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  • • Very common and most are not cancer

    • Central diagnostic question is whether the lesion is benign or malignant

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Epidemiology

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  • • Present in about 5% of the population

    • 5% of nodules represent thyroid cancer

    • 2-fold more common in females, although malignant nodules slightly more common in males

    • Risk of malignancy greater in persons older than 60 or in children younger than 15

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Symptoms and Signs

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  • • Often asymptomatic, and discovered as a nodule on routine physical exam or exam for another head/neck pathology

    • Occasional pain

    • Hoarseness

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Laboratory Findings

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  • • Serum thyroid-stimulating level (TSH) level (low in solitary toxic nodule, normal or elevated in nonfunctioning nodules)

    • Fine-needle aspiration biopsy can have the following results:

    • -Malignant

      -Benign

      -Indeterminate

      -Inadequate

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Imaging Findings

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  • US

    • -Can distinguish size of nodules and assess for presence of nonpalpable nodules

      -Also can distinguish solid from cystic nodules

    Thyroid scintigraphy: Not routinely indicated; sole remaining indication is in patients with hyperthyroidism and thyroid nodule.

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Rule Out

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  • • Thyroid cancer

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  • • Complete history and physical exam

    • -Focus on duration of swelling, recent growth, local symptoms (dysphagia, pain, voice changes), and systemic symptoms (hyperthyroidism, hypothyroidism); the patient's age, sex, place of birth, family history, and history of head/neck irradiation are most important

    • Thyroid function tests

    • Cervical ultrasound to assess thyroid and regional lymph nodes

    • Fine-needle aspiration biopsy; ultrasound-guided has a higher diagnostic rate

    • Observation, medical therapy, or surgery

    • Thyroid scintigraphy only if patient hyperthyroid (rare)

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Surgery

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Indications

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  • • Obstruction of the aerodigestive tract

    • FNA biopsy with malignant or indeterminate result

    • 3 successive inadequate biopsies

    • Recurrence of cyst after 2 aspirations

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Medical

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  • • TSH suppression with l-thyroxine if patient hypothyroid; may arrest nodule growth

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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]
Wong CK et al. Thyroid nodules: Rational management. World J Surg. 2000;24:934.  [PubMed: 10865037]

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