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  • • More aggressive variant of follicular thyroid neoplasms

    • History of radiation to the neck in some patients

    • Painless or enlarging nodule, dysphagia, or hoarseness

    • Firm or hard, fixed thyroid nodule; cervical lymphadenopathy

    • Normal thyroid function; solid nodule stippled with calcium (US), cold (radioiodine scan), positive or suspicious cytologic studies

    • Family history of thyroid cancer

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Epidemiology

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  • • Accounts for approximately 2% of all malignant thyroid tumors

    • Appears later in life than papillary thyroid cancers, with peak incidence in fifth decade

    • More common in women

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Symptoms and Signs

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  • • Thyroid nodule: Hard, rubbery, or soft

    • Enlarged or hard cervical lymph nodes

    • Pain in the thyroid or paralaryngeal neck

    • Hoarseness

    • Dyspnea

    • Stridor

    • Dysphagia

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Laboratory Findings

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  • • Normal thyroid-stimulating hormone (TSH)

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Imaging Findings

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  • • Solid or cystic nodule on US

    • Nonfunctioning (cold) on radioiodine scan

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  • • Fine-needle aspiration (FNA) is unable to reliably differentiate the atypical cells of invasive Hürthle adenocarcinoma from its counterpart benign adenoma

    • Sometimes bilateral and multicentric

    • Commonly metastasize to cervical lymph nodes

    • 95% resistant to radioiodine

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Rule Out

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  • • Concurrent hyperparathyroidism (so that it can be treated during the same operation if necessary)

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  • • Complete history and physical exam

    • -With attention to risk factors, family history, palpable characteristics of the nodule, or lymphadenopathy

    • Measurement of serum TSH and calcium

    • FNA biopsy

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  • • Treatment starts with operative removal

    • External beam radiation may palliate nonresectable metastases that are resistant to radioiodine

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Surgery

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Indications

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  • • All Hürthle cell neoplasms should be excised unless the Hürthle cell adenoma can be diagnosed with certainty on FNA

    • Bulky or palpable nodal recurrences

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Medications

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  • • Suppressive doses of thyroid hormone after thyroid ablation or thyroidectomy

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Treatment Monitoring

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  • • Semiannual or yearly neck exams, serum thyroglobulin, thyroglobulin antibodies, and whole body radioiodine scan

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Complications

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  • • Neck hematoma

    • Superior laryngeal nerve injury

    • Recurrent laryngeal nerve injury

    • Transient of permanent hypoparathyroidism

    • Wound infection

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Prognosis

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  • • Worse prognosis predicted by extensive angioinvasion, older age, and presence of distant metastases

    • 10-year survival rate, approximately 70%

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References

Cooper DS et al: Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2006;16:109.  [PubMed: 16420177]

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Practice Guidelines

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