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      Endocrine Society of India management guidelines for patients with thyroid nodules: A position statement

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          Abstract

          Thyroid nodules are common. Thyroid cancer is rarer. No guidelines exist for management of thyroid nodules in the Indian context and these recommendations are intended for this purpose. The consensus committee reviewed important articles, including previously published consensus statements. Management points were scored according to the level of evidence. These guidelines cover the clinical evaluation and include the interpretation of imaging and fine needle aspiration cytology of thyroid nodules. The guidelines also cover the management of special situations like thyroid incidentalomas, cystic thyroid lesion and nodules detected during pregnancy. The consensus guidelines represent a summary of current medical evidence for thyroid nodule management and the committee has attempted to optimize the guidelines for the clinical practice setting in India.

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          Most cited references20

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          The spectrum of thyroid disease in a community: the Whickham survey.

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            Pathogenesis, diagnosis and management of thyroid nodules in children.

            According to the literature thyroid nodules are quite rare in the first two decades of life. However, there are some exceptions, relating to areas with an iodine deficiency or affected by radioactive fallout, where the risk of nodules and carcinomas is increased. Therefore, it is a great challenge for the physician to distinguish between benign and malignant lesions preoperatively, and not only in these areas of greater risk. A careful work-up, comprising the patient's history, clinical examination, laboratory tests, thyroid ultrasound, scintigraphy, fine-needle aspiration biopsy (FNAB) and molecular studies, is mandatory to improve the preoperative diagnosis. The differential diagnosis should also include benign thyroid conditions such as: (i) congenital hypothyroidism due to dyshormonogenesis or ectopy, (ii) thyroid hemiagenesis, (iii) thyroglossal duct cyst, (iv) simple goiter, (v) cystic lesion, (vi) nodular hyperplasia, (vii) follicular adenoma, (viii) Graves' disease and (ix) Hashimoto thyroiditis, all of which can predispose to the development of thyroid nodules. The majority of thyroid carcinomas derive from the follicular cell (papillary, follicular, insular and undifferentiated (or anaplastic) thyroid carcinoma), whereas medullary thyroid carcinoma derives from calcitonin-producing cells. Inherited forms of thyroid cancer may occur, especially in relation to medullary thyroid carcinoma. FNAB is a critical factor in establishing the preoperative diagnosis. However, we should keep in mind the fact that a conventional cytological evaluation can miss the neoplastic nature of a lesion and the employment of immunocytochemical and molecular studies of aspirates from FNAB can give us a more precise diagnosis of neoplasia in thyroid nodules once they are detected.
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              The indeterminate thyroid fine-needle aspiration: experience from an academic center using terminology similar to that proposed in the 2007 National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference.

              To date, thyroid fine-needle aspiration (FNA) has been used by clinicians as the screening test of choice to determine whether surgery is required and this is what the pathology report should communicate. Standard terminology for reporting thyroid FNA has not been implemented yet, and pathologists have used various reporting systems to communicate results. A significant source of confusion among both pathologists and clinicians has been the use of the indeterminate category. On the basis of an analysis of 1150 thyroid FNAs in 2000, this institution modified the reporting of thyroid biopsy results into 6 categories, including unsatisfactory. The indeterminate category was separated into 3 subroups: 1) indeterminate for neoplasia (IND), 2) follicular neoplasm (FN), and 3) suspicious for malignancy (SUSP). Repeat FNA in 6 months to 12 months was recommended for IND and surgery for FN and SUSP categories. To determine the validity of this approach, the outcomes of this reporting system from July of 2000 to December of 2006 were analyzed. The IND category was used for 2 subsets of cases: (a) those that morphologically fall into the gray zone between adenomatoid nodule (AN) and FN, for Hurthle cell nodule (hyperplasia vs neoplasm), and chronic lymphocytic thyroiditis with concern for neoplasia; and (b) for suboptimal specimens due to low epithelial cellularity or collection artifacts. Among 5194 thyroid nodules, the IND category comprised 18%. FNA follow-up was done in 21% of IND cases: 58% were benign/negative and did not require surgery based on cytology alone. Surgical follow-up in 46% of IND showed 52% were benign/negative, and 42% were follicular/Hurthle cell adenomas. The surgical yield of malignancy in IND was low (6%) when compared with the FN category, which was 14% (more than 2x that of the IND category), and the SUSP category, which was 53% (almost 9x that of the IND category). A 6-tier reporting system for thyroid FNA was effective for determining which patients needed surgery versus follow-up FNA and also guided the clinician on the extent of surgery. 2009 American Cancer Society.
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                Author and article information

                Journal
                Indian J Endocrinol Metab
                IJEM
                Indian Journal of Endocrinology and Metabolism
                Medknow Publications (India )
                2230-8210
                2230-9500
                Jan-Mar 2011
                : 15
                : 1
                : 2-8
                Affiliations
                [1] Department of Endocrinology, Amrita Institute of Medical Sciences, Cochin, India
                [1 ] Bharti Hospital, Karnal, Haryana, India
                [2 ] Excel Center, Guwahati, India
                [3 ] Endocrine Surgery Division, Department of Surgery, Amrita Institute of Medical Sciences, Cochin, India
                [4 ] Department of Endocrinology, St. Johns Medical College, Bangalore, India
                [5 ] Department of Endocrinology, Osmania Medical College, Hyderabad, India
                Author notes
                Corresponding Author: Dr. A. G. Unnikrishnan, Department of Endocrinology, Amrita Institute of Medical Sciences, Cochin - 682041, India. E-mail: unnikrishnanag@ 123456aims.amrita.edu
                Article
                IJEM-15-2
                10.4103/2230-8210.77566
                3079862
                21584159
                9c037600-6922-4dfb-ab4e-e000361cc158
                Copyright: © Indian Journal of Endocrinology and Metabolism

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Categories
                Review Article

                Endocrinology & Diabetes
                thyroid nodule,fine needle aspiration cytology,goiter,thyroid cancer
                Endocrinology & Diabetes
                thyroid nodule, fine needle aspiration cytology, goiter, thyroid cancer

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