Hypothryoid / Thyroid Nodule

HYPOTHYROIDISM: 2/2 Etiology: TSH Goal: Controlled / Uncontrolled :  Cardiovascular Manifestations: Clinical Practice Guidelines for hypothyroidism in adults: AACE/ATS Endocrine Prac 2012     Hypothyroidism In the Clinic Annals 2009 Diffuse Pain:  Case 35-2012 (Severe Hypothyroidism)  Myxedema (Image) NEJM  LOW TSH: Investigating low thyroid stimulating hormone (TSH) BMJ 2013 SUBCLINICAL THYROID DISEASES  Subclinical thyroid disease Lancet 2012 THYROID NODULE  Causes of Thyroid Nodule Endo Prac 2010  Benign nodular goiter Chronic lymphocytic thyroiditis Simple or hemorrhagic cysts Follicular adenomas Subacute thyroiditis Papillary carcinoma Follicular carcinoma Hürthle cell carcinoma Poorly differentiated carcinoma Medullary carcinoma Anaplastic carcinoma Primary thyroid lymphoma Sarcoma, teratoma, and miscellaneous tumors Metastatic tumors  Increased risk of Malignancy Endo Prac 2010  History of head and neck irradiation Family history of medullary thyroid carcinoma, multiple endocrine neoplasia type 2, or papillary thyroid carcinomaAge <14 or >70 years Male sex Growing nodule Firm or hard consistency Cervical adenopathy Fixed nodule Persistent dysphonia, dysphagia, or dyspnea  Thyroid Nodule NEJM 2015 Thyroid Nodule NEJM 2015 Thyroid Nodule NEJM 2015 Thyroid Nodule NEJM 2015 USG findings and indications of FNA to rule out malignancy: Please see Fig. 2. in page 8 of Endo Prac 2010  Thyroid Nodule NEJM 2015 Thyroid Nodule NEJM 2015 Thyroid Nodule NEJM 2015 Work up < 1 cm Endo Prac 2010  without suspicious history or  US findings Clinical monitoring with suspicious history or US findings  work up starting with USG FNA to rule out malignancy  >1 cm  Low TSH Next step is to do Thyroid Scan  Hot nodule (ablate, resect or treat medically) Cold Nodule needs further work up with USG FNA  Normal or High TSH USG FNA - 5 outcomes  1. Unsatisfactory tissue samples - needs repeat FNA 2. Benign - Monitor  Colloid Nodule Hyperplastic Nodule Lymphocytic or Granulomatous thyroiditis Benign Cyst   3. Follicular : cannot distinguish as benign or malignant based on cytomorphology  Adenomatoid Hyperplasia Follicular adenoma Follicular carcinoma Hurthle Cell Neoplasm Follicular variant of PTC (papillary thyroid cancer) 3a. AUS - FLUS (Atypical or Follicular lesion of unknown significance) 3b. FN - SFN (Follicular Neoplasia or Suggestive of Follicular Neoplasia) NEJM Editorial 2012 4. Suspicous - suggestive of cancer - either surgery or Gene expression profile  5. Malignant - Surgery  3, 4 - are cytologically indeterminate Needs further risk assessment with gene expression profile Benign: Monitor Malignant: Surgery  References: Minimizing Unnecessary Surgery for Thyroid Nodules NEJM Editorial 2012  The diagnosis and management of thyroid nodules AACE/AME/ETA Guidelines Endo Prac 2010  The Natural History of Benign Thyroid Nodules JAMA 2015 The Thyroid Nodule  NEJM 2004 Initial evaluation of a patient with a thyroid nodule Up-to-date Management of thyroid nodules based upon results of fine needle aspiration Up-to-date  Recent Publications in Endocrinology Thyroid Preoperative Diagnosis of Benign Thyroid Nodules with Indeterminate CytologyStrategies of Radioiodine Ablation in Patients with Low-Risk Thyroid Cancer Pharmacology in Endocrinology Thyroid Disorders Clinical Practice Guidelines for hypothyroidism in adults: AACE/ATS Endocrine Prac 2012     Clinical Practice Guidelines for hypothyroidism in adults: AACE/ATS Endocrine Prac 2012     Clinical Practice Guidelines for hypothyroidism in adults: AACE/ATS Endocrine Prac 2012     Clinical Practice Guidelines for hypothyroidism in adults: AACE/ATS Endocrine Prac 2012     Clinical Practice Guidelines for hypothyroidism in adults: AACE/ATS Endocrine Prac 2012     Clinical Practice Guidelines for hypothyroidism in adults: AACE/ATS Endocrine Prac 2012