Objectives: Thyroid cancer is the most common endocrine cancer in the Philippines affecting primarily women in the reproductive age group. Considering the burden of thyroid cancer in the country, the Department of Health (DOH) called for the development of a national clinical practice guideline that would address patient needs, and aid physicians in clinical decision-making while considering therapeutic cost and availability in the local setting. The 2021 guidelines are aimed at providing optimal care to Filipino patients by assisting clinicians in the evaluation of thyroid nodules and management of well differentiated thyroid cancer. Methods: A steering committee convened to formulate clinical questions pertaining to the screening and evaluation of thyroid nodules, surgical and post operative management of thyroid cancer, and palliative care for unresectable disease. A technical working group reviewed existing clinical guidelines, retrieved through a systematic literature search, synthesized clinical evidence, and drafted recommendations based on the ADAPTE process of clinical practice guideline development. The consensus panel reviewed evidence summaries and voted on recommendations for the final statements of the clinical practice guidelines. Results: The guidelines consist of clinical questions and recommendations grouped into six key areas of management of well differentiated thyroid cancer: screening, diagnosis, surgical treatment, post operative management, surveillance, and palliative care. Conclusion The 2021 guidelines for well differentiated cancer could direct physicians in clinical decision making, and create better outcomes for Filipino patients afflicted with the disease. However, patient management should still be governed by sound clinical judgement and open physician-patient communication.
Consensus ; Carcinoma ; Thyroid Neoplasms ; Thyroid Nodule ; Thyroidectomy

PURPOSE: We studied the patterns of FDG uptake of primary papillary thyroid microcarcinoma (PTMCa) lesions and benign thyroid nodules in dual time point (18)F-FDG PET/CT imaging. MATERIALS AND METHODS: Consecutive 134 patients (154 lesions) with PTMCa and 49 patients (61 nodules) with benign thyroid nodules equal to or less than 1.0 cm who underwent dual time point (18)F-FDG PET/CT study before surgery were enrolled. We calculated the maximum standardized uptake value of PTMCa and benign nodules in both time points, and percent change of SUVmax (delta%SUVmax) and lesion to background ratio of SUVmax (delta%L:B ratio) between both time points. The mean time interval between scans was 23.4+/-4.4 minutes (thyroid to thyroid interval: 10.7+/-4.4 minutes). RESULTS: The mean of SUVmax of PTMCa was increased from 4.9+/-4.3 to 5.3+/-4.7 (p<0.001) and delta%SUVmax was 12.3+/-23.6%. But, the mean of SUVmax of benign nodules was no definite change (2.1+/-1.0 to 2.1+/-1.3, p=0.686) and delta%SUVmax was -0.3+/-20.5%. Of the 154 PTMCa, 100 nodules (64.9%) showed an increase in SUVmax over time, while 19 (31.1%) of the 61 benign thyroid nodules showed an increase (p<0.001). The dual time point (18)F-FDG PET/CT found more PTMCa in visual assessment (62.3% vs. 76.6%, p=0.006), even in smaller than 0.5 cm (38.6% vs. 60.0%, p=0.011). CONCLUSION: Dual time time (18)F-FDG PET/CT imaging was more useful than single time point (18)F-FDG PET/CT imaging for distinction between PTMCa and benign nodule, especially when nodule showed equivocal or negative findings in single time point (18)F-FDG PET/CT imaging or was smaller than 0.5 cm.
Carcinoma, Papillary ; Humans ; Thyroid Gland ; Thyroid Neoplasms ; Thyroid Nodule

BACKGROUND: Follicular patterned thyroid nodules with incomplete nuclear features of papillary thyroid carcinoma (FTN-INPTCs) are difficult to diagnose, and their biological behavior and association with follicular variants of PTC (FVPTCs) have not yet been established. The aim of this study is to determine immunohistochemical and molecular characteristics of FTN-INPTCs. METHODS: We investigated immunohistochemical features (galectin-3, HBME-1, CK19, fibronectin-1, CITED1), BRAF V600E mutation and RASSF1A promoter methylation status in 30 FTN-INPTC cases, along with 26 FVPTCs, 21 follicular adenomas (FAs) and 14 nodular hyperplasias (NHs). RESULTS: Expression of galectin-3, HBME-1, CK19 and CITED1 was significantly higher in FTN-INPTCs than in FAs or NHs, but expression of galectin-3, CK19 and fibronectin-1 was lower in FTN-INPTCs than in FVPTCs. The BRAF V600E mutation was not detected in the benign nodules or FTN-INPTCs, whereas 57% of FVPTCs had the mutation. RASSF1A promoter methylation was higher in FTN-INPTCs than in benign nodules but there was no difference between FTN-INPTCs and FVPTCs. CONCLUSIONS: Our results represent the borderline immunohistochemical and molecular characteristics of FTN-INPTC. We conclude that FTN-INPTC is an intermediate lesion between a benign nodule and a FVPTC, and that it is pathogenetically related to FVPTC.
Adenoma ; Carcinoma ; Carcinoma, Papillary ; Factor IX ; Galectin 3 ; Hyperplasia ; Methylation ; Thyroid Gland ; Thyroid Neoplasms ; Thyroid Nodule

BACKGROUND: Thyroid cancer is a common disease and its prevalence is increasing. Recent reports have shown that an elevated thyrotropin (thyroid stimulating hormone, TSH) level is associated with thyroid cancer risk. However, the association between TSH level and thyroid cancer risk is not yet known for euthyroid patients diagnosed with papillary thyroid microcarcinoma (PTMC). METHODS: Our study included 425 patients who underwent thyroid surgery and were diagnosed with PTMC between 2008 and 2009. Control group patients were diagnosed with benign nodules < or = 1 cm in size by US-guided fine needle aspiration. Nodules with one or more suspected malignant-ultrasonographic feature(s) were excluded from this study. Patients who were not euthyroid or who took thyroid medication were also excluded. RESULTS: The mean age of all patients was 48.5 +/- 11.0 years and 88.8% were women. The mean age of those with PTMC was significantly lower than that of the control group. The mean TSH level was 1.78 +/- 0.93 mIU/L, and the mean free T4 level was 15.96 +/- 2.32 pmol/L. There was no difference in TSH level between the PTMC and control groups (1.77 +/- 0.93 mIU/L vs. 1.79 +/- 0.91 mIU/L, P = 0.829). After adjusting for age, TSH level was not correlated with tumor size (r = 0.02, P = 0.678) in the PTMC group. Moreover, the TSH level did not differ between patients with stage I and stage III-IV carcinoma (stage I, 1.77 +/- 0.95 mIU/L; stage III-IV, 1.79 +/- 0.87 mIU/L; P = 0.856). CONCLUSION: TSH levels are not elevated in euthyroid PTMC patients. Thus, further evaluation is needed before serum TSH can be used as a tumor marker for small nodules < or = 1 cm in size in euthyroid patients.
Biopsy, Fine-Needle ; Carcinoma ; Carcinoma, Papillary ; Female ; Humans ; Prevalence ; Thyroid Gland ; Thyroid Neoplasms ; Thyroid Nodule ; Thyrotropin

BACKGROUND: Follicular neoplasm (FN) or Hurthle cell neoplasm (HN) is a less well understood pitfall when evaluating thyroid nodule with fine-needle aspiration (FNA). This study aimed to determine the rates of malignancy and the predictive factors for malignancy in thyroid nodules with a cytological diagnosis of FN or HN. METHODS: The patients who were cytologically diagnosed as having FN or HN after FNA between 1995 and 2004 at Asan Medical Center were included in this study. We collected the pathology data until 2009 and we analyzed the clinical characteristics associated with malignancy. RESULTS: A total 478 patients were cytologically diagnosed as having FN or HN during the study period and 327 (68%) among them underwent thyroid surgery. Thyroid malignancy was confirmed in 157 (48%) of 327 patients. Malignancy was confirmed in 124 patients with FN (124/253, 49%). They were 48 papillary, 65 follicular, 7 Hurthle cell and 3 medullary carcinomas and 1 anaplastic carcinoma. The malignancy in the cases of HN (33/71, 44.6%) was 9 papillary, 4 follicular and 20 Hurthle cell carcinomas. The risk of malignancy was not associated with male gender, a larger tumor size (> 4 cm) or the diagnosis of HN. However, an age below 20 years (RR 3.6, P = 0.03) and above 60 years (RR 2.3, P = 0.04) was associated with an increased risk of malignancy. CONCLUSION: About half of the patients with FN or HN on FNA cytology were diagnosed as having thyroid cancer after surgery. The malignancy rate for the cytologic diagnosis of HN was similar to that for FN. Thyroid surgery should be recommended for this situation, and especially for patients younger than 20 years or older than 60 years.
Biopsy, Fine-Needle ; Carcinoma ; Carcinoma, Medullary ; Humans ; Male ; Thyroid Gland ; Thyroid Neoplasms ; Thyroid Nodule

This report concerns a 71-year-old female with long standing untreated toxic multinodular goiter (TMG) coexisting with anaplastic thyroid carcinoma who presented with progressive shortness of breath and easy fatigability. Thyroid function tests showed suppressed TSH and elevated FT4 and FT3. Anti-thyroid hormone drugs were started. Thyrotropin receptor antibody was negative. A thyroid scan revealed both hot and cold nodules and fine needle aspiration biopsy (FNAB) of the thyroid gland showed colloid nodule. Chest CT scan imaging revealed an enlarged thyroid gland with the right lobe compressing the trachea. Patient underwent total thyroidectomy, final histopathology showed Anaplastic thyroid carcinoma. Our case is interesting from a pathophysiologic perspective,since it suggests that TMG can potentially transform into an aggressive form of thyroid carcinoma. High index of suspicion in patients with TMG with other risk factors for malignancy requires careful evaluation to detect cancer.

Human ; Female ; Aged ; Goiter ; Immunoglobulins, Thyroid-stimulating ; Receptors, Thyrotropin ; Thyroid Carcinoma, Anaplastic ; Thyroid Hormones ; Thyroid Neoplasms ; Thyroid Nodule ; Thyroidectomy ; Hyperthyroidism

PURPOSE: An association between primary hyperparathyroidism and well differentiated thyroid carcinoma has been frequently reported. However, there have been few reports of secondary hyperparathyroidism associated with thyroid carcinoma. This study was performed to evaluate the prevalence of thyroid nodule including thyroid carcinoma in patients with secondary hyperparathyroidism and to suggest more proper diagnostic approach for such cases. METHODS: A retrospective study was performed on fifty-two patients who underwent parathyroid surgery for secondary hyperparathyroidism between March, 1986 and December, 2003. RESULTS: In 20 patients (38.5%), thyroid surgery was added because of coexistent thyroid nodules. Five (25%) out of the 22 patients with coexistent thyroid nodule had thyroid carcinoma. Among the 5 thyroid carcinoma patients, 4 had papillary carcinomas and one had a follicular carcinoma. Mean size of thyroid carcinomas was 1.4 cm (0.3~3.0 cm). CONCLUSION: The prevalence of thyroid carcinoma in patients with secondary hyperparathyroidism was higher than that in the general population. An aggressive diagnostic approach (ultrasonography and FNAB) should be considered when the patients with secondary hyperparathyroidism present with thyroid nodules.
Carcinoma, Papillary ; Humans ; Hyperparathyroidism, Primary ; Hyperparathyroidism, Secondary* ; Prevalence ; Retrospective Studies ; Thyroid Gland* ; Thyroid Neoplasms ; Thyroid Nodule*

The association of thyroid carcinoma and Hashimotos thyroiditis in same thyroid gland is controversial. Incidence of carcinoma who has Hashimotos thyroiditis has been reported from 0.5 to 22.5 per cent by Crile and by Hirabayashi et al. The reason that there are such great diffarences in the reported incidences of carcinoma in Hashimotos disease is the result of the way the material is reported. The carcinomas of the thyroid which occur in association with Hashirnotos thyroiditis are predominently papillary tumors of lower grade malignancy. Thyroid carcinoma need not be feared in patimts with Hashimotos thymiditis, if one examines the ghmd catefully. When patients with Hashimotos disease are treated with thyroxine, there is little or no tendency for Hashimotos disease propess to clinieally detectable carcinoma of the thymid, and the microcarcinoma does not appear. In this case, single thyroid nodule was detected in Hashiimotos disease patient who was treated with thyroxine. There was no significant volume change of thyroid nodule despite of TSH suppression therapy during six months. Therefore we perforrned FNABC twice, the results were highly suspicious thyroid malignancy and subtotoal thyroidectomy was performed. The final pathologic result was microscopic papillary carcinoma with background Hashlmotos thyroiditis. In conclusion, we experienced a case of subsequent microscopic papillary carcinoma of the thyroid in patient with Hashimotos thyroiditis who was TSH suppression therapy with thyroxine.
Carcinoma, Papillary ; Hashimoto Disease ; Humans ; Incidence ; Thyroid Gland ; Thyroid Neoplasms ; Thyroid Nodule ; Thyroidectomy ; Thyroiditis ; Thyroxine

PURPOSE: The purpose of this study is to suggest predictive ultrasonographic finding of papillary thyroid microcarcinoma (PTMC) with lymph node metastasis (LNM), compared to PTMC without LNM. MATERIALS AND METHODS: This study included 93 patients (79 women, 14 men; mean age 46.0 +/- 10.6 years) with surgically proven PTMC. Twenty patients had LNM and 73 patients did not have LNM on surgical specimens. The following ultrasonographic characteristics were evaluated: tumor location, size, shape, echogenicity, margin, presence of calcification, and presence of capsular abutment. Univariate analysis and multivariable stepwise logistic regression analysis were performed for comparison of these characteristics in regard to the presence of LNM in order to determine predictors of LNM. RESULTS: Two factors were significantly related to LNM: presence of capsular abutment (p = 0.0011) and tumor size (cutoff value: > or = 5 mm, p = 0.0058). Lateral lymph node metastasis (LLNM) showed a significant association with macrocalcification (p = 0.015), presence of capsular abutment (p = 0.0104), tumor size (cutoff value: > or = 7 mm, p = 0.002), and upper location of thyroid nodule (p= 0.0255). Presence of capsular abutment was an independent predictive factor for LNM (Odds ratio: 14.83, p = 0.010). Tumor size was an independent predictive factor for LLNM (Odds ratio: 2.102, p = 0.010). CONCLUSION: Presence of capsular abutment and tumor size are important ultrasonographic predictors for LNM or LLNM in patients with PTMC.
Carcinoma, Papillary ; Female ; Humans ; Logistic Models ; Lymph Nodes ; Neoplasm Metastasis ; Thyroid Gland ; Thyroid Neoplasms ; Thyroid Nodule

PURPOSE: A relationship between thyroid disease and primary breast cancer remains controversial. Several studies have demonstrated there is an increased risk of breast cancer in patients with thyroid dysfunction and thyroid cancer. The purpose of this study was to evaluate the incidence, relationship and clinical characteristics of thyroid nodules and cancer in patients with breast cancer. METHODS: Two hundred sixty one women ith primary breast cancer had an ultrasonogram of the thyroid prospectively performed at the Department of General Surgery of the Soonchunhyang University Hospital from April 1995 to December 1999. The thyroid nodules were identified by high-resolution ultrasonography before all patients had undergone breast cancer surgery. RESULTS: Among the 261 patients with breast cancer, thyroid nodules were found in 57 (21.8%). The most prevalent age group of the 57 thyroid nodules was the 5th decade. Twenty-one out of 57 patients with thyroid nodules had undergone thyroid surgery and 14 benign nodules and 7 thyroid cancers (5 papillary carcinoma & 2 follicular carcinoma) were discovered. The incidence of thyroid cancer in the patients with breast cancer was 2.7%. CONCLUSION: Although the factors associated with thyroid nodules and cancer in the patients with breast cancer were not demonstrated, these results were suggested that there may be a relationship between them. Therefore, ultrasonography of the thyroid in patients with breast cancer priorto breast cancer surgery operations is recommended.
Breast Neoplasms* ; Breast* ; Carcinoma, Papillary ; Female ; Humans ; Incidence* ; Prospective Studies ; Thyroid Diseases ; Thyroid Gland* ; Thyroid Neoplasms ; Thyroid Nodule* ; Ultrasonography