyroid Association Guidelines Task Force
on Thyroid Nodules and Differentiated Thyroid Cancer

 A thyroid nodule is a discrete lesion within the thyroid gland that is radiologically
distinct from the surrounding thyroid parenchyma

Generally, only nodules >1 cm should be evaluated,  greater potential to be clinically

significant cancers.

Prevalence of palpable thyroid nodules to be approximately 5% in women and 1% in men living

in iodine-sufficient parts of the world contrast, high-resolution ultrasound (US) can detect
thyroid nodules in 19%–68% of randomly selected individuals, with higher frequencies in women
and the elderly.
The clinical importance of thyroid nodules rests with the need to exclude thyroid cancer, which
occurs in 7%–15% of cases
Epidemiologi

The prevalence of thyroid nodule is increasing rapidly;

Palpable thyroid nodule : 5% in women; 1 % in men living in iodine sufficient area;

High-resolution US : thyroid nodules in 19% - 68% of randomly selected individuals,

higher frequencies in women and the elderly;

Thyroid cancer occurs in 7% - 15% of cases depending on age, sex, radiation

exposure history, family history, and other factors.
Epidemiologi

 0.8 % adult men and 5.3% adult women in Whickham, England

 1.5% men and 6.4% women between 30-59 yrs in Framingham, Mass.

 Ultrasonography : up to 50% nodules beyond 5th decade.

 Autopsy studies : Thyroid nodularity in approximately 37%, 12% solitary nodule.

 Increasing prevalence with age.

 Thyroid cancer in solitary thyroid nodule : 10-15%

 Klasifikasi Nodul Tiroid

2015 American Thyroid Association Management

Guidelines for Adult Patients with Thyroid Nodules
and Differentiated Thyroid Cancer

Screening programs for patients at risk of oncological

disease are usually advocated based on the
following evidence:
(a)a clear demonstration that the patient is indeed
at risk;
(b)demonstration that screening allows the
detection of the disease at an earlier stage;
(c) early diagnosis has an impact on subsequent
outcome, both recurrence and survival.
Topik

Definisi dan etiologi

Faktor risiko nodul tiroid
Patofisiologi nodul tiroid
Diagnosis
tatalaksana
 Faktor Risiko

Perjalanan klinik dari suatu nodul belum

dipahami sepenuhnya. Penelitian dari Kuma
dkk. (1994) melaporkan dari 134 pasien
dengan nodul jinak (dibuktikan secara
sitologis) yang diamati secara fisik dan
ultrasonografi selama 9 sampai 11 tahun
tanpa diberi pengobatan apapun:
• 43% nodul akan mengalami regresi spontan,
• 23% bertambah Besar.
• 33% menetap.
Topik

Definisi dan etiologi

Faktor risiko nodul tiroid
Patofisiologi nodul tiroid
Diagnosis
tatalaksana
Patofisiologi Nodul Tiroid
Patofisiologi Nodul Tiroid
Patofisiologi Nodul Tiroid
Topik

Definisi dan etiologi

Faktor risiko nodul tiroid
Patofisiologi nodul tiroid
Diagnosis
tatalaksana
 The philosophy of the management of thyroid nodule is to
Diagnosis identify the small proportion of patients with thyroid cancer and
avoid unnecessary surgery or treatment for the majority.
 Clinical Aspects Diagnostic Workup

Age

Ultrasonography
Family history

History of irradiation: head and neck

FNAB

Rapid growth and pain Radionuclide scintigraphy

Dysphonia, dysphagia, and dyspnea

CT scan, MRI, PET Scan

Hyper or hypothyroidism
Laboratory examination
Drugs and iodine supplement
Diagnosis
Diagnosis
Ultrasonography
Morphological imaging

Size and volume of nodule

Differentiate :
• simple cysts (low risk of being malignant)
• solid, mixed cystic (5% risk of being malignant)
Guidance for diagnostic and therapeutic procedures

Monitoring effect of treatment

Can not reliably distinguish benign and malignant lesions

Hegedus L. N Engl J Med 2004

USG TIROID
USG TIROID
 Thyroid ultrasound features and risk of malignancy

• Thyroid cyst
• Mostly cystic nodule with reverberating artifacts
• Isoechoic spongiform nodule

Isoechoic nodule with:

• central vascularity
• microcalcification
• indeterminate hyperechoic spots
• elevated stiffness on elastography
 Thyroid ultrasound features and risk of malignancy

• Marked hypoechogenicity
• Microcalcification
• Irregular (spiculated) margins
• More tall than wide
• Extracapsular growth
• Suspicious regional lymph node

A thyroid nodule was detected on carotid sonography of a 23-year-old man,

performed because of reported dizziness. Thyroid palpation yielded an normal
result, and the thyrotropin level was 0.8 mIU/L. Thyroid US showed a 7-mm right
nodule with microcalcifications typical of papillary thyroid carcinoma. Results of
thyroidectomy confirmed papillary thyroid carcinoma.

(Dean and Gharib, 2008)

* Differential diagnosis of thyroid cancer and selection of nodule suitable for FNAB;
* High predictive of malignancy (sensitvity 94.1%);
* Misleading results in benigns nodule with coarse calcification;
* Cystic lesion : can not give useful information;
* Lack of sensitivity for follicular thyroid carcinoma.
 Fine Needle
Aspiration Biopsy

 Safe, simple, cost-effective, and quick

 First line diagnostic test
 About 4% aspirates are malignant, mainly papillary
 Limitasi :
• Adequacy of specimen and accuracy of cytopathologic interpretation
• 20% of samples are initially unsatisfactory
• Follicular adenomas cannot be distinguished from carcinomas; 15% will be malignant
• False negatives ~ 1%
US-guided FNAB

 Reduce the number of diagnostic thyroidectomy

 Improve diagnostic accuracy post-thyroidectomy
FNAB / BAJAH
FNAB/BAJAH
Sidik tiroid (skintigrafi tiroid, thyroid scan)

 pencitraan isotopik yang akan memberikan gambaran morfologi

fungsional, yang berarti hasil pencitraan merupakan refleksi dari fungsi
jaringan tiroid.
 NaI-123 / NaI-131 :Trapping & Organification

 Tc-99m pertechnetate: Only trapping

 Tc-99m Sestamibi/MIBI : Tumor scanning agent

 F-18 FDG : Metabolic agent

 INDIKASI SIDIK TIROID

 The diagnosis of ectopic thyroid tissue;  subclinical hyperthyroidism

 Single thyroid nodule & supressed TSH level  to identify occult hyperfunctioning tissue
 FNA biopsy is not necessary for hot thyroid  follicular lesions
nodules
 to identify a functioning cellular adenoma
 Multinodular Goiter that may be benign;
 even without supressed TSH,  however, more such noduler are cold on
scintigraphy;
 to identify cold or indeterminate areas for
FNA biopsy  determine eligibility for radioiodine therapy
 and hot areas that do not need cytologic  To distinguish low-uptake from high uptake
evaluation; thyrotoxicosis.
Sidik Tiroid

Berdasarkan distribusi radioaktivitas pada sidik tiroid dapat dilihat :

 Distribusi difus – rata di kedua lobi (normal)
 Distribusi kurang/tidak menangkap radioaktivitas pada suatu area /nodul ,
disebut dingin (cold nodule)
 Penangkapan radioaktivitas pada satu area / nodul lebih tinggi dari jaringan
sekitarnya , disebut sebagai nodul panas (Hot nodule)
 Penangkapan radioaktivitas di suatu daerah/nodul sedikit meninggi / hampir
sama dengan daerah sekitarnya disebut sebagai nodul hangat (warm nodule
area) , nodule hangat disebabkan oleh hiperplasia jaringan tiroid fungsional di
daerah tersebut.
Sidik Tiroid -NORMAL

• Thyroid lobes : two elliptical columns, slightly

angled towards each other inferiorly; lateral
margins are usually straight or concave.
• The isthmus may or may not be visualized;
lobus pyramidalis can be recognized in 10 % pts.
• Salivary gland and gastric mucosa are usually
visualized (NIS is present in these tissues)
Sidik Tiroid –COLD NODULE

• Cold nodule (90% of nodules)  5 – 10 % risk

of being malignant
Sidik Tiroid –HOT NODULE

• Nodul tiroid autonom (Autonomously Funcional

Thyroid Nodule = AFTN) adalah nodule tiroid
fungsional yang tampak sebagai nodul panas dan
menekan fungsional yang tampak sebagai nodul
panas dan menekan fungsi jaringan tiroid normal
sekitarnya.
Topik

Definisi dan etiologi

Faktor risiko nodul tiroid
Patofisiologi nodul tiroid
Diagnosis
tatalaksana
No therapy for benign nodule

Hormonal suppression therapy with l-thyroxine

Aspiration and Percutaneous Ethanol Injection

Interstitial Laser Photocoagulation (ILP)

Radiofrequency ablation

Radioactive iodine

Surgery
Terapi Supresi dengan I-tiroksin.

 pilihan yang paling sering dan mudah dilakukan.  menghambat

pertumbuhan nodul serta mungkin bermanfaat pada nodul kecil.
 hanya sekitar 20% nodul yang responsif
 . Terapi supresi dilakukan dengan memberikan I-tiroksin dalam dosis
supresi dengan sasaran kadar TSH sekitar 0,1-0,3 mIU/ml.
 selama 6-12 bulan  nodul tidak mengecil atau bertambah besar
perlu dilakukan biopsi ulang atau disarankan operasi.
 Komplikasi : hipertiroidisme subklinik dengan efek samping berupa
osteopeni atau gangguan pada jantung.
Suntikan ethanol perkutan
(Percutaneus Ethanol Injection).

 menyebabkan dehidrasi seluler, denaturisasi protein dan nekrosis

koaglatif pada jaringan tiroid dan infark hemoragik akibat
trombosis vaskular, akan terjadi juga penurunan aktivitas enzim
pada sel-sel yang masih viable yang mengelilingi jaringan nekrotik.
 Terapi sklerosing dengan etanol dilakukan pada nodul jinak atau
kistik dengan menyuntikkan larutan etanol (alkohol).
 6 bulan ukuran nodul bisa berkurang sebesar 45%
 Efek samping : rasa nyeri yang hebat, rembesan (leakage) alkohol
ke jaringan ekstatiroid, juga ada risiko tirotoksikosis dan paralisis pita
suara.
Terapi Iodium Radioaktif (I-131)

 dilakukan pada nodul tiroid autonom atau nodul panas (fungsional ) baik yang
dalam keadaan eutiroid maupun hipertiroid.

 diberikan pada struma multinodosa non–toksik terutama bagi pasien yang tidak
bersedia dioperasi atau mempunyai risiko tinggi untuk dioperasi.

 mengurangi volume nodul tiroid dan memperbaiki keluhan dan gejala

penekanan pada sebagian besar pasien.

 Efek samping :tiroiditis radiasi (jarang) dan disfungsi tiroid pasca-radiasi seperti
hipertoridisme selintas dan hipotiroidisme.
Terapi Pembedahan

 terhadap jaringan vital disekitar nodul

 Hemitiroidektomi dapat dilakukan pada nodul jinak, sedangkan
berapa luas tiroidektomi yang akan dilakukan pada nodul ganas
tergantung pada jenis histologi dan tingkat risiko prognostik.
 penyulit : perdarahan pasca-pembedahan, obstruksi traskea
pasca –pembedahan , gangguan pada n.rekurens laringeus,
hipoparatiroidi, hipotiroidi atau nodul kambuh.
Terapi laser Interstisial dengan tuntunan
Ultrasonografi

 “low power laser energy ” , energi termik yang diberikan dapat

mengakibatkan nekrosis nodul tanpa atau sedikit sekali kerusakan
pada jaringan sekitarnya. Suatu studi tentang terapi laser yang
dilakukan oleh Dossing dkk (2005) pada 30 pasien dengan nodul
padat-dingin soliter jinak (benign solitary solid-cold nodule)
mendapatkan hasil sebagai berikut: pengecilan volume nodul
sebesar 44%
Terima Kasih