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Surgeons find unsuspected Thyroid Problems in Elderly Patients through Clinical Imaging Studies

Newswise — Routine imaging studies of older patients are finding thyroid nodules that may be malignant before they cause signs or symptoms of disease, and the abnormalities need to be addressed just as aggressively as those that are found by a physician during a physical examination, concluded surgeons from Rush University Medical Center, Chicago, who presented a study of thyroid cancer in the elderly at the 2008 Clinical Congress of the American College of Surgeons.

“Researchers are investigating whether thyroid nodules that are discovered incidentally on imaging studies of the head or neck or chest should be pursued to the same degree as those that present clinically, such as when a patient feels a mass in the thyroid area or has symptoms of thyroid disease.

“This study would suggest that physicians should, because thyroid nodules are discovered incidentally more often in the elderly, and this is the group that is more likely to have thyroid cancer and to die from it,” according to Richard A. Prinz, MD, FACS, Helen Shedd Keith Professor and chair of the department of general surgery, Rush University Medical Center.

According to findings from the study, elderly patients were two times more likely to be diagnosed with thyroid cancer than younger patients while undergoing imaging examinations for other reasons.

Thyroid cancer was found in 41 percent of patients over the age of 65 compared with 22 percent of younger patients.

he study included 241 elderly thyroid cancer patients and 41 younger patients who were treated for the disease at Rush University Medical Center. “Older patients are much more likely to receive clinical testing.

As patients get older, they have their spine evaluated for degenerative arthritis and other conditions that affect the spine.

The same is true with ultrasound Doppler evaluation of the carotid artery for arteriosclerosis, which doesn’t occur until later in life.

Patients in their 70s are likely to have a question about arterial disease or the spine or a chest problem.

"So this group is much more likely to have a thyroid nodule discovered incidentally on some other type of imaging study, and rather than saying it’s probably nothing, physicians have to pursue it,” Dr. Prinz explained.

Results from the study also confirmed that older patients with thyroid cancer have a worse prognosis.

Elderly patients tended to have larger tumors, higher rates of distant metastases, and shorter times to recurrence of disease than younger patients in the study.

The incidence of thyroid cancer has been steadily rising. Between 1973 and 2002, there has been more than a two-fold increase in the number of new cases of thyroid cancer detected each year in the United States.

Thyroid cancer accounts for 1 percent of all malignancies and 0.3 percent of all deaths from cancer among the elderly patients.

Yet only 5 percent of thyroid nodules that can be felt by a physician during a physical examination are diagnosed as malignant, and less than 0.1 percent exhibit signs and symptoms that may be detected in the elderly.

Most forms of thyroid cancer can be treated effectively by surgically removing the thyroid gland as well as any involved lymph nodes in the neck.

Radio-iodine therapy is given to ablate any remaining thyroid tissue after a thyroidectomy (surgical removal of the thyroid), particularly for patients who have tumors that are larger than a centimeter or have disease that has spread to the lymph nodes and surrounding tissue.

Doses that suppress the release of thyroid stimulating hormone also may be given.

“For elderly patients, these treatments are rather benign. Radio-iodine therapy is not associated with complications.

It is not like a typical course of chemotherapy that causes hair loss and increases the risk of developing an infection. The operation is safe and has a low level of complications,” said Dr. Prinz.

Treatment should not be ruled out, therefore, because of the age of a patient.

 “Elderly patients may not be enthused about or encouraged to have treatment because an operation is involved.

"Their physicians may be more concerned about managing chronic disease, such as diabetes or cardiovascular disease, and they may not be as alert to the development of other abnormalities that are picked up on imaging modalities,” he said.

However, primary care and other physicians who review imaging studies of elderly patients should carefully evaluate any suspicious anatomic features in the thyroid, such as any nodules that are larger than a centimeter or that have an irregular border or internal vascularization.

“Once we find a nodule in the thyroid, we can’t put our heads in the sand and ignore .

"We have to look at all the imaging characteristics on incidental scans and, if need be, do an ultrasound of the thyroid, which is the best imaging way to evaluate the thyroid gland.

“If there are worrisome features, we need to do a fine needle aspiration biopsy of the nodule.

"This approach holds true for younger as well as older patients, but since elderly patients are more likely to have cancer, there should be greater concern and more willingness to evaluate any nodules found on imaging scans,” Dr. Prinz said.

Gardner Scott Smith, MD; Matthew Raday, BS; and Paulo Gattuso, MD, also participated in the study.