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1. Clinical Impression? Differentials? Thyroid Carcinoma • commonly manifests as a painless, palpable, solitary thyroid nodule • The patient's age at presentation is important because solitary nodules are most likely to be malignant in patients older than 60 years and in patients younger than 30 years • • thyroid nodules are associated with an increased rate of malignancy in male individuals Malignant thyroid nodules are usually painless Differentials: • • • • • • • Papillary carcinoma Follicular carcinoma Hürthle cell carcinoma Medullary carcinoma Anaplastic carcinoma Primary thyroid lymphoma Metastasis PAPILLARY vs. FOLLICULAR Papillary Thyroid Cancer • • • • • • • Follicular Thyroid Cancer · Peak onset ages 40 through 60 Peak onset ages 30 through 50 Females more common than males · Females more common than males by 3 to 1 ratio by 3 to 1 ratio directly related to tumor size Prognosis directly related to tumor · Prognosis [less than 1.0 cm (3/8 inch) good size [less than 1.5 cm (1/2 inch) prognosis] good prognosis] · Rarely associated with radiation exposure Accounts for 85% of thyroid cancers · Spread to lymph nodes is uncommon due to radiation exposure (~10%) Spread to lymph nodes of the neck · Invasion into vascular structures (veins and arteries) within the thyroid gland is present in more than 50% of cases common Distant spread (to lungs or bones) is · Distant spread (to lungs or bones) is very uncommon uncommon, but more common than with Overall cure rate very high (near papillary cancer 100% for small lesions in young · Overall cure rate high (near 95% for small patients) lesions in young patients), decreases with advanced age 2. Work ups A. Physical Examination • head and neck • examination with careful attention to the thyroid gland and cervical soft tissues • Hard and fixed thyroid nodules are more suggestive of malignancy than supple mobile nodules are. • Thyroid carcinoma is usually nontender to palpation. • Firm cervical masses are highly suggestive of regional lymph node metastases. • Vocal fold paralysis implies involvement of the recurrent laryngeal nerve. B. Measurement of Thyroid Hormones • thyroid-stimulating hormone (TSH) assay, to screen for hypothyroidism or hyperthyroidism. • A low serum TSH value suggests an autonomously functioning nodule, which typically is benign. • Malignant disease cannot be ruled out on the basis of low or high TSH levels. C. Imaging procedures • Ultrasound also can be used to assess for cervical lymphadenopathy and to guide fine-needle aspiration (FNA) biopsy. • The usefulness of ultrasonography for distinguish between malignant and benign nodules is limited. • Microcalcifications noted on sonograms are assoHelpful in distinguishing solid nodules from cystic ones, and providing information about size and multicentricity. D. Fine-needle aspiration biopsy (FNAB) • FNAB is highly cost-effective compared with traditional workups like nuclear imaging and ultrasonography. • Papillary thyroid carcinoma and MTC are often positively identified on the basis of FNAB results alone. • definitive surgical planning can be undertaken at the outset. • Patients with follicular neoplasm, as determined with FNAB results, should undergo surgery for thyroid lobectomy for tissue diagnosis. 3. Treatment Surgical Treament • Primary treatment for papillary and follicular carcinoma is surgical excision whenever possible. • Near-total thyroidectomy with lymph node dissection • After thyroidectomy, patients undergo radioiodine scanning to detect regional or distant metastatic disease followed by radioablation of any residual disease found. – Patient should be treated for several weeks postoperatively with (liothyronine 25 micro grab bid-tid) – Withdrawal for an additional 2 weeks 4. Management Thyroid suppression • Patients take T4 in daily doses sufficient to suppress TSH production by the pituitary. • Low TSH levels in the bloodstream reduce tumoral growth rates and reduce recurrence rates of welldifferentiated thyroid carcinomas. Follow-up care • Patients are regularly monitored every 6-12 months with serial radioiodine scanning and serum thyroglobulin measurements after surgery and radioiodine therapy. • Thyroglobulin- a useful marker of tumor recurrence because welldifferentiated thyroid cancers synthesize thyroglobulin. • Serum thyroglobulin is measured during the withdrawal of thyroid hormone or the administration of recombinant TSH. • Serum antithyroglobulin antibody levels should be obtained with each thyroglobulin measurement. • Rising thyroglobulin level after thyroid ablation suggests recurrence. • Ultrasonography of the neck can also be used to detect regional recurrences. 5. Complications