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{{familytree | | C01 | | | | |!| | | | | C03 |C01= '''Bethesda classification system''' |C03= '''TIRAD classification system'''}}
{{familytree | | C01 | | | | |!| | | | | C03 |C01= '''Bethesda classification system''' |C03= '''TIRAD classification system'''}}
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{{familytree | | |!| | | | | |!| | | | | |!| }}
{{familytree | | C01 | | | | |!| | | | | C03 |C01= Based on thyroid cytopathology |C03= Based on sonographhic features}}
{{familytree | | C01 | | | | |!| | | | | C03 |C01= Based on thyroid [[cytopathology]] |C03= Based on [[Ultrasound|sonographhic]] features}}
{{familytree | | |!| | | | | |!| | | | | |!| }}
{{familytree | | |!| | | | | |!| | | | | |!| }}
{{familytree | boxstyle=text-align: left; | | C01 | | | | |!| | | | | C03 |C01= •Benign <br> •Nondiagnostic or Unsatisfactory <br> •Follicular lesion of undetermined significance <br> •Atypia of undetermined significance <br> •Follicular neoplasm <br> •Suspicious for a follicular neoplasm <br> •Malignant <br> | C03= •TIRADS 1=Normal thyroid gland <br> •TIRADS 2=Benign lesions <br> •TIRADS 3=Probably benign lesions <br> •TIRADS 4= Contain 1-4 suspicious features <br> •TIRADS 5=Contain all five suspicious features <br> •TIRADS 6=Biopsy proven malignancy}}
{{familytree | boxstyle=text-align: left; | | C01 | | | | |!| | | | | C03 |C01= •[[Benign]] <br> •Nondiagnostic or Unsatisfactory <br> •Follicular lesion of undetermined significance <br> •[[Atypia]] of undetermined significance <br> •Follicular neoplasm <br> •Suspicious for a follicular neoplasm <br> •[[Malignant]] <br> | C03= •TIRADS 1=Normal [[thyroid gland]] <br> •TIRADS 2=[[Benign]] lesions <br> •TIRADS 3=Probably [[benign]] lesions <br> •TIRADS 4= Contain 1-4 suspicious features <br> •TIRADS 5=Contain all five suspicious features <br> •TIRADS 6=Biopsy proven [[malignancy]]}}
{{familytree | | | | | | | | C02 | | | | | | | C02= Differentiated and anaplastic thyroid carcinoma }}
{{familytree | | | | | | | | C02 | | | | | | | C02= Differentiated and anaplastic thyroid carcinoma }}
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{{familytree | | | | |,|-|-|-|^|-|-|-|.| | | }}
{{familytree | | | | F01 | | | | | | F02 | | | | F01 = '''TNM staging AJCC UICC 2017''' |  F02 = '''Classification based on their origin'''}}
{{familytree | | | | F01 | | | | | | F02 | | | | F01 = '''TNM staging AJCC UICC 2017''' |  F02 = '''Classification based on their origin'''}}
{{familytree | | | | |!| | | | | |,|-|^|-|.| | | | }}
{{familytree | | | | |!| | | | | |,|-|^|-|.| | | | }}
{{familytree | boxstyle=text-align: left; | | | | F01 | | | X01 | | | | X02 | | | F01 = C02= Papillary, follicular, poorly differentiated, Hurthle cell and anaplastic thyroid carcinoma: <br> •Primary tumor (T) <br> •Regional lymph nodes (N) <br> •Distant metastasis (M) | X01 = Nonmedullary (epithelial) thyroid cancers (NMTCs) <br> •Papillary cell tumors <br> •Follicular tumors <br> •Hurthle cell tumors <br> •Anaplastic tumors> | X02 = Medullary thyroid cancers }}
{{familytree | boxstyle=text-align: left; | | | | F01 | | | X01 | | | | X02 | | | F01 = C02= [[Papillary thyroid cancer|Papillary]], [[Follicular thyroid cancer
|follicular]], poorly differentiated, Hurthle cell and [[Anaplastic thyroid cancer|anaplastic thyroid carcinoma]]: <br> •Primary tumor (T) <br> •Regional [[lymph node|lymph nodes]] (N) <br> •Distant [[metastasis]] (M) | X01 = Nonmedullary (epithelial) [[thyroid cancers]] (NMTCs) <br> •Papillary cell tumors <br> •Follicular tumors <br> •Hurthle cell tumors <br> •Anaplastic tumors> | X02 = Medullary thyroid cancers }}
{{familytree/end}}
{{familytree/end}}



Revision as of 19:14, 11 October 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahshid Mir, M.D. [2]

Overview

Classification

 
 
 
 
 
 
 
Thyroid nodule classification
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bethesda classification system
 
 
 
 
 
 
 
 
 
 
TIRAD classification system
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Based on thyroid cytopathology
 
 
 
 
 
 
 
 
 
 
Based on sonographhic features
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Benign
•Nondiagnostic or Unsatisfactory
•Follicular lesion of undetermined significance
Atypia of undetermined significance
•Follicular neoplasm
•Suspicious for a follicular neoplasm
Malignant
 
 
 
 
 
 
 
 
 
 
•TIRADS 1=Normal thyroid gland
•TIRADS 2=Benign lesions
•TIRADS 3=Probably benign lesions
•TIRADS 4= Contain 1-4 suspicious features
•TIRADS 5=Contain all five suspicious features
•TIRADS 6=Biopsy proven malignancy
 
 
 
 
 
 
 
Differentiated and anaplastic thyroid carcinoma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TNM staging AJCC UICC 2017
 
 
 
 
 
Classification based on their origin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
C02= Papillary, [[Follicular thyroid cancer |follicular]], poorly differentiated, Hurthle cell and anaplastic thyroid carcinoma:
•Primary tumor (T)
•Regional lymph nodes (N)
•Distant metastasis (M)
 
 
Nonmedullary (epithelial) thyroid cancers (NMTCs)
•Papillary cell tumors
•Follicular tumors
•Hurthle cell tumors
•Anaplastic tumors>
 
 
 
Medullary thyroid cancers
 
 

The Bethesda System for Reporting Thyroid Cytopathology

To address terminology and other issues related to thyroid fine-needle aspiration (FNA), the National Cancer Institute (NCI) developed a new classification method called "The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC)".[1]

classification FNA cytology Predicted risk of malignancy
Benign
  • Macrofollicular
  • Adenomatoid/hyperplastic nodules
  • Colloid adenomas (most common)
  • Nodular goiter
  • Lymphocytic thyroiditis
  • Granulomatous thyroiditis
0–3 %
Nondiagnostic or Unsatisfactory 1–4 %
Follicular lesion of undetermined significance
  • Mixed macro- and microfollicular nodules
5–15 %
Atypia of undetermined significance
  • Atypical cells
Follicular neoplasm
  • Microfollicular nodules
    • Hurthle cell lesions
15–30 %
Suspicious for a follicular neoplasm
  • Suspicious for Hurthle cell neoplasm
60–75 %
Malignant
  • PTC (most common)
  • MTC
  • Anaplastic carcinoma
  • High-grade metastatic cancers
97–99 %

Classification based on TNM

The TNM classification (tumor-node-metastasis) was adopted by the American Joint Committee on Cancer and the International Union against Cancer more than 10 years ago. This classification system mainly focuses on prognosis, and is developed to avoid heterogeneity of prognostic classification schemes used for differentiated thyroid cancers.

9360506

Differentiated and anaplastic thyroid carcinoma TNM staging AJCC UICC 2017

Papillary, follicular, poorly differentiated, Hurthle cell and anaplastic thyroid carcinoma
Primary tumor (T) Regional lymph nodes (N) Distant metastasis (M)
T category T criteria N category N criteria M category M criteria
TX Primary tumor cannot be assessed NX Regional lymph nodes cannot be assessed M0 No distant metastasis
T0 No evidence of primary tumor N0 No evidence of locoregional lymph node metastasis M1 Distant metastasis
T1 Tumor ≤2 cm in greatest dimension limited to the thyroid N0a One or more cytologically or histologically confirmed benign lymph nodes
T1a Tumor ≤1 cm in greatest dimension limited to the thyroid N0b No radiologic or clinical evidence of locoregional lymph node metastasis
T1b Tumor >1 cm but ≤2 cm in greatest dimension limited to the thyroid N1 Metastasis to regional nodes
T2 Tumor >2 cm but ≤4 cm in greatest dimension limited to the thyroid N1a Metastasis to level VI or VII (pretracheal, paratracheal, or prelaryngeal/Delphian, or upper mediastinal) lymph nodes. This can be unilateral or bilateral disease.
T3 Tumor >4 cm limited to the thyroid, or gross extrathyroidal extension invading only strap muscles N1b Metastasis to unilateral, bilateral, or contralateral lateral neck lymph nodes (levels I, II, III, IV, or V) or retropharyngeal lymph nodes
T3a Tumor >4 cm limited to the thyroid
T3b Gross extrathyroidal extension invading only strap muscles (sternohyoid, sternothyroid, thyrohyoid, or omohyoid muscles) from a tumor of any size
T4 Includes gross extrathyroidal extension
T4a Gross extrathyroidal extension invading subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve from a tumor of any size
T4b Gross extrathyroidal extension invading prevertebral fascia or encasing the carotid artery or mediastinal vessels from a tumor of any size

Thyroid Nodule Classification Based on the Ultrasound Features

Classification system has been proposed by Horvath et al, with a modified recommendation from Jin Kwak et al.[2]

TIRADS 1 Normal thyroid gland
TIRADS 2 Benign lesions
  • Avascular anechoic lesion with echogenic specks (colloid type I)
  • vascular heteroechoic non-expansile, non-encapsulated nodules with peripheral halo (colloid type II)
  • isoechoic or heteroechoic, non-encapsulated, expansile vascular nodules (colloid type III)
0% risk of malignancy
TIRADS 3 Probably benign lesions
  • Nodule property:
    • Hyperechoic, iso-echoic or hypoechoic nodules, with partially formed capsule and peripheral vascularity, usually in setting of Hashimoto's thyroiditis (Hashimoto's pseudonodule)
<5% risk of malignancy
TIRADS 4 4a One suspicious feature
  • Suspicious lesions:
    • solid component
      • high stiffness of nodule on elastography if available
    • markedly hypoechoic nodule
    • microlobulations or irregular margins
    • microcalcifications
    • taller-than-wider shape
5-10% risk of malignancy
4b Two suspicious features 10-80% risk of malignancy
4c Three/four suspicious features
TIRADS 5 All five suspicious features Probably malignant lesions (more than 80% risk of malignancy) >80% risk of malignancy
TIRADS 6 Biopsy proven malignancy

Classification of neoplastic thyroid nodules based on their origin:

Origin histologic subtypes Subclass
Nonmedullary thyroid cancers (NMTCs) 95% of tumors thyroid epithelial cells papillary (85%) 95% are sporadic tumors

5% may be related to inherited genetics due to familial origin

  • Classic varient
  • tall cell variant
  • insular varient
  • columnar variant
  • Hürthle or oxyphilic variant
  • solid or trabecular variant
  • clear cell variant
  • diffuse sclerosing variant
  • cribriform morular variant
  • hobnail variant
follicular (11%)
  • Benign follicular adenoma
  • Minimally invasive follicular carcinoma
  • Widely invasive follicular carcinoma
  • Encapsulated follicular variant of papillary thyroid cancer
  • Infiltrative variant of papillary thyroid cancer
Hürthle cell (3%)
anaplastic (1%)
Medullary thyroid cancers (MTCs) 5% of all thyroid malignancies calcitonin-producing parafollicular cells 20% they are familial and occur as part of the multiple endocrine neoplasia (MEN) syndromes

Of the differentiated cancers, papillary cancer comprises about 85% of cases compared to about 10% that have follicular histology, and 3% that are Hu¨rthle cell or oxyphil tumors

References

  1. Cibas ES, Ali SZ (2009). "The Bethesda System for Reporting Thyroid Cytopathology". Thyroid. 19 (11): 1159–65. doi:10.1089/thy.2009.0274. PMID 19888858.
  2. Horvath E, Majlis S, Rossi R, Franco C, Niedmann JP, Castro A, Dominguez M (2009). "An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management". J. Clin. Endocrinol. Metab. 94 (5): 1748–51. doi:10.1210/jc.2008-1724. PMID 19276237.

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