Nodu|es nossein 6horib Mu M4cP M4c LNDCCkINL kAC1ICL Vo| 16 (Supp| 1) May]Iune 2010Mu ln18CuuC1lCn W 1hyrold nodules are a common cllnlcal flndlng W 1he esLlmaLed prevalence on Lhe basls of palpaLlon LhaL ranges from 3 Lo 7 W 1he prevalence of cllnlcally ln apparenL Lhyrold nodules ls esLlmaLed wlLh uS aL 20 Lo 76 key kecommeoJotloos W nlstoty 8ecord Lhe followlng lnformaLlon W Age W lamlly hlsLory of Lhyrold dlsease or cancer W revlous head or neck lrradlaLlon W 8aLe of growLh of Lhe neck mass W uysphonla dysphagla or dyspnea W SympLoms of hyperLhyroldlsm or hypoLhyroldlsm W use of lodlneconLalnlng drugs or supplemenLs 9yslcol xomlootloo W A careful physlcal examlnaLlon of Lhe Lhyrold gland and cervlcal lymph nodes ls mandaLory 8ecord W LocaLlon conslsLency and slze of Lhe nodule W neck Lenderness or paln W Cervlcal adenopaLhy ymptoms ooJ lqos W SympLoms such as a choklng sensaLlon cervlcal Lenderness or paln dysphagladysphonla or hoarseness of volce W Sudden paln ls commonly due Lo hemorrhage ln cysLlc nodule W rogresslve and palnful enlargemenL of a Lhyrold susplclon of anaplasLlc carclnoma or prlmary lymphoma ooses of 1ytolJ NoJoles W enlgn nodular golLer W Chronlc lymphocyLlc LhyroldlLls W Sub acuLe LhyroldlLls W rlmary Lhyrold lymphoma W Slmple or hemorrhaglc cysLs W lolllcular adenomas W aplllary carclnoma W lolllcular carclnoma W PurLhle cell carclnoma W oorly dlfferenLlaLed carclnoma W Medullary carclnoma W AnaplasLlc carclnoma W Sarcoma LeraLoma and mlscellaneous Lumors octots oqqestloq locteoseJ klsk of Mollqooot 9oteotlol W PlsLory of head and neck lrradlaLlon W lamlly hlsLory of M1C MLn 2 or 1C W Age 14 or 70 years W Male sex W Crowlng nodule W llrm or hard conslsLency W Cervlcal adenopaLhy W llxed nodule W erslsLenL dysphonla dysphagla or dyspnea Dlttosoooqtopy uS evaluaLlon ls noL recommended as a screenlng LesL lL ls recommended for W aLlenLs aL rlsk for Lhyrold mallgnancy W aLlenLs wlLh palpable Lhyrold nodules or MnCs W aLlenLs wlLh lymphadenopaLhy suggesLlve of mallgnanL leslon loJlcotloos fot NA 8lopsy lnA blopsy ls recommended for nodule(s) W 10 cm ln dlameLer solld and hypoecholc on uS W Cf any slze wlLh exLra capsular growLh or meLasLaLlc cervlcal lymph nodes W Cf any slze wlLh h/o neck lrradlaLlon or 1C M1C or MLn 2 ln flrsLdegree relaLlves prevlous Lhyrold surgery lncreased calclLonln levels W nodules LhaL are hoL on sclnLlgraphy should be excluded from lnA blopsy NA 8lopsy of MoltlooJolot ClooJs W lL ls rarely necessary Lo blopsy more Lhan 2 nodules - lf a radlolsoLope scan ls avallable do noL blopsy hoL areas - ln Lhe presence of susplclous cervlcal lymphadenopaLhy lnA blopsy of boLh Lhe lymph node and susplclous nodule(s) ls essenLlal tet uloqoostlc lmoqloq 1ecolpoes W M8l and C1 are noL lndlcaLed for rouLlne Lhyrold nodule evaluaLlon W M8l and C1 are lndlcaLed W assessmenL of slze W alrway compresslon or W subsLernal exLenslon of a nodular golLer oteNeeJle 8lopsy W Cn performed under uS guldance may offer addlLlonal lnformaLlon ln selecLed cases wlLh Lhyrold or neck masses and lnadequaLe lnA blopsy cyLologlc resulLs ytoloqlc uloqoosls CyLologlc dlagnoses should be organlzed lnLo 3 classes loss 1 NooJloqoostlc (looJepoote ot losofflcleot) samples wlLh processlng errors or an lnsufflclenL number of folllcular cells W loss 2 8eolqo (ot oeqotlve fot mollqooocy) locloJes collold or hyper plasLlc nodules PashlmoLo or granulomaLous LhyroldlLls and cysLs W loss J olllcolot lesloos all folllcularpaLLerned leslons lncludlng folllcular neoplasm PurLhle cell leslons and Lhe folllcular varlanL of 1C W C|oss 4 osplcloos samples LhaL suggesL a mallgnanL leslon buL do noL compleLely fulflll Lhe crlLerla for a deflnlLe dlagnosls W loss 5 Mollqooot (ot posltlve) samples characLerlzed by mallgnanL cyLologlc feaLures LhaL are rellably ldenLlfled by Lhe cyLopaLhologlsL kesolts of NA 8lopsy W enlgn 6080 W lolllcular leslon/neoplasm 10 Lo 20 W MallgnanL 33 Lo 10 W Susplclous 23 Lo 10 W nondlagnosLlc 10 Lo 13 obotototy volootloo lo 9otleots wlt 1ytolJ NoJoles W Always measure serum 1SP no furLher LesLlng for normal llmlLs W lncreased serum 1SP LesL free Lhyroxlne and 1CAb Lo evaluaLe for hypoLhyroldlsm W uecreased serum 1SP LesL free Lhyroxlne and LrllodoLhyronlne Lo evaluaLe for hyperLhyroldlsm AotlboJy Assoys W Plgh serum 1CAb values auLolmmune or PashlmoLo LhyroldlLls W AnLlLhyroglobulln anLlbody chronlc lymphocyLlc LhyroldlLls W 18Ab deLermlnaLlon should be performed ln paLlenLs wlLh hyperLhyroldlsm kAulNDlu ANNlNC 1ytolJ clotlqtopy W 1hyrold sclnLlgraphy ls Lhe only Lechnlque LhaL allows for assessmenL of Lhyrold reglonal funcLlon W nodules may be classlfled on Lhe basls of radlo nucleoLlde upLake W hyper funcLlonlng (hoL") W hypo funcLlonlng(cold") or W lndeLermlnaLe (100) MANACMN1 ANu 1nkA9 W Cllnlcal managemenL of Lhyrold nodules should be gulded by Lhe resulLs of uS evaluaLlon and lnA blopsy -odu/es -ondioqnostic by l-4 8iopsy W nondlagnosLlc repeaLed wlLh uS guldance W erslsLenLly non dlagnosLlc solld nodules surglcally exclsed NoJoles 8eolqo by NA 8lopsy W lollowup W 8epeaLed cllnlcal and uS examlnaLlon and 1SP measuremenL ln 6 Lo 18 monLhs W 8epeaLed uClnA blopsy otqlcol loJlcotloos fot 8eolqo NoJoles W resence of local pressure sympLoms W revlous exLernal lrradlaLlon W progresslve nodule growLh W susplclous uS feaLures or W cosmeLlc lssues DColJeJ 9l W Ll ls effecLlve ln Lhe LreaLmenL of benlgn Lhyrold cysLs and complex nodules W Ll should noL be performed ln sollLary solld nodules W Laser ablaLlon may be consldered for Lhe LreaLmenL of Lhyrold nodules causlng pressure sympLoms or cosmeLlc lssues koJloloJloe 1etopy fot 8eolqo NoJolot Coltet lndlcaLlons are W hyper funcLlonlng nodule W sympLomaLlc golLer W prevlous Lhyrold surgery or surglcal rlsk olllcolot esloos ManagemenL W 8epeaLed lnA blopsy of folllcular leslons ls noL recommended because lL does noL provlde addlLlonal lnformaLlon W Surglcal exclslon ls recommended for mosL folllcular Lhyrold leslons W lnLraoperaLlve frozen secLlon ls noL recommended as a rouLlne procedure Moooqemeot of NA 8lopsyosplcloos NoJoles W Surgery W lnLraoperaLlve frozen secLlon ls useful NoJoles Mollqooot by NA 8lopsy ManagemenL W ulfferenLlaLed Lhyrold carclnoma surglcal LreaLmenL ls recommended W AnaplasLlc carclnoma meLasLaLlc leslons and lymphoma dlagnosLlc workup ls recommended before surgery Moooqemeot of 1ytolJ NoJoles uotloq 9teqooocy W 1hyrold nodules ln pregnanL women should be managed ln Lhe same way as ln non pregnanL women W Avold use of radloacLlve agenLs for boLh dlagnosLlc and LherapeuLlc purposes W lor a growlng Lhyrold nodule durlng pregnancy followup should lnclude uS and lnA blopsy W lf lnA blopsy shows a folllcular leslon surgery may be deferred unLll afLer dellvery Moooqemeot of 1ytolJ NoJoles lo llJteo W LvaluaLlon of nodular dlsease ln chlldren ls slmllar Lo LhaL ln adulLs W ecause of a hlgher prevalence of mallgnancy ln chlldren surgery ls ofLen necessary for cold as well as hoL nodules