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  • • 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; nodule stippled with calcium (x-ray), solid (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 10% of all malignant thyroid tumors

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

    • 3 times more common in women than in men

    • Incidence decreasing as the intake of dietary iodine has increased

    • 80% of encapsulated follicular tumors > 4 cm are malignant

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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) levels

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Imaging Findings

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  • US: Solid or cystic nodule

    Radioiodine scans: Nonfunctioning (cold)

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

    • Follicular carcinoma distinguished from follicular adenoma by capsular and vascular invasion

    • 7% spread lymphatically; most spread hematogenously (to lungs, skeleton, liver, and CNS)

    • Skeletal metastases may appear 10 years after resection of primary tumor

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Rule Out

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  • • Concurrent hyperparathyroidism (so that it can be treated at 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

    • Cervical ultrasound to assess the thyroid gland and cervical adenopathy

    • Fine-needle aspiration biopsy

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  • • 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 follicular thyroid cancers should be excised

    • Imageable or palpable nodal recurrences

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Medications

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

    • Radioactive iodine therapy for remnant, recurrent, or metastatic disease

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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 or 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 nearly 100% with only microinvasion

    • 10-year survival about 72% with angioinvasion

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References

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

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