A 42-year-old woman presents with a solitary thyroid nodule. Physical examination revealed a mobile nodule measuring 2 by 3 cm without lymphadenopathy. Initial workup should include laboratory tests such as TSH, ultrasound of the thyroid, and ultrasound-guided fine needle aspiration of the nodule. The majority of thyroid nodules are benign, and fine needle aspiration is the most accurate way to determine if surgical intervention is needed. Iodine deficiency, which can cause goiter or hypothyroidism, is also a common cause of thyroid nodules in some regions and can be prevented by adequate iodine intake through diet.

1. Thyroid mass Presented by Dr- Hayam M. AL-moutary

2. Case A 42-year-old woman presents with a palpable mass on the left lobe of thyroid gland How to deal with these case?

3. She has no neck pain and no symptoms of thyroid dysfunction. The patient has no family history of thyroid disease and no history of external irradiation. physical examination reveals a solitary, mobile thyroid nodule, 2 cm by 3 cm, without lymphadenopathy

4. Which investigations should be performed? Assuming that the nodule is benign ,which, if any, treatment should be recommended?

6. Type of thyroid mass

7. Approach patient with thyroid nodule

8. Type of thyroid malignancy

9. Iodine deficiency disorder (IDD)

11. Thyroid physiology

12. Thyroid mass Nodule cancer goiter

13. Epidemiology In the United States, 4 to 7 percent of the adult population have a palpable thyroid nodule. Nodules are more common in women and increase in frequency with age and with decreasing iodine intake. The prevalence is much greater with the inclusion of nodules that are detected by ultrasonography or at autopsy. Malignant nodule corresponds to approximately 2 to 4 per 100,000 people per year, constituting only 1 percent of all cancers and 0.5 percent of all cancer deaths.

14. Causes of thyroid nodules Benign Multi noduler goiter Hashimotosthyrioditis Simple or hemorrhagic cysts Follicular adenomas Sub acute thyrioditis AACE/AME Guidelines 2010

15. Causes of thyroid nodules Malignant Papillary carcinoma Follicular carcinoma Hurthie cell carainoma Medullary carcinoma Anaplastic carcinoma Primary thyroid lymphoma Metastatic malignant lesion AACE/AME Guidelines 2010

16. History o Age o Family history of thyroid disease or cancer o Previous head or neck irradiation o Rate of growth of the neck mass o Dysphonia, dysphagia, or dyspnea AACE/AME Guidelines 2010

18. Factors suggesting increased risk of malignant potential (grade C): History of head and neck irradiation Family history of MTC or MEN2 Age <20 or >70 years Male sex Growing nodule Firm or hard consistency Cervical adenopathy Fixed nodule Persistent hoarseness, dysphonia, dysphagia, or dyspnea AACE/AME Guidelines 2010

19. Laboratory Evaluation TSH Assay Serum Free Thyroxine and Free Triiodothyronine Calcitonin Assay

20. Laboratory Evaluation • Serum TSH should be tested (grade B) • If TSH level is low (<0.5 μIU/mL), measure free T4 and T3; if TSH level is high (>5.0 μIU/mL), measure free T4 and TPOAb (grade C) • Serum calcitonin should be measured if FNA or family history suggests MTC (grade B) AACE/AME Guidelines 2010

26. In iodine-deficient areas (grade C)AACE/AME Guidelines 2010

29. Hot & cold nodule

30. Thyroid nodule History& physical examination High or normal TSH Low TSH scintigraphy U/S guided FNA cold hot Suspicious Inadequate Benign-ve Malignant +ve Perform FNA benign Observe and repeat FNAC 1 year Or levothroxin Repeat FNA Surgery Surgery

32. Thyroid Malignancies- Papillary Most common 30% have node metastasis at diagnosis Radiation related Histologically, psammoma bodies distinguish from benign adenoma.

33. Thyroid Malignancies-Follicular 20 % of malignancies Distinguished from normal follicular adenomas by invasion of capsule or blood vessels. May be difficult to determine on FNA

34. Thyroid Malignancies- Medullary 5-10% of cases arise from the C cells which produce calcitonin diagnosis based on elevated thyrocalcitonin levels and thyroid nodule (cold)

35. Thyroid Malignancies- Anaplastic < 10% Highly aggressive with local extension at time of diagnosis. No suitable therapy Prognosis < 1 yr from diagnosis

36. Iodine Deficiency Iodine is a chemical element. It is found in trace amounts in the human body, in which its only known function is in the synthesis of thyroid hormones Severe iodine deficiency results in impaired thyroid hormone synthesis and/or thyroid enlargement (goiter). More common in female

38. hypothyroidism,

39. cretinism,

40. decreased fertility rate,

41. increased infant mortality,

45. Physical The first sign of iodine deficiency is diffuse thyroid enlargement, which becomes multinodular over time. In patients with hypothyroidism due to severe iodine deficiency, one might see signs such as dry skin, periorbital edema, and delayed relaxation phase of the deep tendon reflexes.

47. 20-49 mcg of iodine per liter moderate deficiency

51. The WHO recommendations for iodine intake are 150 mcg/d for adults and adolescents

53. Levothyroxine (Synthroid, Levothroid, Levoxyl)12.5-50 mcg/d PO and increase by 25-50 mcg/d PO q2-4wk, not to exceed 100-200 mcg/d PO Surgery

54. Summary Most nodules are asymptomatic, and absence of symptoms does not rule out malignancy The initial evaluation should include measurement of the serum thyrotropin level and a fine-needle aspiration, preferably guided by ultrasonography IDD are common in our region can be preventable by take recommended dose of iodine from natural source

56. AACE/AME Guidelines 2010